NURS 3234 Exam 1 Practice Questions
A nurse caring for a pt who is hospitalized following a double mastectomy is preparing a discharge plan for the pt. Which action should be the focus of this termination phase of the helping relationship? a. determining the progress made in achieving established goals b. clarifying when the pt should take medications c. reporting the progress made in teaching to the staff d. including all family members in the teaching session
a
A nurse caring for pts in a long-term care facility is implementing intervention to help promote sleep in elderly pts. Which action is recommended for these pts? a. increase physical activities during the day b. encourage short periods of napping during the day c. increase fluids during the evening d. dispense diuretics during the afternoon hours
a
A nurse is administering a pain med to a pt. In addition to checking his ID bracelet, the nurse correctly verifies his identity by: a. asking pt his name b. reading pt's name on the sign over the bed c. asking pt's roommate to verify his name d. asking "are you Mr. Brown?"
a
A nurse is administering an oral med to a pt via a gastric tube. The nurse observes the med enter the tube, and then the tube becomes clogged. What would be the appropriate initial action? a. attempt to dislodge the med with a 10 mL syringe b. notify the primary care provider c. remove the tube and replace it with another tube d. flush the tube with 60 mL of water
a
A nurse is assessing the following children. Which child would the nurse identify as having the greatest risk for choking and suffocating? a. a toddler playing with his 9 year old brother's construction set b. a 4 year old eating yogurt for lunch c. an infant covered with a small blanket and asleep in the crib d. a 3 year old drinking a glass of juice
a
A nurse is caring for an 80 year old female pt who is living in a long-term care facility. To help this pt adapt to her present circumstances, the nurse is using reminiscence as therapy. Which question would encourage reminiscence? a. "tell me about how you celebrated christmas when you were young" b. "tell me how you plan to spend your time this weekend" c. "did you enjoy the choral group that performed here yesterday?" d. "why don't you want to talk about your feelings?"
a
A nurse is inserting an oropharyngeal airway for a pt who vomits when it is inserted. Which action would be the first that should be taken by the nurse related to this occurence? a. quickly position the pt on his or her side b. put on disposable gloves and remove the oral airway c. check that the airway is the appropriate size for the pt d. put on sterile gloves and suction the airway
a
A nurse is instructing a pt who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this pt? a. support weight on stronger leg and cane and advance weaker foot forward b. hold the cane in the same hand of the leg with the most severe deficit c. stand with as much weight distributed on the cane as possible d. do not use the cane to rise from a sitting position, as this is unsafe
a
A nurse is teaching parents in a class about the use of car seats and restraints for infants and children. Which info is accurate and should be included in the teaching plan? a. booster seats should be used for children until they are 4'9 tall and weight between 80-100 lbs b. most US states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle c. infants and toddlers up to 2 years of age (or up to the max height and weight for the seat) should be in a front-facing safety seat d. children older than 6 years may be restrained using a car seat belt in the back seat
a
A nurse is using the SOAP format of documentation to document care of a pt who is diagnosed with type 2 diabetes. Which source of info would be the nurse's focus when completing this documentation? a. a pt problem list b. notes describing a pt's condition c. overall trends in pt status d. planned interventions and pt outcomes
a
A nurse observes some involuntary muscle jerking in a sleeping pt. The nurse determines that the pt is most likely in which stage of sleep? a. stage I NREM sleep b. stage II NREM sleep c. stage IV NREM sleep d. REM sleep
a
A nurse sees a pt walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. It is important that the nurse assess the pt for: a. pain b. anxiety c. depression d. fluid volume deficit
a
A nurse working in a long-term care facility uses proper pt-care ergonomics when handling and transferring pts to avoid back injury. Which action should be the focus of these preventive measures? a. carefully assessing the pt care environment b. using 2 nurses to lift a pt who cannot assist c. wearing a back belt to perform routine duties d. properly documenting the pt lift
a
An elderly pt is confined to bedrest following cervical spine surgery to treat nerve pinching. The nurse is vigilant about turning the pt and assessing the pt regularly to prevent the formation of pressure ulcers. What type of agent is the stimulus for pressure ulcers? a. mechanical b. thermal c. chemical d. electrical
a
Mr. Wright is recovering from abdominal surgery. When the nurse assists him to walk, she observes that he grimaces, moves stiffly, and becomes pale. She is aware that he has consistently refused his pain medication. What would be a priority nursing diagnosis for this pt? a. acute pain related to fear of taking prescribed post op medications b. impaired physical mobility related to surgical procedure c. anxiety related to outcome of surgery d. risk for infection related to surgical incision
a
The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this pt? a. CRIES scale b. COMFORT scale c. FLACC scale d. FACES scale
a
To determine the significance of a BP reading of 148/100, it is first necessary for the nurse to: a. compare this reading to standards b. check the taxonomy of nursing diagnoses for a pertinent label c. check a medical text for the signs and symptoms of high BP d. consult with colleagues
a
To promote sleep in a pt, a nurse suggest what intervention? a. follow the usual bedtime routine if possible b drink 2-3 glasses of water at bedtime c. have a large snack at bedtime d. take a sedative-hypnotic every night at bedtime
a
When a fire occurs in a pts room, what would be the nurse's priority? a. rescue the pt b. extinguish fire c. sound alarm d. run for help
a
When interacting with a pt, the nurse answers "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate communication technique? a. cliche b. giving advice c. being judgmental d. changing the subject
a
When the initial nursing assessment revealed that a pt had not had a BM for 2 days, the student nurse wrote the diagnostic label "constipation." Which of the following comments is the nurse most likely to hear from the instructor? a. hold on a minute.... nursing diagnoses should always be derived from clusters of significant data rather than from a single clue b. job well done.... you've identified this problem early and we can manage it before it becomes more acute c. is this an actual or possible diagnosis? d. this is a medical, not nursing problem
a
What action does the nurse perform to follow safe technique when using the portable oxygen cylinder? a. checking the amount of oxygen in the cylinder before using it b. using a cylinder for a pt transfer that indicates available oxygen is 500 psi c. placing the oxygen cylinder on the stretcher next to the pt d. discontinuing oxygen flow by turning the cylinder key counterclockwise until tight
a unsafe to have 500 psi or less, cylinder should be secured properly , need to turn clockwise
A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states "How is she doing, since the baby's father is no help?" What is the nurse's best response to the neighbor? a. new mothers need support b. the lack of a father is difficult c. how are you today? d. it is a very sad situation
a - general statement
A nurse is assessing pts in a skilled nursing facility for sleep deficits. Which pts would be considered at a higher risk for having sleep disturbances? Select all that apply. a. a pt who has uncontrolled hypothyroidism b. a pt with coronary artery disease c. a pt who has GERD d. a pt who is HIV positive e. a pt who is taking corticosteroids for arthritis f. a pt with a UTI
a, b, c
A nurse caring for pts in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply. a. promotes the pts sense of well-being b. prevents deterioration of oral cavity c. contributes to decreased incidence of aspiration pneumonia d. eliminates the need for flossing e. decreases oropharyngeal secretions f. compensates for an inadequate diet
a, b, c others are false
Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. a. closely assess the pt before, during, and after the procedure b. hyperoxygenate the pt before and after the suctioning c. limit the application of suction to 20-30 seconds d. monitor the pt's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve e. use an appropriate suction pressure (80-150 mmHg) f. insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube
a, b, d, e
A nurse is preparing meds for pts in the ICU. The nurse is aware that there are pt variables that may affect the absorption of these meds. Which statements accurately describe these variables? Select all that apply. a. pts in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed b. some people experience the same response with a placebo as with the active drug used in studies c. people with liver disease metabolie drugs more quickly than people with normal liver functioning d. a pt who receives a pain med in a nosy environment may not receive the full benefit from the med's effects e. oral meds should not be given with food as the food may delay the absorption of the meds f. circadian rhythms and cycles may influence drug action
a, b, d, f
