Nurs 200 - Quizzes 3-8 / Prep For Final

What is the priority action of the nurse prior to transferring a patient from bed to wheelchair? A Lock the brakes on the bed. B. Place the wheelchair parallel to the bed. C. Place the bed in its lowest position. D. Place a transfer belt on the patient.

A Lock the brakes on the bed.

Which of the following describes systole? (select all that apply) Systole is the period in which the ventricles relax A. Systole is normally silent between S1 and S2 B. Systole is the period in which the ventricles contract C. Systole is normally longer than diastole D. Systole begins with S1 and ends with S2

A! Systole is normally silent between S1 and S2 C! Systole is the period in which the ventricles contract D! Systole begins with S1 and ends with S2

The nurse is instructing the unlicensed assistive personnel (UAP) how to transfer a patient with left-sided weakness form the bed to a wheelchair. Which statement by the assistant tells the nurse that the assistant has understood the instructions? A. "The wheelchair should be placed on the right side of the bed" B. "The wheelchair should be placed at the head of the bed" C. "I will place the wheelchair behind the patient" D. "As long as I assist the patient, it does not matter where the wheelchair goes"

A. "The wheelchair should be placed on the right side of the bed"

The nurse is caring for a patient who has just been given bolus tube feedings through a nasogastric (NG) tube. How high should the nurse position the head of the bed? A. 45 degrees B. 90 degrees C. 15 degrees D. 25 degrees

A. 45 degrees

Development of an infection occurs in a cycle that depends on what six elements?

A. An infectious agent or pathogen B. A reservoir or source C. A portal of exit from the reservoir D. A mode of transmission E. A portal of entry to a host F. A susceptible host

Which should the nurse do first when caring for a patient who experiences new onset of restlessness, agitation, and confusion? A. Assess pulse oximetry B. Suction the mouth C. Administer oxygen D. Reduce environmental stimuli

A. Assess pulse oximetry

While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working? A. Assessment B. Diagnosis C. Implementation D. Evaluation

A. Assessment

Which of the following steps should the nurse take when administering an enteral tube feeding? (Select all that apply) A. Check for aspirate B. Allow the feeding to flow in by gravity C. Flush the tube with water after the feeding D. Elevate the head of the bed 15 degrees E. Set up for a sterile procedure

A. Check for aspirate B. Allow the feeding to flow in by gravity C. Flush the tube with water after the feeding

Which of the following is the most crucial goal of therapeutic communication when helping patients deal with personal issues and painful feelings? A. Conveying respect and acceptance even if all of the patient's behaviors are not tolerated B. Mutual sharing of information, spontaneity, emotions, and intimacy C. Communicating empathy through maintaining gentle touching of the patient D. Guaranteeing total confidentiality and anonymity for the patient

A. Conveying respect and acceptance even if all of the patient's behaviors are not tolerated

Older adults with cardiovascular disease must balance which of the following measures for optimal health? A. Diet, exercise, and medication B. Stress, hypertension, and pain C. Social events, diet, and smoking D. Mental health, diet, and stress

A. Diet, exercise, and medication

The nurse must lift a 15-pound box of supplies from a low shelf on the supply cart to a table. Which technique should the nurse use to protect herself from a back injury? A. Hold the box as close to the body as possible. B. Straighten the knees to support the center of gravity. C. Face the box, pick it up, and rotate the upper body toward the table. D. Place the feet together to provide a strong base of support.

A. Hold the box as close to the body as possible.

Bowel sounds that are extremely soft and infrequent and associated with manipulation of the bowel during surgery or inflammation are described as which of the following? A. Hypoactive B. Hyperactive C. Diaphragmatic D. Audible

A. Hypoactive

As a member of the safety committee, the nurse's task is to identify actions to prevent patient falls. Which intervention should the nurse emphasize as most important to prevent falls? A. Keep the environment tidy. B. Display the phone number to the nurses' station. C. Read label directions. D. Keep electrical cords under the bed.

A. Keep the environment tidy.

The nurse finds the apical impulse below the fifth intercostal space. Which of the following findings does the nurse suspect? A. Left ventricular enlargement B. Right ventricular enlargement C. Right atrial enlargement D. Left atrial enlargement

A. Left ventricular enlargement

The nurse is teaching a patient on proper use of a cane. What should the nurse include in this teaching? A. Move the weaker leg forward while the weight is between the cane and the stronger leg. B. Move the cane forward while the body weight is on the weaker leg. C. Hold the cane on the weaker side of the body. D. The length of the cane should permit the elbow to be fully extended.

