power point questions foundations

5. A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time? 1)Brachial 2)Carotid 3)Femoral 4)Popliteal

2)Carotid

You find out you need to have a minor surgical procedure that necessitates several days of hospitalization afterwards. Your surgeon operates out of several hospitals. Which hospital would you choose? 1.Hospital A is staffed with diploma and AD nurses. 2.Hospital B is staffed with diploma and BSN charge nurses. 3.Hospital C is staffed with AD and BSN nurses.

3.Hospital C is staffed with AD and BSN nurses.

One factor that prevents nursing from being described as a profession rather than as a "job" would be 1.Nursing knowledge is based on scientific knowledge. 2.Nurses create a plan of care using nursing diagnoses. 3.Most nurses only work to earn a paycheck. 4.In general, the work of the nurse is determined by the healthcare facilities as employers.

4.In general, the work of the nurse is determined by the healthcare facilities as employers.

The atrioventricular (AV) node is the pacemaker of the heart. A. True B. False

B. False

The nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients would require the implementation of airborne precautions? A. A diagnosis of HIV B. A positive PPD with an abnormal chest x-ray C. A diagnosis of viral pneumonia D. A diagnosis of methicillin resistant staph-aureas

........

3. A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse.

......look in doc for diagram

6. A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply) 1) Place the client in a semi-fowlers position. 2) Have the client rest an arm across the abdomen. 3) Observe one full respiratory cycle before counting the rate. 4) Count the rate for 30 sec if it is irregular. 5) Count and report any signs the client demonstrates.

1) Place the client in a semi-fowlers position. 2) Have the client rest an arm across the abdomen. 3) Observe one full respiratory cycle before counting the rate.

4. A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? 1)Assess the apical pulse for a full minute. 2)Assess the apical pulse with a Doppler device. 3)Assess the pedal pulses for a full minute. 4)Assess the pedal pulses with a Doppler device.

1)Assess the apical pulse for a full minute

2. A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take? 1)Wait 30 min and return to measure the oral temperature. 2)Provide the client a sip of warm water, wait 5 min, and measure the temperature. 3)Document that the nurse was unable to measure the client's temperature. 4) Proceed to measure the oral temperature.

1)Wait 30 min and return to measure the oral temperature.

1. An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure? 1. Blood Pressure 2. Respiratory Rate 3. Pulse 4. Temperature

1. Blood Pressure

Which organization is directly responsible for regulating the practice of nursing in each state? 1.The state board of nursing 2.The state legislature 3.The American Nurses Association 4.The American Medical Association

1.The state board of nursing

7. A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94. The client denies any history of hypertension. Which of the following actions should the nurse take first? 1) Request a prescription for an antihypertensive medication. 2) Ask the client if she is having pain. 3) Request a prescription for an antianxiety medication. 4) Return in 30 min to recheck the clients blood pressure.

2) Ask the client if she is having pain.

The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn? A. 30 to 60 Correct B. 22 to 28 C. 16 to 20 D. 10 to 15

A. 30 to 60 Correct

The nurse is caring for a client who has tested positive for AIDS. Which of the following actions would be appropriate for this client? A. Implementing standard precautions B. Wearing gowns and goggles when entering the room C. Implementing contact precautions for all client interactions D. Assigning the client a private room

A. Implementing standard precautions

A client's activity level has decreased after hip replacement surgery. The client has been receiving opioid analgesia and has decreased fluid intake. Which type of diagnosis will the nurse choose? A. Risk B. Syndrome C. Actual D. Possible

A. Risk

Documentation of nursing care for home health clients requires ongoing assessment of need for skilled nursing care. A. True B. False

A. True

The client has a draining abdominal wound that has become infected. In caring for the client, the nurse will implement A.Contact precautions B.Droplet precautions C.No precautions D.Airborne precautions

A.Contact precautions

The nurse is admitting a stable client for a minor outpatient procedure. What site would the most commonly use to assess the pulse rate? A.Radial B.Apical C.Carotid D.Brachial

A.Radial

The nurse is taking the blood prssure on multiple clients. Which reading warrants the nurse to contact the doctor? A. 94/60 B. 98/36 C. 110/50 D. 140/78

B. 98/36

The nurse understands that which statement is correct regarding respiratory rates? A.Infants have a lower respiratory rate than adults B. B. Healthy adults breathe between 12 and 20 times a minute C.A compensatory response to a fever is to breath at a slower rate D.An increase in intracranial pressure results in an increased rate

B. B. Healthy adults breathe between 12 and 20 times a minute

1. While caring for a child, you identify that additional safety teaching is needed when a young and inexperienced mother states that: A. teenagers need to practice safe sex. B. a 3-year-old can safely sit in the front seat of the car. C. children need to wear safety equipment when bike riding. D. children need to learn to swim even if they do not have a pool.

B. a 3-year-old can safely sit in the front seat of the car.

2. A young girl with long hair is experiencing a problem with matting. The most appropriate action to take would be: A. cutting the matted hair away. B. braiding the hair to reduce tangles. C. using a grease-type product to tame the hair. D. keeping the hair oil free by applying powder every morning.

