Questions throughout exams/quizes PCC Final
Which of the following triggers a physiological response to stress? A. A threatening event B. A stress neutral event C. A stress challenging event D. A mental illness event
A. A threatening event
During a teaching season, the nurse tells a patient with a recent neck injury that damage to the nerves is comparable to a water hose that has been pinched off. During this teaching session, the nurse is using the process of: A. Analogy B. Discovery C. Role Playing D. Demonstration
A. Analogy
Which of the following clinical manifestations is the most important for the nurse to report to the health care provider? A. Anuria B. Polyuria C. Nocturia D. Micturition
A. Anuria
In the operating room, a patient tells a circulating nurse that he is going to have a cataract in his left eye removed. If the nurse notes that the consent form indicates that surgery is to be performed on the right eye, what should be the nurse's first action? A. Ask the patient his name B. Notify the surgeon and anesthesiologist C. Check to see whether the patient has received any preoperative medications D. Assume that the patient is a little confused because he is older
A. Ask the patient his name
A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? A. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. B. Irrigate the wound with an antiseptic prior to obtaining the specimen. C. Include intact skin at the wound edges in the culture. D. Swab an area of skin away from the wound to identify the usual flora
A. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.
The nurse is caring for a patient with chronic pain. Which question best evaluates whether the pain management plan is effective? A. Does the pain keep you from doing the things you enjoy? B. Can you describe the quality of your pain? C. Has there been a change in the location of the pain? D. How would you rate your pain?
A. Does the pain keep you from doing the things you enjoy?
A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first? A. Gloves B. Gown C. Face shield D. Mask
A. Gloves
An intervention to keep an infant safe at home is: A. Have the infant sleep on their back B. Place them on their stomach when sleeping C. Securely fasten them in a forward facing car seat in the passenger seat D. Keep them in a playpen during all waking hours
A. Have the infant sleep on their back
The client, who has identified that he wants to quit smoking, states "I just want to beat this thing. I hate feeling like i hae to smoke to feel right." Based on his statement, the nurse identifies that his primary motivation comes from power; the best intervention would be to: A. Help him see the personal victory and control in cutting back by 2 cigarettes a day B. Help him find and connect with a smoking cessation support group. C. Show him pictures of what happens to the lungs when someone smokes and discuss the other long term consequences of smoking D. Encourage him to visit with a smoking cessation coach who can guide and support him throughout each step of the quitting process.
A. Help him see the personal victory and control in cutting back by 2 cigarettes a day
With respect to the concept of caring, most nursing theories: A. Identify caring as highly relational involving patient and nurse B. embrace the disease orientation to health care as Watson does. C. Recognize Leininger's theory and reject culture as a caring force D. Stress the universality of expression of caring
A. Identify caring as highly relational involving patient and nurse
Which cardiovascular findings will the nurse anticipate for a patient experiencing unrelieved acute pain? Select all that apply A. Increased heart rate B. Decreased coagulation C. Decreased cardiac output D. Increased blood pressure E. Decreased myocardial O2 consumption
A. Increased heart rate D. Increased blood pressure
The nurse is assessing an immobile patient. Which of the following is the most important assessment for early detection of complications of immobility? A. Lung sounds throughout all lung fields B. Urine output the past 12 hours C. Neurological assessment D. Hand grip strength bilaterally
A. Lung sounds throughout all lung fields
The nurse is caring for a client with a wound healing by full-thickness repair. The client is in the final phase of wound healing and knows this takes extended time to heal. What phase is this in the healing process? A. Maturation B. Proliferative C. Inflammatory D. Hemostasis
A. Maturation
Surgical or invasive strategies for pain management are used for: A. Pain relief when other treatment modalities have failed B. Initial treatment of arthritis C. Post operative pain D. The patient seeking narcotics
A. Pain relief when other treatment modalities have failed
A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first? A. Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. B. Apply a condom catheter to a client who is incontinent C. Feed a client who has bilateral casts due to upper arm fractures D. Deliver a clean voided urine specimen to the laboratory.
A. Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast.
As a nurse, you would utilize Watson's theory on transpersonal caring with a patient by: A. Placing care before cure. B. Placing cure before care C. A focus on cultural beliefs D. Doing tasks for another
A. Placing care before cure.
The nurse is caring for a patient who has been sitting in the chair for 2 hours. Which of the following complications of immobility is the patient at greatest risk for developing? A. Pressure ulcer B. Muscle atrophy C. Fecal impaction D. Cognitive impairment
A. Pressure ulcer
The patient has had a surgical procedure with wound cloure using staples. This wound will heal by A. Primary intention B. Secondary intention C. Tertiary intention D. Quadruple intention
A. Primary intention
A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching? A. Protein B. Calcium C. Vitamin B1 D. Vitamin D
A. Protein
A nurse is teaching a group of mothers about first aid. Should poison come in contact with their childs clothing and skin, which action should the nurse instruct the mothers to take first? A. Remove the contaminated clothing immediately. B. Flood the contaminated area with lukewarm water. C. Wash the contaminated area with soap and water and rinse. D. Call the nearest poison control center immediately.
A. Remove the contaminated clothing immediately.
A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following laboratory findings will affect wound healing? A. Serum albumin 3.2 g/dL B. Hemoglobin 16 g/dL C. WBC count 8,000/mm3 D. PTT 1.8
A. Serum albumin 3.2 g/dL
A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first? A. Take an arterial blood gas (ABG) specimen to the laboratory. B. Transport a client to the radiology department for an x-ray. C. Pass fresh water to clients on the unit. D. Obtain a routine urine sample from a newly-admitted client
A. Take an arterial blood gas (ABG) specimen to the laboratory.
A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the nurse include in the teaching? (Select all that apply.) A. Vitamin A B. Vitamin B12 C. Vitamin C D. Vitamin D E. Vitamin K
A. Vitamin A B. Vitamin B12 C. Vitamin C E. Vitamin K
Upon entering the room of a patient with a healing stage III pressure ulcer, the nurse noticed an odor, observes a purulent discharge, along with increased redness at the wound site. what priority action should the nurse take? A. completing a head-to-toe assessment, including current treatment, vital signs, and laboratory results B. Notifying the health care provider by utilizing situation, background, assessment and recommendation (SBAR) C. Consulting the wound care nurse about the change in status and the potential for infection. D. conferring with the charge nurse about the change in status and the potential for infection.
A. completing a head-to-toe assessment, including current treatment, vital signs, and laboratory results
While preparing a teaching plan, the nurse described what the learner will be able to accomplish after the teaching session. which action did the nurse complete? A. developed learning objectives B. Provided positive reinforcement C. implemented interpersonal communication D. Presented facts and knowledge
A. developed learning objectives
an intervention to keep an infant safe at home is: A. have infant sleep on there back B. place them on there stomach while sleeping C. securely fasten them in a forward facing car seat in the passenger seat D. keep them in a playpen during all waking hours
A. have infant sleep on there back
The nurse is caring for a patient who has been sitting in the chair for 2 hours. Which of the following complications of immobility is the patient at greatest risk for developing? A. pressure ulcer B. muscle atrophy C. Fecal impaction D. cognitive impairment
A. pressure ulcer
It is best for nurses to have a broad understanding of cultural influences on health care because of: A. the increasing global diversity B. requirements set by the Health Insurance Portability and Accountability Act (HIPPA) C. a litigious society we live in D. rules sent down from the government
A. the increasing global diversity
The nurse is assessing a patient's readiness to be discharged. what is the most appropriate question for the nurse to ask to determine the patient's learning needs before planning the teaching session? A. what do you need to know before you are able to be dismissed from the hospital? B. What are your hobbies and occupation? C. What were your grades and learning style when you were in school? D. Where is your family? They really should be here for this.
