Exam 3 LEAH questions

med term matching 1. systolic pressure 2. systolic pressure 3. top number in BP documentation 4. bottom number of the BP 5. pulse deficit Answer choices 1. measurement of the pressure exereted against the walls of the arteries by the blood during relaxation of the heart 2. when the pulse rate is greater than 100 3. measurement of the pressure exerted against the wall of the arteries by the blood during contraction of the heart 4. apical HR less than 60 5. apical HR is higher an the radial pulse rate

1. 3 2.3 3. 3 4. 1 5. 5

Matching terms 1. Process of being cleaned with solutions to kill pathogens 2. use of steam under pressure, gas, or radiation to kill pathogens and their spores 3. used to kill pathogens on equipment and supplies that cannot be heated 4. refers to the potential presence of pathogens on a sterile object resulting from contact with an unsterile surface 5. area that is free from all microorganisms where additional sterile items can be placed until they are ready for use Answer choices a. disinfected b. sterilized c. chemical disinfection d. contamination e. sterile field

1. a 2. b 3. c 4. d 5. e

A college-aged student has tested positive for influenza A. rank in order and match the stages of infection the student goes through from the beginning to end of the disease process Stage 1 Stage 2 Stage 3 Stage 4 Answer choices: a. developmental stage b. incubation stage c. prodromal stage d. self-actualization stage e. prodromal stage f. convalescent stage

1. b 2. c 3. e 4. f idk she ****ed this question up on the test. this was what she had on for answers. hopefully not on the final

Match the terms 1. Protrusion of viscera through an incision 2. new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal 3. composed of clear, portion of the blood and from membranes 4. mixture of serum and red blood cells 5. comprised of white blood cells, liquefied dead tissue debris, and both dead and live bacteria Answer choices: a. serosanguineous drainage b. localized mass of usually clotted blood c. softening through liquid; overhydration d. serous drainage e. evisceration f. purulent drainage g. granulation tissue

1. evisceration 2. granulation tissue 3. serous drainage 4. serosanguineous drainage 5. purulent drainage

a nurse at the health care facility is preparing the medication dosage for a client. Why should the nurse read and compare the label on the medication with the MAR at least three times (before, during, after) while preparing the medication for administration? a. ensure that the right medication is given at the right time by the right route b. complies with the medical order and ensures that the right dose is given c. ensures that the medication has been administered to the right client d. demonstrates timely administration and compliance with the medical order

a

A client is taking ginkgo biloba, a botanical supplement. She asks the nurse if it would be safe to take aspirin for her arthritis at the same time. The nurse's response is based on what knowledge? a. gingko biloba affects platelet function and should not be taken with aspirin b. aspirin will not have any effect if taken at the same time as ginkgo biloba c. ginkgo biloba does not have any effect on the blood, so it is safe d. ginkgo biloba has an anticoagulant effect, and aspirin increases clotting

a

A female is on isolation because she acquired a methicillin-resistant staphylococcus aureus (MRSA) infection after hospitalization for hip replacement surgery. What name is given to this type of infection? a. healthcare-associated (HAI) b. viral c. iatrogenic d. antimicrobial

a

A nurse is admitting a client to a geriatric medicine unit. Which nursing action would the nurse perform to reduce the client's risk for a fall? a. Orient the client to the room and environment upon admission b. Provide the client with a bedpan to reduce ambulating to the restroom c. Administer pain medications sparingly in order to minimize any cognitive side effects. d. Place client in a shared room with client who is stable and oriented.

a

All of the following are nursing strategies/ interventions to address age-related changes in the skin except? a. use of antibacterial floral soap b. do not apply tape to the skin unless necessary c. clean perineal area daily but do not bathe full body on daily basis d. check skin frequently for tears, irritation, or breakdown

a

Bathing serves a variety of purposes, including: a. promoting circulation by stimulating the skin's peripheral nerve endings and underlying tissues b. provide privacy for the patient. Make sure the call device is within reache c. encourage independence have the patient do it all themselves d. ensure privacy and warmth

a

The medical chart of a newly admitted client note a penicillin allergy, yet the physician has just written an order for an antibiotic in the same drug family after reviewing the client's would culture and sensitivity. How should the nurse respond to this situation? a. Withhold the medication until the potential drug allergy has been addressed by the care team b. Administer the medication and increase the frequency of assessments in the hours that follow c. Substitute an antibiotic with similar action, but one that is from a different drug family d. Discuss the severity, signs and symptoms of the drug allergy with the client in order to ascertain the risks of administration

a

The nurse is aware that the antiviral medication is most effective when given during which phase of the infectious process? a. prodromal stage b. incubation period c. full stage of illness d. convalescent period

