Final Exam Questions

A nurse enters pt room and notices a small fire above the pt bed. In which order will the nurse perform the steps starting with the first one 1. Pull the alarm 2. Remove pt 3. Use fire extinguisher 4. Close doors and windows

2, 1, 4, 3

How many teaspoons in a ml

5

A nurse notices that a client has not voided in 6 hours. Which question should the nurse ask to assist in getting a diagnosis of urinary retention. A Do you feel like you need to go to the bathroom? B Are you able to walk to bathroom by yourself? C when last did you take your medication? D Do you have a safety rail in your bathroom a home

A Do you feel like you need to go to the bathroom?

A nurse is observing a fam member change a dressing in the home health environment. Which observation indicates fam member has correct understanding of how to manage contaminated dressing? A. Fam places used dressing in plastic bag B. Fam saves part of the dressing cuz it looks clean C. The family member removes gloves and gathers dressings for disposal D. Fam wraps dressing in toilet tissue before putting it in trash

A. Fam places used dressing in plastic bag

A nurse is encouraging a reluctant post op client to deep breathe and cough. Which explanation can the nurse provide to encourage pt to comply? A. If you don't deep breath and cough, you'll get pneumonia B. You'll only need to cough a few times during the shift C. Let's try clearing the throat cuz that'll work D. Deep breathing and coughing will clear the anesthesia

A. If you don't deep breath and cough, you'll get pneumonia

A nurse is prepping pt for procedure on right great toe. Which action will be most important to include in this pt's prep? A. Mark surgical site

A. Mark surgical site

Pt asks nurse for a non medical solution to worry and work stress. Which therapy should nurse recommend A. Meditation B Accupuncture C. Herbs D. Cryopractic care

A. Meditation

A nurse is reviewing surgical consent with a pt and finds that the pt does not understand what procedure will be completed. What is the nurses next best step? A. Notify the hcp about the pt questions

A. Notify the hcp about the pt questions

A nurse is taking history on a client who cannot speak English. Which action will the nurse take? A. Obtain an interpreter B. Refer to a speech therapist C. Let a close family member talk D. Find a mental health specialist

A. Obtain an interpreter

A nurse is teaching a culturally diverse pt with a learning disability about nutritional needs. What must the nurse do first before starting the teaching session? A. Obtain pics of food B. Get interpreter C. Establish rapport D. Refer to dietician

A. Obtain pics of food/rapport

A nurse is evaluating outcomes for a pt with insomnia. Which key principle will the nurse consider during this process? A. PT is best evaluator of sleep B. nurse is best evaluator of sleep C. effective interventions are the best evaluators of sleep D. observations of pt are best evaluators of sleep

A. PT is best evaluator of sleep

Before administering an enema to an 80 year old pt, the pt says "I don't think I will be able to hold the enema". Which is the next priority of the nurse? A. Roll client into right line Sims position B. Position client into dorsal recumbent position on bedpan C. Insert rectal plug to retain enema solution D. Assisting client to bedside commode and administering enema

A. Roll client into right line Sims position

A nurse is caring for an older adult pt with nausea vomiting and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address pt. heath care needs A. The electricity was turned off 3 days ago B. Water comes from county water supply C. Son and family recently moved into the home D. Home isn't furnished with microwave

A. The electricity was turned off 3 days ago

Nurse is caring for a pt who becomes nauseated and vomits without warning. The nurse has contaminated hands. What action is best for the nurse to take next? A. Wash hands with antimicrobial soap and water

A. Wash hands with antimicrobial soap and water

A nurse is teaching a client and fam about wound care. Which technique would the nurse teach to best prevent transmission of pathogens? A. Washing hands B Washing wounds C Wearing gloves D. Wearing eye protection

A. Washing hands

A nurse is discussing lack of sleep with a middle aged adult, which area should the nurse most likely assess to determine a possible cause? A. anxiety B. loud teens C. Caring for pets D. late night tv

A. anxiety

A home health nurse is caring for a pt with tactile and visual deficits.The nurse is concerned about injury related to the inability to feel harmful stimuli and teaches the patients strategies to maintain independence. Which action by the client indicates successful learning? A. ask nurse to test temp of water before entering bath B. Place colored stickers on faucet handles to indicate temp C. replace all lace up shoes with velcro straps for ease D. use heating pad on low setting to keep warm

