Exam 1 Review Questions
For clients to participate in goal setting, they should be: A. Alert and have some degree of independence. B. Ambulatory and mobile. C. Able to speak and write. D. Able to read and write.
A. Alert and have some degree of independence.
An elderly client with pneumonia may appear with which of the following symptoms first? A. Altered mental status and dehydration B. Fever and chills C. Hemoptysis and dyspnea D. Pleuritic chest pain and cough
A. Altered mental status and dehydration Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are common symptoms of pneumonia, but elderly clients may first appear with only an altered mental status and dehydration due to a blunted immune response.
A client comes to the outpatient clinic where you work complaining of abdominal pain, diarrhea, shortness of breath and epistaxis. Which of the following actions would you take first? A. Ask the client about any recent travel to Asia or the Middle East. B. Screening clients for upper respiratory tract symptoms. C. Determine whether the client has had recommended immunizations. D. Call an ambulance to take the client immediately to the hospital.
A. Ask the client about any recent travel to Asia or the Middle East. The client's clinical manifestation suggest possible avian influenza (bird flu). If the client has traveled recently in Asia or the Middle East, where outbreaks of bird flu have occurred, you will need to institute airborne and contact precautions immediately.
A 24-year-old client comes into the clinic complaining of right-sided chest pain and shortness of breath. He reports that it started suddenly. The assessment should include which of the following interventions? A. Auscultation of breath sounds B. Chest x-ray C. Echocardiogram D. Electrocardiogram (ECG)
A. Auscultation of breath sounds Because the client is short of breath, listening to breath sounds is a good idea. He may need a chest x-ray and an ECG, but a physician must order these tests. Unless a cardiac source for the client's pain is identified, he won't need an echocardiogram.
You are preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA. Which PPE items will you plan to use. Select all that apply A. Gloves. B. N95 respirator. C. Surgical Mask. D. Googles. E. Gown.
A. Gloves, E. Gown A gown and gloves should be used when coming in contact with linens that may be decontaminated by the client's wound secretions.
Which of the following is the FIRST priority in preventing infections when providing care for a client? A. Handwashing B. Wearing gloves C. Using a barrier between client's furniture and nurse's bag D. Wearing gowns and goggles
A. Handwashing Handwashing remains the most effective way to avoid spreading infection. However, too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client and before entering the nursing bag.
A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to a nursing assistant who is assisting with the client's care? A. Implement contact precautions when handling the client. B. Educate the client and family members on ways to prevent transmission of VRE. C. Monitor the results of the laboratory culture and sensitivity test. D. Collaborate with other departments when the client is transported for ordered test.
A. Implement contact precautions when handling the client. All hospital personnel who care for the client are responsible for correct implementation of contact precautions.
Once a nurse assesses a client's condition and identifies appropriate nursing diagnoses, a: A. Plan is developed for nursing care. B. Physical assessment begins. C. List of priorities is determined. D. Review of the assessment is conducted with other team members.
A. Plan is developed for nursing care.
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? A. Stiffness of the right ankle joint B. Soreness of the gums C. Short-term memory loss. D. Decreased appetite.
A. Stiffness of the right ankle joint
Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which of the following medical conditions? A. A diagnosis of AIDS and cytomegalovirus B. A positive PPD with an abnormal chest x-ray C. A tentative diagnosis of viral pneumonia D. Advanced carcinoma of the lung
B. A positive PPD with an abnormal chest x-ray The client who must be placed in airborne precautions is the client with a positive PPD (purified protein derivative) who has a positive x-ray for a suspicious tuberculin lesion.
A patient returns from surgery with an indwelling urinary catheter in place and empty. Six hours later, the volume is 120ml. The drainage system has no obstructions. Which intervention has priority? A. Give a 500 ml bolus of isotonic saline B. Evaluate the patient's circulation and vital signs C. Flush the urinary catheter with sterile water or saline D. Place the patient in the shock position, and notify the surgeon
B. Evaluate the patient's circulation and vital signs A total UO of 120ml is too low. Assess the patient's circulation and hemodynamic stability for signs of hypovolemia. A fluid bolus may be required, but only after further nursing assessment and a doctor's order.
A client centered goal is a specific and measurable behavior or response that reflects a client's: A. Desire for specific health care interventions B. Highest possible level of wellness and independence in function. C. Physician's goal for the specific client. D. Response when compared to another client with a like problem.
B. Highest possible level of wellness and independence in function.
When establishing realistic goals, the nurse: A. Bases the goals on the nurse's personal knowledge. B. Knows the resources of the health care facility, family, and the client. C. Must have a client who is physically and emotionally stable. D. Must have the client's cooperation.
B. Knows the resources of the health care facility, family, and the client.
The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process? A. Assessment B. Nursing diagnosis C. Planning D. Evaluation
B. Nursing diagnosis The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. During the assessment step, the nurse systematically collects data about the patient or family. During the planning step, the nurse develops strategies to resolve or decrease the patient's problem. During the evaluation step, the nurse determines the effectiveness of the plan of care.
