Test 1 (Module 1-5) Practice Questions

The nurse is assisting the wife of a client who has been diagnosed with hypertension to monitor his blood pressure. The nurse states that the blood pressure should be taken: (Select all that apply.) 1. At the same time each day 2. On the same arm each time 3. In the same position each time 4. After the client has had a brief rest 5. After his blood pressure medication 6. Right before getting up in the morning

1,2,3,4

Which of the following factors make using a pulse oximeter on an elderly client challenging? (Select all that apply.) 1. Possibility of decreased cardiac output 2. Potential for peripheral vascular disease 3. Existence of decreased red blood cell count 4. Uncooperative behavior related to senility 5. Inability to comprehend rationale for monitoring 6. Vasoconstriction related to impaired heat regulation

1,2,3,6

The nurse is assessing a client's blood pressure to establish a baseline. The pressure in the right arm is 12 mm Hg lower than that in the left arm. The nurse most appropriately realizes that these data: 1. Reflect a normal variation 2. Should be reported to the client's health care provider 3. Dictate that pressure should be monitored in the left arm 4. Indicate that the client may be experiencing vascular problems

2

The nurse is discussing risk factors for hypertension with family members attending a self-help group meeting for clients in cardiac rehabilitation. Which of the following statements made by the nurse are relevant to this discussion on prevention of this disorder? (Select all that apply.) 1. "Low fat foods are your blood pressure's best friend." 2. "Have your triglyceride's checked on a regular basis." 3. "Ideal weight is ideal for keeping blood pressure under control." 4. "Nicotine is a no-no when attempting to control blood pressure." 5. "If they are prescribed, take your blood pressure medicine as suggested." 6. "Keep alcohol consumption down and your blood pressure will be down."

1,2,3,4,6

A false high blood pressure reading may be assessed, as the nurse explains to the nurse assistant, if the assistant: 1. Wraps the cuff too loosely around the arm 2. Deflates the blood pressure cuff too quickly 3. Repeats the blood pressure assessment too soon 4. Presses the stethoscope too firmly in the antecubital fossa

1

A nurse administers pain medication for a client complaining of pain. The nurse first assesses vital signs and finds them to be as follows: blood pressure, 134/92 mm Hg; pulse, 90 beats per minute; respirations, 26 breaths per minute. The nurse's most appropriate action is to: 1. Give the medication 2. Ask if the client is anxious 3. Check the client's dressing for bleeding 4. Recheck the client's vital signs in 30 minutes

1

After measuring the client's vital signs, the nurse obtains the following results: blood pressure = 180/100 mm Hg, pulse = 82 beats/min, R = 16 breaths/min, and rectal temp = 37.5° C. The nurse should: 1. Retake the blood pressure 2. Retake the client's temperature 3. Report all of the findings immediately 4. Record the findings as within normal limits

1

An 84-year-old client with diabetes is admitted for insulin regulation. Which of the following blood pressure, pulse, and respiration measurements, respectively, is considered to be within the expected limits for a client of this age? 1. BP = 138/88 mm Hg, P = 68 beats/min, R = 16 breaths/min 2. BP = 104/52 mm Hg, P = 68 beats/min, R = 30 breaths/min 3. BP = 108/80 mm Hg, P = 112 beats/min, R = 15 breaths/min 4. BP = 132/74 mm Hg, P = 90 beats/min, R = 24 breaths/min

1

The client is seen in the emergency center for heat exhaustion as a result of exposure. The nurse anticipates that treatment will include: 1. Replacement of fluid and electrolytes 2. Initiation of oral antibiotic therapy 3. Application of hypothermia wraps 4. Alcohol sponge baths

1

The nurse appropriately instructs trained ancillary personnel to use an electronic blood pressure cuff to take the blood pressure of which of the following clients? 1. A 25-year-old who was admitted for alcohol detoxification 2. A 69-year-old diagnosed with Parkinson's disease 5 years ago 3. A 57-year-old placed on antihypertensive medication therapy 2 months ago 4. An 80-year-old client whose systolic BP is routinely assessed in the high 80s

