Foundations exam 2
A nurse assesses a terminally ill patient with a DNR order, with findings of decreased blood pressure, urinary and bowel incontinence, loss of reflexes, and Cheyne-Stokes respirations. Based on these findings, the nurse recognizes which of the following?
These are signs of impending death.
A patient scheduled for complex heart surgery has been reading the Bible for hours each day, cries often, and is not sleeping well. What might these observations cue the nurse about the patient?
These behaviors are signs of spiritual distress.
What would a nurse instruct a patient to do after administration of a sublingual medication?
Try not to swallow while the pill dissolves.
The nurse is following the Joint Commissions national patient safety goals when giving medications. Based on these goals, how can the nurse improve the accuracy of patient identification?
Use two patient identifiers (one may be the room number).
A nurse is teaching a lawn-care worker about the risk of hearing loss. What might be recommended?
Wear earplugs while using lawn equipment.
A community health nurse is conducting a seminar on vision self-care. What might be one topic included in the teaching plan?
Wear sunglasses when working outside.
What statement by a patient would indicate that a nurse had successfully implemented a teaching/learning strategy to prevent injury in the home?
Well, I always let the boys play in the bathtub; they love it.
Which of the following questions asked by the nurse when taking a patients health history would collect data about infection control?
When did you complete your immunizations?
Which of the following most accurately defines an infection?
a disease resulting from pathogens in or on the body
An adolescent has recently had a ring inserted into her navel. What is the adolescent at risk for developing?
a local and/or systemic infection
Which of the following people is at greater risk for accidental injury?
a worker who operates industrial machines
A nurse is converting the dosage of a medication to a different unit in the metric system. The medication label specifies the drug as being 0.5 g per tablet. The order is for 500 mg. How many tablets will the nurse give?
1 0.5*1000=500=1 tablet
A physician orders Cipro 500 mg, PO q12h for a patient with bronchial pneumonia. The nurse has Cipro 250 mg on hand. How many tablets would the nurse dispense?
2 tablets
A physician has ordered peak and trough levels of a medication. When would the nurse schedule the trough level specimen?
30 minutes before the next dose
A nurse teaches the parents of a toddler about normal sleep patterns for this age group. How many hours of sleep per night is normal near the end of this stage?
8 10 hours
Which of the following are characteristics of the stage of infection known as full stage of illness? Select all that apply.
A & C
A woman tests positive for the human immunodeficiency virus antibody but has no symptoms. She is considered a carrier. What component of the infection cycle does the woman illustrate?
A) a reservoir
A terminally ill patient, in severe pain, asks a nurse to help her die. What must the nurse consider morally, ethically, and professionally before answering the patient?
ANA Code for Nurses, ethical and professional standards
A woman has had a breast removed to treat cancer. What type of loss will she most likely experience?
Actual loss
Which of the following statements accurately describe a component of the inflammatory response? Select all that apply.
All the above
A patient with type 1 diabetes has impaired sensation in her lower extremities. What teaching would be necessary to reduce her risk of injury?
Always test the temperature of bath water before stepping in.
Which of the following is an example of a perceived loss?
An older patient grieves for the loss of his independence.
A patient with an upper respiratory infection (common cold) tells the nurse, I am so angry with the nurse practitioner because he would not give me any antibiotics. What would be the most accurate response by the nurse?
Antibiotics have no effect on viruses.
A nurse is caring for a patient who is unconscious. Which of the following is a recommended guideline for communication with this patient?
Be careful what is said in front of the patient as he or she might hear you.
A grade school nurse is addressing parents at a PTA meeting regarding car safety. Which of the following is a recommended safety guideline for this age group?
Booster seats should be used for children until they are 4-feet 9-inches tall or at least 8 years of age.
A patient comes to the emergency department with major burns over 40% of his body. Although all of the following are true, which one would provide the rationale for a nursing diagnosis of Risk for Infection?
C) Intact skin and mucous membranes protect against microbial invasion.
A nurse caring for critically ill patients uses interventions to help patients maintain a sense of self. Which of the following are recommended interventions?
Converse with the patient about his or her life experience.
A man on an airplane is sitting by a woman who is coughing and sneezing. If she has an infection, what is the most likely means of transmission from the woman to the man?
D) airborne route
A nurse has conducted a timed get up and go test to assess an older adults risk for a fall. The patient completes the test in 30 seconds. Based on the finding, what will the nurse do?
Develop a care plan for Impaired Physical Mobility.
