final exam practice questions

PHYSIOLOGICAL RESPONSES FOR TEMPERATURE

1. Disease or trauma of the hypothalamus or spinal cord will alter temperature control.2. Hypothalamus also receives messages from cold and warm thermal receptors located throughout body.

pyrexia

-temperature above normal (fever)- aka febrile=fever- 100.4-104.0 0F- 38-41 0C

A patient from a specific cultural group wears a talisman to ward off evil spirits. The nurse recognizes this as an example of: A. A belief in biomedical treatment B. A cultural healing practice C. A psychological coping mechanism D. A religious affiliation practice

Answer: B. A cultural healing practice Rationale: Wearing talismans or other objects to ward off evil spirits is an example of a cultural healing practice. This practice is common in many traditional cultures and is considered part of the cultural approach to maintaining health. The other options do not specifically address cultural healing practices related to spiritual beliefs.

A 55-year-old male patient expresses concern about erectile dysfunction following a diagnosis of diabetes. What is the most appropriate nursing response? A) "Erectile dysfunction is common with diabetes and may be treated." B) "It is unlikely that your diabetes is causing this problem." C) "You should focus on managing your blood sugar rather than this issue." D) "You should accept this as a normal part of aging."

Answer: A) "Erectile dysfunction is common with diabetes and may be treated."Rationale: Diabetes can damage blood vessels and nerves, leading to erectile dysfunction. Offering reassurance and discussing potential treatments demonstrates patient-centered care.

A nurse accidentally administers the wrong medication to a patient, but no harm occurs. What is the nurse's best legal and ethical course of action? A) Document the error and report it to the nurse manager. B) Do nothing since the patient was not harmed. C) Complete an incident report but avoid documenting in the patient's chart. D) Monitor the patient closely without reporting the error.

Answer: A) Document the error and report it to the nurse manager.Rationale: The nurse is legally and ethically required to report medication errors, even if no harm occurred. This promotes transparency, helps prevent future errors, and is in line with the ethical principle of veracity (truth-telling).

A nurse is assessing a patient with newly diagnosed Type 1 diabetes. Which of the following symptoms would be most consistent with this diagnosis? A. Increased thirst and frequent urination B. Gradual weight gain and increased appetite C. Blurred vision and slow wound healing D. Elevated blood pressure and nausea

Answer: A. Increased thirst and frequent urination Rationale: These symptoms are typical of Type 1 diabetes due to the body's inability to use glucose properly.

Which of the following describes medical asepsis? A. Procedures that keep areas free of pathogens. B. Practices designed to reduce the number and spread of microorganisms. C. Procedures to sterilize equipment and surgical tools. D. Isolation procedures in sterile settings.

Answer: B Rationale: Medical asepsis refers to practices designed to reduce the number and spread of microorganisms ("clean" technique), whereas surgical asepsis (sterile technique) keeps areas free from pathogens (A).

A 60-year-old patient is admitted to the hospital with complaints of increasing shortness of breath over the past week. The patient has a history of chronic obstructive pulmonary disease (COPD) and hypertension. During the physical assessment, the nurse notes the following findings: use of accessory muscles during breathing, decreased breath sounds in the lower lung fields, and an oxygen saturation level of 88%. Based on these findings, which of the following is the most appropriate initial action by the nurse?A) Schedule a chest X-ray to further investigate lung pathology.B) Administer a dose of the patient's prescribed bronchodilator.C) Increase the patient's supplemental oxygen to 6 liters per minute.D) Obtain a detailed health history from the patient's family about COPD management

Answer: B) Administer a dose of the patient's prescribed bronchodilator. Rationale: The patient's symptoms of shortness of breath, use of accessory muscles, decreased breath sounds, and low oxygen saturation suggest that the COPD may be exacerbated. The most appropriate initial action is to administer the prescribed bronchodilator (Option B). Bronchodilators help to open the airways and improve breathing, which can quickly address symptoms of airway obstruction and improve oxygenation. Option A (Schedule a chest X-ray) is a valid action but is not the immediate priority. A chest X-ray is useful for further diagnosing the underlying cause but does not address the acute symptoms. Option C (Increase the patient's supplemental oxygen) could be considered, but simply increasing oxygen may not address the underlying cause of the shortness of breath, which is likely related toairway obstruction. Option D (Obtain a detailed health history from the family) is important for comprehensive care but is not the immediate action needed to address the current acute symptoms of the patient.

A patient asks the nurse if certain medications can affect sexual function. Which class of drugs is most likely to cause sexual dysfunction? A) Antibiotics. B) Antihypertensives. C) Antacids. D) Anticoagulants.

Answer: B) Antihypertensives.Rationale: Antihypertensive medications, such as beta-blockers and diuretics, can cause sexual dysfunction by affecting blood flow and nerve function.

A nurse is performing a physical assessment on a 72-year-old patient who has just been admitted for worsening confusion and weakness. The patient's vital signs are stable, but the nurse notes that the patient has a pressure ulcer on the sacral area. Which of the following is the most appropriate initial nursing action? A) Consult the wound care specialist for an evaluation.B) Assess the patient's nutritional status and hydration levels.C) Administer prescribed pain medication for comfort.D) Document the presence and characteristics of the pressure ulcer.

