week 3 dynamic quiz
a nurse is caring for a pt who is having a difficulty with muscle coordination following a head injury. the nurse should suspect injury to which of the following areas of the brain? a. hypothalamus b. cerebral cortex c. pituitary d. cerebellum
cerebellum
a nurse is preparing to assess the function to the pt's trigeminal nerve (cranial nerve V). which of the following tests should the nurse gather for the test? a. sugar b. coffee c. cotton wisps d. Snellen chart
cotton wisps
a nurse is caring for a pt who is immobile. the nurse should recognize that immobility places the pt at risk of which of the following health alterations? a. increased intestinal mobility b. respiratory alkalosis c. decreased cardiac output d. hypocalcemia
decreased cardiac output
a nurse is caring for a pt who has a hearing impairment. which of the following interventions should the nurse use when speaking with the pt? a. speak directly into the pt's impaired ear b. exaggerate lip movements c. speak loudly d. face the pt when speaking
face the pt when speaking
a nurse is applying an ice bag to the ankle of a pt following a sports injury. which of the following actions should the nurse take? a. leave the bag in place for 45 min b. fill the bag 2/3 full with ice c. place the ice bag uncovered on the pt's ankle d. tell the pt that the numbness is expected when the ice bag is in place
fill the bag 2/3 full with ice
a nurse in a same-day procedure unit is caring for several pts who are undergoing different types of procedures. the nurse should anticipate that the pt who has which of the following devices can safely undergo MRI? a. coronary artery stents b. aneurysm clip c. hearing aids d. automated internal defibrillator
hearing aids
a nurse in an oncology clinic is assessing a pt who is undergoing treatment for ovarian cancer. which of the following statements by the pt indicates she is experiencing psychological distress? a. "my parents are retired, and they have come to help with our children" b. "i am going to ask my husband to go to counseling with me" c. "i keep having nightmares about my upcoming surgery" d. "my girlfriends bought me a nice wig"
"i keep having nightmares about my upcoming surgery"
a nursing is teaching a pt who has low back pain about heat therapy. which of the following statements by the pt indicates an understanding of teaching? a. "i need to place a towel between the heating pad and my skin" b. "I'll need to turn up the temp if i can't feel the heat" c. "i'll sleep on top of the heating pad to increase the heat penetration" d. "keep the heat continuously on my back will help it heal"
"i need to place a towel between the heating pad and my skin"
a nurse in a provider's office is talking with an older adult pt who reports having trouble sleeping. which of the following statements should the nurse identify as a possible cause of the pt's sleeping difficulties? a. "i take a warm shower when getting ready for bed." b. "i often have a cup of coffee with my dessert before going to bed" c. "i usually read a chapter in a book before i go to bed" d. "i make sure i do my exercises in the morning"
"i often have a cup of coffee with my dessert before going to bed"
a nurse is teaching a group of older adults about expected age-related changes. which of the following statements by a group member indicates that the teaching has been effective? a. "i should expect my heart rate to take longer to return to normal after I exercise as I get older" b. "urinary incontinence is something i will have to live with as i grow older" c. i can expect to have less ear wax as i get older" d. "my stomach will empty more quickly after meals as i grow older"
"i should expect my heart rate to take longer to return to normal after I exercise as I get older"
a community health nurse is conduction a class about body mechanics for county office workers. which of the following instructions should the nurse include? (select all that apply) a. sit with your back supported b. keep your knees at hip level c. use an ergonomically designed computer keyboard d. keep your elbows away from your body e. adjust the monitor screen so you have to tilt your head slightly to look at
-sit with your back supported -keep your knees at hip level -use an ergonomically designed computer keyboard
a nurse is preparing to administer heparin 500 units/hr to a pt who has DVT. heparin is available at 25,000units in 500mL of 5% dextrose in water. the nurse should set the IV pump to deliver how many mL/hr? (round to the nearest whole number)
10ml/hr
a nurse is preparing to administer heparin 900 units/hr via IV infusion. The amount is available is heparin is 25,000 units in 500mL 5% dextrose in water. the nurse should set the IV pump to deliver how many mL/hr? (round to the nearest whole number)
18mL/hr