A. what do you need to know before you are able to be dismissed from the hospital?
When the nurse walks into the patients room, she notices fire coming from the patients trash can. Rank the following actions in the order they should be performed by the nurse. 1 should be done first; 4 should be last. A. Activate the fire alarm. B. Move the patient out of the room. C. Close all doors and windows. D. Put out the fire using the proper extinguisher.
B, A, C, D
While caring for a child, you identify that additional safety teaching is needed when a young and inexperienced mother states that: A. Teenagers need to practice safe sex B. A 3-year-old can safely sit in the front seat of the car C. Children need to wear safety equipment when bike riding. D. Children need to learn to swim even if they do not have a pool.
B. A 3-year-old can safely sit in the front seat of the car
A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first? A. A client who has a nasogastric tube for decompression and the gastric aspirate is green with a pH of 5.3 B. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided C. A client who has COPD and the capillary refill time on both hands is 4 seconds D. A client who has late-stage cirrhosis and whose breath has a fruity odor
B. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided
A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first? A. A client who has diarrhea and requests clear liquids for breakfast B. A client who has a cast on the left leg and reports numbness and paresthesia C. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 D. A client who has pneumonia and has an axillary temperature of 38° C (101° F)
B. A client who has a cast on the left leg and reports numbness and paresthesia
A nurse has received change-of-shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse assess first? A. A client who had a blood glucose reading at 0650 of 70 mg/dL after receiving 50% dextrose for a hypoglycemic episode B. A client who was admitted for chest pain and is reporting a new onset of indigestion C. A client who has pneumonia and was treated for a temperature of 38.9° C (102° F) at 0400 D. A client who has pulled out the peripheral IV catheter and is scheduled to receive a dose of famotidine at 0800
B. A client who was admitted for chest pain and is reporting a new onset of indigestion
A patient is at risk for developing a deep vein thrombosis after surgery. Which interventions would reduce the risk of this complication? (Select all that apply.) A Applying heat to the operative site B Administering prophylactic anticoagulant drugs C Administering intermittent positive pressure ventilation D Restricting the range of motion of the unaffected lower extremity E Encouraging the patient to wear compression gradient stocking
B. Administering prophylactic anticoagulant drugs E. Encouraging the patient to wear compression gradient stocking
You are a nurse working in the college student health center. You receive a call that an athlete has just fallen and has been injured. You know that according to the general adaptation syndrome, the athlete will be exhibiting: A. An increased appetite B. An increased heart rate C. A decreased in perspiration D. A decreased in respiratory rate
B. An increased heart rate
.A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first? A. Apply a tourniquet just above the wound. B. Apply pressure directly to the wound. C. Start two large-bore IV catheters. D. Place the client in a modified Trendelenburg position.
B. Apply pressure directly to the wound.
The nurse uses the correct technique for obtaining a 24-hour urine specimen by collecting: A. All the urine in a large container at the bedside B. Asking the patient to void and discard that urine, then collecting urine for 24 hours at the time of the next void C. Asking the patient to avoid all caffeinated beverages D. Continue collecting urine from the original start time, in the event the patient accidently voids in the toilet (Just not this on the lab requisition)
B. Asking the patient to void and discard that urine, then collecting urine for 24 hours at the time of the next void
The nurse is preparing to provide patient-centered care and culturally competent care. Which of the following should the nurse do first? A. use the RESPECT model B. Assess own biases and attitudes C. read the transcultural care theory D. determine the dominant culture in the area B. Assess own biases and attitudes
B. Assess own biases and attitudes
According to TeamSTEPPS, a strategy to communicate important or critical information is: A. Shout-out B. Call-out C. Check-back D. I pass the Baton
B. Call-out
A 70-year-old female has been hospitalized for three months post open exploratory abdominal surgery and developed recurrect clostridioides difficile (C.Diff) infection. Which of the following is true concering recurrect C. diff infections? A. a complication of C.diff is fluid overload B. Clients may benefit from a fecal microbiota transplantation C. Long-term antibiotic therapy decreases the risk of acquiring C. diff infection D. Good hand hygiene with an alcohol-based cleanser will prevent spreading of the organism
B. Clients may benefit from a fecal microbiota transplantation
A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse plan to initiate? A. Droplet B. Contact C. Airborne D. Protective
B. Contact
A nurse is caring for a client who has not followed the guidelines for their prescribes medication theraoy. which of he following should the nurse consider as contributing factors to the client's non-adherence? (select all that apply.) A. gender B. Culture C. Literacy D. Motivation
B. Culture C. Literacy D. Motivation
A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material? A. Discard the dressing in the bedside trash receptacle. B. Dispose of the dressing in a biohazardous waste container. C. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle. D. Double-bag the dressing in clear bags and label it "biohazard".
