Exam 1

The nurse is caring for an elderly patient with an impaired cognitive function who can follow simple commands and answer questions. Which pain scale will the nurse use to assess this patient's pain level? A. Wong-Baker Faces scale B. 0 - 10 numerical scale C. POSS scale D. FLACC scale

A

The nurse is applying wrist restraints to the confused patient. What will the nurse do in order to ensure that the restraints are placed on the patient appropriately in order for the patient to maintain normal circulation? Answers:A. Insert 1 finger between the restraint and the wrist B. Insert 2 fingers between the restraint and the chest C. Insert 2 fingers between the restraint and the wrist D. Place the index finger between the restraint and the wrist

C

The nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. The nurse notes that the client's respiratory rate is 9 breaths per minute. The client is somnolent, with minimal response to physical stimulation. The nurse should prepare to administer which medication? Answers:A. Nebulized albuterol B. Oral modafinil C. Intravenous naloxone D. Intravenous flumazenil

C

The nurse is caring for a patient who has PRN orders for pain medicine. The patient states that their pain is a 6 out of 10. The nurse has the following orders: Give one 5mg Oxycodone tablet for moderate pain every 4 - 6 hours. Give two 5mg Oxycodone tablets for severe pain every 4 - 6 hours. What will the nurse administer based on the patient's report of pain? A. Two 5mg Oxycodone tablets B. A non-opioid medication due to the pain level being mild C. One 5mg Oxycodone tablet D. None of the above. The nurse will call the doctor to get an IV pain medication order

C

The CNA is changing an unoccupied bed. What action by the CNA will prompt the nurse to intervene? Answers:A. The CNA raises the bed to working height B. The CNA raises the bed to working height C. The CNA wears clean gloves D. The CNA holds soiled linens close to the body to secure them

D

The South Carolina RN has decided to do some travel work for an agency. The first assignment will be located in North Carolina. What legal implications will the nurse need to be aware of regarding travel nursing? Answers:A. The nurse needs to know the nurse practice laws of North Carolina only B. The nurse needs to know the nurse practice laws of South Carolina only C. The nurse needs to know the nurse practice laws of South Carolina only because every state has the same "scope of practice" laws D. The nurse needs to know the nurse practice laws of any state that they travel to and provide care

D

The nurse is discussing nursing theory with the student nurse. The nurse knows that the student nurse understands the information when the student nurse states: Answers:A. "The most important concept of nursing theory is the person." B. "The most important concept of nursing theory is research." C. "Nursing theory is used to create new issues in nursing." D. "Nursing theory is not widely used in the profession."

A

The registered nurse delegated to the CNA to get a set of vital signs for Ms. Santiago. The CNA completed the task, documented, and reported off to the nurse. The CNA stated, "I got those vital signs that you asked for and the patient's blood pressure was really high: 180/100." What action by the RN is priority at this time? Answers:A. Reassess the patient's blood pressure B. Report the findings to the doctor C. Request that the CNA get another blood pressure in 10 minutes D. Ask the patient if they have a headache and blurred vision

A

The nurse is caring for a patient on the medical-surgical floor who has been scheduled for surgery. The patient states, "I am ready for the surgery but I am scared that I will develop a clot afterwards." What information will the nurse provide the patient at this time? Answers:A. "You are currently on an anticoagulant and will stay on that for 4 to 6 months postop to prevent complications." B. "In order to prevent clots, we will start doing deep-breathing exercises every 2 hours postop." C. "Since you do not have a history of clots, you will more than likely not develop one after surgery." D. "We will start early ambulation and leg exercise postop in order to prevent clot formation."

?

A nurse is educating adolescents on how to prevent infections. What statement by one of the adolescents indicates that more education is needed? Answers:A. "I don't wear a condom when I have sex, but I know my partners." B. "I will wash my hands before and after going to the bathroom." C. "I always eat fruits and vegetables, and I sleep eight hours a night." D. "When I have an infection, I rest and take my medications."

