NRSG 1500 Exam #2

Match the "C" component of PICO using the question "Does the use of guided imagery compared with standard care affect the postoperative pain in hospitalized adolescents?" a. Adolescents receiving standard care b. Postoperative pain c. Hospitalized adolescents d. Guided imager

A. Adolescents receiving standard care

Place the steps of the EBP process in the appropriate order. 1. Critically appraise the evidence you gather. 2. Ask the clinical question in PICOT format. 3. Evaluate the outcomes of the practice decision or change. 4. Search for the most relevant and best evidence. 5. Cultivate a spirit of inquiry. 6. Integrate the evidence. 7. Communicate the outcomes of the EBP change. a. 2, 5, 4, 6, 1, 3, 7 b. 5, 2, 4, 1, 6, 3, 7 c. 5, 2, 4, 6, 1, 3, 7 d. 2, 5, 4, 1, 6, 3, 7

B. 5, 2, 4, 1, 6, 3, 7

Practice theory is... a. Very abstract; attempts to describe nursing in a global context b. Specific to a particular situation; brings theory to the bedside c. Applies theory from other disciplines to nursing practice d. Addresses a specific phenomenon and reflects practice

B. Specific to a particular situation; brings theory to the bedside

Which condition would the nurse give the highest priority to for a client admitted in the emergency department? a. Hypoglycemia b. Chest wall trauma c. Airway obstruction d. External hemorrhage

C. Airway obstruction

Which client would require the highest priority care from the nurse in the emergency department? a. An adult client with an ankle sprain b. An infant with a rash of unknown origin c. An adult client with unstable vital signs and chest pain d. A pediatric client with multiple fractures after a motor vehicle accident

C. An adult client with unstable vital signs and chest pain

What term would the nurse use to describe the exudate characteristic of a serosanguineous wound? a. Greenish-blue pus b. Creamy yellow exudate c. Blood-tinged amber fluid d. Bright red exudate

C. Blood-tinged amber fluid

A nurse enters their postoperative patients room and notices 2 staples have fallen out and that there is a slight separation in the wound. Which complication of wound healing has occurred? a. Hemorrhage b. Infection c. Dehiscence d. Evisceration

C. Dehiscence

During a physical examination, which assessment would the nurse anticipate when a client is placed in the lithotomy position? a. Heart b. Rectum c. Female genitalia d. Musculoskeletal system

C. Female genitalia

Match the "P" component of PICO using the question "Does the use of guided imagery compared with standard care affect the postoperative pain in hospitalized adolescents?" a. Adolescents receiving standard care b. Postoperative pain c. Hospitalized adolescents d. Guided imager

C. Hospitalized adolescents

An RN is teaching a nursing student about skin assessment. Which statement made by the nursing student is incorrect? a. "Skin assessments are best performed in daylight" b. "Skin assessments performed at cool room temperatures can result in cyanosis" c. "Skin assessments performed at warm room temperatures can result in vasodilation" d. "In the absence of sunlight, skin assessments are performed best with other sources of light instead of fluorescent light"

D. "In the absence of sunlight, skin assessments are performed best with other sources of light instead of fluorescent light"

Match the "I" component of PICO using the question "Does the use of guided imagery compared with standard care affect the postoperative pain in hospitalized adolescents?" a. Adolescents receiving standard care b. Postoperative pain c. Hospitalized adolescents d. Guided imager

D. Guided imager

A nurse is preparing to care for a Latino patient who speaks little English and has presented with pneumonia, which nursing theory would be best to follow? a. Orem's Self-Care Deficit Nursing Theory b. Leininger's Culture Care Theory c. Nightingale Environmental Theory d. Peplau's Interpersonal Theory e. All of the above

E. All of the above

A nurse assessed a patients wound dressing at 0800 and returns at 1000 and notices an excess amount of serosanguineous drainage, they pull back the dressing and notice separation of the wound. What is the nurses priority action? a. Redress wound b. Call provider immediately c. Assess for infection d. Document and do hourly checks

B. Call provider immediately

Which client would the nurse care for first based on vital signs? a. Client A: RR 16 breaths/min, BP 128/62 mm Hg b. Client B: RR 28 breaths/min, SpO2 70% c. Client C: RR 14 breaths/min, BP 140/86 d. Client D: RR 20 breaths/min, SpO2 90%