A. Move the weaker leg forward while the weight is between the cane and the stronger leg.

The nurse is working on a hospital committee focused on preventing back injury in nurses. Which recommendation by this committee is most likely to result in a decrease in back injuries if followed? A. No solo lifting of patients is permitted in the facility. B. In order to prevent injury, nurses must strive to become physically fit. C. Nurses must wear back belts when lifting patients. D. All nursing personnel must attend annual body mechanics education.

A. No solo lifting of patients is permitted in the facility.

The nurse is considering the use of restraints for a patient. Which of the following situations is an appropriate reasoning for instituting restraints? A. Patient is picking at their intravenous access site. B. Patient does not want to stay in bed but wants to sit in the lounge with others. C. Patient wanders around the care area. D. Patient fell after frequently attempting to get out of bed.

A. Patient is picking at their intravenous access site.

In what phase of the helping relationship does the nurse review patient assessment data and develops a plan of action? A. Preinteraction phase B. Termination phase C. Working phase D. Introductory phase

A. Preinteraction Phase

Which of the following are correct guidelines for charting in the patient record? A. Record the time of each entry B. Always use abbreviated terminology C. Chart at the end of the shift only D. Use initials for signing chart

A. Record the time of each entry

To assess the patient's pedal pulses, which of the following should the nurse palpate? A. Top of the foot and inner side of each foot B. Popliteal space and the medial aspect of the ankle C. Posterior aspect of the foot and anterior aspect of the ankle D. Medial aspect of the foot and the ventral aspect of the ankle

A. Top of the foot and inner side of each foot

The nurse is assisting the patient to dangle on the bedside. After raising the head of the bed, in which position should the nurse face? A. Toward the far corner of the foot of the bed B. Toward the side of the bed C. Directly toward the patient D. Toward the nearest corner of the head of the bed

A. Toward the far corner of the foot of the bed

During an interaction with a newly admitted patient who suddenly becomes silent and stares off into space, what is the most therapeutic response by the nurse? A. "Don't you want to talk anymore?" B. "I noticed you have become very quiet." C. "Why have you fallen silent?" D. "I know I've done something to upset you."

B. "I noticed you have become very quiet."

During an assessment, a patient who is not very talkative appears pale, diaphoretic, and restless in the bed, and says "leave me alone." Which subjective data should the nurse document? A. Restlessness B. "Leave me alone" C. Not talkative D. Pale and diaphoretic

B. "Leave me alone"

When completing oral suctioning with a Yankauer, the nurse understands that which of the following techniques should be utilized? A. Standard precautions B. Clean technique only C. Sterile technique only D. Sterile or clean technique

B. Clean technique only

The nurse is preparing to conduct a mental status assessment. Which of the following functions are included in this assessment? A. Cognitive and effective functions B. Cognitive and affective functions C. Affective and knowledge functions D. Affective and memory functions

B. Cognitive and affective functions

What is the best defense against any legal malpractice for the nurse? A. Assuming those reading the chart understand common interventions (ex: turning) occurred B. Complete charting by using the steps of the nursing process as a framework C. Using the word error whenever a recording mistake has been made D. Using abbreviations for convenience throughout the patient chart

B. Complete charting by using the steps of the nursing process as a framework

The nurse is caring for a patient on the first post-operative day. The physician has ordered an incentive spirometer for the patient. What should the nurse instruct the patient to do? A. Breathe through his nose while using the spirometer B. Complete the breathing exercises 4 to 5 times every hour while awake C. Blow vigorously into the device to make the ball rise D. Hold his breath and count to 10 before using the spirometer

B. Complete the breathing exercises 4 to 5 times every hour while awake

The nurse is reviewing the nursing process with a first-year nursing student. What should the nurse explain as being the purpose of the diagnosis phase? Select all that apply. A. Develop a plan. B. Develop a list of problems. C. Identify patient strengths. D. Specify goals and outcomes. E. Identify problems that can be prevented.

