N-510 QUIZ #1

What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery? A) Ask the patient to describe the effect of pain on the ability to cope. B) Observe cardiac monitor for increased heart rate C) Assess the patient body language D) Ask the patient to rate the level of pain

ANS: D) Ask the patient to rate the level of pain

A nurse is planning care for a client who is postoperative. Which of the following statements about pain management should the nurse consider when implementing client care? (Select all that apply.) 1.The use of analgesics will eventually lead to addiction. 2.Each client's expression of pain may be different and individualized. 3." As needed" dosing of analgesic medications is preferred over "around-the-clock dosing" 4.Pain level and pain tolerance can be assessed using a scale from 0 to 10 5. All clients will express the feeling of pain both verbally and nonverbally

ANS: 2,4&5 2. Each client's expression of pain may be different and individualized. 4.Pain level and pain tolerance can be assessed using a scale from 0 to 10 5. All clients will express the feeling of pain both verbally and nonverbally

A Charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administrated the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation

ANS: A AssessmentThe newly licensed nurse should have used the assessment step of the nursing process by asking the client to evaluate the severity of pain on a 0 to 10 scale. The nurse should also have asked about the characteristics of the pain and assessed for any changes that might have contributed to the worsening of the pain.

During a routine physical examination of a 70-year-old patient, a blowing sound is auscultated over the carotid artery. The nurse notifies the medical provider of the unexpected physical finding known as: A) Bruit B) Phlebitis C) Clubbing D) Murmur

ANS: A Bruit is the sound of turbulence of blood passing through a narrowed blood vessels. A bruit can reflect cardiovascular disease in the carotid artery.

In which order will the nurse use the nursing process steps during the clinical decision-making process? 1. Evaluating goals 2. Assessing patient needs 3. Planning priorities of care 4. Determining nursing diagnoses 5. Implementing nursing interventions A.2, 4, 3, 5, 1 B.4, 3, 2, 1, 5 C.1, 2, 4, 5, 3 D.5, 1, 2, 3, 4

ANS: A The American Nurses Association developed standards that set forth the framework necessary for critical thinking in the application of the five-step nursing process: assessment, diagnosis, planning, implementation, and evaluation.

While completing an admission database, the nurse is interviewing a patient who states "I am allergic to latex." Which action will the nurse take first? A.Immediately place the patient in isolation. B.Ask the patient to describe the type of reaction. C.Proceed to the termination phase of the interview. D.Document the latex allergy on the medication administration record.

ANS: B The nurse should further assess and ask the patient to describe the type of reaction. The patient will not need to be placed in isolation; before terminating the interview or documenting the allergy, health care personnel need to be aware of what type of response the patient suffered.

The nurse is caring for a Black patient with COPD. The nurse knows the best location to assess for cyanosis is the: A) Earlobes B) Abdomen C) Oral Mucosa D) Lower extremities

ANS: C Oral Mucosa

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistant then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The nursing assistant states she was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked, and it has dropped even lower. The nurse first made an error in what phase of the nursing process? A. Evaluation B. Planning C. Assessment D. Diagnosis

ANS: C The diagnostic process should flow from the assessment. In this case, the nurse should have assessed the patient's blood pressure before giving the medication. The nurse could have prevented the patient's untoward reaction if the low blood pressure was assessed first. Diagnosis follows assessment. Administering the medication occurs in implementation, but this is not the first error. There are no errors in evaluation.

1. A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene? A. The student nurse reads the patient's plan of care. B. The student nurse reviews the patient's medical record. C. The student nurse shares patient information with a friend. D. The student nurse documents medication administered to the patient.

ANS: C When you are a student in a clinical setting, confidentiality and compliance with the Health Insurance Portability and Accountability Act (HIPAA) are part of professional practice. When a student nurse shares patient information with a friend, confidentiality and HIPAA standards have been violated, causing the preceptor to intervene. You can review your patients' medical records only to seek information needed to provide safe and effective patient care. For example, when you are assigned to care for a patient, you need to review the patient's medical record and plan of care. You do not share this information with classmates and you do not access the medical records of other patients on the unit.