If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following? A. Fail to show changes in blood pressure B. Produce a false-high measurement C. Cause sciatic nerve damage D. Produce a false-low measurement
B. Produce a false-high measurement
A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, "How long will it take for my scars to disappear?" which statement would be the nurse's best response? A. "The contraction phase of wound healing can take 2 to 3 years." B. "Wound healing is very individual but within 4 months the scar should fade." C. "With your history and the type of location of the injury, it's hard to say." D. "If you don't develop an infection, the wound should heal any time between 1 and 3 years from now."
C. "With your history and the type of location of the injury, it's hard to say." Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information.
To balance water output, an average adult must have daily fluid intake of approximately: A. 500-900 ml. B. 1,000-2,000 ml. C. 2,000-3,000 ml. D. 4,000-6,000 ml.
C. 2,000-3,000 ml. An adult human at rest takes appropriately 2, 500 ml of fluid daily.
The nurse writes an expected outcome statement in measurable terms. An example is: A. Client will have less pain B. Client will be pain free. C. Client will report pain acuity less than 4 on a scale of 0-10 D. Client will take pain medication every 4 hours around the clock
C. Client will report pain acuity less than 4 on a scale of 0-10
Planning is a category of nursing behaviors in which: A. The nurse determines the health care needed for the client. B. The Physician determines the plan of care for the client. C. Client-centered goals and expected outcomes are established. D. The client determines the care needed.
C. Client-centered goals and expected outcomes are established.
Which of the following infection control activity should be delegated to an experienced nursing assistant? A. Asking clients about the duration of antibiotic therapy. B. Demonstrating correct handwashing techniques to client and family. C. Disinfecting blood pressure cuffs after clients are discharged. D. Screening clients for upper respiratory tract symptoms.
C. Disinfecting blood pressure cuffs after clients are discharged. Nursing assistants can follow agency protocol to disinfect items that come in contact wth intact skin by cleaning with chemicals such as alcohol.
A 29-year-old client is diagnosed with scarlet fever. Which of the following is the most appropriate type of isolation for this client? A. Airborne B. Contact C. Droplet D. Standard
C. Droplet Tonsillitis is contagious and is spread by droplet transmission.
Which of the following nursing interventions are written correctly? (Select all that apply.) A. Apply continuous passive motion machine during day B. Perform neurovascular checks C. Elevate head of bed 30 degrees before meals D. Change dressing once a shift
C. Elevate head of bed 30 degrees before meals It is specific in what to do and when.
Which of the following organisms most commonly causes community-acquired pneumonia in adults? A. Haemiphilus influenzae B. Klebsiella pneumoniae C. Streptococcus pneumoniae D. Staphylococcus aureus
C. Streptococcus pneumoniae Pneumococcal or streptococcal pneumonia, caused by streptococcus pneumoniae, is the most common cause of community-acquired pneumonia.
A patient is experiencing which type of incontinence if she experiences leaking urine when she coughs, sneezes, or lifts heavy objects? A. Overflow B. Reflex C. Stress D. Urge
C. Stress Stress incontinence is an involuntary loss of a small amount of urine due to sudden increased intra-abdominal pressure, such as with coughing or sneezing.
Well formulated, client-centered goals should: A. Meet immediate client needs. B. Include preventative health care. C. Include rehabilitation needs. D. All of the above.
D. All of the above.
Collaborative interventions are therapies that require: A. Physician and nurse interventions. B. Nurse and client interventions. C. Client and Physician intervention. D. Multiple health care professionals.
D. Multiple health care professionals.
After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal: A. Encourage client to implement guided imagery when pain begins. B. Determine effect of pain intensity on client function. C. Administer analgesic 30 minutes before physical therapy treatment. D. Pain intensity reported as a 3 or less during hospital stay.
D. Pain intensity reported as a 3 or less during hospital stay. This is measurable and objective.
A high level of oxygen exerts which of the following effects on the lung? A. Improves oxygen uptake B. Increases carbon dioxide levels C. Stabilizes carbon dioxide levels D. Reduces amount of functional alveolar surface area
D. Reduces amount of functional alveolar surface area Oxygen toxicity causes direct pulmonary trauma, reducing the amount of alveolar surface area available for gaseous exchange, which results in increased carbon dioxide levels and decreased oxygen uptake.
Which statement regarding heart sounds is correct? A. S1 and S2 sound equally loud over the entire cardiac area. B. S1 and S2 sound fainter at the apex C. S1 and S2 sound fainter at the base D. S1 is loudest at the apex, and S2 is loudest at the base
D. S1 is loudest at the apex, and S2 is loudest at the base The S1 sound—the "lub" sound—is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2—the "dub" sound—is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1.
The planning step of the nursing process includes which of the following activities? A. Assessing and diagnosing B. Evaluating goal achievement C. Performing nursing actions and documenting them D. Setting goals and selecting interventions
D. Setting goals and selecting interventions
Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client? A. Semi-Fowler's B. Supine C. High-Fowler's D. Side-lying
D. Side-lying Because of lethargy, the post tonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he awake is best. The semi-Fowler's, supine, and high-Fowler's position don't allow for adequate oral drainage in a lethargic post tonsillectomy client, and increase the risk of blood aspiration.
Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client's: A. Physician B. Non Emergent, non-life threatening needs C. Future well-being D. Urgency of problems
D. Urgency of problems
You are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will you perform the following actions? 1. Take off the gown. 2. Remove N95 respirator. 3. Perform hand hygiene. 4. Take off goggles. 5. Remove gloves. A. 5, 4, 1, 2, 3 B. 4, 5, 2, 1, 3 C. 1, 2, 4, 5, 3 D. 2, 4, 2, 1, 3
A. 5, 4, 1, 2, 3 The sequence will prevent contact of the contaminated gloves and gowns with areas (such as your hair) that cannot be easily cleaned after client contact and stop transmission of microorganisms to you and your other clients.
Mrs. Kennedy had a CVA (cerebrovascular accident) and has severe right-sided weakness. She has been taught to walk with a cane. The nurse is evaluating her use of the cane prior to discharge. Which of the following reflects correct use of the cane? A. Holding the cane in her left hand, Mrs. Kennedy moves the cane forward first, then her right leg, and finally her left leg B. Holding the cane in her right hand, Mrs. Kennedy moves the cane forward first, then her left leg, and finally her right leg C. Holding the cane in her right hand, Mrs. Kennedy moves the cane and her right leg forward, then moves her left leg forward. D. Holding the cane in her left hand, Mrs. Kennedy moves the cane and her left leg forward, then moves her right leg forward
A. Holding the cane in her left hand, Mrs. Kennedy moves the cane forward first, then her right leg, and finally her left leg
To initiate an intervention the nurse must be competent in three areas, which include: A. Knowledge, function, and specific skills B. Experience, advanced education, and skills. C. Skills, finances, and leadership. D. Leadership, autonomy, and skills.
A. Knowledge, function, and specific skills
What do you think is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding? A. measure intake and output. B. check albumin level. C. monitor glucose levels. D. increase enteral feeding
A. measure intake and output.
A pulse oximetry gives what type of information about the client? A. Amount of carbon dioxide in the blood B. Amount of oxygen in the blood C. Percentage of hemoglobin carrying oxygen D. Respiratory rate
C. Percentage of hemoglobin carrying oxygen The pulse oximeter determines the percentage of hemoglobin carrying oxygen. This doesn't ensure that the oxygen being carried through the bloodstream is actually being taken up by the tissue.
Four clients with infections arrive at the emergency department with some existing infection, however, only one private room is available. Which of the following client is the most appropriate to assign to the private room? A. A client with toxic shock syndrome and a temperature of 102.4°F (39.1°C). B. A client with diarrhea caused by C. difficile. C. A client with a wound infected with VRE. D. A client with a cough who may have Koch disease.
D. A client with a cough who may have Koch disease. Clients with infections that require airborne precautions (such as TB) need to be in private rooms.
A client with primary TB infection can expect to develop which of the following conditions? A. Active TB within 2 weeks B. Active TB within 1 month C. A fever that requires hospitalization D. A positive skin test
D. A positive skin test A primary TB infection occurs when the bacillus has successfully invaded the entire body after entering through the lungs. At this point, the bacilli are walled off and skin tests read positive. However, all but infants and immunosuppressed people will remain asymptomatic. The general population has a 10% risk of developing active TB over their lifetime, in many cases because of a break in the body's immune defenses. The active stage shows the classic symptoms of TB: fever, hemoptysis, and night sweats.
You're preparing for urinary catheterization of a trauma patient and you observe bleeding at the urethral meatus. Which action has priority? A. Irrigate and clean the meatus before catheterization B. Check the discharge for occult blood before catheterization C. Heavily lubricate the catheter before insertion D. Delay catheterization and notify the doctor
D. Delay catheterization and notify the doctor Bleeding at the urethral meatus is evidence that the urethra is injured. Because catheterization can cause further harm, consult with the doctor.
An eighty five year old man was admitted for surgery for benign prostatic hypertrophy. Preoperatively he was alert, oriented, cooperative, and knowledgeable about his surgery. Several hours after surgery, the evening nurse found him acutely confused, agitated, and trying to climb over the protective side rails on his bed. The most appropriate nursing intervention that will calm an agitated client is A. limit visits by staff. B. encourage family phone calls. C. position in a bright, busy area. D. speak soothingly and provide quiet music.
D. speak soothingly and provide quiet music.
You're planning your medication teaching for your patient with a UTI prescribed phenazopyridine (Pyridium). What do you include? A. "Your urine might turn bright orange." B. "You need to take this antibiotic for 7 days." C. "Take this drug between meals and at bedtime." D. "Don't take this drug if you're allergic to penicillin."
A. "Your urine might turn bright orange." The drug turns the urine orange. It may be prescribed for longer than 7 days and is usually ordered three times a day after meals. Phenazopyridine is an azo (nitrogenous) analgesic; not an antibiotic.
A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? A. A 79 year-old malnourished client on bed rest B. An obese client who uses a wheelchair C. An incontinent client who has had 3 diarrhea stools D. An 80 year-old ambulatory diabetic client
A. A 79 year-old malnourished client on bed rest Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubitus, due in part to poor hydration and inadequate protein intake.
