NMNC 1135 Exam 1
The nurse works at an agency where military time is used for documentation, and needs to document that a patient was transported to the operating room for an emergency procedure at 8 in the evening. Point to the area on the clockface below that indicates 8 in the evening in military time: Clock shows timings from 1300 to 2400 in increments of 100.
2000
A nursing student is confused and frustrated working with NIC/NOC/NANDA language on care plans. What advantage of this system does the nursing faculty explain to the student? a. It is a common language that can be incorporated into clinical information systems. b. It is easy-to-implement nursing-focused language that all systems will eventually use. c. It provides an avenue for understandable billing practices for health care costs. d. Its specific nomenclature and wording increase the visibility of nursing as a profession.
a
A patient asks the nurse why his mouth is so dry after radiation therapy to his head and neck. What is the most appropriate response from the nurse? a. "Radiation reduces the flow of saliva." b. "Radiation causes the mucous lining of the mouth to become thin." c. "It would be best to discuss this with your radiation oncologist." d. "Drinking more fluids will help to alleviate the problem."
a
Besides meticulous hand hygiene identify another practice that helps reduce the risk of spreading infection. a. Maintaining a clean environment in the patient's room b. Restricting visitors to immediate family only c. Leaving gloves on to administer medications d. Placing the patient on droplet precaution
a
List the steps for applying personal protection equipment (PPE).1. Apply gown, pull sleeves down to wrist.2. Apply surgical mask.3. Apply eyewear.4. Apply clean gloves.5. Bring glove cuffs over gown. a. 1, 2, 3, 4, 5 b. 2, 1, 3, 4, 5 c. 4, 1, 2, 3, 5 d. 3, 2, 1, 4, 5
a
The nurse is working the evening shift at a hospital that uses military time for documentation. The nurse administered morphine 2 mg intravenously (IV) for pain at 3:45 PM, changed the dressing over the patient's abdominal incision at 5:34 PM, and administered Ancef 1 g IV at 8:00 PM. Using correct military time, which of the following is the correct label of documentation for each task with the time that it was completed? a. 15 45, 17 34, 20 00 b. 3 45, 17 34, 20 00 c. 15 45, 5 34, 8 00 d. 3 45, 5 34, 8 00
a
When cleansing the eyes, which of the following should the nurse avoid doing? a. Cleanse each eye from the outer canthus to the inner canthus. b. Avoid cross-contamination by using different parts of the washcloth for each eye. c. Close the eyelids of the unconscious patient to maintain eye moisture and prevent injury. d. Apply a warm, damp cloth for 2 to 3 minutes to crusts that have formed before removal.
a
A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to sever pain. Which of the following nursing actions are appropriate? (Select all that apply.) a. Repeat the details of the prescription back to the provider b. Have another nurse listen to the telephone prescription c. Obtain the providers signature on the prescription within 24 hr. d. Decline the verbal prescription because it is not an emergency situation Tell the charge nurse that the provider has prescribed morphine by telephone
a,b,c
A patient states, "I would like to see what is written in my medical record." What is the nurse's best response? a. "Only your family can read your medical record." b. "You have the right to read your record." c. "Patients are not allowed to read their records." d. "Only health care workers have access to patient records."
b
A staff nurse is interested in informatics and wishes to become an Informatics Nurse Specialist (INS). What step is necessary to obtain that certification? a. Earn a bachelor's degree in computer science or informatics. b. Get on-the-job training in software from a software vendor. c. Obtain graduate education in informatics or a related specialty. d. Take the certification exam offered by the National League of Nursing.
c
Match each line of documentation with the appropriate SOAP category (Subjective [S], Objective [O], Assessment [A], Plan [P]). a. _ Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device. b. _ "The pain increases every time I try to turn on my left side." c. _ Acute pain related to tissue injury from surgical incision. d. _ Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.