B. Dispose of the dressing in a biohazardous waste container.
The nurse is caring for a patient of Japanese heritage who refuses pain medication despite the nurse explaining its importance in the helaing process. Which interventions by the nurse would be appropriate for this patient (select all that apply) A. Assess the pateints pain levels at less frequent intervals B. Document in the patient's record that the patient does not want to take the prescribed pain medication C. Notify the primary care provider of the patient's noncompliance D. Utilize nonpharmacological measure to help control the patient's pain
B. Document in the patient's record that the patient does not want to take the prescribed pain medication D. Utilize nonpharmacological measure to help control the patient's pain
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? A. Apply a cloth vest restraint. B. Encourage a family member to stay with the patient. C. Administer lorazepam (an antianxiety medication). D. Keep the patients bed side rails up.
B. Encourage a family member to stay with the patient.
The nurse is completing a urinary assessment on an older adult male client. When asked about voiding, he shared he has difficulty emptying his bladder. The nurse knows this is likely a symptom of which of the following conditions? A. Increased Bladder tone B. Enlarged prostate gland C. Large urine volume D. Urinary trace infection
B. Enlarged prostate gland
A nurse is caring for a client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing? A. Kidney beans B. Grilled salmon C. Peanut butter D. Raw spinach
B. Grilled salmon
A patient with COPD is admitted to the emergency department with severe dyspnea. on assessment, the nurse noted the patient's respiratory rate is 30 breaths per min. HR is 120 beats per minute and 02 is 86%. The patient is using accessory muscles to breathe. which action should the nurse prioritize (select all that apply) A. administer a IV antibiotic B. Initiating oxygen therapy via nasal cannula at 2 liters per min C. Administer pain meds to alleviate discomfort D. Prepare for endotracheal intubation and mechanical ventilation E. Raise the HOB to high fowlers position
B. Initiating oxygen therapy via nasal cannula at 2 liters per min D. Prepare for endotracheal intubation and mechanical ventilation E. Raise the HOB to high fowlers position
A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion? A. Sudden lethargy. B. Muffled heart sounds. C. Flattened neck veins. D. Bradycardia.
B. Muffled Heart sounds
A nurse is preparing to perform wound irrigation on a client who has a puncture wound to the left leg. Identify the sequence of steps the nurse should take to perform the irrigation. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) A. Don clean gloves and remove the client's dressing. B. Place a waterproof pad under the client's leg. C. Irrigate the wound until the solution becomes clear. D. Open a sterile dressing set and supplies. E. Clean the wound using a circular motion.
B. Place a waterproof pad under the client's leg. A. Don clean gloves and remove the client's dressing. E. Clean the wound using a circular motion. D. Open a sterile dressing set and supplies. C. Irrigate the wound until the solution becomes clear.
A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority? A. Instruct the client about home disposal of contaminated dressings. B. Schedule a follow-up visit by a home health nurse for dressing changes. C. Provide a dietary list of foods which promote wound healing. D. Establish a follow-up appointment with the client's provider.
