Process and Skills Quizzes Week 4-8 (Exam #2)

A nurse is calculating the total fluid intake for a client during an 4-hr period. The client consumed 3 ounces of tea, 5 ounces of chicken broth, 1/2 cup of water, and 2 tablespoons of ice chips. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number, enter numbers only, no units of measure). (Hint: always document half for ice chips).

375

A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development? A. Braden Scale B. FLACC Scale C. Morse Scale D. Glasgow Scale

A

A nurse is caring for a patient connected to continuous GI suctioning who begins to demonstrate altered level of consciousness and a new dysrhythmia. Which of the following acid/base imbalances does the nurse suspect? A. Metabolic Alkalosis B. Respiratory Alkalosis C. Respiratory Acidosis D. Metabolic Acidosis

A

A patient has a decreased potassium level. What high-potassium foods would the nurse teach the patient to eat? A. Oranges, bananas, broccoli B. Lunch meat, salted nuts, bread C. Apples, pears, tea D. Carbonated beverages, beer, olives

A

The nurse is caring for a 78-year old patient who has had outpatient surgery. When assisting the patient to ambulate for the first time postoperatively, which instructions will the nurse provide to decrease the potential for orthostatic hypotension? A. Stand upright for 2 to 3 minutes prior to ambulating. B. Sit upright on the side of the bed for 15 seconds prior to ambulating C.Avoid drinking fluids to prevent the need for frequent toileting. D. Sit in a chair for 60 minutes prior to ambulating.

A

The nurse is caring for a 78-year-old patient with aortic stenosis. Which data obtained by the nurse would be most important to report to the health care provider? A. The patient complains of chest pressure when ambulating B. A loud systolic murmur is heard along the right sternal border C. Total serum cholesterol level is 268 mg/dL D. The point of maximal impulse (PMI) is at the left midclavicular line

A

The nurse is preparing to insert a nasogastric tube. To determine the length of the tube needed to be inserted, how should the nurse measure the tube? A. From the tip of the nose to the earlobe to the xiphoid process B. From the tip of the nose to the earlobe C. From the tip of the earlobe to the mouth to the xiphoid process D. From the tip of the earlobe to the xiphoid process

A

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next? A. Document the color, odor, amount, and type of wound drainage. B. Measure length, width, and depth of the wound. C. Determine the extent of wound undermining. D. Massage the healthy tissue surrounding the wound.

A

The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? A. Calcium 17.5 mg/dL B. Potassium 3.9 mEq/L C. Magnesium 2.1 mEq/L D. Sodium 144 mEq/L

A

When the nurse interviews a patient who is to have outpatient surgery using general anesthesia, which information is most important to communicate to the surgeon and anesthesiologist before surgery? A. The patient's father died after receiving general anesthesia for abdominal surgery. B. The patient drank 4 ounces of apple juice 6 hours before coming to the hospital. C. The patient drinks 3 or 4 cups of coffee every morning before going to work. D. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago.

A

When transporting an inpatient to the surgical department, a nurse from another area of the hospital is able to access which area? A. Holding area B. Sterile core C. Corridors of the surgical suite D. Operating room

A

Which discharge instruction should the emergency department nurse include for a patient with a sprained ankle? A. Use pillows to elevate the ankle above the heart. B. Keep the ankle loosely wrapped with gauze. C. Apply a heating pad to reduce muscle spasms. D. Gently move the ankle through the range of motion.

A

Which procedure is done for curative purposes? A. Appendectomy B. Bronchoscopy C. Laparotomy D. Rhinoplasty

A

Many common herbal products can cause surgical problems. Which of the following herbs should the nurse teach the patient to avoid before surgery to prevent an increase in bleeding for the surgical patient (select all that apply)? A. Fish oil B. Garlic C. Vitamin E D. Ginseng E. Valerian

A B C

Which actions should the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur? (Select all that apply.) A. Assess pain severity and discuss strategies to relieve pain. B. Teach about the need for strict bed rest. C. Support the left leg when repositioning the patient. D. Monitor serum calcium. E. Assist the patient and family as they discuss the prognosis.

