Foundations of Nursing (228) Final

Which information should the nurse share with a patient about skin traction? 1. "It will help you remember to keep your legs apart." 2. "It uses pins and weights to help align bones." 3. "It will help decrease muscle spasms." 4. "It uses weights to help calcium move into the bone."

3. "It will help decrease muscle spasms."

Which action should the nurse take when positioning a patient who has limited mobility? 1. Place pillows under the patient's upper arms. 2. Elevate the patient's knee with three pillows. 3. Pull the patient's lower shoulder just slightly forward. 4. Keep the heel firmly positioned against the mattress.

3. Pull the patient's lower shoulder just slightly forward

The nurse is caring for a patient who has a drain that works by suction. The nurse is caring for which type of drain? 1. T-tube 2. Jackson-Pratt 3. Penrose drain 4. Montgomery strap

2. Jackson-Pratt

The nurse is applying a mask before entering the room of a patient on transmission precautions. Which action should the nurse take? 1. Bring lower ties up on the head 2. Straighten the flexible band across the bridge of the nose 3. Pull the mask underneath the chin 4. Tie the lower ties at the neck first

3. Pull the mask underneath the chin

Place the steps of the nursing process in order.

Evaluation Assessment Diagnosis Implementation Planning

The nurse is contributing data to the care plan from a primary source. Which source did the nurse use? 1. Patient 2. Nurse 3. Chart 4. Therapist

Patient

The nurse is asked by a coworker which system is most effective for regulating acid-base balance. How should the nurse respond? 1. "It is the renal system." 2. "It is the cardiac system." 3. "It is the respiratory system." 4. "It is the buffer system."

1. "It is the renal system"

Which statement by the nurse indicates a correct understanding of charting? 1. "My charting can be used against me in a court of law." 2. "'Not charted, not done' is always true." 3. "Shortcuts are only used if time is short." 4. "I use several of my own abbreviations when charting."

1. "My charting can be used against me in a court of law."

The nurse is reviewing patients' charts. Which findings would adversely affect the ability to fight off infection? Select all that apply. 1. A 95-year-old patient 2. A 1-month-old infant 3. A patient with rheumatoid arthritis 4. A patient with a sedentary lifestyle 5. A patient who consumes a well-balanced diet

1. A 95-year-old patient 2. A 1-month-old infant 3. A patient with rheumatoid arthritis 4. A patient with a sedentary lifestyle

The nurse lives in a state that requires a specific number of continuing education (CE) hours for license renewal. Which guideline regarding continuing education is incorrect? 1. CEs are offered at no charge to nurses because of the importance. 2. Nursing is dynamic, and nurses need to be abreast of changes in practice. 3. Nurses will want CEs because it helps assure safe and quality patient care. 4. From the beginning of nursing school until graduation, significant changes occur.

1. CEs are offered at no charge to nurses because of the importance

The nurse is collecting data from a patient about specific information to contribute to the health history. Which type of questions should the nurse use to obtain this data? 1. Closed-ended 2. Open-ended 3. Nondirective 4. Health literacy

1. Close-ended

When assessing a patient's eyes, the nurse can shine a light into one of the patient's eyes and both pupils should have a rapid constriction that is simultaneous and equal. This action is known as which of the following? 1. Consensual reflex 2. Accommodation response 3. PERRLA 4. Ptosis

1. Consensual reflex

__________________ is the process of killing bloodborne pathogens and interfering with the growth of organisms that cause infection. 1. Disinfection 2. Contamination 3. Boiling 4. Autoclaving

1. Disinfecting

Which documentation practices can increase the nurse's chance of malpractice? Select all that apply. 1. Documents a change in respirations but does not document a change in blood pressure 2. Charts information on Mary B. Smith's chart that occurred with Mary A. Smith 3. Forgets to inform the health-care provider that the patient was bit by a tick while camping 4. Administers medications at 0900 and charts on the medication administration record at 0905 5. Does not transcribe the order for supplemental oxygen

1. Documents a change in respirations but does not document a change in blood pressure 2. Charts information on Mary B. Smith's chart that occurred with Mary A. Smith 3. Forgets to inform the health-care provider that the patient was bit by a tick while camping 5. Does not transcribe the order for supplemental oxygen

The nurse works in a church clinic and once a week sees older adult patients. Which physiological changes does the nurse expect to see in patients between the ages of 65 and 75 years? 1. Elevated blood pressure and high cholesterol. 2. Limitations that prevent involvement in prior interests. 3. The loss of ability and desire to move about and travel. 4. The realization that sometimes assistance is necessary.

1. Elevated BP and high cholesterol

The nurse works in an oncology unit. Which action by the nurse violates the principles of sterility maintained in this restricted area? 1. Goes to the cafeteria with shoes uncovered 2. Puts on a lab coat when leaving the unit 3. Changes into hospital-laundered scrubs 4. Leaves street clothing in an assigned locker

1. Goes to cafeteria with shoes uncovered

The nurse works in a clinic that provides care for older adult patients. A patient tells the nurse, "I am so upset. Money is disappearing from my investment accounts." Which initial information will the nurse attempt to learn from the patient? 1. If someone recently solicited personal information over the telephone 2. If the patient is experiencing memory loss about personal affairs 3. If the patient has family members who may be involved with the patient's finances 4. If the patient can confirm the dates and amounts of withdraws

1. If someone recently solicited information over telephone

The nurse is describing to a patient how the oxygen moves from the bloodstream to the body's cells. Which process is the nurse discussing? 1. Internal respiration. 2. External respiration. 3. Inhalation. 4. Exhalation.

1. Internal respiration

When a patient states, "I am not happy with my care and I am not staying," the nurse should suspect that which form may need to be completed? 1. Leaving AMA form 2. Physician's discharge order 3. Medication reconciliation 4. Discharge instruction form

1. Leaving AMA form

The nurse is providing care for a patient who returned to the unit after gastric surgery. The patient has a nasogastric (NG) tube in place and is ordered to be NPO (nothing by mouth). The patient reports severe nausea. Which action should the nurse take first? 1. Make sure the NG tube is functioning. 2. Offer the patient medication for pain control. 3. Administer an oral antiemetic medication. 4. Check if the health-care provider will order ice chips.

1. Make sure NG tube is functioning

The nurse understands that a variety of pharmacological methods of pain management exists. Which types of medications are available to help control pain? Select all that apply. 1. Nonopioid analgesics. 2. Ajuvant analgesics. 3. Patient-controlled analgesia (PCA). 4. Opiate/opioid medications. 5. Nonsteroidal antiflammatory drugs (NSAIDs)

1. Nonopioid analgesics. 2. Ajuvant analgesics. 4. Opiate/opioid medications. 5. Nonsteroidal antiflammatory drugs (NSAIDs)

The nurse is assisting with the delivery of meal trays. Which actions should the nurse perform to prepare a patient's environment for eating? Select all that apply. 1. Offer the patient a soapy and clean washcloth for the hands. 2. Turn off the patient's television to avoid distractions to eating. 3. Remove any articles that emit an odor which may decrease the patient's appetite. 4. Inquire if the patient needs to go to the bathroom or use a bedpan prior to eating. 5. Place the patient on the side of the bed to mimic normal eating position.

1. Offer the patient a soapy and clean washcloth for the hands. 3. Remove any articles that emit an odor which may decrease the patient's appetite. 4. Inquire if the patient needs to go to the bathroom or use a bedpan prior to eating.

The nurse is caring for multiple patients who are experiencing altered bladder function. Which patient will be the nurse's priority? 1. The patient with painful bladder contractions and distention 2. The patient diagnosed with urinary retention who just voided 3. The patient who is experiencing total urinary incontinence 4. The patient with an enlarged prostate who voids small amounts of urine frequently

1. Patient with painful bladder contractions and distention

The nurse is putting on personal protective equipment to provide care to a patient in transmission-based precautions. Which action should the nurse use to apply the gloves? 1. Place the gloves over the sleeves of the gown 2. Put the first glove on the dominant hand 3. Expose a slight area at the wrists 4. Double-glove

1. Place the gloves over the sleeves of the gown

The nurse dangles the patient and the patient reports dizziness. Which action should the nurse take first? 1. Place the patient in the Fowler's position. 2. Take the patient's blood pressure. 3. Take the patient's pulse. 4. Place the patient in the standing position.

1. Place the patient in the Fowler's position.

The nurse is providing care for a patient diagnosed with advanced colon cancer. The patient is scheduled for palliative surgery. Which purpose does the nurse identify for the type of surgery planned for this patient? 1. Remove as much of the tumor as possible. 2. Dissect the tumor and reconnect the bowel. 3. Remove the colon and form an ileostomy. 4. Implant a chemotherapy pump for a cure.

1. Remove as much of the tumor as possible.

The nurse is providing care to a patient on contact precautions. The nurse accidently rips a glove on the side of the bed. Which infection control precaution should the nurse implement? 1. Remove gloves and wash hands 2. Apply another clean glove over the ripped glove 3. Take off gloves and put on new ones 4. Finish care with the untorn gloved hand

1. Remove gloves and wash hands

The nurse works in an acute care facility. During meal time, which preparation is most important for the nurse make in order to promote nutritional intake for the patient? 1. Remove noxious items from the immediate environment. 2. Inquire if the patient prefers to eat in the bed or sitting in a chair. 3. Describe the items on the patient's tray and ask if any substitutions are desired. 4. Offer to either help feed or prepare the food for the patient's self-feeding.

1. Remove noxious items from the immediate environment.

The nurse is placing a nasogastric (NG) tube for a patient as prescribed. Which action is correct if the patient begins to gag during the process? 1. Remove the tube because it is in the larynx. 2. Pull the tube out slightly to stop the gagging. 3. Provide the patient with an emesis basin and proceed. 4. Give the patient sips of a favorite beverage as a distraction.

1. Remove tube because it is in the larynx

The nurse is washing hands before providing care to a patient in droplet precautions. Which technique should the nurse use? 1. Rinse hands with fingers pointing downward 2. Turn faucet off with dry hand 3. Wash hands for at least 10 seconds 4. Use bar soap to wash hands

1. Rinse hands with fingers pointing downward

The nurse is using the Braden Scale to determine pressure injury risk. Which parameters would the nurse assess? Select all that apply. 1. Sensory perception 2. Moisture 3. Nutrition 4. Age 5. Presence of chronic illnesses

1. Sensory perception 2. Moisture 3. Nutrition

The nurse in the operating room is aware that each person has a specific purpose. Which member of the surgical team is responsible for sustaining the patient's life and ensuring that the patient remains comfortable? 1. The anesthesia provider 2. The surgeon 3. The first surgical assistant 4. The scrub nurse

1. The anesthesia provider

The nurse is seeing a patient that is considered to be old-old. The patient is cared for in an adult child's home. Which finding causes the nurse to suspect elder abuse? 1. The patient has lacerations in varying stages of healing. 2. The patient is dressed too warm for the climate. 3. The patient appears to be sleepy and unresponsive. 4. The patient's scalp and fingernails are dirty and unkempt.

