Exam 1 Review

A health care provider prescribes aspirin 650 mg every 4 hours PO when febrile. For which patient will this order be appropriate? A. A 62 year old with a high fever from an infection B. A 21 year old with a sprained ankle C. A 7 year old with a bleeding disorder D. A 35 year old with a severe headache from hypertension

A

A nurse is caring for a frail older adult client with chronic obstructive pulmonary disease (COPD). The client always remains in a sitting position to help him breathe more easily. Based on the understanding that prolonged sitting may put pressure on bony prominences, the nurse frequently assesses which area of this client? A. Sacrum B. Elbows C. Heels D. Back of the skull

A

A nurse is preparing a client for an invasive diagnostic procedure of the urinary system. What statement by the nurse would help reduce the client's anxiety? A. "Let me explain to you what they do during this procedure." B. "Why are you so worried? Do you think you have a tumor?" C. "I have had this done to me, and it only hurt for a little while." D. "We do these procedures everyday so you don't need to worry."

A

A young adult woman has had orthopedic surgery on her right knee. The first time she gets out of bed, she describes weakness, dizziness, and feeling faint. The nurse correctly recognizes that which condition is likely affecting the client? A. Orthostatic hypotension B. Anemia C. Thrombophlebitis D. Bradycardia

A

A young woman comes to the emergency department with severe abdominal cramping and frequent bloody stools. Food poisoning is suspected. What diagnostic test would be used to confirm this diagnosis? A. Stool Sample B. Routine urinalysis C. Sputum sample D. Chest xray

A

The client suffered cardiac arrest, was resuscitated, and has now been on a ventilator for several days. The client had a written advance directive, which the spouse brought from home. The primary care provider (PCP) is encouraging the spouse to consent for placement of a percutaneous endoscopic gastrostomy (PEG) tube, which is contrary to the client's advance directive. After the PCP leaves, the spouse states, "I wish I knew what my spouse wanted." What is the best reply by the nurse? A. "The spouse did tell you in the advance directive." B. "Your spouse will live with the PEG tube but die without it." C. "You will now have to make the decision." D. "The PCP only wants what is best for your spouse."

A

The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for developing an infection? A. A patient who is recovering from a right total hip surgery. B. A patient who is in observation for chest pain. C. A patient who has been admitted for stabilization of heart problems. D. A patient who has been admitted with dehydration.

A

The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse expect to be increased after collaboration with the dietitian? A. Protein B. Vitamin E C. Fat D. Carbohydrate

A

The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5 degrees F and the WBCs are 10,500/mm3. Which action should the nurse take first? A. Utilize SBAR to notify the primary health care provider. B. Reevaluate the temperature and white blood cell count in 4 hours. C. Check to see what solution was used for skin preparation in surgery. D. Plan to change the surgical dressing during the shift.

A

When transferring a client from bed to a stretcher, the nurses working together turn the client to position a transfer board partially underneath the client. What is the rationale for using a transfer board in this procedure? A. To reduce friction as the client is pulled laterally onto the stretcher B. To protect the client's head from hitting the headboard C. To lift the client off the bed D.To slide the board with the client onto the stretcher

A

Which action indicates a nurse is using critical thinking for implementation of nursing care to patients? A. Determines whether an intervention is correct and appropriate for the given situation. B. Establishes goals for a particular patient without assessment. C. Evaluates the effectiveness of interventions. D. Reads over the steps and performs a procedure despite lack of clinical competency.

A

The patient and the nurse are discussing the vector transmitted Rickettsia rickettsii—Rocky Mountain spotted fever. Which patient statement to the nurse indicates understanding regarding the mode of transmission for this disease? A. "When camping, I will wear insect repellent." B. "When camping, I will drink bottled water." C. "When camping, I will use sunscreen." D. "When camping, I will wash my hands with hand gel."

A.

The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group about the most important thing to do to prevent the spread of infection. Which information did the nurse share with the preschool workers? A. Wash their hands between each interaction with children. B. Suggest that parents provide a multivitamin to the children. C. Clean the toys every afternoon before putting them away. D. Encourage preschool children to eat a nutritious diet.

A.

