Exam 2

A nurse uses the 5 rights of delegation when providing care. Which "rights" did the nurse use? (select all that apply) A. right direction B. right cost-effectiveness C. right circumstances D. right person E. right supervision F. right task

A. right direction C. right circumstances D. right person E. right supervision F. right task

A nurse is assessing a pts wound. Which nursing observation will indicate the wound healed by secondary intention? A. scarring that may be severe B. minimal loss of tissue function C. minimal scar tissue D. thin scar where sutures were placed

A. scarring that may be severe

A nurse is prioritizing care. Match the level of priority to the pts. A. pt w pneumonia that needs to be turned B. pt w an acute asthma attack C. pt who needs teaching before being discharged 1. high priority 2. intermediate priority 3. low priority

1. high priority - B. pt w an acute asthma attack 2. intermediate priority - A. pt w pneumonia that needs to be turned 3. low priority - C. pt who needs teaching before being discharged

A pt has an infection of the terminal bronchioles & alveoli that involves the right lower lobe of the lung. Which abnormal pulmonary findings will the nurse expect? A. fever & tachypnea w crackles over the right lower lobe B. dyspnea w diminished breath sounds bilaterally C. asymmetric chest expansion on the right side D. prolonges expiration w an occasional wheeze in the right lower lobe

A. fever & tachypnea w crackles over the right lower lobe

The nurse is caring for 6 pts in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these pts. Which statement is an appropriate suggestion by another nurse? A. "begin w the highest priority diagnoses, then select appropriate interventions" B. "make sure you identify the scientific rationale for each intervention 1st" C. "decide on goals & outcomes you have chosen for the pts" D. "choose all the interventions & preform them in order of time needed for each one"

A. "begin w the highest priority diagnoses, then select appropriate interventions"

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection & has prescribed antibiotic therapy for the nurse the initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following findings should the nurse expect? (select all that apply) A. increase in incisional pain B. fever & chills C. reddened wound edges D. increase in purulent drainage E. decrease in thirst

A. increase in incisional pain B. fever & chills C. reddened wound edges D. increase in purulent drainage

A charge nurse is reviewing the step of the nursing process w a group of nurses. Which of the following data should the charge nurse identify as objective data? (select all that apply) A. Respiratory rate is 22/min w even, unlabored respirations B. the client's partner states, "they said they hurt after walking about 10mins" C. the client's pain rating is 3 on a scale of 0-10 D. the nurse observes the client walking w a limp E. the client's skin is pink, warm, and dry

A. Respiratory rate is 22/min w even, unlabored respirations D. the nurse observes the client walking w a limp E. the client's skin is pink, warm, and dry

The nurse is obtaining a health history from a pt. Which techniques help the nurse to obtain complete data & establish rapport w the pt? (select all that apply) A. asking for clarification B. using professional jargon C. providing false reassurances D. showing empathy E. asking leading questions

A. asking for clarification D. showing empathy

A pt is experiencing oliguria. Which action should the nurse preform 1st? A. assess for bladder distention B. request an order for diuretics C. encourage the pt to drink caffeinated beverages D. increase the pts intravenous fluid rate

A. assess for bladder distention

A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the clients MAR & noted the last dose of pain medication was 6 hr. ago. The prescription reads every 4 hr. PRN pain. The nurse administered the medication & checked w the client 40 min. later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? A. assessment B. planning C. intervention D. evaluation

A. assessment

A nurse is auscultating a pts lung fields. The nurse documents, "lung sounds clear to auscultation in all lung fields." Which lung sounds did the nurse hear? (select all that apply) A. bronchial sounds over the trachea B. rhonchi in the lower lung lobes that clear with coughing C. vesicular sounds heard in the lesser bronchi, bronchioles and lobes D. bronchovesicular sounds lateral to the lower trachea on front & back of the chest E. bronchial sounds over the lower lung lobes

A. bronchial sounds over the trachea C. vesicular sounds heard in the lesser bronchi, bronchioles and lobes D. bronchovesicular sounds lateral to the lower trachea on front & back of the chest

A nurse is collecting a history from a pt disabled by rheumatoid arthritis. Which question by the nurse will determine the pts functional ability? A. "does the pain contribute to your decreased functional ability?" B. "how do you feel about your diagnosis of rheumatoid arthritis?" C. "how has your arthritis affected your daily life?" D. "when did your arthritis symptoms first begin?"

C. "how has your arthritis affected your daily life?"

A nurse is preforming a focused problem-based health history on a dyspneic pt who reports orthopnea. Which question by the nurse will provide more info about the severity of the pts report? A. "how far can you walk w/o becoming breathless?" B. "how many pillows do you use to sleep at night?" C. "how is this problem interfering w your social life?" D. "do you have swelling in your feet?"