B. Schedule a follow-up visit by a home health nurse for dressing changes.
A patient comes into the emergency department complaining of chest pain. When discussing possible reasons why the chest pain has occurred. The nurse learns that the patient is depressed because of the loss of a job. This type of crisis can be classified as: A. Maturational B. Situational C. Sociocultural D. Posttraumatic
B. Situational
The nurse is teaching a class to parents who are toddlers and preschoolers, about prevention of the most common causes of fatal accidents in the home. Which of the following is the most important to include in the presentation. A. Remove small rugs from the home B. Store all cleaning products in a locked cabinet C. Check for the presence of lead paint in the home D. Use gaits at the bottom and top of stairs.
B. Store all cleaning products in a locked cabinet
A nurse is preparing to do patient teaching. Which patient finding will cause the nurse to postpone a teaching session? A. the patient is in the acceptance phase B. The patient is very fatigued C. The patient is mildly anxious D. the patient is asking questions
B. The patient is very fatigued
A nurse recognizes an acute pain episode is related to which physiological event? A. Fever B. Tissue damage C. Pathology such as a tumor D. Brain dysfunction
B. Tissue damage
To reduce the risk of pneumonia in a patient who just returned from surgery for a repair of a fractured hip, a priority nursing intervention is: A. To have the patient rise slowly from a lying to sitting position B. To have the patient cough and deep breathe 1-2 hours C. To get a pneumonia vaccine D. To ambulate the patient every 1-2 hours B. To have the patient cough and deep breathe 1-2 hours
B. To have the patient cough and deep breathe 1-2 hours
A newly admitted patient was found wandering the hallways for the past two nights. The most appropriate nursing interventions to prevent a fall for this patient would include: A. Raise all four side rails when darkness falls B. Use an electronic bed monitoring device C. Place the patient in a room close to the nursing station D. Use a loose-fitting vest type jacket restraint
B. Use an electronic bed monitoring device
A nurse is caring for a patient from a culture different from the nurse's. in order to provide culturally competent care, the nurse realizes: A. members of the same cultural group share similar feelings about their religion B. cultural beliefs are individually expressed among those from the same culture C. a shared cultural background generals mutual regard for one and another. D. the nurse must agree with the cultural differences of the patient
B. cultural beliefs are individually expressed among those from the same culture
which of the following is an example of teritary prevention measure for a health promotion plan of care for a patient newly diagnosed with diabetes? A. avoid cancer causing agents B. foot screening techniques C. screening for sexually transmitted infections D. seat belt use
B. foot screening techniques
The nurse admits a 78-year old male client who states he has trouble urinating and appears agitated. During the inital abdominal assessment, the nurse notes that the client's lower abdomen is markedly distended. Which of the following physician orders should the nurse implement first? A. initiate a 2-hour voiding schedule B. insert a urinary straight catheter C. Draw for blood urea nitrogen (BUN) and creatinine (CR) tests D. Restrict fluids for the clients after the evening meal
B. insert a urinary straight catheter
to reduce the risk of pneumonia in a patient who just returned from surgery for a repair of a fractured hip, a priority nursing intervention is: A. to have the patient rise slowly from a lying position B. to have the patient cough and deep breathe every 1-2 hours C. to get a pneumonia vaccine D. to ambulate the patient every 1-2 hours
B. to have the patient cough and deep breathe every 1-2 hours
A nurse is planning on increasing protein for a patient whose wound has not healed. the nurse recognizes that the amount of protein intake needed for wound healing is: A. 1.25-1.5 Grams/pound/day B. 1.5-2.5 grams/kg/day C. 1.25-1.5 grams/kg/day D. 1.5-2.5 grams/pound/day
C. 1.25-1.5 grams/kg/day
A nurse on a medical unit is assessing four clients for urinary retention. Which of the following clients have manifestations of urinary retention A. A client who has an elevated BUN B. A client who reports painful urination C. A client who reports urinary frequency D A client who has glucose in his urine
C. A client who reports urinary frequency
A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately? A. An adolescent female client who is belligerent and has slurred speech B. A toddler who has a laceration on his forehead and is screaming C. A middle adult male who is diaphoretic and reports epigastric pain D. A young adult with a painful sunburn of his face and arms
C. A middle adult male who is diaphoretic and reports epigastric pain
A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first? A. A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min B. A toddler who has otitis media, a temperature of 39.2° C (102.6° F), and purulent ear discharge C. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough D. An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication
C. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough
A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first? A. Check the client's vital signs. B. Assess the client's pain level. C. Cover the wound with a moist, sterile gauze dressing. D. Obtain a culture and sensitivity of the wound drainage.