Answer: B) Assess the patient's nutritional status and hydration levels. Rationale: Pressure ulcers often result from poor nutrition and dehydration, which can impair skin integrity and healing. Assessing the patient's nutritional and hydration status is crucial for addressing the root causes of pressure ulcer formation. While documenting the ulcer (Option D) and consulting a specialist (Option A) are important, they are not the immediate actions that address potential underlying issues affecting the patient's skin.

During a health history interview, a patient reports experiencing chronic pain but expresses reluctance to take prescribed opioids. What should the nurse do next?A) Document the patient's refusal and proceed with pain management alternatives.B) Educate the patient on the benefits and risks of opioid therapy.C) Report the patient's reluctance to the healthcare provider immediately.D) Suggest alternative non-opioid pain medications without further discussion.

Answer: B) Educate the patient on the benefits and risks of opioid therapy. Rationale: Educating the patient about the benefits and risks of opioid therapy helps them make an informed decision about their pain management. Documenting the patient's concerns (Option A) and suggesting alternatives (Option D) are also important but should follow a thorough discussion of the medication options. Reporting to the healthcare provider (Option C) may be necessary but should not replace patient education

A nurse is providing discharge education to a patient who has undergone a prostatectomy. The patient expresses concerns about sexual functioning post-surgery. What is the most appropriate nursing intervention? A) Inform the patient that sexual function will not return. B) Reassure the patient that sexual function may return over time and refer to a specialist if needed. C) Suggest the patient refrain from sexual activity indefinitely. D) Provide no information since this is a normal consequence of the surgery.

Answer: B) Reassure the patient that sexual function may return over time and refer to a specialist if needed.Rationale: Many men experience temporary sexual dysfunction following prostate surgery. Reassuring the patient and offering referrals to specialists can help address concerns and promote recovery.

A female patient reports discomfort during sexual activity. The nurse identifies that the patient is experiencing dyspareunia. Which intervention is most appropriate for the nurse to recommend? A) Avoid sexual activity altogether. B) Use of a water-based lubricant. C) Doubling up on contraceptives. D) Taking an antihistamine before sexual activity.

Answer: B) Use of a water-based lubricant.Rationale: Dyspareunia, or painful intercourse, can often be alleviated by using a water-based lubricant to reduce friction and discomfort during sexual activity.

A nurse is positioning a patient in Fowler's position. Which of the following interventions should the nurse include to prevent flexion contracture of the neck? A. Use a soft, large pillow under the head B. Allow the head to rest against the mattress or support with a small pillow C. Elevate the knees to prevent pressure on the lower legs D. Use a hand-wrist splint to prevent contractures

Answer: B. Allow the head to rest against the mattress or support with a small pillowRationale: In Fowler's position, to prevent flexion contracture of the neck, the head should either rest directly on the mattress or be supported with a small pillow to maintain proper alignment. Using a soft, large pillow can lead to neck flexion.

A patient with hand weakness is being fitted with a cane. Which type of cane should the nurse recommend? A. Single-ended cane with a half-circle handle B. Single-ended cane with a straight handle C. Tripod cane D. Quad cane

Answer: B. Single-ended cane with a straight handleRationale: A single-ended cane with a straight handle is recommended for patients with hand weakness, as the handgrip is easier to hold. It is not recommended for patients with poor balance, but it provides support for those with hand weakness.

A patient is placed in the lateral position. Which of the following actions should the nurse take to prevent internal rotation of the femur? A. Flex the lower arm and position comfortably B. Use a pillow to support the leg from the groin to the foot C. Align the shoulders with the hips D. Place a small pillow under the head and neck

Answer: B. Use a pillow to support the leg from the groin to the footRationale: Supporting the leg from the groin to the foot with a pillow helps prevent internal rotation and adduction of the femur, which is a common risk in the lateral position.

1. A nurse is caring for a patient who refuses life-saving treatment due to religious beliefs. Which ethical principle is the nurse demonstrating by respecting the patient's decision? A) Beneficence. B) Justice. C) Autonomy. D) Nonmaleficence.

Answer: C) Autonomy.Rationale: Autonomy refers to respecting a patient's right to make their own healthcare decisions. In this case, the nurse is respecting the patient's choice to refuse treatment, even if it results in harm, in accordance with their religious beliefs.

A nurse promises to return with pain medication but forgets to do so. Which ethical principle is the nurse violating? A) Beneficence. B) Justice. C) Fidelity. D) Veracity.

Answer: C) Fidelity.Rationale: Fidelity refers to keeping promises and commitments. By failing to return with the pain medication as promised, the nurse is not upholding fidelity.

A nurse is taking the blood pressure of a hypertensive patient and notices a temporary disappearance of sounds between the first tapping sound and the muffled, swishing sounds. This phenomenon is known as: A. Pulse pressure B. Korotkoff gap C. Auscultatory gap D. Diastolic pressure

Answer: C. Auscultatory gapRationale: The auscultatory gap is the temporary disappearance of Korotkoff sounds between phases I and II, which is common in hypertensive patients. If unrecognized, it can lead to underestimation of systolic pressure or overestimation of diastolic pressure.

A patient's dietary history reveals a high intake of saturated fats. What health condition is this patient at increased risk for? A. Diabetes mellitus B. Hypertension C. Cardiovascular disease D. Osteoporosis

Answer: C. Cardiovascular disease Rationale: High intake of saturated fats increases the risk of cardiovascular disease by contributing to high cholesterol levels.

