Practice Questions

A nurse is caring for a patient with enuresis. For which patient is this a normal finding?

12 month old child who has involuntary urination

A nurse is delivering 3L/min oxygen to the client via nasal cannula. What percentage (fiO2) is the client receiving?

32%

Which enema would be used for a patient with intestinal parasites?

Anthelmintic Enema

Which of the following direct visualization tests uses a long, flexible, fiberoptic-lighted scope to visualize the rectum, colon, and distal small bowel?

Colonoscopy

True or False: Asepsis is used to prevent introducing microorganisms from the environment into the patient.

False

True or False: Health Care providers are not mandatory reporters of elder mistreatment.

False

True or False: If the patient is unconscious oral care should be avoided.

False

True or False: Red meat is an incomplete protein.

False Animal = complete Plant = incomplete

True or False: There are no interventions effective for preventing urinary incontinence.

False Maintain fluid, electrolyte, & acid-base balance, empty bladder completely at regular intervals, develop plan to modify factors contributing to current or future urinary problems, correct unhealthy urinary habits

True or False: A sterile urine specimen from a patient with an indwelling catheter should be obtained from the collection bag.

False Sterile urine specimens should be collected using the collection port NOT from the collection bag

Analyze the following ABG's: pH: 7.48 PaCO2: 35 mmHg HCO3: 28 mEq/L

Metabolic Alkalosis

What type of movement passes through a semi-permeable membrane from a low concentration to a high concentration?

Osmosis

At which stage of infection the patient is unaware of being contagious?

Prodromal stage

Analyze the following ABG's: pH: 7.25 PaCO2: 47 mmHg HCO3: 25 mEq/L

Respiratory Acidosis

What is the primary electrolyte of the ECF?

Sodium

True or False: Burnout can be compared with the exhaustion stage of stress.

True

True or False: For homeostasis to occur, cations must equal anions and input must be equivalent to output.

True

True or False: Insulin is a form of treatment for hyperkalemia because it facilitates glucose uptake and an influx of potassium.

True

True or False: When collecting stool using the technique "timedspecimen," the nurse should consider the first stool passed by the patient as the start of the collection period.

True

True or False: sensory deprivation occurs when a person experiences decreases sensory input that is monotonous or meaningless.

True

True or False: Diuretics cause increased urine production, resulting in the need for increased urination and possibly urge incontinence.

True Diuretics prevent reabsorption of water and certain electrolytes

What infection is the greatest among HAIs?

UTIs

The nurse is assessing for correct placement of the nasogastric tube. The nurse aspirates the stomach contents and checks the gastric pH. The nurse verifies correct tube placement if which pH value is noted? a. 3.5 b. 7.0 c. 7.35 d. 7.5

a. 3.5

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied supplemental oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed: a. 6 L / minute b. 1 L / minute c. 4 L / minute d. 10 L / minute

a. 6 L / minute

A nurse is evaluating patients to determine their need for parenteral nutrition (PN). Which patients would be the best candidates for this type of nutritional support? Select all that apply. a. A patient with irritable bowel syndrome who has intractable diarrhea b. A patient with celiac disease not absorbing nutrients from the GI tract c. A patient who is underweight and needs short-term nutritional support d. A patient who has anorexia and refuses to take foods via the oral route e. A patient with burns who has not been able to eat adequately for 5 days

a. A patient with irritable bowel syndrome who has intractable diarrhea b. A patient with celiac disease not absorbing nutrients from the GI tract e. A patient with burns who has not been able to eat adequately for 5 days

A nurse is evaluating a patient following the administration of an enteral feeding. Which findings are normal and indicated patient tolerance to the feeding? Select all that apply. a. Absence of nausea, vomiting b. Bowel sounds within normal range c. Large amount of gastric residual d. Absence of diarrhea and constipation e. Slight abdominal pain and distention

a. Absence of nausea, vomiting b. Bowel sounds within normal range d. Absence of diarrhea and constipation

