Nursing Fundamentals Midterm Exam

Which is the nurse's best legal safeguard? - Competent practice - Written or implied contracts - Client education - Collective bargaining

Competent practice

A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Of the following subjective data collected, which statement obtained during the health history would be a cue to planning care for this problem? - "I just feel so bad about myself these days." - "My skin is so dry I just can't keep from scratching." - "I often have diarrhea after I eat spicy foods." - "I get out of breath when I walk a few steps."

"I get out of breath when I walk a few steps."

Which statement is true of factors that influence communication? - Culture and lifestyle influence the communication process. - Distance from a client has little effect on a nurse's message. - Nurses provide the same information to all clients, regardless of age. - Men and women have similar communication styles.

Culture and lifestyle influence the communication process.

The client complains of shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing? - Psychosocial - Ongoing - Focused - Comprehensive

Focused

The client reports experiencing abdominal pain. The nurse auscultates the client's abdomen and hears gurgling sounds. What additional information does the nurse assess about this gurgling sound? - Frequency - Rhythm - Turgor - Texture

Frequency

A nursing student is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touch the bed linens. What action should the nurse take to maintain surgical asepsis for this procedure? - Do nothing, because the patient is on antibiotics - Complete the procedure and report what happened - Apologize to the patient and complete the procedure - Gather new sterile supplies and start over

Gather new sterile supplies and start over

Which nursing intervention can help a client maintain healthy skin? - Keep the client well hydrated. - Recommend wearing tight-fitting clothes in hot weather. - Remove adhesive tape quickly from the skin. - Avoid bathing the client with mild soap.

Keep the client well hydrated.

Which of the following landmarks is the correct one for best auscultation of the mitral valve? - Left second intercostal space, midclavicular line - Left seventh intercostal space, midclavicular line - Left fifth intercostal space, midclavicular line - Left intercostal space, midaxillary line

Left fifth intercostal space, midclavicular line

While assessing breath sounds, a nurse hears crackles. Which of the following cause these abnormal sounds? - Narrowed small air passages - Air in the lungs - Moisture in air passages - A narrowing of the upper airway

Moisture in air passages

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an elderly patient? - Assist patient to cough, turn, deep breathe every shift - Discontinue humidification delivery device on oxygen flowmeter - Monitor oxygen saturation and frequently assess lung bases. - Encourage patient to drink through a straw to prevent aspiration.

Monitor oxygen saturation and frequently assess lung bases.

Of the following actions, which is clearly a nursing responsibility? -Performing surgical procedures - Monitoring health status changes - Ordering diagnostic examinations - Prescribing medications

Monitoring health status changes

Which is the legal source of rules of conduct for nurses? - Nurse Practice Acts - Constitution of the United States - Agency policies and protocols - American Nurses Association

Nurse Practice Acts

The nurse is gathering data on a patient. Which data will the nurse report as objective data? - Patient reports a headache last 2 days - Patient is complaining of nausea - Patient's respiratory rate is 16 - Patient states "I don't feel well"

Patient's respiratory rate is 16

The nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care? - Slide the client, rather than lifting, when turning. - Turn and reposition the client at least once every 8 hours. - Use antibacterial soap when bathing client - Post a turning schedule at the client's bedside.

Post a turning schedule at the client's bedside.

A nurse has taken a telephone order from a physician for an emergency medication. The dose of the medication is abnormally high. What should the nurse do next? - Refuse to administer the medication. - Question the medication order - Document concerns about the order. - Administer the medication based on the order

Question the medication order

The nurse has begun a comprehensive assessment on the client and asks him his name, his date of birth, if he knows where he is, and what day of the week it is. In doing this the nurse is testing his client's: - level of consciousness - intelligence - social and cognitive skills - physical and mental development

level of consciousness

The nurse is performing an assessment on a new client. While auscultating lung sounds, the nurse knows that bronchial sounds are heard best - midaxilliary - distal to the xyphoid process - on the anterior chest - above the clavicle

on the anterior chest

The nurse is caring for a client who is immobile. The nurse is aware that this patient is At Risk for Impaired Skin Integrity because - local nerve damage leads to pain sensation - pressure reduces circulation to affected tissues - inadequate blood flow leads to decreased tissue ischemia - clients with limited caloric intake develop thicker skin

pressure reduces circulation to affected tissues

The nurse is caring for a patient with rubeola (measles) and will implement which transmission-based precautions for this patient? - masks to be worn by staff when the patient leaves her room - private or shared room - N-95 mask to be worn by the patient at all times - private room with negative airflow pressure

private room with negative airflow pressure

A staff development nurse is discussing techniques to prevent back injury with a group of nurse aides. The nurse informs the group that back stress and injury can best be prevented by: - holding the object that you are lifting/moving away from the body. - using the strength of the back muscles during strenuous activities - spreading their feet shoulder-width apart to broaden the base of support - pulling equipment, rather than pushing it, when possible.

