NUR 112 EXAM 2

When testing near vision, the nurse should position printed text how many inches away from the patient? 1. 20 2. 18 3. 16 4. 14

4. 14

The nurse applause resistance to the top of the clients foot and asked him to pull his toes toward his knee. The nurse observes act of motion against some, but not against four, resistance. How should the nurse document this finding? 1. 5: normal 2 4: slight weakness 3. 3: weakness 4. 2: poor ROM

2. Slight weakness

When assessing the quality of a clients pedal pulses, what is the nurse assessing? Choose all that apply. 1. Rhythm of the pulses 2. Strength of the pulses 3. Bilateral equality of pulses 4. Rate compared with apical pulse

2. Strength of the pulses 3. Bilateral equality of pulses

The nurse notes ptosis in a patient who just arrived in the emergency department. The nurse quickly triage the patient because she knows that this finding, along with other symptoms, might suggest 1. Hyper 2. Stroke 3. Glaucoma 4. Macular degeneration

2. Stroke

While the nurse assesses a newborn of African-American descent, the mother points out of blue/black Mongolian spot on the newborns back and asks, what's that? Is something wrong with my baby? Which response by the nurse is best? 1. I'll ask the position to look at the spot 2. Those spots are quite common and typically fade with time 3. You may want a plastic surgeon to look at that 4. That spot is benign so it's nothing you need to worry about

2. Those spots are quite common and typically fade with time

Abdominal palpation should be avoided in a child who has which disorder? 1. Appendicitis 2. Wilms tumor 3. Crohn's disease 4. Small bowel obstruction

2. Wilms tumor

Broncovesicular Breath sounds are best heard over which area? 1. Midline over the trachea just below the larynx 2. Fourth intercostal space In the midclavicular line 3. First and second intercostal spaces next to the sternum 4. At the base of the lungs near the diaphragm

3. First and second intercostal spaces next to the sternum

A patient's jugular venous pressure measures 5 cm. This finding indicates: 1. A normal finding 2. Hypovolemia 3. Heart failure 4. Dehydration

3. Heart failure

An adult admitted to the hospital after a stroke does not respond to verbal stimuli. What should the nurse do next to try to provoke a response? 1. Apply pressure to the mandible at the jaw. 2. Rub the patient's sternum 3. Squeeze the trapezius muscle 4. Gently shake the patient's shoulder

4. Gently shake the patient's shoulder

For which of the following patients would it be most important to obtain an apical/radial pulse and calculate the pulse deficit? A patient who 1. Had abdominal surgery two hours ago 2. Suffered a fractured hip yesterday 3. Is dehydrated from vomiting 4. Has a heart or lung disease

4. Has a heart or lung disease

While assessing an older adult patient, the nurse notes clubbing of the fingers. This finding is a sign of: 1. Fungal infection 2. Poor circulation 3. Iron deficiency 4. Long-term hypoxia

4. Long-term hypoxia

The nurse is caring for a patient who underwent abdominal surgery 24 hours ago and has a nasogastric tube to intermittent suction. How should the nurse proceed when performing an abdominal assessment on this patient? 1. Avoid palpating the patient's abdomen 2. Turn off the section before auscultating bowel sounds 3. Listen for bowel sounds for two minutes in each quadrant 4. Because the abdomen before auscultating bowel sounds

2. Turn off the suction before auscultating bowel sounds

A female patient has excessive facial hair. The nurse to document this finding as: 1. Alopecia 2. Albinism 3.Hirsutism 4. Lanugo

3. Hirsutism

During a clinic interview, a client states he has been experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement? 1. Ask the client when is the Day dizziness occurs 2. Help the client to assume a recumbent position 3. Measure both heart rate and blood pressure with a client standing 4. Measure vital signs with a client supine, sitting, standing.