The nurse is assessing a patient's temperature and obtains a reading of 38.4°C (101.1°F) orally. Which nursing action is most appropriate? a) Recheck the temperature rectally to confirm accuracy b) Administer antipyretic medication as ordered c) Encourage the patient to drink cold water d) Apply warm blankets to prevent shivering

Answer: b) Administer antipyretic medication as ordered Rationale: A temperature of 38.4°C indicates a fever. Administering an antipyretic (e.g., acetaminophen) is an appropriate intervention to reduce the fever. Rechecking the temperature rectally is unnecessary since oral readings are reliable, and cold water is not the primary intervention for fever.

A nurse assesses a patient who has a respiratory rate of 28 breaths per minute. What is the most appropriate initial nursing intervention? a) Notify the healthcare provider immediately b) Encourage the patient to use pursed-lip breathing c) Administer a bronchodilator as prescribed d) Position the patient in the supine position

Answer: b) Encourage the patient to use pursed-lip breathing Rationale: Pursed-lip breathing helps slow down the breathing rate and improves gas exchange. Notifying the healthcare provider and administering medication can be done after initial nursing interventions. The supine position can worsen respiratory distress; instead, elevate the head of the bed.

The nurse is teaching a patient about factors affecting oxygen saturation. Which of the following statements by the patient indicates a need for further teaching? a) "Smoking can reduce my oxygen levels." b) "I should avoid walking for too long at high altitudes." c) "Anemia may give me a falsely high oxygen reading." d) "I should report oxygen levels below 95% to my doctor."

Answer: c) "Anemia may give me a falsely high oxygen reading." Rationale: Anemia typically causes a falsely low oxygen saturation reading due to the reduced hemoglobin available to carry oxygen. This statement indicates the need for further clarification regarding anemia and its effects on SpO2 readings.

A nurse is working with a patient to find mutually acceptable treatment options that fit the patient's cultural beliefs. Which part of the ETHNIC model does this action represent? A. Explanation B. Negotiate C. Collaboration D. Intervention

B. Negotiate Rationale: "Negotiate" in the ETHNIC model refers to working with the patient to find mutually acceptable treatment options that respect the patient's cultural beliefs. The other options represent different stages of the model but do not specifically involve finding mutually acceptable options.

Which of the following health problems is most commonly associated with Native American and Alaska Native populations?A. ThalassemiaB. Breast cancerC. Fetal alcohol syndromeD. Tay-Sachs disease

C. Fetal alcohol syndrome Rationale: Fetal alcohol syndrome is a common health issue among Native American and Alaska Native populations. Thalassemia is more common in Asian populations, breast cancer in White populations, and Tay-Sachs disease in Eastern European Jewish populations.

The nurse observes that Mr. Gargan is experiencing difficulty sleeping. Which intervention should the nurse implement first? A) Administer a sedative to help him sleep. B) Use relaxation techniques and guided imagery to promote sleep. C) Increase his physical activity during the day. D) Check for any physical discomfort that may be affecting sleep.

Correct Answer: D) Check for any physical discomfort that may be affecting sleep. Rationale: Before implementing other interventions, the nurse should assess for any physical discomfort or other factors that may contribute to sleep disturbances, as addressing these issues is crucial for effective care.

Mr. Gargan states he is scared about what to expect after death. Which of the following responses by the nurse would be most therapeutic? A) "You shouldn't worry about death; focus on getting better." B) "Many people experience similar fears. It's a normal reaction. "C) "There's nothing to fear; just think positively. "D) "Let's talk about your health instead."

Correct Answer: B) "Many people experience similar fears. It's a normal reaction." Rationale: Acknowledging that many people have similar fears normalizes Mr. Gargan's feelings, providing emotional support and reassurance that his concerns are valid.

When caring for a patient who practices Judaism, which of the following nursing actions is essential to respect the patient's beliefs? A) Schedule all treatments on the Sabbath to avoid delays in care .B) Provide kosher meals in accordance with dietary laws. C) Encourage the patient to participate in non-Jewish religious practices. D) Disregard the patient's need for religious accommodations.

Correct Answer: B) Provide kosher meals in accordance with dietary laws. Rationale: Observant Jewish patients have specific dietary requirements, including the consumption of kosher food. It is essential for the nurse to respect these dietary restrictions and accommodate the patient's religious practices, especially regarding food.

Which of the following best describes the difference between spirituality and religion? A) Spirituality is formal, while religion is personal. B) Spirituality includes religious beliefs but is broader in scope. C) Religion is the search for meaning, while spirituality is adherence to rules. D) Spirituality requires organized practices, while religion does not.

Correct Answer: B) Spirituality includes religious beliefs but is broader in scope. Rationale: Spirituality encompasses personal beliefs and experiences that may include religion but extends beyond formal practices and organized structures.

A nurse is caring for a patient who refuses a blood transfusion due to religious beliefs. Which nursing intervention is most appropriate? A) Convince the patient to accept the transfusion for their health. B) Document the refusal and notify the physician. C) Encourage the patient to discuss their beliefs with the healthcare team. D) Ignore the patient's wishes and proceed with treatment.

Correct Answer: C) Encourage the patient to discuss their beliefs with the healthcare team. Rationale: Encouraging dialogue allows the patient to explain their beliefs, which fosters understanding and respect for their choices. It also helps the healthcare team provide care that aligns with the patient's values.