A patient who recently had a central line inserted asks if there any risks to receiving parenteral nutrition. The RN understands that the use of parenteral nutrition is MOST likely associated with: A. Sepsis B. Gastritis C. Megacolon D. Aspiration

A.

A 68 year old female who has experienced a Cerebral Vascular Accident (CVA) has left-sided paralysis and slurred speech. The patient has been evaluated by speech therapy and has the ability to swallow. What type of diet would be the BEST choice for this patient? A. Clear liquid diet B. Mechanical soft diet C. Full liquid diet D. Low residue diet

B

A group of nurse researchers has proposed a study to examine the efficacy of a new wound care product. Which aspect of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence? A. The nurses have given multiple opportunities for potential participants to ask questions, and have been following the informed consent process systematically B. The nurses are taking every reasonable measure to ensure that no participants experience impaired wound healing as a result of the study intervention C. The nurses have completed a literature review that suggests that the new treatment may result in decreased wound healing time D. The nurses have organized the study in such a way that the foreseeable risks and benefits are distributed as fairly as possible.

B

A male client who has had outpatient surgery is unable to void while lying supine. What can the nurse do to facilitate his voiding? A. Pour cold water over his genitalia B. Assist him to a standing position C. Tell him he has to void to be discharged D. Ask his wife to assist with the urinal

B

A nurse is carrying out an order to remove an indwelling catheter. What is the FIRST step of this skill? A. Tell the client burning may initially occur B. Wash hands and put on gloves C. Ask the client to take several deep breaths D. Deflate the balloon by aspirating the fluid

B

A nurse is preparing to provide hygiene care. Which principle should the nurse consider when planning hygiene care? A. During hygiene care do not take the time to learn about patient needs B. No two individuals perform hygiene in the same manner. C. It is important to standardize a patient's hygienic practices. D. Hygiene care is always routine and expected

B

A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens? A. Appropriate use of gloves B. Effective hand hygiene C. When eye protection is needed D. Saline wound irrigation

B

A nurse is using professional standards to influence clinical decisions. What is the rationale for the nurse's actions? A. Establishes minimal passing standards for testing. B. Uses critical thinking for the highest level of quality nursing care. C. Bypasses the patient's feelings to promote ethical standards. D. Utilizes evidence-based practice based on nurses' needs.

B

A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? A. Discuss the surgical procedure and reason for the pain. B. Explore other options for pain relief. C. Explain to the patient that nothing else has been ordered. D. Offer to notify the health care provider after morning rounds are completed.

B

A patient in your ambulatory care setting has decided to uphold a strict vegetarian diet. Which of the following statements would best educate the vegetarian patient? A. 400 grams of carbohydrates are needed daily to prevent ketosis B. Protein is required for all body structures and needs constant replacement C. All essential nutrients can be obtained by taking vitamin and mineral supplements D. Carbohydrates and fats both hold 4 calories per gram

B

The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer? A. Stage IV B. Stage II C. Stage I D. Stage III

B

The nurse closely monitors an older adult for signs of medication toxicity. Which physiological change is the reason for the nurse's action? A. Increased liver mass B. Reduced kidney functioning C. Increased gastric motility D. Reduced esophageal stricture

B

The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first? A. Avoid accidentally removing the drain B. Provide analgesic medications as ordered. C. Don sterile gloves. D. Gather supplies.

B

The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient's health care needs? A. The water comes from the county water supply B. The electricity was turned off 3 days ago C. A son and family recently moved into the home. D. This home is not furnished with a microwave oven.

B

The nurse is gathering data on a patient. Which data will the nurse report as objective data? A. Nauseated. B. Respirations 16 C. States "doesn't feel good." D. Reports a headache.

B

The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise? A. Collaborative problem B. Etiology C. Defining characteristic D. Nursing diagnosis

B

The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing? A. Risk factor prevention B. Primary prevention C. Secondary prevention D. Tertiary prevention

B

The patient's son requests to view documentation in the medical record. What is the nurse's best response to this request? A. "I'll be happy to get that for you." B. "You will need your mother's permission." C. "I cannot let you see the chart without a doctor's order." D. "You are not allowed to look at it."

