Fundamentals Vsim Qs Final
11. Mr. Russell experienced dysphagia and mild left-sided weakness following his stroke. For which additional symptoms of stroke should the nurse assess? (Select all that apply.) a. Sensory deficits b. Hearing loss c. Urinary incontinence d. Communication difficulties e. Decreased peristalsis
a,c,d
2. The nurse has an order to complete neurochecks every four hours. Which assessments would the nurse include in the neurological examination? (Select all that apply.) a. Cranial nerves b. Range of motion c. Level of consciousness d. Sensory perception e. Memory
a,c,d,e
25. Which factors increase a postop patient's risk of infection? (Select all that apply.) a. Weight b. Presence of pain c. Age d. Presence of an incision e. Immunosuppression
a,c,d,e
1. When taking a patient's health history, which of the following does the nurse identify as risk factors for having a stroke? (Select all that apply.) a. Hypertension b. Recent weight loss c. Smoking d. Asthma e. Diabetes mellitus
a,c,e
41. The nurse is caring for a patient experiencing the effects of paraplegia. What urinary condition is associated with this diagnosis? a. Chronic cystitis b. Neurogenic bladder c. Oliguria d. Stress incontinence
b
12. The nurse is assessing a patient using the Glasgow Coma Scale. Which of the folliwng are components of that scale? (Select all that apply.) a. Brainstem reflexes b. Respirations c. Motor response d. Verbal response e. Eye opening
c,d,e
38. The nurse is caring for a patient who is unable to urinate voluntarily since a gunshot injury. Patient data associated with which intervention will provide information regarding the patient's kidney function? a. Results of precathetriziation bladder scans b. Number of times the patient requests oxybutynin over a 24 hour period c. Urinary output over 8 hours d. Daily serum creatinine levels
d
44. The nurse is providing discharge education on complications associated with intermittent self-catheterization. Which possible complications should the nurse include in the teaching session? (Select all that apply.) a. Bladder perforation b. UTI c. Nephrotic syndrome d. Urethral strictures e. Bladder spasms
a,b,d,e
3. The nurse is caring for four medical-surgical patients. Which patient should be assessed using the Glasgow Coma Scale? a. An 85 year old patient with dementia and increasing confusion b. A 47 year old patient who suffered a brain injury and lost consciousness in a MVA c. A 51 year old patient with cancer who is experiencing episodes of anxiety and depression d. A 32 year old patient who is paraplegic and has pneumonia
b
22. When bathing a patient who requires contact and droplet precautions, which PPE will the nurse put on? (Select all that apply.) a. Goggles b. Gloves c. Mask d. Gown e. HEPA respirator
b,c,d
43. The nurse is preparing to catheterize a female patient and is positioning the patient. Which position(s) would be appropriate for this procedure? (Select all that apply.) a. Supine b. Dorsal recumbent c. Lithotomy d. Semi-Fowler's e. Side lying
b,e
16. The nurse is calling in a report to the provider using the SBAR format. Which statement by the nurse would be the "S" when using this reporting technique? a. The patient was admitted with a stroke and mild left hemiplegia b. The patient's lungs are clear to auscultation c. The patient began coughing when eating breakfast this morning d. I recommend the patient be sent for a swallow study
c
27. When performing hand hygiene, when is it necessary to use soap and water instead of an alcohol-based hand rub? a. Before inserting an invasive device b. After direct contact with non-intact skin c. After using the bathroom d. Before donning gloves
c
30. Mr. Griffin is receiving enoxaparin sodium therapy. Which assessment data would the nurse report to the patient's health care provider to ensure his postop safety? a. A Hgb reading of 15 g/dL b. Reports no bowel movement for two days c. Moderate amount of gum bleeding after completing oral hygiene d. A platelet reading of 260,000 per mcL
c
37. The nurse has an order to check a patient's post-void residual urine. How would the nurse carry out this order? a. Insert a straight catheter and measure the urinary output in two hours b. Calculate the difference between the patient's intake and output c. Measure the amount of urine in the bladder using a bladder scanner d. Palpate the bladder for distention and record findings in the chart
c
4. The nurse is caring for a patient who is suspected of having a stroke. What should be the nurse's first action to ensure patient safety when it appears the patient is having difficulty swallowing prescribed oral medication? a. Schedule an immediate speech therapist swallow study b. Educate the patient to the substantial risk of aspiration associated with a stroke c. Hold this dose of medication and make the patient NPO d. Notify the provider of the suspected problem
c
5. A patient is experiencing dysphagia following a stroke. How should the nurse position the patient when administering medications? a. Supine b. Left lateral c. High Fowler's d. Semi-Fowler's
