PN 2006 pre lec/quizzes/midterm review

The nurse considers several new female patients to receive additional teaching on the need for more frequent Pap smears and gynecological examinations. Which of the following patients is at higher risks for cervical cancer and thus having the greatest need for patient education? a. 25 year old, smokes 1/2 pack of cigarettes per day, has multiple sexual partners bc nonsmokers, 13 years old, not sexually active c. 45 year old, stopped smoking 20 years ago, history of hysterectomy d. social smoker, 18 year old, celibate

a. 25 year old, smokes 1/2 pack of cigarettes per day, has multiple sexual partners

Prior to commencing a patient's tube feed, it is important to remember to position the patient in supine position true or false

false

Rubella requires contact precautions. True or false

false

Subjective data should never be included in charting. true or false

false

When a patient has a seizure it is important to retrain their arms and legs to prevent them hurting themselves true or false

false

When administering a fleet, the patient should be lying on their right side. true or false

false

When performing an abdominal assessment, it is important to palpate the painful areas first. true or false

false

a patient with Glasgow coma scale score 15 would be considered in a coma. true or false

false

an oxygen saturation of level of 85%-95% would be considered normal true or false

false

"cohorting" involves placing patients with similar infections in the same room together. true or false

true

A blowing sound osculated over the carotid artery is know as bruit true or false

true

A patient who is expecting diarrhea after starting a new tube feed formula may be experiencing formula intolerance. true or false

true

Abnormal gait in a patient, might include, staggering, foot scarping, or high stepping true or false

true

An example of a report is when a nurse prepares an audiotaped exchanged with another nurse of information about a patient. true or false

true

Assisting with oral care will help to enhance a patient sense of taste. true or false

true

At present, the most reliable ,method for verification of placement of a feeding tubes is X-ray. true or false

true

Certain medications, like chemotherapeutics or steroids may impede wound healing. true or false

true

Discharge planning begins at admission true or false

true

Examples of adventurous breath sounds might include rhonchi and crackles true or false

true

Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. true or false

true

Macerated skin around a wound could suggest that the wound is being kept too moist true or false

true

Subjective data includes a patient's feelings, perception, and reported symptoms true or false

true

Types of internal feeding tubes can include, gastrostomy tubes, jejunal tubes, and nasogastric tubes. true or false

true

Wheeezes can be described as high-pitched musical sounds that are heard on inspiration and expirations true or false

true

Wheezes can be described as high-pitched musical sounds that are heard on inspiration and expiration true or false

true

When cresting care plans the nurse should consider the needs of the family family members as well true or false

true

examples of adventitious breath sounds might include rhonchi and crackles true or false

true

non blanching erthyema is an indication of a stage 1 pressure ulcer true or false

true

small, circumscribed skin lesions filled with serious fluid could be described as vesicle. true or false

true

General assessments are only done once per shift. true or false

false

It is normal and does not require intervention should a patient refuse to look at their stoma during care. true or false

false

Items below the waist are considered to be sterile. true or false

false

A patient in the emergency department is complaining of left lower abdominal pain. The comprehensive abdominal examination would include, in proper order, which of the following? A. Inspection, palpation, auscultation B. Percussion, inspection, auscultation C. Inspection, palpation, percussion D. Inspection, auscultation, palpation

D. Inspection, auscultation, palpation

An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimer's disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is: 1. Confusion 2. Impaired judgment 3. Sensory deficits 4. History of falls

4. History of falls

On admission, a patient weighs 250 pounds. The weight is recorded as 256 pounds on the second inpatient day. The nurse should evaluate the patient for A. Fluid retention. B. Fluid loss. C. Decreased nutritional reserves. D. Anorexia.

A. Fluid retention.

A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. When performing an abdominal assessment, the nurse should A. Recommend that the patient take more laxatives. B. Ask the patient about the color of her stools. C. Avoid sexual references such as possible pregnancy. D. Assess first the spots that are most tender.

B. Ask the patient about the color of her stools.

When evaluating a plan of care, the nurse reviews the goals for the patient. Which goal statement is realistic to assign to a patient with a pelvic fracture on bed rest? The patient will increase mobility by A. Ambulating in the hallway two times this shift. B.Turning side to back to side with assistance every 2 hours. C.Using the walker correctly to ambulate to the bathroom as needed. D.Using a sliding board correctly to transfer to the bedside commode as needed.