B. Develop a list of problems. C. Identify patient strengths. E. Identify problems that can be prevented.

A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health patient who began with these symptoms 5 days ago. A goal was that the patient's symptoms would be eliminated within 48 hours. The patient is being seen after a week, and has had no diarrhea or vomiting for the past 5 days. Which of the following actions should the nurse take? A. Keep the problem on the care plan, in case the symptoms return. B. Document that the problem has been resolved and discontinue the care for the problem. C. Assume that whatever the cause was, the symptoms may return, but document that the goal was met. D. Document that the potential problem is being prevented because the symptoms have stopped.

B. Document that the problem has been resolved and discontinue the care for the problem.

While preparing a patient for a procedure, the nurse notes that the patient has become unresponsive and respirations have become shallow. What type of assessment should the nurse complete at this time? A. Initial assessment B. Emergency assessment C. Time-lapsed assessment D. Problem-focused assessment

B. Emergency assessment (This change in the patient's condition requires an emergency assessment. An emergency assessment is performed during any physiological or psychological crisis to identify life threating problems or over looked problems. An initial assessment is done when a client is admitted to a health agency to establish a complete database for problem identification, reference, and future comparison. Time-lapsed assessment is done several months after the initial assessment to compare the client's current status to baseline data previously obtained. A problem focused assessment is ongoing process integrated with nursing care to determine the status of a specific problem identified in an earlier assessment (p.161).)

Patient centered-care includes which of the following? (Select all that apply) A. Speak to patients and families using medical terms B. Encourage family to participate in care C. Assess patient preferences D. Using facial expressions to convey feelings E. Actively listen to the patient

B. Encourage family to participate in care C. Assess patient preferences E. Actively listen to the patient

Which of the following is an uncontrollable risk factor that has been linked to the development of cardiovascular disease? A. Exercise B. Heredity C. Stress D. Obesity

B. Heredity

The heart sound S4 is often heard in older adults and can be an indication of what? A. Peripheral vascular disease B. Hypertension C. Arteriosclerosis D. Pulmonary edema

B. Hypertension

Which of the following physical assessment findings would the nurse expect to find in a patient with advanced chronic obstructive pulmonary disease (COPD)? A. Underdeveloped neck muscles B. Increased anteroposterior chest diameter C. Symmetric thorax D. Collapsed neck veins

B. Increased anteroposterior chest diameter

During the examination of the thorax, which of the following should the nurse use as the starting point for locating the ribs anteriorly? A. Left midclavicular line B. Manubriosternal junction (Angle of Louis) C. Right midclavicular line D. Manubrium of sternum

B. Manubriosternal junction (Angle of Louis)

Which type of artificial airway may be placed on an alert patient with an intact gag reflex? A. Oropharyngeal airway B. Nasopharyngeal airway C. Tracheostomy tube D. Endotracheal tube

B. Nasopharyngeal airway

A patient who expresses anger at a diagnosis by slamming a food tray on the table is using what type of communication? A. Verbal B. Non-verbal C. Termination D. Silence

B. Non-verbal

Which of the following describes a patient experiencing shortness of breath when lying down? A. Hypoxia B. Orthopnea C. Dyspnea D. Hyperpnea

B. Orthopnea

A patient has been having pain without any clear pathology for cause. Which of the following nursing diagnoses should the nurse identify as the most appropriate for this patient? A. Pain due to unknown factors B. Pain related to unknown etiology C. Pain manifested by patient's report D. Pain caused by psychosomatic condition

B. Pain related to unknown etiology

The nurse is preparing to assess a patient's reflexes and sensation. What equipment should the nurse gather before entering the room? Select all that apply. A. Stethoscope B. Percussion hammer C. Sterile safety pin D. Penlight E. Wisps of cotton

B. Percussion hammer C. Sterile safety pin E. Wisps of cotton

A newly admitted patient has contractures of both lower extremities. What nursing intervention should be included in this patient's plan of care? A. Frequent position changes to reverse the contractures B. Range-of-motion exercises to prevent worsening of contractures C. Exercises to strengthen flexor muscles D. Weight-bearing activities to stimulate joint relaxation

B. Range-of-motion exercises to prevent worsening of contractures

The nurse understands that the gallbladder is found in which of the four abdominal quadrants? A. Left upper quadrant B. Right upper quadrant C. Left lower quadrant D. Right lower quadrant

B. Right upper quadrant

The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for a patient with chronic asthma. In looking at the patient's coping skills, the nurse realizes that the patient has a vast knowledge about the disease. Why should the nurse utilize this information? A. The patient will be more active in the plan. B. Strengths can be an aid to mobilizing health and the healing process. C. It will be easier for the nurse to educate the patient about other interventions. D. The nurse won't have to spend time going over the pathology of the patient's disease.