A

A postoperative patient has just been admitted to the post-anesthesia care unit (PACU). What assessment by the PACU nurse takes priority? A. Airway B. Bleeding C. Cardiac rhythm D. Breathing

A

The charge nurse is making assignments for the oncoming shift. Which patient will the charge nurse assign to the LPN? A. Mr. Cruz: 75-year-old male admitted a week ago for a leg wound that requires wet to dry dressings every 3 days and scheduled Tylenol B. Mr. Wazowski: 30-year-old make with a new diagnosis of diabetes that will discharge today and need education C. Mrs. Simpson: 55-year-old female in the emergency room that will be admitted to the floor today with a gastrointestinal bleed D. Mr. Peralta: 50-year-old male admitted with sickle cell crisis who is receiving oral and IV pain medication routinely

A

The nurse is caring for a 32-year-old male admitted with gastric ulcers who has the mental capacity of a child. The doctor has ordered an invasive test that requires informed consent to be signed. Who will the nurse contact in order to sign this consent? Answers:A. The patient's legal guardian B. The patient's closest adult relative C. The doctor D. The patient

A

The registered nurse is caring for a patient who has new orders from the admitting physician. The nurse reviews the orders and determines that they are inappropriate for this patient and may cause harm. The nurse refuses to carry out the new orders. What should the nurse do next? Answers:A. Notify the charge nurse B. Carry out the new orders because the nurse does not have the right to refuse the doctor's orders C. Chart a nurse"s note in the patient's medical record D. Delegate the orders to the LPN if the orders are within their scope of practice

A

The registered nurse is discussing different aspects of Good Samaritan acts. The nurse would be correct in including which of the following statements? Answers:A. "It is alright to leave the scene when another qualified person takes over." B. "If you do not know how to perform a skill, ask someone to teach you at this time." C. "It is alright to accept compensation as long as you do not require it." D. "Once you evaluate the scene, you should leave the scene to go get more help."

A

The student nurse wants to be prepared if a fire were to take place. The student nurse states, "I do not know how to use a fire extinguisher." What information will the nurse provide to the student nurse at this time? Answers:A. "To work a fire extinguisher, you should pull the safety pin, aim the hose, squeeze the handle and sweep the hose from side to side at the base of the fire." B. "In order to work a fire extinguisher, you need to pull the alarm, aim the hose, and sweep the base of the fire." C. "You should only pull the alarm, firemen will come and use the fire extinguishers correctly." D. "To work a fire extinguisher, you should pull the safety pin, aim the hose, squeeze the handle, and sweep the hose from side to side at the highest point of the fire."

A

The nurse has performed the following activities during the shift. Which activities are violations of client privacy and/or confidentiality? Select all that apply. Answers:A. Removing a printed report of a client from the hospital premises to write a case study for a staff meeting B. Discussing the client's HIV status over Lunch with a friend, a nurse on another team located on the same nursing unit C. Leaving the mobile computer screen, which contains client information, open when a visitor asked questions D. Responding to the client's questions about the plan of care with a visitor present in the room E. Answering questions from a client's visitor before verifying the visitor has permission to receive the information

A, B, C, E

The nurse is discussing the topic of nursing liability with a nursing student. Which statements will the nurse include in this discussion? Select all that apply. Answers:A. "You should know your state's nurse practice act because they are not all the same." B. "When you delegate a task to the nurse's aide, it then becomes their responsibility only" C. "It is important to know the scope of practice for those you intend to delegate to." D. "If you have a compact state license, you can practice in all states." E. "The RN can delegate vital signs, bathing, feeding, and client education to the nurse's aide."

A, C

What education will the RN provide to the nursing student in order to be compliant with the Health Insurance Portability and Accountability Act (HIPAA)? Select all that apply A. "You should not discuss patients on the elevator or in the cafeteria." B. "Speak loud and clear when giving report on a patient to another nurse via the the phone." C. "You can access any patient's medical record as long as it is over a secure network." D. "Place your patient assignment papers face down." E. "Store patients' medical chart in a secure location."

A, D, E

The nurse is teaching hygiene to a middle-aged adult. What does she need to consider about her client? Select all that apply A. Socioeconomic Status B. Educational Status C. Culture D. Health State E. Personal Preference

A,B,C,D,E

A nurse instructor explains the concept of health to the students. Which statement accurately describes this state of being? Answers:A. Health is an absence of illness. B. Health is a state of optimal functioning. C. Health is not determined by the client. D. Health is always an objective state.

B

The nurse is about to witness the patient sign a consent form for a procedure. What question will the nurse ask prior to witnessing the signature in order to make sure the patient fully understands the procedure? A. "Did the doctor explain to you what the procedure is, risks of the procedure, and other treatment potions?" B. "Can you explain to me what procedure you are having?" C. "Do you have any questions about your upcoming procedure?" D. "What concerns do you have about the procedure?"