1. The patient has lacerations in varying stages of healing

The nurse is assigned to care for a patient receiving parenteral nutrition. Which reason does the nurse identify as inappropriate for parenteral nutrition? 1. The patient needs extra nutrition to increase weight. 2. The patient is unconscious and unable to eat. 3. The patient's digestive tract needs rest due to surgery or disease. 4. The patient is unable to absorb nutrition from the gastrointestinal (GI) tract.

1. The patient needs extra nutrition to increase weight

The nurse in a long-term care facility learns that a patient is being transferred to a different facility. The patient's family is waiting to move the patient by car to the new facility and asks about the delay. The nurse learns that the patient's discharge summary is not available. Which member of the staff does the nurse contact for completion of this summary? 1. The transferring facility's health-care provider 2. The facility's director of nursing 3. The nurse manager in the patient's unit 4. The nurse currently assigned to the patient

1. The transferring facility's health-care provider

The nurse is caring for a patient who is experiencing a pain level of 4 on a scale of 0-10 after the administration of pain medication. Before seeking an increase in the patient's medication order, the nurse decides to try distraction. Which activities are considered to be distractions for pain management? Select all that apply. 1. Turning on the television 2. Attempting to nap 3. Receiving a back rub 4. Working on word puzzles 5. Drinking a warm beverage

1. Turning on the television 3. Receiving a back rub 4. Working on word puzzles

The nurse works on a post-surgical unit. A patient who had surgery on this day requests pain medication. When the nurse enters the patient's room, the patient is sleeping. Which is the correct action for the nurse to take? 1. Wake the patient and give the medication. 2. Allow the patient to sleep. 3. Hold the medication until the patient asks again. 4. Document the medication as not being needed

1. Wake patient and give med

A patient has a viral infection. Which information would the nurse share with the patient? 1. "You will need to take an antibiotic to kill the virus." 2. "The virus can only multiply inside the body." 3. "The virus normally lives in the body." 4. "You will most likely have to take several medications."

2. "The virus can only multiply inside the body."

The nurse works in a long-term care facility. A new nurse expresses a lack of understanding about how older patients should be treated. Which comment by the experienced nurse reflects ageism? 1. "Always try to make your care as personalized to the individual as possible." 2. "You know how old people are, think about how your grandmother behaved." 3. "Don't make assumptions about what an older patient needs." 4. "Remember, some of these patients are younger than their chronological ages

2. "You know how old people are, think about how your grandmother behaved."

The nurse is monitoring the intake and output for a patient. Which substances will the nurse include as intake? Select all that apply. 1. A serving of ice cream. 2. A fruit-flavored gelatin. 3. Part of a can of cola. 4. An infused IV solution. 5. A bowl of clear broth.

2. A fruit-flavored gelatin. 3. Part of a can of cola. 4. An infused IV solution. 5. A bowl of clear broth.

The nurse is collecting data on a wound that is healing by second intention. Which patient finding will the nurse most likely observe? 1. An abdominal incision closed with staples 2. A gaping wound being packed with moist gauze 3. A wound that was open for several days and then sutured 4. An approximated incision closed with sutures

2. A gaping wound being packed with moist gauze

Which actions indicate the nurse understands narrative charting? Select all that apply. 1. Charts by exception 2. Charts in chronological order 3. Charts from admission to discharge 4. Charts using the acronym SOAP 5. Charts concisely and succinctly

2. Charts in chronological order 3. Charts from admission to discharge 5. Charts concisely and succinctly

The nurse is completing the admission process for a patient. When the nurse begins the personal property inventory, the patient states, "I have a large amount of cash in my jacket." Which action will the nurse take? 1. Ask the patient the amount of cash and record the amount. 2. Count the money with another nurse and document the amount. 3. Send the cash home with a family member who is present. 4. Inquire about the reason the patient has so much cash on their person.

2. Count money with another nurse and document amount

The nurse is caring for a patient who sustained an injury that is edematous and painful. The health-care provider orders alternating heat and cold therapy. The nurse is aware that the cold therapy will help with pain and swelling. Which therapeutic purpose does the nurse recognize for the heat therapy? 1. Counteracts the vasodilation from the cold therapy 2. Delivers oxygen, nutrients, and white blood cells (WBCs) for healing 3. Decreases pain and stiffness of involved joints 4. Provides temperature relief from the cold therapy

2. Delivers oxygen, nutrients, and white blood cells (WBCs) for healing

The nurse is explaining how oxygen moves from the blood to the body's cells. Which process is the nurse describing? 1. Osmosis 2. Diffusion 3. Filtration 4. Crenation

2. Diffusion

Which patient examples would the nurse classify as primary defenses against infection? Select all that apply. 1. Has an intravenous antibiotic infusing 2. Expectorates sputum 3. Urinates acidic urine 4. Secretes bile into the intestines 5. Develops a temperature

2. Expectorates sputum 3. Urinates acidic urine 4. Secretes bile into the intestines

The nurse is administering an enema to a patient. Which action should the nurse take? 1. Lubricate tube with petroleum-based lubricant. 2. Gradually raise the container 12 to 18 inches (30.5 to 45.7 cm) above the patient's hip level. 3. If resistance is felt, open the tubing to allow a large amount of fluid to flow. 4. Elevate the container if the patient reports cramping.

2. Gradually raise the container 12 to 18 inches (30.5 to 45.7 cm) above the patient's hip level.

The nurse is caring for a patient in tongs. Which area would the nurse monitor closely? 1. Lower leg 2. Head 3. Upper arm 4. Hip

2. Head

The nurse oversees a sterilization department. Instruments that are going to be sterilized are first prepared for the process. Which preparation step is correct? 1. Instruments are first soaked in a solution of hot water and antimicrobial soap. 2. Hinged instruments are left unhinged to prevent damage during sterilization preparation. 3. Instruments are rinsed with a strong solution of chlorine bleach after being washed. 4. The instruments are dried by a strong blast of air before being wrapped.

2. Hinged instruments are left unhinged to prevent damage during sterile preparation

The nurse is preparing to administer medication intramuscularly, and selects the correct size of syringe and needle. Which method will the nurse use to attach the needle to the syringe and keep the needle sterile? 1. Touch only the needle hub during attachment. 2. Hold the needle by the plastic cover during attachment. 3. Keep the needle in the package until it is attached to the syringe. 4. Wear sterile gloves until the hub is firmly attached to the syringe.

2. Hold the needle by the plastic cover during attachment.

The nurse is observing changes in a patient's mental functioning and skin color. Which condition is causing these changes? 1. Hypoxemia. 2. Hypoxia. 3. Cyanosis. 4. Crepitus

2. Hypoxia

A patient has a Kock pouch. Which technique would the nurse use? 1. Replace the bag when one-third to one-half full. 2. Insert a catheter to drain the pouch. 3. Store the external pouch below the stoma. 4. Make sure the patient wears the bag constantly.

2. Insert a catheter to drain the pouch.

The nurse is caring for a patient who has a leg infection. Which action indicates the nurse is using sterile technique? 1. Washes hands for 2 minutes 2. Inserts a Foley catheter 3. Removes the patient's lunch tray 4. Uses contact precautions

2. Inserts foley cath

The nurse is removing personal protective equipment (PPE) after providing care. In which area should the nurse take off the PPE? 1. Just outside of the patient's door 2. Just inside the patient's room 3. In the hallway 4. In the nursing lounge

2. Just inside the patient's room

The nurse is caring for a patient with a tracheotomy. Which action should the nurse take? 1. Throw the obturator away. 2. Make sure the cuff is inflated when the patient eats. 3. Remove the inner cannula to suction a fenestrated tracheostomy tube. 4. Use a Passy-Muir valve to allow more air flow but prevents the patient from talking.

2. Make sure the cuff is inflated when the patient eats.

The nurse is preparing to administer medication to an older adult patient. For which reason should the nurse check the patient for indications of toxicity? 1. An older adult may not be able to voice the effects of toxicity. 2. Older adults have a decrease in liver and kidney function. 3. It is difficult to distinguish the causes of toxicity in an older adult. 4. Older adults have a decreased ability to experience or describe pain.

2. Older adults have a decrease in liver and kidney function

The nurse is reviewing laboratory reports and observes a patient's incision is infected with Escherichia coli. The nurse is most likely caring for which patient? 1. One who had open heart surgery 2. One who had bowel surgery 3. One who had shoulder surgery 4. One who had brain surgery

2. One who had bowel surgery

The nurse asks for two other coworkers to assist in turning a patient as a unit. Which patient is the nurse turning? 1. One who has severe leg pain 2. One who has had the spine fused 3. One who is in a coma from a drug overdose 4. One who is disoriented to time and place

2. One who has had the spine fused

The nurse is transferring a patient who has right-sided weakness from the bed to the wheelchair. Which action should the nurse take? 1. Raise the bed to waist level. 2. Place the wheelchair on the patient's left side. 3. Apply the transfer belt on the patient's hips. 4. Logroll the patient to the side of the bed.

2. Place the wheelchair on the patient's left side

The nurse and the unlicensed assistive personnel (UAP) are caring for a patient after a direct anterior approach for a hip replacement. Which action by the UAP would cause the nurse to intervene? 1. Assisting the patient to turn 2. Placing an abduction pillow between the patient's legs 3. Obtaining fresh water for the patient 4. Allowing the patient to cross legs for comfort

2. Placing an abduction pillow between pt's legs

A patient has potassium prescribed. Which patient finding would cause the nurse to notify the health-care provider or charge nurse? 1. Patient's potassium level is 3.1 mEq/L. 2. Patient's urine output is 20 mL/hr. 3. Patient's IV potassium is mixed in pharmacy. 4. Patient's IV potassium rate is 10 mEq/hr.

