Nursing 111 Test 2
A primary health care provider orders a dose of medication for a child at 2mg/kg of body weight. The child weighs 64 pounds. Before determining the prescribed dose, the nurse must convert the child's weight from pounds to kilograms. How many kilograms does the child weigh? Record your answer using a whole number followed with no space then kg (for example, 72kg). Answer:
29kg
A partial bath is similar to a full bath except the legs are omitted. Select one: True False
False
A trochanter roll is used to prevent internal rotation of the hips in the Fowler's position. Select one: True False
False
A nurse is caring for a middle-aged adult admitted to the hospital who had prescriptions for six different medications. Which nursing action is the priority before administering these medications to the patient? Select one: a. Teach the patient the therapeutic action of the medications. b. Verify that the medications are compatible. c. Ensure that these medications are included on the medication reconciliation form. d. Have the antidotes for medications easily available.
b.
The nurse is reviewing the results of lab results conducted on a patient admitted with a respiratory disorder. The lab finding that is most significant for this patient would be? Select one: a. Oxygen saturation 96% b. Hemoglobin level 8.3 c. Blood pH 7.40 d. Serum Sodium 140 mg/dL
b.
When suctioning an adult, which size should be used? Select one: a. Fr. 8 b. Fr. 18 c. Fr. 10
b.
The six rights of medication administration are right medication, right patient: Select one or more: a. right name b. right dose c. right documentation d. right time e. right route f. right birthdate
b. c. d. e.
A nurse is caring for a patient who recently had spinal surgery requiring the patient to be supine in bed. What dependent nursing action should the nurse implement that will help prevent complications associated with venous stasis? Select one: a. Assess vital signs routinely. b. Encourage ankle-pumping exercises. c. Apply sequential compression devices. d. Place in semi-Fowler position occasionally
c.
A nurse is repositioning a patient in right Sim's position. What action should the nurse implement when positioning this patient? Select one: a. Position the left arm behind the body. b. Rest the right leg on the top of the left leg. c. Flex the right arm and rest it on a pillow. d. Turn the body halfway between the lateral and prone position.
d.
A patient with chronic obstructive lung disease is prescribed oxygen 24% 2L/min. The nurse realizes the best way to provide oxygen to this client would be with a Select one: a. Venturi mask b. Nonrebreather mask c. Nasal cannula d. Face mask
c.
When correctly performing nasopharyngeal suctioning, the suction attempt should last Select one: a. 15-20 seconds b. 20-30 seconds c. 10-15 seconds d. 5-10 seconds
c.
A nurse is repositioning a patient in the right lateral position. What action should the nurse implement when positioning this patient? Select one: a. Rest the head on one pillow. b. Extend the right arm and rest it on a pillow. c. Support the hip to the knee with a trochanter roll. d. Flex the hip and knee and rest the left leg on the right leg.
a.
A patient diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation and dyspnea. The nurse would identify which of the following diagnoses as being a priority for this patient? Select one: a. Impaired Gas Exchange. b. Anxiety c. Ineffective Tissue Perfusion d. Impaired Physical Mobility
a.
Using a wall suction unit, the pressure for suctioning an adult should be set at Select one: a. 100-120 mm Hg b. 10-15 mm Hg c. 200-350 mm Hg d. 50-95 mm Hg
a.
Which of the following is not a function of the upper airway? Select one: a. For clearance mechanism such as coughing. b. Transport gases to lower airways c. Warming, filtration, and humidification of inspired air d. Protect the lower airway from foreign matter
a.
Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing? Select one: a. Have the patient place the specimen in a container and enclose the container in a plastic bag. b. Offer the patient an antiseptic mouthwash just before he expectorates the sputum. c. Have the patient expectorate the sputum while the nurse holds the container. d. Have the patient expectorate the sputum into a sterile container.
d.
A nurse is ambulating a patient in the hall several rooms away from the patient's room. During the walk, the patient states, " I am dizzy and I feel weak." What action by the nurse is most appropriate at this time? Select one: a. Return the patient to bed. b. Lower the patient to the floor gently. c. Walk toward the patient's room slowly. d. Call another nurse to assist with the patient
b.
The nurse teaches a patient how to use an incentive spirometer. What patient outcome will support the conclusion that the use of incentive spirometer was effective? Select one: a. Coughing will be stimulated. b. Supplemental oxygen use will be reduced. c. Sputum will be expectorated. d. Inspiratory volume will be increased.
d.
True or False For proper medication administration, the nurse should check medications at least three times prior to administering the drug to the patient. Select one: True False
True
A nurse is positioning a patient in the supported prone position. What action should the nurse implement when positioning the patient? Select one: a. Put pillows under the patients' thighs. b. Place pillows alongside the patient's hips. c. Place a large pillow under the patient's head. d. Put a small pillow under the patient's abdomen.
d.
When should a nurse suction a patient? Select one: a. Every 2 hours b. Every 1 hour c. As desired d. As needed
d.
In providing perineal care for a female patient, the labia minora is cleansed before the labia majora. Select one: True False
False
True or False The first step in medication administration is to check for patient allergies. Select one: True False
False
The nurse's responsibility in medication reconciliation is: select all that apply Select one or more: a. compare the admission list of medications to the medications ordered for the patient during the hospital stay and notify MD with discrepancies. b. verify the patient's complete list of medications upon admission. c. verify the patient's list of medications every 24 hours. d. review list of medications with patient at discharge and discuss any changes from pre-hospital medications. e. verify medications with patient each time before administering to make sure patient knows what medication is for.
a. b. d.
A nurse is caring for a patient with pressure ulcers over the left ischial tuberosities. In what position should the nurse place the patient to relieve pressure in these areas? Select one or more: a. Sim's b. Prone c. Orthopenic d. Right Lateral e. High-Fowler
a. b. d.
A nurse is caring for a patient with a diagnosis of venous stasis of the lower left leg. Which independent nursing action is important for the nurse to implement? Select one: a. Apply a warm soak to the left leg twice a day. b. Massage the legs gently from distal to proximal. c. Elevate the left leg on a pillow. d. Maintain venous compression devices to both legs.
c.
A nurse is providing passive range-of-motion exercises. Which principle is important? Select one: a. Increase the speed of exercises progressively and according to the patient's tolerance. b. Assist the patient to complete all planes of movement when the patient is unable to do so. c. Support above and below the joint being exercised. d. Repeat each movement ten times.
c.
The nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions in the nurses priority? Select one: a. Increase the oxygen flow. b. Attain a specimen for arterial blood gases. c. Assist the client to Fowlers position. d. Promote removal of pulmonary secretions.
c.
Which of the following is true about expiration? Select one: a. The length of which is half of the length of inspiration b. Requires energy to be carried out c. A passive process d. Stridor is commonly heard during expiration
c.
A patient is admitted with a possible DVT. Nursing interventions should be implemented to prevent which complication? Select one: a. Renal failure b. Pneumonia c. Myocardial Infarction d. Pulmonary embolism
d.
The bed position for a patient is with head of bed at 55degrees. This position is best used for which of the following patients? Select one: a. A cardiac patient b. A post thoracic surgery c. A COPD patient d. A patient with reflux
d.
To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test? Select one: a. Total hemoglobin b. Red blood cell count c. Sputum culture d. Arterial blood gas analysis
d.
