Funds Exam 3
the RN wants to determine the pt's feelings about the dx. which question is the most appropriate? a. "tell me about your reactions to the diagnosis" b. "are you worried about how it will affect your life" c. "what did the doctor tell you about your diagnosis?" d. "how is your family responding to the diagnosis?"
a. "tell me about your reactions to the diagnosis"
a pt w/ cerebral edema would most likely be ordered what type of solution? a. 3% saline b. 0.9% normal saline c. lactated ringer's d. 0.225% normal saline
a. 3% saline
who protects the public? SATA a. BON b. NPA c. ANA d. code of ethics
a. BON b. NPA d. code of ethics
what is the priority assessment when giving an inotrope medication? a. HR b. SpO2 c. BP d. RR
a. HR
what is the most concerning electrolyte imbalance? a. K of 5.7 b. Ca of 10.5 c. K of 3.7 d. Ca of 8.4
a. K of 5.7
pH- 7.2, CO2- 48, HCO3- 22. what could the LUNGS do to fix this ABG imbalance? a. breathing faster b. increase in HCO3 c. breathing slower d. peeing less
a. breathing faster
what is TRUE about a 24 hr urine collection procedure? a. first void is discarded then collection is started b. collect as many voids as possible in 24 hrs c. completed for culture & sensitivity d. requires catheter
a. first void is discarded then collection is started
the nurse can verify what data & therefore the data could be considered objective? a. "i am hungry" b. "i ate 50% of my lunch" c. "i have the urge to urinate" d. "i am uncertain about my discharge plan"
b. "i ate 50% of my lunch"
which braden scale score is most concerning? a. 18 b. 6 c. 23 d. 0
b. 6
who protects the nurse? a. BON b. ANA c. code of ethics d. NPA
b. ANA
which of the following is NOT a hypertonic fluid? a. 3% saline b. D5W c. 10% dextrose in water (D10W) d. 5% dextrose in lactated ringer's
b. D5W
which lab would be concerning for a pt ordered to receive Enoxaparin 40 mEq SQ daily? a. RBC 5.2 b. Plt 60 c. INR 2.5 d. H&H 13&35
b. Plt 60 enoxaparin = lovenox = always check platelets before admin!! do not give if plt < 100
what vital sign is the best indicator for CHF impact? a. RR b. SpO2 c. BP d. HR
b. SpO2
what is priority when assessing restraints? a. document b. assess the need to continue c. assess personal needs of the pt d. notifying family of continuation
b. assess the need to continue
the nurse understands that the appropriateness of a nursing dx is supported by? a. diagnostic statement b. defining characteristics c. risk factors d. planned interventions
b. defining characteristics
what is the body's response/fix for hyperkalemia? a. breathe slower b. diarrhea c. slow parastalsis d. increase heart rate
b. diarrhea
enteral nutrition complications include... a. elevated potassium levels b. elevated glucose levels c. elevated fluid levels d. elevated sodium levels
b. elevated glucose levels
what type of food would be most problematic for a pt w/ esophageal dysphagia? a. pudding b. soup c. sliced steak d. water
c. sliced steak
pH- 7.2, CO2- 48, HCO3- 22. what could cause this ABG imbalance? a. breathing too slowly b. breathing too fast c. kidney failing d. diarrhea
a. breathing too slowly
spirituality in the older adult. SATA a. changes as they age b. stays the same as they age c. focuses more on self d. focuses more on relationships
a. changes as they age d. focuses more on relationships
when a med error occurs, the RN will do all of the following except? a. chart about the variance report b. call doctor c. reassess pt d. notify pt
a. chart about the variance report
data clustering is critical for what step of ADPIE? a. diagnosis (D) b. assessment (A) c. planning (P) d. implementation (I)
a. diagnosis (D)
you're caring for a pt w/ newly diagnosed dysphagia. which is NOT a concern w/ this pt? a. gastrointestinal infection b. dehydration c. decreased nutritional status d. aspiration PNE
a. gastrointestinal infection
what is the correct order for doffing? a. gloves, eyewear, gown, mask b. gloves, mask, eyewear, gown c. gloves, eyewear, mask, gown d. gloves, gown, eyewear, mask
a. gloves, eyewear, gown, mask
what is the correct order of donning? a. gown, mask, eyewear, gloves b. gloves, eyewear, mask, gown c. gown, eyewear, mask, gloves d. gloves, mask, eyewear, gown
a. gown, mask, eyewear, gloves
______________ fluids remove water from the extracellular space and put it into the intracellular space a. hypotonic b. hypertonic c. isotonic d. colloids
a. hypotonic
