PCC1 - Final Exam Review Part two
35. Which nursing intervention promotes perfusion and healing of the surgical wound for an older adult? a) Keep the patient adequately hydrated b) Minimize the use of tape on the skin c) Provide rest for the patient throughout the day d) Change the dressing as soon as it gets wet
A
18. Which medication would the nurse anticipate the healthcare provider will prescribe to relieve the pain experienced by a patient with rheumatoid arthritis? a) Aspirin b) Hydromorphone c) Meperidine d) Alprazolam
A Rationale: Because of its anti-inflammatory effect, acetylsalicylic acid (found in aspirin) is useful in treating arthritis symptoms.
39. Which finding may indicate postoperative bleeding to a nurse in the post anesthesia unit caring for a patient who had major abdominal surgery? a) Oliguria b) Bradypnea c) Hypoglycemia d) Pulse deficit
A Rationale: Bleeding leads to poor renal perfusion and compensatory mechanisms that cause sodium and water retention, leading to decreased urine output (oliguria).
29. Which finding would be of most concern when the nurse assesses a patient with emphysema? a) Oral cyanosis b) Pursed-lip expiration c) Barrel chest d) Respirations 26 breaths per minute
A Rationale: Central cyanosis indicated hypoxemia and requires further assessment and actions such as checking oxygen saturation and administration of oxygen.
1. The nurse is teaching the unlicensed assistant personnel about ways to prevent the spread of infection. The nurse decides to emphasize the need to break the cycle of infection. Which teaching would be priority? a) Hand washing before/after providing patient care b) Cleaning all equipment with an approved disinfectant after use c) Wearing PPE when providing patient care d) Using medical and surgical aseptic techniques at all times
A Rationale: Hand washing before/after is the single most effective means of preventing the spread of infection by breaking the cycle of infection.
22. Which action would the nurse take first when caring for a postoperative patient who reports pain? a) Perform a focused assessment b) Provide an ice bag c) Document the patient's complaint in the chart d) Administer pain medication as prescribed
A Rationale: The first step of the nursing process is assessment; the nurse would assess the patient is make sure that the complaint of pain is not indicative of another problem that requires intervention.
7. Which factor would the nurse consider in addition to physiological needs when planning care for a group of patients? a) Patient expectations b) Number of patients assigned c) Routine care time schedule d) Skill level of nursing assistive personnel
A Rationale: The nurse would consider patient expectations as well as the physiological priorities. Working closely with patients and displaying a caring attitude will increase compliance and patient satisfaction.
32. Which finding in a patient seen at the outpatient clinic supports a diagnosis of an arterial ulcer? (Select all that apply.) a) Lack of hair b) Thickened toenails c) Copious ulcer drainage d) Diminished pedal pulse e) Brown skin discoloration
A, B, D Rationale: Prolonged lack of oxygen to hair follicles and toes results in hair loss and thickened toenails. Inadequate arterial perfusion results in diminished pedal pulse quality.
41. Which assessment item(s) needs to be documented on a patient with restraints? (Select all that apply.) a) Pulse near the restrained area b) Temperature of the restrained area c) Convenience of restraining the patient d) Skin integrity surrounding the restraint e) Behavior leading to the need for restraint
A, B, D, E Rationale: Restraint use requires assessment of the body area restrained, such as pulse quality, temperature, and skin integrity. Behavior necessitating restraint should be assessed and documented.
17. The nurse is caring for a patient with chronic back pain. Which nursing considerations would be made when determining the patient's plan of care? (Select all that apply.) a) Ask the patient about the acceptable level of pain b) Eliminate all activities that precipitate the pain c) Administer the pain medications regularly around the clock d) Use a different pain scale each time to promote patient education e) Assess the patient's pain every 20 minutes
A, C Rationale: The nurse works together with the patient to determine the tolerable level of pain. Considering that the patient has chronic, not acute pain, the goal of pain management is to decrease pain to a tolerable level instead of eliminating pain completely.