B

What are two essential techniques when collecting a stool specimen? A. Following policies and selecting containers B. Hand hygiene and wearing gloves C. Using a no-touch method and toilet paper D. Wearing goggles and an isolation gown

B

While performing range-of-motion exercises on a client, a nurse bends a client's foot so that the toes are brought up, as though to point them at the knee. What is the term for this type of movement? A. Inversion B. Dorsiflexion C. Plantar Flexion D. Rotation

B

A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess? A. Cultural background B. Socioeconomic factors C. Perception of functioning D. Family practices

C

A nurse is caring for a client who is a practicing Jehovah's Witness. The physician orders two units of packed cells based on his low hemoglobin and hematocrit levels. The nurse states to the surgeon that it is unethical to go against the client's beliefs even though his blood counts are very low. What is the best description of the nurse's intentions? A. being legally responsible B. siding with the client over the surgeon C. acting in the client's best interest D. observing institutional policies

C

A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development? A. Shortness of breath B. Adequate dietary intake C. Decreased level of consciousness D. Muscular pain

C

A staff development nurse is discussing techniques to prevent back injury with a group of nurse aides. The nurse informs the group that back stress and injury can be prevented by: A. Using the strength of the back muscles during strenuous activities B. Pulling equipment, rather than pushing it, when possible C. Spreading the feet shoulder width apart to broaden the base of support D. Holding the object that you are lifting/moving away from the body

C

A woman age 83 years who has suffered a cerebrovascular accident and is unable to swallow refuses the insertion of a feeding tube. This is an example of what ethical principle? A. Veracity B. Justice C. Autonomy D. Nonmaleficence

C

The MOST likely associated risk with the use of enteral nutrition is: A. Leukopenia B. Phlebitis C. Aspiration D. Gastric emptying

C

The nurse is admitting a patient with an infectious disease process. Which question will be most appropriate for a nurse to ask about the patient's susceptibility to this infectious process? A. "Do you have any children living in the home?" B. "Do you have any religious beliefs that will influence your care?" C. "Do you have a chronic disease?" D. "Do you have a spouse?"

C

The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood glucose levels. During the admission process, the nurse asks the patient about employment status and displays a nonjudgmental attitude. What is the rationale for the nurse's actions? A. Employment status is an internal variable that impacts compliance B. External variables have little effect on compliance C. A person's compliance is affected by economic status. D. Noncompliant patients thrive on the disapproval of authority figures.

C

The nurse is caring for a group of patients. Which patient will the nurse see first? A. A patient with a Stage IV pressure ulcer B. A patient with a Braden Scale score of 18 C. A patient with appendicitis using a heating pad D. A patient with an incision that is approximated

C

The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says "I always bathe in the evening." Which action by the nurse is best? A. Explain the importance of maintaining morning hygiene practices. B. Cancel hygiene for the day and attempt again in the morning. C. Defer the bath until evening and pass on the information to the next shift. D. Tell the patient that daily morning baths are the "normal" routine.

C

The nurse is preparing to administer an injection into the deltoid muscle of an adult patient weighing approximately 160 lb. Which needle size and length will the nurse choose? A. 27 gauge × 5/8 inch B. 18 gauge × 1 1/2 inch C. 25 gauge × 1 inch D. 23 gauge × 1/2 inch

C

The patient is to receive phenytoin at 0900. When will be the ideal time for the nurse to schedule a trough level? A. 0900 B. 0800 C. 0830 D. 0930

C

Which nursing observation will indicate the patient is at risk for pressure ulcer formation? A. Capillary refill is less than 2 seconds B. Ate two thirds of breakfast C.Fecal incontinence D. A raised red rash on the right shin

C

Which patient scenario of a surgical patient in pain is most indicative of critical thinking? A. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed B. Administering pain-relief medication according to what was given last shift C. Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past D. Offering pain-relief medication based on the health care provider's orders

C

A nurse is teaching a patient about medications. Which statement from the patient indicates teaching is effective? A. "My parenteral medication must be taken with food." B. "If I am 30 minutes late taking my medication, I should skip that dose." C. "I will rotate the sites in my left leg when I give my insulin." D. "Once I start feeling better, I will stop taking my antibiotic."

C.