2. Pt's urine output is 20 mL/hour

The nurse is caring for a patient receiving intermittent tube feedings. Prior to administering the next feeding, the nurse checks for residual volume. Which action by the nurse is correct if the residual amount is 130 mL? 1. Hold the feeding for 1 hr and recheck the residual volume. 2. Return the residual and proceed with the next feeding as ordered. 3. Document the residual volume in the medical record and notify the health-care provider. 4. Ask if the patient feels abdominal fullness and proceed accordingly.

2. Return residual and proceed with next feeding as ordered

The nurse is providing care for a patient diagnosed with renal disease. Which dietary restrictions will the nurse expect for this patient? Select all that apply. 1. Fiber restricted. 2. Sodium restricted. 3. Fat restricted. 4. Calorie restricted. 5. Protein restricted.

2. Sodium restricted 5. Protein restricted

The nurse admits an older adult patient who is physically slight in build. The patient is confused and restless. The health-care provider orders the patient on strict bedrest. The nurse is concerned about patient safety and uses _________________________ to prevent the patient from getting between the side rails. 1. Chair monitors 2. Soft restraints 3. Leg monitor 4. Four-way restraints

2. Soft restraints

The nurse in an extended care facility has a number of patients who are increased fall risks. Which patient is at greater risk due to the method of fall prevention? 1. The patient with Alzheimer disease who wears an ankle alarm due to wandering 2. The ambulatory patient who wears a restraint vest at night to prevent falls 3. The patient who needs assistance walking who has a pressure alarm under a chair cushion 4. Bolsters placed along the sides of a patient who attempts to crawl between the side rails

2. The ambulatory patient who wears a restraint vest at night to prevent falls

The nurse is pouring a sterile solution into a small cup on the sterile field. Which action by the nurse is considered incorrect? 1. The solution is poured slowly to prevent splashing onto the sterile field. 2. The label of the solution bottle is opposite the nurse's palm. 3. The solution bottle is held 4 to 6 inches above the cup on the sterile field. 4. The lip of the solution bottle is cleaned by pouring a small amount of liquid into the trash can.

2. The label of the solution bottle is opposite nurse's palm

Which actions are correct when nursing personnel are logrolling a patient? 1. The person at the feet directs the turn. 2. The patient's head and neck are supported during the turn. 3. The patient is turned in thirds: head, then body, then extremities. 4. One stands at the head, one stands at the hips, and one stands at the feet

2. The patient's head and neck are supported during the turn

The nurse is caring for a patient admitted with pain from an unknown cause. The patient is requesting opioid pain medications around the clock for pain at level 7 on a scale of 0 to 10. Which factor indicates that the nurse may be resistant to pain management? 1. Pain at a level 7 is unacceptable regardless of the cause. 2. The presence of pain from an unknown cause is related to drug seeking. 3. Pain is what the patient states it is and should be treated accordingly. 4. The nurse will focus on the effectiveness and side effects of pain

2. The presence of pain from an unknown cause is related to drug seeking.

The nurse is providing care to a patient who is ordered a nasogastric (NG) tube placement for gastric decompression for gastric distention and vomiting. The nurse notes the patient's vomitus is a greenish-yellow liquid. Which conclusion will the nurse draw from the appearance of the vomitus? 1. The vomitus has the appearance of bright red blood. 2. The vomitus is from the duodenum. 3. The vomitus has a coffee-ground appearance. 4. The vomitus appears to be darker red blood.

2. The vomitus is from the duodenum

The nurse is having an immobile patient breathe deeply. Which goal is the nurse trying to achieve? 1. To prevent orthostatic hypotension 2. To prevent atelectasis 3. To prevent renal calculi 4. To prevent compression neuropathy

2. To prevent atelectasis

The nurse is reviewing instruction about using a newly prescribed steroid inhaler with a patient. The patient is already using a bronchodilator inhaler. Which information is most important for the nurse to emphasize? 1. To rinse the mouth with water and spit it out after using the steroid inhaler. 2. To use the bronchodilator inhaler before the steroid inhaler. 3. To wait 5 min between the use of the two inhalers. 4. To hold the dispensed medication for 10 sec after it is inhaled.

2. To use bronchodilator inhaler before the steroid

The nurse is hired to work in a pain clinic. The nurse manager encourages the nurse to look at pain in a holistic manner. Which focus will help the nurse to achieve this outlook? 1. Realize that the patient's pain is probably causing sleep deprivation. 2. Understand that pain touches every aspect of the patient's life. 3. Accept that patients with pain will likely display anger and irritation. 4. Focus on the patient as an individual as well as their abilities.

2. Understand that pain touches every aspect of the patient's life

The nurse is caring for a resident in a long-term care facility. Which action should the nurse take when charting care about this resident? 1. Sign just the last entry on the page. 2. Use a specific time for each entry. 3. Write illegibly with a black pen. 4. Chart the procedure before it is done

2. Use a specific time for each entry

Which suggestion to conserve energy would the nurse make to a patient with chronic lung disease? 1. Stand while shaving. 2. Use a terrycloth robe after bathing. 3. Try to finish brushing teeth without resting. 4. After showering, obtain several small towels to dry body.

2. Use a terrycloth robe after bathing.

The nurse is caring for a patient with a viral infection. Which action is essential for the nurse to take to prevent the spread of infection? 1. Identify the patient with two identifiers 2. Wash hands before and after care 3. Use sterile technique 4. Take vital signs, especially temperature

2. Wash hands before and after care

The nurse is taking the written test regarding fires in the hospital setting. Which response on the nurse's test is correct? 1. "R" means "respond to the fire." 2. "A" means "assist patients to safety." 3. "C" means "confine the fire to one room or area." 4. "E" means "exit the hospital by way of the stairways."

3. "C" means "confine the fire to one room or area."

The nurse is preparing to administer a dose of viscus medication IM to a patient. The patient is a muscular male. Which needle does the nurse select? 1. A 24-gauge needle due to the thickness of the medication 2. A 14-gauge needle in order to easily penetrate the muscle 3. A 20-gauge needle to accommodate the medication and location of the IM 4. A 27-gauge needle to allow for rapid instillation of the medication

3. A 20-gauge needle to accommodate the medication and location of the IM

The licensed practical nurse/licensed vocational nurse (LPN/LVN) is a newly hired scrub nurse who is responsible for assisting the operating room (OR) nursing staff in setting up the OR. The scrub nurse utilizes the OR "cheat sheets" to assure proper preparation. Which information is unlikely to be included on the "cheat sheets"? 1. Information about the equipment needed for a specific type of surgery 2. Validation that the OR has been disinfected and is ready to receive the patient 3. A list of the names and titles of the personnel who will be in the OR during surgery 4. The individual surgeon's preferences for equipment and glove size

3. A list of the names and titles of the personnel who will be in the OR during surgery

The nurse provides care and evaluation for multiple older adults in a clinic setting. Which patient will the nurse identify as being at greatest risk for cardiovascular problems? 1. An old-old female patient who constantly reports feeling cold. 2. A young-old male who experiences leg pain after walking a short distance. 3. A middle-old female who is overweight with a family history of heart disease. 4. A middle-old male patient with hypertension and hypercholesterolemia.

3. A middle old male patient with hypertension and hypercholesterolemia

The nurse works in a long-term care facility. Which reason is the least important for using sterile procedures in this setting? 1. Wound dressings are used and changed. 2. Indwelling urinary catheters are common. 3. As in the hospital, pathogens are a concern. 4. Injectable medications are used regularly

3. As in the hospital, pathogens are a concern

The nurse is preparing to administer an oral narcotic pain medication to a patient. The health-care provider's order reads in part, "dispense 1½ tablets orally." Which action does the nurse take? 1. Breaks one of the tables in half and stores it in the patient's bin for the next dose. 2. Disposes of half of the second tablet by flushing it down the sink drain. 3. Asks another nurse to witness the wasting of one-half tablet of the medication. 4. Documents the information about wasting one-half tablet in the medical record.

3. Asks another nurse to witness the wasting of one-half tablet of the medication.

The nurse must use an N95 respirator to care for a patient. Which action should the nurse take? 1. Share the mask with other nursing personnel 2. Use the mask on the isolation cart 3. Be personally fitted for the mask 4. Make sure a small area of the mask is loose

3. Be personally fitted for the mask

The nurse is using DAR charting. Which information would the nurse chart after the A for a patient with food poisoning? 1. Diarrhea from food poisoning 2. Stools liquid and foul smelling 3. Bedside commode placed near bed 4. Reports, "I'm having diarrhea quite often"

3. Bedside commode placed near bed

A patient is taking iron for low red blood cells. The nurse would expect the patient's feces to be which color? 1. Green 2. Red 3. Black 4. Tan

3. Black

The nurse is providing care for a patient who has a nasogastric (NG) tube in place. Which nursing responsibility is incorrect? 1. Reassess q2h for vomiting, cramping, or pain. 2. Monitor for passage of rectal flatus indicating the return of peristalsis. 3. Clamp off the tube and auscultate bowel sounds every shift. 4. Provide mouth care and apply lip moisturizer q2h.

3. Clamp off tube and auscultate bowel sounds every shift

Which term would the nurse use in report to describe a patient's fracture that broke into many small pieces? 1. Hairline 2. Stump 3. Comminuted 4. Arthroplasty

3. Comminuted

The LPN/LVN reviews a patient's care plan. Which nursing diagnosis is the priority? 1. Caregiver role strain 2. Spiritual distress 3. Deficient fluid volume 4. Anxiety

3. Deficient fluid volume

The nurse is caring for a patient who is recovering from surgery. The health-care provider's diet order is to advance as tolerated. Which reassessment finding indicates to the nurse that the patient's diet should be advanced to full liquid? 1. Hypoactive bowel sounds with abdominal distension 2. Nausea and vomiting occurs throughout the shift. 3. Flatus is passed and there is a report of hunger. 4. Bowel movements have been frequent and watery.

3. Flatus is passed and there is a report of hunger

The nurse works in a long-term care facility. An unlicensed assistive personnel (UAP) tells the nurse that a couple of residents are having sexual intercourse in a room occupied by a single resident. Which action will the nurse take first? 1. Check to see if the UAP's report is accurate. 2. Ascertain if the act is consensual to both residents. 3. Inquire if the resident's door was closed. 4. Plan to discuss safe sex practices with the couple.

3. Inquire if the resident's door was closed

The nurse is reinforcing instructions with a patient on how to insert a vaginal cream for treatment of an infection. Which information, if shared with the patient, would result in ineffective treatment? 1. Telling the patient to remain supine for a period of 5 to 15 min. 2. Directing the patient to insert the application tube 3 in. into the vagina. 3. Instructing the patient to insert the application tube while sitting on the toilet. 4. Suggesting that the patient may want to wear a perineal pad to protect clothing.