A student nurse is administering medications through a nasogastric tube connected to continuous suction. How will the student do this accurately?
Disconnect tubing from the suction before giving drugs, and clamp tubing for 20 to 30 minutes.
What federal agency enforces the official standards for drugs in the United States?
Food and Drug Administration
A dying patient states in writing ahead of time what her choices would be for healthcare should certain circumstances develop. What is the term for this document?
advance directives
A nurse is conducting a prenatal class for expectant parents. What is one topic that should be addressed to promote safety in the developing fetus?
alcohol consumption and smoking
Which of the following group of terms best defines spiritual distress?
alienation, despair
Which of the following groups of terms best describes sleep?
altered consciousness, relative inactivity
A nurse has seen several patients at a community health center. Which of the patients would be most at risk for developing an infection?
an older adult with several chronic illnesses
A man is diagnosed with terminal kidney failure. His wife demonstrates loss and grief behaviors. What type of loss is the wife experiencing?
anticipatory loss
What are the recommended cleansing agents for hand hygiene in any setting when the risk of infection is high?
antimicrobial products
A patient who has had abdominal surgery develops an infection in the wound while still hospitalized. Which of the following agents is most likely the cause of the infection?
bacteria
What factor is used to most accurately calculate drug dosages for a child?
body surface area (BSA)
What type of cognitive responses might a nurse assess in a patient with sensory deprivation?
decreased attention span, difficulty problem solving
A nurse is caring for an adolescent who is diagnosed with mononucleosis, commonly called the kissing disease. The nurse explains that the organisms causing this disease were transmitted by:
direct contact
If an individual has smallpox, how would it most likely be spread?
direct contact
A nurse is administering lithium to a Japanese patient. What cultural factor should the nurse consider regarding the effects of the medications?
elevated serum levels may occur causing symptoms of drug toxicity
An elderly woman in a long-term care facility has fallen and sustained several injuries. Which of her injuries would be the most serious fall-related injury?
fractured hip
A nursing home recently has had a significant number of nosocomial infections. Which of the following measures might be instituted to decrease this trend?
having written infection-prevention practices for all employees
A nurse is preparing to administer a medication by intravenous piggyback. Where will the piggyback container be placed?
higher than the primary solution container
Which of the following expected outcomes demonstrates the effectiveness of a plan of care to promote rest and sleep?
identifies factors that interfere with normal sleep pattern
Which of the following is an example of the bodys defense against infection?
immune response
Immobility affects the body in many ways. What is one serious effect of immobility on the cardiovascular system?
increased cardiac workload
Bedrest, with resultant immobility, affects the whole body. What is one effect on the musculoskeletal system?
increased risk for contractures
What safety device for children is mandated by law in all 50 states?
infant car seats and carriers
A nurse is administering a medication to a patient for acute pain. Of the various routes for drug administration, which would be chosen because it is absorbed more rapidly?
injected medications
In which of the following healthcare settings is a patient more likely to be at risk for sensory deprivation?
long-term care
Mrs. Treem is on isolation because she acquired a methicillin-resistant S. aureus (MRSA) infection after hospitalization for hip replacement surgery. What name is given to this type of infection?
nosocomial
Which of the following best describes sexuality?
physical, emotional, and mental gender
Which of the following healthcare providers have prescriptive authority? Select all that apply.
physician dentist advance practice nurses
Which of the following nonpharmacologic, independent nursing interventions may be used to promote relaxation without also causing sensory overload?
playing music the patient chooses
Of all possible nursing interventions to break the chain of infection, which is the most effective?
practicing hand hygiene
A college-aged student has influenza. At what stage of the infection is the student most infectious?
prodromal stage
What term is used to describe the sense, usually at a subconscious level, of the movements and position of the body and especially its limbs, independent of vision?
proprioception
What are the primary nursing considerations when assisting with or conducting a physical assessment of the genitalia?
respecting the patients privacy and modesty
A home care patient has both visual and hearing deficits. Although all of the following are important, what would be a high priority concern when planning and implementing care?
safety
A patient tells his nurse that he has difficulty hearing related to working in a loud factory setting for 15 years. What is the term for this condition?
sensory deficit
A patient admitted to the hospital for major surgery is at risk for what type of sensory alteration?
sensory overload
A nurse asks the mother of a hospitalized 2-year-old patient to bring in his favorite blanket or stuffed animal. What sense is the nurse trying to stimulate with this intervention?
tactile
What do most nursing interventions pertaining to sexuality involve?
teaching to promote sexual health
Bioterrorism has become a commonly used term. What is the definition of bioterrorism?
the deliberate spread of pathogens into a community
A patient taking insulin has his levels adjusted to ensure the concentration of drug in the blood serum produces the desired effect without causing toxicity. What is the term for this desired effect?
therapeutic range
A nurse providing palliative care for a dying man and his family knows that the goal of palliative care is:
to aggressively treat the symptoms of the disease.