A client is on bedrest, and an enema has been ordered. In what position should the nurse position the client? A. Fowler's B. Sitting C. Prone D. Sims'

D

A client is questioning the need for surgery. The client asks the nurse, "What should I do?" What answer by the nurse is based on advocacy? A. "Let me talk to your doctor and I will let you know what is said." B. "You should ask some of the more experienced nurses this question." C. "If I were you, I would not have this surgical procedure." D. "Tell me what reason you do not want the surgery."

D

A nurse is assessing a patient's skin. Which patient is most at risk for impaired skin integrity? A. A patient with strong pedal pulses B. A patient who is afebrile C. A patient with adequate skin turgor D. A patient who is diaphoretic

D

A registered nurse interprets that a scribbled medication prescription reads 25 mg. The nurse administers 25 mg of the medication to a patient and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error? A. Hospital B. Pharmacist C. Health care provider D. Nurse

D

The nurse and a new nurse in orientation are caring for a patient with pneumonia. Which statement by the new nurse will indicate a correct understanding of this condition? A. "Clinical signs and symptoms are not present in pneumonia." B. "We need to isolate the patient in a private negative-pressure room." C. "The patient will not be able to return home." D. "An infectious disease like pneumonia may not pose a risk to others.

D

The nurse cares for a newly admitted client who will soon need to be taken to the radiology department for a CT scan. The client has a Body Mass Index (BMI) of 52. Which of the following strategies to transport the client is most appropriate? A.Enlist the aid of two other staff members and pull the client across the bed and onto a stretcher B. Position a friction-reducing sheet under the client before attempting the transfer C. Transport the client to the radiology department in the hospital bed D. Obtain a mechanical lateral transfer device to move the client onto the stretcher

D

The nurse has become aware of missing narcotics in the patient care area. Which ethical principle obligates the nurse to report the missing medications? A. Advocacy B. Accountability C. Confidentiality D. Responsibility

D

The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take? A. Asking the nursing assistive personnel if the wound looks better B. Leaving the dressing off the wound for easier access and more frequent assessments C. Documenting the progress of wound healing as "better" in the chart D. Measuring the wound and observe for redness, swelling, or drainage

D

The nurse is caring for a patient whose plan of care states that a change of dressing is to occur twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse's next action? A. Discontinue the plan of care for wound care. B. Wait and change the dressing at 1800 as ordered. C. Reassess the dressing and the wound in 2 hours D. Revise the plan of care and change the dressing now.

D

What is an appropriate intervention for the patient who is experiencing a loss of appetite? A. Have the patient sit in a semi-fowler's position for meals B. Educate the patient to avoid processed foods, as they may lack nutritive value C. Administer Zofran 500 mg every 6 hours prn for appetite loss per the prescriber's order D. Offer appealing food in small portions

D

When the nurse discovers a patient on the floor, the patient states, "I fell out of bed". The nurse assesses the patient and then places the patient back in bed. Which action should the nurse take next? A. Re-assess the patient. B. Complete an incident report. C. Do nothing, no harm has occurred. D. Notify the health care provider.

D

Which action by the nurse indicates a safe and efficient use of social networks? A. Vents about a patient problem at work. B. Friends a patient. C. Posts a picture of a patient's infected foot. D. Promotes support for a local health charity.

D

Which action should the nurse take to best develop critical thinking skills? A. Study 3 hours more each night. B. Attend all in-service opportunities. C. Interview staff nurses about their nursing experiences. D. Actively participate in clinical experiences.

D

Which action should the nurse take when using critical thinking to make clinical decisions? A. Makes decisions based on intuition. B. Reads and follows the heath care provider's orders. C. Accepts one established way to provide care. D. Considers what is important in any given situation.

D

Which information concerning a goal indicates a nurse has a good understanding of its purpose? A. It is a realistic statement predicting any negative responses to treatments. B. It is a statement describing the patient's accomplishments without a time restriction. C. It is a measurable change in a patient's physical state. D. It is a broad statement describing a desired change in a patient's behavior.

D

Which of the following modes of value transmission is most likely to lead to confusion and conflict? A. Modeling B. Responsible choice C. Moralizing D. Laissez-faire

D