a

The nurse preparing to perform an abdominal assessment on a client places the client in a supine position. the patient is complaining of pain in the left upper quadrant. What abdominal quadrant does the nurse start assessing first? a. RLQ B. LLQ C. LUQ D. RUQ

a

Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. the nurse considers the client's plan of care and responses to nursing interventions during the assessment. What type of assessment is the nurse performing? a. ongoing partial assessment b. comprehensive assessment c. focused assessment d. emergency assessment

a

What are the pertinent body systems can provide data about the patient's hygiene status and the patient's ability to maintain acceptable personal hygiene? a. musculoskeletal b. brain c. diabetes d. surgery

a

What factors affect overall personal hygiene? a. culture and religious practices b. use of organic products only c. pain d. piercing and tattoo's

a

What is the nursing process stage that co-insides with preoperative nursing interventions that provide the patient with the necessary psychological and physical preparation for surgery and the postoperative phase a. implementation b. assessment c. analysis d. evaluating

a

Why is it important to obtain information from a client related to the use of herbal supplements during a health history? a. some herbs or supplements may interact with a client's prescribed medications b. nurses have special knowledge related to the use of herbs and supplements c. some herbs or supplements require a special diet d. the herb or supplement may need to be acquired from another country

a

Rank in order the phases of wound healing: how the should occur when a wound heals in optimal circumstances a. hemostasis b. inflammatory phase c. proliferation phase d. maturation phase

a,b,c,d

The nursing supervisor is concerned about excessive use of physical restraints on the unit. What interventions would the nursing supervisor employ to decrease the use of restraints? SATA a. Review and change, if needed, current policies at the agency for adherence to accepted national standards b. Provide classes for the nursing staff about appropriate use of restraints and alternatives to restraints c. Encourage the nurses to use medications instead of physical restraints d. Evaluate each client who is restrained and consults with the client's nurse about the use of the restraint e. Obtain additional bed alarms or position-sensitive electronic devices for use as needed.

a,b,d,e

a nurse is performing patient care for a severely ill patient who has cancer. Which nursing intervention are likely to assist this patient to maintain a positive sense of self? sata a the nurse makes a point to address the patient upon entering the room b. the nurse avoids fatiguing the patient by performing all procedures in silence c. the nurse performs care in a manner that respects the patient's privacy and sensibilities d. the nurse offers the patient a simple explanation before moving her in any way e. the nurse ignores negative feelings from the patient since they are part of the grieving process f. the nurse avoids conversing with the patient about her life, family, and occupation

a,c,d

A client with an upper respiratory infection (common cold) tells the nurse, "I am so angry because the nurse practitioner would not give me any antibiotics? What would be the most appropriate response by the nurse a. let me talk to the physician and see what we can do b. antibiotics have no effect on viruses c. why do you think you need an antibiotic d. I know what you mean; you need an antibiotic

b

What is the type of procedure that is preplanned and based on the patient's choice and availability of scheduling for the patient, surgeon, and facility. This is the nonurgent procedure that does not have to be done immediately a. emergency surgery b. elective surgery c. diagnostic d. urgent surgery

b

When conducting a physical assessment, what should the nurse assess and document about the size and shape of body parts? a. actual measurements in centimeters b. symmetry (comparison of bilateral body parts) c. indications of general health status d. vital signs of all extremities (arms and legs)

b

Which of the following can a nurse assess by palpation? a. heart sounds, lung sounds, blood pressure b. temperature, turgor, moisture c. vision, hearing, cranial nerves d. tissue density, gait, reflexes

b

Which of the following patients have one or more vital signs that are outside of normal range? a. 28 yr old male with BP 118/76, HR 66 regular and strong, RR 17, SpO2 98% and denies pain or discomfort b. 93 yr old female with BP 102/62, HR 58 regular and weak, RR 23, SpO2 92% and denies pain c. Newborn male with apical pulse of 140 regular, RR 45, SpO2 95% crying gently d. 15 yr old female with BP 114/68, HR 80, RR 16, SpO2 99% and denies pain or discomfort.

b

after a brain stem infarction a nurse should observe for which condition? a. aphasia b. bradycardia c. numbness and tingling to the face or arm d. contralateral hemiplegia

b

an 86 yr old patient is admitted to the hospital with chest pain and is hearing impaired. Which intervention should the nurse use when assessing this patient? a. ask the family to go home and get the hearing aide b. lower your voice pitch while facing the patient c. talk louder/shout so the patient can hear you d. clean the ears out

b

The nurse triaged a number of clients in the emergency department. Which clients would the nurse identify as risk for infection? sata a. the client who is taking antihypertensive medications and experienced orthostatic hypotension b. the client who has AIDS and is taking antiretroviral medications c. the client reports abdominal pain for 1 day and exhibits an elevated white blood cell count d. the client who has breast cancer is receiving chemotherapy, and has a low white blood cell count e. the older adult client who is cachectic in appearance. f. the client whose electrocardiogram and cardiac enzymes are normal