4. Measure vital signs with a client Supine, sitting, standing.

In evaluating a clients blood pressure for hypertension, it would be most important to 1. Use the same type of manometer each time 2. Auscultate all five Korotkoff sounds 3. Measure the blood pressure in both arms 4. Monitor the blood pressure for a pattern

4. Monitor the blood pressure for a pattern

The client has had a fever, ranging from 99.8F orally, over the last 24 hours. The clients fever would be classified as 1. Constant 2. Intermittent 3. Relapsing 4. Remittent

4. Remittent

In caring for a client who has a fever, it would be important for the nurse to monitor for increased 1. Urine output 2. Sensitivity to pain 3. Blood pressure 4. Respiratory rate

4. Respiratory rate

Which skin assessment finding would cause the nurse to suspect dehydration in the middle aged patient admitted to the hospital with travelers diarrhea? 1. Edema 2. Hyperhidrosis 3. Pallor 4. Tenting

4. Tenting

Hi pitched breath sounds produced by airway narrowing or known as: 1. Rales 2. Crackles 3. Rhonci 4. Wheezing

4. Wheezing

Which of the following is an abnormal capillary refill finding that the nurse should report?

Anything 4 seconds or over

Which aspect of restraint use can the nurse delegate to the nursing assistive personnel? 1. Assessing the patient status 2. Determining the need for Restraint 3. Evaluating the patient's response to restraints 4. Applying And removing the restraints

Applying and removing the restraints

A patient is brought to the emergency department after inhaling mercury. The nurse should be alert for which acute adverse effects associated with mercury inhalation? 1. Chest pain, pneumonitis, an inflammation of the mouth 2. Intestinal obstruction and numbness in the hands 3. Hypotension, oliguria, and tingling of the feet 4. Tachycardia, hematuria, and diaphoresis

Chest pain, Pneumonitis, an inflammation of the mouth

A child is brought to the emergency department after swallowing liquid cleanser. He is awake and alert and able to swallow. Which action should the nurse take first? 1. Administer a dose of syrup of ipecac 2. Administer activated charcoal immediately 3. Give water to the child immediately 4. Call the nearest poison control center

Give water to the child immediately

Where should the nurse assess skin color changes in the dark skin patient 1. Nail beds 2. Any exposed area 3. Oral mucosa 4. Palms of the hands

Oral mucosa

Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis? 1. Risk for falls 2. Risk for ineffective airway clearance or choking 3. Risk for poisoning 4. Risk for suffocation or drowning

Risk for falls

A patient in the emergency department is angry, healing, cursing, and waving his arms when the nurse comes to the treatment cubicle. Which action by the nurse is advisable? 1. Reassure the patient by entering the room alone 2. Ask the patient if he's carrying any weapons 3. Stay between the patient in the door keep the door open 4. Make eye contact while Stating firmly I will not tolerate cursing and threats

Stay between the patient and the door keep the door open

The admission assessment form indicates that the patient has pedal pulses that are rated 1 in amplitude. This documentation indicates that the patient's pulses are : 1. Bounding 2. Normal 3. Full 4. Diminished

4. Diminished

While palpating the anterior chest the nurse notes crackling in the skin around the patient's chest tube insertion site. The nurse recognizes this finding is 1. Tactile fremitus 2. Egophony 3. Bronchophony 4. Crepitus

4. Crepitus

A clients average normal temperature is 98°F. Which of the following temperatures would be expected during the night in this healthy young adult client who does not have a fever, inflammatory process, or underlying health problem 1. 97.2F 2. 98F 3. 98.6F 4. 99.2F

1. 97.2F

The nurse is teaching a client how to use a portable blood pressure device to monitor his blood pressure at home. It would be most important for the nurse to 1. Ask the client to demonstrate the use of the blood pressure device 2. Explain the importance of frequent calibration of the device 3. Give the client a chart to record his blood pressure readings 4. Provide written instructions of the information talk

1. Ask the client to demonstrate the use of the blood pressure DeVos

Which statement best describes the procedure used to assess capillary refill? 1. Briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in color 2. Press firmly with your finger tip for five seconds over a bony area , release pressure, and observe the skin for the reaction 3. Tap on the skin with short strokes from your fingers 4. Lift a fold of skin, and allow it to return to its normal position

1. Briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in color

The lift people of a patient feels to accommodate. Desponding may reflect an abnormality in which cranial nerve? 1. CN III 2. CN V 3. CN

1. CN III

The nurse is assessing vital signs for a client after surgical procedure on the left leg. IV fluids are infusing. It would be most important for the nurse to 1. Compare the left pedal pulse with the right pedal pulse 2. Count the clients respiratory rate for 1 full minute 3. Take the blood pressure in the arm without an IV 4. Take an oral temperature with an electronic thermometer

1. Compare the left pedal pulse with the right pedal pulse

Which of the following procedure techniques has the most affect on the accuracy of an apical pulse count 1. Counting the rate for 1 full minute 2. Exposing only the left side of the chest 3. Determining while assessment of apical pulse is indicated 4. Using your ring finger to palpate the intercostal spaces

1. Counting the rate for 1 full minutes

Match the breath sound with the appropriate description 1. High-pitched sound heard on inspiration in infants 2. High-pitched continuous musical sound 3. High-pitched popping or low pitched bubbling sounds 4. Low pitched continuous sounds that clear with coughing 5. Labored snoring sound

1. Crackles 2. Rhonci 3. Stridor 4. Wheezes 5. Stertor

The nurse assesses the following changes in a clients vital signs. Which client situation should be reported to the primary care provider? 1. Decreased blood pressure after standing up 2. Decreased temperature after a period of diaphoresis 3. Increased heart rate after walking down the hall 4. Increased respiratory rate when the heart rate increases

1. Decreased blood pressure after standing up

Which disorder my limit a patient's visual field? Select all that apply. 1. Diabetes 2. Advanced glaucoma 3. Peripheral vascular disease 4. Cataracts

1. Diabetes 2. Advanced glaucoma 4. Cataracs

The nurse should assess skin temperature by using the: 1. Dorsum of the hand 2. Pad of the fingertip 3. Palm of the hand 4. Dorsum of the wrist

1. Dorsum of the hand

All of the following clinical signs may be present with hypoxia. However, only two are specific indicators of hypoxia. (That is if they are present it means that the patient is probably hypoxic) Which ones are specific indicators of hypoxia? Choose all that apply. 1. Feelings of anxiety 2. Crackles in the lungs bases 3. Increased heart rate 4. Improved breathing in upright position

1. Feelings of anxiety 3. Increased heart rate

The nurse notes an S3 heart sound while performing an assessment on a patient admitted with an acute myocardial infarction. The nurse notifies the position of the funding, which most likely suggests: 1. Heart failure 2. Coronary artery disease 3. Hypertension 4. Pulmonic stenosis

1. Heart failure

The nursing instructor asked students how they would assess the fifth vital sign which student would be correct? 1. I would have a client right her pain on a scale of 0 to 10 2. I would ask the client when she had her last bowel movement 3. I would take the clients pulse oximetry reading 4. I would interview the client about history of tobacco use

1. I would have a client right her pain on a scale of 0 to 10

Which of the following interventions would be appropriate for a client who has a fever? Choose all that apply. 1. Put an ice pack on the clients neck and axillae. 2. Provide the client a blanket when he's shivering 3. Offer the client fluids to drink every one to two hours 4. Take the temperature using a tympanic thermometer

1. Put an ice pack on the clients neck and axillae 3. Offer the client fluids to drink every one to two hours

For which of the following adult clients should the nurse make follow-up observations and monitor the vital signs closely? A client whose 1. Resting morning blood pressure is 136/86 while the afternoon BP is 128/84 mm Hg. 2. Oral temperature is 97.9°F in the morning and 99.8°F in the evening 3. Heart rate was 76 bpm before eating and 88 bpm after eating 4. Respiratory rate is 16 breaths per minute when standing and 18 when lying down

1. Resting morning blood pressure is 136/86 well the afternoon BP is 128/84 mm Hg

A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Which finding the nurse expect when assessing the patient's nails? 1. Soft boggy nails 2. Brittle nails 3. Thickened nails 4. Thick nails with yellowing

