Zoom Final Review Questions

The nurse is monitoring the status of a post-op patient in the immediate post-op period. The nurse would become most concerned with which sign that could indicate an evolving complication? A) Increasing restlessness B) A pulse of 86 bpm C) BP of 110/70 D) Hypoactive bowel sounds in all 4 quadrants

A

The nurse is preparing to care for a patient who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube? A) Deflate the cuff on the tube B) Place the inner cannula into the tube C) Ensure the patient is able to speak D) Ensure patient is able to swallow

A

The nurse notes documentation that a patient is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? A) Irregular respiratory rate/depth and periods of apnea B) Regular rapid and deep, sustained respirations C) Totally irregular respirations in rhythm and depth D) Regular slow respirations with shallow depth

A

Patient data includes: lethargy, deep/rapid respirations, ABG results = pH 7.31, PaO2 88 (normal), PaCO2 38 (normal) and HCO3 of 16 (low). How should the nurse interpret these results? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis

A - low pH and low bicarb (HCO3) indicate metabolic acidosis

Which of the following can be routinely delegated to assistive personnel? A) Oropharyngeal suctioning B) Airway suctioning using a closed method C) Endotracheal tube care D) Tracheostomy care

A - not a sterile procedure

While eating lunch in the hospital cafeteria, a nursing student overhears 2 nurses talking about a patient. Which is the important information for the nurses to remember when talking about a patient? A) Talking about a patient in publin places is a violation of the patient's confidentiality B) The patient's rights to confidentiality do not apply to the break time of employees C) It is acceptable for the nurses to talk about a patient because they are on the same treatment team D) The nurses taking care of the client should not share information with each other that the client has told them separately

A - only share what is necessary to help TREAT the patient and keep them SAFE

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the patient to eat which food item that is naturally high in vitamin C to promote wound healing? A) milk B) bananas C) oranges D) chicken

C

A patient is deemed to be in a vegetative state secondary to traumatic brain injury. The patient has a living will which declines use of mechanical ventilation if such a situation were to arise. A family member insists that heroic measures be invoked. The health care team plans to respect the patient's wishes. Which ethical principle is the health care team trying to uphold? A) Beneficience B) Autonomy C) Fidelity D) Justice

B

The nurse is assessing the motor and sensory function of an unconscious patient. The nurse should use which technique to test the patient's peripheral response to pain? A) Sternal rub B) Nail bed pressure C) Pressure on the orbital rim D) Squeezing of the SCM muscle

B

The nurse assesses a patient's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? A) Red, hard skin B) Serous drainge C) Purulent drainage D) Warm, tender skin

B

The nurse has just admitted the following patient: 75 y/o with new-onset confusion and hyponatremia. When making room assignments, the charge nurse should take which action? A) Assign the patient to a semi-private room B) Assign the patient to a room near the nurse's station C) Place the patient in a room nearest to the water fountain D) Place the patient on telemetry to monitor for peaked T waves

B

The nurse is caring for a post-op patient who has been receiving opioid pain meds. The nurse enters the patient's room and finds them very drowsy and records the following vital signs: temp is 97.2 orally, HR 52, BP 101/58, RR 11, SpO2 93% on 3L O2 via nasal cannula. Which action should the nurse take next? A) Document findings B) Attempt to arouse patient C) Contact health care provider immediately D) Check medication administration history

B

The nurse is creating a plan of care for a patient receiving enteral feedings via a gastrostomy tube. The nurse should plan to include which intervention in the plan of care? A) Provide oral fluids 3x a day B) Check around the stoma site for skin irritation C) Medicate w/ antidiarrheal meds every day D) Use sterile technique when adminstering tube feedings

B

The nurse is teaching a patient who is preparing for discharge from the hospital after having a stroke about prevention of pressure ulcers while the patient has limited mobility. Which statement by the client indicates a need for further teaching? A) I will inspect my skin daily B) I can sit in my favorite chair all day C) I need to drink at least 2 L of fluid daily D) I will make sure that my skin is clean and well moisturized