B. Client B: RR 28 breaths/min, SpO2 70%

Patient turned to one side with one leg placed over the other is an example of which examination position? a. Prone b. Lateral recumbent c. Knee-chest d. Lithotomy

B. Lateral recumbent

A nurse is caring for a patient admitted to the neurological unit with the diagnosis of a stroke and right-sided weakness. The nurse assumes responsibility for bathing and feeding the patient until the patient can begin performing these activities. The nurse in this situation is applying the theory developed by: a. Johnson. b. Orem. c. Roy. d. Peplau.

B. Orem

Match the "O" component of PICO using the question "Does the use of guided imagery compared with standard care affect the postoperative pain in hospitalized adolescents?" a. Adolescents receiving standard care b. Postoperative pain c. Hospitalized adolescents d. Guided imager

B. Postoperative pain

The nurse assesses the client's incision site after bariatric surgery for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? a. Loosening of the sutures b. Sharp increase in serosanguineous drainage c. Purplish color of the incision d. Protrusion of organs through an open incision

B. Sharp increase in serosanguineous drainage

A client has stage III pressure injury. Which nursing intervention can prevent further injury by eliminating shearing force? a. Maintain the HOB 30 degrees or less b. Use lift sheets to pull up, transfer, and position the client c. Reposition the client every 2 hours, propping with pillows d. Perform passive ROM exercises every 8 hours

B. Use lift sheets to pull up, transfer, and position the client

A nurse just administered morphine to their patient and notices that their respirations are 8 breaths/minute and shallow. Which breathing pattern is the patient experiencing? a. Hyperpnea b. Hyperventilation c. Hypoventilation d. Cheyne-Stokes

C. Hypoventilation

After change of shift report, which client would the nurse assess first? a. A client with possible lung cancer who is scheduled for a bronchoscopy b. A client with left pleural effusion who is scheduled for a thoracentesis c. A client with hospital-acquired pneumonia and decreased breath sounds d. A client with an acute asthma exacerbation and 85% oxygen saturation

D. A client with an acute asthma exacerbation and 85% oxygen saturation

Which action would the nurse take first in a client whose vital signs are BP 100/60 mm Hg, pulse 104 bpm, RR 22, and oxygen saturation 95% two hours after hip surgery? a. Check the dressing on the incision b. Increase the intravenous flow rate c. Obtain the client's oral temperature d. Monitor the vital signs every 15 minutes

A. Check the dressing on the incision

While caring for a patient who presents with a fever, cough, and body ache, which order is priority and should be completed first? a. Culture STAT b. Antibiotic STAT c. Antihistamine PRN Q6H d. Antipyretics STAT

A. Culture STAT

When assessing a patient, you notice malodorous, think, green purulent drainage. You call to notify the doctor and they give you three orders; a wound culture, a wound care consult, and an IV for vancomycin. In what order should you execute the orders? a. Culture, IV, consult b. Consult, IV, culture c. IV, culture, consult d. IV, consult, culture

A. Culture, IV, consult

Which action would the nurse take first when a client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures? a. Establish an airway and stabilize the cervical spine b. Assess heart sounds and find carotid and femoral pulses c. Check for alertness, orientation, and pupil reaction to light d. Remove clothing to enable further assessment of injuries

A. Establish an airway and stabilize the cervical spine

When taking care of patients, a nurse routinely asks whether they take any vitamins or herbal medications, encourages family members to bring in music that the patients like to help the patients relax, and frequently prays with her patients if that is important to them. The nurse is practicing which model? a. Holistic b. Health belief c. Transtheoretical d. Health promotion

A. Holistic

Which combination of client responses would the nurse determine represents the highest risk for the development of pressure injuries? a. Incontinence; inability to move independently b. Periodic diaphoresis; occasional sliding down in bed c. Minimal reaction to painful stimuli; receiving tube feedings d. Spending extensive time in a chair; body mass index of 23

A. Incontinence; inability to move independently

Which action is likely to help prevent pressure injuries for a client who has paraplegia? a. Inspecting the skin every day b. Providing a rubber seat cushion c. Massaging body lotion over reddened areas d. Applying a heating pad to bony prominences