The nursing care plan is: A. A written guideline for implementation and evaluation. B. A documentation of client care. C. A projection of potential alterations in client behaviors D. A tool to set goals and project outcomes.
A. A written guideline for implementation and evaluation.
A client was infected with TB 10 years ago but never developed the disease. He's now being treated for cancer. The client begins to develop signs of TB. This is known as which of the following types of infection? A. Active infection B. Primary infection C. Superinfection D. Tertiary infection
A. Active infection Some people carry dormant TB infections that may develop into active disease. In addition, primary sites of infection containing TB bacilli may remain inactive for years and then activate when the client's resistance is lowered, as when a client is being treated for cancer. There's no such thing as tertiary infection, and superinfection doesn't apply in this case.
When auscultating the chest of a client with pneumonia, the nurse would expect to hear which of the following sounds over areas of consolidation? A. Bronchial B. Bronchovesicular C. Tubular D. Vesicular
A. Bronchial Chest auscultation reveals bronchial breath sounds over areas of consolidation.
When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: A. Length of time the current treatment has been in place B. The spouse's reaction to the client's dressing change C. Client's concern about the current treatment D. Physician's reluctance to change the current treatment plan
A. Length of time the current treatment has been in place This gives the consulting nurse facts that will influence a new plan. Other choices are all subjective and emotional issues about the current treatment plant and may cause bias in the decision of a new treatment plan by the nurse consultant.
You are caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant S. aureus (VRSA). Which of these nursing actions can you delegate to an LPN/LVN? A. Obtain wound cultures during dressing changes. B. Plan ways to improve the client's oral protein intake. C. Assess risk for further skin breakdown. D. Educate the client about home care of the leg ulcer.
A. Obtain wound cultures during dressing changes. LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound culture. Options B, C, and D: Teaching, assessment, and planning of care are complex actions that should be carried out by a licensed nurse.
A client who has recently traveled to China comes to the emergency department (ED) with increasing shortness of breath and is strongly suspected of having a severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first? A. Place the client on contact and airborne precautions. B. Obtain blood, urine, and sputum for cultures. C. Administer methylprednisolone (Solu-Medrol) 1 gram/IV. D. Infuse normal saline at 100ml/hr.
A. Place the client on contact and airborne precautions.
A hospitalized 88-year-old client who has been receiving antibiotics for 10 days tells you that he is having frequent watery stools. Which action will you take first? A. Place the client on contact precaution. B. Instruct the client about correct handwashing. C. Obtain stool specimens for culture. D. Notify the physician about the loose stools.
A. Place the client on contact precaution. The client's age, history of antibiotic therapy, and watery stools suggest that he may have Clostridium difficile infection. The initial action should be able to place him on contact precautions to prevent the spread of C. difficile to other clients.
When positioned properly, the tip of a central venous catheter should lie in the: A. Superior vena cava B. Basilica vein C. Jugular vein D. Subclavian vein
A. Superior vena cava When the central venous catheter is positioned correctly, its tip lies in the superior vena cava, inferior vena cava, or the right atrium—that is, in central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica, jugular, and subclavian veins are common insertion sites for central venous catheters.
Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The most important factor to consider in this assessment is: A. correct illumination of the environment. B. amount of regular exercise. C. the resting pulse rate. D. status of salt intake.
A. correct illumination of the environment. To prevent falls, the environment should be well lighted. Night lights should be used if necessary. Other factors to assess include removing loose scatter rugs, removing spills, and installing handrails and grab bars as appropriate.
A young adult is being treated for second and third degree burns over 25% of his body and is now ready for discharge. The nurse evaluates his understanding of discharge instructions relating to wound care and is satisfied that he is prepared for home care when he makes which statement? A. "I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath water." B. "If any healed areas break open I should first cover them with a sterile dressing and then report it." C. "I must wear my Jobst elastic garment all day and can only remove it when I'm going to bed." D. "I can expect occasional periods of low-grade fever and can take Tylenol every 4 hours."
B. "If any healed areas break open I should first cover them with a sterile dressing and then report it."
You have a patient that might have a urinary tract infection (UTI). Which statement by the patient suggests that a UTI is likely? A. "I pee a lot." B. "It burns when I pee." C. "I go hours without the urge to pee." D. "My pee smells sweet."
B. "It burns when I pee." A common symptom of a UTI is dysuria. A patient with a UTI often reports frequent voiding of small amounts and the urgency to void. Urine that smells sweet is often associated with diabetic ketoacidosis.
The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first? A. A client who is ambulatory. B. A client, who has a fever, is diaphoretic and restless. C. A client scheduled for OT at 1300. D. A client who just had an appendectomy and has just received pain medication.
B. A client, who has a fever, is diaphoretic and restless.
A community health nurse is conducting an educational session with community members regarding TB. The nurse tells the group that one of the first symptoms associated with TB is: A. A bloody, productive coug B. A cough with the expectoration of mucoid sputum C. Chest pain D. Dyspnea
B. A cough with the expectoration of mucoid sputum
As goals, outcomes, and interventions are developed, the nurse must: A. Be in charge of all care and planning for the client. B. Be aware of and committed to accepted standards of practice from nursing and other disciples. C. Not change the plan of care for the client. D. Be in control of all interventions for the client.