A. ask nurse to test temp of water before entering bath

A nurse is caring for pt who suddenly becomes confused and tries to remove IV infusion. Which priority action will the nurse take? A. assess pt B. gather restraints C. try alternatives to restraint D. call hcp for restraint order

A. assess pt

A nurse is reviewing client's database for specific changes and discovers that the client hasn't voided in over 8 hrs. The kidney lab results are abnormal and pt's oral intake has significantly decreased from previous shift. Which part of the nursing process should the nurse proceed to after this review? A. diagnosis B. Planning C. Implementation D. Evaluation

A. diagnosis

A nurse is using therapeutic communication with a client. Which technique will the nurse use to ensure effective communication? A. interpersonal communication to change negative self talk to positive self talk. B. Small group communication to present information to an audience. C. Electronic communication to access a patient in another city D. Intrapersonal communication to build strong homes

A. interpersonal communication to change negative self talk to positive self talk.

Which situation will cause the nurse to intervene and follow up on the nursing assistive personnel's behavior? The NAP: A. is calling the older adult patient honey B. is facing the older adult patient when talking C. cleans the older adult patients glasses gently D allows time for the older patient to respond

A. is calling the older adult patient honey

A pt has fallen several times in the last week in an attempt to go to the bathroom. Pt gets up 3-4x/night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem? A. limit fluid and caffeine intake before bed B.Leave bathroom light on to illuminate pathway C. Practice fetal exercises to strengthen bladder muscles D. Clear path to bathroom of all obstacles before bed time

A. limit fluid and caffeine intake before bed

A nurse is caring for a client on a med surgery unit who is experiencing exacerbation of asthma. Which intervention will be most appropriate to help this client sleep? A. place bed in semi fowlers position B. offer iron rich meals C. provide snack before bed time D. encourage pt to read

A. place bed in semi fowlers position

A nurse is establishing relationship with a pt who is severely visually impaired and is teaching the pt how to contact the nurse. Which action will the nurse take. A. place raised brail sticker on call button B. Explain to pt that staff will stop by once an hour to see if they need anything C. Instruct pt to tell fam member to get staff attention D. color code call light system

A. place raised brail sticker on call button

A client requests the nurse's help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the pt's inability to void A. pt can be anxious making it difficult for abdominal and perineal muscles to relax enough to void B. Client is not recognizing physiological symptoms C. Client is lonely and calling nurse under false pretenses to get attention D. Client isn't drinking enough fluids to get enough urine.

A. pt can be anxious making it difficult for abdominal and perineal muscles to relax enough to void

A nurse is supervising the log rolling of a patient. To which patient is the nurse most likely providing the care? A. pt with neck injury B. pt with hypostatic pneumonia C. pt with total knee replacement D. pt with stage 4 pressure ulcer

A. pt with neck injury

A nurse hears a coworker state that anyone can be a nurse because it's so automated with machinery. What is the nurses best response? A. technology use has to be combined with nursing judgement B. Focus of effective nursing care is tech C. if it's so easy why don't you do it

A. technology use has to be combined with nursing judgement

A pt is using laxative 3x/day to lose weight. After stopping laxative use the pt has difficulty with constipation and wonders if laxatives should be taken again. Which info will nurse share with pt. A.Long term laxative use causes bowel to be less responsive to stimuli causing constipation to occur B. Laxatives can cause trauma to intestinal lining and scarring may result causing decreased peristalsis C. Longterm use of emollient laxatives can be used in some situations for constipation D. Laxative cause the body to become malnourished so when the pt starts eating again the body absorbs all the food and there's no waste produced.

A.Long term laxative use causes bowel to be less responsive to stimuli causing constipation to occur

the pt has a calculated bmi of 34. How will the pt classify this finding? A.Obsese

A.Obsese

A nurse is using research findings to improve clinical care. Which technique is the nurse using? A.performance improvement B. Integrative delivery network C. Nursing sensitive outcome D. Utilization review committee

A.performance improvement

An older adult pt is using a wheelchair to attend a physical therapy appt. Which action by the nurse indicates safe transport of the patient A.Positions client buttocks close to wheelchair seat B Backs wheelchair to elevator leading with large rear wheels first C Places locked wheelchair on same side of bed as patient's weaker side D. Unlocks wheelchair for easy maneuverability when pt is transferring.