3. Instructing the patient to insert the application tube while sitting on the toilet.

During surgery a patient's vital signs are closely monitored by the anesthesia provider. The patient's temperature is carefully watched for a condition called malignant hyperthermia. Which factor is relative to this condition? 1. It causes an increase in temperature due to a malignancy. 2. It indicates that the body has been invaded by infectious pathogens. 3. It occurs because of an inherited genetic trait. 4. It is in response to intravenous medications

3. It occurs because of an inherited genetic trait

The nurse is observing a patient with a weak left leg walk with a cane. Which patient action indicates a correct understanding of using a cane? 1. Places the cane by the left leg 2. Leans over the cane while walking 3. Moves the left leg and cane together, then the right leg 4. Has the height of the cane to the top of the hip bone

3. Moves the left leg and cane together, then the right leg

The nurse is caring for several patients who have colostomies. Which patient does the nurse expect to have the most liquid effluent? 1. One who has a transverse colostomy 2. One who has a sigmoid colostomy 3. One who has an ascending colostomy 4. One who has a descending colostomy

3. One who has an ascending colostomy

A patient has a high phosphorus blood level. The nurse is most likely caring for which patient? 1. One who has bowel disorders 2. One who has malnutrition 3. One who has chronic kidney disease 4. One who has vomiting and diarrhea

3. One who has chronic kidney disease

A patient is using a nebulizer with a mouthpiece. Which technique would the nurse observe for in this patient? 1. Patient breathes fast and shallow throughout the treatment. 2. Patient securely holds mouthpiece with teeth. 3. Patient breathes in through mouth and out through nose. 4. Patient opens mouth to exhale.

3. Patient breathes in through mouth and out through nose

Which action by the nurse is the most important way to prevent health-care-associated infections (HAIs)? 1. Wear protective personal equipment 2. Administer antibiotics 3. Perform handwashing 4. Follow transmission-based precautions

3. Perform handwashing

Which sputum finding would concern the nurse the most? 1. Thick yellow sputum. 2. Thin green sputum. 3. Pink frothy sputum. 4. Rust-colored sputum.

3. Pink frothy sputum

A patient's chest tube becomes disconnected from the drainage unit when the patient was transferred from the bed to the chair. Which action is the nurse's first priority? 1. Check for bubbles in the water seal chamber. 2. Milk the tubing of the chest tube system. 3. Place the end of the tube in water. 4. Clamp the chest tube with padded hemostats

3. Place the end of tube in water

A patient is taking furosemide. Which electrolyte level should the nurse monitor? 1. Copper 2. Zinc 3. Potassium 4. Phosphorus

3. Potassium

As the nurse is ambulating a patient, the patient states, "I feel like I am going to pass out," and the patient begins to slump. Which action should the nurse take? 1. Hold the patient upright. 2. Bend back to lower the patient to the floor. 3. Pull the patient toward the nurse. 4. Slide the patient down the front of the nurse's leg.

3. Pull the patient towards the nurse

The nurse is providing care for a patient with a percutaneous endoscopic gastrostomy (PEG) tube. Which care is appropriate for the nurse to provide for the patient? 1. Check whether the tape anchoring the tube is intact. 2. Position the tube to relieve pressure and prevent pressure injuries. 3. Reassess for skin integrity and cleanse around the insertion site. 4. Place in a supine position for the instillation of formula or medications.

3. Reassess for skin integrity and cleanse around insertion site

The nurse is reviewing the medications for a patient who is being discharged. Which action by the nurse to reconcile the patient's medications is inappropriate? 1. Compare market and generic names to identify medication duplicates. 2. Previous home medications are either continued or discontinued. 3. Recognize that a dose change for a medication is intended. 4. Prescriptions are provided for any newly ordered medications.

3. Recognize that a dose change for a medication is intended.

Which chart entry would the nurse document in a patient's chart? 1. Drank 150 cc of fluid with no pain. 2. Progressing well after abdominal surgery. 3. Right abdominal dressing dry and intact. 4. Administered MS for abdominal pain.

3. Right abdominal dressing dry and intact.

Which patient finding would the nurse report to the registered nurse (RN) about an abdominal wound? 1. White blood cell count was 16,000; white blood cell count today is 13,000. 2. Wound measuring 2 cm by 3 cm and 4 cm deep; wound is now 2 cm by 2 cm and 3 cm deep. 3. Slight wound exudate; excessive thick wound exudate today. 4. Severe edema around wound; slight edema around wound today.

3. Slight wound exudate; excessive thick wound exudate today

Which charting entry best reflects the nurse's evaluation of patient learning for constipation? 1. States that was glad to learn about constipation 2. Nodded head in agreement to increase fluids 3. States, "I will eat more high-fiber foods" 4. Seemed to understand instructions

3. States, "I will eat more high fiber foods."

The nurse is contributing to the plan of care for a patient with chronic lung disease. Which intervention should the nurse recommend including in the patient's plan of care? 1. Suggest eating fast. 2. Eat breads and pasta for ease of chewing. 3. Suggest a high-protein, caloric supplement. 4. Eat three meals a day evenly spaced throughout the day.

3. Suggest a high protein, caloric supplement

The nurse is caring for several different patients that have a lack of electrolytes. Which action should the nurse take? 1. Offer beef jerky to a patient with hypernatremia. 2. Offer dried fruits to a patient with hyperkalemia. 3. Suggest almonds for a patient with hypomagnesemia. 4. Suggest tomatoes for a patient with hypocalcemia.

3. Suggest almonds for a patient with hypomagnesia

A patient is having hard, infrequent stools. Which action should the nurse take? 1. Restrict fluid 2. Place on bedrest 3. Suggest eating yogurt 4. Decrease fiber intake

3. Suggest eating yogurt

The nurse encourages a patient to receive an annual flu immunization to prevent influenza. Which link in the infection chain did the nurse affect? 1. Infectious agent 2. Portal of entry 3. Susceptible host 4. Reservoir

3. Susceptible host

The nurse is reviewing a patient's blood levels of white blood cells and lymphocytes. Which line of defense against infection is the nurse checking? 1. Primary 2. Secondary 3. Tertiary 4. Quaternary

3. Tertiary

The nurse is preparing to set up a sterile field in a patient's room. Which consideration by the nurse is the least important? 1. The availability of an appropriate surface to set up the sterile field 2. The positioning of the sterile field so that the nurse can access it properly 3. The cleanliness of the surface of the over-the-bed table for locating the sterile field 4. The acquisition of equipment that is sterile and not past the expiration date

3. The cleanliness of the surface of the over the bed table for locating the sterile field

The nurse works in an acute care setting. When reviewing safety factors, the nurse becomes aware of many conditions that can contribute to patient safety. Which factor will the nurse identify as a contributing factor to an unsafe patient environment? 1. The patient is required to wear a hospital gown and slippers. 2. The patient feels confined to a room that is unfamiliar. 3. The patient finds the environment like a maze within a maze. 4. The patient may feel that privacy is compromised.

3. The patient finds the environment like a maze within a maze

The nurse works at a community clinic. Which older adult patient exhibits the positive aspects of aging to the nurse? 1. The patient who no longer attends church because of the inability to drive. 2. The patient who visits family in another state twice a year. 3. The patient who volunteers services as a small business advisor. 4. The patient who resists shopping for new clothing and personal services.

3. The pt who volunteers services as a small business advisor

The nurse is preparing to administer an intramuscular (IM) injection to a patient. Which information will assist the nurse in selecting the correct syringe size? 1. The consistency of the medication to be injected. 2. The dosage amount of the medication to be given. 3. The volume of medication that will be drawn up. 4. The physical size of the patient getting the medication.

3. The volume of medication that will be drawn up.

The nurse is reviewing a patient's plan of care. Which goal would the nurse most likely observe for a wet-to-damp dressing? 1. To blanch the wound surfaces 2. To prevent evisceration of the wound 3. To debride dead tissue in the wound 4. To reduce formation of wound keloids

3. To debride dead tissue in the wound

The nurse works as a scrub nurse and is preparing to perform hand hygiene for a surgical procedure. Which action is avoided during this preparation? 1. Use a sink that has hot and cold running water adjusted with a foot or knee control. 2. Use an orange stick or similar object to clean under and around the nails. 3. Use a soft-bristle brush to thoroughly clean hands, arms, and nails. 4. Use an alcohol-based hand rub in place of soap and water for greater effectiveness.

3. Use a soft-bristle brush to thoroughly clean hands, arms and nail

The nurse is caring for a patient who has tuberculosis. Which infection control precaution should the nurse implement? 1. Wear a mask and gown. 2. Leave the patient's door open. 3. Use an airborne infection isolation room. 4. Reuse gloves as needed.

3. Use an airborne infection isolation room

The nurse is preparing to discuss the physiological factors that make women more likely than men to contract a urinary tract infection (UTI). Which information should the nurse avoid presenting? 1. Women have a shorter urethra than men. 2. The urethra is located closer to the anus. 3. The vaginal pH supports the growth of pathogens. 4. Intercourse exposes the urethra to microbes.

3. Vaginal pH supports growth of pathogens

The nurse is preparing a 2.25-mL injection for an adolescent. A patient insists the injection be given in the arm. Which action does the nurse take? 1. Ask the patient to select a second site choice. 2. Tell the patient the gluteus maximus is best. 3. Give the medication as the patient requests. 4 Explain that the volume of medication is too large.

4 Explain that the volume of medication is too large.

Which statement by the patient will alert the nurse to the possibility of metabolic alkalosis? 1. "I am so anxious I can hardly catch my breath." 2. "I have had my colon removed." 3. "I have uncontrolled diabetes." 4. "I take a lot of antacids for my heartburn."

4. "I take a lot of antaacids for my heartburn."

Which patient would the nurse monitor most closely for hypervolemia? 1. A patient who loves ham and beans. 2. A patient who has a fever. 3. A patient who is hyperventilating from anxiety. 4. A patient who is elderly with heart failure.