b,c,d,e

Which of the following assessments provide you with data regarding the quality of circulation to a patient's extremities? a. oral temperature b. strength of pedal dorsalis pulse c. skin temperature of hands and feet d. pulse rate e. BP f. color of nail beds g. capillary refill time

b,c,d,e,f,g

The nurse at an outpatient surgical clinic witness client signatures. When obtaining signatures, which clients are able to sign their own consent for the procedure/surgery? sata a. a 7 yr old who needs an open reduction internal fixation (orif) of right arm b. a 62 yr old with macular degeneration who is ordered a routine colonoscopy c. a 16 yr old who is obtaining an elective breast reduction for back pain d. a married 17 yr old who requires a cholecystectomy for relief from nausea and pain e. a 72 yr old widow with dementia who needs a mastectomy for cancer removal.

b,d

A nurse at a health care facility administers a prescribed drug to a client and does not record doing so in the medical administration record. The nurse who comes during the next shift, assuming that the medication has not been administered, administers the same drug to the client again. The nurse on the previous shift calls to inform the health care facility that the administration of the drug to this client in the earlier shift was not recorded. What should the nurse on duty to immediately upon detection of the medication error? a. report the incident to the physician b. report the incident to the supervising nurse c. check the client's condition d. fill in the accident report sheet

c

A nurse is caring for a stable toddler diagnosed with accidental poisoning due to the ingestion of cleaning solution. What must be included in educating parents about how to protect a toddler from unintentional poisoning? a. closely monitor the toddler's activity b. label poisonous solutions c. keep cleaning solutions locked up d. do not leave toddler alone.

c

A pressure injury prevention program should include. all of the following interventions except? a. routine assessment of skin b. risk of pressure injuries c. massage treatment d. repositioning

c

The nurse is exiting the room of a client who has a clostridium difficile infection. What actions would the nurse perform? sata a. use the hand sanitizer b. remove the respirator c. remove gloves by securing the first glove inside the second glove d. turn gown inside out and roll the gown into a bundle before discarding e. wash hands with soap and water

c,d,e

A client interesting in acupuncture asks a nurse, " just exactly what does it do?" what would the nurse explain? a. acupuncture is based on philosophy of laying on of hands b. I don't think it does anything, so I don't know anything about it c. it uses a manual process of adjusting the spine d. it changes the flow of energy and helps healing

d

A client taking insulin has his levels adjusted to ensure that the concentration of drug in the blood serum produces the desired effect without causing toxicity. What is the term for this desired effect? a. peak level b. trough level c. half-life d. therapeutic range

d

A nurse is bunching the tissue of a client when administering a subcutaneous injection to that client. what is reasoning for bunching when injecting Subcutaneously? a. to prevent needlestick injury b. to ensure accuracy of landmarking c. to facilitate blood circulation at injection site d. to avoid instilling medication within the muscle

d

A nursing student is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure? a. Do nothing, because the client is on antibiotics b. complete the procedure and then report what happened c. apologize to the client and complete the procedure d. gather new supplies and start over

d

A sophomore in high school has missed a lot of school this year because of leukemia. he said he is falling behind in everything, misses, " hanging out at the mall" with his friends most of all. for what disturbance in self-concept is this patient at risk? a. personal identity disturbance b. body image disturbance c. self-esteem disturbance d. altered role performance

d

All of the following are functions of skin except? a. absorption b. sensation c. temperature regulation d. palpation e. protection

d

An emergency room nurse is assessing a toddler with multiple bruises and burns. The nurse suspects the toddler has been abused. What is legally required of the nurse? a. Nothing; the nurse has no control over the toddler's home b. Refer the caregivers of the toddler to a home health nurse c. Verbally confront the caregivers about the suspicions. d. Report suspicions about the abuse to proper authorities

d

a hospitalized client asks the nurse for "some aspirin for my headache". there is no order for aspirin for this client. What will the nurse do? a. go ahead and give the client aspirin, a common self-prescribed drug b. ask the client's visitors if they have any aspirin for the client c. ask the client's family to bring some aspirin from home d. state that an order form the doctor is legally required and check with the doctor

d

a man on an airplane is sitting by a woman who is coughing and sneezing. if she has an infection, what is most likely the means of transmission from the woman to the man? a. direct contact b. indirect contact c. vectors d. airborne route

d

Which are examples of objective data collected during a nursing history and physical examination of a newly admitted client? SATA a. fatigue b. nausea c. pain d. fever e. HTN

d,e

HOT SPOT know the where to palpate the dorsalis pedis pulse

dorsalis pedis pulse