A C D E

Which statements are true when the nurse is measuring blood pressure (BP)? Select All That Apply A. The client should sit quietly while BP is being measured. B. The client's BP should be measured 1 hour before consuming alcohol. C. Using a BP cuff that is too small will give a higher BP measurement. D. Using a BP cuff that is too large will give a higher BP measurement. E. The client's arm should be positioned at the level of the heart.

A C E

Which assessments will alert the nurse that a patient's IV has infiltrated? Select all that apply. A. Edema of the extremity near the insertion site B. Reddish streak proximal to the insertion site C. Skin discolored or pale in appearance D. Pain and warmth at the insertion site E. Palpable venous cord F. Skin cool to the touch

A C F

A nurse is preparing to administer a blood transfusion. Which assessment finding would the nurse report immediately? A. Blood pressure 120/60 B. Temperature 101.3 F C. Poor skin turgor and pallor D. Heart rate of 100 beats per minute

B

A patient has reported to the preadmission clinic for her scheduled hysterectomy. The patient tells the nurse that she does not entirely understand why she cannot eat or drink before surgery. What explanation should the nurse provide to this patient? A. 'Your surgeon and anesthetist need your stomach empty during surgery in case there is a need to insert a tube into your stomach.' B. 'You are asked to refrain from eating and drinking so there is less chance that you will inhale food or fluids into your lungs.' C. 'You need to fast before surgery so that the surgical team has a baseline for managing your fluid balance and nutritional status.' D. 'It is important to rest your stomach and bowels during and after surgery so that blood flow is concentrated to your vital organs.'

B

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? A. Taking medications as prescribed B. Thorough hand hygiene C. Proper intake of food and fluids D. Adequate sleep and rest

B

The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring fluid volume status for both of these patients? A. Assess the patients for edema in extremities. B. Weigh the patients every morning before breakfast. C. Ask the patients to record their intake and output. D. Measure the patients' blood pressures every 4 hours.

B

The nurse is caring for a patient newly diagnosed with hypertension. Which statement by the patient indicates the need for further teaching? A. "I will consult a dietician to help get my weight under control." B. "If I take my blood pressure and it is normal, I don't have to take my blood pressure pills." C. "When getting up from bed, I will sit for a short period before standing up." D. "I think I'm going to sign up for a yoga class twice a week to help reduce my stress."

B

The nurse is caring for a patient who has a pelvic fracture and an external fixation device. How should the nurse perform assessment of pressure areas and provide skin care to the patient's back and sacrum? A. Ask the patient to turn to the side independently. B. Have the patient lift the back and buttocks using a trapeze. C. Roll the patient over to the side by pushing on the patient's hips. D. Defer back assessment until the patient is ambulatory.

B

The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding? A. exposed bone with eschar B. nonblanchable redness C. visible subcutaneous fat D. a shallow open injury

B

The patient has just started on enteral feedings, and is now reporting abdominal cramping. Which action will the nurse take first? A. Instill cold formula to "numb" the stomach. B. Slow the rate of tube feeding. C. Change the tube feeding to a high-fat formula. D. Consult with the health care provider about prokinetic medication.

B

The surgical floor receives a patient from the PACU. The nursing assessment revels that the patient has a patent airway and stable vital signs. Which action should the nurse take next? A. Assess the patient's pain level B. Check the dressing for signs of bleeding C. Empty any peri-incisional drains D. Assess the patient's bladder

B

When developing a community health program to decrease the incidence of rheumatic fever, which action would be most important for the community health nurse to include? A. Vaccinate high-risk groups in the community with streptococcal vaccine. B. Teach community members to seek treatment for streptococcal pharyngitis. C. Teach about the importance of monitoring temperature when sore throats occur. D. Teach about prophylactic antibiotics to those with a family history of rheumatic fever.