c
21. Which statement is true about transient bacteria? (Select all that apply.) a. Found in greatest numbers under the fingernails b. Requires friction with a brush to assure removal c. Can be easily removed through frequent, effective hand washing d. Occurs commonly on hands e. Relatively few are found on clean areas of skin
c,d,e
18. In which stage of the development of an infection does the patient present the greatest risk to others? a. Convalescent b. Incubation c. Full stage d. Prodromal
d
28. When considering hand hygiene, which action will best remove a possible microorganism reservoir? a. Rubbing hands together for at least 20 seconds b. Using warm, not hot, water c. Taking care not to splash the water d. Removing any rings
d
17. Which statement best defines a human infection? a. A disease state that is a result of pathogens in or on the body b. The result of the presence of bacteria, viruses or fungi in the body c. The presence of an illness that can spread form one human to another d. A pathological condition that elevates the body's internal temperature above its baseline
a
35. Which piece of PPE should be removed only after leaving the patient's room? a. Respiratory mask b. Gown c. Face shield d. Goggles
a
26. Which interventions will help minimize the risk of infection postop? (Select all that apply.) a. Following aseptic technique when changing incision dressings b. Implementing standard precautions c. Assessing temperature frequently—VS frequently help reduce risk of infection d. Maintaining hydration e. Managing pain effectively
a,b,c,d
47. The nurse has received an order to collect a urine sample. Which characteristics would the nurse observe for when assessing the patient's specimen? (Select all that apply.) a. Sediment b. Color c. Odor d. pH e. Clarity
a,b,c,e
29. What actions are appropriate when donning PPE for contact isolation? (Select all that apply.) a. Don gloves b. Perform hand hygiene c. Choose and apply appropriate eye protection d. Put on gown, being sure to securely tie or fasten e. Place mask snugly over mouth and nose
a,b,d
39. What information presented to a patient concerning a bladder scan will assist in addressing anxieties about the procedure? (Select all that apply.) a. The patient's body is draped to promote modesty b. The scanner is moved over the skin of the patient's lower abdomen c. The procedure is necessary when a patient experiences difficulty voiding d. The scan does not cause the patient any pain e. The scan produces an image of the patient's bladder and the amount of urine it contains
a,b,d
45. The nurse is recording fluid intake for Ms. Johnson. Which items on the dinner tray should the nurse include when completing this documentation? (Select all that apply.) a. Iced tea b. Creamed corn c. Tomato soup d. Applesauce e. Ice cream
a,c,e
24. The nurse is conducting a neurovascular assessment on a postop knee replacement patient. Which assessment data could be considered an initial indication of neurological impairment? a. Skin temperature on affected leg is cooler distal to the incision b. Patient reports "pins and needles" sensation below the incision site c. Patient rates pain as 8 out of 10 on comparative pain scale d. Skin directly surrounding incisional area is taut and firm to the touch
b
33. Mr. Griffin's surgical care includes anticoagulation therapy. Which diagnostic blood count indicates a risk for spontaneous bleeding and should be reported to his HCP immediately? a. Ca >10.2 mg/dL b. Platelet of <50,000/uL c. WBC <500/mm3 d. RBC >5.3 million/uL
b
34. When following the proper procedure for removing gloves that are a part of contact precautions, where should the first removed inverted glove ve stored while the second glove is being removed? a. Placed in the designed trash receptacle b. In the palm of the gloved hand c. Cradled within the lap of the gown d. In the palm of the ungloved hand
b
9. A patient has been admitted with a diagnosis of stroke, and the nurse has received orders to hold warfarin until lab results are received. What lab result does the nurse anticipate reviewing prior to administering this medication? a. D-dimer b. PT/INR c. Platelets d. H & H
b
20. Which interventions will the nurse implement when maintaining medical asepsis? (Select all that apply.) a. Allow only sterile items to touch sterile items b. Practice good hand hygiene c. Keep personal fingernails short d. Do not place soiled bed linen on the floor e. Clean the least soiled areas first
b,c,d,e
14. The nurse is caring for a stroke patient with mild dysphagia. What would be an appropriate nursing intervention for this patient in order to minimize risk for injury? (Select all that apply.) a. Placing food in an easily accessible position b. Providing mouth care immediately before meals c. Providing a 30-minute rest period prior to mealtimes d. Educating the patient about the importance of alternating liquids and solids e. Positioning the patient upright in chair if not contraindicated
c,d,e