A. Inspecting the skin every day

A client who had thoracic surgery reports pain at the incision site when coughing and deep breathing. Which action would the nurse take? a. Instruct the client to splint the wound with a pillow when coughing b. Place the client in the supine position and inspect the site of the incision c. Assess the intensity of the pain and administer the prescribed analgesic d. Notify the health care provider immediately and then check for wound dehiscence

A. Instruct the client to splint the wound with a pillow when coughing

Which assessment is the priority after checking airway for a client with a cervical spinal cord injury? a. Level of consciousness b. Sensory perception in all extremities c. Presence and location of diaphoresis d. Vital sign assessment and oxygen assessment

A. Level of consciousness

The nurse is caring for a client who underwent surgical resection of an oral cancerous tumor. Which client problem is of highest priority to guide care? a. Maintain airway b. Monitor vital signs c. Administer IV fluids d. Empty surgical drains

A. Maintain airway

A nurse is conducting a home visit with a new mom and her three children. While in the home the nurse weighs each family member and reviews their 3-day food diary. She checks the mom's blood pressure and encourages the mom to take the children for a 30-minute walk every day. The nurse is addressing which level of need, according to Maslow's Hierarchy of Needs? a. Physiological b. Safety and security c. Love and belonging d. Self-actualization

A. Physiological

A nurse is caring for a patient who recently lost a leg in a motor vehicle accident. The nurse best assists the patient to cope with this situation by applying which of the following theories? a. Roy b. Watson c. Johnson d. Benner

A. Roy

Which feature is associated with the "maturation phase" of normal wound healing? a. The scar is firm and inelastic on palpation b. Fibrin strands form a scaffold or framework c. White blood cells migrate into the wound d. Epithelial cells are grown over the granulation tissue bed

A. The scar is firm and inelastic on palpation

Grand theory is... a. Very abstract; attempts to describe nursing in a global context b. Specific to a particular situation; brings theory to the bedside c. Applies theory from other disciplines to nursing practice d. Addresses a specific phenomenon and reflects practice

A. Very abstract; attempts to describe nursing in a global context

Using Maslow's hierarchy of needs, identify the priority for a patient who is experiencing chest pain and difficulty breathing. a. Self-actualization b. Air, water, and nutrition c. Safety d. Esteem and self-esteem needs

B. Air, water, and nutrition

Which activity by the community nurse is an illness prevention strategy? a. Encouraging the client to exercise daily b. Arranging an immunization program for chickenpox c. Teaching the community about stress management d. Teaching the client about maintaining a nutritious diet

B. Arranging an immunization program for chickenpox

Which action would the nurse on the unit take first when an older client with heart failure is transferred from the emergency department to the medical service? a. Interview the client for a health history b. Assess the client's heart and lung sounds c. Monitor the client's peripheral pulse quality d. Obtain the client's blood specimen for electrolytes

B. Assess the client's heart and lung sounds

Which client would the nurse assess first? a. 40-year-old with 30 pack-year cigarette history who reports tingling in both feet b. 420-year-old who takes anti hypertensive medication and reports bilateral 4+ ankle swelling c. 65-year-old who reports tearing abdominal pain and has a history of uncontrolled hypertension d. 70-year-old with peripheral arterial disease who reports severe lower leg burning and numbness

C. 65-year-old who reports tearing abdominal pain and has a history of uncontrolled hypertension

Shared theory is... a. Very abstract; attempts to describe nursing in a global context b. Specific to a particular situation; brings theory to the bedside c. Applies theory from other disciplines to nursing practice d. Addresses a specific phenomenon and reflects practice

C. Applies theory from other disciplines to nursing practice

When a client with emphysema who smokes 2 packs of cigarettes per day is attempting to quit smoking, which action would the nurse take first? a. Suggest that the client cut back to 1 pack per day b. Refer the client to a tobacco-cessation program c. Ask the client about previous attempts at tobacco cessation d. Suggest that the client use medication to assist with quitting

C. Ask the client about previous attempts at tobacco cessation

When performing a focused respiratory assessment, which action would the nurse take first? a. Examine for any abnormal respiratory patterns b. Inspect for changes in skin color or temperature c. Check for any evidence of respiratory distress d. Determine the shape and symmetry of the chest