B Backs wheelchair to elevator leading with large rear wheels first

A nurse questions a hcp decision to not tell a patient about a cancer diagnosis. Which ethical principle is the nurse trying to uphold for the pt? A consequentialism B autonomy C fidelity D. justice

B autonomy

The nurse is caring for a pt with a terminal disease. The nurse sits down and touches the pt's hand. What technique is the patient using? A. doing for B establishing presence

B establishing presence

A nurse provides immunization to children and adults through the public health department. Which type of healthcare is the nurse providing A. primary' B preventative C. restorative D. continuing

B preventative

A client just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy? A. "Tomorrow will be better" B. "This must be hard news to hear." C. "What's your biggest fear about this diagnosis?" D. "I believe you can overcome this because I've seen how strong you are."

B. "This must be hard news to hear." C. "What's your biggest fear about this diagnosis?"

When professionals work together to solve ethical dilemmas, nurses must examine their own values. What is the best rationale for this? A. fact is separate from opinion B. Different perspectives are respected C. attitudes can be provoked D. so group identifies 1 correct solution

B. Different perspectives are respected

A nurse explains pain relief measures available after surgery during preop tx to surgical pt. Which comment from client represents need for additional teaching on this topic? A.pt says" I will be asked to rate my pain on a pain scale" B. Pt says "I will have minimal pain bc anesthesia" C. Pt. says " I will take the pain meds as the provider prescribes it" D. Pt says " I will take my pain meds before doing post op exercises"

B. Pt says "I will have minimal pain bc anesthesia"

A nurse is assessing pressure points in a client place in the SIMS position. Which areas will the nurse observe? A. allium, clavicle, knees B. Shoulder, iliac spine, ankles

B. Shoulder, iliac spine, ankles

A pt is presented to ambulatory/surgurcial center to have a colonoscopy. The pt is scheduled to receive moderate/conscious sedation during procedure. How will the nurse interpret this information? A.The procedure results in loss of sensation in area of the body B. The procedure requires depressed level of consciousness C. The procedure will be performed on outpatient basis D. the procedure necessitates the pt to be immobile.

B. The procedure requires depressed level of consciousness

The client is having a hard time dealing with an AIDS diagnosis. The client states "It's not fair. I'm totally isolated from God and my family because of this. Even my father won't even speak to me. " What should the nurse do? A. tell the pt to move on and focus on getting better B. Use therapeutic communication to establish trust and caring C. Assure the pt that the father will accept situation soon D. Point out pt has no control and accept consequences

B. Use therapeutic communication to establish trust and caring

A confused older-adult client is wearing thick glasses and a hearing aid. Which intervention is the priority to facilitate communication? A. focus on tasks to be completed B. allow time for the patient to respond C. limit conversations with the client D. use gestures and other nonverbal cues.

B. allow time for the patient to respond

Upon assessment a nurse notices that a pt's respirations have increased and the tip of the nose and ears are becoming cyanotic the nurse finds the patients pulse is over 100. According to Maslow's hierarchy of needs which pt need should the nurse address first? A. self esteem B. physiological C. self actualization D. love and belonging

B. physiological

A nurse is concerned about the skin integrity of a pt in intraoperative phase of surgery. Which action does the nurse take to minimize skin breakdown? A. encourage pt to bathe pre surgery. B. securing attachments in the operating room with foam padding C. Periodically adjusting pt during surgery D. measuring time pt is in a given position during surgery

B. securing attachments in the operating room with foam padding

After assessing a client a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurses actions A. to form language that can only be encoded by nurses B. to distinguish nurse's role from physician's C. develop clinical judgement based on other's intuition D to help nurses focus on scope of medical practice