The nurse is caring for a client who has a chest tube in place that is draining blood from a hemothorax. Which item will the nurse obtain to respond appropriately to accidental disconnection of the chest tube from the drainage device? a. An unopened bottle of sterile water b. A Heimlich valve c. Two rubber-tipped clamps d. A spare chest tube insertion kit

a. An unopened bottle of sterile water

The nurse is preparing to instill medications into a client's nasogastric tube. Which actions should the nurse take before instilling the medications? Select all that apply. a. Check the residual volume b. Discard the residual so that the medications can be absorbed better c. Turn off the suction to the nasogastric tube d. Remove the tube and place it in the other nostril

a. Check the residual volume c. Turn off the suction to the nasogastric tube

Name the condition associated with the abnormal spasm of facial muscles induced by tapping on the facial nerve. a. Chvostek b. Trousseau c. Convulsion d. tetany

a. Chvostek

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. a. Closely assess the patient before, during, and after the procedure b. Hyperoxygenate the patient before and after suctioning c. Limit the application of suction to 20 to 30 seconds per pass d. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve e. Use appropriate suction pressure (80-150mmHg)

a. Closely assess the patient before, during, and after the procedure b. Hyperoxygenate the patient before and after suctioning d. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve e. Use appropriate suction pressure (80-150mmHg)

The nurse is informed while receiving shift report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia? a. Confusion b. Decreased blood pressure c. Decreased respiratory rate d. Hyperactivity

a. Confusion

The home care nurse visits a client who has dyspnea. The nurse notes that client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe? a. Crackles in the lower lobes b. Inspiratory stridor c. Expiratory stridor d. Wheezing in the upper lobes

a. Crackles in the lower lobes

According to Ericksons stages of development, which stage is the middle-aged adult in? a. Generativity vs. Stagnation b. Trust vs Mistrust c. Intimacy vs. Isolation d. Ego Identity vs. Despair

a. Generativity vs. Stagnation

A nurse aspirates fluid through a nasogastric tube and checks the fluid for color and consistency. Which of the following would the nurse identify as a normal finding suggesting gastric placement of the tube? a. Grassy green with particles b. Deep golden yellow fluid c. Off-white, mucus-tinged fluid d. Serosanguineous fluid

a. Grassy green with particles

A client with a diagnosis of advanced Alzheimer's disease is unable to follow directions required to use an inhaled bronchodilator. Which medication delivery system is most appropriate for this client? a. Nebulizer b. Dry powder inhaler c. Metered-dose inhaler with spacer d. Metered-dose inhaler without spacer

a. Nebulizer

A nurse is receiving a provider's prescription by telephone for morphine for a patient who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.) a. Obtain the provider's signature on the prescription within 24 hr b. Have another nurse listen to the telephone prescription c. Decline the verbal prescription because it is not an emergency situation d. Repeat the details of the prescription back to the provider e. Tell the charge nurse that the provider has prescribed morphine by telephone

a. Obtain the provider's signature on the prescription within 24 hr b. Have another nurse listen to the telephone prescription d. Repeat the details of the prescription back to the provider

What structural changes to the respiratory system should a nurse observe when caring for older adults? a. Respiratory muscles become weaker b. Diminished coughing and gag reflexes c. Increased use of accessory muscles for breathing d. Increased mouth breathing and snoring

a. Respiratory muscles become weaker

The nurse is inserting an NG tube in a patient with a bowel obstruction. In what position would the nurse place the patient for the procedure? a. Semi-Fowlers or High Fowlers b. Supine c. Reverse trendenlenberg d. The nurse should NOT place an NG tube in a patient with a bowel obstruction

a. Semi-Fowlers or High Fowlers

A nurse is teaching a patient how to use a meter-dosed inhaler to control asthma. What are appropriate guidelines for this procedure? (Select all that apply) a. Shake the inhaler well and remove the mouthpiece covers from the MDI and spacer b. Take shallow breaths when breathing through the spacer c. Depress the canister releasing one puff into the spacer and inhale slowly and deeply d. After inhaling, exhale quickly through pursued lips e. Wait 1 to 5 minutes as prescribed before administering the next puff f. Gargle and rinse with salt water after using the MDI

a. Shake the inhaler well and remove the mouthpiece covers from the MDI and spacer c. Depress the canister releasing one puff into the spacer and inhale slowly and deeply e. Wait 1 to 5 minutes as prescribed before administering the next puff

Which one of the following vitamins affects visual acuity in dim light, formation and maintenance of skin and mucous membranes, and the immune function? a. Vitamin A b. Vitamin D c. Vitamin E d. Vitamin K

a. Vitamin A

What therapeutic interventions may be used to treat hyperkalemia? (Select all that apply) a. administration of furosemide/lasix b. dialysis c. administration of spironolactone d. administration of kayexalate

a. administration of furosemide/lasix b. dialysis d. administration of kayexalate