B. Be aware of and committed to accepted standards of practice from nursing and other disciples. (Involving PT, etc.)
A client's wound is not healing and appears to be worsening with the current treatment. The nurse first considers: A. Notifying the physician B. Calling the wound care nurse C. Changing the wound care treatment D. Consulting with another nurse
B. Calling the wound care nurse
A client has active TB. Which of the following symptoms will he exhibit? A. Chest and lower back pain B. Chills, fever, night sweats, and hemoptysis C. Fever of more than 104*F and nausea D. Headache and photophobia
B. Chills, fever, night sweats, and hemoptysis Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Chest pain may be present from coughing, but isn't usual. Clients with TB typically have low-grade fevers, not higher than 102*F. Nausea, headache, and photophobia aren't usual TB symptoms.
An adult woman is admitted to an isolation unit in the hospital after tuberculosis was detected during a pre-employment physical. Although frightened about her diagnosis, she is anxious to cooperate with the therapeutic regimen. The teaching plan includes information regarding the most common means of transmitting the tubercle bacillus from one individual to another. Which contamination is usually responsible? A. Hands B. Droplet nuclei C. Milk Products D. Eating Utensils
B. Droplet nuclei The most frequent means of transmission of the tubercle bacillus is by droplet nuclei. The bacillus is present in the air as a result of coughing, sneezing, and expectoration of sputum by an infected person.
When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including: A. Apply a cold pack to the tibia. B. Elevate the leg 5 inches above the heart. C. Perform range of motion to right leg every 4 hours. D. Administer aspirin 325 mg every 4 hours as needed
B. Elevate the leg 5 inches above the heart. This does not require a physician's order. (A & D require an order; C is not appropriate for a fractured tibia)
Your 60 y.o. patient with pyelonephritis and possible septicemia has had five UTIs over the past two years. She is fatigued from lack of sleep, has lost weight, and urinates frequently even in the night. Her labs show: sodium, 154 mEq/L; osmolarity 340 mOsm/L; glucose, 127 mg/dl; and potassium, 3.9 mEq/L. Which nursing diagnosis is priority? A. Fluid volume deficit related to osmotic diuresis induced by hyponatremia B. Fluid volume deficit related to inability to conserve water C. Altered nutrition: Less than body requirements related to hypermetabolic state D. Altered nutrition: Less than body requirements related to catabolic effects of insulin deficiency
B. Fluid volume deficit related to inability to conserve water
A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nursing assistant indicates the best understanding of the correct protocol for blood and body fluid isolation? A. Masks should be worn with all client contact. B. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items. C. Isolation gowns are not needed. D. A private room is always indicated.
B. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items. Masks should only be worn during procedures that are likely to cause splashes of blood or body fluid. Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous membranes; for handling soiled items; and for performing venipuncture. Gowns should be worn during procedures that are likely to cause splashes of blood or body fluids. A private room is only indicated if the client's hygiene is poor.
A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will you need to put on when preparing to assess the client? Select all that apply A. Goggles. B. Gown. C. Gloves. D. Shoe covers. E. N95 respirator. F. Surgical face mask.
B. Gown, C. Gloves, E. N95 Respirator Because herpes zoster is spread through airborne means and by direct contact with the lesions, you should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves. Options A and D: Goggles and shoe covers are not needed for airborne or contact precautions. Option F: Surgical face mask filters only large particles and will not provide protection from herpes zoster.
A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client? A. Promote fluid balance B. Prevent infection C. Promote rest D. Prevent injury
B. Prevent infection The client is at risk for infection because WBC count is dangerously low. Hb level and HCT are within normal limits
A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important? A. A history of increased aspirin use B. Recent pelvic surgery C. An active daily walking program D. A history of diabetes
B. Recent pelvic surgery The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep vein is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease.
The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free from infection throughout hospitalization. This statement is an example of a (an): A. Nursing diagnosis B. Short-term goal C. Long-term goal D. Expected outcome
B. Short-term goal
Mrs. Jones will have to change the dressing on her injured right leg twice a day. The dressing will be a sterile dressing, using 4 X 4s, normal saline irrigant, and abdominal pads. Which statement best indicates that Mrs. Jones understands the importance of maintaining asepsis? A. "If I drop the 4 X 4s on the floor, I can use them as long as they are not soiled." B "If I drop the 4 X 4s on the floor, I can use them if I rinse them with sterile normal saline." C. "If I question the sterility of any dressing material, I should not use it." D. "I should put on my sterile gloves, then open the bottle of saline to soak the 4 X 4s."
C. "If I question the sterility of any dressing material, I should not use it." If there is ever any doubt about the sterility of an instrument or dressing, it should not be used.