B. Strengths can be an aid to mobilizing health and the healing process.

Which of the following is described as the amount of volume that a normal adult takes in during inspiration and expiration? A. Respiratory quality B. Tidal volume C. Cardiac output D. Ventilation

B. Tidal volume

Breath sounds that are soft-intensity and low-pitched created by air moving through small airways are classified as which of the following? A. Adventitious B. Vesicular C. Bronchovesicular D. Bronchial

B. Vesicular

A patient says, "I hate the idea of being an invalid after they cut off my leg." Which of the following would be the most therapeutic response by the nurse? A. "At least you still have one good leg to use." B. "Let's finish the preoperative teaching." C. "Tell me more about how you are feeling." D. "You're lucky to have a wife to care for you."

C. "Tell me more about how you are feeling."

The nurse is performing a musculoskeletal assessment on a patient admitted with a possible stroke. How should the nurses assess muscle grip strength? A. Ask the patient to hold an arm up and resist while the nurse tries to push it down. B. Ask the patient to flex each arm and then try to extend it against the nurse's attempt to keep the arm in flexion. C. Ask the patient to grasp the nurse's index and middle fingers while the nurse tries to pull the fingers out. D. Ask the patient to shrug the shoulders against the resistance of the nurse's hands.

C. Ask the patient to grasp the nurse's index and middle fingers while the nurse tries to pull the fingers out.

When completing an abdominal assessment, which of the following methods of examination must occur first to prevent false assessment findings? A. Percussion B. Inspection C. Auscultation D. Palpitation

C. Auscultation

The patient has a history of postural hypotension. Which activities should the nurse advise this patient as likely to cause a drop in blood pressure? A. Light meals B. Use of a rocking chair C. Bending down to the floor

C. Bending down to the floor

Which type of nutritional assessment data is the nurse collecting when reviewing hemoglobin, serum albumin, and total lymphocyte lab values? A. Anthropometric data B. Dietary data C. Biochemical data D. Clinical data

C. Biochemical data

A patient has decided to become a vegetarian and is concerned about obtaining adequate protein intake. Which of the following food combinations would provide a complete protein source? A. A mixture of almonds and brazil nuts B. Rye toast with jam C. Brown rice with kidney beans D. A brown rice barley medley

C. Brown rice with kidney beans

The nurse assesses the respiratory status of a patient who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which of the following findings would be expected? A. Normal breath sounds B. Prolonging inspiration C. Coarse crackles and rhonchi D. Normal chest movement

C. Coarse crackles and rhonchi

What is the root cause for 82% of sentinel events? A. Increased health care provider workload B. Administration of wrong meds C. Communication breakdown D. Incorrect diagnoses

C. Communication breakdown

The nurse decides to seek wound care alternatives for a patient's ulcer that is not healing after treatment for 2 weeks. In which phase of the nursing process is the nurse functioning? A. Diagnosis B. Implementation C. Evaluation D. Assessment

C. Evaluation

A patient is admitted for continuing care following a motor vehicle crash. The admitting nurse will develop the initial plan of care, but who will be involved with the ongoing planning of this patient's care? A. The admitting nurse B. Only nurses who work with the patient C. Everybody involved in this patient's care D. The patient and the patient's support system

C. Everybody involved in this patient's care

The home care nurse wants to ensure the safety of an older patient who lives at home alone. Which intervention should the nurse identify as a way to prevent this patient from falling? A. Turn the light on after getting out of bed. B. Place socks on feet. C. Exercise regularly. D. Check vision every 5 years.

C. Exercise regularly.

Which of the following should the nurse monitor in a patient who has been receiving total parental nutrition (TPN) for 3 days? A. The amount, color, and consistency of the aspirate from the feeding. B. Lung sounds and pulse oximetry measurements to assess for aspiration of feeding. C. Frequent finger stick blood sugar results to monitor for hyperglycemia. D. Frequent finger stick blood sugar results to monitor for hypoglycemia.