S-b O-d A-c P-a
A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? a. "CPOE reduces transcription errors." b. "CPOE reduces the time needed for health care providers to write orders." c. "CPOE eliminates verbal and telephone orders from health care providers." d. "CPOE reduces the time nurses use to communicate with health care providers."
a
A nurse has finished getting shift report. Which patient should the nurse see first? a. Patient just transferred from the emergency department b. Patient who needs to get out of bed and ambulate c. Pneumonia patient getting respiratory treatment d. Postoperative patient requesting pain medication
a
A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first? a. Face b. Feet c. Chest d. Arms
a
An experienced nurse is precepting a new graduate. Prior to charting, the preceptor instructs the new nurse to do which of the following? a. Abbreviate as much as possible to keep records short. b. Do not use any abbreviations at all in patients' charts. c. Look up the facility's list of "do not use" abbreviations. d. Use only abbreviations seen in other nurses' charting.
c
A nurse is listening to a student provide instruction to a patient who is having difficulty with activities needed to care for soft contact lenses. Which of the following statements by the nursing student might require some correction by the nurse? a. Use tap water to clean soft lenses. b. Follow recommendations of lens manufacturer when inserting the lenses. c. Keep lenses moist or wet when not worn. d. Use fresh solution daily when storing and disinfecting lenses.
a
A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? a. Turn the client's head to the side. b. Place two fingers in the client's mouth to open. c. Brush the client's teeth once per day. d. Inject a mouth rinse into the center of the client's mouth.
a
A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following actions should the nurse include the client's plan of care? a. Schedule rest periods during morning care. b. Discontinue morning care for 2 days. c. Perform all care as quickly as possible. d. Ask a family member to come in and bathe the client.
a
A nurse uses long firm, strokes distal to proximal while bathing a patient's legs because: a. It promotes venous circulation. b. It covers a larger area of the leg. c. It completes care in a timely fashion. d. It prevents blood clots in legs.
a
The nurse has redressed a wound and now plans to administer medications. What should the nurse remember to do next? a. Leave gloves on to administer medications. b. Remove gloves and perform hand hygiene before leaving the room. c. Remove gloves and perform hand hygiene before administering the medication. d. Leave the medication on the bedside table to avoid having to remove gloves.
c
The nurse is writing a narrative progress note. Identify each of the following statements as subjective data (S) or objective data (O): a. April 24, 2019 (0900) b. Repositioned patient on left side. c. Medicated with hydrocodone-acetaminophen 5/325 mg, 2 tablets PO. d. "The pain in my incision increases every time I try to turn on my right side." e. S. Eastman, RN f. Surgical incision right lower quadrant, 3 inches in length, well approximated, sutures intact, no drainage g. Rates pain 7/10 at location of surgical incision.
O:a,b,c,e,f,g S:d
A patient who has been placed on Contact Precautions for Clostridium difficile (C. difficile) asks you to explain what he should 464know about this organism. What is the most appropriate information to include in patient teaching? (Select all that apply.) a. The organism is usually transmitted through the fecal-oral route. b. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. c. Everyone coming into the room must be wearing a gown and gloves. d. While the patient is in Contact Precautions, he cannot leave the room. e. C. difficile dies quickly once outside the body.
a,b,c
The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing health care-acquired infections? (Select all that apply.) a. Teaching correct handwashing to assigned patients b. Using correct procedures in starting and caring for an intravenous infusion c. Providing perineal care to a patient with an indwelling urinary catheter d. Isolating a patient on antibiotics who has been having loose stool for 24 hours e. Decreasing a patient's environmental stimuli to decrease nausea
a,b,c
The nurse is caring for a male patient who has asked to be shaved with a disposable razor. The nurse knows that she will need to take which of the following into consideration? (Select all that apply.) a. The condition of the skin and any irritated or open areas b. Laboratory values (e.g., anticoagulation studies such as PT, platelet count) and whether the patient is receiving anticoagulation therapy, which would indicate a bleeding tendency c. The ability of the patient to help with the procedure and to manipulate the razor d. Intake of fluids, to determine hydration of the skin
a,b,c
A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply.) a. Medication error b. Needlesticks c. Conflict with provider and nursing staff d. Omission of prescription e. Missed specimen collection of a prescribed laboratory test
a,b,d
Which of these statements are true regarding disinfection and cleaning? (Select all that apply.) a. Proper cleaning requires mechanical removal of all soil from an object or area. b. General environmental cleaning is an example of medical asepsis. c. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. d. Cleaning in a direction from the least to the most contaminated area helps reduce infections. e. Disinfecting and sterilizing medical devices and equipment involve the same procedures.