B.Turning side to back to side with assistance every 2 hours

While working on a long term care unit, health care aid (HCA) asks the nurse if they could chart the bowel care that the HCA did earlier this morning. Which of the following in true concerning charting? a. As a team leader the nurse should take this opportunity to provide education to the HCA on the importance of charting b. It is acceptable for the nurse to chart in this instance because the HCA is. to regulated c. The nurse is required to report the HCA to the manager as the HCAs conduct is unprofessional d. The nurse should refuse the request and tell the HCA to chart whenever they have time

a. As a team leader the nurse should take this opportunity to provide education to the HCA on the importance of charting

A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse'a best action in response to her observations? a. Ask the patient about the facial grimacing with movement b. Proceed to the next patients room while making sounds c. Offer a massage because the patient does not want any more pain medicine. d. Administer the pain medication ordered for moderate to severe pain

a. Ask the patient about the facial grimacing with movement

In which step of the nursing process does the nurse determine if the patient's condition has improved and whether the patient has met expected outcomes? a. Evaluation b. Implementation c. Planning d. Assessment

a. Evaluation

The nurse admits the patient with mild chest pain from emergency department. what should the nurse implement first to gain patient corporation during a physical assessment? a. Explain the procedure and it's purpose b. Perform assessment in stages over the day c. Complete assessment within 3 to 5 minutes d. Assess painful areas before non-tender areas

a. Explain the procedure and it's purpose

A nurse wanting to assess a patients daily weights. Where should the nurse look? a. Graphic sheet and flow sheet b. Database c. Progress notes d. Medical history and examination

a. Graphic sheet and flow sheet

A home care patient receives oxygen by nonbreather (NRB) mask. Which does the nurse include when teaching the caregiver about the oxygen delivery system? a. Keep the plastic bag at the end of the mask inflated b. offer fluids frequently and apply moisturizer to prevent dry skin c. Remove the elastic head strap to prevent skin breakdown at the ears d. Adjust the oxygen flow rate whenever the patient feels like the need more oxygen

a. Keep the plastic bag at the end of the mask inflated

While setting up a sterile field for a procedure, the nurse knocks a linen-wrapped sterile package to the floor. Which reaction allows the nurse to maintain safe practice? a. Replace the dropped item b. Brush away the visible debris c. Record the procedure as clean d. Inspect the package for tears

a. Replace the dropped item

A 79 year old resident in a long term care facility is known to "wander" at night and has fallen in the past. Which of the following nursing interventions is the most appropriate for this client? a. The client should be checked frequently during the night b. An abdominal restraint should be placed on the client during sleeping hours c. The client should be placed in a room away from the acidity of the nursing station d. A radio should be left playing at the bedside to assist in reality orientation

a. The client should be checked frequently during the night

The nurse assessing with a patients with a cast extending from just below the left knee to the toes. which assessment contain a desirable patient outcome? a. The toes are pink bilaterally b. The cast is warm at the ankle c. Paresthesia is present in the left foot d. The cast is snug at the knee

a. The toes are pink bilaterally

For the client with receptive aphasia, which of the following nursing interventions is the most effective? a. Using a system of simple gestures and repeated behaviours to communicate b. Providing the client with a letter chart to use to answer complex questions c. Offering the client a notepad to write questions and concerns d. Obtaing a referral for a speech therapist

a. Using a system of simple gestures and repeated behaviours to communicate

the patient is being assessed for a possible respiratory problem. In which position should the patient be placed to facilitate chest expansion during a thoracic assessment ? a. high fowlers b. Doral recumbent c. side-lying d. prone

a. high fowlers

The nurse is instructing a patient how to breathe during auscultation of the lungs. Intructions by the nurse has been effective if the patient breathes in which manner? a. Takes a deep breath and holds it b. Breathe with the mouth open c. Cough and then takes a deep breath d. Takes rapid shallow breath

b. Breathe with the mouth open

A medical diagnosis and a nursing diagnosis are the same thing true or false

false

The nurse instructs a patient about home colostomy care. What informative does the nurse include in patient teaching about caring for the pouch? a. Empty the pouch when it is at least three-fourths full b. Change the pouch every 3 to 7 days c. Empty the pouch at least every 4 hours around the clock d. Change the pouch every other day

b. Change the pouch every 3 to 7 days

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. How should the nurse proceed? a. Notify the physician to recommend a psychological evaluation. b.Consider cultural differences during this assessment. c.Ask the patient to make eye contact to determine her affect. d.Continue with the interview and document that the patient is depressed

b. Consider cultural differences during this assessment.