B

The nurse is teaching an older client about measures to prevent constipation. Which statement by the client indicates a need for further teaching? A) I walk 1-2 miles every day B) I need to decrease fiber in my diet C) I have a bowel movement every other day D) I drink 6-8 glasses of water every day

B

The nurse is testing the extraocular eye movements in a patient to assess for muscle weakness in the eye. The nurse should implement which assessment technique to assess for muscle weakness in the eye? A) Test corneal reflex B) Test the 6 cardinal positions C) Test visual acuity w/ Snellen chart D) Test sensory function by asking patient to close their eyes and then lightly touch their forehead, cheeks, and chin

B

Two nurses are leaving the room of a patient whose care required them to wear a gown, mask and gloves. Which action by these nurses could lead to the spread of infection? A) Taking the gloves off first before removing the gown B) Removing the gown without rolling it from inside out C) Washing the hands after the entire procedure has been completed D) Removing the gloves and then removing the gown using the neck ties

B

Which statement by a nursing student demonstrates an understanding of collaboration? A) Collab is a new way of interacting with physicians B) Collab means that the care team can make all of the decisions for the patient C) Collab with the patients has been used by nurses throughout the history of nursing D) Collab is an outdated concept that has been replaced by managed care

B

The nurse is conducting a dietary assessment on a patient who is vegan. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet?

B12 - associated w/ animal fats

An appropriate technique for NG tube insertion is for the nurse to: A) Position the patient supine B) Apply oil-based lubricant to plastic tube C) Advance the tube while the patient swallows D) Measure the tube length from the nose to the sternum

C

The clinic nurse is performing an assessment on a patient with a diagnosis of rheumatoid arthritis. The nurse checks for which assessment finding that is associated with RA? A) Age of onset is generally 65 or older B) Complaints of pain that is more severe after activity C) Systemic symptoms such as fatigue, anorexia, and weight loss D) Joint pain is asymmetrical and associated with past injuries to the joint

C

The nurse creates a plan of care for s patient with DVT. Which patient position or activity should be included in the plan? A) Out-of-bed activities as desired B) Bed rest w/ affected extremity kept flat C) Bed rest w/ elevation of the affected extremity D) Bed rest w/ affected extremity in a dependent position

C

The nurse is caring for a patient who is 1 day post-op for a total hip replacement. Which is the best position the patient should be placed in? A) Side-lying on the operative side B) On the nonoperative side w/ legs adducted C) On the nonoperative side w/ legs abducted D) Side-lying w/ the affected leg internally rotated

C

The nurse is caring for a patient with terminal cancer who is close to death. On reviewing the plan of care, the nurse determines which intervention is the priority? A) Keep the patient well sedated so that the patient is totally unaware of what is happening B) Make sure the family has privacy and is kept informed of what is happening at all times C) Maintain the patient's dignity and self-esteem and make the patient as comfortable as possible D) Carry out health care providers prescriptions so that all prescribed treatments are done on time

C

The nurse is caring for two patients. One has heart failure, and the other has dehydration. Ongoing assessment of the patients' fluid volume status is essential to good nursing care. What is the most effective way to assess ECV (extracellular volume) status for both of these patients? A) Look for edema or skin tenting B) Measures strict intake and output C) Perform daily weights at the same time of day D) Take blood pressure every 2 hours

C

The nurse is preparing to ambulate a patient on the third day after cardiac surgery. What should the nurse plan to do to enable the patient to best tolerate the ambulation? A) Remove the telemetry equipment B) Provide the patient a walker C) Premedicate the patient w/ an analgesic D) Encourage the patient to cough and breathe deeply

C

The nurse plans to assess the patient's memory. Which task should the nurse ask the patient to perform? A) Tell me where you are B) Can you tell me the date C) Repeat the following words back to me.... D) What does this mean: 'A stitch in time saves nine'?