1. Soft boggy nails

The nurse is performing an otoscopic Examination on an adult patient. She has a patient tilt his head to the side not being examined and looks into the ear Canal to make sure a foreign body is not present. Which step should she perform next? 1. Straighten the ear canal by pulling that helix up and back 2. Insert the speculum into the ear canal slowly 3. Test the mobility of the tympanic membrane 4. Straighten the air canal by pulling the helix down and back

1. Straighten the ear canal by pulling the helix up and back

A six week old infant is brought to the pediatricians office for a well-baby check up. The nurse notes of flattening of the skull. Flattening of the skull in the infant might suggest; 1. The baby has been lying in the same position for several hours a day 2. A disorder associated with excessive growth hormone 3. An accumulation of excessive cerebrospinal fluid 4. Temporomandibular joint syndrome

1. The baby has been lying in the same position for several hours a day

During a thermometer exchange program at a local hospital, a person drops of mercury thermometer On the floor. Assume the nurse has been trained and clean up of such a special. Select all that are appropriate. How should the nurse Intervine? 1. Using gloves and a paper towel place to mercury in a plastic bag, and dispose of it 2. Notify the hazardous material management team immediately 3. Evacuate the area immediately 4. After putting on a gown, gloves, and a mask, clean up the mercury 5. Wash your hands well after removing the spill 6. Ventilate the area well for several days

1. Using gloves and a paper towel, placed a mercury in a plastic bag, and dispose of it. 5. Wash your hands while after removing the spill 6. Ventilate the area well for several days

Which blood pressure has a pulse pressure within normal limits? Choose all that apply. 1. 104/50 MM Hg 2. 120/62 MM Hg 3. 120/80 MM Hg 4. 130/86 MM Hg

120/80 MM Hg 130/86 MM Hg

The nurse hears rhonchi when auscultating a clients lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds? 1) Have the client take several deep breaths. 2) Request the client take a deep breath and cough. 3) Take the clients blood pressure and apical pulse. 4) Count the clients respiratory rate for 1 minute

2) Request the client take a deep breath and cough.

A clients vital signs 4 hours ago were temperature (oral) 101.4F, heart rate 110/min, respiratory rate 26/min, and blood pressure 124/78 mm Hg. The temperature is now 99.4F. Based only on the expected relationship between temperature and respiratory rate, the nurse might best anticipate the clients respiratory rate to be 1. 16 2. 18 3. 20 4. 22

2. 18

The clients temperature is 101.1F. Which is the correct conversion to centigrade? 1. 38.0C 2. 38.4C 3. 38.8C 4. 39.2C

2. 38.4C

The nurse asked the patient to spread his fingers and then bring them together again, which of the following is the nurse testing when I ask him to bring his fingers together? 1. Abduction 2. Add duction 3. Flexion 4. Extension

2. Add duction

Which of the following sets of vital signs are all within normal limits for patients at rest? 1. Infant: T 98.8F (rectal), HR 160, RR 16, BP 120/54 2. Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68 3. Adult: T 99.6F (oral), HR 48, RR 22, BP 130/84 4. Older Adult: T 98.6F (oral), HR 110, RR 28, BP 170/95

2. Adolescent: T 98.2F (oral), HR 80, RR 18, BP 108/68

At last measurement, the clients bottle sounds were as follows; oral temperature 98°F, heart rate 76 bpm, respiratory rate 16 breaths per minute, and blood pressure 118/60 mm Hg. Four hours later, the vital signs are as follows; oral temperature 103.2°F, heart rate 76 bpm, respiratory rate 14 breaths per minute, and blood pressure 120/66. Which should be the nurses first intervention at this time? 1. Ask the client if he has had a warm drink in the last 30 minutes 2. Notify the primary care provider of the clients temperature 3. Asked the client if he is feeling chilled 4. I take the temperature by a different route

2. Ask the client if he has had a warm drink in the last 30 minutes

A mother Brings her six month old infant to the clinic for a while baby check up. How should the nurse proceed when weighing the patient? 1. Have the mother remain outside the room. 2. Ask the mother to remove the infant clothing and diaper 3. Why the infant wearing only the diaper 4. Place the infant supine on the scale with his knees extended