B. braiding the hair to reduce tangles.

1. You are caring for a non-English-speaking male patient. When preparing to assist him with personal hygiene, you should: A. use soap and water on all types of skin. B. ensure that culture and ethnicity influence hygiene practices. C. shave facial hair to make the patient more comfortable. D. know that all patients need to be bathed daily.

B. ensure that culture and ethnicity influence hygiene practices.

2. A newly admitted patient was found wandering the hallways for the past two nights. The most appropriate nursing interventions to prevent a fall for this patient would include: A. raise all four side rails when darkness falls. B. use an electronic bed monitoring device. C. place the patient in a room close to the nursing station. D. use a loose-fitting vest-type jacket restraint.

B. use an electronic bed monitoring device.

3. Mr. Zenobia's chronic cancer pain has recently increased and he asks the home health nurse what can be done. In relation to his long-acting morphine, which is an appropriate response by the nurse? A."If you take more morphine, it will not change your pain relief." B."I'll call the primary care provider and ask for an increased dose." C."The amount you are taking now is all I can give you." D."I'm worried if we increase your dose that you will stop breathing."

B."I'll call the primary care provider and ask for an increased dose."

To maintain proper posture, it is important to A.Sleep on the softest mattress possible. B.Avoid arching shoulders forward when sitting. C.Keep your knees locked when standing upright. D.Keep your stomach muscles relaxed to prevent back spasms.

B.Avoid arching shoulders forward when sitting.

There are no legal consequences for nurses who do not follow the ANA Standards of Professional Performance as these are not laws. A.True B.False

B.False

2. The nurse is assessing the confused client. In trying to determine the client's level of pain, the nurse should A.Be aware that confused clients do not feel as much pain due to their confusion. B.Observe the client carefully for changes in behavior or vital signs. C.Ask the client's family how much pain the client normally has. D.Use only pain scales that feature numbers or "faces" the client can point to.

B.Observe the client carefully for changes in behavior or vital signs.

The nurse documents the following: "Client able to administer own insulin per subcutaneous injection using correct technique." In Focus charting, this statement would be followed by which letter? A.D B.R C.P D.E

B.R

Trina, an RN on the nursing unit, states to the student nurse, "I see you are working with Beth today. Make sure you watch your patient carefully because I think Beth is one of our worst nurses." The student knows that this statement could be considered A.Libel B.Slander C.Fraud D.Invasion of privacy

B.Slander

A patient is pyrexic. Which piece of equipment will the nurse obtain to monitor this condition? A.Stethoscope B.Thermometer C.Blood pressure cuff D.Sphygmomanoter

B.Thermometer

A nurse is caring for a group of patients. Which patient will the nurse see first? A. A crying infant with P-165 and R-54 B. A sleeping toddler with P-88 and R-23 C. A calm adolescent with P-95 and R-26 Correct D. An exercising adult with P-108 and R-24

C. A calm adolescent with P-95 and R-26 Correct

The nurse can best determine adequate arterial oxygen of the blood by assessing : A.Heart Rate B. Hemoglobin level C. Arterial oxygen level D. Arterial carbon dioxide level

C. Arterial oxygen level

The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to praise the NAP? A.Ulnar site B. Radial site C. Brachial site Correct D. Femoral site

C. Brachial site Correct

The client has reddened skin and an open abrasion on the elbow from prolonged bedrest. When examining the components of the nursing diagnosis Impaired Skin Integrity, what would be the reddened skin and open abrasion? A. Related factors B. Risk factors C. Defining characteristics D. Diagnostic label

C. Defining characteristics

A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient's blood pressure (BP)? A. Smoking increases BP for up to 3 hours. B. Caffeine increases BP for up to 15 minutes. C. Smoking result in vasoconstriction, falsely elevating BP. Correct D. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement.

C. Smoking result in vasoconstriction, falsely elevating BP. Correct

3. A nurse floats to a busy surgical unit and administers a wrong medication to a patient. This error can be classified as: A. a poisoning accident. B. an equipment-related accident. C. a procedure-related accident. D. an accident related to time management.

C. a procedure-related accident.

A 15-year-old male comes to the clinic seeking treatment for "a problem." The nursing history reveals the client may have a sexually transmitted infection (STI). Which is the most appropriate initial response by the nurse? A."I will need a list of all the people with whom you have had relations." B."Have you told your parents about this situation?" C."Let's discuss how you feel about this situation." D."You will need to practice safe sex. Let's discuss how to use condoms."

C."Let's discuss how you feel about this situation."

It is most important for the nurse to understand the various ways in which pain is classified so that he or she can A.Document the client's pain using accurate terms. B.Be clear in communication with the physician. C.Develop an effective pain management plan. D.Educate the client thoroughly.

C.Develop an effective pain management plan.