What type of pressure acts as an agent that pulls water with the utilization of albumin? (select all that apply) a. filtration b. oncotic pressure c. hydrostatic pressure d. colloid osmotic pressure

a. filtration b. oncotic pressure d. colloid osmotic pressure

What are normal Physiological changes that may occur in middle adulthood? Select all that apply. a. hormonal Imbalances b. fine lines and wrinkles begin c. trouble performing ADL's d. presbyopia e. presbycusis f. nails thicken and yellow g. muscle Mass, strength, and agility increases

a. hormonal imbalances b. fine lines and wrinkles begin d. presbyopia e. presbycusis

Jenny, a 25 year old client who has chronic abdominal pain has learned to control the pain with the use of imagery and hypnosis. A family member asks the nurse how these techniques work. The nurse's reply is based on the information that these strategies: a. impact the cognitive and affective components of pain b. increase the modulating effect of the efferent pathways c. prevents transmission of nociceptive stimuli to the cortex d. slows the release of transmitter chemicals in the dorsal horn

a. impact the cognitive and affective components of pain

Massive cell damage such as burns or crushing injuries can lead to what complications? (select all that apply) a. metabolic acidosis b. hyperkalemia c. hypokalemia d. metabolic alkalosis

a. metabolic acidosis b. hyperkalemia

What special populations are most at risk for swift fluid variations? (Select all that apply) a. obese patients b. patients with lean muscle mass c. end-stage renal disease patients d. fetus e. congestive heart failure patients f. elderly patients

a. obese patients c. end-stage renal disease patients d. fetus e. congestive heart failure patients f. elderly patients

What are the 3-T's associated with Hypomagnesemia? (select all that apply) a. tetany b. tremors c. twitching d. trousseau

a. tetany b. tremors c. twitching

A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manger include? (Select all that apply.) a. Communication of client information can occur at the nurse's station b. A client can request a copy of their medical record c. Family members should provide a code prior to receiving client health information d. A nurse can photocopy a client's medical record for transfer to another facility

all are correct

Which term describes a condition in which 24-hour urine output is less than 50 mL?

anuria

The nurse caring for a patient with an NG tube understands that the most serious potential complication of NG tube feedings is:

aspiration

Based on Erickson's stages of development, the middle-aged adult who does not achieve their developmental tasks may be considered to be in stagnation. Which statement is an example of this finding? a. "I am helping my parents move to an assisted living" b. "I spend all of my time going to the doctor to make sure I am not sick" c. "I Have enough money to help my son and his wife when they may need it." d. "I earned this grey hair and I like it"

b. "I spend all of my time going to the doctor to make sure I am not sick"

This is known as an acute, temporary state of confusion that can resolve in hours, days, or weeks a. Dementia b. Delirium c. Sundowning d. Alzheimer's

b. Delirium

Which of the following is true about the helping relationship? (Select all that apply.) a. It occurs spontaneously b. It occurs for a specific purpose c. Participants move towards their own individual goals d. Characterized by an unequal sharing of information

b. It occurs for a specific purpose d. Characterized by an unequal sharing of information

Following a fall that left and elderly male patient temporarily bedridden, the nurse is using the spices tool to evaluate him for cascade iatrogenesis. Which are the correct aspects of this tool? Select all that apply a. S-Senility b. P-problems with feeding c. I-irritableness d. C-Confusion e. Edema of the legs f. Skin Breakdown

b. P-problems with feeding d. C-Confusion f. Skin Breakdown

A nurse is preparing information for a change-of-shift report. Which of the following information should the nurse include in the report? (Select all that apply.) a. BP from previous day b. bone scan scheduled for today c. I/O for the shift d. medication routine from the MAR

b. bone scan scheduled for today c. I/O for the shift

Maria's 15 year old son, Julian, was admitted to the hospital with 2nd degree burns. Julian has been receiving morphine through patient controlled analgesia (PCA) for one week. Julian wakes up frequently during the night complaining of pain. The most appropriate action by the nurse is to: a. tell pt mother to administer a dose of morphine every 1-2 hours from PCA while pt is sleeping b. consult with the HCP about using a different treatment protocol to control the pts pain c. request that the HCP order a bolus dose of morphine to be given when the pt awakens with pain d. teach the pt to push the button every 10 minutes for an hour before going to sleep even if the pain is minimal

b. consult with the HCP about using a different treatment protocol to control the pts pain