2. Ask the mother to remove the infants clothing and upper

Which of the following is a correct developmental outcome for an infant? The infants anterior fontanelle or soft spot typically fuses: 1. At about 8 weeks 2. At about 14 weeks 3. By 6 months 4. Before 1 year of age

2. At about 14 weeks

Which assessment should the nurse perform if she knows a palpable thyroid gland? 1. Illuminate the thyroid gland for the presence of fluid 2. Auscultate The thyroid gland for bruits 3. Precocious the thyroid gland for mass size 4. Measure the thyroid gland to assess change

2. Auscultate the thyroid gland for bruits

Which abnormal laboratory value is associated with icteric sclerae? 1. Bleeding Time 2. BiliRubin 3. Hemoglobin 4. Glucose

2. BiliRubin

Which assessment question helps assess immediate memory? 1. How did you get to the hospital today 2. Can you repeat the numbers 2, 7, 9 for me? 3. Do you recall the three items I mentioned earlier 4. When was your birthday including the year

2. Can you repeat the numbers two, seven, nine for me?

An 85-year-old patient is brought to the emergency department with Lethargy and hypotension . When the nurse assesses the patient's tongue, she notes that it appears dry and furry. This finding suggests: 1. Fungal infection 2. Dehydration 3. Allergy 4. Iron deficiency

2. Dehydration

Which of the following pieces of information in the clients health history might indicate a risk for primary hypertension? 1. Consumes a high protein diet 2. Drinks three to four beers every day 3. Has a family history of kidney disease 4. Does not engage in physical except use

2. Drinks three to four beers every day

Which one of the following clients I would probably have a higher than normal respiratory rate? A client who has 1. Had surgery and is receiving a narcotic analgesic 2. Had surgery and lost a unit of blood intraoperatively 3. Lived at a higher altitude and then moved to sea level 4. Been exposed to the cold and is now hypothermic

2. Had surgery and lost a unit of blood

Which portion of the ear is Responsible for maintaining equilibrium? 1. External ear 2. Inner ear 3. Middle ear 4. Ossicles

2. Inner ear

Which point should the nurse include when teaching safety precautions to a mother of a toddler? Select all that apply. 1. Make sure the child sleeps on his back at night 2. Keep the telephone number of the poison control center accessible 3. Use a front facing car seat placed in the backseat of the car 4. Keep syrup with a iPECAC On hand in case of accidental poisoning

2. Keep the telephone number of the poison control center accessible 3. Use a front facing car seat place in the backseat of the car

Assuming that all or accurate, which documentation about a patient's level of consciousness is best 1. Patient is lethargic and slept when undisturbed 2. Patient response to tactile stimulation; falls back to sleep immediately after tactile and verbal stimulation are stopped 3. Patient slept throughout the day missing his meals and bath 4. Patient appears to be tired as he slept throughout the day except when bathed

2. Patient response to tactile stimulation; falls back to sleep immediately after tactile and verbal stimulation are stopped

The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday. Which founding requires further assessment? Select all that apply. 1. Blood pressure 110/64 MM Hg 2. Pulse rate 118 bpm 3. Respiratory rate 35 bpm 4. Oral temperature 98.6°F or 37°C

2. Pulse rate 118 bpm 3. Respiratory rate 35 breaths per minute

Which assessment data best supports a report of severe pain in an adult client who's baseline bottle signs are within an average normal range? 1. Oral temperature 100°F 2: Respiratory rate 26 breaths per minute and shallow 3. Apical heart rate 56 bpm 4. Blood pressure 124/82 MM Hg

2. Respiratory rate 26 breaths per minute and shallow

Which test should the patient under go on a weber test is positive 1.Romberg test 2. Rinnie test 3. Pure tone audiometer 4. Tympanometry