1

The nurse enters the room to measure the client's pulse rate. The nurse recognizes that the client's rate may be increased as a result of: 1. A febrile condition 2. Administration of digoxin 3. The client's athletic conditioning 4. Unrelieved severe postoperative pain

1

The nurse has asked the assistive personnel to take the blood pressure of a client who experienced a left mastectomy 3 days ago. Which of the following statements by the assistive personnel shows the best understanding regarding the appropriate assessment technique for this particular client? 1. "Is there anything affecting her right arm?" 2. "Has she been experiencing any edema in that left arm?" 3. "How long has it been since she had her breast removed?" 4. "I'll wait until she's been medicated for pain before I take it."

1

The nurse has assessed a client's blood pressure (BP) using the left thigh because of bilateral upper arm casts. The client's precasting left arm BP was 108/70 mm Hg. The nurse expects the present BP reading to be: 1. 10-40 mm Hg higher systolic pressure than before the casting 2. 5-10 mm Hg higher reading in both systolic and diastolic pressures 3. Representative of the original baseline established before the casting 4. A slight decrease in the diastolic pressure when compared to precasting pressure

1

The nurse measures the blood pressure in the leg due to the fact that the client has bilateral casts on the upper extremities. The nurse palpates the pulse before the measurement at the: 1. Popliteal fossa behind the knee 2. Inner side of the ankle below the medial malleolus 3. Top of the foot between the extension tendons of the great toe 4. Inguinal ligament midway between the symphysis pubis and the anterior superior iliac spine

1

The nurse is discussing the correct technique for taking a blood pressure with clients and their caregivers. Which of the following nursing statements would appropriately identify the most likely causes for experiencing difficulty actually hearing the blood pressure? (Select all that apply.) 1. "The cuff cannot be too small or too big." 2. "Don't release the air out of the cuff to quickly." 3. "Keep the arm you are using at the level of the heart." 4. "If you are having difficulty, try taking it in the other arm." 5. "The stethoscope needs to be placed directly over a pulse point." 6. "Remember to pump up the cuff until you can no longer feel the pulse."

1,2,5,6

A client is being monitored with pulse oximetry. On review of the following factors, the nurse suspects that the values will be influenced by: 1. The placement of the sensor on the extremity 2. A diagnosis of peripheral vascular disease 3. A reduced amount of artificial light in the room 4. The increased ambient temperature of the client's room

2

An individual contacts the emergency department of the local hospital to ask what to do for a skiing partner who appears to be suffering from hypothermia. The victim is alert and able to respond to questions. The nurse instructs the individual who has called to have the victim: 1. Take sips of brandy 2. Drink a bowl of warm soup 3. Drink a cup of very hot coffee 4. Run the affected extremities under hot water

2

The appropriate site for taking the pulse of a 2-year-old is: 1. Radial 2. Apical 3. Femoral 4. Pedal

2

The client comes to the emergency department after having been in the sun for an extended period of time. The nurse also determines that the client is taking a diuretic. Heatstroke is suspected and the nurse observes for: 1. Diaphoresis 2. Confusion 3. Temperature of 36 C 4. Decreased heart rate

2

The nurse appropriately instructs trained ancillary personnel to avoid using an electronic blood pressure cuff to take the blood pressure of which of the following clients? 1. A 25-year-old who was admitted for depression and anxiety 2. A 69-year-old diagnosed with Parkinson's disease 5 years ago 3. A 57-year-old prescribed antihypertensive medication 6 weeks ago 4. An 80-year-old client whose systolic BP is routinely assessed in the low 90s

2

The nurse has assigned nursing assistive personnel to obtain the blood pressures on the unit's clients. Which of the following statements made by the assistive personnel shows the best understanding regarding appropriate communication of the BP readings? 1. "I'll ask the clients what their blood pressure usually runs." 2. "I'll give you a list of all the readings I get before I chart them." 3. "I'll chart the results and let you know whose pressure is high." 4. "I'll recheck any pressure that seems higher than their normal."