C. Frequent finger stick blood sugar results to monitor for hyperglycemia.

A patient has the goal statement "Patient will be able to state two positive aspects of rehab therapy by the end of the week." Which of the following statements demonstrates that the nurse appropriately evaluated this goal? A. Goal not met, patient able to state one positive aspect by the end of the week. B. Goal met, patient able to state one positive aspect by the end of the week. C. Goal met, patient able to state two positive aspects of therapy by week's end. D. Goal incomplete, patient not able to positively state anything about rehab

C. Goal met, patient able to state two positive aspects of therapy by week's end.

The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process? A. Deliver care to a patient in an organized way. B. Implement a plan that is close to the medical model. C. Identify patient needs and deliver care to meet those needs. D. Make sure that standardized care is available to patients.

C. Identify patient needs and deliver care to meet those needs.

The nurse provides a back rub to a patient after administering a pain medication with the hope that these two actions will help decrease the patient's pain. Which phase of the nursing process is this nurse implementing? A. Assessment B. Diagnosis C. Implementation D. Evaluation

C. Implementation

The nurse is assessing the lower extremities of the patient with peripheral vascular disease (PVD). The nurse would expect to find which of the following signs of PVD? A. Hairy legs B. Pink, cool skin C. Marked edema D. Warm, moist skin

C. Marked edema

The nurse is reviewing information about the formulation of nursing diagnoses. What should the nurse identify as the area in which nursing diagnoses differ from medical diagnoses and collaborative problems? A. Mental status of the patient B. Chronic nature of the illness C. Nursing care focus D. Prognosis

C. Nursing care focus

A nurse calculates a patient's body mass index (BMI) as 32kg/m2. This finding indicates that the patient is suffering from which of the following alterations in nutrition? A. Overweight B. Underweight C. Obesity D. Protein-calorie malnutrition

C. Obesity

A patient is demonstrating confusion and is unable to recall the date and time for the nurse. How should the nurse document this data? A. Inference B. Subjective data C. Objective data D. Secondary data

C. Objective data

The nurse has asked the unlicensed assistive personnel (UAP) to help with admitting a patient. Which of the following activities can be delegated to the UAP? A. Collect nursing history and assessment data B. Assess the patient's lung sounds C. Obtain the patient's height and weight D. Administer scheduled medications

C. Obtain the patient's height and weight

What therapeutic communication technique does this interaction demonstrate? Nurse: "Tell me more about that." A. Restating/paraphrasing B. Changing subject C. Open ended questions D. Giving information

C. Open ended questions

A discharge goal for a patient is to have improved mobility. Which outcome statement did the nurse write appropriately? A. Patient will not fall. B. Patient will ambulate freely in house. C. Patient will ambulate without a walker by 6 weeks. D. Patient will have freer movement in daily activities.

C. Patient will ambulate without a walker by 6 weeks.

A patient who needs to follow a clear liquid diet may eat which of the following foods? A. Vegetable juices B. Yogurt C. Popsicles D. Pureed soup

C. Popsicles

The nurse has formulated the following diagnosis: Activity intolerance, related to weakness and debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label? A. Weakness and debilitation B. Activity intolerance C. Reports of fatigue D. Physical activity

C. Reports of fatigue

Which of the following characteristics is a normal finding upon palpitation of the abdomen? A. Tenderness B. Hypersensitivity C. Smooth, consistent tension D. Superficial masses

C. Smooth, consistent tension

During the initial interview, a patient with an eating disorder remarks, "I can't stand myself and the way I look." Which of the following statements by the nurse would be most appropriate? A. "Don't worry, you'll soon be back in shape" B. "I don't think you look bad at all" C. "Tell me more about your feelings" D. "Everyone who has the same problem feels like you do"

C. Tell me more about your feelings

During the cardiovascular assessment, the nurse finds the patient has jugular vein distention. What could this indicate? A. The patient has an infection B. The patient has normal heart function C. The patient has advanced cardiopulmonary disease D. The patient is experiencing dehydration

C. The patient has advanced cardiopulmonary disease

In order to assess the thorax for vocal fremitus which of the following assessment techniques is used? A. Auscultation B. Percussion C. Inspection D. Palpation

D, Palpation

A Mexican-American patient is receiving discharge teaching on diabetes management and carbohydrate counting. Which statement by the nurse best reflects an understanding of the ethnic and cultural impact on dietary choices? A. "Make sure you measure out your rice before you cook it. A ½ cup of dry rice is 75 carbohydrates." B. "Beans are a complex carbohydrate and are more difficult for your body to breakdown, therefore the impact on your blood sugar is lower." C. "As a diabetic you will need to make sure you eat less rice, beans, and tortillas and more chicken, fish, and vegetables." D. "Do you have any personal, cultural, or ethnic food preferences? What foods do you eat most often?"