A nurse is teaching a pt with a sleep disorder how to keep a sleep diary. Which data would the nurse have the pt document? Select all that apply. a. daily mental activities b. daily physical activities c. morning and evening body temp d. daily measurement of fluid intake and output e. presence of anxiety or worries affecting sleep f. morning and evening BP readings
a, b, e
A nurse formulates the following diagnosis for an elderly pt who is having trouble getting to sleep at night: Disturbed Sleep Pattern: Initiation of Sleep. Which of the following nursing interventions would the nurse perform related to this diagnosis? Select all that apply. a. arrange for assessment for depression and treatment b. discourage napping during the day c. decrease fluids during the evening d. administer diuretics in the morning e. encourage the pt to engage in some type of physical activity f. assess meds for side effects of sleep pattern disturbances
a, b, e, f
In addition to standard precautions, the nurse would initiate droplet precautions for which pts? Select all that apply. a. pt diagnosed with rubella b. pt diagnosed with diptheria c. pt diagnosed with varicella d. pt diagnosed with TB e. pt diagnosed with MRSA f. pt diagnosed with adenovirus infection
a, b, f
The 3 types of responses to pain are physiologic, behavioral, and affective. Which are examples of behavioral responses to pain? Select all that apply a. pt cradles a wrist that was injured in a car accident b. a child is moaning and crying due to a stomachache c. a pt's pulse is increased following a myocardial infarction d. a pt in pain strikes out at a nurse who attempt to bathe him e. a pt who has chronic cancer pain is depressed and withdrawn f. a child pulls away from a nurse trying to give him an injection
a, b, f physiologic would be increased BP or dilation of pupils affective responses are anger, withdrawal, and depression
A nurse caring for older adults in a long-term care facility knows that several physical changes occur in the aging adult. Which characteristics best describe these changes? Select all that apply. a. fatty tissue is redistributed b. the skin is drier and wrinkles appear c. cardiac output increases d. muscle mass increases e. hormone production increases f. visual and hearing acuity diminishes
a, b, f - physical changes others just cause menopause or andropause
A 17 year old has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the pt? a. use the axillae to bear body weight b. keep elbows close to the sides of the body c. when rising, extend the uninjured leg to prevent weight bearing d. to climb stairs, place weight on affected leg first
b
A nurse is caring for a 25 year old male pt who is comatose following a head injury. The pt has several piercings in his ears and nose. The piercing in his nose appears to be new and is crusted and slightly inflamed. Which action would be appropriate when caring for this pt's piercings? a. do not remove or wash the piercings without permission from pt b. rinse the sites with warm water and remove crusts with a cotton swab c. wash the sites with alcohol and apply an antibiotic ointment d. remove the jewelry and allow the sites to heal over
b do not use alcohol, peroxide, or ointments at the site or remove unless absolutely necessary!
A nurse is using the Katz Index of Independence in Activities of Daily Living to assess the mobility of an 80 year old hospitalized female pt. During the pt interview the nurse documents the following pt data: pt bathes self completely but needs help with dressing.. pt toilets independently and is continent. pt needs help moving from bed to chair. pt follows directions and can feed self. Based on this data, which score would the pt receive? a. 2 b. 4 c. 5 d. 6
b one point is awarded for independence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding
A nurse assesses a pt and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bedrest as evidenced by reddened areas of skin on the heals and back. Which phrase represents the etiology of this diagnostic statement? a. risk for impaired skin integrity b. related to prescribed bedrest c. as evidenced by d. as evidenced by reddened areas of skin of the heels and back
b risk for impaired skin integrity is the problem as evidenced by reddened areas of skin on heels and back are the defining characteristics of the problem
A nurse makes a clinical judgement that an African American male pt in a stressful job is more vulnerable to developing hypertension than white male pts in the same or similar situation. The nurse has formulated what type of nursing diagnosis? a. actual b. risk c. possible d. wellness
b - a clinical judgement that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a risk nursing diagnosis
A nurse assess a pt's body temp in the late afternoon as 99F. What would be the nurse's best action related to this slight elevation in temperature? a. assess the pt for infection b. record the temp as a normal finding c. call the physician for an order for antipyretics d. decrease the room temp
b - slight increase in late afternoon is the result of normal circadian rhythm and does not need to be reported unless it gets higher
Based on Erikson's theory, middle adults who do not achieve their developmental tasks may be considered to be in stagnation. Which statement is one example of this finding? a. "I am helping my parents move into an assisted-living facility" b. "I spend all of my time going to the doctor to be sure I am not sick" c. "I have enough money to help my son and his wife when they need it" d. "I earned this gray hair and I like it!"
b - tend to become overly concerned about their own health
A nurse is caring for an 80-year-old pt who has become weak and fatigues easily. He is unable to wash his body and always asks the nurse to brush his teeth. Based on this info, what is an appropriate nursing diagnosis for this pt? a. risk for impaired skin integrity related to immobility b. bathing/hygiene self-care deficit related to decreased strength and endurance c. social isolation related to lack of visitors d. impaired oral mucous membrane related to inability to brush his teeth
b - the others may be appropriate but not enough info is known
A nurse is caring for a 16 year old male pt who has been hospitalized for an acute asthma exacerbation. Which testing methods might the nurse use to measure the pt's O2 sat? Select all that apply. a. thoracentesis b. spirometry c. pulse oximetry d. peak expiratory flow rate e. diffusion capacity f. maximal respiratory pressure
b, c, d
According to the Health Insurance Portability and Accountability Act of 1996, if a health institution wants to release PHI for purposes other than treatment, payment, and routine health care operations, the pt must be asked to sign an authorization. The nurse is aware that there are exceptions to this requirement. In which of the following cases is an authorization form not needed? Select all that apply. a. news media are preparing a report on the condition of a public figure b. data are needed for the tracking and notification of disease outbreaks c. protected health info is needed by a coroner d. child abuse and neglect are suspected e. protected health info is needed to facilitate organ donation f. the sister of a pt with Alzheimer's wants to help provide care
b, c, d, e
A nurse caring for pts in a skilled nursing facility performs risk assessments on the pts for foot and nail problems. Which pts would be at higher risk? Select all that apply. a. pt who is taking antibiotics for chronic bronchitis b. pt diagnosed with type II diabetes c. pt who is obese d. pt who has nervous habit of biting his nails e. pt diagnoses with prostate cancer f. pt whose job involves frequent hand washing
b, c, d, f nail and foot difficulties can be due to deficient self-care abilities, vascular disease, arthritis, DM, history of biting nails or trimming improperly, frequent of prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity
A nurse is providing discharge teaching for pts regarding their meds. For which pts would the nurse recommend actions to promote sleep? Select all that apply. a. a pt who is taking iron supplements for anemia b. a pt with Parksinson disease who is taking dopamine c. an elderly pt taking diuretics for CHF d. a pt who is taking antibiotics for an ear infection e. a pt who is prescribed antidepressants f. a pt who is taking low-dose aspirin prophylactically
b, c, e
A nurse instructor is teaching a class of student nurses about the nature of pain. Which statements accurately describe this phenomenon? Select all that apply. a. pain is whatever the physician treating the pain says it is b. pain exists whenever the person experiencing it says it exists c. pain is an emotional and sensory reaction to tissue damage d. pain is a simple, universal, and easy-to-describe phenomenon e. pain that occurs without a known cause is psychological in nature f. pain is classified by duration, location, source, transmission, and etiology
b, c, f
A nurse is assisting a post op pt with conditioning exercises to prepare for ambulation. The nurse correctly instructs the pt to do which actions? Select all that apply. a. do full-body push ups in bed 6-8 times b. breathe in and out smoothly during quadriceps drills c. place the bed in the lowest position or use a footstool for dangling d. dangle of side of bed for 30-60 minutes e. allow the nurse to bathe the pt completely to prevent fatigue f. perform quadriceps 2-3 times per hour, 4-6 times a day
b, c, f
A nurse is caring for an older adult pt who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this pt? Select all that apply. a. bronchial pneumonia b. impaired gas exchange c. ineffective airway clearance d. potential complication: sepsis e. infection related to pneumonia f. risk for septic shock
b, c, f nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, they are not medical diagnoses!