4. A pt who is elderly with heart failure

A patient has fallen. Which piece of equipment would the nurse request a coworker to obtain while the nurse stays with the patient? 1. A hydraulic patient lift 2. A slide sheet 3. A transfer belt 4. A sling-type battery-operated patient lift

4. A sling-type battery-operated patient lift

The nurse is caring for a patient who has septicemia. Which culture result would the nurse review to determine the pathogen causing the septicemia? 1. Wound 2. Sputum 3. Urine 4. Blood

4. Blood

The nurse has a patient who is on a 24-hour urinary collection. The unlicensed assistive personnel (UAP) reports to the nurse that the final needed urine specimen was accidentally flushed. Which action will the nurse take? 1. Call the health-care provider to ask if a new specimen collection needs to be started. 2. Ask the UAP to add the next collected specimen to the collection jug. 3. Document the specific reasons that caused the collection to be started again. 4. Dispose of the collection jug and start the collection process over.

4. Dispose of the collection jug and start process over

The nurse works in a hospital that uses electronic health records (EHRs). Which situation violates the Security Rule? 1. Closing computer screens before walking away 2. Giving access only to personnel caring for a patient 3. Denying family members access to the medical record 4. Failing to report a breach in the use of one's password

4. Failing to report a breach in the use of one's password

The nurse is administering antibiotic drops to a patient's right eye for an infection. Which action by the nurse is incorrect when administering this drug? 1. Placing the medication into the middle of the conjunctival sac 2. Preventing injury by bracing the hand on the patient's cheek or forehead 3. Keeping the medicine local with gentle pressure on the lacrimal duct 4. Having the patient tilt the head back and slightly toward the left

4. Having the patient tilt the head back and slightly toward the left

Which patient would the nurse monitor most closely for loss of body water? 1. Adult male 2. Teenage female 3. Older adult male 4. Infant female

4. Infant female

The nurse is observing an unlicensed assistive personnel (UAP) move a patient in bed. Which action by the UAP would the nurse praise? 1. Slides the patient across the bed 2. Pulls the patient across the bed 3. Drags the patient across the bed 4. Lifts the patient across the bed

4. Lifts the patient across the bed

The nurse writes the following in a patient's chart: Heart tones strong. However, the nurse meant to write weak rather than strong. What should the nurse do? 1. Scratch out strong and add weak. 2. Place correction fluid over strong and then write weak. 3. Write weak over the word strong. 4. Make a single horizontal line through strong and initial it.

4. Make a single horizontal line through strong and initial it

The nurse is checking for blood in the stool. Which specimen should the nurse obtain? 1. One for a sensitivity test 2. One for an ova and parasite test 3 One for a culture test 4. One for a guaiac test

4. One for a guaiac test

The nurse is caring for a patient who had an indwelling urinary catheter removed during the previous shift. The nurse is concerned because the patient has not voided in the last 9 hours. Which action should the nurse take first? 1. Call the health-care provider to obtain an order for a straight catheterization. 2. Review the fluid intake the patient had during the previous shift. 3. Ask the patient if they have attempted to void without the catheter. 4. Perform a bladder scan to identify retained urine

4. Perform bladder scan to identify retained urine

The nurse is in the process of releasing a patient to go to surgery. When checking the patient's preoperative checklist, the nurse notes the patient was not given the opportunity to void before receiving preoperative medication. Which action should the nurse take? 1. Call the circulating nurse and report the patient may need to void. 2. Inform the patient they can ask to void while in the holding area. 3. Ascertain if the patient can be assisted to the bathroom before leaving the unit. 4. Provide a bedpan or urinal so the patient can void before leaving the unit.

4. Provide a bedpan or urinal so the patient can void before leaving the unit

The registered nurse (RN) asks if the licensed practical nurse/licensed vocational nurse (LPN/LVN) is comfortable caring for a patient who has a central venous catheter (CVC) for the delivery of total parenteral nutrition (TPN). Which reaction by the LPN/LVN is correct? 1. Accept the assignment with an understanding that the RN will assist the LPN/LVN. 2. Request that an additional LPN/LVN be assigned to assist with the patient's care. 3. Assume responsibility with clear instructions for when the LPN/LVN is to notify the RN. 4. Refuse the assignment because it is outside the scope of practice for the LPN/LVN.

4. Refuse the assignment because it is outside the scope of practice for the LPN/LVN.

The nurse is reviewing information about pain and discomfort control after surgery. Which information is most important for the nurse to reinforce with a patient? 1. Being able to move about and cough and deep-breathe is easier with pain medication. 2. The strength of the pain medication will be decreased as the pain decreases. 3. Pain is easier to control if pain medication is given before the pain is severe. 4. Research shows that the body recovers and heals faster when pain is controlled.

4. Research shows that the body recovers and heals faster when pain is controlled.

The nurse works in an extended care facility. Which method of routine patient identification is the nurse most likely to use in this setting? 1. Picture and medical record number 2. Room number and date of birth 3. Patient name and picture 4. Room number and picture

4. Room number and picture

The nurse works in a health-care provider's office and is interviewing an older adult patient who is seeking medical care for an acute upper respiratory condition. Which other body system will the nurse be able to easily evaluate during the interviewing process? 1. Cardiovascular functions. 2. Gastrointestinal (GI) functions. 3. Integumentary changes. 4. Sensory and neurological processes

4. Sensory and neurological processes

The nurse is observing an unlicensed assistive personnel (UAP) provide care to patients on transmission-based precautions. Which action by the UAP would cause the nurse to intervene? 1. The UAP wears an N95 respirator for a patient with chickenpox. 2. The UAP leaves the disposable blood pressure cuff in a patient's room who is on droplet precautions. 3. The UAP enters a semi-private room and pulls the curtain because one patient is on droplet precautions. 4. The UAP dons only gloves to provide a bath to a patient on contact precautions.

4. The UAP dons only gloves to provide a bath to a patient on contact precautions

A patient is being admitted to the hospital through the admission department. Which information gathered during this process can potentially influence nursing care? 1. The place of the patient's employment 2. The insurance coverage provided 3. The reason for the patient's admission 4. The existence of an advance directive

4. The existence of an advance directive

The nurse is caring for a patient who has a secondary infection. The nurse is most likely caring for which patient? 1. The small male child who has meningitis 2. The male who had a wound infection from Staphylococcus that also has infected the face 3. The older adult who has pneumonia and is receiving antibiotics 4. The female who is taking an antibiotic for a bacterial infection but then develops a yeast infection

4. The female who is taking an antibiotic for a bacterial infection but then develops a yeast infection

The nurse is providing care for a patient with a nasogastric (NG) tube. The nurse is preparing to administer medications through the NG tube. Which finding should the nurse report before medication administration? 1. Aspirated gastric contents indicate a pH level equal to the acidity of stomach juices. 2. The radioscopic verification was obtained at the time of tube placement. 3. The silk tape holding the tube in place has begun to peel away. 4. The indelible ink mark on the tube is several inches from the nares.

4. The indelible ink mark on the tube is several inches from the nares

The nurse is preparing to review discharge instructions with a patient. Which behavior by the nurse verifies the patient's understanding regarding the instructions? 1. The patient signs the discharge form as an expression of understanding. 2. The nurse documents the patient has no questions about discharge instructions. 3. The nurse documents the specific topics reviewed with the patient. 4. The patient is asked questions about the information presented.

4. The patient is asked questions about the information presented

The nurse is planning to administer a parenteral medication and selects a tuberculin syringe. Besides performing an intradermal tuberculosis (TB) test, for which reason will the nurse select this size syringe? 1. To give an IM to a thin, older adult patient. 2. To administer insulin to a school-age patient 3. To administer eye medications to an adult patient 4. To give a precise amount of medication to a newborn

4. To give a precise amount of medication to a newborn

A nurse is discussing Medicare and states that this insurance is primarily for people older than what age? Enter answer as a whole number.

65

Which patient situation would the nurse use to describe transmission of infection by indirect contact? 1. Patient kisses spouse who has a cold. 2. Patient sneezes into palm and then shakes the nurse's hand. 3. Patient vomits and nurse cleans emesis with ungloved hands. 4. Patient coughs on portable electric thermometer and another patient uses the electric thermometer.

Patient coughs on portable electric thermometer and another patient uses the electric thermometer.

The nurse is beginning care with a patient who was just admitted with stroke. What is essential for the nurse to develop in the nurse-patient relationship? 1. Humor 2. Trust 3. Encouragement 4. Intellect

2. Trust

The licensed practical nurse/licensed vocational nurse is reinforcing teaching with a patient who is a member of a health maintenance organization (HMO). Which statement made by the patient would indicate that teaching has been effective? 1. "I should obtain prior authorization before a computed tomography scan is performed." 2. "I have a nurse that can make referrals for me." 3. "I will pay depending on how many times I see my primary care physician." 4. "I can decide if an appointment with an endocrine specialist is needed."

"I should obtain prior authorization before a computed tomography scan is performed."

The nurse is assisting the registered nurse (RN) in presenting a staff educational program about blood pressure. Which statement by staff members indicates successful teaching? Select all that apply. 1. "Blood pressure can decrease from hemorrhage." 2. "Increased intracranial pressure will cause the blood pressure to lower." 3. "Overhydration increases blood pressure." 4. "Nicotine can raise blood pressure for a short time." 5. "The parasympathetic nervous system lowers blood pressure."

1. "BP can decrease from hemorrhage." 3. "Overhydration increases blood pressure." 5. "The parasympathetic nervous system lowers blood pressure."

Which statements from the nurse indicate a correct understanding of active listening? Select all that apply. 1. "I also listen to what the patient is not saying." 2. "I use all my senses to interpret verbal and nonverbal messages from the patient." 3. "I focus solely on the spoken words of the patient." 4. "I tune out other distractions and focus on the patient." 5. "I know what I am going to say before the patient is through speaking."

1. "I also listen to what the patient is not saying." 2. "I use all my senses to interpret verbal and nonverbal messages from the patient." 4. "I tune out other distractions and focus on the patient."

Which statement would an assertive nurse use during patient care? 1."I do not appreciate that kind of behavior." 2."Do you think you could walk for me today?" 3."It doesn't matter what I do." 4."Who do you think you are talking to?"

1. "I do not appreciate that kind of behavior."

The new graduate nurse states, "I am always fearful that I will forget part of the physical assessment process." Which assistance does the experienced nurse provide? 1. "Start at the top and move downward to the toes, then do the arms and legs." 2. "I begin with the part of the body associated with the symptoms shared by the patient." 3. "Everyone has their own technique so just find an order that makes sense to you." 4. "Write everything down and go back if you need to find missing

1. "Start at the top and move downward to the toes, then do the arms and legs."

Which responses by the nurse would facilitate communication? Select all that apply. 1. "What is causing you the greatest concern at this time?" 2. "Tell me more about this pain you are having." 3. "Why did you do that?" 4. "I don't think you should divorce your spouse." 5. "It will be OK; my father had this surgery and did fine."