D. "Do you have any personal, cultural, or ethnic food preferences? What foods do you eat most often?"

A patient has entered a smoking cessation program to quit smoking. He tells the nurse he has not smoked a cigarette for 3 weeks, but is afraid he will slip up and smoke because of current job pressures. What would be the most appropriate reply for the nurse to make in response to the patient's comments? A. "Don't worry about it. Everyone has difficulty quitting smoking and you should expect to as well" B. "If you increase your self-control, I am sure you will be able to avoid smoking" C. "Try taking a couple of days of vacation to relieve the stress of your job" D. "It is good that you can talk about your concerns. Try calling a friend when you want to smoke"

D. "It is good that you can talk about your concerns. Try calling a friend when you want to smoke"

Delivering oxygen via a nasal cannula is effective up to what flow rate? A. 4 L/min B. 2 L/min C. 8 L/min D. 6 L/min

D. 6 L/min

The nurse is listening to a patient's heartbeat and is focusing on the second heart sound. Which heart valves produce this sound? A. Mitral and tricuspid B. Aortic and tricuspid C. Mitral and pulmonic D. Aortic and pulmonic

D. Aortic and pulmonic

A nurse is assessing a patient's bilateral pulses for symmetry. Which pulse site should not be assessed on both sides of the body at the same time? A. Brachial B. Radial C. Femoral D. Carotid

D. Carotid

Identify the barrier to communication in the following interaction.Patient: "When can I expect to be told about how to take my insulin?"Nurse: "Let's discuss your diet now so that you will know what to eat when you get home. We can discuss insulin some other time." A. Giving information B. Stereotyping C. Presenting reality D. Changing the subject

D. Changing the subject

Two days after an ileostomy, the patient refuses nursing care and requests to be left alone. What should be the nurse's first action? A. Allow the client the privacy he requests B. Invite a member of the ostomy association for a visit C. Tell the client that he must begin to deal with the situation D. Encourage the client to verbalize his feelings

D. Encourage the client to verbalize his feelings

A nurse places a nasogastric tube into a patient. Which is the best method the nurse should use to confirm placement prior to initiating tube feedings? A. Confirm the length of the tube insertion is consistent with the height of the patient B. Measure the pH of the aspirated fluid C. Auscultate for a "whooshing" sound over the stomach while injecting air through the NG tube D. Ensure chest x-ray verifies correct tube placement

D. Ensure chest x-ray verifies correct tube placement

A patient is diagnosed with pneumonia and has been hospitalized for several days. Which of the following nursing diagnoses should the nurse identify as a priority for this patient? A. Altered oral mucous membranes, related to dry mouth B. Activity intolerance, related to oxygen supply imbalance C. Knowledge deficit, related to medication regimen D. Ineffective airway clearance, related to increased secretions

D. Ineffective airway clearance, related to increased secretions

Calculate the patient's intake and output. For breakfast the patient left 3 oz of an 8 oz cup of coffee, had 3 oz of orange juice, and 4 oz of oatmeal. At 0930 the patient consumed 6 oz of water with medications. Following the medication administration, the patient had an emesis of 200 mL. The patient urinated 350 mL, and the abdominal drain collected 50 mL of bloody drainage. A. Intake = 480 mL, output = 550 mL B. Intake = 450 mL, output = 350 mL C. Intake = 540 mL, output = 400 mL D. Intake = 420 mL, output = 600 mL

D. Intake = 420 mL, output = 600 mL

The nurse is preparing to assess a patient's status using the Glasgow Coma Scale. Which of the following areas is the nurse assessing in this patient? A. Musculoskeletal response B. Memory C. Orientation D. Motor response

D. Motor response

A patient presents in respiratory distress with oxygen saturation at 60%. Which oxygen delivery system will deliver the highest oxygen concentration possible for this patient? A. Nasal cannula B. Venturi mask C. Face mask D. Nonrebreather mask

D. Nonrebreather mask

The nurse identifies for a patient the nursing diagnosis "Fluid volume deficit, related to active fluid loss, secondary to diarrhea." Which of the following would be an appropriate goal statement for this diagnosis? A. Patient will have good skin turgor. B. Patient will drink more fluids by tomorrow. C. Patient will have moist mucous membranes. D. Patient will have intake of at least 1000 mL within 24 hours.