B. to distinguish nurse's role from physician's

Which nursing action will most likely increase a pt's risk for developing a healthcare associated infection? A. nurse using surgical aseptic technique to suction airway B. using clean technique to insert urinary catheter C. cleansing stroke from urinary meatus to the rectum D. A sterile bottle solution used more than once in 24 hr period

B. using clean technique to insert urinary catheter

A smiling client angrily states, " I will not cough and deep breathe." How will the the nurse interpret this finding? The client's A. trying to trick the nurse B. Personal space was violated C. Affect is inappropriate D. Vocabulary is poor

C. Affect is inappropriate

Which assessment questions should the nurse ask to best assess and understand how visual alterations are affecting the client self care ability. A. Have you stopped reading books or switched to books on tape B. What do you do to protect yourself from injury at work C. Are you able to prepare a meal or write a check D. How does your vision impairment make you feel

C. Are you able to prepare a meal or write a check

A nurse is caring for an older adult pt on bedrest with potential sensory deprivation. Which action will the nurse take? A.offer pt backrub B. hang do not disturb sign on her door C. Ask pt if they want newspaper to read D. put pt in room furthest from nursing station

C. Ask pt if they want newspaper to read

A client with heart failure is learning to reduce salt in the diet. When would be the best time for the nurse to address this topic? A. At bed time when pt is relaxed B. At bath time when the nurse is cleaning the pt C. At lunch time when the nurse is delivering food tray D. At medication administration time.

C. At lunch time when the nurse is delivering food tray

Which assessment question should the nurse if stress incontinence is suspected? A. DO you think your bladder feels distended? B. Do you empty your bladder completely when you void? C. Do you experience leakage when you cough or sneeze? D. Do your symptoms increase with consumption of alcohol or caffeine?

C. Do you experience leakage when you cough or sneeze?

A client needs assistance in eliminating an aesthetics gaseous medication (nitrous oxide) what action does the nurse take A. suction client respiratory secretions B. Suggest voiding every2 hrs C. Encourage client to cough and deep breathe D. Increase Fluid intake

C. Encourage client to cough and deep breathe

A nurse is monitoring a pt in the post anesthesia care unit for post op, fluid, and electrolyte balance. Which action will be most appropriate for the nurse to take? A. encouraging copious amounts of water B. start additional IV line C. Measure and record all intake and output D. Weigh pt and compare to preop weight.

C. Measure and record all intake and output

A nurse is preparing to teach a pt about smoking cessation. Which factors should a nurse asses to determine a pts ability to learn? A. Stages of grieving and overall physical health B. developmental capability and physical capabilities C. Psychosocial adaptation to illness and active participation D. Sociocultural background and motivation

C. Psychosocial adaptation to illness and active participation

The nurse finds it difficult to care for a patient whose advance directive states that no extraordinary resuscitation measures should be taken. Which step may help the nurse to find resolution in this assignment? A. Call for an ethical committee consult. B. Decline the assignment on religious grounds. C. Scrutinize her own personal values. D. Convince the family to challenge the directive.

C. Scrutinize her own personal values.

A nurse is caring for a client susceptible to infection. Which advice will nurse include in an info session to decrease infection risk? A. Teach client about fall prevention B. Teach pt to take temp C. Tell pt to eat nutritious foods D. Teach pt about dangers of alcohol

C. Tell pt to eat nutritious foods

A nurse is providing care to a client. Which action suggests the nurse is following national pt safety goals? A. identify pt with 1 identifier before transferring pt to xray B. Initiates IV catheter with clean technique on 1st try C. Use med barcode when administering med D. Obtains vital signs to place on pt chart

C. Use med barcode when administering med

A nurse is using theoretical knowledge to provide client care. Which nursing behavior is an example of theoretical knowledge? A reads about diff concepts B. Reflects on clinical experiences C. combines art and science of nursing D. creates narrow understanding of nursing practice

C. combines art and science of nursing

Nurse is teaching client relaxation techniques to decrease stress. Which finding will support nurse evaluation that the therapy is effective A. dilated pupils B. increased blood sugar C. decreased heart rate D. elevated bp

C. decreased heart rate

The client exhibits the following: tachycardia, increased thirst, headache, decreased urine output, and increased body temp. The nurse analyzes the data. What nursing diagnosis will the nurse assign to the client? A. failure to thrive B. hypothermia C. deficient fluid volume D. Nausea