2

The nurse has assigned the vital signs of the elderly clients residing in the facility's assisted living unit to the nursing assistant. Which of the following statements made by the ancillary personnel requires immediate correction by the RN? 1. "As you age your blood pressure may go up, but it doesn't have to if your vessels are healthy." 2. "If anyone's oral temperature is over 100° F, I'll let you know right away since that means they have a fever." 3. "I always wait a good 30 minutes after returning the older client back to bed before I count their pulse." 4. "I watch the elderly client's stomach and count the number of times it rises when I am counting respirations."

2

The nurse has just taken vital signs for a 30-year-old client. Based on the results, the nurse will report the following finding that is out of the expected range for a client of this age: 1. T = 37.4° C 2. P = 110 beats/min 3. R = 20 breaths/min 4. BP = 120/76 mm Hg

2

The nurse is assessing an elderly client's blood pressure during a routine visit. When asked, the client volunteers that when he took his pressure at home yesterday it was 126/72 mm Hg. The nurse determines that the client's pressure today is 134/70 mm Hg. The nurse recognizes that the most likely cause of the elevation is: 1. The difference between the monitoring equipment being used 2. The client may be experiencing mild anxiety regarding the check-up 3. The effects of aging on the client's ability to hear the first Korotkoff sound 4. The client is not inflating the cuff sufficiently to detect the systolic pressure

2

The nurse recognizes that which of the following clients present at the annual July 4th marathon is at greatest risk for hyperthermia and the resulting heatstroke? 1. A 34-year-old running for the first time in the July 4th marathon who is sweating profusely 2. A 16-year-old volunteer, with type 1, insulin-dependent diabetes, who is checking runners in for the marathon at the starting gate 3. A 75-year-old who is prescribed medication for Crohn's disease and who is sitting outdoors watching her granddaughter run the marathon 4. A 55-year-old diagnosed with bipolar disease and prescribed a phenothiazine (Serentil), who will be walking the marathon course

2

The nurse recognizes that which of the following clients present at the annual July 4th marathon is showing the most compelling signs of hyperthermia and the resulting heatstroke? 1. The 75-year-old who has forgot where the car is parked 2. The 16-year-old volunteer whose skin appears sunburned but dry 3. The 34-year-old who finished the race and is reporting leg cramps 4. The 55-year-old observer who complains of nausea and being thirsty

2

Which of the following sites is best suited for measuring oxygen saturation (pulse oximetry)? 1. A polished ring finger of a client with pneumonia whose nail capillary refill time is 2.5 seconds 2. A pierced earlobe of a client with a closed head injury whose nail capillary refill time is 3.5 seconds 3. The ring finger of a client with Parkinson's disease that has a capillary refill time of less than 3 seconds 4. An earlobe of a client who is experiencing moderate diaphoresis with a nail capillary refill time of 3.5 seconds

2

While the nurse is taking the client's blood pressure, the client asks if the reading is high. In accordance with the newest guidelines, the nurse informs the client that a blood pressure measurement that is consistent with hypertension is: 1. 120/70 mm Hg 2. 130/84 mm Hg 3. 120/78 mm Hg 4. 118/80 mm Hg

2

The nurse is discussing the proper technique for obtaining an accurate blood pressure reading with assistive nursing personnel. Which of the following statements reflect techniques that will minimize the risk of a false high systolic reading? (Select all that apply.) 1. "Slowly deflate the pressure from the cuff." 2. "Wrap the cuff snuggly around the client's arm." 3. "Always support the client's arm at the level of the heart." 4. "Be sure that the cuff is wide enough for the client's arm." 5. "Allow the arm to rest before repeating the blood pressure." 6. "Make sure your stethoscope is fitted in your ears appropriately."

2,3,4,5

The nurse is providing a health promotion session regarding the factors that contribute to heatstroke for members of a college cross-country running team. Which of the following statements should the nurse include in the discussion? (Select all that apply.) 1. "Take frequent breaks to rest out of the sun." 2. "The greater the humidity, the greater the hazard." 3. "Wear clothing that will absorb the perspiration." 4. "The higher the temperature, the higher the risk." 5. "The more fluids you drink, the fewer chances you take." 6. "Pay attention to pacing yourself when it's hot and muggy."