Injuries among older adults resulting from falls in the home are due to intrinsic and extrinsic factors. Which one of the following is an example of an extrinsic factor? a. Illness b. Environmental obstacles c. Drug therapy d. Alcohol use

b. Environmental obstacles

In which of the following situations should the nurse use surgical asepsis? a. Performing urinary catheter care b. Inserting a Foley catheter c. Performing nasogastric tube care d. Inseting a nasogastric tube

b. Inserting a Foley catheter

The nurse recognizes that changes in elimination occur with the aging process. Which one of the following is an expected change affecting bowel elimination? a. Change in nerve innervation and sensation cause diarrhea b. Mastication processes are less efficient c. Esophageal emptying time is increased d. Absorptive processes are increased in the intestinal mucosa

b. Mastication processes are less efficient

The nurse set up a sterile field and notes several tiny holes in the drape of the table that served as the wrap for the pack. What does the nurse do to facilitate completion of the procedure? a. Use a sterile towel to cover the existing holes b. Replaces the entire sterile field and the supplies c. Avoids using any of the sterile items near the holes d. Moves the sterile supplies to a replacement drape

b. Replaces the entire sterile field and the supplies

The nurse has completed the admission for a client admitted to the hospital's sub-acute care unit. Of the following nursing diagnosis identified by the nurse's, which one takes the highest priority? a. Adjustment, impaired b. Risk for injury c. Social isolation d. Communication, impaired verbal

b. Risk for injury

The nurse completes preparation of the sterile field to change a patient's dressing when the patient's dinner tray arrives. Which action should the nurse take? a. Change the dressing and using clean technique to save time b. Set up the tray aside and proceed with the dressing change c. Use the sterile field on another patient in another room d. Cover the setup with a sterile drape and let the patient eat

b. Set up the tray aside and proceed with the dressing change

The nurse teaches the patient in proper handwashing technique before discharge and ask for a return demonstration, which hand hygiene technique indicates the patient teaching by the nurse is effective? a. The patient turns off the tap and then dries hands b. Soap, water, and friction are used by the patient c. The patient wash his hands with very hot water d. A basin with warm soapy water is used

b. Soap, water, and friction are used by the patient

The patient is in isolation in a negative pressure room for active tuberculosis. He coughs and spews large amounts of blood thinks sputum but is too weak to cover his mouth and nose with a tissue. Which is the most important intervention for the nurse to implement for self protection while providing nursing care? a. Cover the patient's mouth and nose snugly with a surgical mask b. Wear an N-95 mask, gloves, face shield, and isolation gown c. Place tissues and a contaminated waste container within reach. d. Use a properly fitted surgical mask and gloves to help with tissues

b. Wear an N-95 mask, gloves, face shield, and isolation gown

Which of the following is the most accurate way to determine the correct placement of a newly inserted tube feed? a. Patient description of placement b. X-ray c. ph of aspirated contents d. Surgical report from physcian

b. X-ray

A patient has no bowel sounds in his upper left quadrant. After listening carefully for 10 seconds, you believe that: a. The patient may have a bowel obstruction b. You need to listen longer in all quadrants c. This is a medical emergency d. The patient may have an ileus

b. You need to listen longer in all quadrants

The nurse is instructing a patient how to breathe during auscultation of the lungs. Instruction by the nurse has been effective if the patient breathes in which manner? a. takes a deep breath and holds it b. breathes with the mouth open c. coughs and then takes a deep breath d. takes rapid shallow breaths

b. breathes with the mouth open

A patient's tube feed has finished running through. Which of the following nursing measures would be helpful in preventing clogging in the tubing? a. remove feeding tube from the patient's abdomen b. flush with 20-30 ml of water after feed c. ascertain that feeding tube is in correct position by sending the patient for an x-ray d. leave the patient in left lateral sim's position