how is a med error documented in a pt's chart? a. include facts b. include reason c. include variance report d. include opinions
a. include facts
which breathing pattern is related to the body's response to metabolic acidosis? a. kussmaul b. apnea c. bradypnea d. Cheyne-Stokes
a. kussmaul
what is NOT required to initiate restraints? a. order b. concern for harm to self or others c. prior non-restrictive attempts d. documentation of assessment & efforts
a. order
wound dressings do all of the following except? a. promote a very dry environment b. protect from environment c. promote a moist environment d. promote homeostasis
a. promote a very dry environment
which pt does NOT require additional nutrients in their diet? a. pt w/ epilepsy b. pt w/ post-op incision c. pt w/ burns d. pt w/ braden scale score of 10
a. pt w/ epilepsy
which pt would NOT be a candidate for a hypotonic solution? a. pt/ increased intracranial pressure b. pt w/ diabetic ketoacidosis c. pt experiencing hyperosmolar hyperglycemia d. all of the options are correct
a. pt w/ increased intracranial pressure
what condition would result in hyperkalemia? a. renal failure b. diuretic use c. alkalosis d. diarrhea
a. renal failure
pt w/ a secondary intention wound c/o pain @ the dressing. what is the most appropriate next step? a. take a look @ the dressing b. call doctor c. give pain meds d. remove dressing
a. take a look @ the dressing
your pt is refusing a bath. what do you do first? a. talk to pt about refusal b. call family to notify c. complete variance report d. give the pt an ulitmatum
a. talk to pt about refusal
contraindicated care in oropharyngeal dysphagia? a. thin fluids b. discontinue use of straws c. use stronger side of mouth d. eating slower & chin tuck
a. thin fluids
battery is... a. touching w/out consent b. the same as assault c. speaking poorly of another d. threatening to harm
a. touching w/out consent
D5W solutions are sometimes considered a hypotonic solution as well as an isotonic solution b/c after the body metabolizes the dextrose, the solution acts as a hypotonic solution a. true b. false
a. true
when administering ophthalmic ointment, the nurse instructs the pt to do what? a. rub in circular motion b. close eye & rub lid lightly in circular motion c. blink several times d. stay lying on side
b. close eye & rub lid lightly in circular motion
discharge teaching focuses on all but what? a. home med reconciliation b. excluding referrals c. anticipating needs d. continuity of care
b. excluding referrals
isotonic fluids cause shifting of water from the extracellular space to the intracellular space a. true b. false
b. false
which attribute is NOT included in the ANA code of ethics? a. confidentiality b. fidelity c. advocacy d. accountability
b. fidelity
goals & outcomes should NOT... a. be attainable b. have same timeframe always c. be updated often d. be pt centered
b. have same timeframe always
what type of fluid would a pt w/ severe hyponatremia most likely be started on? a. hypotonic b. hypertonic c. isotonic d. colloid
b. hypertonic
which electrolyte imbalance is directly related to clotting concern? a. hyponatremia b. hypocalcemia c. hypernatremia d. hypercalcemia
b. hypocalcemia
expected pain outcomes include all except? a. improved quality of life b. improved sleep c. improved comfort d. to meet pt pain goal
b. improved sleep
fidelity is to... a. do good b. keep promises c. teach d. do no harm
b. keep promises
what is NOT an expected outcome of renal failure? a. oliguria b. metabolic alkalosis c. metabolic acidosis d. anuria
b. metabolic alkalosis
which nursing intervention is helpful to attain a high level of fidelity? a. except the pt to inform you when they need you b. monitor the pt's response to pain medication c. f/u only when there is a change in condition d. practice in accordance w/ medical standard of care
b. monitor the pt's response to pain medication
who is permitted to discontinue restraints for a pt? a. UAP b. nurse c. family d. nursing student
b. nurse
which of the following is an indication for enteral nutrition? a. severe malabsorption b. prolonged intubation c. absence of dysphagia d. overdose of medications
b. prolonged intubation
the Nurse Practice Act (NPA) protects who? a. nurse b. public c. state d. employer
b. public
