Intro to Health Concepts-Exam 1

A client is admitted to the hospital with an elevated temperature, nausea, and pain and tenderness in the lower right quadrant of the abdomen. After receiving pain medication, the client continues to complain of pain at a level of 8 on a 0-10 pain scale. The client is not scheduled to receive pain medications for at least another 2 hours. Given these circumstances, which statement by the nurse is most appropriate? -"Let's try a heating pad or warm blanket to see if that helps with your discomfort." -"I will inform the healthcare provider about your continued pain." -"Try to rest for a while longer until it is time to receive your medication" -"I do not have any medications ordered for you at this time."

"I will inform the healthcare provider about your continued pain."

A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching? -"I will need to take a pain medication daily." -"I need to drink 8 cups of liquid each day." -"I will need to empty my bladder regularly and completely." -"I will need to wipe my perineal area from back to front after urination."

"I will need to wipe my perineal area from back to front after urination."

The nurse makes a home visit to a client recovering from influenza. Which client statements indicate that desired outcomes have been met? Select all that apply. -"I went back to work." -"I haven't had chills since I left the hospital." -"I slept the whole night without coughing." -"I was able to take a walk today." -"I'm eating healthy foods now."

-"I haven't had chills since I left the hospital." -"I slept the whole night without coughing."

A client is recovering from surgery to repair a fractured hip. Which actions by the nurse may reduce this client's risk for osteomyelitis in the postoperative period? Select all that apply. -Administer antibiotics as prescribed. -Administer anticoagulants as prescribed. -Assess wound for size, color, and drainage. -Assess for pain every 1-2 hours. -Use sterile technique for dressing changes.

-Administer antibiotics as prescribed. -Assess wound for size, color, and drainage. -Use sterile technique for dressing changes.

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.) -Diarrhea -Contractures of the extremities -Crackles in lungs -Polyuria -Pressure ulcers

-Contractures of the extremities -Crackles in lungs -Pressure ulcers

When providing care to a client with a wound, which evidence-based interventions should the nurse anticipate carrying out? Select all that apply. -Keeping the wound covered -Keeping the wound dry -Only covering the wound if a scab forms -Teaching the client that proper wound management can reduce scarring -Ensuring that the wound remains moist

-Keeping the wound covered -Teaching the client that proper wound management can reduce scarring -Ensuring that the wound remains moist

The nurse is caring for a client with severe inflammation. Which assessment findings would indicate a systemic reaction to inflammation? Select all that apply. -Tachypnea -Erythema -Pain -Tachycardia -Edema

-Tachypnea -Tachycardia

The nurse is caring for a client who is exhibiting signs of a systemic infection following surgery. Which diagnostic tests would the nurse anticipate being ordered? Select all that apply. -Urinalysis -White blood cell count -White blood cell differential -Serum electrolyte levels -Wound culture

-Urinalysis -White blood cell count -White blood cell differential -Wound culture

The nurse knows to keep a close eye on vitals of the patient that has pneumonia because it is an infection. What vitals would signify that the patient has gone septic? -80/40 -120/80 -166/75 -200/99

80/40

A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis? -Respiratory depression -A client who is taking a thiazide diuretic -A client who is vomiting -A client who has diarrhea

A client who has diarrhea

A nurse conducted a class on fall prevention for a group of older adult clients in the community. Which observation during a client home visit indicates that teaching on fall prevention was effective? -The locks were changed on the doors. -Scatter rugs are placed in the kitchen. -A shower seat was placed in the shower. -All meat is placed in the freezer.

A shower seat was placed in the shower.

When a nurse performs or observes nursing practices that are not safe, the nurse has a responsibility to report those actions. This principle ties the concept of safety to what other nursing concept? -Advocacy -Assessment -Accountability -Clinical Decision Making

Accountability

Which action by the novice nurse demonstrates commitment to a new job on a busy cardiac care unit? -Joining the American Nurses Association (ANA) -Arriving at every shift on time -Exhibiting clinical competence -Questioning the preceptor during all procedures

Arriving at every shift on time

List the pathophysiologic processes involved in appendicitis in sequential order. A) The appendix becomes distended with fluid secreted by its mucosa. B) The proximal lumen of the appendix becomes obstructed. C) Purulent exudate forms and causes further distention of the appendix. D) Pressure within the lumen of the appendix increases. E) Tissue necrosis occurs and gangrene develops.

