Exam 2 - Elsevier Prep Questions
A (Raise the head of the bed to 45 degrees.) (Raising the head of the bed brings the diaphragm down and allows for better chest expansion, thus improving ventilation.)
The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first? A) Raise the head of the bed to 45 degrees. B) Take his oxygen saturation with a pulse oximeter. C) Take his blood pressure and respiratory rate. D) Notify the health care provider of his shortness of breath.
A, B (Rib fractures would cause splinting and pain to increase respiratory rate. Pregnancy impedes diaphragmatic excursion, causing shallow, frequent breaths.)
Which of the following patients is at most risk for tachypnea? (Select all that apply.) A) Patient just admitted with four rib fractures B) Woman who is 9 months' pregnant C) Adult who has consumed alcoholic beverages D) Adolescent awaking from sleep
A (Sharp pleuritic pain that worsens on inspiration) (When the lung collapses, the thoracic space fills with air on each inspiration, and the atmospheric air irritates the parietal pleura, causing pain.)
A patient was admitted after a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax, which includes which of the following? A) Sharp pleuritic pain that worsens on inspiration B) Crackles over lung bases of affected lung C) Tracheal deviation toward the affected lung D) Increased diaphragmatic excursion on side of rib fractures
B (Right popliteal and right axillae) (The only extremity that does not have a compromised artery to auscultate is the right lower leg after the sequential device is removed. The tympanic membrane and temporal artery are affected by facial surgery and oxygen mask.)
A 55-year-old widowed patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. What sites do you instruct the nursing assistant to use for obtaining the patient's blood pressure and temperature? A) Right antecubital and tympanic membrane B) Right popliteal and right axillae C) Left antecubital and oral D) Left popliteal and temporal artery
D (Inspiratory crackles in lung bases) (Decreased effective contraction of left side of heart leads to back up of fluid in the lungs, increasing hydrostatic pressure and causing pulmonary edema, resulting in crackles in lung bases.)
A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds? A) Sonorous wheezes in the left lower lung B) Rhonchi midsternum C) Crackles only in apex of lungs D) Inspiratory crackles in lung bases
D (Cardiopulmonary disease and lung cancer) (Effects of nicotine on blood vessels and lung tissue have been proven to increase pathological changes, leading to heart disease and lung cancer.)
A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder: A) Alcoholism and hypertension B) Obesity and diabetes C) Stress-related illnesses D) Cardiopulmonary disease and lung cancer
B (Frequent change of position) (Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting the effectiveness of gas exchange processes.)
The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion? A) Antibiotics B) Frequent change of position C) Oxygen humidification D) Chest physiotherapy
B (You need to use words the patients can understand when writing the directions.) (Patients need to be able to understand information that you provide to them; ensure that written instructions are provided at a level that matches the patients' reading ability.)
You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet? A) The new federal laws require that teaching sheets be e-mailed to patients after they are discharged. B) You need to use words the patients can understand when writing the directions. C) The form needs to be given to patients in a sealed envelope to protect their health information. D) The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home.
D (156/82 mm Hg) (When you use a blood pressure cuff that is too narrow or short, your patient will most likely have a BP reading that is higher than it really is; you will get a false-high reading.)
You observe a nursing student taking a blood pressure (BP) on a patient. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. The student used a BP cuff that was too narrow for the patient. Which of the following BP readings made by the student is most likely caused by the incorrect choice of BP cuff? A) 96/40 mm Hg B) 110/66 mm Hg C) 130/70 mm Hg D) 156/82 mm Hg
A ("CPOE reduces transcription errors.") (CPOE eliminates the need for someone to transcribe the orders because it allows the provider to enter the order directly.)
A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? A) "CPOE reduces transcription errors." B) "CPOE reduces the time necessary for health care providers to write orders." C) "Health care providers can write orders from any computer that has Internet access." D) "CPOE reduces the time nurses use to communicate with health care providers."