a,b,d
A nurse is reviewing health care-related information on the Internet using the CARS acronym. Which of the following are components of this system? (Select all that apply.) a. Accuracy b. Credibility c. Rationale d. Reasonableness e. Support
a,b,d,e
The nurse is transferring a patient to a long-term, skilled care facility and has just given a telephone report to a registered nurse (RN) who works at that facility and who will be receiving the patient. In documenting this call, the nurse begins by writing the date and time the report was given and the name of the RN taking the report. Which of the following pieces of information does the nurse include in the documentation of this telephone call? (Select all that apply.) a. The patient's name, age, and admitting diagnoses b. The discussion of any allergies to food and medications that the patient has c. That the nurse receiving the report was advised that the patient is "needy" and "on the call light all the time" d. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol e. Description of any unresolved problems and current interventions in place
a,b,d,e
A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are manifestations of a systemic infection? (Select all that apply.) a. Fever b. Malaise c. Edema d. Pain or tenderness e. Increase in pulse and respiratory rate
a,b,e
A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply.) a. Inspect the feet daily. b. Use moisturizing lotion on the feet. c. Wash the feet with warm water and let them air dry. d. Use over-the-counter products to treat abrasions. e. Wear cotton socks.
a,b,e
The nurse who works at the local hospital is transferring a patient to an acute rehabilitation center in another town. To complete the transfer, information from the patient's electronic health record must be printed and faxed to the acute rehabilitation center. Which of the following actions is most appropriate for the nurse to take to maintain privacy and confidentiality of the patient's information when faxing this information? (Select all that apply.) a. Confirm that the fax number for the acute rehabilitation center is correct before sending the fax. b. Use the encryption feature on the fax machine to encode the information and make it impossible for staff at the acute rehabilitation center to read the information unless they have the encryption key. c. Fax the patient's information without a cover sheet so that the person receiving the information at the acute rehabilitation center can identify it more quickly. d. After sending the fax, place the information that was printed out in a standard trash can after ripping it into several pieces. e. After sending the fax, place the information that was printed out in a secure canister marked for shredding.
a,b,e
Which type of personal protective equipment should the nurse wear when caring for a pediatric patient who is placed on Airborne Precautions for confirmed chickenpox/herpes zoster? (Select all that apply.) a. Disposable gown b. N95 respirator mask c. Face shield or goggles d. Disposable mask e. Gloves
a,b,e
A nurse is taking care of a patient on airborne precautions for tuberculosis. Which would be an appropriate intervention? (Select all that apply.) a. Place patient in a private room. b. Explain why the patient across the hall is not on precautions. c. Wear gloves when giving an intramuscular injection. d. Educate patient regarding his or her isolation. e. Wear a surgical mask into the room to take vital signs.
a,c,d
The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care: (Select all that apply.) a. Use antimicrobial toothpaste. b. Brush teeth 4 times a day. c. Use 0.12% chlorhexidine gluconate (CHG) oral rinses. d. Use a soft toothbrush for oral care. e. Avoid cleaning the gums and tongue.
a,c,d
The nurse is working in an agency that has recently implemented an electronic health record. Which of the following are acceptable practices for maintaining the security and confidentiality of electronic health record information? (Select all that apply.) a. Using a strong password and changing your password frequently according to agency policy b. Allowing a temporary staff member to use your computer user name and password to access the electronic record c. Ensuring that work lists (and any other data that must be printed from the electronic health record) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed d. Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient's care e. Remaining logged in to a computer to save time if you only need to step away to administer a medication
a,c,d
When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.) a. Check for needed adaptive equipment. b. Exaggerate lip movements to help the patient lip-read. c. Give the patient time to respond to questions. d. Keep communication short and to the point. e. Communicate only through written information.
a,c,d
3. Motivational interviewing (MI) is a technique that applies understanding a patient's values and goals in helping the patient make behavioral changes. When using motivational interviewing, what outcomes does the nurse expect? (Select all that apply.) a. Gaining an understanding of the patient's motivations b. Directing the patient to avoid poor health choices c. Recognizing the patient's strengths and supporting his or her efforts d. Providing assessment data that can be shared with families to promote change e. Identifying differences in patient's health goals and current behaviors
a,c,e
Put the following steps for removal of protective barriers after leaving an isolation room in order. a. Remove and dispose of gloves. b. Perform hand hygiene. c. Remove eyewear or goggles. d. Untie top and then bottom mask strings and remove from face. e. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side.