Which patient is at greatest risk for developing a urinary tract infection (UTI)? A. 35 y.o. woman with a fractured wrist B. A 20 y.o. woman with asthma C. A 50 y.o. postmenopausal woman D. A 28 y.o. with angina
C. A 50 y.o. postmenopausal woman Women are more prone to UTI's after menopause due to reduced estrogen levels. Reduced estrogen levels lead to reduced levels of vaginal Lactobacilli bacteria, which protect against infection. Angina, asthma and fractures don't increase the risk of UTI.
The nurse in charge is evaluating the infection control procedures on the unit. Which finding indicates a break in technique and the need for education of staff? A. The nurse aide is not wearing gloves when feeding an elderly client. B. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing. C. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care. D. The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict isolation.
C. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care. Persons with exudative lesions or weeping dermatitis should not give direct client care or handle client-care equipment until the condition resolves.
Malcolm is a newly assigned as a triage nurse, on his first day of work, the following clients arrive at the ED. Which among the client require the most rapid action to protect other clients in the ED from infection? A. A travel blogger who needs tuberculosis testing after an exposure to a person with TB during his trip. B. An elderly woman who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) leg wound infection. C. A pregnant woman with a blister-like rash on the face and is possibly having varicella. D. An infant with a runny nose and whose older brother has pertussis.
C. A pregnant woman with a blister-like rash on the face and is possibly having varicella. Chickenpox (Varicella) is transmitted by airborne and that can be easily transferred to the other clients in the emergency unit. The pregnant woman with the rash should be isolated right away from other clients through placement in a negative-pressure room.
After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first. 1. Constipation 2. Anticipated grieving 3. Ineffective airway clearance 4. Ineffective tissue perfusion. A. 3, 4, 2, 1 B. 4, 3, 2, 1 C. 1, 3, 2, 4 D. 3, 4, 1, 2
D. 3, 4, 1, 2
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time? A. Impaired gas exchanges related to increased blood flow B. Fluid volume excess related to peripheral vascular disease C. Risk for injury related to edema D. Altered peripheral tissue perfusion related to venous congestion
D. Altered peripheral tissue perfusion related to venous congestion Altered peripheral tissue perfusion related to venous congestion" takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis.
Which of the following information about a client who has meningococcal meningitis has the best indicator that you can discontinue droplet precautions? A. Cough is productive of clear, nonpurulent mucus. B. Pupils are equal and reactive to light. C. Temperature is lower than 100°F (37.8°C). D. Appropriate antibiotics have been given for 24 hours.
D. Appropriate antibiotics have been given for 24 hours. Current CDC evidenced-based guidelines indicate that droplet precautions for clients with meningococcal meningitis can be discontinued when the client has received antibiotic therapy for 24 hours.
The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following? A. Decreased cardiac output B. Pleural effusion C. Inadequate peripheral circulation D. Decreased oxygenation of the blood
D. Decreased oxygenation of the blood A client with pneumonia has less lung surface available for the diffusion of gases because of the inflammatory pulmonary response that creates lung exudate and results in reduced oxygenation of the blood. The client becomes cyanotic because blood is not adequately oxygenated in the lungs before it enters the peripheral circulation.
A 76-year old client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no signs of respiratory distress. Which of the following is a normal physiologic change related to aging? A. Increased elastic recoil of the lungs B. Increased number of functional capillaries in the alveoli C. Decreased residual volume D. Decreased vital capacity
D. Decreased vital capacity Reduction in VC is a normal physiologic change in the older adult. Other normal physiologic changes include decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increase is residual volume.
A patient diagnosed with sepsis from a UTI is being discharged. What do you plan to include in her discharge teaching? A. Take cool baths B. Avoid tampon use C. Avoid sexual activity D. Drink 8 to 20 eight-oz glasses of water daily
D. Drink 8 to 20 eight-oz glasses of water daily Drinking 2-3L of water daily inhibits bacterial growth in the bladder and helps flush the bacteria from the bladder. The patient should be instructed to void after sexual activity.
Nurse Nikki is revising a client's care plan. During which step of the nursing process does such revision take place? A. Assessment B. Planning C. Implementation D. Evaluation
D. Evaluation During the evaluation step of the nursing process the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan.
The following statements appear on a nursing care plan for a client after a mastectomy: Incision site approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile. These statements are examples of: A. Nursing interventions B. Short-term goals C. Long-term goals D. Expected outcomes
D. Expected outcomes
A female client is admitted to the emergency department with complaints of chest pain shortness of breath. The nurse's assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distension, it's typically due to: A. neck tumor B. An electrolyte imbalance C. Dehydration D. Fluid overload
D. Fluid overload Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend, which can be seen most obviously in the neck veins.
Which of the following statements best explains how opening up collapsed alveoli improves oxygenation? A. Alveoli need oxygen to live B. Alveoli have no effect on oxygenation C. Collapsed alveoli increase oxygen demand D. Gaseous exchange occurs in the alveolar membrane
D. Gaseous exchange occurs in the alveolar membrane Gaseous exchange occurs in the alveolar membrane, so if the alveoli collapse, no exchange occurs, Collapsed alveoli receive oxygen, as well as other nutrients, from the bloodstream. Collapsed alveoli have no effect on oxygen demand, though by decreasing the surface area available for gas exchange, they decrease oxygenation of the blood.