2. When discussing with a graduate nurse the delegation of patient tasks such as assistance with daily living activities, which statement about accountability would the nurse leader include? a) "Accountability is the ability to perform duties in a specific role." b) The term accountability refers to the obligation and dependability to accomplish work." c) "Remaining answerable for one's choices to oneself and others characterizes accountability." d) "Accountability is the ability to delegate responsibility for a task to a competent individual."
B Rationale: Accountability is remaining answerable for one's choices to oneself and others.
36. Which action would the nurse implement to assess for signs of hemorrhage when a patient arrives in the post anesthesia care unit in the supine position after a nephrectomy? a) Press the patient's nail beds to assess capillary refill b) Turn the patient to observe the dressings c) Monitor the patient's blood pressure for a rapid increase d) Observe the patient for hemoptysis when suctioning
B Rationale: Because of the anatomical position of the incision, drainage will flow by gravity and accumulate under the patient.
10. Which technique would the nurse employ for an obstetrical patient with a foreign body airway obstruction? a) Back blows b) Chest thrusts c) Suprapubic thrusts d) Abdominal thrusts
B Rationale: Chest thrusts are performed for an obstetrical (pregnant) patient with a foreign airway body obstruction.
16. For which physiological condition would the nurse teach an older adult patient about the use of isometric exercises? a) Kyphosis b) Muscle atrophy c) Decreased bone density d) Decreased range of motion (ROM)
B Rationale: Muscle atrophy occurs due to muscular weakness; isometric exercise can help increase muscular strength.
28. A patient with COPD is admitted to the hospital with a tentative diagnosis of pleuritis. It is important for the nurse to perform which intervention? a) Administer opioids frequently b) Assess for signs of pneumonia c) Give medication to suppress coughing d) Limit fluid intake to prevent pulmonary edema
B Rationale: Patient with pleuritic disease are prone to developing pneumonia because of impaired lung expansion, air exchange, and drainage.
40. Which finding will the nurse expect when caring for a patient who is in hypovolemic shock? a) Slow heart rate b) Cool skin temperature c) Bounding radial pulses d) Increased urine output
B Rationale: Shunting of blood to vital organs such as the heart and brain occurs in hypovolemic shock, leading to cool skin because of decreased skin perfusion.
24. The nurse repositions a patient who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange? a) Supine b) Orthopneic c) Low-fowler d) Semi-fowler
B Rationale: The orthopneic position is a sitting position that permits maximum lung expansion for gaseous exchange.
8. Which patient in the emergency department would the nurse assess first? a) Patient who reports a sharp chest pain with deep inspiration for the past week b) Patient with chest pressure and ST segment elevation on the electrocardiogram c) Patient with palpitations and paroxysmal atrial fibrillation at a rate of 136 beats/min d) Patient with a history of heart failure with ascites and bilateral 4+ ankle swelling
B Rationale: The patient with chest pressure and ST segment elevation on the electrocardiogram will need emergency treatment of ST segment elevation myocardial infarction (STEMI), including transport to the cardiac catheterization lab for percutaneous coronary intervention within 90 minutes and should be seen first.
4. A critically injured patient was brought to the hospital after a car accident, and the patient needs immediate triage for determining the nature and acuity of the injuries. Which healthcare team member would this task be delegated to? a) Nurse manager b) Registered nurse c) Licensed practical nurse d) Primary healthcare provider
B Rationale: When a patient arrives at the hospital after a trauma, it is the responsibility of the registered nurse to determine the nature and acuity of injuries.
30. Which finding would the nurse expect to identify when assessing a patient with a pleural effusion? a) Moist crackles at the posterior of the lungs b) Increased resonance with percussion of the involved area c) Reduced or absent breath sounds at the base of the lung d) Deviation of the trachea toward the involved side
C Rationale: Compression of the lung by fluid accumulates at the base of the lungs reduces lung expansion and air exchange.
14. A patient newly diagnosed with type 1 diabetes asks why it is necessary to exercise on a regular basis. Which response is accurate? a) "Exercise decreases insulin sensitivity." b) "It stimulates glucagon production." c) "Exercise improves the cellular uptake of glucose." d) "It reduces metabolic requirements for glucose."