B. "how many pillows do you use to sleep at night?"

The prescriber orders a specific flow rate of 24% to be delivered to a pt via an oxygen delivery device. The nurse recognizes the delivery device that will deliver a more precise FiO2 is? A. a face tent B. a venturi mask C. a nasal cannula D. a simple face mask

B. a venturi mask

A nurse is auscultating heart sounds. Placing the stethoscope at the 2nd left & right intercostal spaces, the nurse can hear the: A. atrial & pulmonic valves B. aortic & pulmonic valves C. atrioventricular valves D. mitral & tricuspid valves

B. aortic & pulmonic valves

A home health nurse visits a client who has COPD & receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority? A. increase the oxygen flow to 3 L/min B. assess the client's respiratory status C. call emergency services for the client D. have the client cough & expectorate secretions

B. assess the client's respiratory status

A nurse is caring for a client who has an endotracheal tube & is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take 1st? A. prepare the client for a reintubation B. assess the clients airway C. suction the clients mouth D. elevate the clients head of bed

B. assess the clients airway

A nurse determines that the pts condition has improved & has met expected outcomes. Which step of the nursing process is the nurse exhibiting? A. assessment B. evaluation C. planning D. implementation

B. evaluation

A pt comes to the ED & reports to the triage nurse, "I'm having a heart attack." What is the triage nurse's top priority? A. the nurse should collect info on personal data & insurance coverage B. have nurse perform a focused assessment C. have a nurse immediately collect data for a comprehensive assessment D. ask the pt to wait in the waiting area until called

B. have nurse perform a focused assessment

A nurse is completing an assessment. Which findings will the nurse report as subjective data? (select all that apply) A. pt pacing the floor while awaiting test results B. pt describing excitement about discharge C. pts wound appearance D. pts statement of fear regarding upcoming surgery E. pts temperature

B. pt describing excitement about discharge D. pts statement of fear regarding upcoming surgery

The nurse is auscultating heart tones on a pt & places the stethoscope at the 4th intercostal space at the left sternal border. Which valve is the nurse auscultating? A. aortic B. tricuspid C. pulmonic D. mitral

B. tricuspid

Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions? A. drawing on past clinical experiences to formulate standardized care plans B. using the nursing process C. depending on the charge nurse to determine priorities of care D. relying on recall of information from past lectures & textbooks

B. using the nursing process

The following statements are on a pts nursing care plan. Which statement will the nurse use as an outcome for a goal of care? A. the pt will demonstrate increased tolerance to activity over the next month B. the pt will demonstrate increased mobility in 2 days C. the pt will verbalize a decreased pain level less than 3 on a 0-10 scale by the end of this shift D. the pt will understand needed dietary changes by discharge

C. the pt will verbalize a decreased pain level less than 3 on a 0-10 scale by the end of this shift

A nurse inspects the abdomen of a pt for skin color, surface characteristics, & surface movement. What part of the abdominal assessment does the nurse perform next? A. deep palpation for masses or aortic pulsation B. light palpation for tenderness & muscle tone C. auscultation of the bowel sounds in all 4 quadrants D. percussion for tones in all 4 quadrants

C. auscultation of the bowel sounds in all 4 quadrants

A nurse inspects a pts hands & notices clubbing of the fingers. The nurse correlates this finding with what condition? A. a pulmonary infection B. allergic reaction C. chronic hypoxemia D. chest trauma

C. chronic hypoxemia

A nurse is caring for a client who is receiving oxygen via nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following? A. delivers a constant rate of a specific concentration of oxygen B. delivers a high concentration of oxygen C. delivers a low concentration of oxygen D. restricts the clients ability to eat, speak, or drink

C. delivers a low concentration of oxygen

A nurse is preforming a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temp.? A. palmar surface B. fingertips C. dorsal surface D. base of the fingers

C. dorsal surface

A nurse is assessing a pts peripheral circulation. Which finding indicated venous insufficiency of the pts legs? A. leg pain that increases when legs are raised B. paresthesias & weak peripheral pulses C. edema that is worse at the end of the day D. leg pain that can intensify w walking

C. edema that is worse at the end of the day

The nurse is caring for a pt w a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this pt? A. primary intention B. partial-thickness wound repair C. full-thickness wound repair D. quaternary intention

C. full-thickness wound repair

A pts need for oxygenation falls into which category of Maslow's Hierarchy of needs? A. self actualization B. safety & security C. physiologic D. self-esteem

