NURS200 Final Module 1-9 Quizzes

When preparing for a bed bath why should the nurse offer the patient a bedpan, urinal, or the commode prior to performing the procedure?

Warm water and activity can stimulate the need to void

The nurse needs vital signs assessed for four patients. Which patient should the nurse assess and not assign to the UAP?

Patient returning to the nursing unit after cardiac catherization

During an interaction witha newly admitted patient who suddenly becomes silent and stares off into space, what is the most therapeutic response by the nurse?

A:"I noticed you have become very quiet"

A Mexican-American patient is receiving discharge teaching on diabetes management and carbohydrate counting. Which statement by the nurse best reflects an understanding of the ethnic and cultural impact on dietary choices?

"Do you have any personal, cultural, or ethnic food preferences? What foods do you eat most often?"

When preparinf a patiwnt for discharge the nurse notes that thw patient has a temperature of 101.8. Which phrase is most appropriate for the nurse to use when speaking with the When preparing a patient for discharge the nurse notes that the patient has a temperature healthcare provider?

"I am concerned about the patient's readiness for discharge because his most recent temperature was 101.8.

An older patient has an oral temperature reading of 97.2 degrees F. The nurse realizes that this patient's low temperature could be due to which observation?

Loss of subcutaneous fat is noted.

During the examination of the thorax, which of the following should the nurse use as the starting point for locating the ribs anteriorly?

Manubriosternal junction (Angle of Louis)

The nurse is assessing the lower extremities of the patient with peripheral vascular disease (PVD), The nurse would expect to find which of the following signs of PVD?

Marked edema

The nurse is listening to a patient's heartbeat and is focusing on the second heart sound. Which heart valves produce this sound?

Aortic and pulmonic

personnel. What should the nurse The nurse has delegated the making of unoccupied assess regarding patient safety once the beds are beds to unlicensed assistive completed?

Call light being readily available

A nurse is assessing a patient's bilateral pulses for symmetry. Which pulse site should not be assessed on both sides of the body at the same time?

Carotid

Which of the following is an uncontrollable risk factor that has been linked to the development of cardiovascular disease?

Heredity

A patient says, "I hate the idea of being an invalid after they cut off my leg." Which of the following would be the most therapeutic response by the nurse?

"Tell me more about how you are feeling."

During the initial interview, a patient with an eating disorder remarks, "I can't stand myself and the way I look." Which of the following statements by the nurse would be most appropriate?

"Tell me more about your feelings"

Which type of artificial airway may be placed on an alert patient with an intact gag reflex?

Nasopharyngeal airway

The heart sound S4 is often heard in older adults and can be an indication of what?

Hypertension

Which of the following is the most crucial goal of therapeutic communication when helping patients deal with personal issues and painful feelings?

A:Conveying respect and acceptance even if all of the patient's behaviors are not tolerated

The nurse is caring for a patient who has just been given bolus tube feedings through a nasogastric (NG) tube. How high should the nurse position the head of the bed?

45 degrees

Delivering oxygen via a nasal cannula effective up to what flow rate?

6 L/min

Body temperature may be measured in all of the following ways except which of the following?

Radial

Which should the nurse do first when caring for a patient who experiences new onset of restlessness, agitation, and confusion?

Assess pulse oximetry

When completing an abdominal assessment, which of the following methods of examination must occur first to prevent false assessment findings?

Auscultation

Which type of nutritional assessment data is the nurse collecting when reviewing hemoglobin, serum albumin, and total lymphocyte lab values?

Biochemical data

A patient's admission vital signs are: temperature 99.1 degrees F, pulse 75, respirations 16 and unlabored, and blood pressure 185/110. Which of the following vital signs is the most concerning to the nurse?

Blood pressure

A patient has decided to become a vegetarian and is concerned about obtaining adequate protein intake. Which of the following food combinations would provide a complete protein source?

Brown rice with kidney beans

The nurse is caring for a patient with Clostridium difficile infection. Which behavior indicates that the nurse needs additional information about this disease?

C. Performs hand hygiene with an alcohol-based disinfectant

Which of the following steps should the nurse take when administering an enteral tube feeding? (Select all that apply)

Check for aspirate Flush the tube with water after the feeding Allow the feeding to flow in by gravity Check for aspirate

12. A nurse comes across a fire in a patient's room caused by a candle flame and multiple books lying on the bedside table. Which class of fire extinguisher should be used for this type of fire?

Class A

When completing oral suctioning with a Yankauer, the nurse understands that which of the following techniques should be utilized?

Clean technique only

The nurse assesses the respiratory status of a patient who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which of the following findings would be expected?

Coarse crackles and rhonchi

The nurse is caring for a patient on the first post-operative day. The physician has ordered an incentive spirometer for the patient. What should the nurse instruct the patient to do?

Complete the breathing exercises 4 to 5 times every hour while awake

2 sleeping patient has the following vital signs: respiratory rate of 10, temperature 98.5, blood pressure 135/75, heart rate 78, and oxygenation 98%. Which of the following actions should the nurse take?