spreading their feet shoulder-width apart to broaden the base of support

An 85-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility? - stiffness in his ankles, knees and hip joints - Short-term memory loss. - Soreness of the gums - Decreased appetite.

stiffness in his ankles, knees and hip joints

Which organization has established safety standards about the use of electrical equipment, isolation techniques, and toxic chemicals? - The Occupational Safety and Health Administration (OSHA) - The Centers for Disease Control and Prevention (CDC) - The Nurse Practitioner Data Bank - Equal Employment Opportunity Commission (EEOC)

The Occupational Safety and Health Administration (OSHA)

The nurse reviews a client's health record and reads that the client has +1 edema of his bilateral ankles. How should the nurse interpret this finding? - The degree of edema equals a 2mm depth upon pressing the area firmly - the client does not have edema - The degree of edema equals a 6mm depth upon pressing the area firmly - The nurse needs a second attempt to palpate the client's ankles

The degree of edema equals a 2mm depth upon pressing the area firmly

A client has suddenly become very ill and needs to be transferred in the intensive care unit (ICU). Which action by the nurse would best ensure continuity of care? - The nurse ensures the client's chart and his belongings are moved with the client. - The nurse provides an SBAR report to the nurse in the ICU. - The nurse writes the information for the nursing assistant to give to the ICU nurse. - The nurse would ask the family to provide additional information.

The nurse provides an SBAR report to the nurse in the ICU.

During systole, the ventricles contract and the following valves open (select 2 answers) - aortic valve - tricuspid valve - pulmonic valve - mitral valve

- aortic valve - pulmonic valve

The nurse suspects that a client has an infected surgical wound and should assess for which signs? (Select 3 answers) - pain - redness - rigidity - coolness - swelling

- pain - redness - swelling

During diastole, the following valves are open (select 2 answers) - tricuspid valve - pulmonic valve - mitral valve - aortic valve

- tricuspid valve - mitral valve

Which is an example of nonverbal communication? - A client's face is contorted with pain. - A client asks the nurse for a pain shot. - A nurse says "I am going to help you walk now." - A nurse presents information to a group of clients.

A client's face is contorted with pain.

A document that lists the medical treatment a patient chooses to refuse if unable to make decisions is the: - Incident report - Advance directives - Durable power of attorney - Informed consent

Advance directives

Ethical principles for professional nursing practice in a clinical setting are guided by the principles of conduct that are written as the: - Standards of care from experts in the practice field - Nurse Practice Act (NPA) written by state legislation - Good Samaritan laws for civil guidelines - American Nurses Association's (ANA's) Code of Ethics

American Nurses Association's (ANA's) Code of Ethics

The nurse enters a client's room and finds that the client has fallen on her way to the bathroom. Which is the best nursing intervention for this client? - Briefly leave the client in order to call the primary health care provider to assess the client's condition - Assess the client and document the assessment findings and interventions in the client's medical record, followed by completion of incident report - Perform a head to toe assessment in order to determine whether an incident report is necessary - Assist the client back to bed and teach her about falls-prevention measures

Assess the client and document the assessment findings and interventions in the client's medical record, followed by completion of incident report

A nurse is discharging a client from the hospital. When should discharge planning be initiated? - Before admission to an acute health care setting - At the time of admission to an acute health care setting - At the time of discharge from an acute health care setting - When the client is at home after acute care

At the time of admission to an acute health care setting

A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out? - Include it with other documentation of the error - Place it in the client's medical record. - Take it home and keep it locked up. - Submit it according to agency policy

Submit it according to agency policy

True or False: Nurses have the right to refuse administration of any medication that, based on their knowledge and experience may be harmful to the patient. True False

True

The nurse is changing a dressing and providing wound care. Which activity should she perform first? - Wash hands thoroughly. - Put on latex gloves. - Slowly remove the soiled dressing - Assess the drainage in the dressing.

Wash hands thoroughly.

A murmur is heard at the second right intercostal space along the right sternal border. Which valve is best auscultated in this area? - tricuspid - aortic - pulmonic - mitral

aortic

A health____________ is a collection of subjective information supplied by the patient about their health status, whereas a physical assessment is a collection of objective data that provides information about changes in the patient's body system. - problem - standard - collaboration - history

history

The nurse performs an assessment on a newly admitted patient. The nurse understands that the primary purpose of this admission assessment is to - diagnose if the patient is at risk for falls - ensure that the patient's skin is intact - identify important data - introduce nursing staff to the patient

identify important data

Which phrase best describes continuity of care? - serving the needs of children - focusing on acute care in the hospital - providing single-episode care services - facilitating transition between settings

facilitating transition between settings

A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should: - reduce the client's fluid intake. - perform passive range-of-motion (ROM) exercises. - turn and position him frequently. - encourage the client to use a footboard.

turn and position him frequently.

In which situation is an alcohol-based rub an inappropriate option for hand hygiene? - when the nurse is caring for a client with an active infection - when the nurse anticipates contact with client's skin - when the nurse's hands are visibly soiled - when the nurse leaves the room of an immunocompromised client

when the nurse's hands are visibly soiled