A nurse working in a long-term care facility is providing teaching to pts with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. a. refrain from exercise b. reduce anxiety c. eat meals 1-2 hrs prior to breathing treatments d. eat a high-protein/high-calorie diet e. maintain a high-Fowler's position when possible f. drink 2-3 pints of clear fluids daily
b, d, e should pace physical activities and schedule frequent resting periods, meals should be eaten 1-2 after breathing treatments and exercises, drink 2-3 quarts of clear fluids daily
A nurse who is caring for older adults in a senior daycare center documents findings as related to which normal aging process? Select all that apply. a. a pt's increased skin elasticity causes wrinkles on the face and arms b. exposure to sun over the years causes a pt's skin to be pigmented c. a pt's toenails have become thinner with a bluish tint to the nail beds d. a pt experiences a hip fracture due to porous and brittle bones e. fragile blood vessels in the dermis allow for more easy bruising of a pt's forearm f. increased bladder capacity causes decreased voiding in an older patient
b, d, e - correct a, c, f are false
A RN is writing a diagnosis for a 28 year old male pt who is in traction due to multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. a. nurse uses the nursing interview to collect pt data b. nurse analyzes data collected in nursing assessment c. nurse develops a care plan for this pt d. nurse points out the pt's strengths e. nurse assesses the pt's mental status f. nurse identifies community resources to help his family cope
b, d, f
The nurse caring for pts in a long-term care facility knows that there are factors that place certain pts at higher risk for falls. Which pts would the nurse consider to be in this category? Select all that apply a. older than 60 years b. who has already fallen twice c. who is taking antibiotics d. who experiences postural hypotension e. who is experiencing nausea from chemotherapy f. 70 year old who is transferred to long-term care facility
b, d, f over 65, history of falls, postural hypotension, unfamiliar environment, medications like diuretics, tranquilizers, sedatives, hypnotics, or analgesics NOT chemotherapy or antibiotics
Following a fall that left an elderly male pt temporarily bedridden, the nurse is using the SPICES assessment tool to evaluate him for cascade iatrogenesis. Which are correct aspects of this tool? Select all that apply. a. S = senility b. P = problems with feeding c. I = irritableness d. C = confusion e. E = edema of legs f. S = skin breakdown
b, d, f S = sleep disorders P = problems with eating or feeding I = incontinence C = confusion E = evidence of falls S = skin breakdown
A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. Which steps in this procedure are performed correctly? Select all that apply. a. the nurse removes all jewelry including a platinum wedding band b. the nurse washes hands to one inch above wrists c. the nurse uses approx 2 teaspoons of liquid soap d. the nurse keeps hands higher than elbows when placing under faucet e. the nurses uses friction motion when washing for at least 15 sec f. the nurse rinses thoroughly with water flowing toward fingertips
b, e, f
A nurse is administering heparin subcutaneously to a pt. what is the correct technique for this procedure? a. aspirate before giving and gently massage after the injection b. do not aspirate, massage the site for 1 min c. do not aspirate before or massage after injection d. massage the site of the injection, aspiration is not necessary but will do no harm
c
A nurse is assisting a pt who is 2 days post op from a c-section to sit in a chair. After assisting the pt to the side of the bed and to stand up, the pt's knees buckle and she tells the nurse she feels faint. What should the nurse do in this situation? a. wait a few minutes and then continue the move to the chair b. call for assistance and continue the move to the chair c. lower the pt back to the side of the bed and pivot her back into bed d. have the pt sit down on the bed and dangle her feet before movin
c
A nurse is caring for a 26 year old male pt who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the pt to reposition him on his side? a. have pt extend his arms outward and cross his legs on top of a pillow b. stand at the side of the bed in which the pt will be turned while another nurse gently pushes the pt from the other side c. have pt cross his arms on his chest and place a pillow between his knees d. place a cervical collar on the pt's neck and gently roll him to the other side of the bed
c
A nurse is caring for a 72 year old male pt who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? a. dorsal recumbant b. lateral positions c. fowlers d. sims
c
A nurse is caring for a pt who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. Which diagnosis would be most appropriate for this pt? a. ineffective coping: multiple stressors of new job b. sleep deprivation: difficulty falling asleep c. disturbed sleep pattern: altered sleep-wake pattern d. risk for injury: activity intolerance/sleep deprivation
c
A nurse is discussing with an older female pt the factors that affect sleep. What fact does the nurse teach her? a. drinking a cup of regular tea at night induces sleep b. using alcohol moderately promotes a deep sleep c. aging decreases the amount of REM sleep a person experiences d. exercising decreases REM and NREM sleep
c
A nurse is finished with patient care. How would the nurse remove PPE when leaving the room? a. remove gown, goggles, mask, gloves, and exit the room b. remove gloves, perform hand hygiene, then remove gown, mask, and goggles c. untie gown waiststrings, remove gloves, goggles, gown, mask, perform hand hygiene d. remove goggles, mask, gloves, gown, and perform hand hygiene
c
A nurse is following the principles of medical asepsis when performing pt care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? a. the nurse carries the pt's soiled bed linens close to the body to prevent spreading microorganisms into the air b. the nurse places soiled bed linens and hospital gowns on the floor when making the bed c. the nurse moves the pt table away from the nurse's body when wiping it off after a meal d. the nurse cleans the most soiled items in the pt's bathroom first and follows with the cleaner items
c
A nurse is preparing a sterile field using a packaged sterile drape for a confused pt who is scheduled for a surgical procedure. When setting up the field, the pt accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation? a. ask another nurse to hold the hand of the pt and continue setting up the field b. remove the instrument that was touched by the pt and continue setting up the sterile field c. discard the supplies and prepare a new sterile field with another person holding the pts hand d. no action is necessary since the pt has touched his or her own sterile field
c
A nurse is reconstituting powdered meds in a vial. Which action is a recommended step in this process? a. the nurse draws up the proper amount of powdered medication into the syringe b. the nurse inserts the needle through the rubber stopper of the diluent vial c. the nurse gently agitates the powdered med vial to mix the powder and diluent completely d. the nurse draws up the prescribed amount of medication while holding the syringe horizontally at eye level
c
A nurse is securing a pt's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? a. instruct assistant to notify the primary care provider b. assess the pt's VS c. remove the tape, adjust the depth to ordered depth and reapply the tape d. no action is required as depth will adjust automatically
c
A nurse uses a whirlpool to relax a pt following intense physical therapy to restore movement in her legs. What is the potent pain-blocking neuromodulator, released through relaxation techniques? a. prostaglandins b. substance p c. endorphins d. serotonin
c
A nursing instructor teaching classes in gerontology to nursing students discusses myths related to the aging of adults. Which statement is a myth about older adults? a. most older adults live in their own homes b. healthy older adults enjoy sexual activity c. old age means mental deterioration d. older adults want to be attractive to others
c
A nursing student is nervous and concerned about the work she is about to do at the clinical facility. To allay anxiety and be successful in her provision of care, it is most important for her to: a. determine the established goals of the institution b. be sure her verbal and nonverbal communication is congruent c. engage in self-talk to plan her day and decrease her fear d. speak with her fellow colleagues about how they feel
c
A resident who is called to see a pt in the middle of the night is leaving the unit but then remember that he forgot to write a new order for a pain med a nurse had requested for another pt. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the physician's order sheet. The nurse's best response is" a. thank you for taking care of this! b. get a second nurse to listen to the order, and after writing the order on the physician order sheet, have both nurses sign it c. i am sorry, but verbal orders can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly d. try calling another resident for the order or wait until the next shift