when administering a hypertonic solution, what should the RN closely watch for? a. signs of dehydration b. pulmonary edema c. fluid volume deficit d. increased lactate level
b. pulmonary edema
which statement made by the student indicates a need for further teaching in relation to immobility? a. immobility may cause social isolation & loneliness b. withdrawn pts typically want to take part in their care c. altered mobility places pts @ risk for behavioral changes d. pts w/ restricted mobility may have depression
b. withdrawn pts typically want to take part in their care
the nurse is educating the pt about sleep & exercise. what is true? a. the more fatigued you are, the better you will sleep b. working out at least 2 hrs before sleep is best c. complete strenuous activity within 30 mins or an hour of sleep d. only do exercise in AM hrs
b. working out at least 2 hrs before sleep is best
the doctor orders an isotonic fluid for a pt. which of the following is NOT an isotonic fluid? a. 0.9% normal saline b. lactated ringer's c. 0.45% saline d. 5% dextrose in 0.225% saline
c. 0.45% saline
what is the hallmark sign of hypocalcemia? a. tachycardia b. edema c. Chvostek's sign d. dry mucous membranes
c. Chvostek's sign
complications of wound healing include all except? a. dehiscence or evisceration b. hemorrhage c. DVT's d. infection
c. DVT's
what is the metabolic (renal) portion of an ABG? a. pH b. CO2 c. HCO3 d. PO2
c. HCO3
50 y/o cirrhosis pt should NOT get which fluid? a. NS b. 5D5W c. LR d. 0.9% NaCl
c. LR
what is the difference between airborne & droplet precautions? a. sterile vs clean gloves b. time spent in the room c. N95 vs surgical mask d. doctors order vs no order
c. N95 vs surgical mask
scope of practice for nurses comes from? a. ANA code of ethics b. Texas nurses association c. Nurse Practice Act (NPA) d. hospital of employment
c. Nurse Practice Act (NPA)
which of the wounds below requires debridement? SATA a. wound culture positive for staph aureus b. copious amounts of purulent drainage c. areas of eschar d. boggy peri-wound
c. areas of eschar d. boggy peri-wound
which reason would support the use of restraints? a. confused & disoriented b. verbally aggressive c. attempting to remove necessary medical devices d. paralyzed
c. attempting to remove necessary medical devices
who is most @ risk of infection? a. post-operative pt b. WBC of 19 c. diabetic wound d. pneumonia
c. diabetic wound
what step in ADPIE is used when the RN id's the pt's elevated vital signs are significant? a. implementation (I) b. planning (P) c. diagnosis (D) d. assessment (A)
c. diagnosis (D)
what is the first intervention for a pt w/ body image disturbance & concern for intimacy? a. provide pt time to think b. provide support group resources c. discuss their body image disturbance d. reassurance
c. discuss their body image disturbance
which condition could lead to cell lysis, if not properly monitored? a. isotonicity b. hypertonicity c. hypotonicity d. none of the options are correct
c. hypotonicity
pH- 7.2, CO2- 48, HCO3- 22. what could the KIDNEYS do to fix this ABG imbalance? a. breathing slower b. breathing faster c. increase in HCO3 d. peeing less
c. increase in HCO3
which intervention is appropriate to prevent a pressure ulcer from getting infected? a. documenting wound appearance b. obtaining wound culture c. irrigating & cleansing wound per order d. turning pt q2h
c. irrigating & cleansing wound per order
when the cell presents w/ the same concentration on the inside & outside w/ no shifting of fluids, what is it called? a. hypotonic b. hypertonic c. isotonic d. osmosis
c. isotonic
which statement is FALSE regarding informed consent? a. it is signed after opportunity for questions b. it must be signed while pt is free of mind-altering meds c. it can be witnessed by a nurse or nursing student d. it may be withdrawn @ any time
c. it can be witnessed by a nurse or nursing student
what is NOT an expected complication of left-sided CHF? a. dyspnea b. decreased cardiac output c. jugular vein distention d. altered tissue perfusion
c. jugular vein distention
what is NOT included in the C of the "RACE" mnemonic? a. closing doors b. placing wet towels along base of doors c. opening windows d. turn off sources of oxygen
c. opening windows
which is metabolic acidosis? a. pH- 7.2, CO2- 50, HCO3- 22 b. pH- 7.5, CO2- 35, HCO3- 22 c. pH- 7.2, CO2- 36, HCO3- 20 d. pH- 7.7, CO2- 36, HCO3- 20