The nurse working with aging individuals knows the use of antioxidants to slow the aging process corresponds to which theory? a. crosslink theory b. free radical theory c. wear and tear theory d. immunity theory

b. free radical theory

Mr. Jones is a 72 year old male who has been admitted with metastatic bone cancer. When doing a pain assessment for Mr. Jones, which question asked by the nurse will give the most information about Mr. Jones pain? a. how long have you had this pain? b. how would you describe your pain? c. how much medication do you take for the pain? d. how many times per day to you take medication for pain?

b. how would you describe your pain?

Excessive amounts of ________ can lead to diarrhea a. sodium b. magnesium c. potassium d. calcium

b. magnesium

A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply.) a. conflict with provider and nursing staff b. medication error c. patient fall d. accidental needle sticks

b. medication error c. patient fall d. accidental needle sticks

Theo is a cognitively impaired client who has a history of diabetes, COPD, and Alzheimer's disease. For a cognitively impaired client who cannot accurately report pain, what is the first action the nurse should take? a. closely assess for nonverbal signs such as grimacing or rocking b. obtain baseline behavioral indicators from family members c. look at the MAR and chart, to note the time of the last dose and response d. give the maximum PRN dose within the minimum time frame for relief

b. obtain baseline behavioral indicators from family members

Which is the most therapeutic response by the nurse to a client who expresses fears and concerns about death and dying? a. "Is there family or clergy member I can call to visit you?" b. "Let's talk about the good times you have with family and friends." c. "People are often fearful of the unknown. Tell me more about your concerns." d. "Has someone on the healthcare team told you you are dying?"

c. "People are often fearful of the unknown. Tell me more about your concerns."

The nurse is caring for a client with emphysema. A review of the client's chart reveals pH 7.36, PaO2 73mmHg,PaCO2 64 mm Hg, and HCO3 35mEq/L. The nurse would question which of the following orders? a. Pulse oximetry b. High-Fowler's position c. 4 L / minute O2 (66ml/second) per nasal cannula d. Increase fluid intake to 3L/da

c. 4 L / minute O2 (66ml/second) per nasal cannula

The nurse is performing an assessment of an older adult, which report would prompt the nurse to consider a pathologic process may be occurring? Select all that Apply a. Patient's report of decreased height b. Patients report of needing to go to the bathroom frequently c. Patient's report of frequent episodes of incontinence. d. Patient report of losing 10lbs in the past month

c. Patient's report of frequent episodes of incontinence. d. Patient report of losing 10lbs in the past month

The nurse is preparing to insert an NG tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action? a. Mark the tube at 10 inches b. Mark the tube at 32 inches c. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process d. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum

c. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process

The nurse is administering medication to a patient via an enteral feeding tube. Which are accurate guidelines related to this procedure. Select all that apply a. Crush the enteric-coated pill for mixing in water b. Flush open the tube with 60ml of very warm water c. Use the recommended procedure for checking tube placement in the stomach or intestine d. Give each medication separately and flush with water between each drug e. Lower the head of the bed to prevent reflux f. Adjust the amount of water used if the patient's fluid intake is restricted

c. Use the recommended procedure for checking tube placement in the stomach or intestine d. Give each medication separately and flush with water between each drug f. Adjust the amount of water used if the patient's fluid intake is restricted

Severe vomiting may cause what electrolyte imbalance? (Select all that apply) a. respiratory alkalosis b. increase PaCO2 c. hypochloremia d. metabolic alkalosis

c. hypochloremia d. metabolic alkalosis

A nurse is caring for a pt in the alarm phase of GAS. Which response by the patient would be expected? a. decreased HR b increased digestion c. increased HR d. increased fatigue

c. increased HR

A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which problem verbalized by the patient should the nurse identify as the priority? ​ a. "I spent my whole life dreaming about retirement, and now I wish I had my job back"​ b. "It's been so stressful for me to have to depend on my child to help around the house" c. "I just heard my friend Al died. That's the third one in three months" d. "I keep forgetting which medications I have taken during the day"

d. "I keep forgetting which medications I have taken during the day"