2,4,5,6

A client has developed pneumonia, and his temperature has increased to 37.7° C. The client is shivering and "feels uncomfortable." The nurse should: 1. Apply hot packs to the axilla and groin 2. Wrap the client's four extremities 3. Restrict oral fluid consumption 4. Apply a hypothermia mattress

3

A client has just gotten out of bed to go to the bathroom. As the nurse enters the room, the client says, "I feel dizzy." The nurse should: 1. Go for help 2. Take the client's blood pressure 3. Assist the client into a sitting position 4. Tell the client to take several deep breaths

3

The client appears to be breathing faster than before. The nurse should: 1. Ask the client if he has felt stressful 2. Have the client lay down on the bed 3. Count the client's rate of respirations 4. Palpate the client's own radial pulse

3

The client is identified by the nurse as having a remittent fever. The student asks what that means and the nurse explains that a remittent fever is: 1. A constant body temperature above 100.4° F with little fluctuation 2. Spikes that are interspersed with normal temperatures within 24 hours 3. Spikes and falls in temperature, but temperature does not return to the normal limits 4. Periods of febrile episodes interspersed with normal body temperatures

3

The client's apical pulse will be taken by a student. According to the nurse the stethoscope should be placed along the left clavicular line at the: 1. Second to third intercostal space 2. Third to fourth intercostal space 3. Fourth to fifth intercostal space 4. Fifth to sixth intercostal space

3

The nurse has assigned nursing assistive personnel to obtain the blood pressures on the unit's clients. Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate communication of the BP readings? 1. "I'll give you a list of all the readings after I chart them." 2. "May I ask the clients what their blood pressure usually runs?" 3. "I'll chart the results and let you know whose pressure is running high." 4. "Do you want me to take the readings before they get their medications?"

3

The nurse has assigned nursing assistive personnel to obtain the temperatures on the unit's clients. Which of the following statements made by the assistive personnel shows the greatest need for additional instruction regarding appropriate temperature monitoring orally? 1. "Are all the clients cooperative enough to take the temperatures orally?" 2. "Do you want me to take the temperature tympanically on everyone?" 3. "I'll wait until breakfast is over so I won't distract them from eating." 4. "I'll chart the results and let you know whose temperature is running high."

3

The nurse is using a manual cuff to assess the blood pressure of a client experiencing hypertension. To best ensure accommodation for a possible auscultatory gap, the nurse should use which of the following as a guide for inflating the cuff appropriately? 1. Review the client's chart for his last blood pressure reading. 2. Ask the client what his typical blood pressure reading is when taken manually. 3. Inflate 30 mm Hg higher than where the radial pulse can no longer be palpated. 4. Take the client's blood pressure both sitting and standing and use the higher reading.

3

The nurse is working in the newborn nursery. In planning for temperature measurement, the nurse will obtain the reading on the infants by using the: 1. Oral site 2. Rectal site 3. Axillary site 4. Tympanic site

3

The student nurse is assessing the vital signs of a 10-year-old client. The expected values for a client of this age are: 1. P = 140 beats/min, R = 50 breaths/min, BP = 80/50 mm Hg 2. P = 100 beats/min, R = 40 breaths/min, BP = 90/60 mm Hg 3. P = 80 beats/min, R = 22 breaths/min, BP = 110/70 mm Hg 4. P = 60 beats/min, R = 12 breaths/min, BP = 160/90 mm Hg

3

When using a glass thermometer at home to accurately assess axillary temperature, the nurse should tell the parent of a 1 1/2-year-old child to: 1. Hold the thermometer at the bulb end 2. Cleanse the thermometer in hot water 3. Assess the thermometer for 5 minutes 4. Allow the child to hold the thermometer

3

A 6-year-old boy has just eaten a grape popsicle and the nurse is ready to take vital signs. An appropriate action would be to: 1. Take the rectal temperature 2. Take the oral temperature as planned 3. Have the child rinse out the mouth with warm water 4. Wait 20 minutes before assessing the oral temperature