Why is it important for the nurse to teach and role model proper body mechanics?
to promote health and prevent illness
The following procedures have been ordered and implemented for a hospitalized patient. Which procedure carries the greatest risk for a nosocomial infection?
urinary catheterization
A nurse teaches a rural community group how to avoid contracting West Nile virus by using approved insect repellant and wearing proper coverings when outdoors. By what means is the pathogen involved in West Nile virus transmitted?
vectors
Which anatomic site is recommended for intramuscular injections for adults?
ventrogluteal muscles
A patient has a severe abdominal injury with damage to the liver and colon from a motorcycle crash. What type of pain will predominate?
visceral pain
A patients bed partner reports the patient often has irregular snoring and silence followed by a snort. Does this warrant further assessment?
yes, this is an indicator of obstructive apnea
A student nurse is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure?
Gather new sterile supplies and start over.
A nurse is administering an intramuscular injection of a viscous medication using the appropriate- gauge needle. What does the nurse need to know about needle gauges?
Gauges range from 18 to 30, with 18 being the largest.
A nurse is teaching adolescents how to prevent infections. What statement by one of the adolescents indicates that more teaching is needed?
I dont wear a condom when I have sex, but I know my partners.
A nurse is teaching an older adult at home about taking newly prescribed medications. Which of the following would be included?
I have written the names of your drugs with times to take them
Which of the following nursing diagnoses describes disturbed sensory perception as the etiology?
Ineffective Coping related to sensory overload
A patient comes to the emergency department with major burns over 40% of his body. Although all of the following are true, which one would provide the rationale for a nursing diagnosis of Risk for Infection?
Intact skin and mucous membranes protect against microbial invasion.
A patient asks a nurse to explain a living will. What is the nurses best answer?
It lists specific instructions for healthcare provisions.
Kbler-Ross defines five stages of psychosocial responses to dying and death. Which of the following statements is characteristic of the bargaining stage?
Just let me live to see my grandson born.
Nurses provide many interventions to prevent falls in healthcare settings. Which of the following would be an appropriate fall-prevention intervention?
Lock wheels on beds and wheelchairs.
A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out?
Maintain it according to agency policy.
A dying patient and family have requested that no attempts be made to resuscitate the patient in the event of death. A doctor has written a DNR order. What is the nurses responsibility if the patient dies?
Make no attempt to resuscitate the patient.
What is the most significant difficulty regarding sexuality faced by people taking medications for hypertension?
Medications change sexual functioning.
Which of the following statements is typical of the first stage of grieving described by Engel?
No, not me
What must a nurse do each time medications are administered to ensure that medication errors do not occur?
Observe the three checks and five rights.
Which one of the following statements accurately describes the process known as grief reaction?
Reactions to grief may differ from patient to family.
A confused elderly woman who keeps attempting to remove tubes from her surgical incision is placed in wrist restraints. Which of the following diagnoses would be appropriate for this patient?
Risk for Disuse Syndrome
A nurse is caring for a patient with a serious bacterial infection. The patient is dehydrated. Knowledge of the physical effects of the infection would support which of the following nursing diagnoses?
Risk for Imbalanced Body Temperature
A patient verbalizes to a mental health counselor that his life is meaningless since his wife divorced him and that he no longer wants to live. What nursing diagnosis, resulting from his spiritual distress, would be appropriate?
Risk for Self-Directed Violence
Which of the following nursing diagnoses would be appropriate for teaching interventions for a single mother who leaves her toddler unattended in the bathtub?
Risk for Suffocation
A nurse caring for a patient who has gas gangrene knows that this infection originated in which of the following reservoirs?
Soil
A patient who has had a recent below-knee amputation tells the nurse that he feels as though his toes are cramping. What would the nurse say in return?
That is called phantom pain, and it is not unusual.
A nurse is making a home care visit to a patient with a hearing deficit. What can she do to facilitate communication with the patient?
A) Ask for permission to turn off the television set during the visit.