What is the leading cause of cognitive impairment in old age? a. Stroke b. Malnutrition c. Loss of cardiac reserve d. Alzheimer's disease

d. Alzheimer's disease

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation? a. Hematocrit values b. Hemoglobin levels c. Pulmonary function d. Arterial blood gas

d. Arterial blood gas

The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes pale with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take? a. Assess lung sounds b. Reposition the client c. Elevate the head of the bed d. Assess oxygen tubing connection

d. Assess oxygen tubing connection

The nurse is assessing a client with lung cancer. What manifestations may suggest the client has chronic hypoxia? a. Edema b. Hemoptysis c. Constipation d. Clubbing

d. Clubbing

Which class of medications is administered in the home or the hospital to relieve inflammation in the lung tissue? a. Antibiotics b. Antihistamines c. Expectorants d. Corticosteroids

d. Corticosteroids

A patient with COPD is unable to perform personal hygiene without becoming exhausted. Which nursing intervention would be appropriate for this patient? a. Assist with bathing and hygiene tasks even if the patient feels capable of performing them alone b. Teach the patient not to talk about the procedure, just to perform it at the best of his or her ability c. Teach the patient to take short shallow breaths when performing hygiene measures d. Group personal care activities into smaller steps, allowing rest periods between activities

d. Group personal care activities into smaller steps, allowing rest periods between activities

A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a nasogastric tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placement of the tube? a. Auscultate the bowel sounds b. Measure the gastric aspirate pH c. Measure the amount of residual in the tube d. Obtain an order for an xray of the tube

d. Obtain an order for an xray of the tube

A nurse is assigned to care for a client admitted to the health care facility with a diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of: a. Croup b. Asthma c. Alcohol use d. Pneumonia

d. Pneumonia

When caring for a client with a tracheostomy, the nurse would perform which recommended action? a. Clean the wound around the tube and inner cannula at least every 24 hours b. Assess a newly inserted tracheostomy every 3-4 hours c. Use gauze dressings over the tracheostomy that are filled with cotton d. Suction the tracheostomy tube using sterile technique

d. Suction the tracheostomy tube using sterile technique

What is the name for the product that occurs when manufacturers partially hydrogenate liquid oils? a. Lipids b. Triglycerides c. Cholesterol d. Trans fat

d. Trans fat Cholesterol is a fat-like substance only found in animal products

Linh is a 40 year old client who is admitted to the acute med-surg unit with a diagnosis of appendicitis. He complains of constant pain rated at a 6 out of 10. What is the best way to schedule medication for a client with constant pain? a. after each meal b. only prior to painful procedures c. by IV bolus after the pain assessment is completed d. around the clock

d. around the clock

Which of the following anxiety symptoms indicate the patient is having a panic attack? a. restless, increased questioning b. quivering voice, "butterflies in the stomach", increased RR, pulse c. difficulty communicating, dizziness, nausea d. loss of control, terror, dyspnea, palpitations, loss of rational thought

d. loss of control, terror, dyspnea, palpitations, loss of rational thought

A pt diagnosed with cancer says, "This is a mistake. I exercise daily, and feel fine." What coping mechanism is this?

denial

Which diagnosis is most appropriate for a patient with a new ileostomy?

disturbed body image

Which food is a recommended for an older adult who is constipated?

fruit Constipating foods: cheese, lean meat, eggs, pasta Foods with laxative effect: fruits and vegetables, bran, chocolate, alcohol, coffee Gas-producing foods: onions, cabbage, beans, cauliflower

When doffing PPE, the clinician should remove what item first?

gloves

What deficiency causes Trousseau's sign?

hypocalcemia

____________________ communication, or self-talk, is the communication that happens within the individual

intrapersonal

A nurse is administering a large-volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient complains of severe cramping. What would be the appropriate nursing intervention in this situation?

lower the solution container and check the temperature and flow rate

What interventions can the nurse implement for a patient with a decrease in vision?

provide adequate lighting and clear pathways of clutter to prevent injury

When approaching hospitalized patients, clinicians should follow _____ precautions.

standard; universal

A nurse is changing the stoma appliance on a patient' ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia?

stoma is a purple-blue color

What intervention would the nurse implement for a patient with a decrease in hearing?

use a lower tone of voice near the patient's ear

The best way to communicate with a confused patient is to:

use frequent eye contact with the pt

During the _____________ phase, the nurse works together with the patient to meet the patient's physical and psychosocial needs.

working