c
An older pt with an unsteady gait requests a tub bath. Which action would be most appropriate? a. add alpha-keri oil to the water to prevent dry skin b. allow pt to lock the door to guarantee privacy c. assist the pt in and out of the tub to prevent falling d. keep the water temp very warm bc pt chills easily
c
The nurse assesses pts to determine their risk for health care-associated infections. Which hospitalized pt is most at risk for developing this type of infection? a. a 60 year old pt who smokes 2 packs of cigs daily b. a 40 year old pt who has a WBC count of 6,000 c. a 65 year old pt who has an indwelling urinary catheter in place d. a 60 year old pt who is a vegetarian and slightly underweight
c
What is the leading cause of cognitive impairment in old age? a. stroke b. malnutrition c. alzheimers d. loss of cardiac reserve
c
When developing the plan of care for a pt with chronic pain, the nurse plans interventions based on the knowledge that chronic pain is most effectively relieved when analgesics are administered in what manner? a. on a PRN basis b. conservatively c. around the clock d. intramuscularly
c
While discussing home safety with the nurse, a pt admits that she always smokes a cigarette in bed before falling asleep at night, Which nursing diagnosis would be the priority for this pt? a. impaired gas exchange related to cigarette smoking b. anxiety related to inability to stop smoking c. risk for suffocation related to unfamiliarity with fire prevention guidelines d. deficient knowledge related to lack of follow-through of recommendation to stop smoking
c
Mr. James has an eye infection with a moderate amount of discharge. Which action would be most appropriate for the nurse to use when cleaning his eyes? a. using hydrogen peroxide b. wiping form the outer canthus to the inner canthus c. positioning him on the same side as the eye to be cleansed d. using only one cotton ball per eye
c go from inner to outer use normal saline use one cotton ball for each stroke
A nurse is about to bathe a female pt who has an intravenous access in place in her forearm. The pt's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing, What should the nurse do? a. temporarily disconnect the IV tubing at a point close to the pt and thread it through the gown sleeve b. cut the gown with scissors to allow arm movement c. thread the bag and tubing through the gown sleeve, keeping the line intact d. temporarily disconnect the tubing from the IV container, threading it through the gown
c opening IV line causes potential for infection, cutting gown only used in emergency
A pt with COPD is unable to perform ADLs without becoming exhausted. Which nursing diagnosis best describes this alteration in oxygenation as the etiology? a. decreased cardiac output related to difficulty breathing b. impaired gas exchange related to use of bronchodilators c. fatigue related to impaired oxygen transport system d. ineffective airway clearance related to fatigue
c the others are examples of nursing diagnoses indicating alterations in oxygenation as the problem
A nurse caring for adults in a physician's office notes that some pts age more rapidly than other pts of the same age. The nurse researches aging theorists that attempt to describe how and why aging occurs. Which statements apply to the immunity theory of aging? Select all that apply. a. chemical reactions in the body produce damage to the CNS b. free radicals have adverse effects on adjacent molecules c. decrease in size and function of the thymus causes infection d. there is much interest in the role of vitamin supplements e. lifespan depends on a great extent to generic factors f. organisms wear out from increased metabolic functioning
c and d - this theory focuses on the functions of the immune system and states that the immune response declines steadily after younger adulthood as the thymus loses size and function, causing more infections a - is the cross-linkage theory b - free radical theory e - the genetic theory of aging f - the wear and tear theory
A school nurse is teaching parents about home safety and fires. What info would be accurate to include in the teaching plan? Select all that apply. a. 60% of US fire deaths occur in the home b. most fatal fires occur when people are cooking c. most people who die in fires die of smoke inhalation d. over 1/3 of fire deaths occur in a home without a smoke detector e. fires are more likely to occur in homes without electricity or gas f. more fires occur in homes occupied by single parents
c, d, e
During an interaction with a pt diagnosed with epilepsy, a nurse notes that the pt is silent after she communicates the plan of care. What would be the appropriate nurse responses in this situation? Select all that apply. a. fill the silence with lighter conversation directed at the pt b. use time to perform the care that is needed uninterrupted c. discuss the silence the the pt to ascertain its meaning d. allow the pt time to think and explore inner thoughts e. determine if pt's culture requires pauses between conversation f. arrange for a counselor to help the pt cope with emotional issues
c, d, e
The nurse is administering a med to a pt via a nasogastric tube. Which are accurate guidelines related to this procedure? Select all that apply. a. crush the enteric coated pill for mixing in a liquid b. flush open the tube with 60 mL of very warm water c. check for proper placement of the nasogastric tube d. give each med separately and flush with water between each drug e. lower the head of the bed to prevent reflux f. adjust the amount of water used if pt's fluid intake is restricted
c, d, f
A nurse is documenting pt data in the medical record of a pt admitted to the hospital with a diagnosis of appendicitis. The physician has ordered 10 mg morphine IV every 3-4 hours. Which examples of documentation of care for this pt follows recommended guidelines? Select all that apply. a. 6/12/15 0945 Morphine 10 mg administered IV. Pt's response to pain appears to be exaggerated. M. Patrick, RN b. 6/12/15 0945 Morphine 10 mg administered IV. Pt seems to be comfortable. M. Patrick, RN c. 6/12/15 0945 30 minutes following administration of morphine 10 mg IV pt reports pain as 2 on a scale of 1 to 10. M. Patrick, RN d. 6/12/15 0945 Pt reports severe pain in right lower quadrant. M. Patrick, RN e. 6/12/15 0945 Morphine 10 mg will be administered to pt every 3-4 hours. M. Patrick, RN f. 6/12/15 0945 Pt states she does not want pain medication despite return of pain After discussing idtuation, pt agrees to medication administration
c, d, f enter info in a complete, accurate, concise, current, and factual manner indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions avoid stereotypes or generalizations never document an intervention before carrying it out
A nurse observes a slight increase in a pt's VS while he is sleeping during the night. According to the pt's stage of sleep, the nurse expects what conditions to be true? Select all that apply. a. he is aware of her surroundings at this point b. he is in delta sleep at this time c. it would be most difficult to awaken him at this time d. this is most likely an NREM stage e. this stage constitutes around 20-25% of total sleep f. the muscles are relaxed in this stage
c, e - this is REM sleep
A nurse is abulating a 48 year old female pt for the first time following surgery for a knee replacement. Shortly after beginning to walk, the pt tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the pt: a. grasp gait belt b. stay with pt and call for help c. place feet wide apart with one foot in front d. gently slide pt down to floor, protecting her head e. pull the weight of the pt backward against your body f. rock your pelvis out on the side of the pt
c, f, a, e, d, b
A 3 year old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admission interview, the nurse should implement which communication techniques to elicit the most info from the parents? a. the use of reflective questions b. the use of closed questions c. the use of assertive questions d. the use of clarifying questions
d
A 49 year old who injured his spine is receiving rehab services in a short-term rehab center. The nurse caring for him correctly tells the aide not to place him in which position? a. side-lying b. fowler's c. sims d. prone
d
A 76 year old pt states "I have been experiencing complications of diabetes." The nurse needs to direct the pt to gain more info. What is the most appropriate comment or question to elicit additional info? a. do you take 2 injections of insulin to decrease the complications? b. most physicians recommend diet and exercise to regulate blood sugar c. most complications of diabetes are related to neuropathy d. what specific complications have you experienced?