31. Which intervention ordered for Mr. Griffin poses the greatest risk for injury? a. Daily dressing change b. Antiembolism stockings c. Activity as tolerated d. Daily complete blood count—risk for bleeding
d
36. What is the final step in removing PPE when caring for a patient requiring droplet precautions? a. Remove respiratory mask b. Place disposal equipment in appropriate receptacle c. Remove gloves d. Perform hand hygiene
d
46. The nurse is preparing to insert an intermittent urinary catheter in a paralyzed female patient. What would be the appropriate action by the nurse? a. Call for a coworker to help hold the patient's legs in position b. Instruct the patient to turn over on her side c. Ask a family member to assist d. Notify the provider that the procedure cannot be completed becayse the patient is paralyzed
a
48. Ms. Johnson is being discharged with an order to continue the medication oxybutynin. What information should be included in the teaching session? a. Your urine may appear reddish-orange b. You may have to urinate more frequently c. This medication helps reduce bladder spasms d. You may experience excessive saliva production
c
19. When considering a 40 year old postop patient, which factor is likely to present the greatest risk for the development of an infection? a. Invasive or indwelling medical procedures or devices b. The pH levels of the body's GI or GU tracts c. Patient's age, gender and race d. Integrity and number of the patient's WBCs
a
7. A patient with dysphagia following a stroke expresses concern about having difficulty eating and drinking. What is the appropriate reply by the nurse? a. Muscle weakness frequently occurs after a stroke; we need to make sure that food is not going into your lungs. b. You will need to ask your provider c. You sound worried; tell me more about your concerns d. We need to make sure your GI tract is working prior to giving you food
a
32. Which nursing interventions will have the greatest impact on minimizing the spread of MRSA among patients on a surgical unit? (Select all that apply.) a. Implementing standard precautions b. Using appropriate PPE c. Administrating prescribed antibiotics d. Obtaining wound cultures as ordered e. Instituting meticulous hand washing technique
a,b,e
13. Mr. Russell has an order for VS and neurochecks every four hours. Which assessment findings, if made by the nurse, would indicate potential neurologic compromise? (Select all that apply.) a. Unequal pupils b. Difficulty swallowing c. Decreasing LOC d. Unsteady gait e. Left-sided weakness
a,c
8. Mr. Russell has been placed on fall precautions. What actions should the nurse take to keep the patient safe? (Select all that apply.) a. Place the call bell within reach b. Keep side rails up x 4 at all times c. Provide non-skid socks for ambulation d. Maintain bed in low position at all times e. Instruct the patient to call for assistance when out of bed
a,c,d,e
6. Which observation supports the possibility that a patient who has experienced a stroke has aspirated? (Select all that apply.) a. Regurgitation in the mouth b. Vomiting c. Hoarseness d. Reports of nausea e. Coughing
a,c,e
10. The nurse is caring for a patient who has experienced a sudden change in LOC and has difficulty speaking. What is the priority action of the nurse? a. Document the findings b. Assess the patient c. Notify the charge nurse d. Wait 15 minutes to see if the problem resolves
b
15. Mr. Russell is being discharged from the hospital following a mild stroke. What instruction would the nurse include in discharge education? a. Be sure to weigh yourself at the same time each day b. It is important that you begin a smoking cessation program c. You only need to take your medication when symptoms are present d. A low-protein diet is necessary to maintain your health
b
40. The nurse is completing a focused assessment on a female patient admitted for altered urinary elimination. What questions would the nurse include when assessing the patient? (Select all that apply.) a. When was your last menstrual period? b. Have you noticed any change in your usual voiding pattern? c. How often do you urinate? d. Is there anything that you do that helps you urinate? e. Do you ever leak urine?
b,c,d,e
23. The nurse is conducting a neurovascular assessment on a postop patient who experienced a TKA. What is the nurse's initial intervention when it appears that there is an absence of a pulse in the affected foot? a. Elevate the affected extremity. b. Assess for parasthesia in the affected extremity c. Assess the capillary refill in both longer extremities d. Notify the patient's health care provider of the assessment finding
c
42. While inserting an intermittent urinary catheter in a female patient, the nurse accidentally inserts the catheter into the vagina. What is the appropriate action by the nurse? a. Allow the patient a period of rest and attempt the procedure at a later time b. Carefully remove the catheter and reinsert it into the urethra c. Leave the catheter in the vagina as a landmark and begin the procedure again with new supplies d. Remove the catheter and re-start the procedure using a new sterile kit
c