A nurse is caring for a patient who identifies as an atheist. Which action by the nurse demonstrates respect for the patient's beliefs? A) Encourage the patient to explore spirituality. B) Offer the patient a prayer before the procedure. C) Avoid discussions about spirituality or religion .D) Ask the patient about their personal beliefs regarding life and death.

Correct Answer: D) Ask the patient about their personal beliefs regarding life and death. Rationale: Asking the patient about their beliefs allows the nurse to understand and respect the patient's perspective without imposing spiritual beliefs. It fosters open communication and supports patient-centered care.

what are the surface temperature

Forehead (disposable chemical strip).Armpitoral

A nurse is assessing a patient's cultural background to provide personalized care. What question should the nurse ask to gather relevant cultural information?A. "Do you have a specific dietary preference or restriction?"B. "Why are you using alternative therapies instead of the prescribed treatment?"C. "Do you believe in Western medicine?"D. "Why do you rely on your family for medical decisions?"

Rationale: The correct answer is A. Asking about dietary preferences is a respectful and relevant way to gather information about the patient's culture. B, C, and D are judgmental and could alienate the patient.

A nurse is providing education on diabetes management to a patient from a low socioeconomic background. What should the nurse prioritize in the teaching plan?A. Avoid discussing cost-effective meal options.B. Include culturally relevant, affordable food choices in the plan.C. Focus on high-cost, high-quality foods to manage diabetes.D. Ignore the patient's cultural food preferences.

Rationale: The correct answer is B. Incorporating affordable and culturally relevant food choices into the diabetes management plan promotes adherence to the treatment. A, C, and D are dismissive of the patient's financial and cultural needs.

A nurse is caring for a patient from a cultural background that emphasizes natural remedies. The patient requests to use herbal supplements along with prescribed medications. What is the nurse's best response? A. "Herbal supplements are not safe, so you should only take the prescribed medications. "B. "I will check with the healthcare provider to ensure the supplements won't interact with your medications. "C. "You should stop taking the supplements while you're in the hospital. "D. "Herbal supplements are not effective, and you should trust the prescribed medications."

Rationale: The correct answer is B. The nurse respects the patient's cultural beliefs and collaborates with the healthcare team to ensure safety. Option A disregards the patient's cultural practices, C dismisses the patient's preferences, and D is judgmental and dismissive.

A nurse is caring for a patient from a culture where the family is deeply involved in care decisions. What should the nurse do first to provide culturally competent care?A. Tell the family that only the patient can make healthcare decisions.B. Ask the patient who they would like to involve in their care decisions.C. Assume the patient wants the family involved based on cultural norms.D. Exclude the family from discussions about the patient's care.

Rationale: The correct answer is B. The nurse should first ask the patient who they want involved in care decisions to respect both the patient's autonomy and cultural preferences. A, C, and D disregard patient-centered care principles.

A nurse is preparing to discharge a patient who is part of a close-knit family where males make healthcare decisions. The nurse notices that the patient has not been involved in discussions about their care. What is the most appropriate nursing intervention? A. Educate only the male family members about the discharge plan. B. Include the patient and the family members in the discharge planning .C. Respect the family's cultural practice and avoid discussing care with the patient. D. Discharge the patient without including the family, as the patient is an adult.

Rationale: The correct answer is B. The nurse should respect the cultural practice but also ensure the patient is included in the care discussions. A ignores the patient's autonomy, C does not encourage patient-centered care, and D ignores the family dynamic.

A patient from a culture that emphasizes community decision-making refuses to accept a treatment plan without consulting their family. How should the nurse respond?A. Tell the patient that family involvement is unnecessary.B. Allow the patient to discuss the treatment plan with their family.C. Implement the treatment plan without involving the family.D. Insist that the patient make the decision independently.

Rationale: The correct answer is B. The nurse should respect the patient's cultural practice of involving family in decision-making. A, C, and D do not respect the patient's cultural values and may create conflict or mistrust.

A nurse is working with a Hispanic patient who only speaks Spanish. The nurse does not speak Spanish and needs to explain a complex medical procedure. What is the best course of action? A. Ask a bilingual family member to interpret. B. Use non-verbal communication to explain the procedure. C. Request a professional medical interpreter.D. Use a language translation app to communicate.

Rationale: The correct answer is C. A professional interpreter ensures accuracy, confidentiality, and that the patient fully understands the procedure. Option A could lead to misinterpretation or breaches in confidentiality. B and D are not adequate for explaining complex medical information.

A patient refuses a blood transfusion due to religious beliefs, even though it is needed for a life-saving surgery. What action should the nurse take?A. Administer the blood transfusion as ordered by the physician.B. Call the family to try and persuade the patient to change their decision.C. Respect the patient's decision and provide supportive care.D. Seek a court order to force the patient to receive the transfusion.

Rationale: The correct answer is C. Nurses must respect patients' autonomy and religious beliefs, even when they conflict with medical advice. Forcing treatment (as in A and D) or involving the family to pressure the patient (B) violates the patient's rights.

Which of the following is a barrier to culturally competent nursing care?A. Using an interpreter during patient communication.B. Assisting a patient in making informed decisions about their care.C. Assuming that all patients from the same culture have the same beliefs.D. Including a patient's family in the care process when culturally appropriate.

Rationale: The correct answer is C. Stereotyping patients based on cultural background is a barrier to culturally competent care. A, B, and D are examples of culturally competent practices.