b. flush with 20-30 ml of water after feed

The nurse is listening to the patient's lungs. Which information should the nurse use to document normal patient lung sounds? a. inspiratory wheezing in the upper lobes b. no adventitious breath sounds c. rales in the right lower lobe d. pleural friction rub in the left lung

b. no adventitious breath sounds

In preparation for a rectal examination of a non-ambulatory male patient, the patient is informed of the need to be on what position? a. forward sending with flexed hips b. sim's postion c. knee-chest d. Dorsal recumbent

b. sim's postion

The nurse assesses an adult patient with a cardiopulmonary illness and hears a grating sound over the lower lateral lung during inspiration that does not clear with coughing. What would the nurse most likely document as a result of the assessment findings? a. Crackles b. Wheezes c. A pleural friction rub d. Rhonchi

c. A pleural friction rub

What is the best term for breath sounds created by air moving through large lung airway? a. Rhonchi b. Bronchial c. Bronchovesicular d. Vesulcar

c. Bronchovesicular

A patient with a Glasgow coma scale score of 15 would be considered to be in a coma true or false

false

The patient has just been started on an internal feeding and has developed diarrhea after being on the feeding for 2 hours. What is the most likely cause of diarrhea a. Bacterial contamination b. Clostridium difficile c. Formula intolerance d. Antibiotic therapy

c. Formula intolerance

While caring for a patient, the nurse determines that he has a rating of 6 on the Glasgow coma scale. The nurse understands that: a. He has received the highest possible score b. His is not in a coma c. He is in a coma d. He has received the lowest possible score

c. He is in a coma

Which of the following is an example of subjective data? a. Patients temperature b. Patient's wound appearance c. Patient's expression of feae regarding upcoming surgery d. Patient pacing the floor while awaiting test results

c. Patient's expression of feae regarding upcoming surgery

Which of the following is an example of subjective data? a. Patient's tempature b. Patient's wound appearance c. Patient's expression of fear regarding upcoming surgery d. Patient's pacing the floor while awaiting test results

c. Patient's expression of fear regarding upcoming surgery

To gather information about a patient's home and work surroundings, the nurse will need to utilize which method of data collection? a. Carefully review lab results b. Conduct the physical assessment before collecting subjective information c. Perform a through nursing health history d. Prolong the termination phase of the interview

c. Perform a through nursing health history

The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately? a. Continuous output from the stoma b. Liquid consistency of stool c. Presence of blood in the stool d. Noxious door from the stool

c. Presence of blood in the stool

The nurse is caring for a patient with small chronic pressure ulcer on the ankle. Which activity can the nurse delegate to the health care assistant? a. Measure the wound for length, width, and depth b. Ask the patient to rate the pain during the dressing change c. Reposition the patient at least every 2 hours d. Examine the wound bed for the type and amount of tissue

c. Reposition the patient at least every 2 hours d. Examine the

Which is the best examination position for a complete physical examination on a weak,geriatric patient with bilateral basilar pneumonia? a. Prone position b. Sims position c. Supine position d. Lateral position

c. Supine position

An oxygen saturation level of 85-95% would be considered normal true or false

false

Application of cold will cause vasodilation and will therefore help to relive pain true or false

false

A patient expresses fear of going home and being alone. Her vital sigma are stable and her incision is nearly completely healed. What can the nurse infer from the subjective data? a. The patient can begin retaking all her previous medications b. The patient can now perform the dressing change herself c. The patient is apprehensive about discharge d. The wound is healing as expected and the surgery was a success

c. The patient is apprehensive about discharge

A nurse preceptor is working with a student nurse. Which behavior by the student nurse willrequire the nurse preceptor to intervene? a. The student nurse reviews the patient's medical record. b. The student nurse reads the patient's plan of care. c. The student nurse shares patient information with a friend. d. The student nurse documents medication administered to the patient

c. The student nurse shares patient information with a friend.