B (Electronic health record.) (This is an example of an electronic health record. The electronic health record is an electronic record of patient health information generated whenever a patient accesses medical care in any health care delivery setting. In this question you are able to access information about the patient from the current hospitalization and from four previous times when the patient accessed care.)
On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system? A) Information technology. B) Electronic health record. C) Personal health information. D) Administrative information system.
A (84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%) (Oxygen saturation is low, indicating a problem with ventilation or diffusion, which is related to the respiratory rate.)
The licensed practice nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first? A) 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% B) 54-year-old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72 C) 63-year-old man with venous ulcers from diabetes, temperature 37.3°C (99.1°F), HR 84 D) 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62
A (VII — Facial) (The facial nerve innervates the sensory and motor functions of the face above the brow, the cheeks, and the chin and controls face symmetry and smile.)
The nurse teaches a patient about cranial nerves to help explain why the patient's right side of the mouth droops instead of moving up into a smile. What nerve does the nurse explain to the patient? A) VII — Facial B) V — Trigeminal C) XII — Hypoglossal D) XI— Spinal accessory
B (The nurses were charting by exception.) (Given that the initial assessment indicated that the pulmonary system was within normal limits, the facility is most likely documenting by exception. There is no need for further documentation unless the pulmonary assessment changes and is no longer within normal limits.)
While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because: A) The nurses forgot to document on the pulmonary system. B) The nurses were charting by exception. C) The computer is not working correctly. D) The physician does not have authorization to view the nursing assessment.
A, B, D (Adhesive tape, rubber foley catheters, and rubber-coated plungers should be avoided for patients with latex allergies since they can trigger an allergic or anaphylactic response.)
As a nurse prepares to provide morning care and treatments, it is important to question a patient about a latex allergy before which intervention? (Select all that apply.) A) Applying adhesive tape to anchor a nasogastric tube B) Inserting a rubber Foley catheter into the patient's bladder C) Providing oral hygiene using a standard toothbrush and toothpaste D) Giving an injection using plastic syringes with rubbercoated plungers E) Applying a transparent wound dressing
C (Supine with the right arm abducted and hand under the head and neck) (Lying on the back allows breast tissue to relax; raising the arm over the patient's head causes the breast tissue to flatten, and palpation can more accurately locate any nodules or tumors, especially cancerous tumors that are fixed against the chest wall.)
How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast? A) Supine with both arms overhead with palms upward B) Sitting with hands clasped just above the umbilicus C) Supine with the right arm abducted and hand under the head and neck D) Lying on the right side, adducting the right arm on the side of the body
C (148/82, 148/78, 134/86) (The definition of hypertension requires two elevated blood pressure measurements in a row. All of the other choices describe prehypertension.)
The following blood pressures, taken 6 months apart, were recorded from patients screened by the nurse at the assisted living facility. Which patient should be referred to the healthcare provider for hypertension evaluation? A) 120/80, 118/78, 124/82 B) 128/84, 124/86, 128/88 C) 148/82, 148/78, 134/86 D) 154/78, 118/76, 126/84
A, B, C (Pain in the lower calf area indicates vascular, not respiratory, status.)
The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? (Select all that apply.) A) SpO2 levels B) Amount of sputum production C) Change in respiratory rate and pattern D) Pain in lower calf area
C (Place the back of your hand against the child's forehead and then on the back of the neck.) (Temperature is best evaluated by palpating the skin with the dorsum or back of the hand. It is best to select two areas to compare to allow you to detect a change in body surface temperature.)
The nurse is teaching a young mother to palpate her 8-year-old child to quickly evaluate if the child has a fever. Which information is important for the nurse to include? A) Place the palm of the hand on the child's back. B) Lightly touch the child's forehead with the fingertips. C) Place the back of your hand against the child's forehead and then on the back of the neck. D) Use the pads of your fingers and press against the child's neck and over the thorax.
D ("What does this mean: 'A stitch in time saves nine? ' ") (Abstract reasoning requires cognitive functioning and the ability to identify relationships between concepts.)