Of the following interventions for the client who is immobile, the nurse will give priority to A.Encouraging a diet high in fiber and extra fluids B.Administering the prn medication for sleep C.Having the client use the incentive spirometer q 2 hrs D.Massaging the client's legs every hour

C.Having the client use the incentive spirometer q 2 hrs

The client has right-sided hemiplegia as a result of a stroke (brain attack) and wants a cup of hot coffee. Even though the client is insistent, the nurse does not permit her to drink the coffee unsupervised. This nurse is using the ethical principle of A.Autonomy B.Fidelity C.Nonmaleficence D.Justice

C.Nonmaleficence

A patient has a head injury and damages the hypothalmus. Which vital sign will the nurse monitor most closely? A.Pulse B.Respirations C.Temperature D.Blood Pressure

C.Temperature

It is 6am and the UAP reports to the nurse that the patient has a temp of 96.7 tympanic which factor would explain this reading? A.The patients room is cold B.The patient was drinking cold water C.The patient is exhibiting a normal circadian rhythm D.The patient just completed a warm shower

C.The patient is exhibiting a normal circadian rhythm

A nurse is working in an emergency room when a client presents with symptoms of influenza. Which of the following actions would be the priority? A. Swab the client for a confirmation of the diagnosis B. Administer antiviral medication Tamiflu C. Complete a full assessment of the client D. Implement droplet precautions

D. Implement droplet precautions

The nursing assistive personnel (NAP) is taking vital signs and reports that a patient's blood pressure is abnormally low. What should the nurse do next? A. Ask the NAP retake the blood pressure. B. Instruct the NAP to assess the patient's other vital signs. C. Disregard the report and have it rechecked at the next scheduled time. D. Retake the blood pressure personally and assess the patient's condition.Correct

D. Retake the blood pressure personally and assess the patient's condition.Correct

1. Health disparities are unequal burdens of disease morbidity and mortality rates experienced by racial and ethnic groups. These disparities are often exacerbated by: A. bias. B. stereotyping. C. prejudice. D. all of the above.

D. all of the above.

4. When assessing the blood pressure of a school-age child, using an adult cuff of normal size will affect the reading and produce a value that is: A. accurate. B. indistinct. C. falsely low. D. falsely high.

D. falsely high.

The unlicensed assistive personnel reports vital signs for a patient to the nurse. Temp 99.2F oral, Pulse 88 and regular, Resp 18 regular, Blood Pressure 178/112 , O2 saturation of 96% , and 3/10 headache what should the nurse be most concerned about? A.Temperature B.Pulse C.Respirations D.Blood Pressure

D.Blood Pressure

Identify the true statement about devices used when assisting clients to ambulate. A.The client should stand a foot back from the back legs of a walker. B.A cane should be used by the client to support the weakest side of the body. C.A transfer belt should be placed around the client's chest for maximum lift. D.Each crutch-walking gait begins with the client in the tripod position.

D.Each crutch-walking gait begins with the client in the tripod position.

Using the MORAL acronym for making an ethical decision, under which "letter" would the following action fall? The physician explains to the laboring woman the impact on the unborn child of refusing a cesarean birth. A.M B.L C.R D.O

D.O

On admission to Hospital A, the patient indicates that he would like information about making a living will. The nurse informs the patient that the hospital does not have a process in place to facilitate this. Hospital A is not in compliance with the A.Health Insurance Portability and Accountability Act B.Emergency Medical Treatment and Active Labor Act C.Americans with Disabilities Act D.Patient Self-Determination Act

D.Patient Self-Determination Act

The nurse has just medicated a client for pain. Documentation of this intervention would be found on the: A.Kardex and graphic sheet B.IPOC and discharge summary C.Flow sheet and assessment checklist D.Progress notes and MAR

D.Progress notes and MAR

The nurse is performing an initial assessment of a patient with a severe infection at hospital admission. Vital signs for the patient indicate hypotension and tachycardia. Which data pair would support this evaluation? A.Pulse 88, BP 140/88 B.Pulse 96, BP 120/76 C.Pulse 100, BP 118/80 D.Pulse 114, BP 98/60

D.Pulse 114, BP 98/60

The client is admitted with chest pain, which should be the nurses priority assessment? A.Pain B.Blood Pressure C.Heart Rate D.Respiratory Rate

D.Respiratory Rate

The clients blood pressure is being taken at a screening clinic. Which statement to the nurse demonstrates awareness of having a risk factor for hypertension? a."My doctor told me my weight is good and my blood pressure is 118/70" b."I usually have a glass of wine to unwind when I get home from work" c."I plan to get my blood pressure checked more often , as I am African American d."I have colds during the winter, so I plan to get the influenza vaccine each year."

c."I plan to get my blood pressure checked more often , as I am African American

Why do nurses need teaching skills?

•Teaching clients is part of independent nursing practice. •The American Nurses Association (ANA) standard related to promoting health demands skill in teaching clients. •Patients participate in healthcare decisions. •Hospital stays are brief. •Healthcare is expensive.