1. "What is causing you the greatest concern at this time?" 2. "Tell me more about this pain you are having."

The licensed practical nurse/licensed vocational nurse (LPN/LVN) is using the skill of palpation during the reassessment of a patient. Which conditions will the nurse expect to find with palpation? Select all that apply. 1. A fatty tumor beneath the skin on the arm. 2. A pulse deficit between the left and right foot. 3. Pitting edema in the lower extremities. 4. A liver mass related to a medical diagnosis. 5. Muscle rigidity in a seizing neck muscle.

1. A fatty tumor beneath the skin on the arm. 2. A pulse deficit between the left and right foot. 3. Pitting edema in the lower extremities. 5. Muscle rigidity in a seizing neck muscle.

Which behavior by the nurse represents professionalism? 1. Administers the wrong drug to a patient and tells the nurse in charge 2. Quickly suctions a patient while focusing solely on the skill to be performed 3. Tenderly cares for all patients in the exact same manner 4. Takes longer to return after breaks to relax and recharge himself or herself

1. Administers the wrong drug to a patient and tells the nurse in charge

Part of the assessment process involves an interview by the admitting nurse. Which information will be included in the interview portion of assessment? Select all that apply. 1. Medical history. 2. Personal identity. 3. Food and drug allergies. 4. Details about current condition. 5. Patient expectations of hospitalization.

1. Medical history. 2. Personal identity. 3. Food and drug allergies. 4. Details about current condition. 5. Patient expectations of hospitalization.

The LPN/LVN is collecting data from a patient by performing an interview. Which action should the nurse take first? 1. Develop rapport 2. Perform a physical assessment 3. Take vital signs 4. Ask questions from the form

1. Develop rapport

An adult child brings an older adult patient to a clinic. The patient is in soiled clothing, has a body odor of urine, and is unable to answer questions. Which additional assessment is most important for the nurse to perform? 1. Evaluate the patient for signs of current or past physical injuries. 2. Inquire if the adult child feels burdened with patient care. 3. Ask the adult child the reason for bringing the patient to the clinic. 4. Determine the patient's physical and cognitive level of functioning.

1. Evaluate the patient for signs of current or past physical injuries

A patient who has an abdominal wound needs a special diet and is being discharged today. The patient lives alone and has arthritis. The patient reports that he cannot afford the dressing supplies and that he does not feel confident he can change the dressing correctly. Which health-care team members does the licensed practical nurse/licensed vocational nurse expect to be consulted? Select all that apply. 1. Home health nurse 2. Medical social worker 3. Registered dietitian 4. Speech and language therapist 5. Respiratory therapist

1. Home health nurse 2. Medical social worker 3. Registered dietitian

Which are important characteristics for a nurse to have? Select all that apply. 1. Is responsible 2. Makes patients laugh 3. Tells the truth 4. Has a caring attitude 5. Is organized

1. Is responsible 3. Tells the truth 4. Has a caring attitude 5. Is organized

The nurse is preparing to review the physical assessment performed on a newly admitted patient. Which purpose of the physical assessment will the nurse identify as inaccurate? 1. It provides guidelines for decisions about medical treatment. 2. It establishes a baseline of the patient's current condition for comparison. 3. It uses data to evaluate the effectiveness of nursing interventions. 4. It identifies real or potential problems for which the patient is at risk.

1. It provides guidelines for decisions about medical treatment

Which information should the nurse include in a change-of-shift report? Select all that apply. 1. Lungs clear bilaterally with no cough. 2. Oh, I forgot, the blood pressure is continuing to rise. 3. You should see what the patient's mother is wearing. 4. Chest x-ray indicates tuberculosis. 5. Patient uses a walker.

1. Lungs clear bilaterally with no cough. 2. Oh, I forgot, the blood pressure is continuing to rise. 4. Chest x-ray indicates tuberculosis. 5. Patient uses a walker.

The registered nurse (RN) is preparing a patient assignment for the licensed practical nurse/licensed vocational nurse (LPN/LVN). Which assignment does the RN recognize as being within the LPN/LVN's scope of practice? 1. Maintain input and output for a patient admitted for dehydration. 2. Perform the initial dressing change for a patient after abdominal surgery. 3. Teach a patient newly diagnosed with diabetes mellitus about diet management. 4. Assess a patient after a stroke for the ability to perform activities of self-care.

1. Maintain input and output for a patient admitted for dehydration

A patient has a fever. Which independent intervention can the nurse implement? 1. Administer acetaminophen every 4 hours 2. Place a cool washcloth on the patient's forehead 3. Start IV fluids for hydration 4. Obtain blood cultures to determine cause of fever

2. place cool washcloth on Pt's forehead

A nurse is describing for new staff members the factors in health-care delivery that are influenced by economics. Which two major factors would the nurse include to reinforce this assertion? Select all that apply. 1. Medical necessity 2. Capitation 3. Point-of-Service plan (POS) 4. Preferred Provider Organization (PPO) 5. Appropriate level of care

1. Medical necessity 5. Appropriate level of care

A patient who suffered a stroke needs to learn to eat again. Which health-care team member would be consulted? 1. Occupational therapist 2. Pathologist 3. Radiologic technologist 4. Phlebotomist

1. Occupational therapist

Which patient is most likely to be insured by Medicaid? 1. One who has a low income 2. One who is 75 years old 3. One who is in a severe vehicle accident 4. One who has a certificate of degree of Indian blood (CDIB)

1. One who has a low income

The nurse enters a patient's room and discovers the patient sitting on the side of the bed and leaning forward over the bedside table. Which condition does the nurse associate with the patient's position? 1. Orthopnea. 2. Lethargy. 3. Dysphagia. 4. Hypoxia.

1. Orthopnea

The nurse is checking the vital signs sheet. Which findings would the nurse determine are normal for adult patients? Select all that apply. 1. P - 88, R - 14, BP - 118/64, T - 97°F (36.1°C) 2. P - 110, R - 26, BP - 86/40, T - 98°F (36.7°C) 3. P - 65, R - 18, BP - 110/70, T - 99.6°F (37.5°C) 4. P - 52, R - 10, BP - 145/95, T - 102°F (38.9°C) 5. P - 76, R - 20, BP - 112/74, T - 98.6°F (37°C

1. P - 88, R - 14, BP - 118/64, T - 97°F (36.1°C) 3. P - 65, R - 18, BP - 110/70, T - 99.6°F (37.5°C) 5. P - 76, R - 20, BP - 112/74, T - 98.6°F (37°C

Which situations would cause the nurse to take a patient's vital signs more often? Select all that apply. 1. Patient is receiving blood. 2. Patient is unstable after hip replacement. 3. Patient's blood pressure was 120/68 and it is now 100/45. 4. Patient is about to be discharged. 5. Patient is cold and clammy

1. Patient is receiving blood. 2. Patient is unstable after hip replacement. 3. Patient's blood pressure was 120/68 and it is now 100/45. 5. Patient is cold and clammy

The nurse hears in report that a patient has tachycardia. What will the nurse expect to find when collecting data from the patient? 1. Patient's heart rate is above 100 beats per minute. 2. Patient's respiratory rate is above 20 respirations per minute. 3. Patient is hypothermic. 4. Patient has increased intracranial pressure.

1. Patient's heart rate is above 100 BPM

The nurse is contributing to the plan of care for a patient with pyrexia. Which interventions should the nurse recommend including in the patient's plan of care? Select all that apply. 1. Provide additional fluid intake 2. Offer three meals per day 3. Provide mouth care 4. Promote rest periods 5. Avoid antipyretics

1. Provide additional fluid intake 3. Provide mouth care 4. Promote rest periods

The nurse is working on a young pediatric unit. How would the nurse inform the unlicensed assistive personnel to place a tympanic thermometer? 1. Pull the pinna downward and back 2. Pull the pinna upward and back 3. Pull the pinna sideward and up 4. Pull the pinna straight up

1. Pull the pinna downward and back

The nurse is collecting data from a patient who is febrile. Which signs and symptoms would the nurse observe? Select all that apply. 1. Reddened face 2. Increased pulse rate 3. Decreased respiratory rate 4. Decreased appetite 5. Increased irritability

1. Reddened face 2. Increased pulse rate 4. Decreased appetite 5. Increased irritability

The nurse is caring for a patient who was in a motorcycle accident. The patient is stable and progressing as expected but will require extensive physical therapy for the lower extremities. Which facility does the licensed practical nurse/licensed vocational nurse (LPN/LVN) expect the health-care provider will recommend for this patient? 1. Rehabilitation facility 2. Long-term acute care hospital (LTACH) 3. Detoxification unit 4. Ambulatory care clinics

1. Rehab facility

A patient's blood pressure drops when changing positions. Which information would the nurse share with the patient? 1. Rise slowly to a standing position 2. Use the modified Trendelenburg position 3. Reduce dietary intake of salt 4. Walk immediately upon standing

1. Rise slowly to a standing position

The nurse is on an airplane when another passenger becomes short of breath. The flight attendant asks for assistance from anyone with medical training. When the nurse's traveling companion suggests that the nurse assist, the nurse states, "I am not risking legal repercussions in this setting." Which should the nurse consider? 1. The Good Samaritan Law will protect the nurse. 2. Refusing assistance is the same as abandonment. 3. The nurse has a professional obligation to assist. 4. The nurse is covered by the airline's insurance.

1. The Good Samaritan Law will protect the nurse.

The nurse is newly hired on the cardiac stepdown unit, and is reviewing the principles of evaluating the apical pulse. Which conclusions made by the nurse about the apical pulse are correct? Select all that apply. 1. The first sound, S1, is louder and represents the "lubb" sound. 2. The apical pulse is taken for 1 full min as a standard of practice. 3. The apical pulse is best heard right of the sternum at the second intercostal space. 4. An S2 sound is longer and represents a conduction delay. 5. Evenly spaced beats indicates that the cardiac rhythm is regular

1. The first sound, S1, is louder and represents the "lubb" sound. 2. The apical pulse is taken for 1 full min as a standard of practice. 5. Evenly spaced beats indicates that the cardiac rhythm is regular

Which statement made by the nurse indicates a correct understanding of the Nurse Practice Act? 1. The law addresses every level of nursing. 2. Texas and California do not have these laws. 3. The health board enforces these laws. 4. The law allows the LPN to be supervised only by a physician.