You have delegated vital signs to assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse's most appropriate advice would be to: A. take a rectal temperature. B. take the oral temperature as planned. C. advise the patient to drink a glass of cold water. D. wait 30 minutes and take an oral temperature.

ANS: D

After providing care, a nurse charts in the patient's record. Which entry will the nurse document? A. The patient is in pain because he appears unhappy B. Drank adequate amounts of water C. Apparently is asleep with eyes closed D. The patient has a left abdominal incision 1 inch in length without redness drainage or edema

ANS: D A factual record contains descriptive, objective information about what a nurse observes, hears, palpates, and smells. Objective data is obtained through direct observation and measurement (left abdominal incision 1 inch in length without redness drainage or edema). For example, "B/P 80/50, patient diaphoretic, heart rate 102 and regular." Avoid vague terms such as appears, seems, or apparently because these words suggest that you are stating an opinion, do not accurately communicate facts, and do not inform another caregiver of details regarding behaviors exhibited by the patient. The use of exact measurements establishes accuracy. For example, a description such as "Intake, 360 mL of water" is more accurate than "Patient drank an adequate amount of fluid."

A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient? A.Risk for impaired skin integrity B.Risk for infection C.Spiritual distress D.Reflex urinary incontinence

ANS: D Reflex urinary incontinence is highest priority. If a patient's incontinence is not addressed, then the patient is at higher risk of impaired skin integrity and infection. Remember that the Risk for diagnoses are potential problems. They may be prioritized higher in some cases but not in this situation. Spiritual distress is an actual diagnosis, but the adverse effects that could result from not assisting the patient with urinary elimination take priority in this case.

The patient requires temperatures to be taken every two hours. Which of the following cannot be delegated to nursing assistive personnel? A. Selecting appropriate route and device B. Obtaining temperature measurement at ordered frequency C. Being aware of the usual values for the patient D. Assessing changes in body temperature

ANS: D The nurse is responsible for assessing changes in body temperature. The nurse instructs nursing assistive personnel to select the appropriate route and device to measure temperature, to obtain temperature measurement at ordered frequency, and to be aware of the usual values fAor the patient.

A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? A. "Documentation is a communication tool for the interprofessional health care team." B. "Documentation provides informaition to the client about financial charges for care provided." C. "Documentation provides information for a client audit. "D. "Documentation allows providers to monitor the nurse's activities."

Ans: A Documentation provides information to facilitate communication among members of the interprofessional health care team in making client-centered decisions, planning appropriate therapies, and evaluating a client's progress.

When conducting an abdominal assessment, the first skill a nurse puts to use is: A. auscultation. B. inspection. C. palpation. D. percussion.

B

You notice that a teenager has an irregular radial pulse. The best action you should take includes: A. reading the history and physical. B. assessing the apical pulse rate for 1 full minute. C. auscultating for strength and depth of pulse. D. asking whether the patient feels any palpitations or faintness of breath.

B

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

B. BP A nurse who is supervising an AP's work is accountable for the work that the AP completes. Therefore, the nurse should verify anything that seems unusual. The BP the AP reported is low; therefore, the nurse should verify that this result is accurate before taking any other actions.

A postoperative patient is breathing rapidly. You should immediately A. call the physician. B. assess temperature C. assess the oxygen saturation. D. ask the patient if he feels uncomfortable.

C

When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true? A. Chronic pain is psychological in nature. B. Regular use of narcotic analgesics always leads to drug addiction. C. Patients are the best judges of their pain. D. Amount of pain is reflective of actual tissue damage.

C

When meeting a patient for the first time, it is important to establish a baseline assessment that will enable a nurse to refer back to: A. physiological outcomes of care. B. the normal range of physical findings. C. a pattern of findings identified when the patient is first assessed. D. clinical judgments made about a patient's changing health status.

C

A patient complains of thirst and headache. The patient appears emaciated. Upon initial examination, you find that the skin does not return to normal shape. This finding is consistent with: A. pallor. B. edema. C. erythema. D. poor skin turgor.

D