2. The nurse assesses a patient using the Glasgow Coma Scale (GCS) and records a score of 7. What does this score indicate? A) Fully alert and oriented. B) Mild brain injury. C) Moderate brain injury. D) Severe brain injury.

Rationale:A GCS score of 7 indicates a severe brain injury (D). A score of 8 or below reflects a coma or severe neurological impairment.

. A patient receiving anticoagulant therapy has a PT/INR level of 5.5. What is the nurse's priority action? A) Administer the next dose as scheduled. B) Notify the healthcare provider. C) Encourage the patient to eat more leafy greens. D) Administer vitamin K.

Rationale:A PT/INR of 5.5 indicates a risk of bleeding. The nurse should notify the healthcare provider (B) for further instructions.

. A nurse recognizes that patient self-esteem is affected by body image. Which patient is most likely to experience altered self-esteem? A) A patient with a newly diagnosed infection. B) A patient with a recent mastectomy. C) A patient recovering from a mild stroke. D) A patient with a broken arm.

Rationale:A patient with a recent mastectomy (B) may experience altered self-esteem due to changes in body image.

A nurse is caring for a post-operative patient. Which assessment finding would indicate a complication? A) Blood pressure 120/80 mmHg. B) Temperature 101.5°F. C) Heart rate of 80 bpm. D) Pain level of 4/10.

Rationale:A post-operative temperature of 101.5°F (B) may indicate an infection, which is a potential complication.

Which of the following patients is at the highest risk for pressure ulcer development? A) A 22-year-old with a fractured leg. B) A 50-year-old post-stroke patient with limited mobility. C) A 35-year-old with appendicitis. D) A 40-year-old undergoing chemotherapy.

Rationale:A post-stroke patient with limited mobility (B) is at the highest risk for pressure ulcers due to impaired movement and possible sensory perception deficits.

A nurse assesses a postoperative patient and notices absent bowel sounds. What is the most appropriate action? A) Document the findings as normal. B) Notify the healthcare provider immediately. C) Encourage the patient to increase fluid intake. D) Reassess in 4 hours.

Rationale:Absent bowel sounds immediately post-op can be normal, but the nurse should reassess (D) in a few hours to ensure normal peristalsis resumes.

A patient with asthma is wheezing and has a respiratory rate of 28 breaths per minute. What is the priority nursing intervention? A) Administer a bronchodilator. B) Apply oxygen. C) Position the patient in high Fowler's. D) Encourage deep breathing and coughing.

Rationale:Administering a bronchodilator (A) is the priority to relieve bronchoconstriction and improve airflow.

A nurse is caring for a patient with impaired respiratory function. According to Maslow's hierarchy of needs, which intervention should the nurse prioritize? A) Providing emotional support to reduce anxiety. B) Assisting the patient with spiritual needs. C) Administering oxygen therapy as ordered. D) Encouraging family visits to promote a sense of belonging.

Rationale:Administering oxygen therapy (C) addresses the patient's physiological needs, which is the highest priority in Maslow's hierarchy of needs.

. A nurse is assessing a patient's radial pulse and notes it is irregular. What should the nurse do next? A) Count the pulse for 30 seconds. B) Count the pulse for a full minute. C) Document the findings and continue the assessment. D) Reassess in 15 minutes.

Rationale:An irregular pulse should be counted for a full minute (B) to ensure an accurate assessment.

A nurse is performing a sexual history on a patient experiencing erectile dysfunction. What is the most appropriate question to ask? A) "How would you describe the problem?" B) "Do you feel embarrassed about your condition?" C) "Are you able to perform sexually with your partner?" D) "What are your expectations for treatment?"

Rationale:Asking the patient to describe the problem (A) allows for an open discussion and better understanding of the patient's condition.

Which nursing action reflects the ethical principle of autonomy? A) The nurse respects the patient's decision to refuse a blood transfusion. B) The nurse ensures that all patients receive the same quality of care. C) The nurse avoids causing harm to the patient by withholding treatment. D) The nurse provides information truthfully to the patient about their diagnosis.

Rationale:Autonomy (A) involves respecting the patient's right to make their own healthcare decisions, including refusing treatment.

Which nursing intervention reflects beneficence? A) Providing pain relief to a patient. B) Allowing a patient to make their own healthcare decisions. C) Protecting a patient's confidentiality. D) Ensuring equal access to healthcare services.

Rationale:Beneficence (A) refers to actions that benefit the patient, such as providing pain relief.

A patient is prescribed a beta-blocker. Which vital sign is most important for the nurse to assess before administering the medication? A) Respiratory rate. B) Heart rate. C) Blood pressure. D) Temperature.

Rationale:Beta-blockers primarily affect the heart, so the heart rate (B) should be assessed before administration. Beta-blockers can lower heart rate significantly.

. A patient with a spinal cord injury is experiencing reflex incontinence. Which intervention is most appropriate? A) Implementing bladder training with scheduled voiding. B) Instructing the patient to avoid fluid intake in the evening. C) Encouraging the use of absorbent pads during the day. D) Administering anticholinergic medications to reduce bladder spasms.

Rationale:Bladder training (A) helps manage reflex incontinence by scheduling voiding at regular intervals.

When performing a head-to-toe assessment, the nurse hears crackles in the lungs. What condition might this indicate? A) Asthma. B) Pneumonia. C) Chronic obstructive pulmonary disease (COPD). D) Bronchitis.