C. Cover the wound with a moist, sterile gauze dressing.
Which of the following is a physiological outcome of immobility: A. Decreased cardiac workload B. Decreased oxygen demand C. Decreased lung expansion D. Increased pain
C. Decreased lung expansion
The nurse is teaching about goals of Health people 2030. which of the following goals should the nurse include in the teaching session? A. eliminate healthy behaviors in America B. eliminate quality of life in vulnerable populations C. eliminate health disparities in America D. Eliminate all health problems in America
C. Eliminate health disparities in America
The nurse is choosing a method to assess the level of pain a 2 year old has following surgery. Which is the best method to use? A. Numeric pain scale B. Check to see what the parents think the child's pain level is C. FACES scale D. Chart the child has no pain since they didn't have pain on the previous shift
C. FACES scale
A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds? A. Abrasion B. Contusion C. Laceration D. Puncture
C. Laceration
A nurse is assessing a client who has a puncture wound on his foot. Which of the following findings is a manifestation of acute osteomyelitis? A. Numbness of toes on the affected foot B. Hypothermia C. Localized erythema D. Bradycardia
C. Localized erythema
The nurse is caring for a postoperative patient who is receiving patient-controlled analgesia (PCA). Which concept about controlling pain is most important for the nurse to convey to the patient? A. A basal dose will deliver a basic dose of analgesic periodically. B. Excessive doses are locked out if a triggered dose is premature. C. Pain medication should be administered before the pain becomes intense. D. An extra dose of medication is delivered whenever the trigger is compressed.
C. Pain medication should be administered before the pain becomes intense.
The nurse is performing an irrigation of a colostomy. During the instillation of the irrigant solution, the client begins to complain of abdominal cramping. What is the appropriate nursing action? A. Notify the physician immediately B. Increase the height of the irrigation C. Stop the irrigation temporarily D. medicate for pain and resume irrigation
C. Stop the irrigation temporarily
A nurse is receiving shift report about a group of assigned clients. Which of the following actions should the nurse plan to take first? A. Ask the provider about advancing a client's diet. B. Reinsert an intravenous catheter that was removed due to infiltration. C. Suction the tracheostomy of a client who has copious secretions. D. Check the laboratory findings of a preoperative client scheduled for surgery later in the shift.
C. Suction the tracheostomy of a client who has copious secretions.
A client had abdominal surgery for drainage of a large abscess. The wound margins have not been approximated and are being irrigated and packed every 6 hours. The surgeon plans to surgically close this wound in 2 weeks. This wound will heal by which type on intention? A. Primary B. Partial- thickness C. Tertiary D. Skin-grafting
C. Tertiary
A nurse working in a surgical unit reviews the wound healing process and the types of healing. Which of the following defines primary intention healing? A. Involves minimal tissue loss with wound edges that are well-approximated. B. wound only affects the dermis and epidermis. No scars are formed. C. Two surfaces of granulation tissue are brought together by suturing D. The wound is left open and it heals from the inner layer to the surface
C. Two surfaces of granulation tissue are brought together by suturing
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take? A. Wear an N95 respirator mask. B. Wear sterile gloves. C. Wear clean gloves. D. Wear protective eyewear.