C. Check for any evidence of respiratory distress

A nurse finished vitals on their patient 30 minutes ago and is checking to see how they are doing when the patient states that their chest is "feeling funny". Which action should the nurse take first? a. Reassure them that it is just anxiety from being in the hospital b. Notify the provider c. Retake their vitals d. Check their most recently documented vitals

C. Retake their vitals

A nurse assesses their patients blood pressure and finds that it is 134/86. What category does their blood pressure reading fall under? a. Normal b. Elevated c. Stage 1 hypertension d. Stage 2 hypertension

C. Stage 1 hypertension

A patient lying on their back on a bed is an example of which examination position? a. Sitting b. Prone c. Supine d. Lateral recumbent

C. Supine

A patient discharged a week ago following a stroke is currently participating in rehabilitation sessions provided by nurses, physical therapists, and registered dietitians in an outpatient setting. In what level of prevention is the patient participating? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Transtheoretical prevention

C. Tertiary prevention

A nurse is reading a research article discussing a new practice to decrease the incidence of catheter-associated urinary tract infections. One section of the article describes who was studied and how the data were collected to answer the research questions and hypotheses. What section of the research article is currently being read? a. The literature review b. The data analysis c. The methods d. The implications for practice

C. The methods

Nurses in a community clinic are conducting an EBP project focused on improving the outcomes of children with asthma. The PICO question asked by the nurses is "In school-age children, does the use of an electronic gaming education module versus educational book affect the usage of inhalers?" In the question, what is the "O"? a. School-age children b. Educational book c. Use of inhalers d. Electronic gaming education

C. Use of inhalers

Middle range theory is... a. Very abstract; attempts to describe nursing in a global context b. Specific to a particular situation; brings theory to the bedside c. Applies theory from other disciplines to nursing practice d. Addresses a specific phenomenon and reflects practice

D. Addresses a specific phenomenon and reflects practice

If a patient has eviscerated, the very first action the nurse should take is... a. Call provider immediately b. Redress wound c. Assess for infection d. Apply moist, sterile gauze

D. Apply moist, sterile gauze

A nurse assesses a patients right radial pulse and finds that it is +1 and irregular, what is the nurses next best course of action? a. Document b. Check left radial pulse and compare c. Notify the provider d. Check apical pulse

D. Check apical pulse

A patient lying on back with a pillow under head, hands raised above shoulders and legs flexed with a gap between legs is an example of which examination position? a. Lithotomy b. Knee-chest c. Lateral recumbent d. Dorsal recumbent

D. Dorsal recumbent

Which meal is most appropriate for a client with a large pressure injury? a. Hamburger with french fries b. Turkey meatloaf with brown rice c. Pasta and tomato sauce with a side salad d. Grilled chicken, steamed spinach, and a side of orange slices

D. Grilled chicken, steamed spinach, and a side of orange slices

A nurse is analyzing data generated during a patient assessment to determine the best plan of care. Which layer of the NCSBN-CJM best describes the cognitive process being used by the nurse at this time? a. Layer 0 b. Layer 1 c. Layer 2 d. Layer 3 e. Layer 4

D. Layer 3

A nurse ensures that each patient's room is clean; well ventilated; and free from clutter, excessive noise, and extremes in temperature. Which theorist's work is the nurse practicing in this example? a. Henderson b. Orem c. King d. Nightingale

D. Nightingale

Which type of health service would the nurse offer in a health promotion or primary care program? a. Home care b. Immunization c. Sports medicine d. Nutrition counseling

D. Nutrition counseling

The components of the nursing metaparadigm include: a. Person, health, environment, and theory. b. Health, theory, concepts, and environment. c. Nurses, physicians, health, and patient needs. d. Person, health, environment, and nursing.

D. Person, health, environment, and nursing.

Which intervention would be included in the plan of care for the prevention of a pressure injury? a. Positioning a client directly on the trochanter b. Keeping the client's skin directly off the plastic surfaces c. Keeping the head of the bed elevated above 30 degrees d. Placing a rubber ring or donut under the client's sacral area

b. Keeping the client's skin directly off the plastic surfaces