Rationale:Crackles are commonly associated with pneumonia (B), which involves fluid in the alveoli.

A patient with a history of diabetes is concerned about sexual dysfunction. What factor may contribute to this concern? A) Diabetes damages capillary beds, reducing blood flow to sexual organs. B) Diabetes causes excessive weight gain, leading to sexual dysfunction. C) Diabetes medications often cause sexual side effects. D) Diabetes lowers testosterone levels, impacting libido.

Rationale:Diabetes can damage capillary beds, reducing blood flow to sexual organs (A), which may lead to sexual dysfunction.

The nurse is teaching a diabetic patient about foot care. Which of the following instructions should the nurse include? (Select all that apply.) A) "Inspect your feet daily for cuts or blisters." B) "Soak your feet in warm water daily." C) "Avoid walking barefoot." D) "Use lotion to keep your feet moist, but avoid between the toes."

Rationale:Diabetic patients should inspect their feet daily (A), avoid walking barefoot (C), and use lotion carefully (D) to prevent dryness but not between the toes to avoid fungal infections.

The nurse is teaching a patient with diabetes about foot care. Which statement indicates the patient understands the teaching? A) "I should soak my feet in warm water every night." B) "I can go barefoot as long as I'm at home." C) "I should inspect my feet daily for sores or blisters." D) "I don't need to worry about cutting my toenails."

Rationale:Diabetic patients should inspect their feet daily (C) to catch any sores or blisters early and prevent complications like infections.

. A patient is prescribed a diuretic. What is the most important electrolyte to monitor? A) Sodium. B) Potassium. C) Calcium. D) Magnesium.

Rationale:Diuretics can lead to potassium loss, so potassium (B) should be closely monitored.

The nurse is preparing a patient for a colonoscopy. What is the most important instruction for the nurse to provide to the patient? A) "You can have a light meal the night before the procedure." B) "You will need to drink a bowel-cleansing solution the day before." C) "You will receive a sedative during the procedure to prevent discomfort." D) "The procedure will only take about 10 minutes."

Rationale:Drinking a bowel-cleansing solution (B) is crucial for preparing the patient for a colonoscopy to ensure the colon is clear for visualization. This preparation is the most important instruction for the patient to follow.

1. The nurse is educating a group of patients about effective stress management techniques. Which of the following techniques should the nurse include in the teaching? (Select all that apply.) A) Guided imagery. B) Excessive sleeping. C) Meditation. D) Smoking cessation. E) Regular exercise.

Rationale:Effective stress management techniques include guided imagery (A), meditation (C), and regular exercise (E). Excessive sleeping (B) is not effective, and smoking cessation (D) is related to health promotion rather than direct stress management.

A patient is scheduled for surgery and expresses fear about the procedure. What is the most appropriate nursing intervention? A) Reassure the patient that everything will be fine. B) Explain the surgical procedure in detail. C) Ask the patient to elaborate on their concerns. D) Notify the surgeon of the patient's anxiety.

Rationale:Encouraging the patient to talk about their concerns (C) is a therapeutic communication technique that allows the nurse to assess and address specific fears.

A nurse notices red, raised areas on a patient's skin during an assessment. What is the appropriate term for this finding? A) Pallor. B) Jaundice. C) Erythema. D) Cyanosis.

Rationale:Erythema (C) is the correct term for red, raised areas, often indicating inflammation or infection.

The nurse is performing a neurological assessment and notes a patient has unilateral facial drooping. What cranial nerve is likely affected? A) Cranial nerve II. B) Cranial nerve V. C) Cranial nerve VII. D) Cranial nerve X.

Rationale:Facial drooping indicates an issue with cranial nerve VII (C), which controls the muscles of facial expression.

1. Which of the following is Florence Nightingale most known for in nursing history? A) Founding the American Red Cross. B) Establishing the first training school for nurses. C) Advocating for mental health reform. D) Creating the first public health nursing service.

Rationale:Florence Nightingale (B) is known for establishing the first nursing training school, setting standards for nursing education, and improving sanitation practices. A) Founding the American Red Cross.

A nurse is assessing a patient with a history of heart failure. Which signs and symptoms are indicative of fluid overload? (Select all that apply.) A) Distended neck veins. B) Hypotension. C) Crackles in the lungs. D) Weight gain

Rationale:Fluid overload can present with distended neck veins (A), crackles in the lungs (C), and weight gain (D), indicating increased fluid retention.

The nurse is caring for a patient with pneumonia. Which interventions should be included in the care plan? (Select all that apply.) A) Encourage deep breathing and coughing exercises. B) Administer antibiotics as prescribed. C) Keep the head of the bed flat. D) Provide increased fluid intake.

Rationale:For pneumonia, deep breathing and coughing exercises (A), antibiotics (B), and increased fluid intake (D) are essential to improve lung function and hydration. Keeping the head of the bed flat (C) would hinder breathing.

A patient on a low-sodium diet asks the nurse for help with meal choices. Which food should the nurse recommend? A) Canned soup. B) Fresh fruit. C) Processed cheese. D) Frozen meals.

Rationale:Fresh fruit (B) is low in sodium and a healthy option for patients on low-sodium diets.

A nurse is teaching a patient about stress management techniques. Which technique involves the patient imagining a peaceful setting to reduce anxiety? A) Guided imagery. B) Meditation. C) Relaxation. D) Crisis intervention.