C. Wear clean gloves.
A nurse is planning a lesson for primary prevention of health promotion for a group of healthy individuals at a work place. the lesson should indicate: A. early detection of diabetes with blood glucose testing B. referral to support groups C. nutrition and fitness activities D. screening for communicable diseases
C. nutrition and fitness activities
A nurse has tought a patient about health eating habits. Which learning objective/outcome is more appropriate for the affective domain? he patient will: A. State 3 facts about healthy eating B. Identify two food for a healthy snack C. verbalize the value of eating healthy D. Cook a meal with low-fat oil
C. verbalize the value of eating healthy
.A nurse is preparing to exit the room of a client who has methicillin-resistant Staphylococcus aureus (MRSA) in a draining wound. Identify the sequence the nurse should follow before leaving the client's room. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) A. Perform hand hygiene. B. Remove the face mask. C. Remove the gown. D. Remove the gloves. E. Remove the eyewear.
D. E. C. B. A.
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? A. Raise the foot of the bed to a 90° angle. B. Remove the dressing to inspect the wound. C. Prepare to insert a central line. D. Administer oxygen via nasal cannula.
D. Administer oxygen via nasal cannula.
The nurse is assessing a newly diagnosed diabetic, and the client's readiness to learn about glucose monitoring. Before planning teaching activities, which approach would be the most effective? A. Instruct the client about the long-term effects of uncontrolled diabetes B. Provide the client with all the latest research from the internet on glucose monitoring C. Refer the client to the diabetic specialist who can assist the client with the glucometer D. Assist the client in developing realistic short-term goals
D. Assist the client in developing realistic short-term goals
A patient who is learning to deal with their stressor is participating in a method that has the goal to change a pattern of thinking or behavior. This would be considered: A. Meditation B. Time management C. Health education D. Cognitive behavioral therapy
D. Cognitive behavioral therapy
Despite less-restrictive interventions, a patients behavior escalates, requiring emergency application of restraints. Which of the following must the nurse do in this situation? A. Obtain a physicians order before applying restraints. B. Monitor the patients status every 4 hours while restrained. C. Release the restraints and check circulation every hour. D. Continually reevaluate the patients need for restraint.
D. Continually reevaluate the patients need for restraint.
A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, Which of the following actions should the nurse take first? A. Raise the head of the client's bed 15° to 20°. B. Place the client supine with knees bent. C. Assess the client for manifestations of shock. D. Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.
D. Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.
A nurse is planning a lesson for certified nursing assistants on safety in the environment. Which of the following would be identified as an environmental safety hazard in a nursing facility. A. Developmental age B. Motor vehicle accidents C. Impaired mobility D. Improper hand hygiene
D. Improper hand hygiene
A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing? A. One cup of brown rice B. One cup of orange juice C. One cup of pureed avocado D. One cup of lentils
D. One cup of lentils
Which patient with the following ostomy, would the nurse anticipate as having the most formed stool? A. One with a right Ascending colon ostomy B. One witha. transverse colon ostomy C. One with a left descending colon ostomy D. One with a sigmoid colon ostomy
D. One with a sigmoid colon ostomy
Which statement describes referred pain? A. Painful responses to normally innocuous stimuli B. Pain that arises from skin and mucous membranes C. Prolonged pain after the original noxious stimuli ends D. Pain perceived at a different location than noxious stimuli
D. Pain perceived at a different location than noxious stimuli
Which clinical finding will the nurse anticipate for a patient experiencing chronic pain? A. Report of mild pain B. Diaphoresis and pallor C. Pain lasting longer than 6 months D. Periods of increasing and decreasing pain
D. Periods of increasing and decreasing pain
A patient newly diagnosed with diabetes needs to learn how to use a glucometer. Use a glucometer constitutes. A. Affective learning B. Cognitive learning C. Motivational Learning D. Psychomotor learning
D. Psychomotor learning
A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? A. Serous B. Purulent C. Sanguineous D. Serosanguineous
D. Serosanguineous
An elderly client has a foul-smelling, open wound on the right trochanter. Bone is visible in the center of the wound and the remaining tissues are covered with a thick, black-brown substance. Which of the following nursing assessments and treatments is most appropriate? This wound is a: A. Stage 3 pressure ulcer and has wet-to-damp dressings changed 4 times a day B.. Stage 3 pressure ulcer and has a hydrocolloid dressing to be changed every 2 days C. stage 4 pressure ulcer and should be packed with gauze 4X4's and changed PRN. D. Stage 4 pressure ulcer and has wet-to-dry dressing change twice a day.