C

The nurse visits a patient at home. The patient states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication? A) I see B) Really? C) You're having difficulty sleeping? D) Sometimes I have trouble sleeping too

C

The patient's daughter requests to see her father's medical record. What is the nurse's best response to this request? A) I will be right back with that information B) I am not allowed to let you look at it C) This can only be allowed if your father grants you permission D) Let me contact the physician to see if this can be done for you

C

Which of the following is an expected outcome for a cardiac assessment? A) Apical pulse rate = 58 bpm B) Carotid bruits present C) PMI palpable at L 5th intercostal space at midclavicular line D) Jugular vein distended w/ patient in sitting position

C

While completing an assessment, the nurse hears crackles in the patient's lung fields. The patient reports sleeping on three pillows to help with difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record? A) A-fib B) Myocardial ischemia C) L sided heart failure D) R sided heart failure

C

The nurse is performing an assessment on an older patient who is having difficulty sleeping at night. Which statement by the patient indicates the need for further teaching regarding measure to improve sleep? A) I swim 3x a week B) I have stopped smoking cigars C) I drink hot chocolate before bedtime D) I read for 40 minutes before

C - hot chocolate has caffeine

The nurse is instructing a hospitalized patient with a diagnosis of emphysema about measures that will enahnce the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the patient to assume? A) Sitting up in bed B) Side-lying in bed C) Sitting in a recliner chair D) Sitting up and leaning on an overbed table

D

A hydrocolloid dressing is prescribed for a patient with a leg ulcer. The home health nurse is preparing a plan of care for the client and should appropriately document which intervention? A) Change the hydrocolloid dressing daily B) Apply the hydrocolloid dressing over a normal-saline soaked dressing C) Apply hydrocolloid dressing over a dry, sterile dressing D) Change the hydrocolloid dressing every 3-5 days

D

A staff nurse is precepting a new grad nurse and the new grad is assigned to care for a patient with chronic pain. Which statement indicates the need for furthering teaching regarding pain management? A) I will be sure to ask my patient what his pain level is on a scale of 0-10 B) I know that pain in older adults can manifest as sleep disturbances or depression C) I know that I should follow up after giving medication to make sure it is effective D) I will be sure to cue in to any indications that the patient may be exaggerating their pain

D

The nurse gives an inaccurate dose of medication to a patient. After assessment of the patient, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. Which action should the nurse manager anticipate will take place next? A) The incident will be reported to the board of nursing B) The incident will be documented in the personnel file C) The error will result in suspension and be written in the annual performance appraisal D) The incident report will be used to review quality of care and determine potential risks

D

The nurse is caring for an older patient in a long-term care facility. Which action contributes to encouraging autonomy for the patient? A) Planning meals for the patient B) Decorating the room for the patient C) Scheduling haircut appointments for the patient D) Allowing the patient to choose social activities

D

The nurse is conducting a health screening for osteoporosis. Which client is at greatest risk for developing this disorder? A) 25 y/o woman who runs B) 36 y/o man w/ asthma C) 70 y/o who consumes excess alcohol D) 65 y/o sedentary woman who smokes cigarettes

D

Which approach would the nurse use to begin a conversation about the goals for end of life care? A) Encourage family members to think more positively B) Avoid discussion because it has to do with medical, not nursing diagnoses C) Initiate discussion about advance directives with the patient, family and health care team D) Ask the patient to identify beliefs about goals of care

D

The nurse suspects that a patient is not fully aware of the implications of a procedure and the patient is about to sign an informed consent. What action would be most appropriate for the nurse to take? A) Ask a family member to sign the consent because the patient seems unsure at the time B) Tell the patient he can ask the health care provider for more details when he gets to the operating room C) Ask the client if the health care provider explained the procedure before obtaining the signature D) Inform the health care provider that the client does not appear to fully understand the procedure and withhold obtaining the signature

D - upholding patient's autonomy

What sense is affected by presbycusis?

Hearing

what conditions might a patient have if they are in metabolic acidosis?

diabetic ketoacidosis, chronic diarrhea, too much aspirin or salicylate

Peaked T waves are a sign of what?

hyperkalemia

what is the term for needing to sleep w/ the head of the bed up because of breathing issues?

orthopnea

what is remote memory?

recall of information from the distant past