a,c,e,d,b
Which of the following actions are steps used when making an unoccupied bed? (Select all that apply.) a. Raise bed to working height. b. Wear clean gloves at all times. c. Apply all bottom linen on one side of bed before moving to opposite side. d. Remove soiled linen and place on the floor. e. Tuck top sheet and blanket in at bottom of bed using a modified mitered corner. f. Keep top blanket at head of bed when procedure is completed. g. Make horizontal toe pleat with all top layers of linen.
a,c,e,g
An 88-year-old patient comes to the medical clinic regularly. During a recent visit the nurse noticed that the patient had lost 10 lbs in 6 weeks without being on a special diet. The patient tells the nurse that he has had trouble chewing his food. Which of the following factors are normal aging changes that can affect an older adult's oral health? (Select all that apply.) a. Dentures do not always fit properly. b. Most older adults have an increase in saliva secretions. c. With aging the periodontal membrane becomes tighter and painful. d. Many older adults are edentulous, and remaining teeth are often decayed. e. The teeth of elderly patients are more sensitive to hot and cold.
a,d
The nurse is supervising a beginning nursing student and allowing the student to complete documentation of care under direct observation. Which of the following actions are not appropriate and would require intervention? The nursing student: (Select all that apply.) a. Documents a medication given by another nursing student. b. Includes the date and time of the entry into the medical record. c. Enters assessment data into the electronic medical record using the computer mounted on the wall in the patient's room. d. Leaves a slip of paper with her user name and password in the patient's room. e. Starts to enter "Docusate sodium 100 mg ordered at 08:00 held. Patient declined to take dose stating, "I had several loose stools yesterday, and I'm afraid if I take this dose the problem will get worse," as a narrative comment.
a,d
A nurse and health care provider are talking in the hallway about a patient's condition. The health care provider says that the patient needs an x-ray. Which action by the nurse is most appropriate? a. Document the order and facilitate the patient having the x-ray. b. Explain that you will call x-ray when the health care provider inputs the order. c. Inform the health care provider that verbal orders are prohibited now. d. Repeat the order to the health care provider and document it in the chart.
b
A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? a. Pull down and out at the back of the upper denture to remove. b. Brush the dentures with a toothbrush and denture cleaner. c. Rinse the dentures with hot water after cleaning them. d. Place the dentures in a clean, dry storage container after cleaning them.
b
A patient is diagnosed with meningitis. Which type of isolation precaution is most appropriate for this patient? a. Reverse isolation b. Droplet Precautions c. Standard Precautions d. Contact Precautions
b
A patient with chemotherapy-related stomatitis calls the physician's office to talk with the nurse. What suggestions should the nurse make to help this patient? a. Rinse 2 to 3 times a day with an alcohol-based mouthwash and use a water-based mouth moisturizer afterward. b. Rinse the mouth before and after meals and at bedtime with a saltwater or baking soda solution per protocol, and apply a moisturizing gel to the lips if needed. c. Brush the teeth gently with water before each meal and suck on mints to help alleviate discomfort. d. Discomfort and irritation may be minimized by using a toothette sponge moistened with water to clean the teeth and the oral cavity.
b
Patient-to-patient transmission of infection cannot occur if gloves are routinely used. a. True b. False
b
Place in correct order the following abbreviated steps for making an occupied bed.1. Raise bed to working height and lower side rail from side where you are standing.2. Perform hand hygiene and apply gloves.3. Remove soiled top sheet and bedspread and place in linen bag.4. Place bath blanket on patient and assist to a side-lying position facing away from you.5. Apply fanfolded bottom sheet, mattress pad, and drawsheet.6. Lower side rail on remaining side, unfold linens from under patient, and complete bed making.7. Raise side rail on completed side and ask patient to turn toward you, rolling over layered linens to the other side.8. Place top sheet on patient along with bedspread or blanket if desired; make foot pleat, tuck, and miter corners at foot of bed.9. Position patient, raise side rail, lower bed to lowest position with brakes locked, and place call light within reach.10. Assess environment for safety, identify patient, provide privacy, and explain procedure. a. 1, 2, 3, 4, 10, 5, 7, 9, 8, 6 b. 10, 2, 1, 3, 4, 5, 7, 6, 8, 9 c. 10, 2, 1, 4, 3, 7, 5, 6, 8, 9 d. 9, 8, 6, 1, 2, 3, 10, 5, 7, 4
b
The nurse contacts a provider about a change in a patient's condition and receives several new orders for the patient over the phone. When documenting telephone orders in the electronic health record, most hospitals require a nurse to do which of the following? a. Print out a copy of all telephone orders entered into the electronic health record in order to keep them in personal records for legal purposes. b. "Read back" all telephone orders to the provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the electronic health record. c. Record telephone orders in the electronic health record, but wait to implement the order(s) until they are electronically signed by the health care provider who gave them. d. Implement telephone order(s) immediately, but insist that the health care provider come to the patient care unit to personally enter the order(s) into the electronic health record within the next 24 hours.