The nurse plans to assess the patient's abstract reasoning. Which task should the nurse ask the patient to perform? A) "Tell me where you are." B) "What can you tell me about your illness?" C) "Repeat these numbers back to me: 7...5...8." D) "What does this mean: 'A stitch in time saves nine? ' "
A (Record the amount and continue to monitor drainage) (Dark-red drainage after surgery - 50 to 200 mL per hour in first 3 hours - is expected, but be aware of sudden increases greater than 100 mL per hour after the first 3 hours, especially if it becomes bright red in color.)
Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? A) Record the amount and continue to monitor drainage B) Notify the health care provider C) Strip the chest tube starting at the chest D) Increase the suction by 10 mm Hg
C (Incentive spirometer) (An incentive spirometer is used to encourage deep breathing to inflate alveoli and open pores of Kohn. The rest are used to treat atelectasis and increased mucus production.)
Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient? A) Postural drainage B) Chest percussion C) Incentive spirometer D) Suctioning
B (Pain reported when palpating posterior lower thorax) (Any areas of tenderness or pain over the posterior thorax could indicate injury such as a broken rib or disturbance of the integumentary system. Further palpation should be avoided until more assessment data are collected, either through further health history or diagnostic testing. All other findings are normal.)
While assessing the adult patient's lungs, the nurse identifies the following assessment findings. Which finding should be reported to the health care provider? A) Respiratory rate: 14 B) Pain reported when palpating posterior lower thorax C) Thorax rising and falling symmetrically for right and left lungs D) Vesicular breath sounds heard with auscultation of peripheral lung fields
D (Oxygen saturation: 96%) (Oxygen therapy increases oxygen saturation. Temperature is not affected by the oxygen. There is no change in heart rate. Administering oxygen should decrease the respiratory rate. The decline in blood pressure is unlikely to be caused by oxygen.)
A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 pounds. Her vital signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8°C (98.2°F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy? A) Temperature: 37°C (98.6°F) B) Radial pulse: 112 C) Respiratory rate: 24 D) Oxygen saturation: 96% E) Blood pressure: 134/78
C (Assess the patient's apical pulse and evidence of a pulse deficit) (Your priority is to assess the patient first. The nurse cannot delegate vital signs to an unstable patient. Therefore first you determine if the patient has a pulse deficit. Calling for a stat electrocardiogram and preparing to administer cardiac-stimulating medications require notification of the health care provider and occur after you assess the patient.)
A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a very slow radial pulse of 44. What is your priority intervention? A) Request that the nursing assistant repeat the pulse check B) Call for a stat electrocardiogram (ECG) C) Assess the patient's apical pulse and evidence of a pulse deficit D) Prepare to administer cardiac-stimulating medications
C (Nail polish interferes with sensor function.) (Nail polish reduces light transmission and can alter oxygen saturation measurement.)
As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. Your best reply is: A) Nail polish attracts microorganisms and contaminates the finger sensor. B) Nail polish increases oxygen saturation. C) Nail polish interferes with sensor function. D) Nail polish creates excessive heat in sensor probe.
A, B (Dietary habits may include caffeine fluids and foods that stimulate heart rate. Medication list may include pharmacological agents that increase or decrease heart rate.)
During a patient's routine annual physical, she tells you that she has noted that her heart feels like it's " racing, " usually in the later morning, early afternoon, or just before she goes to bed. Her radial pulse rate is 68 beats/min and regular; her blood pressure is 134/82 mm Hg. What additional information is helpful in evaluating the patient's racing heart? (Select all that apply.) A) Dietary habits B) Medication list C) Exercise regimen D) Age, weight, and height
D (Palpation of a right dorsalis pedis pulse with strength of +1) (A weak pulse may indicate disruption of arterial flow and should be reported immediately. Mild bruising is normal, but if it increases in size, the femoral artery may be leaking, requiring further follow-up with the health care provider. Other findings are within normal limits and do not require notification.)
