NURS 1871 EAQs for Final Exam

In which order does the chain of infection cycle occur chronologically?

1. Infectious agent 2. Reservoir 3. Portal of exit 4. Mode of transmission 5. Portal of entry 6. Host

A patient who had undergone a hysterectomy 10 days ago came for a follow-up visit. The patient notices purulent drainage at the incision site. The nurse suspects wound infection and performs assessment for confirmation. Which clinical findings would the nurse evaluate? Select all that apply. A. Pain B. Redness C. Paleness D. Tenderness E. Cold senssation

A, B, D

When communicating with a patient who has a visual impairment, which techniques should the nurse use? Select all that apply. A. Sit at eye level in front of the patient B. Cover the mouth while talking C. Provide diffuse, bright light without glare D. Avoid standing in front of the patient E. Encourage the use of eyeglasses or magnifying glasses

A, C, E

Which equipment is used to sterilize surgical instruments? A. Autoclave B. Boiling water C. Chemical sterilants D. Ethylene oxide (ETO) gas

A. Autoclave

Which body system is involved in presbycusis? A. Ears B. Eyes C. Taste D. Touch

A. Ears

The nurse is assessing a patient who has gynecomastia. Which is a sign of gynecomastia? A. Enlarged breasts in males B. Atrophy of glandular tissue C. Replacement of milk ducts by fat D. Decreased muscle mass, tone, and elasticity of the breast

A. Enlarged breasts in males

Which is the most effective way to break the chain of infection? A. Hand hygiene B. Wearing gloves C. Placing patients in isolation D. Providing private rooms for patients

A. Hand hygiene

An older patient is diagnosed with dorsal kyphosis. What is a contributing factor for developing this disorder? A. Osteoporosis B. Impacted cerumen C. Subdural hematomas D. Calcification of costal cartilage

A. Osteoporosis

Which nursing intervention is most beneficial for an immobile postsurgical patient to decrease the risk for integumentary complications? A. Padding all the bony prominences B. Maintaining adequate fluid balance C. Place a pillow over an incisional area D. Palpate claves for redness, tenderness, and warmth

A. Padding all the body prominences

The nurse is instructed to clean artery forceps contaminated with blood. Arrange the steps of cleaning in the appropriate order.

A. Rinse the artery forceps with cold water B. Wash the artery forceps with soap and water C. Rinse the artery forceps with warm water D. Dry the artery forceps

Which position discourages deep breathing and thoracic expansion? A. Supine B. Side-lying C. Semi-Fowler's D. Reverse Trendelenburg's

A. Supine

The nurse instructs a patient to breathe normally between each set of 10 breaths with the incentive spirometer. What is the rationale behind this instruction? A. To prevent fatigue B. To promote lung expansion C. To reduce the risk of progressive collapse D. To reduce transmission of microorganisms

A. To prevent fatigue

Which risk factor causes secondary infections? A. Trauma B. Hereditary C. Nutrition D. Chronic disease

A. Trauma

A patient is admitted to a hospital for surgery to correct urinary incontinence. About what should the nurse instruct the patient in order to avoid infections while cleaning the perineal region? A. Wipe from the urinary meatus toward the rectum B. Wipe from the rectum toward the urinary meatus C. Clean the perineal region once a day D. Cleaning the perineal area is more important for young women then for older women past menopause

A. Wipe from the urinary meatus toward the rectum

The nurse is teaching a group of older adults. Which principles are helpful in promoting learning in older adults? Select all that apply. A. Sit to the side rather than directly facing the patient B. Ask for feedback from the patient C. Present one idea or concept at a time D. Speak fast and in a loud voice E. Use audio and visual cues while teaching

B, C E

The nurse is assessing a group of patients in a health screening program. A patient complains of itching and irritation under the right arm and the nurse suspects a localized infection. What assessments should be done on this patient? Select all that apply. A. Examine for paleness of skin B. Palpate the area for tenderness C. Inquire about pain and tightness D. Inspect eh area for redness and swelling E. Inquire about gastrointestinal disturbances

B, C, D

The nurse is assessing the housing needs of an older adult with severe arthritis who has recently undergone knee replacement surgery. Which kinds of house are appropriate for this patient? Select all that apply. A. A house with pets B. A house with only one floor C. A house with a shiny floor D. A house with no exterior steps E. A house with many throw rugs

B, D

The nurse is assessing an elderly patient with a pelvic fracture who has a history of osteoporosis. Which statement by the patient relates to extrinsic risk factors for a fall? A. "I frequently have joint pain." B. "I forget my cane while walking." C. "I have a history of frequent falls." D. "I take sedatives to help me sleep."