1. The law addresses every level of nursing.

When the nurse first enters a patient's room, the process of inspection begins. Which conclusion by the nurse can be solely identified through the process of inspection? Select all that apply. 1. The patient needs assistance with personal care. 2. The patient is sweating due to the room temperature. 3. The patient is tall but also overweight. 4. The patient is experiencing respiratory distress. 5. The patient is not connected to tubing or equipment.

1. The patient needs assistance with personal care

The nurse is providing care for a patient scheduled for surgery to amputate gangrenous toes from the left foot. During the shift assessment, the nurse checks pedal pulses, skin color and warmth, and the level of pain. Which finding would prompt the nurse to perform an additional assessment? 1. The patient's right lower leg and ankle are swollen. 2. The pedal pulses to the left foot are lower than 12 hr earlier. 3. The right lower extremity is pink in color and warm to the touch. 4. The level of pain in the left lower extremity is a level 6 on a 0 to 10 scale

1. The patient's right lower leg and ankle are swollen

A patient has a pulse rate of 54. Which question should the nurse ask to determine if this is a normal finding? 1. "Do you smoke?" 2. "Are you a marathon runner?" 3. "Are you stressed about something?" 4. "Do you take theophylline?"

2. "Are you a marathon runner?"

The nurse is making patient care assignments. The nurse would assign the unlicensed assistive personnel (UAP) to take vital signs on which patient? 1. A patient who becomes confused 2. A patient who is 2 days postoperative with no complications 3. A patient who has a gunshot wound that is bleeding profusely 4. A patient who is having a hard time breathing

2. A patient who is 2 days postop with no complications

The nurse is caring for a patient scheduled for surgery. The nurse overhears an unlicensed nursing assistant personnel (UAP) tell the patient, "My mother suffered terribly and died after this same surgery. You better think about it." Which is the nurse's first action? 1. Plan an in-service program about ethics. 2. Ask the patient to share questions and concerns. 3. Inform the health-care provider that the patient may reconsider surgery. 4. Report the UAP's behavior to the nurse manager.

2. Ask the patient to share questions and concerns

A patient with no chronic illnesses or major disability needs help with bathing, dressing, and taking medications; the patient also needs meals provided. Which residential care facility does the licensed practical nurse/licensed vocational nurse (LPN/LVN) expect will be recommended by the health-care provider as the best fit for this patient? 1. Long-term care facility 2. Assisted living facility 3. Memory care facility 4. Independent living facilities

2. Assisted living facility

A nursing student has finished 2 years of general education courses and is now taking nursing courses at a university. Which educational program is the nursing student enrolled in? 1. Diploma 2. Baccalaureate 3. Master's 4. Associate's

2. Baccalaureate

The nurse in an adult clinic is assessing a patient who just arrived. Which assessment of the patient's general appearance indicates physical distress? 1. Facial expression with wide eyes 2. Breathing through the mouth 3. Unkempt physical appearance 4. Slow response to verbal stimuli

2. Breaking through the mouth

The nurse is assigned to care for a patient who is hospitalized. Which patient finding did the nurse most likely find with the use of a stethoscope? 1. Eructation. 2. Carotid bruit. 3. Wheezing. 4. Passing flatus.

2. Carotid bruit

The nurse is caring for all of the following patients. Which patient would most likely have the lowest temperature? 1. Patient is stressed about upcoming surgery. 2. Patient's temperature was taken in the early morning. 3. Patient is ovulating. 4. Patient's activity level increased.

2. Patient's temperature was taken in the early morning

Which phrase should the nurse use to describe the nursing process? 1. Written plan of care 2. Decision-making framework 3. Another word for critical thinking 4. Validation of information

2. Decision making framework

The licensed practical nurse/licensed vocational nurse (LPN/LVN) is reassessing an assigned patient. For which assessment will the LPN/LVN use the skill of palpation? 1. To reassess the location of the liver 2. To reassess for dependent edema 3. To reassess for a bladder distention 4. To reassess for appendix tenderness

2. To reassess for dependent edema

A patient is angry and is insisting on going home even though multiple therapies are in place. The nurse calls the health-care provider and requests a sedative to help calm the patient. Which tort may the nurse be guilty of if the patient is medicated under these conditions? 1. Chemical restraining 2. False imprisonment 3. Battery 4. Assault

2. False imprisonment

The nurse is preparing to perform a head-to-toe assessment on a patient. Which action by the nurse is performed first? 1. Ensure the patient's privacy. 2. Gather all the necessary equipment. 3. Suggest that the patient use the bathroom. 4. Explain the purpose of the assessment.

2. Gather all necessary equipment

A patient has a slightly elevated temperature. Which questions would the nurse ask to determine if there are factors that may have contributed to the elevated temperature? Select all that apply. 1. Had the patient drunk a cold beverage? 2. Had the patient ambulated before the temperature? 3. Had the patient eaten a meal earlier? 4. Was the patient shivering? 5. Was the patient diaphoretic?

2. Had the patient ambulated before the temperature? 3. Had the patient eaten a meal earlier? 4. Was the patient shivering?

A nurse is using a scanning tool to administer medication correctly to a patient. Which area of the Quality and Safety Education for Nurses (QSEN) project best represents the nurse's action? 1. Teamwork and collaboration 2. Informatics 3. Client-centered care 4. Scope of practice

2. Informatics

The nurse is performing a reassessment of a patient's breath sounds. Which action by the nurse is correct during this assessment? 1. Listening to the posterior chest wall prior to listening to the anterior wall 2. Listening to the apex of the lungs before auscultating the lateral aspects 3. Listening to the left side of the chest before listening to the right side 4. Listening to a minimum of two breaths at each auscultation site

2. Listening to the apex of lungs before auscultating the lateral aspects

The nurse is using the ISBARR to report a patient problem to the health-care provider. Which information should the nurse include for the B? 1. Dr. Smith, this is Mary Jones, LPN, at Lakeview Hospital. 2. Mr. Allan is having chest pain that is not relieved by medication. 3. The patient's O2 sats are 86% and pulse is 54 and irregular. Skin is clammy. 4. Would you like an ECG done and cardiac enzymes drawn?

2. Mr. Allan is having chest pain that is not relieved by medication.

The nurse admits a patient to the hospital for injuries related to domestic abuse. The patient fears harm from the abusing spouse while the patient is in the hospital. Which precaution shared by the nurse will provide the patient with the greatest sense of safety? 1. The hospital must abide by the Health Insurance Portability and Accountability Act (HIPAA). 2. No one in the hospital can give information about the patient or even confirm that the patient is there. 3. Health-care personnel in general will not have access to information about the patient. 4. Hospitals have armed security personnel who respond immediately to patient safety issues.

2. No one in the hospital can give information about the patient or even confirm that the patient is there.

Which patient finding would the nurse report as subjective data? 1. Patient vomited green fluid. 2. Patient has stomach cramps. 3. Patient is rubbing abdomen. 4. Patient moans occasionally.

2. Patient has stomach cramps.

Which information that the nurse gives in report is objective? 1. Patient has severe stomachache. 2. Patient's blood pressure is 120/70. 3. Patient is apprehensive about surgery. 4. Patient likes grapefruit juice.

2. Patient's BP is 12/70

A patient went hiking in the woods during the winter and got lost. Upon admission to the emergency department (ED) the patient's temperature is 93.8°F (34.3°C). Which action should the nurse take when assisting the registered nurse (RN)? 1. Apply ice packs to the axillae and groin 2. Place the patient on a heating blanket 3. Leave the head uncovered 4. Administer aspirin

2. Place the patient on a heating blanket

The LPN/LVN is assisting the RN who is writing long- and short-term goals. Which step of the nursing process are the nurses working on? 1. Assessment 2. Planning 3. Evaluation 4. Diagnosis

2. Planning

The nurse is working in a clinic that focuses on the care of patients with respiratory conditions. Which adventitious breath sounds will the nurse recognize as causing the concern? Select all that apply. 1. Crackles that will not clear with a cough. 2. Rhonchi that sounds like snoring and gurgling. 3. Wheezes heard on inspiration and expiration. 4. Stridor present in a toddler in the emergency room. 5. Pleural friction rub present after being in the cold.

2. Rhonchi that sounds like snoring and gurgling. 4. Stridor present in a toddler in the emergency room

The registered nurse (RN) assigns patient care to a licensed practice nurse/licensed vocational nurse (LPN/LVN) and an unlicensed assistive personnel (UAP). Which patient need would require the RN to reassume total responsibility for a patient? 1. The UAP's patient wants assistance with selecting a low-sodium diet. 2. The LPN/LVN's patient with pneumonia develops uncontrollable coughing. 3. The UAP needs to reapply elastic stockings to a patient with lower extremity edema. 4. The LPN/LVN's patient had surgery and needs a daily sterile dressing change.

2. The LPN/LVN's patient with pneumonia develops uncontrollable coughing.

The nurse is performing an abdominal reassessment on a patient who had abdominal surgery under general anesthesia. Which is the correct conclusion if the nurse counts 22 clicks and gurgles after auscultating the patient's abdomen for 1 min? 1. Bowel sounds support a clear liquid diet. 2. The bowel is exhibiting normal activity. 3. Bowel sounds are indicative of a blockage. 4. The bowel is still affected by the anesthesia.

2. The bowel is exhibiting normal activity

The nurse is having problems getting the unlicensed assistive personnel to complete assigned tasks. Which communication technique would the nurse use? 1. "Tasks are not getting completed. Why are you so lazy?" 2. "You have been working here for over 6 months. I don't understand your lack of organizational skills." 3. "Patient care is not getting completed for your assigned patients. What is happening?" 4. "Stop wasting time. Try to get the rest of your work done on time."

3. "Patient care is not getting completed for your assigned patients. What is happening?"

The nurse counts the respirations for 15 seconds and gets 4. How many respirations per minute should the nurse chart on the vital signs sheet? 1. 8 2. 12 3. 16 4. 20

3. 16

The nurse obtains the following vital signs: Radial pulse - 87; Apical pulse - 93; Blood pressure - 134/86. What is the pulse pressure? 1. 86 2. 6 3. 48 4. 220

3. 48

The unlicensed assistive personnel (UAP) is reporting SpO2 results to the nurse. Which finding would cause the nurse to check a patient? 1. 96% on room air 2. 95% with O2 at 2 L/min 3. 88% on room air 4. 92% with O2 at 2 L/min

3. 88% on room air

The following goal is written in a patient's care plan: Patient will verbalize three foods allowed on a heart-healthy diet. Which action should the nurse take to evaluate this goal? 1. Talk to the dietitian about the patient's diet. 2. Suggest foods the patient should eat to protect the heart. 3. Ask the patient to list items that will be eaten after discharge. 4. Monitor the patient for heart disease monthly.