4

A construction worker is seen in the emergency department with low blood pressure, normal pulse rate, diaphoresis, and weakness. These are clinical signs of: 1. Heatstroke 2. Heat cramp 3. Hypothermia 4. Heat exhaustion

4

A spouse assists the nurse evaluating the measurement of the client's blood pressure. The nurse feels additional teaching is required if the spouse is observed: 1. Deflating the cuff at 2 mm Hg/second 2. Having the client sit down for the measurement 3. Using the same time each day for the measurement 4. Taking the blood pressure after the client comes back from a walk

4

The client has bilateral casts on the upper extremities, so the nurse will be measuring the blood pressure in the leg. The nurse expects the diastolic pressure to be: 1. 10 to 40 mm Hg higher than in the brachial artery 2. 20 to 30 mm Hg lower than in the brachial artery 3. 40 to 50 mm Hg higher than in the brachial artery 4. Essentially the same as that in the brachial artery

4

The client is febrile, and the temperature needs to be reduced. The nurse anticipates that treatment will include: 1. An alcohol and water bath 2. Ice packs to the axillae and groin 3. Tepid, plain water sponge down 4. Application of a cooling blanket

4

The nurse is alert to which of the following factors that lowers the blood pressure? 1. Stress-producing anxiety 2. Heavy alcohol consumption 3. Cigarette, cigar, or pipe smoking 4. Prescribed diuretic administration

4

The postoperative vital signs of an average size adult client are: BP = 110/68 mm Hg, P = 54 beats/min, R = 8 breaths/min. The client appears pale, is disoriented, and has minimal urinary output. The nurse should: 1. Retake the vital signs in 30 minutes 2. Continue with care as planned 3. Administer a stimulant 4. Notify the physician

4

Upon entering the room, the nurse notes that the client has an irregular respiratory rate, with periods of apnea and increases in respiration, followed by a reversal of the pattern. The nurse reports this respiratory assessment as: 1. Biot's respirations 2. Kussmaul's respirations 3. Hyperpneic respirations 4. Cheyne-Stokes respirations

4

2. A 74-year-old client currently has a temperature reading of 36° C. The client walks 1 mile every day and takes naps during the day. Which of the following is most likely the reason for the lowered body temperature? A. The lowered temperature is a natural result of the aging processes. B. Increased stress from exercise has probably reduced the temperature. C. The individual circadian rhythm requiring daytime naps lowers the temperature. D. Hormone levels are the most probable cause of the hypothermic condition

A

3. A construction worker comes to the emergency room with low blood pressure, normal pulse, cool skin temperature, diaphoresis, and weakness. These are clinical signs of: A. Heat exhaustion B. Heat stroke C. Heat cramp D. Hypothermia

A

An 84-year-old diabetic client is admitted for insulin regulation. Which of the following blood pressure, pulse, and respiration measurements, respectively, is considered within the expected limits for this client? A. 148/90, 68, 16 B. 94/52, 68, 30 C. 108/80, 112, 15 D. 132/74, 90, 24

A

It is a very busy day on the nursing unit. The RN asks the unlicensed assistive personnel (UAP) to complete the following tasks. He delegates inappropriately when asking the UAP to a. Make sure the client takes his pills after his meal. b. Ambulate the postsurgical client to the bathroom. c. Bathe the client who is listed as a fall risk. d. Feed the client with severe visual impairment.

A

Which is the most important outcome of the nursing process? A. Meet the nursing needs of each client B. Ensure that unit resources are allocated appropriately. C. Decrease the risk of an error regarding the admitting medical diagnosis. D. Reduce the risk of missing important data when collecting information about the client.

A

You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. What is the best nursing action to take first? A) Call the nursing supervisor to discuss the situation B) Discuss the problem with a colleague C) Leave the nursing unit and go home D) Say nothing and begin your work

A

You ask another nurse how to collect a laboratory specimen. The nurse raises her eyebrows and asks, "Why don't you figure it out?" What would be the best response? A) Say nothing and walk away. Find a different nurse to help you. B) "When you brush me off like that, it takes me even longer to do my job." C) "Why do you always put me down like that?" D) "I guess I just enjoy having you make fun of me."