The nurse is assessing a patient who returned 3 hours ago from a cardiac catheterization, during which the large catheter was inserted into the patient's femoral artery in the right groin. Which assessment finding would require immediate follow-up? A) Palpation of a femoral pulse with a heart rate of 76 B) Auscultation of a heart murmur over the left thorax C) Identification of mild bruising at the catheter insertion site D) Palpation of a right dorsalis pedis pulse with strength of +1
A, B, D, G (You need to determine the patient's usual temperature to evaluate the degree of temperature elevation. Heart rate and respiratory rate increase with temperature. The presence of diaphoresis may contribute to fluid volume deficit from hyperthermia.)
A 56-year-old patient with diabetes admitted for community acquired pneumonia has a temperature of 38.2°C (100.8°F) via the temporal artery. Which additional assessment data are needed in planning interventions for the patient's infection? (Select all that apply.) A) Heart rate B) Presence of diaphoresis C) Smoking history D) Respiratory rate E) Recent bowel movement F) Blood pressure in right arm G) Patient's normal temperature H) Blood pressure in distal extremity
D (Perform a complete assessment of all pulses.) (When an LPN reports that one pulse is difficult to obtain, first you need to assess the patient yourself and compare the quality of all pulses.)
A patient returns to your postoperative unit following surgery for right shoulder rotator cuff repair. The licensed practical nurse (LPN) reports that she had difficulty obtaining the patient's heart rate from his right radial pulse. What is your best response? A) Assess the patient's apical pulse to obtain the heart rate. B) Obtain the heart rate from right and left radial sites. C) Obtain the heart rate using the oximeter probe. D) Perform a complete assessment of all pulses.
D (The patient stated that he felt frustrated by the lack of information he received regarding his tests.) (This is a nonjudgmental statement regarding the nurse's observations about the patient. Documenting that the patient had a defiant attitude or was demanding and frequently complaining is judgmental, and information in the medical record should be factual and nonjudgmental. Documenting that the patient appears upset needs to be more specific regarding the reason for the patient's concern.)
As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? A) The patient has a defiant attitude and is demanding his test results. B) The patient appears to be upset with his nurse because he wants his test results immediately. C) The patient is demanding and complains frequently about his doctor. D) The patient stated that he felt frustrated by the lack of information he received regarding his tests.
A (Documented medication given by another nursing student.) (Nurses only document the care they provide; entries in the chart need to be dated, timed, and signed.)
You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: A) Documented medication given by another nursing student. B) Included the date and time of all entries in the chart. C) Stood with his back against the wall while documenting on the computer. D) Signed all documentation electronically.
B, D, C, A (B - "The pain increases every time I try to turn on my left side." D -Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation. C - Acute pain related to tissue injury from surgical incision. A -Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia ,PCA, device.)
Match the correct entry with the appropriate SOAP (Subjective—Objective—Assessment—Plan) category. A. Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device. B. "The pain increases every time I try to turn on my left side." C. Acute pain related to tissue injury from surgical incision. D. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.
A (Fever increases metabolic demands, requiring increased oxygen need.) (When the body cannot meet the increased oxygenation need, the increased metabolic rate causes breakdown of protein and wasting of respiratory muscles, increasing the work of breathing.)
A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104°F (40°C). What physiological process explains why the child is at risk for developing dyspnea? A) Fever increases metabolic demands, requiring increased oxygen need. B) Blood glucose stores are depleted, and the cells do not have energy to use oxygen. C) Carbon dioxide production increases as result of hyperventilation. D) Carbon dioxide production decreases as a result of hypoventilation.
D (Enter only objective and factual information about the patient.) (Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incorrect, it should be left on the record. Never use correction fluid in a written medical record.)
A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? A) Avoid rushing when charting an entry. B) Use correction fluid to remove the entry. C) Draw a single line through the statement and initial it. D) Enter only objective and factual information about the patient.
B (Gives a newly ordered medication before entering the order in the patient's medical record.) (Nurses enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur.)
A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: A) Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report. B) Gives a newly ordered medication before entering the order in the patient's medical record. C) Reads the orders back to the health care provider after receiving them and verifies their accuracy. D) Asks the preceptor to listen in on the phone conversation.