d
A female pt who is having a myocardial infarction complains of pain that is situated in her jaw. The nurse documents this as what type of pain? a. transient b. superficial c. phantom d. reffered
d
A medication order reads: "Hydromorphone, 2 mg IV every 3-4 hrs PRN pain." The prefilled cartridge is available with a label reading "Hydromorphone 2 mg/1mL." The cartridge contains 1.2 mL of hydromorphone. Which nursing action is correct? a. give all the med in the cartridge because it expanded when it was mixed b. call the pharmacy and request the proper dose c. refuse to give the med d. dispose of 0.2 mL correctly before administering the drug
d
A nurse enters a pt's room and examines the pt's IV fluids and cardiac monitor. The pt states "Well, I haven't seen you before. Who are you?" What is the nurse's best response? a. i'm just the IV therapist checking your IV b. i've been transferred to this division and will be caring for you c. i'm sorry, my name is John Smith and I am your nurse d. My name is John Smith, I am your nurse and I'll be taking care of you until 11 pm
d
A nurse enters the room of a pt with cancer. The pt is crying and states "I feel so alone." Which statement is the most therapeutic? a. The nurse stands at the pt's bedside and states "i understand how you feel. my mother said the same thing when she was ill" b. The nurse places a hand on the pt's arm and states "you feel so alone" c. The nurse stands in the pt's room and asks "why do you feel so alone? your wife has been here every day" d. The nurse holds the pt's hand and asks "what makes you feel so alone?"
d
A nurse is caring for an obese 62 year old pt with arthritis who has developed an open reddened area over his sacrum. What is a priority nursing diagnosis for this pt? a. imbalanced nutrition: more than body requirements related to immobility b. impaired physical mobility related to pain and discomfort c. chronic pain related to immobility d. risk for infection related to altered skin integrity
d
A nurse is discharging a pt from the hospital following a heart stent procedure. The pt asks to see a copy of his medical record. What is the nurse's best response? a. i'm sorry, but pts are not allowed to copy their medical records b. i can make a copy of your record for you right now c. you can read your record while you are still a pt, but copying records is not permitted according to HIPAA rules d. i will need to check with our records department to get you a copy
d
A nurse is looking for trends in a post op pt's VS. Which documents would the nurse consult first? a. admission sheet b. admission nursing assessment c. activity flow sheet d. graphic record
d
A nurse is suctioning the nasopharyngeal airway of a pt to maintain to patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? a. the pt vomits during suctioning b. the secretions appear to be stomach contents c. the catheter touches an unsterile surface d. epistaxis is noted with continued suctioning
d
A nurse is writing nursing diagnoses for pts in a psychiatrist's office. Which nursing diagnoses are correctly written as 2-part nursing diagnoses? 1. ineffective coping related to inability to maintain marriage 2. defensive coping related to loss of job and economic security 3. altered thought processes related to panic state 4. decisional conflict related to placement of parent in a long-term care facility a. 1 and 2 b. 3 and 4 c. 1, 2, and 3 d. all of the above
d
A nurse orients an older pt to the safety features in her hospital room. What is a priority component of this admission routine? a. explain how to use telephone b. introduce pt to her roommate c. review the hospital policy on visiting hours d. explain how to operate call bell
d
A nurse providing care of a pt's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? a. notify the physician b. apply an occlusive dressing on the site c. assess the pt for signs of respiratory distress d. put on gloves and insert the chest tube in a bottle of sterile saline
d
A nurse who created a sterile field for a pt is adding a sterile solution to the field. What is an appropriate action when performing this task? a. place the bottle cap on the table with the edges down b. hold the bottle inside the edge of the sterile field c. hold the bottle with the label side opposite the palm of the hand d. pour the solution from a height of 4-6 inches
d
A nurse working in a busy ED is caring for a teenage pt who presents with a burning pain in his mouth, edema of the lips, vomiting, and hemoptysis. The teen admits that he was playing a dare game with friends and was forced to swallow a drain opener preparation. What would be the nurse's priority intervention? a. induce vomiting and call primary care provider b. perform stomach lavage and call the poison control center c. give activated charcoal orally and call physician d. dilute poison with milk and call primary care provider
d
A pregnant woman is receiving an epidural analgesic prior to delivery. The nurse provides vigilant monitoring of this pt to prevent the occurrence of: a. pruritus b. urinary retention c. vomiting d. respiratory depression
d
A pt has an order for an analgesic medication to be given PRN. When would the nurse administer this medication? a. every 3 hours b. every 4 hours c. daily d. as needed
d
A pt is post op following an emergency c-section birth. The pt asks the nurse about the use of pain meds following surgery. What would be a correct response by the nurse? a. its not a good idea to ask for pain meds regularly as it can be addicitive b. it is better to wait until the pain gets unbearable before asking for pain meds c. its natural to have to put up with pain after surgery and it will lessen in intensity in a few days d. your doctor has ordered pain meds for you, which you should not be afraid to request any time you have pain
d
An experienced nurse tells a younger nurse who is working in a retirement home that older adults are different and do not have the same desires, needs, and concerns as other age groups. The nurse also comments that most older adults have "outlived their usefulness." What is the term for this type of prejudice? a. harassment b. whistle blowing c. racism d. ageism
d
An older resident who is disoriented likes to wander the halls of his facility. Which action would be the most appropriate for the nurse to use as an alternative to restraints? a. sitting him in a geriatric chair near the nurse's station b. using the sheets to secure him snugly in bed c. keeping the bed in the high position d. identifying his door with his picture and balloon
d
During rounds, a charge nurse hears the PCT yelling loudly to a pt regarding a transfer from the bed to chair. When entering the room, what is the nurse's best response? a. you need to speak to the pt quietly. you are disturbing the pt b. let me help you with your transfer technique c. when you are finished, be sure to apologize for your rough demeanor d. when your pt is safe and comfortable, meet me at the desk
d
The nurse caring for pts in a hospital setting institutes CDC standard precaution recommendations for which category of pts? a. only pts with diagnosed infections b. only pts with visible blood, body fluids, or sweat c. only pts with nonintact skin d. all pts receiving care in hospitals
d
The nurse has opened the sterile supplies and put on 2 sterile gloves to complete a sterile dressing change, a procedure that required surgical asepsis. The nurse must: a. keep splashes on the sterile field to a minimum b. cover the nose and mouth with gloved hands if a sneeze is imminent c. use forceps soaked in a disinfectant d. consider the outer 1 inch of the sterile field as contaminated
d
What consideration should the nurse keep in mind regarding the use of side rails for a confused pt? a. they prevent confused pts from wandering b. a history of previous fall from a bed with raised side rails is insignificant c. alternative measures are ineffective to prevent wandering d. a person of small stature is at increased risk for injury from entrapment
d
When completing a safety event report, the nurse should: a. include suggestions on how to prevent the incident from recurring b. provide minimal info about the incident c. discuss the details with the pt before documenting them d. objectively describe the incident in detail
d
When describing safety issues and related mortality to a local senior citizens group, what would the nurse identify as the leading cause of hospital admissions for trauma in older adults? a. fires b. exposure to temp extremes c. intimate partner violence d. falls
d
When discussing emergency preparedness with a group of first responders, what info would be important to include about preparation for a terrorist attack? a. posttraumatic stress disorders can be expected in most survivors b. the FDA has collaborated with drug companies to create stockpiles of emergency drugs c. even small doses of radiation result in bone marrow depression and cancer d. blast lung injury is a serious consequence following detonation of an explosive device