B

Which of the following is a manifestation of the potential postoperative respiratory complications of atelectasis and aspiration? A.Hypoventilation B. Hypoxemia C. Hypercapnia D. Airway Obstruction

B

A nurse is caring for a patient receiving enteral nutrition through a gastrostomy tube. The nurse is aware to monitor for which potential complications? (Select all that apply) A. Hypercapnea B. Serum electrolyte imbalance C. Epistaxis D. diarrhea E. Pulmonary aspiration

B C D

A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown? A. Frequently orient client to place and situation B. Massage skin surfaces daily, especially areas under pressure and bony prominences C. Implement a 2-hour repositioning schedule D. Perform passive range-of-motion exercises

C

A blood pressure (BP) of 140/90 mm Hg is considered to be: A. normal B. a hypertensive emergency. C. hypertension. D. prehypertension.

C

A break in sterile technique occurs during surgery when the scrub nurse touches: A. their gown at chest level with a sterile gloved hand. B. the instrument tray with their lower arm while wearing a gown and sterile gloves. C. their mask with a sterile gloved hand. D. the drape at the incision site with a sterile gloved hand.

C

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? A. large numbers of red blood cells B. clear, watery blood C. white blood cells, debris, bacteria D. mixture of serum and red blood cells

C

A nurse is feeding a patient. Which statement would help a person maintain dignity while being fed? A.'I know you don't like me to feed you, but you need to eat.' B. 'I am going to feed you your cereal first and then your eggs.' C. 'What part of your dinner would you like to eat first?' D. 'I wish I had more time so I could feed you all of your meal.'

C

A patient is being admitted to undergo a same-day surgery. Which of the following statements indicates that the patient has deficient knowledge? A. 'My son will be here at noon to take me home.' B. 'I am taking a taxi home, and my daughter will meet me at home.' C. 'I can drive myself home after surgery.' D. 'My husband is taking the day off from work to drive me home.'

C

A patient who is scheduled for surgery in a week tells the nurse doing the preoperative assessment about an allergy to bananas, kiwifruit, and latex products. Which action is most important for the nurse to take? A. Take no action because the patient will not be eating in the OR. B. Notify the dietitian about the food allergies. C. Alert the surgery center about the latex allergy. D. Reassure the patient that all allergies are noted on the medical record.

C

A patient with a lower respiratory infection has pH of 7.25, PaCO2 of 50 mm Hg, and HCO3¯ of 22 mEq/L. The provider has been notified. Which is the priority nursing intervention for this patient? A. Have the patient breathe into a paper bag B. Place the patient in Trendelenburg position C. Encourage the patient to increase respirations D. Check the color of the patient's urine output

C

After Impaired Skin Integrity, which of the following NANDA-I nursing diagnoses would be a priority for a patient who has a large wound from colon surgery, is obese, and is taking corticosteroid medications? A. Risk for Situational Low Self-Esteem B. Anxiety C. Risk for Infection D. Ineffective Coping

C

How will the nurse interpret the following serum lab values for a patient recently admitted with a decreased level of consciousness (LOC) following a seizure? Sodium (Na+): 122 mEq/L Potassium (K+): 4.8 mEq/L Magnesium (Mg++): 2.1 mEq/L Chloride (Cl-): 100 mEq/L A. Hypernatremia B. Hyperkalemia C. Hyponatremia D. Hypomagnesemia

C

The nurse interprets the following ABG values as indicating: pH: 7.46 PaCO2: 33 mmHG HCO3-: 24 mEq/L A. Respiratory Acidosis B. Metabolic Acidosis C. Respiratory Alkalosis D. Metabolic Alkalosis

C

The nurse is caring for a patient with hyperkalemia. Which body system would be most important for the nurse plan to monitor closely? A. Gastrointestinal B. Neurological C. Cardiac D. Respiratory

C

The nurse is teaching a patient about chronic untreated hypertension. What complication will the nurse explain to the patient? A. peripheral edema B. right-sided heart failure C. stroke D. pulmonary insufficiency

C

The nurse notes crackling sounds and a grating sensation with palpation of an older patient's elbow. How should this finding be documented? A. Epicondylitis B. Torticollis C. Crepitation D. Subluxation

C

When caring for a patient with essential hypertension what instruction should the nurse provide to the patient to normalize blood pressure? A. Avoid intake of low-fat diet. B. Increase intake of fluids. C. Reduce sodium intake. D. Increase iodine intake.