C (Clinical decision support system) (A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user.)
A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system? A) Electronic health record B) Clinical documentation C) Clinical decision support system D) Computerized physician order entry
B (Indicate that she has the right to read her record.) (Patients have the right to read their medical records, but the nurse should always know the facility policy regarding personal access to medical records because some require a nurse manager or other official to be present to answer questions about what is in the record. Families may read the records only when the patient has given permission.)
A patient asks for a copy of her medical record. The best response by the nurse is to: A) State that only her family may read the record. B) Indicate that she has the right to read her record. C) Tell her that she is not allowed to read her record. D) Explain that only health care workers have access to her record.
D (Decreased activity tolerance and increased breathlessness) (Hypoxia occurs because of decreased circulating blood volume, which leads to decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a feeling of shortness of breath.)
A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status? A) Increased breathlessness but increased activity tolerance B) Decreased breathlessness and decreased activity tolerance C) Increased activity tolerance and decreased breathlessness D) Decreased activity tolerance and increased breathlessness
C (Intermittent fever pattern)
A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7°C (101.6°F) (0400), 36.6°C (97.9°F) (0800), 36.9°C (98.4°F) (1200), 37.6°C (99.6°F) (1600), and 38.3°C (100.9°F) (2000). How would you describe this pattern of temperature measurements? A) Usual range of circadian rhythm measurements B) Sustained fever pattern C) Intermittent fever pattern D) Resolving fever pattern
D ("If I get short of breath, I'll turn up my oxygen level to 6 L/min.") (Hypoxia is the drive to breathe in a patient with chronic obstructive pulmonary disease who has become used to acidic pH and elevated CO2 levels. Turning up to 6 L/min increases the oxygen level, which turns off the drive to breathe.)
A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his statements would indicate a need for further education? A) "I'll make sure that I rest between activities so I don't get so short of breath." B) "I'll rest for 30 minutes before I eat my meal." C) "If I have trouble breathing at night, I'll use two to three pillows to prop up." D) "If I get short of breath, I'll turn up my oxygen level to 6 L/min."
C (Baseline vital signs) (Knowledge of baseline vital signs is needed to prioritize care.)
A patient has been transferred to your unit from the respiratory intensive care unit, where he has been for the past 2 weeks recovering from pneumonia. He is receiving oxygen via 4 L nasal cannula. His respiratory rate is 26 breaths/min, and his oxygen saturation is 92%. In planning his care, which information is most helpful in determining your priority nursing interventions? A) Activity order B) Medication list C) Baseline vital signs D) Patient's perception of dyspnea
B, D, E (An irregular pulse may be the result of a complication of heart disease and requires the assessment of the apical rate. A respiratory rate of 28 is abnormal, yet the oxygen saturation is normal. Both oxygen saturation and respiratory rate would be expected to be outside of the acceptable range.)
A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant tells you his admitting vital signs. Which measurement should you reassess? (Select all that apply.) A) Right arm BP: 120/80 B) Radial pulse rate: 72 and irregular C) Temporal temperature: 37.4°C (99.3°F) D) Respiratory rate: 28 E) Oxygen saturation: 99%
B (Forms a strong bond with hemoglobin, creating a functional anemia.) (Carbon monoxide strongly binds to hemoglobin, making it unavailable for oxygen binding and transport.)
A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy, not cyanotic, the nurse understands that the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following: A) Stimulates hyperventilation, causing respiratory alkalosis B) Forms a strong bond with hemoglobin, creating a functional anemia. C) Stimulates hypoventilation, causing respiratory acidosis D) Causes alveoli to overinflate, leading to atelectasis
C (Decreased independent ability to cough) (Impaired ability to cough up mucus caused by weakness or very thick secretions indicates a need for suctioning when you know the patient has pneumonia.)
A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? A) Coughing up thick sputum only occasionally B) Coughing up thin, watery sputum easily after nebulization C) Decreased independent ability to cough D) Lung sounds clear only after coughing
A (Nasal cannula) (A nasal cannula delivers precise, high-flow rates of oxygen.)