d
Which of the following nursing diagnoses would be appropriate for many middle adults? a. risk for imbalanced nutrition: less than body requirements b. delayed growth and development c. self-care deficit d. caregiver role strain
d
An unresponsive pt is wearing gas-permeable contact lenses. How would the nurse remove these lenses? a. gently irrigate the eye with an irrigating solution from the inner canthus outward b. grasp the lens with a gentle pinching motion c. don sterile gloves before attempting the removal procedure d. ensure that the lens is centered on the cornea before gently manipulating the lids to release it
d attempt to grasp hard lens might scratch cornea clean, not sterile, gloves are used
A nurse is counseling a 60 year old female pt who refuses to look at or care for a new colostomy. She tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? a. collaborative problem b. interdisciplinary problem c. medical problem d. nursing problem
d - can be treated by nurses within the scope of independent nursing practice
A nurse observes a marked inflammation of the gums, along with recession and bleeding of the gums, and documents this observation using which term? a. glossitis b. caries c. cheilosis d. periodontitis
d - periodontists is a marked inflammation of the gums caries - presence of tooth decay cheilosis - ulceration of the lips glossitis - inflammation of the tongue
A nurse working the night shift in a pediatric unit observes a 10 year old male pt walking the hallway in a sleep state. The child is unaware of his environment and doesn't recall the incident in the morning. Which sleep disorder would the nurse expect? a. bruxism b. cataplexy c. restless leg syndrome d. somnambulism
d - sleepwalking
A med order reads "K-Dur, 20 mEq po b.i.d." When and how does the nurse correctly give this drug? a. daily at bedtime by subcutaneous route b. every other day by mouth c. twice a day by the oral route d. once a week by transdermal path
c
A nurse administers a dose of an oral med for hypertension to a pt who immediately vomits after swallowing the pill. What would be the appropriate initial action of the nurse? a. readminister the med and notify the primary care provider b. readminister the pill in a liquid form if possible c. assess the vomit, looking for pill d. notify the primary care provider
c
A nurse discovers that she made a med error. What should be her first response? a. record the error on the med sheet b. notify the physician regarding course of action c. check the pt's condition to note any possible effect of the error d. complete an incident report, explaining how the mistake was made
c
A nurse is caring of an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this pt? Select all that apply. a. wash skin 2x a day with a mild cleanser and warm water b. use cosmetics liberally to cover blackheads c. use emollients on the area d. squeeze blackheads as they appear e. keep hair off the face and wash hair daily f. avoid sun-tanning booth exposure and use sunscreen
a, e, f
A nurse working with adolescents in a juvenile detention center teaches parents about behaviors that place adolescents at high risk for injury. Which statements accurately describe these risks? Select all that apply, a. each year, underage drinking claims the lives of 5000 individiauls under age of 21 b. approx 1 in 3 HS students reported using some type of tobacco product c. the CDC lists motor vehicle accidents as the number one cause of death for adolescents d. marijuana use among teens has been on the increase and the abuse of prescription meds and OTC drugs has remained at a high level e. homicide rates for teens are high, and youths aged 10-19 years committed almost 500 suicides using firearms f. as many as 30% of children are bullied during their school years and cyber bullying is even more damaging to children
a, c, d
A nurse is caring for pts in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply. a. nurse is providing bed bath for pt b. nurse has visibly soiled hands after changing the bedding of a pt c. nurse removes gloves when pt care is completed d. nurse is inserting a urinary catheter for a female pt e. nurse is assisting with a surgical placement of a cardiac stent f. nurse removes old magazines from a pt's table
a, c, d, f
A nurse is teaching an adolescent pt how to use a MDI to control his asthma. What are appropriate guidelines for this procedure? Select all that apply. a. remove the mouthpiece cover and shake the inhaler well b. take shallow breaths when breathing through the spacer c. depress the canister releasing one puff into the spacer and inhale slowly and deeply d. after inhaling, exhale quickly through pursed lips e. wait 1-5 minutes as prescribed before administering the next puff f. gargle and rinse with salt water after using the MDI
a, c, e
A nurse is providing foot care for pts in a long-term care facility. Which actions are recommended guidelines for this procedure? Select all that apply. a. bath feet thoroughly in a mild soap and tepid water solution b. soak the feet in warm water and bath oil c. dry feet thoroughly, including the area between the toes d. use an alcohol rub if the feet are dry e. use an antifungal foot powder if necessary to prevent fungal infections f. cut the toenails at the lateral corners when trimming the nail
a, c, e avoid soaking feet, use moisturizer if feet are dry avoid digging into or cutting toenails
A nurse is caring for a pt with COPD knows that hypoxia may occur in pts with respiratory problems. What are signs of this serious condition? Select all answers that apply. a. dyspnea b. hypotension c. small pulse pressure d. decreased resp rate e. pallor f. increased pulse rate
a, c, e, f
A nurse is providing ROM exercises for a 53 year old female pt who is recovering from a stroke. During the session, the pt complains that she is "too tired to go on." What would be the priority nursing actions for this pt? Select all that apply. a. stop performing the exercises b. decrease the number of repetitions performed c. re-evaluate the nursing plan of care d. move to the pt's other side to perform exercises e. encourage the pt to finish the exercises then rest f. assess the pt for other symptoms
a, c, f
Nurses performing skin assessments on pts must pay careful attention to cleanliness, color, texture, temp, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply. a. compare bilateral parts for symmetry b. proceed in a toe-to-head systematic manner c. use standard terminology to report and record findings d. do not allow data from nursing history to direct assessment e. document only skin abnormalities on the pt record f. perform appropriate skin assessment when risk factors are identified
a, c, f
A nurse is preparing an exercise program for a 65 year old male pt who has COPD. Which instructions would the nurse include in a teaching plan for this pt? Select all that apply. a. instruct the pt to avoid sudden position changes that may cause dizziness b. recommend that the pt restrict fluid until after exercising is finished c. instruct the pt to push a little further beyond fatigue each session d. instruct the pt to avoid exercising in very cold or very hot temps e. encourage pt to modify exercise if too weak or ill f. recommend that the pt consume a high-carb, low protein diet
a, d
A nurse is teaching a student nurse how to cleanse the perineal area of both male and female pts. What are the accurate guidelines when performing this procedure? Select all that apply. a. for male and females, wash groin area with a small amount of soap and water and rinse b. for females, spread the labia and move the wash-cloth from the anal area toward the pubic area c. for male and females, always proceed from the most contaminated area to the least contaminated area d. for male and females, use a clean portion of the washcloth for each stroke e. for males, clean the tip of the penis first, moving washcloth in a circular motion from meatus outward f. in uncircumcised males, do not retract the foreskin (prepuce) while washing the penis
a, d, e
One of the most common distinctions of pain is whether it is acute or chronic. Which examples describe chronic pain? Select all that apply. a. a pt is receiving chemotherapy for bladder cancer b. an adolescent is admitted to the hospital for an appendectomy c. a pt is experiencing a ruptured aneurysm d. a pt who has fibromyalgia requests pain medication e. a pt has back pain related to an accident that occurred last year f. a pt is experiencing pain from second-degree burns
a, d, e