a nurse is assessing a pt for conductive hearing loss. when using the Rinne test, which of the following results should the nurse identify as an indication that the pt has conductive hearing loss of the L ear? a. air conduction is less than bone conduction in the L ear b. air conduction is greater than bone conduction in the L ear c. sound it lateralizing to the R ear d. sound is lateralizing to the L ear
air conduction is less than bone conduction in the L ear
a nurse on a medical unit is caring for a pt who has difficulty sleeping. which of the following actions should the nurse take to promote the pt's ability to sleep? a. encourage the pt to ambulate in the hallway before bedtime b. allow the pt to maintain the same bedtime routine as at home c. keep the room temp warm d. offer the pt a cup of hot chocolate before bedtime
allow the pt to maintain the same bedtime routine as at home
a nurse is caring for a group of pts in a long term care facility. one of the pts is walking along the hallway and bumping into walls and does not respond to his name. which of the following actions should the nurse take first? a. offer the pt a nutritious snack b. accompany the pt back to his room c. reorient the pt to his surroundings. d. administer a PRN anti-anxiety medication
accompany the pt back to his room
a nurse is administering a subcutaneous heparin to a pt who is at risk for deep vein thrombosis. which of the following actions should the nurse take? a. administer the med in pt's abdomen b. inject the med into a muscle c. massage the site after administering the med d. use a 22-gauge needle to administer med
administer the med in pt's abdomen
a nurse is caring for a pt who states she does not want to get out of bed due to pain from arthritis. which of the following actions should the nurse take? a. tell the pt the provider does not want her to remain in bed b. allow the pt to remain in bed until her pain subsides c. instruct the family to perform ADLs for the pt d. advise the pt to perform range of motion exercises
advise the pt to perform range of motion exercises
a nurse is an acute care facility is planning care for a pt who is alert but temporarily immobile due to a total hip arthroplasty. which of the following interventions should the nurse plan to take to prevent a complication of immobility? a. move the pt from supine to a low fowler's position every 2-3hrs to help prevent orthostatic hypotension b. limit fluid intake to 1L (33.8oz) in 24 hr to help prevent dependent edema c. encourage the pt to turn from side to side every 3-4 hrs to help prevent respiratory complications d. instruct the pt to perform and leg exercises every 1-2hrs while awake to help prevent thrombophlebitis
instruct the pt to perform and leg exercises every 1-2hrs while awake to help prevent thrombophlebitis
a nurse is preparing to administer heparin 12,000units subcutaneously to a pt every 8hrs. heparin 20,000units/1mL is available. how many mL should the nurse administer per dose? (round to nearest tenth)
0.6 mL
a nurse is caring for a pt who reports not sleeping at night, which interferes with her ability to function during the day. which of the following interventions should the nurse suggest to this pt? a. avoid beverages that contain caffeine b. take a sleep medication regularly at bedtime c. watch tv for 30min in bed to relax prior to falling asleep d. advise the pt to take several naps during the day
avoid beverages that contain caffeine
a nurse is caring for a pt who requires ventilatory assistance with breathing following a motor vehicle crash. the nurse should suspect an injury to which part of the brain? a. hypothalamus b. cerebral cortex c. brainstem d. cerebellum
brainstem
a nurse is performing an otoscopic examination of the pt's R ear. the light reflex is visible in the R lower quadrant of the tympanic membrane. which of the following actions should the nurse take in response to this finding? a. obtain an audiology b. document this as an expected finding c. irrigate the ear with warm water d. document mild inflammation
document this as an expected finding
a nurse is caring for a pt who is 12hrs post op following a total hip arthroplasty. which of the following medications should the nurse anticipate administering to the pt to prevent DVT? a. aspirin b. warfarin c. ticagrelor d. enoxaprin
enoxaprin
a nurse is caring for an older adult pt who has an in-the canal hearing aid. the pt states the hearing aid is making a whistling sound. the nurse should identify which of the following factors as a the source for this sound? a. low battery power b. excessive wax in the ear canal c. a volume setting that is too low d. a crack in the ear tube
excessive wax in the ear canal
a nurse is teaching a middle-aged female pt about disease prevention and health maintenance. which of the following diagnostic test should the nurse recommend as part of this health routine? a. annual pap testing b. mammogram every 2 yrs c. eye exam every 2 yrs d. annual colonoscopy
eye exam every 2 yrs