C. deficient fluid volume

Nurse uses holistic approach to care. Which goal is priority? A. integrate spiritual tx B. join physical care with vegan diet C. incorporate mind body and spiritual connection D. use complimentary and alternative therapy

C. incorporate mind body and spiritual connection

Which action will the nurse take to reduce the risk of excoriation to the new costal line of an NG tube A. instill lidocaine in nares once a shift B. tape tubes C. lubcricate nares with lubricant D. Apply ice every few hours

C. lubcricate nares with lubricant

A nurse is caring for a group of med surgery pt. Which client is most at risk for developing infection? A. pt in observation for chest pain B. pt admitted for dehydration C. pt recovering from right total hip surgery D. pt admitted for stabilization of heart problems

C. pt recovering from right total hip surgery

A nurse is admitting a client to the hospital. Pt is a very spiritual person, but doesn't practice any specific religion. How will the nurse interpret this finding A. pt has strong religious affiliation B. this statement is contradictory C. this statement is reasonable D. this indicates lack of hope

C. this statement is reasonable

Which pt will the nurse assess most closely for an ileus? A.pt with fecal impaction B. Pt with chronic cathartic (laxative) abuse C.Pt with surgery for bowel disease and anesthesia D. Pt with hydrochloric acid suppression from meds

C.Pt with surgery for bowel disease and anesthesia

A nurse is implementing care measures for a client's special communication needs. Which client will need the most care measures? AThe client who is oriented, pain free, and blind B. The patient who is alert, hungry, and has strong self esteem C. The patient who is cooperative, depressed, and hard of hearing. D. The patient who is dysgenic, anxious, and has a tracheostomy.

D. The patient who is dysgenic, anxious, and has a tracheostomy.

A nurse has become aware of missing narcotics in the client carrier. Which ethical principle requires the nurse to report missing meds A advocacy B. responsibility C. confidentiality D. Accountability

D. Accountability

During an assessment of a pt the nurse finds the client experiences vertigo. Which sensory deficit will the nurse assess further? A Neurological deficit B Visual deficit C. Hearing deficit D. Balance deficit

D. Balance deficit

What is a nurses priority action to protect a client from med error? A. Reading med labels 3 times B. Administrating as many meds as possible C. Asking anxious fam members to leave room before giving meds D. Checking client's room number against med registration record.

D. Checking client's room number against med registration record.

A nurse is caring for a pt who is immobile and needs to be turned every 2 hours. The pt has poor lower extremity circulation and the nurse is concerned about irritation of the pt's toes. Which device would the nurse use? A. Handrolls B. Trapeze bar C. Trochanter Roll D. Foot Cradle.

D. Foot Cradle.

A nurse is preparing to assist a pt in using the incentive spirometer. Which nursing intervention should the nurse provide first? A. place pt in reverse trendelemburg position B. Explain use of mouthpiece C. Instruct pt to inhale slowly D. Perform Hand Hygine

D. Perform Hand Hygine

A nurse reviews the history of a newly admitted client. Which finding will alert the nurse that the pt is risk for fall A. Pt is 55 B. Pt has 20/20 vision C. Pt has urinary continence D. Pt has orthostatic hypotension

D. Pt has orthostatic hypotension

A nurse is caring for client on contact precautions. Which action will be most appropriate to prevent spread of disease. A. Place pt in room with neg air flow B. Wearing gloves, gown, facemark, goggles for pt interactions C. Transport pt safely and quickly when going to radiology D. Use dedicated bp cuff that stays in room and used for that pt only

D. Use dedicated bp cuff that stays in room and used for that pt only

A pt may need restraints. Which task can a nurse delegate to a NAP? A. determine need for restraint B. assess pt orientation C. obtaining order for restraint D. applying restraint

D. applying restraint

Which clinical manifestation will the nurse expect to observe in a client with excessive wbc in the urine? A. reduced urine specific gravity B. increased bp C. abnormal blood sugar D. fever with chills