Which nursing intervention is most effective in promoting normal defencies for a patient who has muscle weakness in the legs that prevents ambulation? a. Give the patient a pillow to brace against the abdomen while bearing dowm b. Elevate the head of the bed 45 degrees 60 minutes after breakfast c. Uses a mobility device to replace a patient on a bedside commode d. Administer a soup suds enema every 2 hours

c. Uses a mobility device to replace a patient on a bedside commode

In which of the following situation should the nurse use surgical asepsis? a. Performing routine urinary catheter care b. Performing oral care c. Wound care dressing d. Performing nasogastric tube care

c. Wound care dressing

to gather information about a patients home and work surroundings, the nurse will need to utilize which method of data collection? a. carefully review lab results b. conduct the physical assessment before collecting subjective information c. perform a through. nursing health history d. prolong the termination phase of the interview

c. perform a through. nursing health history

The nurse is concerned about pulmonary aspiration when providing her patient with tube feedings. How should the nurse proceed? a.Add blue food colouring to the enteral formula b. Run the formula over 12 hours to decrease volume c. verify tube placement before feeding d. lower the head of the bed to a supine position

c. verify tube placement before feeding

When performing a physical musculoskeletal assessment, an LPN would include: a. Palpation of muscle mass b. Inspection of posture c. Observe of gait d. All of the above

d. All of the above

When performing an abdominal assessment on a resident, you would carry out: a. Visual inspection of abdomen b. Auscultation of bowel sounds in all four quadrants c. Palpation of abdomen for masses & pain d. All of the above

d. All of the above

When providing stoma care, it is important that the nurse should: a. Ensure that the pouch is the right size and the ring fits properly around the stoma b. Clean and dry the patient's skin and stoma throughly with warm tap water c. Assess the patient's skin for any signs of breakdown or irritation d. All of the above

d. All of the above

Which of the following are appropriate charting methods? a.Soap b. DAR c. Narrative d. All of the above

d. All of the above

For the application of heat and cold, the following times should be adhered to: a. Apply as long as the client can tolerate it, checking every 10 minutes b. Apply for 40-45 minutes, check every 10,minutes, repeat Q8H c. Apply for 30-40 minutes, check evert 5 minutes, repeat as often as needed d. Apply for 15-20 minutes, check every 5 minutes, evaluate effectiveness 30 minutes after procedure

d. Apply for 15-20 minutes, check every 5 minutes, evaluate effectiveness 30 minutes after procedure

having a misplaced his stethoscope, a nurse borrows a colleagues stethoscope. He next enters to patients room and identified himself, washes his hands with soap, and states the purpose of his visits. he performs proper identification of the patient before he also auscultates her lungs. which critical health assessment was not performed? a. Running warm water over stethoscope patient comfort b. Cleaning stethoscope with Betadine c. Using alcohol-based hand disinfectant d. Cleaning stethoscope with alcohol

d. Cleaning stethoscope with alcohol

The nurse teaches the patient controlled coughing. Which action should the nurse include in patient teaching effective coughing? a. breathe in quickly 3 to 4 times vigorously b. cough every 4 hours, 24 hours a day c. cough in a low- fowler's position hourly d. Inhale and cough deeply with the mouth open

d. Inhale and cough deeply with the mouth open

Complaints of pain is common when a brace or immobilization devise is properly applied. true or false

false

A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. What should the nurse do first when revising the plan of care? a. Disregard all previous diagnosis and establishing a new plan of care b. Set new priorities of the patient c. Ask physical therapy to assist the patient because of the new injuries d. Reassess the patient

d. Reassess the patient

The Glasgow coma scale involves patients response with: a. their eyes b. verbally c. motor d. all of the above

d. all of the above

Which of the following factors might affect a patient's ability to heal a wound? a. smoking b. anemia c. diet d. all of the above

d. all of the above

Which of the following should be completed with a patient sustains an un-witnessed fall? a. a neurological system assessment b. a muscular system assessment c. a skeletal system assessment d. all of the above

d. all of the above

Which of the following is not part of a neurological assessment? a. level of consciousness b. muscle strength c. orientation d. dietary changes

d. dietary changes

The nurse is performing a neurological assessment which patient behaviour demonstrates a level of consciousness within normal limits a. States name age and date but not location b. is lethargic but responds logically to questions c. respond verbally but words are unintelligible d. responds to questions spontaneously and is alert

d. responds to questions spontaneously and is alert