a nurse is applying an ice bag to the ankle of a pt following a sports injury. which of the following should the nurse take? a. leave the bag in place for 45 min b. fill the bag 2/3 full with ice c. place the ice bag uncovered on the pt's ankle d. tell the pt that the numbness is expected when the ice bag is in place
fill the ice bag 2/3 full with ice
a nurse is admitting a pt who has hearing aids. which of the following actions should the nurse take before beginning the interview process? a. sit beside the pt during the interview b. make sure the device is functioning c. make sure the lighting in the room is soft d. provide a lengthy interview process to allow adequate time to answer questions
make sure the device is functioning
a nurse is using the braden scale to predict the pressure ulcer risk of a pt in a long-term care facility. using this scale, which of the following parameters should the nurse evaluate? a. incontinence b. mental state c. nutrition d. general physical condition
nutrition
a nurse is assessing the competency of a new assistive personnel as they assist in moving the pt in bed. which of the following actions by the AP demonstrates competence? a. lifts with arm extended b. place feet shoulder width apart c. maintains pt's bed in lowest position during move d. twists at the waist during move
place feet shoulder width apart
a nurse is preparing to perform mouth care for an unresponsive pt. which of the following actions should the nurse plan to take? a. place the pt supine b. keep both rails up c. raise the level of the bed d. inspect the pt's mouth using a finger sweep
raise the level of the bed
a nurse is planning to perform passive ROM exercises for a pt. which of the following actions should the nurse take? a. repeat each joint motion 5 times during each session b. move the joint to the point of considerable resistance c. sit approximately 2 ft from the side of the bed closest to the joint being exercised d. exercise the smaller joint first
repeat each joint motion 5 times during each session
a nurse is performing a neurological assessment for a pt. which of the following examinations should the nurse use to check the pt's balance? a. 2 point discrimination test b. glasgow coma scale c. babinski reflex c. romberg test
romberg test
a hospice nurse is visiting with the family member of the pt. the family member states that the pt has insomnia almost nightly. which of the following practices should the nurse identify as contributing to the pt's insomnia? a. the pt watches tv in her bed during the day b. the pt drinks warm milk before bed c. the pt goes to bed at 2200 every night d. the pt gets up to use the bathroom once during the night
the pt watches tv in her bed during the day
A nurse is providing nutrition counseling to middle-aged adult pt who has a sedentary job. which of the following factors should the nurse consider? a. the risk of eating disorders increases at this age b. the pt's basal metabolic rate could decrease c. daily vitamins will become necessary to meet nutritional needs. d. limiting the intake of fish once per week reduces cardiovascular risks
the pt's basal metabolic rate could decrease
a nurse is applying antiembolitic stockings for a pt who has a history of DVT. which of the following actions should the nurse take when applying stockings? a. roll the stocking partially down if too long b. remove the stocking once per day c. bunch and pull the stocking halfway up the calf d. turn the stocking inside out to the heel before applying
turn the stocking inside out to the heel before applying
a nurse is preparing to assist an older adult pt with ambulation following bed rest for 3 days. which of the following actions should the nurse take to decrease the risk of fall? a. use a gait belt during ambulation b. ensure the pt is wearing socks before ambulating c. instruct the pt to sit on the edge of the bed for 15 sec before ambulating d. walk 2 ft behind the pt during ambulation
use a gait belt during ambulation
a nurse is caring for a pt who reports using several herbal medicines. which of the following actions should the nurse take? a. discourage the use of unregulated medications and supplements b. verify the herbal supplements do not interact with meds the provider prescribes c. tell the pt to limit the number of herbal supplements to no more than 2 d. describes the dangers of taking plant-derived meds and supplements
verify the herbal supplements do not interact with meds the provider prescribes
a nurse is preparing to administer heparin 8,000 units subcutaneously every 8 hrs. heparin 10,000units/1 mL is available. how many mL should the nurse administer per dose? (round to the nearest tenth)
0.8 mL
a nurse is caring for a pt who is post op. the IV pump and tenementary monitor are alarming. the pt's roommate is watching TV at a loud volume. the pt is experiencing pain at the incision site and discomfort form an indwelling urinary catheter. which of the following sensory alterations is the pt at risk for experiencing? a. sensory deprivation b. sensory overload c. sensory deficit d. sensory processing disorder
sensory overload