2. Rinnie test

Based on developmental stage, how should the nurse modify the comprehensive physical examination of an older adult? 1. Work rapidly to finish as quickly as possible 2. Sequence the exam to limit position changes 3. Demonstrate equipment before using it 4. Omit portions of the exam that may be tiring

2. Sequence the exam to limit position changes

Which of these steps and taking a blood pressure is correct? Choose all that apply. 1. Use a bladder that encircles 40% of the arm 2. Wrap the cuff snugly around the clients arm 3. Ask the client to hold the arm at a heart level 4. Have the client sit with feet flat on the floor

2. Wrap the cuff snuggly around the clients arm 4. Have a client sit with feet flat on the floor

A client's vital signs at the beginning of the shift are as follows: oral temperature 99.3°F (37°C), heart rate 82 beats per minute, respiratory rate 14 breaths per minute, and blood pressure 118/76. Four hours later the client's oral temperature is 102.2°F (39°C). Based on the temperature change, the nurse should anticipate the client's heart rate would be how many beats per minute? 1. 62 2. 82 3. 102 4. 122

3. 102

An older adult comes to the clinic complaining of pain in the left foot. While assessing the patient, the nurse notes smooth, shiny skin that contains no hair on the clients lower legs. Which condition does findings suggest? 1. Venous insufficiency 2. Hyper 3. Arterial insufficiency 4. Dehydration

3. Arterial insufficiency

Comparing the changes in vital signs as a person ages, which statement is correct? Select all that apply. 1. Blood pressure decreases less than heart rate and respiratory rate 2. Respiratory rate remains fairly stable throughout a persons life 3. Blood pressure increases; heart rate and respiratory rate decline 4. Might have higher blood pressure than women until after menopause

3. Blood pressure increases; heart rate and respiratory rate decline 4. Me and have her blood pressure than women until after menopause

The nurse provides client education regarding hypertension prevention and management. Which of these statements and indicates that the client understands the instructions. 1. I don't have to worry if my blood pressure is high once in a while 2. I guess I will have to make sure I don't drink too much water 3. I can lose some weight to help lower my blood pressure 4. I will need to reduce the amount of milk and other dairy products I use

3. I can lose some weight to help lower my blood pressure

The nurse assesses a four-year-old child's vision as 20/40. This finding is considered: 1. Myopia 2. Hyperopia 3. Normal 4. Presbyopia

3. Normal

The nurse notes a small pulsation at the fifth intercostal space midclavicular line. This should be documented as a: 1. Thrill 2. Murmur 3. Normal finding 4. Heave

3. Normal finding

A clients axillary temperature is 100.8°F. The nurses realize this is outside normal range for this client and that axillary temperatures do not reflect core temperature. What should the nurse is due to obtain a good estimate of the core temperature? 1. Add 1°F to 100.8°F to obtain an oral equivalent 2. Add 2°F to 100.8°F to obtain a rectal equivalent 3. Obtain a rectal temperature reading 4. Obtain a tympanic membrane reading

3. Obtain a rectal temperature rating

The nurse is instructing a client how to appropriately dress an infant in cold weather. Which of the following instructions for the most important for the nurse to include? 1. Be sure to put mittens on the baby 2. Layer the infants clothing 3. place a cap on the infants head 4. Put warm booties on the baby

3. Place a cap on the one infants head

A 48-year-old patient comes to the physicians office complaining of diminished near vision, which The nurse confirms with testing. She should document this finding as: 1. Myopia 2. Diplopia 3. Presbyopia 4. Mydriasis

3. Presbyopia

A father brings his 18 month old child to the pediatric clinic for a while baby check up. The father tells the nurse that he was concerned because it's child's legs are bowed. Which response by the nurse is appropriate? 1. Your child will most likely require physical therapy 2. You should consider having your child seen by an orthopedic surgeon 3. This is a normal finding and children for one year after they've been walking 4. Your child is walking fine, so you don't need to worry