The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient? A) Nasal cannula B) Venturi mask C) Simple face mask without inflated reservoir bag D) Plastic face mask with inflated reservoir bag
A (Appearance and behavior) (The nurse inspects appearance and behavior first as part of the nursing assessment. As the patient enters the room, the nurse can observe his or her appearance and behavior, noting any unusual choice of clothing or hygiene or any signs of confusion, anxiety, or happiness.)
The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? A) Appearance and behavior B) Measurement of vital signs C) Observing specific body systems D) Conducting a detailed health history
A (The aorta can be felt using deep palpation in the upper abdomen near the midline.) (Complete abdominal assessment includes inspection, followed by auscultation, palpation, and percussion - if warranted. Anatomically the aorta is located in the upper abdomen and can be palpated on an average-sized patient. The assessment should be performed when the patient is supine so all assessment techniques can be included. Unless there is an open wound or other abdominal drainage, the aorta should be palpated without gloves to be able to assess skin texture, temperature, and any unusual pulsations. Palpation should be performed routinely, but leave areas of discomfort or pain until last. )
The nurse is planning a staff education conference about abdominal assessment. Which point is important for the nurse to include? A) The aorta can be felt using deep palpation in the upper abdomen near the midline. B) The patient should be sitting to best determine the contour and shape of the abdomen. C) Always wear gloves when palpating the skin on the patient's abdomen. D) Avoid palpating the abdomen if the patient reports any discomfort or feelings of fullness.
A, C, D (By assessing for moisture of the mucous membranes and lips, the nurse can quickly evaluate the patient's hydration status. Weighing a patient shows increases of fluid volume from day to day that could result from cardiac problems. This provides useful information about fluid status over time. Blood pressure can indicate fluid status, but be aware it also can be related to other diseases. Skin on older individuals loses its elasticity, and assessing skin on the dorsum of the hand provides inaccurate data regarding skin turgor.)
The nurse is planning to teach the student nurse how to assess the hydration status of an older adult. Which techniques are appropriate for this situation? (Select all that apply.) A) Inspect the lips and mucous membranes to determine if they are moist. B) Pinch the skin on the back of the hand to see if the skin tents. C) Check the patient's pulse and blood pressure. D) Weigh the patient daily.
A ("The testes are normally round and feel smooth and rubbery.") (Men ages 18 to 24 are in the group at most risk for testicular cancer. Teaching should include normal anatomy. A testicular examination should be planned monthly during a shower since the soap and water ease movement of the fingertips over the skin.)
The nurse is teaching a patient how to perform a testicular self-examination. Which statement by the nurse is correct? A) "The testes are normally round and feel smooth and rubbery." B) "The best time to do a testicular self-examination is before your bath or shower." C) "Perform a testicular self-examination weekly to detect signs of testicular cancer." D) "Since you are over 40 years old, you are in the highest risk group for testicular cancer."
A, D (A normal dorsalis pedis indicates good arterial blood flow to the lower extremities. Chronic loss of arterial flow results in a lack of hair growth and the appearance of shiny tissue. The dorsalis pedis is located along the top of the foot between the great toe and first toe. When there is poor arterial flow, the skin will be cool.)
The nurse is teaching a patient with poor arterial circulation about checking blood flow in the legs. Which information should the nurse include? (Select all that apply.) A) A normal pulse on the top of the foot indicates adequate blood flow to the foot. B) To locate the dorsalis pedis pulse, take the fingers and palpate behind the knee C) When there is poor arterial blood flow, the leg is generally warm to the touch. D) Loss of hair on the lower leg indicates a long-term problem with arterial blood flow.
B (Oral contraceptives and antiinflammatories make the skin more sensitive to the sun.) (Some medications such as oral contraceptives or antiinflammatory medications may increase the skin's sensitivity to ultraviolet (UV) rays. Skin self-care and self-evaluation practices include avoiding the sun when UV rays are strongest (10 AM to 4 PM). In addition, good skin practices indicate that skin protection should be used when using a tanning bed or sunlamp. Moles that are uniformly brown are not a cause of concern.)