B. "I forget my cane while walking."

Which type of elder mistreatment involves desertion of a vulnerable elder at a hospital? A. Physical abuse B. Abandonment C. Caregiver neglect D. Psychosocial abuse

B. Abandonment

What should the nurse observe to assess a patient's maximum potential for chest expansion? A. Ability to maintain a sitting position B. Ability to cough and breathe deeply C. Ability to move independently in bed D. Calves for redness, warmth, and tenderness

B. Ability to cough and breathe deeply

When the nurse is performing surgical hand asepsis, where should the nurse keep his or her hands? A. Below the elbows B. Above the elbows C. At a 45-degree angle D. In a comfortable position

B. Above the elbows

The nurse is caring for an elderly patient who is having difficulty recalling directions after hospitalization. On assessment, the nurse noticed that hypoxia has intensified the condition. What is the possible psychological condition of the patient? A. Stress B. Delirium C. Dementia D. Depression

B. Delirium

The nurse has conducted an assessment of a new patient who has come to the medical clinic. The 82-year-old patient has had osteoarthritis for 10 years and diabetes mellitus for 20 years. The patient is alert but becomes easily distracted during the nursing history. The patient recently moved to a new apartment, and the patient's pet beagle died just 2 months ago. Which is this patient most likely experiencing? A. Dementia B. Depression C. Delirium D. Disengagement

B. Depression

While working with a patient on positive expiratory pressure (PEP) therapy, the nurse instructs the patient to place his or her lips around the mouthpiece of the PEP device. What is the rationale behind this instruction? A. Facilitates diaphragm excursion B. Ensures the patient breathes through the mouth C. Enhances the expansion of the thorax D. Reduces the transmission of microorganisms

B. Ensures the patient breathes through the mouth

Which body system is affected in presbyopia? A. Ears B. Eyes C. Smell D. Taste

B. Eyes

While assessing the health of four patients, the nurse discovers one of the patient's findings to be age-related. Which patient supports the nurse's conclusion? A. Patient A has white sclera. B. Patient B has yellowing of the lens. C. Patient C has a decreased sensitivity to glare. D. Patient D has dilation of pupil in the presence of light.

B. Patient B has yellowing of the lens

How should the nurse position a severely obese postsurgical patient during incentive spirometry? A. Supine B. Side-lying C. High-Fowler's D. Semi-Fowler's'

B. Side-lying

Which condition can be inferred in a patient who complains of involuntary release of urine while laughing, sneezing, and coughing? A. Diabetes mellitus B. Stress incontinence C. Prostate hypertrophy D. Urinary tract infection

B. Stress incontinence

A patient reports a history of obstructive sleep apnea. Which position of sleeping is harmful for the patient? A. Prone position B. Supine position C. Lateral position D. Upright position

B. Supine position

The nurse is teaching a group of older adults the important of daily exercise. Which instructions should the nurse include in the teaching? Select all that apply. A. Always perform exercise outdoors B. Do not drink water before exercising C. Stop exercising if there is chest pain or tightness D. Walking and swimming exercises protect the musculoskeletal system E. Wear good support shoes and clothing appropriate to the exercise

C, D, E

A registered nurse teaches a patient about measures to control the exit and entry of microorganisms. Which statement made by the patient needs correction? A. "I will brush my teeth regularly." B. "I will apply lotion to my skin appropriately." C. "I will apply water-insoluble ointment to my lips." D. "I will clean my perineal area by wiping from the urinary meatus toward the rectum"

C. "I will apply water-insoluble ointment to my lips."

A registered nurse teaches a patient about measures to control the exit and entry of microorganisms. Which statement made by the patient needs correction? A. "I will brush my teeth regularly." B. "I will apply lotion to my skin appropriately." C. "I will apply water-insoluble ointment to my lips." D. "I will clean my perineal area by wiping from the urinary meatus toward the rectum."