D. Patient will have intake of at least 1000 mL within 24 hours.

The patient who is unconscious is developing foot drop. Which of the following is an appropriate nursing action? A. Use only the prone and Sims positions for client positioning. B. Use a device to elevate the linens off the feet. C. Keep the linens on the end of the bed turned back to expose the feet. D. Place high-topped shoes on the patient while in bed.

D. Place high-topped shoes on the patient while in bed.

The nurse is caring for a patient with Parkinson's disease who desires to improve fine motor skills. Which of the following statements is an appropriate collaborative intervention for this patient? A. Make sure lighting and space are adequate for patient. B. Provide assistance as needed with dressing and grooming. C. Assess pain and administer medications to improve muscle tone. D. Provide assistive devices and educate patient to use large handled utensils.

D. Provide assistive devices and educate patient to use large handled utensils.

When conducting a cardiac assessment, the nurse knows that the pattern of beats and the intervals between the beats is defined as which of the following? A. Dysrhythmia B. Arrhythmia C. Pulse volume D. Pulse rhythm

D. Pulse rhythm

Upon entering a room, a patient and spouse are found crying. The nurse decides to sit with them, offering presence and listening to their fears instead of providing the planned education. Which of the following actions did the nurse perform? A. Determining the nurse's need for assistance B. Implementing nursing intervention C. Supervising delegated care D. Reassessing the patient

D. Reassessing the patient

The emergency department (ED) nurse is reporting off via phone call to the intensive care unit (ICU) nurse who is accepting a patient with pneumonia. What information should the ED nurse ensure to provide to the ICU nurse? A. Report elaborate background data or routine care information B. Report only the medical needs of the client's condition C. Report the coming and going of any visitors D. Report exact up to date information about the client's condition

D. Report exact up to date information about the client's condition

Which communication technique is used in this interaction? Patient: "I have been really upset about my blood pressure and having to take these pills."Nurse: "You've been upset about your blood pressure and taking pills."Patient: "I guess I'm worried about what could happen if my blood pressure gets too bad." A. Summarizing B. Informing C. Using humor D. Restating

D. Restating

Which of the following nursing interventions would promote effective airway clearance in a patient with acute respiratory distress? A. Administering sedatives to promote rest B. Administering oxygen every 2 hours C. Turning the client every 4 hours D. Suctioning if cough is ineffective

D. Suctioning if cough is ineffective

The nurse is reviewing the difference between evaluation and assessment with a new graduate nurse. What should the nurse emphasize as the major difference between these two steps in the nursing process? A. Assessment is done at the beginning of the process. B. Evaluation is completed at the end of the process. C. They are the same and there is no need to differentiate. D. The difference is in how the data are used.

D. The difference is in how the data are used.

After an assessment, the nurse reviews the list of patient problems. For which of the following problems should the nurse create nursing diagnoses? A. The ones that address other health professionals' interventions B. The ones that focus on the patient's primary illness C. The ones that have standardized care available D. The ones that the nurse is licensed to treat

D. The ones that the nurse is licensed to treat

The nurse determines that a patient has absent bowel sounds. Which of the following characteristics support this finding? A. Able to auscultate bowel sounds in 3 out of 4 quadrants B. he presence of rough, grating sounds upon auscultation C. The presence of borborygmi upon auscultation D. Unable to hear bowel sounds for over 4 minutes upon auscultation

D. Unable to hear bowel sounds for over 4 minutes upon auscultation

What is the most common mode of droplet transmissions?

Large particles that travel up to 3 feet and come in contact with the host

What is the most common mode of direct transmission?

Person to person OR physical source + susceptible host

What is the most common mode of indirect transmission?

Personal contact of a susceptible host with a contaminated inanimate object

The nurse is unable to palpate the patient's left pedal pulses. Which of the following actions would the nurse take next? A. Use a Doppler ultrasound device B. Auscultate with pulses with a stethoscope C. Call the physician D. Inspect the left lower extremity

A. Use a Doppler ultrasound device