The nurse is teaching a young female patient to practice good skin health. Which information is important for the nurse to include? A) Avoid sunbathing between 3 PM and 7 PM. B) Oral contraceptives and antiinflammatories make the skin more sensitive to the sun. C) Call the health care provider for the presence of a mole on an arm or leg that appears uniformly brown. D) Wear sunscreen with an SPF of 30 or greater if using a sunlamp or tanning parlor.
C (Patient's abduction of right arm was limited to 100 degrees.) (Abduction of the arm includes raising the arm away from the side and above the shoulder.)
The patient is assessed for range of joint movement. He or she is unable to move the right arm above the shoulder. How should the nurse document this finding? A) Patient was not able to flex arm at shoulder. B) Extension of right arm is limited. C) Patient's abduction of right arm was limited to 100 degrees. D) Internal rotation of right arm is limited to less than 90 degrees.
C (Retropharyngeal lymph nodes are enlarged and firm.) (The retropharyngeal nodes are located posteriorly to the throat and are enlarged when an infection is located in the throat or pharynx.)
The patient reports having a sore throat, coughing, and sneezing. While performing a focused assessment, which finding supports the patient's reported symptoms related to upper respiratory infection? A) Buccal mucosa is moist and dark pink. B) Respiratory rate is 18, rhythm is even. C) Retropharyngeal lymph nodes are enlarged and firm. D) Inspection with a tongue depressor on the posterior tongue causes gagging.
C (Place in a secure canister marked for shredding) (Confidential patient information should be shredded. It is generally collected in large secure containers and shredded at scheduled times.)
What is an appropriate way for a nurse to dispose of printed patient information? A) Rip several times and place in a standard trash can B) Place in the patient's paper-based chart C) Place in a secure canister marked for shredding D) Burn the documents
D (Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.) (The statement "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise" provides the most accurate, objective information for the chart.)
Which of the following charting entries is most accurate? A) Patient walked up and down hallway with assistance, tolerated well. B) Patient up, out of bed, walked down hallway and back to room, tolerated well. C) Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk. D) Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.
C (A patient with a fever of 39.4°C (103°F)) (Patients with a fever have a high heart rate. A healthy athlete has a low heart rate because of conditioning. Hypothermia slows the heart. Beta-blockers reduce heart rate.)
Which of the following patients is most at risk for tachycardia? A) A healthy professional tennis player B) A patient admitted with hypothermia C) A patient with a fever of 39.4°C (103°F) D) A 90-year-old male taking beta blockers
D ("I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient.") (Saline has been found to cause more side effects when suctioning and does not increase the amount of secretions removed.)
Which of the following statements made by a student nurse indicates the need for further teaching about suctioning a patient with an endotracheal tube? A) "Suctioning the patient requires sterile technique." B) "I'll apply suction while rotating and withdrawing the suction catheter." C) "I'll suction the mouth after I suction the endotracheal tube." D) "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."
A, B, E (During change of shift report, include essential background information such as the patient's name, age, diagnosis, and allergies. Also include response to treatments such as response to pain-relieving measures. Information about how much the patient ate for breakfast is not necessary. This information is in the chart if the nurse really needs to know. Do not include critical comments about your patients.)
You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.) A) The patient's name, age, and admitting diagnosis B) Allergies to food and medications C) Your evaluation that the patient is "needy" D) How much the patient ate for breakfast E) That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol
C (HIPAA provides you with greater control over your personal health care information.) (HIPAA provides patients with control over who receives and accesses their medical records. It does not allow uncontrolled access to the medical records. HIPAA also does not dictate what must be documented in the patient's medical record.)
You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response? A) HIPAA allows all hospital staff access to your medical record. B) HIPAA limits the information that is documented in your medical record. C) HIPAA provides you with greater control over your personal health care information. D) HIPAA enables health care institutions to release all of your personal information to improve continuity of care.