b
Which requirement for technologically enhanced prescribing does Medicare Part D require? a. Automatic conversion from brand to generic drugs b. Drug plans must support electronic prescribing c. Online, 24-hour Internet pharmacist support d. Physician entry order systems in the hospital
b
While reviewing the pulmonary assessment entered by a nurse in a patient's electronic medical record (EMR), a physician notices that the only information documented in that section is "WDL" (within defined limits). The physician also is not able to find a narrative description of the patient's respiratory status in the nurse's progress notes. What is the most likely reason for this? a. The nurse caring for the patient forgot to document on the pulmonary system. b. The EMR uses a charting-by-exception format. c. The computer shut down unexpectedly when the nurse was documenting the assessment. d. Because of HIPAA regulations, physicians are not authorized to view the nursing assessment.
b
A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select all that apply.) a. Cover errors with correction fluid and write in the correct information b. Put the date and time on all entries c. Document objective data, leaving out opinions d. Use as many abbreviations as possible e. Wait until the end of shift to document
b,c
A critically ill patient with an endotracheal tube and on mechanical ventilation is at risk for ventilator-associated pneumonia (VAP) for which of the following reasons? (Select all that apply.) a. The mucus inside the artificial airway grows gram-negative bacteria. b. An endotracheal tube bypasses normal airway defenses, leading to a change in the normal oral flora. c. A critically ill patient often has a reduced gag reflex. d. Presence of an endotracheal tube makes it impossible to suction oral secretions. e. Critically ill patients have an abnormal amount of mucosa released in oral cavity.
b,c
The nurse is having a complication of dermatitis related to repeated handwashing. Which intervention could be used to help the nurse with the situation? (Select all that apply.) a. Use personal hypoallergenic soap instead of soap provided. b. Use only approved hand lotions or barrier creams. c. Rinse and dry hands thoroughly after every handwashing. d. Quickly wash hands when needed to avoid excess damage to skin. e. Wear gloves and change them frequently instead of washing hands.
b,c
What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? (Select all that apply.) a. Prone position b. Sims' position c. Semi-Fowler's position with head to side d. Trendelenburg position e. Supine position
b,c
2. Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply.) a. To improve the nurse's status with the health team members b. To reduce the risk of errors to the patient c. To provide an optimum level of patient care d. To improve patient outcomes e. To prevent issues that need to be reported to outside agencies
b,c,d
4. The nurse therapeutically responds to an adult patient who is anxious by: (Select all that apply.) a. Matching the rate of speech to be the same as that of the patient b. Providing good eye contact c. Demonstrating a calm presence d. Spending time attentively with the patient e. Assuring the patient that all will be well
b,c,d
A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select all that apply.) a. A single electronic records password is provided for nurses on the same unit b. Family members should provide a code prior to receiving client health information c. Communication of client information can occur at the nurses' station d. A client can request a copy of their medical record E. a nurse may photocopy a client's medical record for transfer to another facility
b,c,d,e
Which of the following are true statements in relation to hand hygiene? (Select all that apply.) a. The percentage of health care workers using hand hygiene has been decreasing over the last few years. b. The incidence of health care-associated infections has decreased because of hand hygiene. c. There must be a mode of transmission for an infection to occur. d. Soap and water must be used when hands are visibly soiled. e. Hand hygiene can be antiseptic hand wash, antiseptic hand rub, or handwashing.
b,c,d,e
A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include? (Select all that apply.) a. Place the client in a room that has negative air pressure at least six exchanges per hour b. Wear a mask when providing care withing 3 ft of the client c. Place a surgical mask on the client if transportation to another department is unavoidable d. Use sterile gloves when handling soiled linens e. Wear a gown when performing care that might result in contamination from secretions.
b,c,e
A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) a. Apply 3 to 5 mL of liquid soap to dry hands. b. Wash the hands with soap and water for at least 15 seconds. c. Rinse the hands with hot water. d. Use a clean paper towel to turn off hand faucets. e. Allow the hands to air dry after washing.