Rationale:Guided imagery (A) involves using mental images of peaceful settings to reduce stress and anxiety.

A nurse is caring for a patient who suddenly becomes unresponsive. The nurse checks for a pulse and does not feel one. What should the nurse do next? A) Call for help and start chest compressions. B) Give two breaths. C) Administer epinephrine. D) Apply oxygen via mask.

Rationale:In the event of a pulseless patient, the nurse should immediately call for help and begin chest compressions (A), according to basic life support (BLS) guidelines.

A nurse is caring for a patient who underwent a hysterectomy. Which nursing interventions can help promote a positive self-concept? (Select all that apply.) A) Encourage the patient to express her feelings about the surgery. B) Focus only on the patient's physical healing. C) Assist the patient in recognizing her strengths. D) Provide education about the surgical procedure. E) Limit family involvement in the patient's care.

Rationale:Interventions that promote positive self-concept include encouraging the patient to express feelings (A), helping the patient recognize her strengths (C), and providing education (D). Focusing only on physical healing (B) and limiting family involvement (E) are not helpful in promoting self-concept.

. The nurse is caring for a patient with a Foley catheter. Which interventions should the nurse include in the care plan to prevent infection? (Select all that apply.) A) Ensure the catheter bag remains below bladder level. B) Change the catheter every 3 days. C) Clean the perineal area daily. D) Empty the drainage bag when it is full. E) Secure the catheter tubing to the leg.

Rationale:Interventions to prevent infection include ensuring the catheter bag remains below bladder level (A), cleaning the perineal area daily (C), and securing the catheter tubing to the leg (E) to prevent trauma and infection. The drainage bag should be emptied regularly, not just when it is full.

A nurse is performing a neurological assessment on a patient who had a stroke. What is the priority assessment? A) Gait and balance. B) Level of consciousness. C) Deep tendon reflexes. D) Sensory function.

Rationale:Level of consciousness (B) is a priority assessment in stroke patients to monitor for changes that may indicate worsening brain function.

During a community health class, the nurse teaches the importance of public health measures. Which historical figure founded public health nursing in New York? A) Mary Breckinridge. B) Lillian Wald. C) Clara Barton. D) Harriet Tubman.

Rationale:Lillian Wald (B) is credited with founding public health nursing in New York.

The nurse is educating a patient about hypertension. Which statement indicates the patient understands lifestyle modifications? A) "I should avoid exercising to keep my blood pressure stable." B) "I need to limit my sodium intake and eat more fruits and vegetables." C) "I should drink alcohol in moderation to lower my blood pressure." D) "I can continue smoking as long as I take my medication."

Rationale:Limiting sodium and increasing fruits and vegetables (B) are essential lifestyle modifications for managing hypertension.

A nurse is developing a plan of care for a patient with impaired skin integrity. Which action best addresses the patient's safety and security needs according to Maslow's hierarchy? A) Keeping the patient's environment clean and free of infection. B) Encouraging family involvement in care. C) Administering prescribed medications for pain relief. D) Assisting the patient with daily hygiene.

Rationale:Maintaining a clean and safe environment (A) addresses the patient's safety and security needs.

The nurse is educating a patient about constipation prevention. Which measures should the nurse include in the teaching? (Select all that apply.) A) Increase dietary fiber intake. B) Avoid drinking water before meals. C) Engage in regular physical activity. D) Take a laxative daily. E) Establish a regular time for bowel movements.

Rationale:Measures to prevent constipation include increasing dietary fiber intake (A), engaging in regular physical activity (C), and establishing a regular time for bowel movements (E). Drinking water before meals should not be avoided, and daily laxative use can lead to dependence and should not be a regular practice.

A nurse is assessing a patient with chronic pain. Which statement indicates the patient is experiencing neuropathic pain? A) "It feels like a burning sensation." B) "It's a dull ache." C) "It's a sharp stabbing pain." D) "It feels like pressure."

Rationale:Neuropathic pain is often described as burning or tingling (A).

Which of the following statements reflects the principle of nonmaleficence? A) "I will administer medication to help alleviate your pain." B) "I will withhold a treatment that could cause more harm than good." C) "I will ensure that your healthcare decisions are respected." D) "I will provide truthful information about your condition."

Rationale:Nonmaleficence (B) is the ethical principle of avoiding harm to the patient, such as withholding potentially harmful treatments.

The nurse is preparing to administer an opioid analgesic to a patient. What is the priority assessment before administration? A) Temperature. B) Respiratory rate. C) Blood pressure. D) Pain level.

Rationale:Opioids can suppress respiration, so it is crucial to assess the respiratory rate (B) before administration.

1. The nurse is teaching a patient with chronic obstructive pulmonary disease (COPD) about oxygen therapy. Which statements by the patient indicate understanding? (Select all that apply.) A) "I should keep my oxygen saturation between 88-92%." B) "I can smoke as long as I lower my oxygen flow rate." C) "I should never adjust my oxygen flow rate without my provider's approval." D) "I should wear cotton clothing to prevent static electricity."

Rationale:Patients with COPD should maintain lower oxygen saturation (A), avoid adjusting the flow rate without approval (C), and use cotton clothing (D) to reduce fire risk with oxygen therapy.