B

The nurse is caring for a client in the emergency department is diagnosed with a myocardial infarction (heart attack). The client describes pain in the left arm and shoulder. What name is given to this type of pain? Answers:A. nociceptive B. referred C. allodynia D. cutaneous

B

The nurse is preparing the patient for surgery during the preoperative phase. The nurse plans to provide preoperative teaching for the patient at this time. Why is it important for teaching to happen during the preoperative phase? Answers:A. Education should be completed during the postoperative phase to decrease patient confusion B. Teaching at this time will allow the nurse to go through all aspects of the upcoming surgery in detail C. Teaching at this time will allow the nurse to provide their opinion regarding the patient's upcoming surgery so that the patient can get a second opinion D. Educating the patient prior to surgery decreases patient anxiety and postoperative complications

B

The registered nurse is caring for a patient on the medical-surgical floor who needs a blood transfusion. Which task will the RN delegate to the LPN at this time? A. Educating the patient on possible reactions prior to the infusion B. Verifying the blood with the RN prior to the RN starting the infusion C. Nothing, the LPN cannot be delegated any tasks related to blood transfusions D. Administering the blood once it is verified

B

The registered nurse is discussing the importance of the understanding the scope of practice with the nursing student. What information will the nurse include in this education? Answers:A. "When delegating, your only need to know your scope of practice." B. "You cannot work outside of the nurse practice act and your scope of practice can be limited depending on which facility you work in." C. "The facility you work in cannot limit your scope of practice if it is in the nurse practice act." D. "You can work outside of the nurse practice act which means your scope of practice can be expanded depending on which facility your work in."

B

A client who has had a recent below-knee amputation tells the nurse that he feels as though his toes are cramping. What would the nurse say in return? Answers:A. "Oh, that is all in your mind. Just forget it." B. "Well, that is really strange. I will notify the doctor." C. "That is called phantom pain, and it is not unusual." D. "I think it might be good to refer you to a psychiatrist."

C

The nurse is applying evidence-based practice (EBP) during a client's wound care. What characteristics of evidence-based practice (EBP) does the nurse demonstrate? Select all that apply. Answers:A. The nurse performs the wound care as it has always been done in the facility. B. The nurse is using a problem-solving approach. C. The nurse blends the science and art of nursing. D. The nurse uses the best evidence available. E. The nurse uses performs care based on institutional protocols.

B, C, D

A nurse is conducting a health history for the client with a skin problem. What question or statement would be most useful in eliciting information about personal hygiene? A. "You must eat a lot of greasy foods to have this acne." B. "Why do you only take a bath once a week?" C. "Tell me about what you do to take care of your skin." D. "Perhaps you don't recognize your bad body odor."

C

The nurse recognizes the following values of the caring, professional nurse identified by the American Association of Colleges of Nursing (AACN)? Select all that apply. Answers:A. Self-sacrifice B. Human dignity C. Sympathy D. Integrity E. Autonomy

B, D, E

The nurse is caring for an elderly patient who has been experiencing confusion, has a weakness, and is a high fall risk due to getting out of the bed without assistance. What alternative measures to restraints will the nurse implement for this patient? Select all that apply Answers:A. Allow the patient to walk unassisted in the hallways B. Implement a toileting schedule for the patient C. Put the bed alarm on D. Use one wrist restraint on the patient's dominant hand E. Relocating the patient to a room that is near the nursing station

B?, C, E

The nurse is caring for an elderly patient. The patient states, "I know that I have decided that I want you to take all measures to save my life, but I've changed my mind. Do I have any options at this point?" The nurse's response will be based on what knowledge? Answers:A. Patients do not have the right to change their decisions once they have been made B. The nurse needs to provide a second opinion C. Patients have the right to change their decisions at any time D. The patient is probably confused and the nurse will need to speak with other family members

C

The nurse is exiting a patient's room who is on isolation precautions. The nurse is wearing all available PPE due to the patient situation. How will the nurse remove the PPE? A. Remove gloves, perform hand hygiene, remove eyewear, gown, mask, perform hygiene B. Remove gloves, eyewear, gown, mask, and then perform hand hygiene C. Remove gloves, perform hand hygiene, remove gown, eyewear, mask, perform hand hygiene D. Remove eyewear, mask, gloves, perform hand hygiene, then remove the gown

C

The nurse is taking care of a patient on contact precautions. During report, the nurse was told that the patient had clostridium difficile (C. Diff) and MRSA. What type of hand hygiene will the nurse perform after care for this patient to prevent the spread of infection to other patients? A. Wash hands with soap and water only if visibly soiled, wash with hand sanitizer otherwise B. Wash hands with soap and water only if visibly soiled, wash with hand sanitizer otherwise C. Wash hands with soap and water after every encounter D. Wash hands with hand sanitizer if visibly soiled

C

A nurse is preparing a patient for discharge after surgery. The patient needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important? Answers:A. "Be sure you keep all your postoperative appointments." B. "Eat a diet high in protein, iron, zinc, and vitamin C." C. "Call your surgeon if you have any questions at home." D. "Wash your hands before touching the drain or dressing."