C. "I will apply water-insoluble ointment to my lips."

Which normal flora of the human colon can cause an infection when it enters the bloodstream? A. Escherichia coli B. Candida albicans C. Bacteroides fragilis D. Plasmodium falciparum

C. Bacteroides fragilis

The nurse sees a 76-year-old in the outpatient clinic. The patient's chief complaint is vision. The patient has really noticed glare in the lights at home; vision is blurred; and the patient is unable to play cards with friends, read, or do needlework. What is this patient experiencing? A. Presbyopia B. Disengagement C. Cataracts D. Depression

C. Catarcats

When a patient experiences kyphosis, which should the nurse recognize as a future risk? A. Decreased bone density in the vertebrae and hips B. Increased risk for pathological stress fractures in the hips C. Changes in the configuration of the spine that affect the lungs and thorax D. Calcification of the bony tissues of the long bones such as in the legs and arm

C. Changes in the configuration of the spine that affect the lungs and thorax

The nurse is reviewing the complete blood count of a postsurgical patient. What is the significance of a high hematocrit value? A. Infection B. Increased risk of a blood clot C. Dehydration D. Polycythemia

C. Dehydration

When an older adult suffers a major life event such as the death of a loved one, a move to a nursing home, or a cancer diagnosis, for what should the nurse be alert? A. Dementia B. Delirium C. Depression D. Stroke

C. Depression

Which position promotes optimal lung expansion during respiratory maneuvers? A. Prone B. Supine C. High-Fowler's D. Trendelenburg's

C. High-Fowler's

Which is a barrier for health care providers to health promotion and disease control for older adults? A. Health literacy B. Personal motivation C. Lack of consistent guidelines D. Previous health care experiences

C. Lack of consistent guidelines

Which drug can be administered to induce conscious sedation during surgery? A. Lidocaine B. Clonidine C. Midazolam D. Dantrolene sodium

C. Midazolam

Which statement about the older adult is true? A. Most older adults are financially poor B. Most older adults are mentally unstable C. Most older adults are tolerant towards others D. Most older adults are worthless after they leave the workforce

C. Most older adults are tolerant toward others

Which microorganism exits through a man's urethral meatus during sexual contact? A. Ebolavirus B. Clostridium difficle C. Neisseria gonorrhea D. Legionella pneumophila

C. Neisseria gonorrhea

In coaching a patient in diaphragmatic breathing, the nurse instructs the postoperative patient to take slow, deep breaths. What is the rationale for this nursing intervention? A. Allows gradual expulsion of air B. Decreases wasted energy C. Prevents panting and hyperventilation D. Allows the patient to feel the movement of the chest

C. Prevents panting and hyperventilation

A patient who is infected with herpes simplex complains of itching and tingling. There are no visible lesions found on examination. To which stage of herpes simplex infection does this patient belong? A. Illness stage B. Incubation stage C. Prodromal stage D. Convalescence stage

C. Prodromal stage

The nurse is working with an older adult after an acute hospitalization. The nurse's goal is to help this person be more in touch with time, place, and person. Which technique should the nurse try? A. Reminiscence B. Validation therapy C. Reality orientation D. Body image interventions

C. Reality orientation

Which outcome of both general anesthesia and conscious sedation is considered desirable? A. Loss of gag reflex B. Loss of blink reflex C. Situational amnesia D. Localized loss of sensation

C. Situational amnesia

Reminiscence strategies are used to evaluate an older adult patient's memory. What do these strategies do? A. They produce a positive mood B. They reduce the patient's anxiety C. They stimulate memory chains through associations D. They allow evaluation of a patient's judgment and general knowledge

C. They stimulate memory chains through associations

The nurse is caring for an elderly patient diagnosed with Alzheimer's disease. Which intervention would help reduce the patient's confusion? A. Reminiscence B. Touch therapy C. Validation therapy D. Reality orientation

C. Validation therapy

Which is a mode of transmission for the human immunodeficiency virus (HIV) infection? A. Vectors B. Droplet C. Vehicles D. Airborne

C. Vehicles

Which instruction is appropriate for a preoperational patient? A. "Take over-the-counter- nonsteroidal antiinflammatory drugs the night before surgery." B. "Avoid fried food beginning 3 hours before surgery." C. "Begin fasting 2 hours before surgery." D. "Avoid any fluid intake for at least 2 hours before surgery."

D. "Avoid any fluid intake for at least 2 hours before surgery."

The registered nurse is discussing the care of a postsurgical older adult with a group of nursing students. Which of a nursing student's statements indicates a need for further discussion? A. "Older adults are at risk of postoperative delirium." B. "Medical complications are more common in older adults." C. "Unexpected drug responses are often observed in older adults." D. "Older adults can tolerate long surgeries due to their increased physiological reserves."