C Rationale: Exercise increases the metabolic rate, and glucose is needed for cellular metabolism; therefore, excess glucose is consumed during exercise.
21. ________ and _______ are factors the nurse would consider the most significant influences on a patient's perception of pain a) Age and sex b) Physical and physiological status c) Previous experience and cultural values d) Intelligence and economic status
C Rationale: Interpretation of pain sensations is highly individual and is based on past experiences, which include cultural values.
9. Which precaution would the nurse identify as a prevention for transmission of human immunodeficiency virus (HIV) and other bloodborne illnesses? a) Barrier b) Droplet c) Standard d) Contact
C Rationale: Standard precautions need to be consistently used by all health care professionals to prevent the transmission of HIV and other bloodborne diseases.
3. When auscultating a patient's chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this finding? a) Adventitious sounds b) Fine crackling sounds c) Vesicular breath sounds d) Diminished breath sounds
C Rationale: Vesicular breath sounds are normal respiratory sounds heard on auscultation as inspired air enters and leaves the alveoli.
11. In which way is the term beneficence in healthcare ethics different from nonmaleficence? a) Beneficence refers to fairness, whereas nonmaleficence refers to the agreement to keep promises b) Beneficence applies to all healthcare professionals, whereas nonmaleficence applies only to nursing professionals c) Beneficence involves taking positive actions to help other whereas nonmaleficence is the avoidance of harm or hurt d) Beneficence refers to the support of a particular cause, whereas nonmaleficence refers to a willingness to respect one's professional obligations
C Rationale: Beneficence is the act of taking positive actions to help others; nonmaleficence is the avoidance of harm or hurt.
26. Which action would the nurse take first when caring for a patient with a possible pulmonary embolus? a) Auscultate the chest b) Obtain the vital signs c) Elevate the head of the bed d) Notify the rapid response team
C Rationale: Elevating the head of the bed promotes better gas exchange by reducing the pressure of the abdominal organs on the diaphragm and increasing thoracic excursion.
19. Which involuntary physiologic response would the nurse monitor development in a patient experiencing pain? a) Crying b) Splinting c) Perspiring d) Grimacing
C Rationale: Perspiration is an involuntary physiologic response, it is mediated by the autonomic nervous system under a variety of circumstances, such as rising ambient temperature, high humidity, stress, and pain.
38. Which action by the nurse is a priority when a patient who is receiving a transfusion of packed red blood cells after cardiac surgery experiences chest discomfort, chills, and anxiety? a) Administer nitroglycerin b) Monitor the patient's vital signs c) Stop the transfusion and administer normal saline d) Ask the patient to describe the pain using a 0-10 scale
C Rationale: The chest discomfort and anxiety may indicate an acute hemolytic reaction to the transfusion; the nurse's first action would be to stop the transfusion and administer normal saline to improve renal perfusion and prevent acute kidney injury secondary to hemolysis.
34. Which explanation would the nurse give to a patient with a diagnosis of myocardial infarction who asks the nurse, "What is causing the pain I am having?" a) Compression of the heart muscle b) Release of myocardial isoenzymes c) Rapid vasodilation of the coronary arteries d) Inadequate oxygenation of the myocardium
D Rationale: Cessation of the blood flow that normally carries oxygen to the myocardium results in pain because of ischemia of myocardial tissue.
27. The nurse's physical assessment of a patient with heart failure reveals tachypnea and bilateral crackles. Which is the priority nursing intervention? a) Assess the patient's oxygen saturation level b) Obtain chest x-ray film immediately c) Notify the primary healthcare provider d) Place the patient in high-fowler position
D Rationale: Placing the patient in high-Fowler position promotes lung expansion and gas exchange; it also decreases venous return and cardiac workload.
5. Which action will the nurse take first when a patient with peripheral arterial disease returns to the nursing unit after a femoral angiogram? a) Check the oral temperature b) Encourage the client to void c) Place the head of the bed flat d) Assess the patient's affected leg
D Rationale: The most common complication of femoral angiogram is bleeding at the arterial access sit, the nurse will first assess the leg pulses, temperature, and color for adequate perfusion.