C. physiologic

The nurse is collaborating with the dietitian about a pt w a Stage III pressure ulcer. Which nutrient will the pt need, as recommended by the dietitian? A. vitamin E B. fat C. protein D. carbohydrate

C. protein

After assessing the pt & identifying the need for headache relief, the nurse administers acetaminophen for the pts headache. Which action by the nurse is priority for this pt? A. eliminate headache from the nursing care plan B. revise the plan of care C. reassess the pts pain level in 30 mins D. direct the nursing assistive personnel to ask if the headache is relieved

C. reassess the pts pain level in 30 mins

A nurse is reviewing a pts care plan. Which info will the nurse identify as a nursing intervention? A. the pt will ambulate in the hallway twice this shift using crutches correctly B. impaired physical mobility related to inability to bear weight on right leg C. the nurse will provide assistance while the pt walks in the hallway twice this shift w crutches D. the pt is unable to bear weight on the right lower extremity

C. the nurse will provide assistance while the pt walks in the hallway twice this shift w crutches

A nurse is planning to preform a sterile dressing change for a client. Which of the following actions should the nurse plan to take? A. hold all items below the nurse's waist B. place sterile supplies inside the 1 inch border of the sterile field C. use sterile forceps to move the sterile items on the sterile field D. position the wrapped package on the bedside table so the outer flap opens towards her

C. use sterile forceps to move the sterile items on the sterile field

A staff nurse delegates a task to a nursing assistive personnel (NAP), knowing that the NAP has never performed the task before. As a result, the pt is injured, & the nurse defensively states that the NAP should have known how to perform such a simple task. Which element of the decision-making process is the nurse lacking? A. autonomy B. responsibility C. authority D. accountability

D. accountability

During a health history interview, the pt states, "I have not had a tetanus immunization for 15 years because I had a really bad reaction to the last one." What is the most appropriate response by the nurse? A. document an allergy to the tetanus vaccine on this pts record B. give the vaccine anyway as true allergies to vaccines are rare C. notify the health care provider that the immunization cannot be given D. ask the pt to describe the bad reaction in more detail

D. ask the pt to describe the bad reaction in more detail

Which pt scenario of a surgical pt in pain is most indicative of critical thinking? A. administering pain-relief medication according to what was given last shift B. explaining to the pt that self-reporting of severe pain is not consistent w the minor procedure that was preformed C. offering pain-relief medication based on the health care provider's orders D. asking the pt what the pain-relief methods, pharmacological & non-pharmacological, have worked in the past

D. asking the pt what the pain-relief methods, pharmacological & non-pharmacological, have worked in the past

The nurse is positioning a pt to maximize oxygenation. If the pts condition allows, which position will the promote oxygenation? A. trendelenburg position B. sims position C. prone position D. fowlers position

D. fowlers position

A nurse is providing nursing care to pts after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse demonstrating? A. assessment B. planning C. evaluation D. implementation

D. implementation

Which action demonstrates a nurse utilizing reflection to improve clinical decision making? A. obtains data in an orderly fashion B. uses an objective approach in pt situations C. provides evidenced-based explanations & research for care of assigned pts D. improves a plan of care while thinking back on interventions effectiveness

D. improves a plan of care while thinking back on interventions effectiveness

A nurse's biggest concern for a pt w an indwelling catheter is which of the following? A. expense B. urethral trauma C. kidney stones D. infection

D. infection

The nurse is caring for a pt who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take? A. leave the dressing off the wound for easier access & more frequent assessments B. ask the nursing assistive personnel if the wound looks better C. document the progress of wound healing as "better" in the chart D. measure the wound & observe for redness, swelling, or drainage

D. measure the wound & observe for redness, swelling, or drainage

The nurse completes a thorough assessment of a pt & analyzes the data to identify nursing diagnoses. Which step of the nursing process comes next? A. implementation B. diagnosis C. assessment D. planning

D. planning

The nurse is caring for a pt who was involved in an automobile accident 2 weeks ago. The pt sustained an injury, which will the nurse consider when planning care to decrease the development of a decubitus ulcer? A. stress B. weight C. resistance D. pressure

D. pressure

Which initial intervention is most appropriate for a patient who has a new onset of chest pain? A. notify the health care provider B. call radiology for a portable chest x-ray C. admin. a PRN med. for pain D. reassess the pt

D. reassess the pt

After providing care, a nurse charts in the pts record. Which entry will the nurse document? A. appears restless when sitting in the chair B. drank adequate amounts of water C. apparently is asleep w eyes closed D. skin pale & cool

D. skin pale & cool