D. Stage 4 pressure ulcer and has wet-to-dry dressing change twice a day.
A nurse is assessing a client who has a pressure injury. the nurse recognizes which of the following findings is a manifestation of a stage 3 pressure injury A. Wound with exposed bone and tendons B. Reddened intact skin that does not blanch with pressure C. Wound with partial-Thickness skin loss D. Wound extending into the subcutaneous tissue
D. Wound extending into the subcutaneous tissue
An experienced medical-surgical nurse chooses to work in obstetrics. Which level of proficiency is the nurse upon initial transition to the obstetrical floor? a. Novice b. Proficient c. Competent d. Advanced beginner
a. Novice
A nurse assesses a patient's fluid status and decides that the patient needs to drink more fluids. The nurse then encourages the patient to drink more fluids. Which concept is the nurse demonstrating? a. Licensure b. Autonomy c. Certification d. Accountability
b. Autonomy
A nurse has compassion fatigue. What is the nurse experiencing? a. Lateral violence and intrapersonal conflict b. Burnout and secondary traumatic stress c. Short-term grief and single stressor d. Physical and mental exhaustion
b. Burnout and secondary traumatic stress
A nurse is providing home care to a home-bound patient treated with intravenous (IV) therapy and enteral nutrition. What is the home health nurse's primary objective after providing necessary care? a. Screening b. Education c. Dependence d. Counseling
b. Education
A nurse is evaluating care based upon the nursing quality indicators. Which areas should the nurse evaluate? (Select all that apply.) a. Patient satisfaction level b. Hospital readmission rates c. Nursing hours per patient day d. Patient falls/falls with injuries e. Value stream analysis for quality
b. Hospital readmission rates c. Nursing hours per patient day d. Patient falls/falls with injuries
A nurse prepares the budget and policies for an intensive care unit. Which role is the nurse implementing? a. Educator b. Manager c. Advocate d. Caregiver
b. Manager
A nurse provides immunization to children and adults through the public health department. Which type of health care is the nurse providing? a. Primary care b. Preventive care c. Restorative care d. Continuing care
b. Preventive care
A patient is scheduled for surgery. When getting ready to obtain the informed consent, the patient tells the nurse, I have no idea what is going to happen. I couldn't ask any questions.‖ The nurse does not allow the patient to sign the permit and notifies the health care provider of the situation. Which role is the nurse displaying? a. Manager b. Patient educator c. Patient advocate d. Clinical nurse specialist
c. Patient advocate
The nurse prescribes strategies and alternatives to attain expected outcome. Which standard of nursing practice is the nurse following? a. Assessment b. Diagnosis c. Planning d. Implementation
c. Planning
A nurse is caring for a patient in the hospital. When should the nurse begin discharge planning? a. When the patient is ready. b. Close to the time of discharge. c. Upon admission to the hospital. d. After an order is written/prescribed.
c. Upon admission to the hospital.
A nurse working in a community hospital's emergency department provides care to a patient having chest pain. Which level of care is the nurse providing? a. Continuing care b. Restorative care c. Preventive care d. Tertiary care
d. Tertiary care
Toddler question Correct answer: Prevent injury in the hospital setting
question was like... a toddler is running around the hospital room, why do we want to distract the patient? or something like that.
If your patient has a pain rating of 8/10, what do you think we should treat the pain with first? ★ Massage? ★ Heat/cold? ★ NSAID / salicylates? ★ Opioid? ★ Acupuncture?
★ Opioid! Or opioid combination.
