Exam 1
The nurse is assessing the pain of an 86-year-old man who is recovering from a right hip open reduction procedure. What element would the nurse know it is important to review to best understand the patient's pain? A. Sleep patterns B. Family history C. Genetic history D. Elimination patterns
A Older adults have special circumstances. Questions about the effects of pain on diet, sleep, and mood should be reviewed with the patient as unlrelieved pain may lead to insomnia or depression.
What are the types of nursing assessments? (select all that apply) A. Physical B. Focused C. Mental D. Emergency E. Comprehensive
B, D, E Three types of nursing assessments include emergency, focused, and comprehensive
The nurse is caring for four patients on the short-stay unit. Which patient would cause the nurse greatest concern? A. A 10-year-old patient with a BP of 103/62 B. A 7-year-old patient with a heart rate of 95 beats/minute C. A 77-year-old patient with a resting heart rate of 69 beats/min D. An 82-year-old patient with a temperature of 37.2°C
D Temperatures considered normal for younger adults may constitute fever in older adults. Options A, B, and C represent normal findings for the patients described.
When assessing respirations in a newborn, the nurse would expect the range of breaths to be: A. 20 - 60 breaths per minute B. 16-24 breaths per minute C. 110 - 180 beats per minute D. 30 - 80 breaths per minute
D. (Believe she accepted A as well) 30 - 80 breaths per minute is correct. Note 110-180 beats per minute is the expected heart rate in a newborn, not respirations.
A nursing instructor is discussing techniques used in the inspection of a patient. What would the instructor list as necessary or important when inspecting a patient? A. Adequate exposure B. Dim lighting C. Therapeutic touch D. Therapeutic communication
A During inspection, adequate exposure of each body part is necessary. Concurrently, nurses take measures to maintain the privacy of patients through appropriate draping, especially over the breasts in women and genitalia in both men and women. Adequate lighting is essential to observe color, texture, and mobility, so option B is incorrect. Options C and D are incorrect, because therapeutic touch and therapeutic communication are not important or necessary when inspecting a patient.
When is SBAR used? A. When communicating patient information between members of the health care team B. Only in the operating room C. Delegating care to nursing assistants D. Expressing concern about a patient's condition to the charge nurse
A Nurses most commonly use SBAR when contacting a provider regarding a patient issue. SBAR also can serve as a method for structuring communication during handoffs, when delegating care to nursing assistants, or when expressing concern regarding a patient's condition to the charge nurse or manager; however, none of these is the most common use.
Student nurses are doing clinical hours on the medical-surgical unit. What additional assessment should the student nurses make when they take patient vital signs? A. Oxygen saturations B. Blood pressure C. Heart Rate D. Mobility
A Oxygen saturation is an additional assessment the nurse should make when taking vital signs. Blood pressure and heart rate will already be assessed when taking vital signs and mobility is incorrect.
Which of the following components would you include in a cultural assessment? Select all that apply Answers: A. Cultural background B. Nutritional practices C. Beliefs and perceptions of health D. Age of the client E. Belief in God F. Communication patterns G. Health practices including alternative
All but D & E; The clients age and whether or not they believe in God is not a part of the cultural assessment
The nurse is caring for a newly admitted adult patient. When performing the general survey of this patient, the nurse knows that accurate measurements such as height and weight provide critical information about what? A. Safety B. State of health C. Growth patterns D. Previous surgeries
B Accurate measurements provide important data about the adult's state of health. If the question was asking about children then the answer would be growth patterns
The nurse-client relationship consists of different phases. In which phase will the nurse provide education on a new assistive device? A. Orientation phase B. Active Working phase C. Termination phase D. All of the above
B During the working phase, the nurse develops a relationship with the patient and begins to meet the patient's needs. This includes working with the client to begin resolving their problem, teaching them about new assistive devices, and implementing a plan. The other two phases do not include education on a new device.
The Joint Commission mandates that nurses assess and reassess a patient's pain level. A nurse's institution mandates pain reassessment at 30 minutes for any drug given intravenously. This mandate is based on what? A. Research that shows that it takes half as long for IV pain medication to work than oral medication B. The time it takes a pain medication to decrease pain intensity C. The time it takes a pain medication to block pain in a patient D. The median half-life of an intravenous pain medication
B Reassessment provides a reliable measure on how well the drug is working for the patient. Most hospitals have a standardized time frame for reassessment that are based on how long it takes pain medication to provide a noticeable decrease in pain intensity
The nurse is assessing a 17-year-old boy with a history of drug addiction. What will be helpful in determining interventions that will be most beneficial for providing adequate pain relief to this patient? A. Gathering information that the patient wants to share about his pain B. Using in-depth questions to collect salient data about the patient's pain C. Collecting objective data that the patient chooses to share D. Collecting subjective data that the nurse notes during assessment
B The use of in-depth questions to collect all sailent data from the pain assessments will be the biggest help in determining what types of interventions will be most beneficial for providing adequate pain relief to the patient.
What steps are involved in the patient-to-patient transmission of pathogens? (Select all that apply.) A. The nurse uses an alcohol-based hand rub for hand hygiene B. Organisms are transferred from the patient to the nurse's hands C. Organisms survive on the nurse's hands for less than 1 minute D. The nurse's contaminated hands come into direct contact with another patient E. Organisms are present in the patient's immediate environment
B, D, E Patient-to-patient transmission of pathogens requires five sequential steps: (1) Organisms are present on a patient's skin or immediate environment; (2) Organisms are transferred from the patient to the nurse's hands; (3) Organisms survive on the nurse's hands for at least several minutes; (4) The nurse omits or performs inadequate or inappropriate hand hygiene; (5) The nurse's contaminated hands come into direct contact with another patient or environment in direct contact with the patient. Therefore, options A and C are incorrect.