D. "Older adults can tolerate long surgeries due to their increased physiological reserves."

A registered nurse is evaluating the statements of the student nurse regarding reproductive changes that occur in both sexes due to aging. Which statement made by the student nurse indicates a need for further teaching? A. "The desire to have sex decreases with aging." B. "Vaginal irritation causes pain during sexual activity." C. "Lack of lubrication of vaginal mucosa causes irritation." D. "Production of sperm in men decreases during the third decade of life."

D. "Production of sperm in men decreases during the third decade of life."

A nurse who is caring for an older adult patient observes that the patient lacks confidence and is unwilling to take medications. Which statement by the nurse would promote positive perception in the patient? A. "You need to take your medication on time." B. "You should accept that aging is a universal truth." C. "You should try talking with people in your same age group." D. "You should try to be happy and spend some time talking with your friends."

D. "You should try to be happy and spend some time talking with your friends."

Which intervention is beneficial in treating malignant hyperthermia caused by an anesthetic agent? A. Coughing B. Deep breathing C. Administration of clonidine D. Administration of dantrolene sodium

D. Administration of dantrolene sodium

An older adult patient complains of knee pain when attempting to do usual activities. Which type of health care setting is most appropriate for this patient? A. Home care B. Acute care C. Skilled nursing care D. Ambulatory care

D. Ambulatory care

When does the nurse wear a gown? A. The patient's hygiene is poor B. The nurse is assisting with medication administration C. The patient has acquired immunodeficiency syndrome (AIDS) or hepatitis D. Blood or body fluids may get on the nurse's clothing from a task that he or she plans to perform

D. Blood or body fluids may get on the nurse's clothing from a task that he or she plans to perform

Which microorganism causes gas gangrene? A. Escherichia coli B. Neisseria gonorrheae C. Staphylococcus aureus D. Clostridium perfringens

D. Clostridium perfringens

In the hospital setting, what is the most likely means of transmitting infection between patients? A. Exposure to another patient's cough B. Sharing equipment among patients C. Disposing of soiled linen in a shared linen bag D. Contact with a healthcare worker's hands

D. Contact with a healthcare worker's hands

A patient has presbyopia. Which visual manifestation would most likely be present upon examination of the patient? A. Difficulty to distinguish between blues and greens B. Difficulty to distinguish between colors such as blue and black C. Difficulty with vision when moving from bright to dark environments D. Decline in the ability of the eyes to accommodate from near to far vision

D. Decline in the ability of the eyes to accommodate from near to far vision

Which description is applicable to therapeutic communication? A. It provides sensory stimulation B. It focuses on older adult recalling the past C. It accepts time descriptions as stated by the older adult D. It provides care by meeting a patient's expressed or unexpressed needs

D. It provides care by meeting a patient's expressed or unexpressed needs

An older adult is unable to distinguish between the colors blue and black. Which is the most likely cause for this condition? A. A hereditary syndrome B. Malnourishment C. A Mental disorder D. Lens discoloration

D. Lens discoloration

Which nursing action may help decrease postoperative nausea? A. Promoting ambulation B. Maintaining adequate fluid intake C. Providing desired servings of food D. Moving the patient slowly when changing positions

D. Moving the patient slowly when changing positions

After interacting with an older adult patient, the nurse suspects that the patient has presbyopia. Which action of the patient supports the nurse's suspicion? A. Repeating words B. Sipping water occasionally C. Asking others to speak loud D. Picking a blue shirt assuming it as black

D. Picking a blue shirt assuming it as black

The caregiver of an older adult patient reports, "My father, in spite of turning up the volume on the radio and television, complains that he is unable to hear." Which condition should the nurse suspect in the patient? A. Kyphosis B. Keratoses C. Presbyopia D. Presbycusis

D. Presbycusis

Which action during leg exercises helps to maintain joint mobility? A. Lifting the buttocks B. Dorsiflexion of the feet C. Plantar flexion of the feet D. Rotating the ankles in complete circles

D. Rotating the ankles in complete circles

Which action helps prevent postoperative atelactasis? A. Pursed-lip exhalation B. Using the chest and shoulders while inhaling C. Repeating breathing exercises three to five times D. Ten deep-breathing exercises every hour

D. Ten deep-breathing exercises every hour

Why should dorsiflexion and plantar flexion of the feet be parts of leg exercises? A. To maintain joint mobility B. To maintain knee mobility C. To facilitate contraction and relaxation of the quadriceps muscles D. To facilitate stretching and contraction of the gastrocnemius muscles

D. To facilitate stretching and contraction of the gastrocnemius muscles