B, A, D, C, E

The warmth and redness that accompany inflammation result from which of the following steps in the inflammatory process? -Hyperemia -Margination of leukocytes -Cellular regeneration -Exudate production

Hyperemia

The nurse makes a medication error. The nurse assessed the patient. The nurse then notified the doctor, floor manager, and the patient's family. What is the next step for the nurse to take? -Take care of the next patient -Feed the patient -Fill out an unusual occurrence form for quality control -Ask the patient not to tell anyone

Fill out an unusual occurrence form for quality control

Which position means the head of the bed is elevated 45-60 degrees and the patient's knees are slightly elevated? -Fowler's -prone -sims -supine

Fowler's

A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first? -Face shield -Mask -Gown -Gloves

Gloves

A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq, PaCO2 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances? -Metabolic alkalosis -Respiratory acidosis -Respiratory alkalosis -Metabolic acidosis

Metabolic acidosis

R.R. came in with DKA and is confused and lethargic. ABGs are the following: PH 7.25 CO2 48 HCO3 15 What acid base problem does R.R. exhibit? -Respiratory acidosis uncompensated -Respiratory acidosis partially compensated -Metabolic acidosis uncompensated -Metabolic acidosis partially compensated

Metabolic acidosis partially compensated

A nurse is admitting a client who has been vomiting excessively and is reporting numbness and tingling of the toes and fingers. The nurse should recognize the client is experiencing which of the following acid-base imbalances? -Respiratory alkalosis -Metabolic acidosis -Respiratory acidosis -Metabolic alkalosis

Metabolic alkalosis

A nurse is caring for a client who is experiencing severe nausea and vomiting after a course of chemotherapy. The nurse should monitor the client for which of the following clinical manifestations? -Respiratory alkalosis -Metabolic acidosis -Respiratory acidosis -Metabolic alkalosis

Metabolic alkalosis

A client in the intensive care unit is combative and pulling at the endotracheal tube, which must remain in place. After exhausting all alternatives, the nurse applies soft restraints to protect the client's airway. Which action should the nurse take next? -Reassess the need for the restraints in 8 hours. -Notify the primary healthcare provider. -Notify the family of the need for restraints. -Document the application of restraints in the chart.

Notify the primary healthcare provider.

A complaint about unsafe working conditions should be reported to which agency? -National Institute for Occupational Safety and Health -Occupational Safety and Health Administration -State board of nursing -American Nurses Association

Occupational Safety and Health Administration

Which of the following is fully compensated? -PH 7.20 CO2 21 HCO3 16 -PH 7.37 CO2 32 HC03 35 -PH 7.25 CO2 68 HCO3 31 -PH 7.54 CO2 25 HCO3 22

PH 7.37 CO2 32 HC03 35

A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect? -HCO3- 30 mEq/L -pH 7.45 -Potassium 3.3 mEq/L -PaCO2 50 mm Hg

PaCO2 50 mm Hg

A nurse is completing a physical assessment of a client who has early osteoarthritis. Which of the following manifestations should the nurse expect? -Pain worsens with activity -Confusion -Increased urination -Diarrhea

Pain worsens with activity

A nurse is planning an in-service on preventing infection for the staff nurses on a hospital's medical-surgical unit. Which of the following should be the priority teaching point for this in-service? -Assessing vital signs once daily -Performing hand hygiene -Raising the temperature in each client's room -Wearing a mask for client care

Performing hand hygiene

The nurse is caring for a client who is admitted with cellulitis of the foot. Which assessment findings support this diagnosis? -Blood cultures -Breath sounds -Redness, pain, and edema at the site -Blood urea nitrogen (BUN) and creatinine

Redness, pain, and edema at the site

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L -Metabolic acidosis -Respiratory alkalosis -Metabolic alkalosis -Respiratory acidosis

Respiratory acidosis

The nurse knows that the patient with a broken hip is at risk for orthostatic hypotension because of immobility. What should the nurse do? -Sit the patient at the side of the bed before getting up -Don't get the patient up -Get the patient up quickly -Put the patient in Trendelenburg position for a few minutes before getting up

Sit the patient at the side of the bed before getting up

A nurse has just received the shift report for a 12-hour shift. As the nurse is preparing to enter a client's room, the nurse overhears a coworker telling an offensive joke with a sexual undertone to the client. Which action by the nurse is appropriate? -Tell the coworker, in private, that such conduct is offensive and not professional. -Ask to be scheduled on a different shift than this coworker. -Ignore the coworker and walk away. -Report the incident to the unit manager.

Tell the coworker, in private, that such conduct is offensive and not professional.