B

A new graduate nurse is being mentored by a more experienced nurse. They are discussing the ways nurses need to remain active professionally. Which of the statements below indicates the new graduate understands ways to remain involved professionally? (Select all that apply.) A) "I am thinking about joining the health committee at my church." B) "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." C) "I will join nursing committees at the hospital after I have several years of experience and better understand the issues affecting nursing." D) "Nurses do not have very much voice in legislation in Washington, DC, because of the shortage of nurses.

A & B

Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse? (Select all that apply.) A) Taking or selling controlled substances B) Refusing to provide health care information to a patient's child C) Reporting suspected abuse and neglect of children D) Applying physical restraints without a written physician's order

A & D

The patient has a fractured femur that is placed in skeletal traction with a fresh plaster cast applied. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to document this because one of the nurse's other patients experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation? (Select all that apply.) A) Failure to document a change in assessment data B) Failure to provide discharge instructions C) Failure to follow the six rights of medication administration D) Failure to use proper medical equipment ordered for patient monitoring E) Failure to notify a health care provider about a change in the patient's condition

A & E

Which nursing interventions meet a client's physiological needs according to Maslow's hierarchy of needs? (Select all that apply) A. Closing the door to a client's room to reduce noise B. Wearing sterile gloves when changing a client's dressing C. Lowering the height of a client's bed to the lowest position D. Encouraging a parent to stay with a hospitalized child overnight E. Providing assistive utensils so that a client can eat independently

A & E

A nurse formulates the following goal with a client: "The client will ambulate in the hall without experiencing activity intolerance." Which statements address the status of this goal? (Select all that apply) A. It is not measurable B. It is not client-centered C. It is missing a parameter D. It is missing a target time E. It is a correctly written goal

A, D & E

Identify behaviors that foster the development of trust. (Select all that apply.) A) Answer the call light promptly. B) Call the patient by first name unless requested otherwise. C) Do all the care as quickly as possible and leave the room so the patient can rest. D) Answer questions honestly. E) Demonstrate competence when doing treatments.

A, D & E

A home health nurse notices significant bruising on a 2-yearold patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take? A) Document her findings and treat the patient B) Instruct the mother on safe handling of a 2-year-old child C) Contact a child abuse hotline D) Discuss this story with a colleague

C

The nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline the nurse will follow? A) A living will allows an appointed person to make health care decisions when the patient is in an incapacitated state. B) A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state. C) The patient cannot make changes in the advance directive once admitted to the hospital. D) A durable power of attorney for health care is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

B

The nurse states, "When you tell me that you're having a hard time living up to expectations, are you talking about your family's expectations?" The nurse is using which therapeutic communication technique? A) Providing information B) Clarifying C) Focusing D) Paraphrasing

B

Which of the following statements would be most likely to block communication? A) "You look kind of tired today." B) "Why do you always put so much salt on your food?" C) "It sounds like this has been a hard time for you." D) "If you use your oxygen when you walk, you may be able to walk farther."

B

. Which of the following is an appropriate site for taking the pulse of a 2-year-old? A. Radial B. Apical C. Femoral D. Pedal

B

A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits? A) Family member B) Surgeon C) Nurse D) Nurse Manager

B

Mrs. Jones states that she gets anxious when she thinks about giving herself insulin. How do you use your understanding of intrapersonal communication to help with this? A) Provide her the opportunity to practice drawing up insulin B) Coach her to give herself positive messages about her ability to do this C) Bring her written material that clearly describes the steps of insulin administration D) Use therapeutic communication to help her express her feeling about giving herself an injection

B

The client begins to breathe rapidly. The nurse should: A. Ask the client if there have been any stressful visitors B. Measure the oxygen saturation level C. Count the rate of respirations D. Take the radial pulse

B

Your patient has just been told that she has cancer, and she is crying. Which actions facilitate therapeutic communication? (Select all that apply.) A) Turning on the television to her favorite show B) Pulling the curtain to provide privacy C) Offering to discuss information about her condition D) Asking her why she is crying E) Sitting quietly by her bed and hold her hand