A 79-year-old client is admitted with pneumonia. Which nursing diagnosis should take priority? A. Acute pain related to lung expansion secondary to lung infection B. Risk for imbalanced fluid volume related to increased insensible fluid losses secondary to fever C. Anxiety related to dyspnea and chest pain D. Ineffective airway clearance related to retained secretions
D. Ineffective airway clearance related to retained secretions Pneumonia is an acute infection of the lung parenchyma. The inflammatory reaction may cause an outpouring of exudate into the alveolar spaces, leading to an ineffective airway clearance related to retained secretions.
A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? A. Acute pain related to surgery B. Deficient fluid volume related to blood and fluid loss from surgery C. Impaired physical mobility related to surgery D. Risk for aspiration related to anesthesia
D. Risk for aspiration related to anesthesia
A diagnosis of pneumonia is typically achieved by which of the following diagnostic tests? A. ABG analysis B. Chest x-ray C. Blood cultures D. Sputum culture and sensitivity
D. Sputum culture and sensitivity Sputum C & S is the best way to identify the organism causing the pneumonia. Chest x-ray will show the area of lung consolidation. ABG analysis will determine the extent of hypoxia present due to the pneumonia, and blood cultures will help determine if the infection is systemic.
Which of the following statements about the nursing process is most accurate? A. The nursing process is a four-step procedure for identifying and resolving patient problems. B. Beginning in Florence Nightingale's days, nursing students learned and practiced the nursing process. C. Use of the nursing process is optional for nurses, since there are many ways to accomplish the work of nursing. D. The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept.
D. The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept.
A client has been treated with antibiotic therapy for right lower-lobe pneumonia for 10 days and will be discharged today. Which of the following physical findings would lead the nurse to believe it is appropriate to discharge this client? A. Continued dyspnea B. Fever of 102 C. Respiratory rate of 32 breaths/minute D. Vesicular breath sounds in right base
D. Vesicular breath sounds in right base If the client still has pneumonia, the breath sounds in the right base will be bronchial, not the normal vesicular breath sounds. If the client still has dyspnea, fever, and increased respiratory rate, he should be examined by the physician before discharge because he may have another source of infection or still have pneumonia.
The nurse is caring for an elderly woman who has had a fractured hip repaired. In the first few days following the surgical repair, which of the following nursing measures will best facilitate the resumption of activities for this client? A. arranging for the wheelchair B. asking her family to visit C. assisting her to sit out of bed in a chair qid D. encouraging the use of an overhead trapeze
D. encouraging the use of an overhead trapeze Using the overhead trapeze prevents hazards of immobility by permitting movement in bed and strengthening of the upper extremities in preparation for ambulation.
The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound. After carefully washing her hands the nurse dons sterile gloves to remove the old dressing. After removing the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves in preparation for cleaning and redressing the wound. The most appropriate action for the charge nurse is to: A. interrupt the procedure to inform the staff nurse that sterile gloves are not needed to remove the old dressing. B. congratulate the nurse on the use of good technique. C. discuss dressing change technique with the nurse at a later date. D. interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves.
D. interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves.
The nurse is evaluating whether nonprofessional staff understand how to prevent transmission of HIV. Which of the following behaviors indicates correct application of universal precautions? A. lab technician rests his hand on the desk to steady it while recapping the needle after drawing blood. B. An aide wears gloves to feed a helpless client. C. An assistant puts on a mask and protective eye wear before assisting the nurse to suction a tracheostomy. D. A pregnant worker refuses to care for a client known to have AIDS.
C. An assistant puts on a mask and protective eye wear before assisting the nurse to suction a tracheostomy. Needles that have been used to draw blood should not be recapped. Gloves are not necessary when feeding, since there is no contact with mucus membranes. Although saliva may have small amounts of HIV in it, the virus does not invade through unbroken skin. There is no evidence in the question to indicate broken skin. Masks and protective eye wear are indicated anytime there is great potential for splashing of body fluids that may be contaminated with blood. Suctioning of a tracheostomy almost always stimulates coughing, which is likely to generate droplets that may splash the health care worker. Clients who are suctioned frequently or have had an invasive procedure like a tracheostomy are likely to have blood in the sputum. There is no reason to restrict pregnant workers from caring for persons with AIDS as long as they utilize universal precautions.
As the infection control nurse in an acute care hospital, which action will you take to most effectively reduce the incidence of health-care-associated infections? A. Screen all newly admitted clients for colonization or infection with MRSA. B. Develop policies that automatically start antibiotic therapy for clients colonized by multi-drug resistant organisms. C. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital. D. Require nursing staff to don gowns to change wound dressings for all clients.
C. Ensure that dispensers for alcohol-based hand rubs are readily available in all client care areas of the hospital. The hands of health care workers are the most common means of transmission of infection from one client to another, the most effective method of preventing spread of infection is to make supplies for hand hygiene readily available for staff to use.