During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all VS are reported and charted within 15 min following assessment. This is an example of which characteristics of effective communication? Select all that apply. a. group decision making b. group leadership c. group power d. group identity e. group patterns of interaction f. group cohesiveness
a, d, e, f
A nurse who is administering meds to pts in an acute care setting studies the pharmocokinetics of the drugs being administered. Which statements accurately describe these mechanisms of action? Select all that apply. a. distribution occurs after a drug has been absorbed into the bloodstream and is made available to body fluids and tissues b. metabolism is the process by which a drug is transferred from its site of entry into the body to the bloodstream c. absorption is the change of a drug from its original form to a new form, usually occurring in the liver d. during first-pass effect, drugs move from the intestinal lumen to the liver by way of the portal vein instead of going into the system's circulation e. the GI tract, as well as sweat, salivary, and mammary glands, are routes of drug administration f. excretion is the process of removing a drug, or its metabolites, from the body
a, d, f
A friend of a nurse calls and asks if she is still working at Memorial Hospital. The nurse replies yes. The friend tells the nurse that his gf's father was just admitted as a pt and he wants the nurse to find out how he is. The friend states "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should take? a. "you shouldn't be asking me to do this. I could be fined or even lose my job for disclosing this info" b. "sorry, but i'm not able to give info about pts to the public, even when my best friend or a family member asks" c. "because of the Health Insurance Portability and Accountability Act, you shouldn't be asking for this info unless the pt has authorized you to receive it! This could get you in trouble!" d. "why do you think sue isn't talking about her worries?"
b
A nurse assisting with a pt bed bath observes that an older female pt has dry skin. The pt states that her skin is always "itchy." Which nursing action would be the nurse's best response? a. bathe pt more frequently b. use emollient on dry skin c. massage the skin with alcohol d. discourage fluid intake
b
A nurse caring for pts in a busy hospital environment should implement which recommendation to promote sleep? a. keep the room light dimmed during the day b. keep the room cool c. keep the door to the room open d. offer a sleep aid medication to pts on a regular basis
b
A nurse caring for pts in a pediatrician's office assesses infants and toddlers for physical developmental milestones. Which pt would the nurse refer to a specialist based on failure to achieve these milestones? a. a 4 month old infant who is unable to roll over b. a 6 month old infant who is unable to hold his head up himself c. an 11 month old infant who cannot walk unassisted d. an 18 month old toddler who cannot jump
b
A nurse if providing postural drainage for a pt with cystic fibrosis. In which position should the nurse place the pt to drain the right lobe of the lung? a. high fowler's position b. left side with pillow under chest wall c. lying position/half on abdomen and half on side d. trendelenberg position
b
A nurse in the rehab division states to her head nurse, Mr. Tyler, "I need the day off and you didn't give it to me!" The head nurse replies, "Well I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of this exchange, what communication by the nurse would have been more effective? a. "Mr. Tyler, I placed a request to have Aug 8th off, but I'm working and I have a doctor's app" b. "Mr. Tyler, I would like to discuss my schedule with you. I requested the 8th of Aug off for a doctor's app. Could I make an app? c. "Mr. Tyler, I will need to call in on the 8th of Aug because I have a doctor's app" d."Mr. Tyler, since you didn't give me the 8th of Aug off, will I need to find someone to work for me"
b
A nurse is caring for a pt who is on bed rest following a spinal injury. In which position would the nurse place the pt's feet to prevent footdrop? a. supination b. dorsiflexion c. hyperextension d. abduction
b
A nurse is caring for an 82 year old woman in a long term care facility who has had 2 UTIs in the past year related to immobility. Which finding would the nurse expect in this pt? a. improved renal blood supply to the kidneys b. urinary stasis c. decreased urinary calcium d. acidic urine formation
b
A nurse is choosing a catheter to use to suction a pt's endotracheal tube via an open system. On which variable would the nurse base the size of the catheter to use? a. the age of the pt b. the size of the endotracheal tube c. the type of secretions to be suctioned d. the height and weight of the pt
b
A nurse is documenting the care given to a 56 year old pt diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation? a. erase or use correcting fluid to completely delete the error b. draw a single line through the entry and rewrite it above or beside it c. use a permanent marker to block out the mistaken entry and rewrite it d. remove the page with the error and rewrite the data on that page correctly
b
A nurse is performing a sleep assessment on a pt being treated for a sleep disorder. During the assessment, the pt falls asleep in the middle of a conversation. The nurse would suspect which disorder? a. REM behavior disorder b. narcolepsy c. enuresis d. sleep apnea
b
A nurse is providing instruction to a pt regarding the procedure to change his colostomy bag. During the teaching session, he asks "What type of foods should I avoid to prevent gas?" The pt's question allows for what type of communication? a. A closed-ended answer b. Information clarification c. The nurse to give advice d. Assertive behavior
b
A nurse is scheduling hygiene for pts on her unit, What is the most important consideration when planning a pt's personal hygiene? a. When the pt had his or her most recent bath b. the pt's usual hygiene practices and preferences c. where the bathing fits in the nurses sched d. the time that is convenient for the PCA
b
A nurse is using PPE when bathing a pt diagnosed with C. diff. Which nursing action related to this activity promotes safe, effective patient care? a. the nurse puts on PPE after entering the pt room b. the nurse works from "clean" areas to "dirty" areas during the bath c. the nurse personalizes the care by substituting glasses for goggles d. the nurse removes PPE prior to leaving pt room
b
A nurse teaches a pt at home to use clean technique when changing a wound dressing. This practice is considered: a. the nurse's preference b. safe for the home setting c. unethical behavior d. grossly negligent
b
A nurse who is caring for a pt diagnosed with HIV/AIDS incurs a needlestick injury when administering the pt's medications. What would be the priority action of the nurse following the exposure? a. report the incident to the appropriate person and file an incident report b. wash the exposed area with warm water and soap c. consent to postexposure prophylaxis at appropriate time d. set up counseling sessions regarding safe practice to protect self
b
A nurse writes nursing diagnoses for pts and their families visiting a community health clinic. Which nursing diagnoses are correctly written as 3 part nursing diagnoses? 1. disabled family coping related to lack of knowledge about home care of child on ventilator 2. imbalanced nutrition: less than body requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20 pound weight loss since beginning the gymnastic program, and greatly less than ideal body weight when compared to standard height and weight charts 3. need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3 month hospital stay as evidenced by repeated comments "i cannot do this" "i know i'll harm her because i'm not a nurse" and "i can't do medical things" 4. spiritual distress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as "how could god do this to me?" "i don't deserve this" " i don't understand, i've tried to live my life well" and "how could god make me suffer this way?" 5. caregiver role strain related to failure of home health aides to appropriately diagnose needs of family caregivers and initiate a plan to facilitate coping as evidenced by caregiver's loss of weight and clinical depression a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. all of the above
b
A nursing student is preparing to administer morning care to a pt. What is the most important question that the nursing student should ask the pt about personal hygiene? a. would you prefer a bath or shower? b. may i help you with a bed bath now or later this morning? c. i will be giving you your bath. do you use soap or shower gel? d. i prefer a shower in the evening, When would you like your bath?