13. How does the nurse play the role of a "change agent" in a community-based nursing practice? a) By helping client identify and clarify health problems b) By establishing relationships with community service organizations c) By establishing an appropriate plan of care, based on assessment of clients d) By identifying and implementing new and more effective approaches to problems
D Rationale: As a change agent, the nurse can empower individuals and their families to creatively solve problems or become instrumental in creating change within a health care agency.
23. Which action by the nurse would be most appropriate when a patient who has been admitted with pulmonary edema and received furosemide via IV needs to void? a) Place the patient on a bed pan b) Use adult briefs on the patient c) Help the patient walk to the bathroom d) Assist the patient to a bedside commode
D Rationale: Assisting the patient to a bedside commode allows the patient to keep the head elevated, which is needed in patients with pulmonary edema to improve oxygenation.
37. Which clinical finding would the nurse expect when assessing a patient with varicose veins? a) Positive Homans sign b) Pallor of the affected extremity c) Prolonged capillary refill in the toes d) Sensation of heaviness in lower legs
D Rationale: Because of dilation in the veins, decrease in venous return, and edema, the patient may experience heaviness in the legs. Homans sign is calf pain when ankle is dorsiflexed (venous thromboembolism)
20. The nurse applies a cold pack to relieve musculoskeletal pain. Which of the following explains the analgesic properties of cold therapy? a) Promotes analgesia and circulation b) Numbs the nerves and dilates the blood vessels c) Promotes circulation and reduces muscle spasms d) Causes local vasoconstriction, preventing edema and muscle spasms
D Rationale: Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and muscle spasms. Cold promotes analgesia but not circulation.
25. Which physiological alteration would the nurse expect when assessing a 6-month-old infant with bronchiolitis? (Respiratory syncytial virus/RSV) a) Decreased heart rate b) Inspiratory stridor c) Increased breath sounds d) Prolonged expiratory phase
D Rationale: Infectious and mechanical changes narrow the bronchial passages and make it difficult for air to leave lungs, prolonging the expiratory phase.
15. Which change in the joint may result in joint pain for older adults? a) Dehydration of discs b) Loss of muscle mass c) Decreased elasticity in the ligaments d) Increased cartilage erosion
D Rationale: Joint pain in an older adult is due to increased cartilage erosion.
6. Which legal implication would the nurse understand about applying restraints to a patient? a) The law allows restraining patient until a written prescription is obtained b) A felony charge may be leveled against nurses who use any kind of restraints c) Nurses are not obligated to report institutions that use restraints unlawfully d) The nurse can be charged with assault and battery for using restraints improperly
D Rationale: Restraint of a patient, whether physical or chemical, is considered a high-risk procedure requiring a valid primary healthcare provider's prescription and intensive monitoring for safety and meeting the patient's needs.
33. Which finding would the nurse expect when caring for a patient with right-sided heart failure? a) Oliguria b) Pallor c) Cool extremities d) Distended neck veins
D Rationale: Veins are distended because of the systemic venous pressure and congestion that is associated with right-sided-heart-failure.
31. Which breathing exercises would the nurse teach a patient with the diagnosis of emphysema? a) An inhalation that is prolonged to promote gas exchange b) Abdominal exercises to limit the use of accessory muscles c) Sit-ups to help strengthen the accessory muscles of respiration d) Diaphragmatic exercises to improve contraction of the diaphragm
D Rationale: With emphysema the diaphragm is flattened and weakened; strengthening the diaphragm is desirable to maximize exhalation.
12. ______ and _______ are primary prevention nursing activities (Select all that apply.) a) Preventing disabilities b) Correcting dietary deficiencies c) Establishing goals for rehabilitation d) Assisting with immunizations programs e) Facilitating a program about the dangers of smoking
D, E Rationale: Immunization programs and stopping smoking prevent the occurrence of disease and are considered primary interventions.