3. Ask the patient to list items that will be eaten after discharge

The nurse ambulates a patient with intestinal gas buildup in the hallway to help relieve the discomfort. Which step of the nursing process did the nurse complete? 1. Assessment 2. Planning 3. Implementation 4. Evaluation

3. Implementation

A patient says to the nurse, "I was hurting so bad that I called my husband at work. He works at a school as a teacher, so it was hard to get a hold of him. The pain is just so overwhelming." The nurse responds by saying, "Are you saying the pain is unbearable?" Which therapeutic technique did the nurse use? 1. Summarizing 2. Reflecting 3. Clarifying 4. Using open-ended question

3. Clarifying

A nurse performs the following duties for a patient: gives a bath, provides whirlpool treatments, draws blood, and administers a breathing treatment. Which type of nursing care delivery is the nurse using? 1. Team nursing 2. Primary care nursing 3. Client-centered care 4. Case management

3. Client-centered care

The LPN/LVN reviews the nursing diagnosis written on the care plan: Risk for infection related to a break in the skin. The italicized phrase represents which component of the nursing diagnosis? 1. Signs and symptoms 2. Defining characteristics 3. Etiology 4. Problem

3. Etiology

The nurse is assigned to care for a patient who was injured during an arrest for a violent crime. The nurse states, "I will not take care of this terrible person." The nurse then leaves the unit and goes home. Which disciplinary action is the charge nurse most likely to initiate against the nurse? 1. Firing for insubordination 2. Inquiry by state board of nursing 3. Filing charges of abandonment 4. Entry of incident in personnel file

3. Filing charges of abandonment

The registered nurse (RN) assigns a licensed practical nurse/licensed vocational nurse (LPN/LVN) the task of inserting a nasogastric (NG) tube. The LPN/LVN has only performed this task once in nursing school on a mannequin. Which behavior by the LPN/LVN is best? 1. Use the facility procedure manual for guidance. 2. Look the procedure up on a medical Web site. 3. Inform the RN and ask for guidance and assistance. 4. Mentally review the procedure and insert the tube.

3. Inform the RN and ask for guidance and assistance

The nurse is preparing to reassess a patient at the beginning of the shift. For which assessment will the nurse need to acquire equipment? 1. Evaluation of pupil size 2. Monitoring respiratory efforts 3. Inspection of the tympanic membrane 4. Performance of muscle movement

3. Inspection of the tympanic membrane

The nurse is reassessing a patient's apical pulse prior to the administration of cardiac medication. Which action by the nurse is inappropriate? 1. Placing the patient on the left side if the patient is unable to sit up 2. Putting the stethoscope at the left fifth intercostal space 3. Listening to the posterior aspect of the thoracic cavity 4. Counting the heartbeats at the left midclavicular line

3. Listening to the posterior aspect of the thoracic cavity

The nurse is reassessing a patient's abdomen. Which reason is correct as to why the nurse alters the normal order of physical assessment techniques? 1. Percussion of the abdomen is last because it is the most painful assessment. 2. Inspection of the abdomen can occur at the beginning or end of the assessment. 3. Palpation of the abdomen before auscultation will alter bowel sounds. 4. Olfaction is used because of the passage of flatus after palpation.

3. Palpation of the abdomen before auscultation will alter bowel sounds

The nurse is giving report about a transgender patient. On the chart, the patient's legal name is shown as Shawn, but the patient prefers the name Lisa. Which information should the nurse share in report to the oncoming shift? 1. He was admitted with chest pain. 2. Shawn does not like orange juice. 3. She has stable vital signs. 4. His mother is in the room.

3. She has stable vital signs

Which specific type of law has the greatest impact on the profession of nursing? 1. Civil 2. Judicial 3. Statutory 4. Constitutional

3. Statutory

The nurse is taking routine vital signs on assigned patients. Which nursing action indicates a correct understanding of taking a blood pressure? 1. Takes the blood pressure in the left arm of a woman who had a left breast mastectomy 2. Takes the blood pressure in the right arm of a patient who has a hemodialysis shunt in the right arm 3. Takes the blood pressure using a cuff that covers two-thirds of the arm circumference 4. Takes the blood pressure with the patient's palm facing downward

3. Takes the blood pressure using a cuff that covers 2/3 of the arm circumference

The licensed practical nurse/licensed vocational nurse (LPN/LVN) reviews the registered nurse's (RN's) assessment notes on a newly admitted patient. For which assessment finding will the LPN/LVN need in order to acquire clarification from the RN? 1. The temperature, texture, and moisture of the patient's skin. 2. The presence of muscle tenderness or rigidity. 3. The level of pain voiced by the patient during abdominal palpation. 4. The quality of the femoral and popliteal pulses.

3. The level of pain voiced by the patient during abdominal palpation

The nurse continues to keep fingers on a patient's radial pulse while counting respirations. What is the rationale for this action? 1. The nurse needs the watch close by to count respirations. 2. The nurse needs additional education to take vital signs. 3. The nurse knows breathing can be controlled by the patient. 4. The nurse knows the pulse and respirations are interconnected.

3. The nurse knows breathing can be controlled by the patient

The nurse on night shift is noted to be spending an unusually long time in a specific patient's room. Which observed behavior by the nursing supervisor would indicate that the nurse has crossed professional boundaries? 1. The nurse is laughing with the patient. 2. The nurse is sitting at the patient's bedside. 3. The nurse makes a note of the patient's home phone. 4. The nurse is providing the patient with a back rub.

3. The nurse makes a note of the patient's home phone

The nurse is reassessing a patient. Which nonverbal behavior by the patient requires that the nurse seek clarification? 1. The patient closes their eyes when the nurse examines the genitalia. 2. The patient comments about the temperature of the examining room. 3. The patient grimaces and pulls away when a joint is palpated. 4. The patient frowns when the nurse asks about family relationships.

3. The patient grimaces and pulls away when a joint is palpated

Which patient finding would cause the nurse to suspect a decreased respiratory rate? 1. The patient just finished ambulating down the hall. 2. The patient is in pain. 3. The patient is sleeping. 4. The patient is anxious about surgery.

3. The patient is sleeping

The nurse is providing care for a patient from a culture whose members are extremely modest and sensitive about being touched. Which statement by the nurse indicates cultural respect for this patient? 1. "Can you suggest how I can check you physically without touching your body?' 2. "The ability to monitor what is going on will be much easier if you are in a gown." 3. "I suggest that we come to some understanding about your culture and your physical care." 4. "May I place my hands under your clothing and touch your abdomen to evaluate the pain?"

4. "May I place my hands under your clothing and touch your abdomen to evaluate the pain?"

The nurse is providing care for a patient who signed an informed consent form for surgery. The nurse overhears the patient state a change of mind regarding the surgery. A family member states, "You need the surgery and I will not let you back out." Which action should the nurse take as a patient advocate? 1. Document the conversations in the patient's medical record. 2. Share the patient and family member's comments with the health-care provider. 3. Tell the family member that the decision to have surgery is the patient's right. 4. Ask the patient about thoughts and feelings regarding the surgery.

4. Ask the patient about thoughts and feelings regarding the surgery

The nurse provides care for a patient who just received a diagnosis of advanced cancer. The patient's family member states, "We can beat this, we will just need to do whatever it takes." Which action by the nurse demonstrates advocacy for the patient? 1. Agree with the family member in an effort to give the patient hope. 2. Inform the patient that new treatments become available every day. 3. Reinforce the health-care provider's information in an attempt to promote reality. 4. Ask the patient to share how they feel about the newly received diagnosis.

4. Ask the patient to share how they feel about the newly received diagnosis.

Which action by the LPN/LVN indicates a correct understanding of the LPN's/LVN's role in the nursing process? 1. Formulates a nursing diagnosis 2. Develops expected outcomes 3. Performs an admission assessment 4. Carries out interventions

4. Carries out interventions

The nurse is observing an unlicensed assistive personnel (UAP) who is caring for a comatose patient. Which action by the UAP would require the nurse to intervene? 1. Talking to the patient about the weather 2. Telling the patient that laboratory personnel is here to draw blood 3. Informing the visitors in the room that they can talk to the patient 4. Explaining the care plan for a family member who is in the hospital to the patient

4. Explaining the care plan for the family member who is in the hospital to the patient

Which patient's vital signs would cause the nurse to notify the registered nurse (RN)? Select all that apply. 1. Newborn patient: P - 140, R - 55 2. Adult patient: P - 64, R - 18 3. Adolescent: P - 88, R - 24 4. Newborn patient: P - 100, R - 22 5. Adult patient: P - 120, R - 24

4. Newborn patient: P - 100, R - 22 5. Adult patient: P - 120, R - 24

Which nursing student can use the title LPN? 1. One who has completed the last test in the last theory class 2. One who has finished the last clinical day 3. One who has graduated from the nursing program 4. One who has passed the National Council Licensure Examination

4. One who has passed the National Council Licensure Exam

When communicating with a patient, the patient says, "I don't think I can go through with this surgery." The nurse replies by stating, "You don't think you can go through with the surgery?"Which therapeutic communication technique did the nurse use? 1. Validation 2. Summarizing 3. Clarification 4. Reflection

4. Reflection

The licensed practical nurse/licensed vocational nurse (LPN/LVN) accompanies the health-care provider who is physically assessing a patient. Which assessment information does the nurse understand the health-care provider acquires with the use of percussion? 1. The extent of a disease within the body. 2. The intensity of pain in specific organs. 3. The detection of malfunction of internal organs. 4. The location and size of organs within the body.

4. The location and size of organs within the body

The nurse is preparing to take a patient's blood pressure. Which action should the nurse take? 1. Position the earpieces of the stethoscope toward the back of the head 2. Place the bell of the stethoscope firmly against the patient's skin 3. Make sure the width of the cuff covers approximately one-third of the upper arm 4. Use the patient's antecubital space to measure blood pressure

4. Use the patient's antecubital space to measure BP

The nurse chooses to take a patient's blood pressure using the brachial artery. The nurse pumped the cuff to 80 and last felt the pulse at 112 and deflates cuff. Which action should the nurse take next? 1. Chart the systolic pressure as 112 2. Pump the cuff to 132 to 142 mm Hg 3. Slowly deflate the cuff at 2 to 3 mm Hg per second 4. Wait 2 minutes

4. Wait 2 min