C

Which of the following intravenous fluid solutions is considered isotonic? A. 0.45% sodium chloride B. Dextrose 5% in 0.9% sodium chloride C. 0.9% sodium chloride D. Dextrose 5% in 0.45% sodium chloride

C

Which of the following patients will have an increased metabolic rate and require nutritional interventions? A. A healthy young adult who works in an office B. A retired person living in a temperate climate C. A person with a serious infection and fever D. An older, sedentary adult with painful joints

C

Which patient statement supports a history of intermittent claudication? A. "I get short of breath when I climb a lot of stairs." B. "When I stand too long, my feet start to swell." C. "My legs cramp when I walk more than one block." D. "My fingers hurt when I go outside in cold weather."

C

The patient is admitted with pain, edema, and warm skin on her lower left leg. What test should the nurse expect to be ordered first? A. Magnetic resonance imaging (MRI) B. Complete blood count (CBC) C. Duplex ultrasound D. Computed venography (phlebogram)

C (With manifestations of VTE, the duplex ultrasound is the most widely used test to diagnose by identifying where a clot is located and its extent)

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action? A. stimulating the wound bed to promote the growth of granulation tissue B. removing excess drainage and wet tissue to prevent maceration of surrounding skin C. removing purulent drainage from the wound bed in order to accurately assess it D. removing dead or infected tissue to promote wound healing

D

A nurse has just received a bag of packed red blood cells. The nurse knows that the blood must not remain at room temperature for longer than: A. 30 minutes B. 1 hour C. 2 hours D. 4 hours

D

A nurse is collaborating with the interdisciplinary team to develop a nutritional plan for a patient with a nonfunctional GI tract due to a massive small bowel resection. Which of the following nutrition interventions would be most appropriate? A. High fiber diet B. Regular diet C. Enteral nutrition D. Parenteral nutrition

D

A nurse is providing instruction to a client about self care for gout. Which of the following will the nurse include? A. The most common location for gout flares is in the 5th metatarsal B. Begin an exercise regimen including running C. Limit oral fluid intake to 1 liter per day D. Avoid food and fluids with high purine content (e.g., red meat, shellfish, liver, wine, and beer)

D

A patient has been diagnosed with prehypertension and has been encouraged to exercise regularly and begin a weight loss program. What other healthcare professional may be helpful for the client to see? A. Pharmacist B. Social worker C. Occupational therapist D. Dietician

D

A patient in the post anesthesia care unit (PACU) has emergence delirium manifested by agitation and thrashing. What should the nurse assess for first? A. Cardiac dysrhythmias B. Neurologic injury C. Distended bladder D. Hypoxia

D

A patient with severe kyphosis is scheduled for dual-energy x-ray absorptiometry (DEXA) testing. Which action should the nurse plan to take? A. Give an oral sedative 60 to 90 minutes before the procedure. B. Screen the patient for allergies to shellfish or iodine products. C. Start an IV line for contrast injection. D. Explain the procedure to the patient.

D

The nurse interprets the following ABG values as indicating: pH: 7.27 PaCO2: 40 mmHG HCO3-: 18 mEq/L A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis

D

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect: A. a decrease in the left pedal pulse B. pallor and coolness of the left foot C. loss of hair on the lower portion of the left leg D. left calf circumference 1' larger than the right

D

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? A. pulling the client up from under the arms B. lubricating the area with skin oil C. improving the client's hydration D. preventing the client from sliding in bed

D

Which assessment finding for a 55-yr-old patient should alert the nurse to the presence of osteoporosis? A. Report of frequent falls B. Aversion to dairy products C. Bowed legs D. Loss of height

D

Paget's Disease (osteitis deformans) is a chronic skeletal bone disorder in which excessive bone resorption is followed by replacement of normal marrow by vascular, fibrous connective tissue. True False

True