b,d
A patient is diagnosed with a multidrug-resistant organism (MDRO) in his surgical wound and asks the nurse what this means. What is the nurse's best response? (Select all that apply.) a. There is more than one organism in the wound that is causing the infection. b. The antibiotics the patient has received are not strong enough to kill the organism. c. The patient will need more than one type of antibiotic to kill the organism. d. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively. e. There are no longer any antibiotic options available to treat the patient's infection.
b,d
Identify the situations in which a nurse should remove gloves and perform hand hygiene. (Select all that apply.) a. Only after providing wound care b. When leaving a patient's room c. When all tasks for a patient are completed d. When going from a contaminated to a clean site
b,d
The student nurse is teaching a family member the importance of foot care for his or her mother, who has diabetes. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply.) a. Cut nails frequently. b. Assess skin for redness, abrasions, and open areas daily. c. Soak feet in water at least 10 minutes before nail care. d. Apply lotion to feet daily. e. Clean between toes after bathing.
b,d,e
The nurse delegates needed hygiene care for an alert elderly patient who had a stroke. Which intervention would be appropriate for the assistive personnel to accomplish during the bath? (Select all that apply) a. Checking distal pulses b. Providing range-of-motion (ROM) exercises to extremities c. Determining type of treatment for stage 1 pressure injury d. Changing the dressing over an intravenous site e. Providing special skin care
b,e
Place the following steps in the correct order for administration of oral care. a. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway. b. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up to 30 degrees. c. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first. d. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity. e. Remove partial plate or dentures if present. f. Gently brush tongue, but avoid stimulating gag reflex.
b,e,a,c,f,d
Which of the following actions by the nurse demonstrate the practice of core principles of surgical asepsis? (Select all that apply.) a. The front and sides of the sterile gown are considered sterile from the waist up. b. Keep the sterile field in view at all times. c. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. d. Only health care personnel within the sterile field must wear personal protective equipment. e. After cleansing the hands with antiseptic rub, apply clean disposable gloves.
b.c
A nurse is preparing information for a change-of-shift report. Which of the following information should the nurse include in the report? a. Input and output for the shift b. Blood pressure from the previous day c. Bone scan scheduled for today d. Medication routine from the medication administration record
c
A nurse is writing a telephone order for medication. Which written order is the safest? a. Furosemide (Lasix) 10.0 mg b.i.d. b. Furosemide (Lasix) 10 mg bid PO c. Furosemide (Lasix) 10 mg two times a day orally d. Furosemide (Lasix) 10 mg 2×/day by mouth
c
A patient is placed on Airborne Precautions for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? a. Provide a dark, quiet room to calm the patient. b. Reduce the level of precautions to keep the patient from becoming angry. c. Explain the reasons for isolation procedures and provide meaningful stimulation. d. Limit family and other caregiver visits to reduce the risk of spreading the infection.
c
A patient receiving chemotherapy experiences stomatitis. The nurse advises the patient to use: a. Community mouthwash. b. Alcohol-based mouth rinse. c. Normal saline rinses. d. Firm toothbrush.
c
A preceptor observes a new graduate nurse discussing changes in a patient's condition with a physician over the phone. The new graduate nurse accepts telephone orders for a new medication and for some laboratory tests from the physician at the end of the conversation. During the conversation the new graduate writes the orders down on a piece of paper to enter them into the electronic medical record when a computer terminal is available. At this hospital new medication orders entered into the electronic medical record can be viewed immediately by hospital pharmacists, and hospital policy states that all new medications must be reviewed by a pharmacist before being administered to patients. Which of the following actions requires the preceptor to intervene? The new nurse: a. Reads the orders back to the health care provider to verify accuracy of transcribing the orders after receiving them over the phone. b. Documents the date and time of the phone conversation, the name of the physician, and the topics discussed in the electronic record. c. Gives a newly ordered medication before entering the order in the patient's medical record. d. Asks the preceptor to listen in on the phone conversation.