According to the 2009 guidelines from the Centers for Disease Control and Prevention (CDC), why are nurses supposed to wear gloves? (Select all that apply.) A. To help maintain a sterile environment B. To reduce transient contamination of the hands C. To reduce the risk of infecting personnel D. To prevent the transmission of bacteria from nurses to patients E. To reduce the number of bacteria in the health care environment
B,C,D The CDC recommends that nurses wear gloves to (1) reduce the risk of personnel acquiring infections from patients, (2) prevent the transmission of flora from health care workers to patients, and (3) reduce transient contamination of the hands of personnel by flora that can be transmitted from one patient to another. Options A and E are incorrect because gloves do not help to maintain a sterile environment, nor do they reduce the number of bacteria in the health care environment.
A nurse performs a comprehensive assessment on a patient. What is included in this assessment? A. A circulatory assessment B. Assessment of the airway C. Complete health history D. Disablity assessment
C A comprehensive assessment includes a complete health history and physical assessment.
The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the patient. The students know that this type of information is assessed in what type of assessment? A. Body systems B. Head to toe C. Functional D. Comprehensive
C A functional assessment focuses on the patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs (Gordon, 1987). Therefore, options A and B are incorrect. Option D is a distracter for this question.
A patient arrives at the emergency department by ambulance after an accident while playing softball. His left leg is swollen and deformed. He describes his pain as a 9 on a 10-point scale. When the nurse assesses the patient's blood pressure, what would he or she expect to find? A. The blood pressure is lower than normal B. There would be no need to assess the blood pressure C. The blood pressure is elevated D. The blood pressure is within normal limit
C Many variables affect vital signs, including pain, stress, anxiety, and activity. Pain and anxiety can contribute to increased blood pressure. This makes options A, B, and D incorrect.
A student nurse studying hypertension would learn that the risk factors for it include what? A. Family history, obesity, alcohol abstinence B. Cigarette smoking, heavy alcohol consumption, hepatic disease C. Prolonged stress, renal disease, heavy alcohol consumption D. High cholesterol and triglyceride levels, family history, hepatic disease
C Risk factors for hypertension include obesity, cigarette smoking, heavy alcohol consumption, prolonged stress, high cholesterol and triglyceride levels, family history, and renal disease. Hepatic disease and alcohol abstinence are not risk factors for hypertension.
The nurse is gathering a complete history of the patient's present illness. The nurse knows that the most effective communication tool to gather this information is what? A. Assessing the patient's vital signs B. Gathering a complete list of the patient's medications C. Asking open-ended questions D. Asking focused questions
C The nurse collects information about the present illness by beginning with open-ended questions and having patients explain symptoms. The most appropriate way to collect data about the present illness is not to assess the patient's vital signs, gather a complete list of the patient's medications, or ask focused questions.
When a patient has an irregular pulse the nurse should first monitor the pulse: A. With a Doppler B. At the carotid C. For a full minute D. At two different sites on the body
C There are indeed times when one wants to measure the pulse in two different pulse points but an irregular pulse is not that reason.
What is the importance of assessing vital signs? Answers:(select all that apply) A. To identify pending problems B. To plan how to improve the patient's condition C. To establish a baseline D. To monitor risks for alterations in health E. To evaluate the patient's response to treatment
C, D, and E are all correct.
The nurse is admitting a patient to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment? A. Covers the body head to toe B. Occurs only in the clinic area C. Involves all body systems D. Is more in-depth on specific issues
D A focused assessment is based on the patient's issues. This type of assessment can occur in all settings, including the clinic, hospital, and home health. It usually involves one or two body systems and is smaller in scope than the comprehensive assessment but is more in-depth on the specific issue(s).
In the absorption phase of pharmacokinetics (what the body does to a drug), which of the following is true? A. The rate of medication absorption determines how soon the medication will take effect B. The medication is changed into an inactive or less active form of the drug. C. The amount of medication absorbed determines it's intensity. D. The route of administration affects the rate and amount of absorption
D Absorption is the transmission of medications from the location of administration (gastrointestinal [GI] tract, muscle, skin, or subcutaneous tissue) to the bloodstream. The most common routes of administration are enteral (through the GI tract) and parenteral (by injection). Each of these routes will have a unique pattern of absorption. The rate of medication absorption determines how soon the medication will take effect. The amount of medication absorbed determines its intensity. The route of administration affects the rate and amount of absorption.
To auscultate low sounds such as murmurs with a stethescope, one uses: A. The diaphragm with light pressure B. The bell with heavy pressure C. The diaphragm with heavy pressure D. The bell with light pressure
D Think BELL - light and low - (2) L's, or think of the bell's clapper which needs to be able to move freely.
A nurse in the emergency department is caring for a patient who is nonverbal following a traumatic injury. What would be the best way for the nurse to assess this patient's level of pain? A. Ask the patient to draw a picture of the pain B. Ask the paramedics what they think is the patient's pain level C. Ask the patient to describe the pain D. Ask the family if they have noticed any changes in the patient's behavior
D When attempting to perform a pain assessment on a patient who cannot self-report pain you should observe patient behaviors and ask the family or caregivers if they have noticed any changes in behavior.