Continue to monitor the patient

1/1 pts The nurse is reviewing the nursing process with a first-year nursing student. What should the nurse explain as being the purpose of the diagnosis phase? Select all that apply.

Develop a list of problems. Identify patient strengths. Identify problems that can prevented.

Older adults with cardiovascular disease must balance which of the following measures for optimal health?

Diet, exercise, and medication

While preparing a patient for a procedure, the nurse notes that the patient has become unresponsive and respirations have become shallow. What type of assessment should the nurse complete at this time?

Emergency assessment

Patient centered-care includes which of the following? (Select all that apply)

Encourage family to participate in care, assess patient preferences, actively listen to the patient

Two days after an ileostomy, the patient refuses nursing care and requests to be left alone. What should be the nurse's first action?

Encourage the client to verbalize his feelings

A nurse places a nasogastric tube into a patient. Which is the best method the nurse should use to confirm placement prior to initiating tube feedings?

Ensure chest x-ray verifies correct tube placement

The nurse notices the pulse oximetry of the client is 85% oxygen saturation. What is the first action the nurse should take?

Ensure that the pulse oximeter is working correctly

Factors that can affect the body temperature include which of the following? (select all that apply)

Environment Circadian rhythms Exercise Hormones

The nurse understands that redness of the skin associated with a variety of conditions is described as which of the following?

Erythema

The nurse decides to seek wound care alternatives fora patient's ulcer that is not healing after treatment for 2 weeks. In which phase of the nursing process is the nurse functioning?

Evaluation

A patient is admitted for continuing care following a motor vehicle crash. The admitting nurse will develop the inital plan of care, but who will be involved with the ongoing planning of this patients care?

Everybody involved in this patients care

Which of the following should the nurse monitor in a patient who has been receiving total parental nutrition (TPN) for 3 days?

Frequent finger stick blood sugar results to monitor for hyperglycemia.

The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process?

Identify patient needs and deliver care to meet those needs.

The nurse provides a back rub to a patient after administering a pain medication with the hope that these two actions will help decrease the patient's pain. Which phase of the nursing process is this nurse implementing?

Implementation

Which of the following physical assessment findings would the nurse expect to find in a patient with advanced chronic obstructive pulmonary disease (COPD)?

Increased anteroposterior chest diameter

Calculate the patient's intake and output. For breakfast the patient left 3 oz of an 8 oz cup of coffe, had 3 oz of OJ and 4 oz of oatmeal. At 0930 the patient consumed 6 oz water with medications. Following the medication administration, the patient had an emesis of 200 mL. The patient urinates 350 mL, and the abdominal drain collected 50 mL of bloody drainage

Intake 420 mL, output 600 mL

A patient has entered a smoking cessation program to quit smoking. He tells the nurse he has not smoked a cigarette for 3 weeks, but is afraid he will slip up and smoke because of current job pressures. What would be the most appropriate reply for the nurse to make in response to the patient's comments?

It is good that you can talk about your concerns. Try calling a friend when you want to smoke"

The nurse finds the apical impulse below the fifth intercostal space. Which of the following findings does the nurse suspect?

Left ventricular enlargement

While the nurse is performing morning care, a patient begins to have a seizure. What should the nurse do to help this patient?

Loosen any clothing around the neck and chest.

l A patient presents in respiratory distress with oxygen saturation at 60 %. Which oxygen delivery system will deliver the highest oxygen concentration possible for this patient?

Nonrebreather mask

A nurse calculates a patient's body mass index (BMI) as 32kg/m2. This finding indicates that the patient is suffering from which of the following alterations in nutrition?

Obesity

What therapeutic communication technique does this interaction demonstrate? Nurse: "Tell about that."

Open ended questions

Which of the following describes a patient experiencing shortness of breath when lying down?

Orthopnea

A patient has been having pain without any clear pathology for cause. Which of the following nursing diagnoses should the nurse identify as the most appropriate for this patient?

Pain related to unknown etiology

In order to assess the thorax for vocal fremitus which of the following assessment techniques is used?

Palpation

Which determinant of blood pressure would best explain a patient's blood pressure reading of 120/100?

Peripheral vascular resistance

A patient who needs to follow a clear liquid diet may eat which of the following foods?

Popsicles

Before discharge from the hospital a patient is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the patient to monitor to determine whether to increase or decrease the exercise level?

Pulse rate

When conducting a cardiac assessment, the nurse knows that the pattern of beats and the intervals between the beats is defined as which of the following?"

Pulse rhythm

Upon entering a room, a patient and spouse are found crying. The nurse decides to sit with them, offering presence and listening to their fears instead of providing the planned education. Which of the actions did the nurse perform?

Reassessing the patient

The nurse has formulated the following diagnosis: Activity intolerance, related to weakness and debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label?

Reports of fatigue

The nurse understands that the gallbladder is found in which of the four abdominal quadrants?

Right upper quadrant

The nurse is shampooing a patient's hair. Which assessment finding should the nurse consider as expected?