A patient complains of sharp, stabbing pain in the left arm and jaw. What is the likely diagnosis? A) Pulmonary embolism. B) Myocardial infarction. C) Stroke. D) Gastroesophageal reflux disease (GERD).

Rationale:Sharp, stabbing pain in the arm and jaw is a common referred pain pattern for a myocardial infarction (B).

A patient with diarrhea is at risk for dehydration. What assessment finding would indicate dehydration? A) Skin tenting. B) Moist mucous membranes. C) Bradycardia. D) Bounding pulse.

Rationale:Skin tenting (A) is a sign of dehydration, which occurs when the skin does not quickly return to its normal position after being pinched due to fluid loss.

During a physical exam, a nurse observes a patient with slow, shallow breathing. This is known as: A) Tachypnea. B) Apnea. C) Hypoventilation. D) Hyperventilation.

Rationale:Slow, shallow breathing is defined as hypoventilation (C).

A patient who just underwent a prostatectomy is experiencing urinary incontinence. Which type of incontinence is most likely? A) Stress incontinence. B) Urge incontinence. C) Reflex incontinence. D) Overflow incontinence.

Rationale:Stress incontinence (A) often occurs after prostate surgery due to weakened pelvic floor muscles.

Which level of care is provided by a trauma center that offers highly specialized services such as neurosurgery and burn care? A) Primary care. B) Secondary care. C) Tertiary care. D) Community care.

Rationale:Tertiary care (C) provides highly specialized services like trauma and neurosurgery.

A patient complains of constipation and abdominal discomfort. Upon assessment, the nurse notes the patient has been taking opioid medications for pain. What is the most appropriate nursing intervention? A) Administer a stool softener. B) Encourage increased fluid intake and mobility. C) Administer a laxative. D) Decrease the patient's opioid dosage.

Rationale:The most appropriate nursing intervention is to encourage increased fluid intake and mobility (B) to stimulate peristalsis and help relieve constipation. While stool softeners or laxatives may be necessary, increasing fluids and activity are first-line interventions for preventing opioid-induced constipation.

A nurse is assessing a patient who has been experiencing diarrhea for the past few days. Which complications should the nurse monitor for? (Select all that apply.) A) Dehydration. B) Hyperkalemia. C) Electrolyte imbalances. D) Hypovolemia .E) Hypocalcemia.

Rationale:The nurse should monitor for dehydration (A), electrolyte imbalances (C), and hypovolemia (D), as diarrhea can cause excessive fluid and electrolyte losses. Hyperkalemia and hypocalcemia are not typical complications of diarrhea.

1. A patient arrives in the emergency room with signs of a myocardial infarction. What is the priority nursing intervention? A) Administer oxygen. B) Administer pain relief. C) Administer nitroglycerin. D) Establish intravenous access.

Rationale:The priority in managing myocardial infarction is oxygen administration to enhance tissue oxygenation (A). Pain relief and nitroglycerin are also important, but oxygen comes first in the ABCs (Airway, Breathing, Circulation) approach.

When a nurse is prioritizing care using the nursing process, which step comes immediately after the assessment phase? A) Planning. B) Implementation. C) Diagnosis. D) Evaluation.

Rationale:The step that follows assessment is diagnosis (C), where the nurse identifies the patient's problems.

A nurse is preparing to administer an intramuscular (IM) injection. Which site is appropriate for a 5-year-old child? A) Deltoid. B) Vastus lateralis. C) Ventrogluteal. D) Dorsogluteal.

Rationale:The vastus lateralis (B) is a preferred IM injection site for children due to its size and development.

A patient has an indwelling urinary catheter. Which action is most important to reduce the risk of infection? A) Encouraging fluid intake. B) Securing the catheter to the leg. C) Emptying the drainage bag every 8 hours. D) Keeping the drainage bag below bladder level.

Rationale:To prevent backflow of urine, which can cause infection, the drainage bag should be kept below bladder level (D).

A nurse is assessing a patient's urine output. Which value should the nurse report to the healthcare provider? A) 40 mL/hr. B) 50 mL/hr. C) 25 mL/hr. D) 60 mL/hr.

Rationale:Urine output less than 30 mL/hr indicates oliguria, which could be a sign of renal dysfunction. Therefore, the nurse should report an output of 25 mL/hr (C) to the healthcare provider.

A patient has been prescribed warfarin. Which foods should the nurse teach the patient to limit due to their vitamin K content? (Select all that apply.) A) Kale. B) Spinach. C) Potatoes. D) Broccoli.

Rationale:Vitamin K-rich foods, such as kale (A), spinach (B), and broccoli (D), should be limited because they can affect warfarin's anticoagulant effect.

A nurse is teaching a patient about preventing urinary tract infections (UTIs). Which statement by the patient indicates an understanding of the teaching? A) "I should drink at least 1,000 mL of water daily." B) "I should wipe from back to front after using the toilet." C) "I should avoid cranberry juice because it can cause infections." D) "I should void immediately after sexual intercourse."

Rationale:Voiding immediately after sexual intercourse (D) helps flush out bacteria and prevent UTIs. Drinking at least 2,000 mL of fluids and wiping from front to back are also important but are not part of this specific response.

what are the core temperature

Tympanic-(Ear)RectalTemporal-(Probe over forehead temporal artery; temporal artery thermomete)

Prone

assessment of hip joint and posterior thorax

Knee-chest

assessment of the rectal area; used for brief period only