3. This is a normal finding in children for one year after they begin walking

A client who has been hospitalized for an infection states the nursing assistant told me my vital signs are all within normal limits that means I'm cured. The nurses best response would be which of the following? 1. Your vital signs confirm that your infection is resolved. How do you feel? 2. I'll let your Health care provider know so you can be discharged 3. Your vital signs are stable but there are other things to assess 4. We still need to keep monitoring your temperature for a while

3. Your vital signs are stable but there are other things to assess

A patient's ankles appear swollen. When the nurse assesses the edema, the skin depresses 6MM, and the depression last two minutes. The nurse should document this finding as: 1. Trace Edema 2. +1 edema 3. +2 edema 4. +3 edema

4. +3 edema

Small hemorrhages are noted under the nail bit of a patient with a history of Intravenous drug abuse. This finding is associated with; 1. Low albumin levels 2. Zinc deficiency 3. Renal disease 4. Bacterial endocarditis

4. Bacterial endocarditis

The nurse notes that the electrical cord on an IV infusion pump is correct. Which action by the nurse is best? 1. Continue to monitor the pump to see if the crack worsens 2. Play the pump back on the utility room shelf 3. A small crack poses no danger so continue using the pump 4. Clearly labeled the pump and send it for repair

4. Clearly labeled a pump and send it for repair

A 78-year-old patient is being seen in the emergency department. The nurse observes his gait and balance appear to be slightly unsteady what assessment should the nurse perform next? 1. Perform to get up and go test 2. Ask the patient if he has fallen in the past year 3. Refer the patient for a comprehensive fall evaluation 4. Administer the timed up and go test

Ask the patient if he has fallen in the past year

Despite less restrictive interventions a patient's behavior escalates requiring emergency application of restraints. Which of the following must a nurse do in the situation 1. Obtain a physicians order before applying restraints 2. Monitor the patient status every four hours while restrained 3. Release the restraints and check circulation every hour 4. Continually reevaluate the patient's need for restraint

Continually reevaluate the patients need for restraint

A patient with a history of falling continually attempts to get out of bed unassisted despite frequent reminders to call for help first. Which action should the nurse take first 1. Apart a cloth vest restraint 2. Encourage a family member to stay with the patient 3. Administer lorazepam or an antianxiety medication 4. Keep the patient's bedside rails up

Encourage a family member to stay with a patient

The nurse suspects a three-year-old child who is coughing vigorously has aspirated a small object. Which action should the nurse take first? 1. Encourage the child to continue coughing 2. Deliver a port abdominal thrusts with a fisted hand 3. Deliver five rapid back blows between the shoulder blades 4. Perform a blind finger sweep of the child's mouth

Encourage the child to continue coughing

A patient has received a radiation implant. The patient is weak and needs help even to turn in bed. Which action should the nurse take when caring for this patient? 1. Avoid giving the patient a complete bed bath 2. Limit the amount of time spent with the patient 3. Allow extra time for the patient to express feelings 4. Do not allow anyone to visit the patient

Limit the amount of time spent with the patient

Which of the following instructions is most important for the nurse to include when teaching a mother of a three-year-old about protecting her child against accidental poisoning? 1. Store medication on countertops out of the child's reach 2. Purchase medication and child resistant containers 3. Take medication's in front of the child, and explain that they are for adults only 4. Never leave the child unattended around medication or cleaning solutions

Never leave the child unattended around medication or cleaning solutions

Which is the most commonly reported the incident in hospitals 1. Equipment malfunction 2. Patient falls 3. Laboratory specimen errors 4. Treatment delays

Patient falls

The joint commission's national speak up campaign encourages patients to become active an informed participants on the healthcare team. The goal is to; 1. Prevent healthcare errors 2. Help control the cost of healthcare 3. Reduce the number of automobile accidents 4. Provide a forum for people without health insurance

Prevent healthcare errors

A nurse is teaching a group of mothers about first aid. Should poison come in contact with their child's clothing and skin, which action should the nurse instruct the mothers to take first? 1. Remove the contaminated clothing immediately 2. Flood the contaminated area with Luke warm water 3. Wash the contaminated area with soap and water and rinse 4. Call the nearest poison control center immediately

Remove the contaminated clothing immediately