B, C & E

A nurse is caring for a patient who recently had coronary bypass surgery. Which are legal sources of standards of care the nurse uses to deliver safe health care? (Select all that apply.) A) Information provided by the head nurse B) Policies and procedures of the employing hospital C) State Nurse Practice Act D) Regulations identified in The Joint Commission's manual E) The American Nurses Association standards of nursing practice

B, C, D & E

Which actions are associated with the evaluation step of the nursing process? (Select all that apply) A. A nurse takes the vital signs when a client reports chest pain. B. A nurse performs a physical assessment of a client just before discharge from a hospital. C. A nurse determines that a client is at risk for impaired skin integrity because of reduced mobility and malnutrition. D. A nurse and client decide that within 3 days the client will learn how to draw up and self administer insulin safely E. A nurse determines that further intervention is necessary when the client experiences sacral edema after being turned and positioned every 2 hours.

B, E

. A client complains of pain and asks the nurse for pain medication. The nurse first assesses vital signs: blood pressure, 134/92; pulse, 100; and respiration 32. The nurse's most appropriate action is to: A. Ask if the client is anxious B. Check the client's dressing for bleeding C. Give the medication D. Recheck the client's vital signs in 30 minutes

C

A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nursing manager because this action is a violation of which act? A) Mental Health Parity Act B) Patient Self-Determination Act (PSDA) C) Health Insurance Portability and Accountability Act (HIPAA) D) Emergency Medical Treatment and Active Labor Act

C

A nurse stops to help in an emergency at the scene of an accident. The injured party files a suit, and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation? A) The nurse's automobile insurance B) The nurse's homeowner's insurance C) The Good Samaritan laws, which grant immunity from suit if there is no gross negligence D) The Patient Care Partnership, which may grant immunity from suit if the injured party consents

C

A patient with limited English proficiency is going to be discharged on new medication. How does the nurse complete the discharge teaching? A) Uses a dictionary to give directions for medication administration B) Explains the directions to the patient's 14-year-old daughter C) Obtains an interpreter to facilitate communication of medication information D) Uses a picture board and visual aids to communicate medication administration information

C

Mr. Sakda emigrated from Thailand. When taking care of him, you note that he looks relaxed and smiles but seldom looks at you directly. How do you respond? A) Use therapeutic communication to assess for increased anxiety B) Sit down and position yourself closer so you are at eye level C) Deflect your eyes downward to show respect D) Continue to maintain eye contact

C

The nurse has a patient who is short of breath and calls the health care provider using SBAR (Situation-Background-Assessment-Recommendation) to help with the communication. What does the nurse first address? A) The respiratory rate is 28. B) The patient has a history of lung cancer. C) The patient is short of breath. D) He or she requests an order for a breathing treatment.

C

The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patients' medical diagnoses on the message board. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)? A) Discussing patient conditions in the nursing report room at the change of shift B) Allowing nursing students to review patient charts before caring for patients to whom they are assigned C) Posting medical information about the patient on a message board in the patient's room D) Releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared

C

When the nurse takes the patient's nursing history, he or she sits: A) Next to the patient. B) 4 to 12 feet from the patient. C) 18 inches to 4 feet from the patient. D) 12 inches to 3 feet from the patient.

C

When working with an older adult, the nurse remembers to avoid: A) Touching the patient. B) Allowing the patient to reminisce. C) Shifting quickly from subject to subject. D) Asking the patient how he or she feels.

C

You are caring for an 80-year-old woman, and you ask her a question while you are across the room washing your hands. She does not answer. What is your next action? A) Leave the room quietly since she evidently does not want to be bothered right now B) Repeat the question in a loud voice, speaking very slowly C) Move to her bedside, get her attention, and repeat the question while facing her D) Bring her a communication board so she can express her needs

C

You are the night shift nurse and are caring for a newly admitted patient who appears to be confused. The family asks to see the patient's medical record. What is the first nursing action to take? A) Give the family the record B) Give the patient the record C) Discuss the issues that concern the family with them D) Call the nursing supervisor

C

A nurse is sued for failure to monitor a patient appropriately after a procedure. Which of the following statements are correct about this lawsuit? (Select all that apply.) A) The nurse represents the plaintiff. B) The defendant must prove injury, damage, or loss. C) The person filing the lawsuit has the burden of proof. D) The plaintiff must prove that a breach in the prevailing standard of care caused an injury.