c. pH- 7.2, CO2- 36, HCO3- 20
which nursing outcome is stated correctly? a. pt will sleep well through the night b. nurse will note 6 hrs of uninterrupted sleep each night c. pt will report 50% improvement in sleep per night d. nurse will observe 50% increase in sleeping
c. pt will report 50% improvement in sleep per night
palliative care is... a. related to spiritual guidance b. related to hospice c. related to quality of life d. related to death
c. related to quality of life
which of the following is a major characteristic of the nursing process? a. the emphasis on medical issues b. the emphasis on only ABC's c. the emphasis on pt needs d. its static nature
c. the emphasis on pt needs
which solution below is NOT a hypertonic solution? a. 5% dextrose in 0.9% saline b. 5% saline c. 5% dextrose in lactated ringer's d. 0.33% saline (1/3 NS)
d. 0.33% saline (1/3 NS)
a pt is being admitted w/ dehydration due to nausea & vomiting. which fluid would you expect the pt to be started on? a. 5% dextrose in 0.9% saline b. 0.33% saline c. 0.225% saline d. 0.9% normal saline
d. 0.9% normal saline
when giving more than one ophthalmic medication, the nurse must wait how long between meds? a. 30 secs b. 1 min c. 3 mins d. 5 mins
d. 5 mins
which braden scale score correlates to the highest risk for pressure ulcer development? a. 23 b. 0 c. 35 d. 9
d. 9
what is FALSE for insomnia? a. difficulty falling asleep b. short sleep c. frequent awakenings d. abnormal movements
d. abnormal movements
delegation to a NAP should include... a. f/u of care b. feedback to NAP c. clear instructions to NAP d. all of the above
d. all of the above
the braden scale looks @ which of the following as risk factors for pressure ulcer development? a. activity/mobility, sensory, nutrition, moisture, friction/shear b. incontinence c. altered cognition d. all of the above
d. all of the above
transient insomnia can occur from? a. tragic loss &/or stressful event b. jet lag c. illness d. all of the above
d. all of the above
what will impact blood pressure assessment? a. pt positioning b. cuff size c. time of day d. all of the above
d. all of the above
working through an ethical dilemma should include review of? a. pt background b. current research on topic c. doctor's point of view d. all of the above
d. all of the above
your fall risk pt gets up frequently during the night due to pain. what intervention would best prevent this issue? a. leave the lights on in bathroom b. place pt on bedrest c. keep room clutter free d. assess/treat pain levels throughout the night
d. assess/treat pain levels throughout the night
which is the best example of practicing pt advocacy? a. documenting all pt care b. working to understand the law & standard of care c. delegating out appropriate care d. assessing the pt's point of view
d. assessing the pt's point of view
what is the cardiac response to hyperkalemia? a. absent reflexes b. tachycardia c. parathesia d. bradycardia
d. bradycardia
who is @ risk of getting c. diff? a. electrolyte imbalance b. nasogastric decompression c. post-op knee surgery d. complicated wound healing
d. complicated wound healing
___________ solutions cause cell dehydration & help increase fluid in the extracellular space a. hypotonic b. osmosis c. isotonic d. hypertonic
d. hypertonic
an altered mobility pt is @ risk of all except? a. hypercalcemia b. atelectasis c. muscle wasting d. hypoglycemia
d. hypoglycemia
your pt has a stage 1 pressure ulcer. which is the most appropriate NANDA? a. risk for impaired skin integrity b. pain c. risk for infection d. impaired skin integrity
d. impaired skin integrity
what non-pharmacological intervention would NOT assist w/ constipation? a. warm prune juice b. increased mobility c. increase fiber intake d. increase meat intake
d. increase meat intake
which medical concern is priority? a. oliguria b. acute pain c. CHF d. obstructive sleep apnea (OSA)
d. obstructive sleep apnea (OSA)
what is NOT the goal of restraints? a. prevent harm b. prevent falls c. prevent injury d. prevent movement
d. prevent movement
pH- 7.7, CO2- 31, HCO3- 23 a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis
d. respiratory alkalosis
what is the preferred site for an IM injection of 2mL? a. deltoid b. dorsogluteal c. vastus lateralis d. ventrogluteal
d. ventrogluteal