c
The nurse is administering a dose of metoprolol to a patient, and is completing the steps of bar code medication administration within the EHR. As the bar code information on the medication is scanned, an alert that states "Do not administer dose if apical heart rate (HR) is <60 beats/minute or systolic blood pressure (SBP) is <90 mm Hg" appears on the computer screen. The alert that appeared on the computer screen is an example of what type of system? a. Electronic health record (EHR) b. Charting by exception c. Clinical decision support system (CDSS) d. Computerized physician order entry (CPOE)
c
The nurse is caring for a patient with a nasogastric feeding tube who is receiving a continuous tube feeding at a rate of 45 mL per hour. The nurse enters the patient assessment data and information that the head of the patient's bed is elevated to 20 degrees. An alert appears on the computer screen warning that this patient is at a high risk for aspiration because the head of the bed is not elevated enough. This warning is known as which type of system? a. Electronic health record b. Clinical documentation c. Clinical decision support system d. Computerized physician order entry
c
The nurse is reviewing the Health Insurance Portability and Accountability Act (HIPAA) regulations with the patient during the admission process. The patient states, "I'm not familiar with these HIPAA regulations. How will they affect my care?" Which of the following is the best response? a. HIPAA allows all hospital staff access to your medical record. b. HIPAA limits the information that is documented in your medical record. c. HIPAA provides you with greater protection of your personal health information. d. HIPAA enables health care institutions to release all of your personal information to improve continuity of care.
c
The nurse observes an adult Middle Eastern patient attempting to bathe himself with only his left hand. The nurse recognizes that this behavior likely relates to: a. Obsessive-compulsive behavior. b. Personal preferences. c. The patient's cultural norm. d. Controlling behaviors.
c
What is the appropriate way for a nurse to dispose of information printed out from a patient's electronic health record? a. Rip the papers up into small pieces and place the pieces into a standard trash can b. Place all papers in the flip-top binder designated for that patient that is located in the nurse's station on the patient care unit c. Place papers with patient information in a secure canister marked for shredding d. Burn documents with patient information in the steel sink located within the dirty supply room on the patient care unit
c
When documenting an assessment of a patient's cardiac system in an electronic health record, the nurse uses the computer mouse to select the "WNL" statement to document the following findings: "Heart sounds S1 & S2 auscultated. Heart rate between 80-100 beats per minute, and regular. Denies chest pain." This is an example of using which of the following documentation formats? a. Focus charting incorporating "Data, Action & Response" (DAR) b. Problem-intervention-evaluation (PIE) c. Charting-by-exception (CBE) d. Narrative documentation
c
When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it is important that the nurse a. keep the sterile field at least 6 ft away from the client's bedside. b. instruct the client to refrain from coughing and sneezing during the dressing change. c. place a mask on the client to limit the spread of micro-organisms into the surgical wound. d. keep a box of facial tissues nearby for the client to use during the dressing change.
c
While planning morning care, which of the following patients would have the highest priority to receive his or her bath first? a. A patient who just returned to the nursing unit from a diagnostic test b. A patient who prefers a bath in the evening when his wife visits and can help him c. A patient who is experiencing frequent incontinent diarrheal stools and urine d. A patient who has been awake all night because of pain 8/10 e. A patient with a malignant brain tumor requires oral care. The patient's level of consciousness has declined, with the patient only being able to respond to voice commands.
c
Integrity of the oral mucosa depends on salivary secretion. Which of the following factors impairs salivary secretion? (Select all that apply.) a. Use of cough drops b. Immunosuppression c. Radiation therapy d. Dehydration e. Presence of oral airway
c,d
When the nurse is assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should the nurse perform before the procedure? (Select all that apply.) a. Oxygen saturation b. Heart rate c. Respirations d. Gag reflex e. Response to painful stimulus
c,d
A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (Select all that apply.) a. A bottle containing a sterile solution b. The edge of the sterile drape at the base of the field c. The inner wrapping of an item on the sterile field d. An irrigation syringe on the sterile field e. One gloved hand with the other gloved hand
c,d,e
Place the following steps for providing oral care to a debilitated patient in the correct order. a. Remove dentures or partial plates if present. b. Apply thin layer of water-soluble moisturizer to lips. c. Perform hand hygiene and apply clean gloves. d. Brush inner and outer surfaces of upper and lower teeth by brushing from gum to crown of each tooth; then clean biting surfaces of teeth. e. If needed, turn on suction machine and connect tubing to suction catheter. f. Position patient in side-lying position with head turned toward mattress in dependent position. g. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway.
c,f,a,e,g,d,b
A manager is reviewing the nursing documentation entered by a staff nurse in a patient's electronic medical record and finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information? a. "Avoid rushing when documenting an entry in the medical record." b. "Use correction fluid to remove the entry." c. "Draw a single line through the statement and initial it." d. Enter only objective and factual information about a patient in the medical record.
