NURS 3632 Exam 1 - Practice Questions

A nurse is administering a pain medication to a patient, Mr. Brown. In addition to checking his identification bracelet, the nurse correctly verifies the patients identity by performing which action?

Asking the patient his name and birthdate

A client with a urinary catheter in place complains of discomfort in the bladder and the urethra.. what should the nurse do first?

Check the patency of the catheter and tubing

Which nursing intervention for catheter car should have the highest priority?

Cleaning the area around the urethral meatus

A nurse is examining a child 2 years old. Asked on her findings, she initiates a care plan for a potential problem with normal growth and development. Which step of the nursing process identifies actual and potential problems?

Diagnosing

A nurse must make an unoccupied bed. Which nursing action is most important?

Ensure that the bottom of the sheet is free of wrinkles

A nurse brings a client the prescribed dose of medication and finds that the client is not in the unit. What should the nurse do in this case?

Return the medication to the medication cart or medication room.

An emancipated patient is at risk for developing a pressure ulcer. In which position should the nurse avoid placing the patient?

Side lying

A client who is unconscious needs frequent mouth care. While performing mouth care, the nurse tale care to place the client in which of the following positions?

Side-lying

A client is scheduled for a colonoscopy and the physician orders a tap water enema. In which position should the nurse place the client?

Sims position

Nurse identifies that a patients pressure ulcer has just partial-thickness skin loss involving the epidermis and dermis. What stage pressure ulcer should the nurse document based on this assessment?

Stage 2

A client with COPD has been prescribed an inhaled bronchodilator. Which technique should the nurse implement in order to ensure safe and complete delivery of the prescribed medication?

Use a space or extender with the MDI

A nurse observes a client pacing the halls, and it appears as if the client has been crying. What is the appropriate action?

Validate perceptions with the client

The nurse us providing hygiene to a patient with peripheral neuropathy. The nurse should:

Wash the feet with lukewarm water and dry well.

The nurse is assessing the client who has an onset of severe back pain of an unknown origin. Which would the nurse ask to encourage discussion?

What do you think caused the onset of your back pain?

What observation should the nurse instruct the client with an ileostomy to report immediately?

absence of drainage from the ileostomy for 6 or more hours

The nurse is assessing several clients with different types of injuries. The nurse would conclude that the client who is least likely to develop a wound infection would be the client with which of the following?

A contusion

A client with a colostomy asks the nurse about types of food that may help to control diarrhea and cause leakage into the pouch. In order to avoid leakage, the nurse should instruct the client to consume:

Applesauce, bananas, rice, tapioca, yogurt

The client complains of pain as the nurse is inflating the balloon during insertion of a Foley catheter. The nurse should take which immediate action?

Aspirate the fluid, advance the catheter farther, and reinflate the balloon.

A nurse is providing for the hygiene and grooming needs for an obese patient who easily becomes short of breath when moving about. Which is the most important nursing intervention?

Assessing response to activity

A nurse discovers that a medication error occurred. What should be the nurses first response?

Check the patient's condition to note any possible effect of the error.

The nurse is assessing the urine of a client with a urinary tract infection. Which of these characteristics should the nurse assess for a patient with a UTI?

Clarity

The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. Which action by the nurse is appropriate?

Consider the outer 1 in of the sterile field as contaminated.

A nurse is teaching the client taking medications by inhalation about the advantages of a spacer device. The nurse tells the client that the spacer:

Disperse medications more deeply and uniformly

The nurse is beginning to administer oral medications to the client. The client states, "I haven't take that pill before. Are you sure it's correct?" The nurse rechecks the MAR and finds that the medication is scheduled to be administered. Which response is most appropriate?

Don't take that pill yet. I will verify the medication was ordered by your primary care provider

A healthcare provider orders a pain medication for a postoperative patient that is a PRN order. When would the nurse administer the medication?

Doses administered as needed for pain relief.

An elderly bedridden client reports being constipated but cannot understand why. What instruction should the nurse give to assist the client?