b
A physician orders a pain med for a post op pt that is a PRN order. When would the nurse administer this med? a. single dose during the post op period b. doses administered as needed for pain relief c. one dose administered immediately d. doses routinely administered as a standing order
b
A pt complains of abdominal pain that is difficult to localize. The nurse documents this as which type of pain? a. cutaneous b. visceral c. superficial d. somatic
b
A pt requires 40 units of NPH insulin and 10 units of regular insulin daily subcutaneously. What is the correct sequence when mixing insulins? a. inject air into the regular insulin vial and withdraw 10 units, then using the same syringe, inject air into the NPH vial and withdraw 40 units of NPH insulin b. inject air into the NPH insulin vial, being careful not to allow the solution to touch the need, next, inject air into the regular insulin vial and withdraw 10 units, then withdraw 40 units of NPH insulin c. inject air into the regular insulin vial, being careful not to allow the solution to touch the needle, next, inject air into the NPH insuline vial and withdraw 40 units, then withdraw 10 units of regular insulin d. inject air into the NPH insuline vial and withdraw 40 units, then using the same syringe, inject air into the regular insulin vial and withdraw 10 units of regular insulin
b
A school nurse is performing an assessment of a student who states: "I'm too tired to keep my head up in class." The student has a low-grade fever. The nurse would interpret these findings as indicating which stage of infection? a. incubation period b. prodromal stage c. full stage of illness d. convalescent period
b
After assessing a pt who is recovering from a stroke in a rehab facility, a nurse interprets and analyzes the pt data. Which of the 4 basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self esteem? a. no problem b. possible problem c. actual nursing diagnosis d. clinical problem other than nursing diagnosis
b
An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a pt with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? a. tilt the pt's head forward b. hold the mask tightly over the pt's nose and mouth c. pull the pt's jaw backward d. compress the bag twice the normal respiratory rate for the pt
b
Applying the gate control theory of pain, what would be an effective nursing intervention for a pt with lower back pain? a. encouraging regular use of analgesics b. applying a most heating pad to the area at prescribed intervals c. reviewing the pain experience with the pt d. ambulating the pt after administering meds
b
Ms. Hall has an order for hydromorphine, 2 mg intravenously q 4 hrs PRN pain. The nurse notes that according to Ms. Hall's chart, she is allergic to Dilaudid. The order for medication was signed by Dr. Long. What would be the correct procedure for the nurse to follow in this situation? a. administer the med, the doctor is responsible b. call Dr. Long and ask that she change the med c. ask the supervisor to administer the med d. ask the pharmacist to provide a med to take the place of Dilaudid
b
The Joint Commission issues guidelines regarding the use of restraints. In which case is a restraint properly used? a. nurse positions a pt in a supine position prior to applying wrist restraints b. nurse ensures that 2 fingers can be inserted between the restraint and pt's ankle c. nurse applies a cloth restraint to the left hand of a pt with an IV catheter in the right wrist d. nurse ties an elbow restraint to the raised side rail of a pts bed
b
When assessing a pt receiving a continuous opioid infusion, the nurse immediately notifies the physician when the pt has: a. a respiratory rate of 10/min with normal depth b. a sedation level of 4 c. mild confusion d. reported constipation
b
When assessing pain in a child, the nurse needs to be aware of what considerations? a. immature neuro development results in reduced sensation of pain b. inadequate or inconsistent relief of pain is widespread c. reliable assessment tools are currently unavailable d. narcotic analgesic use should be avoided
b
When planning care for a pt with chronic lung disease who is receiving oxygen through a nasal cannula, what does the nurse expect? a. the oxygen must be humidified b. the rate will be no more than 2-3 L/min or less c. arterial blood gases will be drawn every 4 hrs to assess the flow rate d. the rate will be 6 L/min or more
b
A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a male pt who has been prescribed morphine via a PCA pump for pain related to pancreatic cancer. Place the following nursing statements related to this call in the order in which they should be performed. a. I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer b. Mr. S has been difficult to arouse and his mental status has changed over the past 12 hrs since using the pump c. You want me to discontinue the PCA pump until you see him tonight at pt rounds d. I am Rosa Clark, an RN working on the second floor of South Street Hospital e. Mr. S was admitted 2 days ago following a diagnosis of pancreatic cancer. f. I think the dosage of morphine in Mr. S's PCA pump needs to be lowered
d, a, e, b, f, c identify/introduction situation background assessment recommendation read-back
A nurse is teaching a pt how to use a meter-dosed inhaler for her asthma. Which comments from the pt assure the nurse that the teaching has been effective? Select all that apply. a. "I will be careful not to shake up the canister before using it" b."I will hold the canister upside-down when using it" c. "I will inhale the medication through my nose" d. "I will continue to inhale when the cold propellant is in my throat" e. "I will only inhale one spray with one breath" f. "I will activate the device while continuing to inhale"
d, e, f
A nurse working the night shift at a hospital observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. a. REM sleep constitutes much of the sleep cycle of a preschool child b. by the age of 8 years, most children no longer take naps c. sleep needs usually decrease when physical growth peaks d. many adolescents do not get enough sleep e. total sleep decreases in adults with a decrease in stage IV sleep f. sleep is less sound in older adults and stage IV sleep may be absent
d, e, f