d
A nurse is administering medications using bar code technology. One of the medications does not have a full bar code on it. Which action by the nurse is best? a. Bypass the bar code system and give the drug. b. Fill out a variance report and administer the drug. c. Have a second nurse verify the drug information. d. Obtain a new dose; return the old one to the pharmacy.
d
A nurse is assigned to care for the following patients. Which patient is most at risk for developing skin problems and thus requiring thorough bathing and skin care? a. A 44-year-old female patient who has had removal of a breast lesion and is having her menstrual period b. A 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration and who has an intravenous line c. A 60-year-old female patient who experienced a stroke with right-sided paralysis and has an orthopedic brace applied to the left leg d. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool
d
A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of? a. Allergic reaction b. Ringworm c. Systemic Lupus erythematosus d. Tuberculosis
d
A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes.The client is experiencing which of the following stages of the infection? a. Prodromal b. Incubation c. Convalescence d. Illness
d
A nurse is preparing to discharge a patient who speaks very little English. Which action by the nurse is best? a. Print the instructions in the patient's native language. b. See if a family member can interpret the instructions. c. Teach a family member the discharge instructions. d. Use a professional interpreter to give the instructions.
d
As the nurse enters a patient's room, the nurse notices that the patient is anxious. The patient quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate way for the nurse to document this observation of the patient? a. "The patient has a defiant attitude and is demanding test results." b. "The patient appears to be upset with the nurse because he wants his test results immediately." c. "The patient is demanding and is complaining about the doctor." d. "The patient stated feelings of frustration from the lack of information received regarding test results."
d
The nurse is changing the dressing over the midline incision of a patient who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts the surgeon (Dr. Oakman) by telephone to discuss changes in the incision that are of concern. Which of the following illustrates the most appropriate way for the nurse to document this conversation? a. Health care provider notified about change in assessment of abdominal incision. T. Wright, RN b. 09-3-18: Notified Dr. Oakman by phone that there is a new area of redness around the patient's incision. T. Wright, RN c. 1015: Contacted Dr. Oakman and notified about changes in abdominal incision. T. Wright, RN d. 09-3-18 (1015): Dr. Oakman contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN
d
The nurse is discussing the advantages of using computerized provider order entry (CPOE) with a nursing colleague. Which statement best describes the major advantage of a CPOE system within an electronic health record? a. CPOE reduces the time necessary for health care providers to write orders. b. CPOE reduces the time needed for nurses to communicate with health care providers. c. Nurses do not need to acknowledge orders entered by CPOE in an electronic health record. d. CPOE improves patient safety by reducing transcription errors.
d
The nurse is reviewing health care provider orders that were handwritten on paper when all computers were down during a system upgrade. Which of the following orders contain an inappropriate abbreviation included on The Joint Commission's "Do Not Use" list and should be clarified with the health care provider? a. Change open midline abdominal incision daily using wet-to-moist normal saline and gauze. b. Lorazepam 0.5 mg PO every 4 hours prn anxiety c. Morphine sulfate 1 mg IVP every 2 hours prn severe pain d. Insulin aspart 8u SQ every morning before breakfast
d
When a nurse delegates hygiene care for a male patient to a nurse assistant, the assistant must use an electric razor to shave the patient with the following diagnosis: a. Congestive heart failure b. Pneumonia c. Arthritis d. Thrombocytopenia
d
When should a gown be worn? a. When the patient's hygiene is poor b. When the nurse is assisting with medication administration c. When the patient has shingles d. When blood or body fluids may get on the nurse's clothing
d
Which of the following documentation entries is most accurate? a. "Patient walked up and down hallway with assistance, tolerated well." b. "Patient up, out of bed, walked down hallway and back to room, tolerated well." c. "Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk." d. "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise."
d
5. A nurse prepares to contact a patient's physician about a change in the patient's condition. Put the following statements in the correct order using SBAR (Situation, Background, Assessment, and Recommendation) communication. a. "She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on levofloxacin at 5 PM yesterday. She states she has a poor appetite, her weight has remained stable over the past 2 days." b. "The patient reported feeling very nauseated after her dose of levofloxacin an hour ago." c. "Is it possible to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" d. "The patient started to complain of nausea yesterday evening and has vomited several times during the night."
d-S, a-B, b-A, c-R