Smooth texture and not oily or dry

Which of the following characteristics is a normal finding upon palpitation of the abdomen?

Smooth, consistent tension

The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for a patient with chronic asthma. In looking at the patient's coping skills, the nurse realizes that the patient has a vast knowledge about the disease. Why should the nurse utilize this information?

Strengths can be an aid to mobilizing health and the healing process. Answered

Which of the following nursing interventions would promote effective airway clearance in a patient with acute respiratory distress? i

Suctioning if cough is ineffective

Which of the following describes systole? (select all that apply)

Systole is the period in which the ventricles contract Systole is normally silent between S1 and S2 Systole begins with S1 and ends with S2

The nurse is reviewing the difference between evaluation and assessment with a new graduate nurse. What should the nurse emphasize as the major difference between these two steps in the nursing process?

The difference is in how the data are used.

After an assessment, the nurse reviews the list of patient problems. For which of the following problems should the nurse create nursing diagnoses?

The ones that the nurse is licensed to treat

During the cardiovascular assessment, the nurse finds the patient has jugular vein distention. What could this indicate?

The patient has advanced cardiopulmonary disease

Which of the following is described as the amount of volume that a normal adult takes in during inspiration and expiration?

Tidal volum

7. While assessing the dorsalis pedis pulse of a patient, the nurse determines that the pulse is not palpable. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds of capillary refilling time. Which of the following is likely cause of these findings?

Too much pressure was applied over the pulse site

To assess the patient's pedal pulses, which of the following should the nurse palpate?

Top of the foot and inner side of each foot

The nurse determines that a patient has absent bowel sounds. Which of the following characteristics support this finding?

Unable to hear bowel sounds for over 4 minutes upon auscultation

The nurse is unable to palpate the patient's left pedal pulses. Which of the following actions would the nurse take next?

Use a Doppler ultrasound device

Breath sounds that are soft-intensity and low-pitched created by air moving through small airways are classified as which of the following?

Vesicular

A patient diagnosed with tuberculosis is scheduled to go to the radiology department for a chest x-ray. Which nursing intervention would be appropriate when preparing to transport the patient?

a. Apply a mask to the patient

The nurse has just been stuck with a syringe while dropping it into a sharps container that was too full in a patient's room. What action should the nurse take first for this puncture wound?

b. Allow some bleeding.

The nurse determines that a patient has active immunity to a microorganism. Which of the following would cause the patient to develop this type of immunity?

b. Having chickenpox

What is the most effective nursing action for preventing and controlling the spread of infection?

b. Thorough handwashing

Identify the barrier to communication in the following interaction. Patient: "When can I expect to be told about how to take my insulin?" Nurse: "Let's discuss your diet now so that you will know what to eat when you get home. We can discuss insulin some other time."

changing the subject

What is the root cause for 82 % sentinel events?

communication breakdown

What is the best defense against any legal malpractice for the nurse?

complete charting by using the steps of the nursing process as a framework

A nurse employed in a preschool agency is planning a staff education program to prevent the spread of an outbreak of an intestinal parasitic disease. The nurse includes which priority prevention measure in the educational session?

d. Staff will practice standard precautions when changing diapers and assisting children with toileting

The nurse is setting up a sterile field. Which action by the nurse best exhibits surgical asepsis?

d. Touching only the inside surface of the first glove while pulling it onto the hand

The nurse is concerned that a break occurred in a sterile field, Which of the following would cause such a break?

d. Transferring a sterile object to sterile field with clean gloved hand

A patient who expresses anger at a diagnosis by slamming a food tray on the table is using what type of communication?

nonverbal

The nurse has asked the unlicensed assistive personnel (UAP) to help with admitting a patient. Which of the following activities can be delegated to the UAP?

obtain the patient's height and weight

In what phase of the helping relationship does the nurse review patient assessment data and develops a plan of action?

preinteraction phase

Which of the following are correct guidelines for charting in the patient record?

record the time of each entry

A patient states "I am dying." The nurse responds "You believe that you are dying?" which therapeutic approach did the nurse use?

reflecting

The emergency department (ICU) nurse who is accepting a patient ensure to provide to the ICU nurse? (ED) nurse is reporting off via phone call to the intensive care unit with pneumonia. What information should the ED nurse

report exact up to date information about the client's condition

Which communication technique is used in this interaction? Patient: "I have been really upset about my blood pressure and having to take these pills." Nurse: "You've been upset about your blood pressure and taking pills. Patient: "I guess I'm worried about what could happen if my blood pressure gets too bad."

restating

Bowel sounds that are extremely soft and infrequent and associated with manipulation of the bowel during surgery or inflammation are described as which of the following?

Нурoactive

techniques. The nurse is educating a patient about proper handwashing techniques. She instructs the patient to use which of the following in order to better protect the skin?

С. Warm water

A fire is contained to one patient unit on the 7th floor (7 West). The patients on 7 West should be moved to what location?

а. 7 East

Which nursing measure is appropriate to break a link in the chain of infection?

а. Wash hands before and after caring for a patient