D. fever with chills

A nurse develops a nursing diagnostic statement for a pt with diagnosis of pneumonia with chest x ray of lower lobe infiltrates. Which nursing diagnosis did the nurse write? A ineffective breathing pattern related to pneumonia B. risk of infection related to chest x ray procedure C. risk for deficient fluid vol related to dehydration D. impaired gas exchange related to alveolar membrane changes

D. impaired gas exchange related to alveolar membrane changes

A client is on a full liquid diet. Which food item by the pt will cause the nurse to intervene? A custard B frozen yogurt C. Pureed vegetables D. mashed potatoes and gravy

D. mashed potatoes and gravy

A client is confused and trying to get out of bed while pulling IV tubing. Which nursing diagnosis will the nurse add to the care plan? A. impaired home maintence B. deficient knowledge C. risk for poisoning D. risk for injury

D. risk for injury

A nurse has administered a pre op med to a pt going to surgery. What action will the nurse take next? A. waste unused med according to policy B. Have pt sign consent forms for surgery C. Notify operating suite that meds have been given D.Tell pt to call for help before going to bathroom

D.Tell pt to call for help before going to bathroom

A nurse is withdrawing a narcotic from the med dispensary and must waste a portion of the medication. What should the nurse do

Have another nurse witness medication waste and document it

Nurse prepares a pain injection for a client, but has to check on another patient and asks a new nurse to administer the meds. Which action by the new nurse is best?

Nurse must draw it herself

A nurse is caring for client in the hospital. When should they begin discharge planning

Upon admission

The nurse is concerned about pulmonary aspiration when providing pt with intermittent tube feeding. Which action is the priority? A. observe color of gastric contents B. Verify tube placement before feeding C.

Verify tube placement before feeding

The nurse is completing a med history for surgical pt in presurgical testing. Which med should the nurse instruct pt to hold in prep of surgery?

Warfin

The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which of the following outcomes would the nurse evaluate as successful for the patient to establish normal defecation? a. The patient reports eliminating a soft, formed stool. b. The patient has quit taking opioid pain medication. c. The patient's lower left quadrant is tender to the touch. d. The nurse hears bowel sounds present in all four quadrants

a. The patient reports eliminating a soft, formed stool.

While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, the nurse would expect to find a. An indwelling Foley catheter. b. Reddened irritated skin on the buttocks. c. Tiny blood clots in the patient's urine. d. Foul-smelling discharge indicative of a UTI.

b. Reddened irritated skin on the buttocks.

The nurse needs to move a patient up in bed using a drawsheet. The nurse has another nurse helping. In which order will the nurses perform the steps, beginning with the first one? 1. Grasp the drawsheet firmly near the patient. 2. Move the patient and drawsheet to the desired position. 3. Position one nurse at each side of the bed. 4. Place the drawsheet under the patient from shoulder to thigh. 5. Place your feet apart with a forward-backward stance. 6. Flex knees and hips and on count of three shift weight from the front to back leg. a. 1, 4, 5, 6, 3, 2 b. 4, 1, 3, 5, 6, 2 c. 3, 4, 1, 5, 6, 2 d. 5, 6, 3, 1, 4, 2

c. 3, 4, 1, 5, 6, 2

A nurse discusses a need for sleep with a client after this the client is able to state factors that hinder sleep. Which statements indicate that the client has a good understanding of the teaching select all that apply. A. drinking coffee at 7pm may interrupt my sleep B Staying up late for a party can interrupt sleep patterns C. Exercising 2hrs before bedtime can decrease relaxation D. Changing time of day I eat dinner can change sleep patterns

drinking coffee at 7pm may interrupt my sleep Staying up late for a party can interrupt sleep patterns Changing time of day I eat dinner can change sleep patterns

A nurse is caring for a client with immobility. Which potential complications will the nurse monitor on this pt. Select all that apply A. Foot drop B. Somnolence C. hypostatic pneumonia D. impaired skin integrity

foot drop, somnolence, impaired skin integrity

A nurse is caring for a pt with a blood borne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an IV line. Which steps will the nurse take next? A. use alcohol swab, remove blood with swab and continue care B.remove gloves, wash hands, reapply new gloves

remove gloves, wash hands, reapply new gloves