Drink hot liquids and increase intake of water and fruit juices

After correctly positioning a client for a urinary catheterization procedure, the nurse sets up a sterile field and places the kit supplies on the area. The nurse hears a page to respond to another client who has fallen in the hallway. Which of the following would be the most appropriate nursing actions?

Ensure the clients safety, discard the sterile equipment, and resound to the other client.

The nurse teaches a client measures to avoid complications associated with urinary elimination. Which of the following indicated to the nurse that the expected outcome is achieved? The client:

Incentivizes symptoms of and measures to prevent urinary tract infection

Client is hospitalized for the first time. Which of the following actions would the nurse take to ensure the safety of the client?

Keep unnecessary furniture out of the way

Profuse smoke is coming out of the heating unit in a patient's room. What should the nurse do first?

Move the patient out of the room

The nurse transcribes an order that reads: Colace 100 mg PO daily. This is an example of which type of order?

Standing

A client has been admitted to the health care facility with an asthmatic attack. The medication order for the client indicated that the nurse administer the prescribed medications immediately. Which standard abbreviation indicates immediate medication?

Stat

An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?

Take a stool softener such as docusate sodium (Colace) daily.

In which of the following situations would the nurse be more justified in implementing trial-and-error problem solving?

The nurse is attempting to landmark an obese clients apical pulse

A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines?

The nurse moves the patient table away from the nurse's body when wiping it off after a meal

When the nurse administers the morning dose of medications during the evening, which of the rights of medication administration has she failed to follow?

Time

A medication order reads: "K-Dur, 20 mEq po BID"when and how does the nurse correctly give this drug?

Twice a day by the oral route

Through the prevention of postoperative complications, the nurse promotes rapid convalescence. Which of the following would be most indicative of a potential postoperative complication in a client that requires further observation?

Urinary output of 20 mL/hr over 2 hours

The nurse is preparing to assist with the ambulating of an older adult client who was on bed rest for three days. Which of the following actions should the nurse take to decrease the risk of a fall?

Use a gait belt during ambulation

The client who is in Bucks traction is constipated. A plan of care that incorporates which breakfast would be the most helpful in reestablishing a normal bowel routine?

an orange, raisin bran and milk and wheat toast with butter

Nurse enters the room of a female client and ask how she is doing, client states "I'm a little nervous this morning". What would be the nurses best reply?

"Can you tell me more about how you are feeling?"

The nurse is providing instructions to the unlicensed assistive personnel (UAP) who will be caring for a client with hand restraints. The nurse asks the UAP to repeat the instructions to ensure that the UAP understands the care. Which statement, if made by the UAP, indicated an understanding of the care for this client?

"I need to remove the restraints at least every 2 hours to perform range-of-motion exercises"

A client uses a cane to assist with ambulation. After teaching the client how to use a cane, the client makes the following statements. Which one indicates to the nurse the need for additional teaching?

"I should hold the cane on my weaker side."

The nurse has reviewed with the pre operative client the procedure for the administration of enema. Which statement by the client would indicate the need for further instruction?

"The enema will be given while I am sitting on the toilet"

A client with a new ileal conduit asks the nurse when he needs to wear his appliance. What should the nurse tell the client?

"You need to wear your appliance all the time."

The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients?

All patients receiving care in hospitals

At what points should the nurse perform the first three checks of medication administration?

As the nurse reaches for the drug package or container

A client comes to the ED complaining of severe chest pain. The nurse ask the client questions and takes VS. Which step in the nursing process is this?

Assesing

Mrs. Hall has an order for acetaminophen, 650 mg, q 6 hours PRN for pain. The nurse notes that according to Mrs. Halls chart, she is allergic to acetaminophen. The order for the medication was signed by Dr. Long. What would be the correct procedure for the nurse to follow in this situation?

Call Dr. long and ask that the medication be changed

A patient's stool specimen is positive for Clostridium difficile. Which isolation precautions should the nurse institute for this patient?

Contact

Self evaluation is a method that nurses use to promote their own development and to grow in confidence in their nursing roles. The process is refereed to as what?

Reflective practice

Which action would the nurse take to use a wide base of support when assisting a client to get up from a chair?

Spread the feet shoulder-width apart before touching the client.