C & D

A client has developed pneumonia and his temperature has increased to 37.7C. The client is shiver and feels uncomfortable. Which of the following is true concerning the physiology of heat production in this client? A. Increased BMR is probably causeing the febrile condition B. Encouraging the client to ambulate would help decrease heat production C. The shivering is likely the cause of the increased temperature D. The client may need to consume more nutrients during the febrile condition

D

A homeless man enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the City Hospital for care. This action is most likely a violation of which of the following laws? A) Health Insurance Portability and Accountability Act (HIPAA) B) Americans with Disabilities Act (ADA) C) Patient Self-Determination Act (PSDA) D) Emergency Medical Treatment and Active Labor Act (EMTALA)

D

A patient needs to learn to use a walker. Which domain is required for learning this skill? A) Affective domain B) Cognitive domain C) Attentional domain D) Psychomotor domain

D

A woman who is a Jehovah's Witness has severe life-threatening injuries and is hemorrhaging following a car accident. The health care provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood. What is the nurse's responsibility? A) Obtain a court order to give the blood B) Coerce the husband into giving the blood C) Call security and have the husband removed from the hospital D) Abide by the husband's wishes and inform the health care provider

D

If measuring blood pressure is necessary in the leg, the nurse expects the diastolic pressure to be: A. 10 to 40 mm Hg higher than in the brachial artery B. 20 to 30 mm Hg lower than in the brachial artery C. 50 mm Hg higher than in the brachial artery D. Essentially the same as that in the brachial artery

D

The client's pulse is 72/minute, easily palpated. In addition, the pedal pulses are equal in strength in both feet. To best assess for an irregularity in the pulses, the nurse should: A. Determine the rate of the pedal pulses B. Auscultate for the strength of the apical pulse C. Examine the electrocardiogram's reading D. Ask the client if there is a pulsation that is abnormal

D

The nurse summarizes the conversation with the patient to determine if the patient has understood him or her. This is what element of the communication process? A) Referent B) Channel C) Environment D) Feedback

D

4. The nurse is ready to take vital signs on a 6-year-old child. The child has just enjoyed a grape popsicle. An appropriate action would be to: A. Take the rectal temperature B. Take the oral temperature as planned C. Have the child rinse out the mouth with warm water D. Wait 30 minutes and take the oral temperature

D

The statement that best explains the role of collaboration with others for the patient's plan of care is which of the following? A) The professional nurse consults the health care provider for direction in establishing goals for patients. B) The professional nurse depends on the latest literature to complete an excellent plan of care for patients. C) The professional nurse works independently to plan and deliver care and does not depend on other staff for assistance. D) The professional nurse works with colleagues and the patient's family to provide combined expertise in planning care.

D

You are caring for Mr. Smith, who is facing amputation of his leg. During the orientation phase of the relationship, what would you do? A) Summarize what you have talked about in the previous sessions B) Review his medical record and talk to other nurses about how he is reacting C) Explore his feelings about losing his leg D) Talk with him about his favorite hobbies

D

1. Tricuspid 2. 4th intercostal space left of the sternum

What is represented by the letter A? Where is it found/heard?

1. Pulmonic 2. 2nd intercostal space left of the sternum

What is represented by the letter B? Where is it found/heard?

1. Aortic 2. 2nd intercostal space right of the sternum

What is represented by the letter C? Where is it found/heard?

1. Erbs point 2. 3rd intercostal space close to the sternum 3. This is where you can hear all valves at once

What is represented by the letter D? Where is it found/heard? What is the significance of this point?

1. Mitral 2. 5th intercostal space mid clavicular left of the sternum

What is represented by the letter E? Where is it found/heard?