A nurse is reprimanded for being habitually late. What action by the nurse would best address this performance issue? -The nurse must have a positive attitude. -The nurse must take responsibility and accept any corrective action. -The nurse must provide proof that all instances of tardiness were unavoidable. -The nurse must trade shifts in order to be on time.

The nurse must take responsibility and accept any corrective action.

Which action by a student nurse is most consistent with commitment to the nursing profession? -The student calls in sick for clinicals because of a respiratory infection. -The student calls in sick for clinicals in order to study for a class exam. -The student declines to observe a new procedure for giving a necessary bath. -The student misses class to attend a political rally.

The student calls in sick for clinicals because of a respiratory infection.

When you cut your finger, the inflammatory process begins. What happens first? -Tissue releases chemicals like prostaglandins and histamine that cause vessel dilation, resulting in hyperemia -Vascular permeability increases and edema occurs from fluid, proteins, and leukocytes leaking into interstitial space -New granulation tissue is formed -Exudate is produced

Tissue releases chemicals like prostaglandins and histamine that cause vessel dilation, resulting in hyperemia

The nurse is teaching a class on infection control. Which nursing measure is most appropriate in breaking a link in the chain of infection? -Place contaminated linens in a paper bag or on the floor. -Use personal protective equipment (PPE). -Wear sterile gloves for client care. -Cover one's cough by placing the mouth in the hand.

Use personal protective equipment (PPE).

The nurse is caring for a client with a self-reported latex allergy. Which strategy can the nurse use to ensure the safety of this client? -Wear hypoallergenic gloves -Wear gloves with powder -Wash hands after taking gloves off -Keep beta adrenergic agonists on hand

Wash hands after taking gloves off

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take? -Wear an N95 respirator mask. -Wear protective eyewear. -Wear sterile gloves. -Wear clean gloves.

Wear clean gloves.

G.H. has COPD and has respiratory acidosis. Which of the following should the nurse educate the patient on upon discharge? -Safe food handling -Wearing BIPAP at night -Safe weight loss -Avoiding hyperventilating

Wearing BIPAP at night

To prevent antibiotic-resistant bacteria, the nurse should educate the patient to -ask for antibiotics when you have the flu -avoid antibiotics at all cost -complete full prescription of antibiotics -stop taking antibiotics when feeling better

complete full prescription of antibiotics

L.G. is hospitalized with a COPD exacerbation. The nurse knows that in order to prevent pneumonia in this patient, they should promote the following: -apnea -lying flat on back -short breaths -deep breathing a coughing

deep breathing a coughing

Because of the way the influenza virus is transmitted from person to person, nurses who are working with clients with influenza should implement -contact precautions. -isolation precautions. -droplet precautions. -airborne precautions.

droplet precautions.

A type of infection that is associated with the delivery of healthcare services in a facility such as a hospital or nursing home is called a(n) -healthcare-associated infection. -latent infection. -etiologic infection. -community-associated infection.

healthcare-associated infection.

A nurse has completed the planning step of the nursing process for a client who has an acid-base imbalance. Which of the following steps should the nurse take next? -evaluation -analysis -assessment -implementation

implementation

A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following? -muscle mass -joint flexibility -muscle strength -bone density

joint flexibility

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray? -gown -hair net -goggles -mask

mask

A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? -PaCO2 above 45 mm Hg -PaO2 below 70 mm Hg -HCO3 above 26 mEq/L -pH below 7.35

pH below 7.35

A nurse in a community health clinic is interviewing a couple who just lost their house in a fire. Using the priority framework of Maslow's hierarchy of needs, which category should the nurse identify for the clients' situation? -self-actulaization -physiological -love and belonging -esteem

physiological

A nurse is working with a social worker and a physical therapist in preparing a discharge projection for a client who is postoperative. Which of the following steps of the nursing process is the nurse engaging in? -planning -assessment -analysis -evaluation

planning

Which position is lying on the stomach? -Fowler's -prone -Sims -supine

prone

E.R. has peptic ulcer disease (PUD). He eats a well balanced diet that him and his wife cook together. He occasionally has a drink with vodka around once per week. He smokes half a pack of cigarettes per week. He walks their dog daily. Which education would be most appropriate to help this patient? -eat a well balanced diet -stop drinking alcohol -smoking cessation -increase exercise

smoking cessation

A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions? -MRSA -Influenza -scabies -tuberculosis

tuberculosis

Which of the following is the most common healthcare-associated infection? -otitis media -cellulitis -urinary tract infeciton -MRSA

urinary tract infection