Which of the following causes the majority of UTI's in hospitalized patients? A. Lack of fluid intake B. Inadequate perineal care C. Invasive procedures D. Immunosuppression
C. Invasive procedures Invasive procedures such as catheterization can introduce bacteria into the urinary tract. A lack of fluid intake could cause concentration of urine, but wouldn't necessarily cause infection.
Which of the following mental status changes may occur when a client with pneumonia is first experiencing hypoxia? A. Coma B. Apathy C. Irritability D. Depression
C. Irritability Clients who are experiencing hypoxia characteristically exhibit irritability, restlessness, or anxiety as initial mental status changes. As the hypoxia becomes more pronounced, the client may become confused and combative. Coma is a late clinical manifestation of hypoxia. Apathy and depression are not symptoms of hypoxia.
Which action will you take to most effectively reduce the incidence of hospital-associated urinary tract infections? A. Teach assistive personnel how to provide good perineal hygiene. B. Ensure that clients have enough adequate fluid intake. C. Limit the use of indwelling foley catheter (IFC). D. Perform dipstick urinalysis for clients with risk factors for UTI.
C. Limit the use of indwelling foley catheter (IFC). The most effective way to reduce the incidence of UTIs in the hospital setting is to avoid using retention catheters.
What effect does hemoglobin amount have on oxygenation status? A. No effect B. More hemoglobin reduces the client's respiratory rate C. Low hemoglobin levels cause reduces oxygen-carrying capacity D. Low hemoglobin levels cause increased oxygen-carrying capacity.
C. Low hemoglobin levels cause reduces oxygen-carrying capacity Hemoglobin carries oxygen to all tissues in the body. If the hemoglobin level is low, the amount of oxygen-carrying capacity is also low. More hemoglobin will increase oxygen-carrying capacity and thus increase the total amount of oxygen available in the blood. If the client has been tachypneic during exertion, or even at rest, because oxygen demand is higher than the available oxygen content, then an increase in hemoglobin may decrease the respiratory rate to normal levels.
*A newly admitted client with streptococcal pharyngitis (tonsillitis) has been placed on droplet precaution. Which of the following statements indicates the best understanding for this type of isolation? A. The client can be placed in a room with another client with measles (rubeola). B. A special mask (N95) should be worn when working with the client. C. Must maintain a spatial distance of 3 feet. D. Gloves should be only worn when giving direct care.
C. Must maintain a spatial distance of 3 feet. (COVID-19 6 FEET!!!) The most common forms of transmission of an organism in a client with tonsillitis are through coughing, sneezing, and talking. Droplets can travel no more than 3ft so precautions should be maintained when there is a possibility of entering this distance.
The right forearm of a client who had a purified protein derivative (PPD) test for tuberculosis is reddened and raised about 3mm where the test was given. This PPD would be read as having which of the following results? A. Indeterminate B. Needs to be redone C. Negative D. Positive
C. Negative This test would be classed as negative. A 5 mm raised area would be a positive result if a client was HIV+ or had recent close contact with someone diagnosed with TB. Indeterminate isn't a term used to describe results of a PPD test. If the PPD is reddened and raised 10mm or more, it's considered positive according to the CDC.
A client with pneumonia develops dyspnea with a respiratory rate of 32 breaths/minute and difficulty expelling his secretions. The nurse auscultates his lung fields and hears bronchial sounds in the left lower lobe. The nurse determines that the client requires which of the following treatments first? A. Antibiotics B. Bed rest C. Oxygen D. Nutritional intake
C. Oxygen The client is having difficulty breathing and is probably becoming hypoxic. As an emergency measure, the nurse can provide oxygen without waiting for a physicians order. Antibiotics may be warranted, but this isn't a nursing decision. The client should be maintained on bedrest if he is dyspneic to minimize his oxygen demands, but providing additional will deal more immediately with his problem. The client will need nutritional support, but while dyspneic, he may be unable to spare the energy needed to eat and at the same time maintain adequate oxygenation.
You are caring for a newly admitted client with increasing dyspnea and dehydration who has possible avian influenza (bird flu). Which of these prescribed actions will you implement first? A. dminister the first dose of oseltamivir (Tamiflu). B. Obtain blood and sputum specimens for testing. C. Provide oxygen using a non-rebreather mask. D. Infuse 5% dextrose in water at 75ml/hr.
C. Provide oxygen using a non-rebreather mask. Because the respiratory manifestations associated with avian influenza are potentially life-threatening, the nurse's initial action should be to start oxygen therapy.
Which of the following diagnostic tests is definitive for TB? A. Chest x-ray B. Mantoux test C. Sputum culture D. Tuberculin test
C. Sputum culture The sputum culture for Mycobacterium tuberculosis is the only method of confirming the diagnosis. Lesions in the lung may not be big enough to be seen on x-ray. Skin tests may be falsely positive or falsely negative.
Mrs. Parker, a 70-year-old woman with severe macular degeneration, is admitted to the hospital the day before scheduled surgery. The nurse's preoperative goals for Mrs. M. would include: A. independently ambulating around the unit. B. reading the routine preoperative education materials. C. maneuvering safely after orientation to the room. D. using a bedpan for elimination needs
C. maneuvering safely after orientation to the room.