D

A nurse is caring for a patient who was diagnosed with back pain 10 years ago and states that she is experiencing moderate pain. The patient's blood pressure is 115/70 and her heart rate is 62. The patient does not appear to be in any distress. What type of pain is this patient likely experiencing and which response by the nurse is most therapeutic? A. Acute; "Your vital signs don't show that you are having pain. Can you describe it?" B. Acute; "You do not look like you are in pain." C. Chronic; "OK, I will go get a narcotic for you." D. Chronic; "What would you like to try to alleviate your pain?"

D

The client suffered cardiac arrest, was resuscitated, and has now been on a ventilator for several days. The client had a written advance directive, which the spouse brought from home. The primary care provider (PCP) is encouraging the spouse to consent for the placement of a percutaneous endoscopic gastrostomy (PEG) tube, which is contrary to the client's advance directive. After the PCP leaves, the spouse states, "I wish I knew what my spouse wanted." What is the best reply by the nurse? Answers:A. "You will now have to make the decision." B. "The PCP only wants what is best for your spouse." C. "Your spouse will live with the PEG tube but die without it." D. "The spouse did tell you in the advance directive."

D

The family member of a patient approaches the nurse's station and requests for the nurse to place the patient in restraints. What intervention should the nurse implement next? Answers:A. Call the doctor for a restraint order B. Place the patient in the appropriate restraints and get a doctor's order within 1 hour C. Explain to the family member that that decision is not theirs to make at this time D. Assess the patient.

D

The nurse is caring for an elderly patient on a medical-surgical floor. The CNA reports to the RN that the patient fell while being assisted to the bathroom. The CNA states that the patient denies any pain or injuries and is back in bed at this time. What action takes priority for the nurse at this time? Answers:A. Notify the doctor B. Administer pain medicine as needed per orders C. Document these statements by the CNA D. Assess the patient

D

The nurse is completing a medication reconciliation for the patient who was admitted with an infection. The patient states, "I only take antibiotics. I've taken several antibiotics over the last few months, some of them were my wife's, but none of them seem to make me feel better." What priority complication is the nurse concerned with at this time? Answers:A. An allergic reaction B. Decreased level of consciousness C. Over-the-counter medication interaction D. A super infection.

D

The nurse is discussing nursing theory with the student nurse. The nurse knows that the student nurse understands the information when the student nurse states: A. "The most important concept of nursing theory is research." B. "Nursing theory is used to create new issues in nursing." C. "Nursing theory is not widely used in the profession." D. "The most important concept of nursing theory is the person."

D

The nurse is preparing to send a client to the operating room for an exploratory laparoscopy. The nurse recognizes that there is no informed consent for the procedure on the client's chart. The nurse informs the physician who is performing the procedure. The physician asks the nurse to obtain the informed consent signature from the client. What is the nurse's best action to the physician's request? Answers:A. Call the house officer to obtain the signature. B. Inform the physician that the nurse manager will need to obtain the signature. C. Obtain the signature and ask another nurse to cosign the signature. D. Inform the physician that it is his responsibility to obtain the signature.

D

The nurse understands that one step in implementing evidence-based practice is to ask a question about a clinical area of interest or intervention. The most common method is the PICOT format. Which of the following accurately defines the letters in the PICOT acronym? A. I = institution B. O = output C. C = compromise D. P = population

D

The post-anesthesia care unit (PACU) charge nurse notes vital signs on four postoperative patients. Which patient would the nurse assess first? Answers:A. Patient with a pulse of 118 beats/min B. Patient with a temperature of 96° F (35.6° C) C. Patient with a blood pressure of 100/50 mm Hg D. Patient with a respiratory rate of 6 breaths/min

D

The nurse has a new order for the patient to receive a patient-controlled analgesia (PCA). Which nursing intervention is appropriate in regards to managing patient-controlled analgesia (PCA)? Answers:A. Assess how much medication the patient has received every 24 hours B. Programming the pump requires one nurse and the doctor's order C. Assess the patient's level of consciousness, respiratory rate, and pain level every 2 to 4 hours D. Educate the patient that every time they hit the medication button, they will receive pain medication

D?