Quiz #3

Normal intraocular pressure range is: a) 8-21 mm Hg b) 26-50 mm Hg c) 110-130 mm Hg d) 60-80 mm Hg

a) 8-21 mm Hg

Your client has strabismus. All of the following tests are appropriate to detect strabismus except: a) A tonometry test b) The cover/uncover test c) Cardinal gazes test d) Corneal light reflex response

a) A tonometry test

A patient had a femoral-popliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a) Appropriate hand hygiene before giving care b) Monitoring the patient's daily white blood cell count c) Assessing the patient's temperature every 4 hours d) Clean technique when changing dressings

a) Appropriate hand hygiene before giving care

A patient is undergoing computed tomography (CT) of a joint. What action by the nurse is most important before the test? a) Assess for seafood or iodine allergy b) Administer sedation as prescribed c) Ensure that the patient has no metal on the body d) Provide pre-procedure pain medication

a) Assess for seafood or iodine allergy

A patient has hypertension and high-risk factors for cardiovascular disease. The patient is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a) Assist in finding one change the patient can control b) Determine what stressors the patient faces in daily life c) Inquire about delegating some of the patient's obligations d) Assess the patient's support system

a) Assist in finding one change the patient can control

The nurse is prioritizing care to prevent pressure sores for a client who is immobilized. Which interventions re appropriate? (Select all that apply) a) Placing a small pillow between bony surfaces b) Elevating the head of the bed to 45 degrees c) Limiting fluids and proteins in the diet d) Using a lift sheet to assist with repositioning e) Repositioning the client who is in a chair every 2 hours f) Keeping the heels off the bed surfaces g) Using a rubber ring to decrease sacral pressure when up in the chair

a) Placing a small pillow between bony surfaces d) Using a lift sheet to assist with repositioning f) Keeping the heels off the bed surfaces

That patient with otitis media reports sever pain during the night but was gone upon awakening in the morning. Which finding does the nurse expect to observe during the client's physical assessment? a) Purulent fluid present in the ear canal b) Pinna and tragus are reddened and swollen c) Tympanic membrane is bluish-gray in color d) Sounds are lateralized toward the affected ear

a) Purulent fluid present in the ear canal

A patient with bone cancer is hospitalized for an unrelated issue. The patient reports pain and it is not yet time for more medication. What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) a) Repositioning patient b) Providing soothing music c) Administering Ibuprofen d) Using a bed cradle to lift sheets of the feet e) Referring the patient to a support group

a) Repositioning the patient b) Providing soothing music

Which nursing intervention is best for the nurse to use to enhance healing of a 1-week-old partial-thickness wound? a) Using papain-urea (Accuzyme) cream as ordered b) Restricting the client's fluid intake c) Covering the wound with an airtight dressing d) Applying hydrocortisone cream as ordered

a) Using papain-urea (Accuzyme) cream as ordered

A nursing technician reports that a client who is receiving IV PCA morphine is responsive, very drowsy, unable to complete a sentence without falling asleep, and has a respiratory rate of 10 breaths per minute. What is the nurse's priority action at this time? a) Wake the client and raise the head of the bed to a 90-degree angle. b) Promptly call the primary health care provider to reduce the opioid dose. c) Document the assessment findings and take vital signs in an hour. d) Give naloxone according to agency protocol.

a) Wake the client and raise the head of the bed to a 90-degree angle

Which statement indicates to the nurse that the client is experiencing some hearing loss? a) "My ears hurt, especially when I yawn." b) "I keep turning the volume up on the TV." c) "I get dizzy when I get up from the chair." d) "I clean my ears daily after I take a shower."

b) "I keep turning up the volume on the TV."

A patient is distressed at body changes related to kyphosis. What response by the nurse is best? a) Explain that these changes are irreversible b) Ask the patient to explain more about these feelings c) Offer to help select clothes to hide the deformity d) Tell the patient that safety is more important that looks

b) Ask the patient to explain more about these feelings

A patient had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower left leg to be pale and cool, with 1+/4+ pedal pulses. What action by the nurse is best? a) Document the findings in the patient's chart b) Assess the neurovascular status of the right leg c) Notify the provider of the findings immediately d) Elevate the left leg on at least two pillows

b) Assess the neurovascular status of the right leg

An emergency department nurse cares for a patient who sustained a crush injury to the right lower leg. The patient reports numbness and tingling in the affected leg? Which action would the nurse take first? a) Apply oxygen by nasal cannula b) Assess the pedal pulses c) Loosen the traction d) Increase the IV flow rate

b) Assess the pedal pulses

Which of the following is not a component of Virchow's Triad? a) Hypercoagulability b) Cardiac Pacemaker c) Venous stasis d) Endothelial damage

b) Cardia Pacemaker

While performing a skin assessment on an elderly client, the nurse observes an isolated brownish-purple lesion with irregular borders on the anterior chest wall. The lesion feels slightly raised on palpation, and crusted blood is visible at the lower edge. Which is the appropriate nursing intervention? a) Wash the lesion gently with warm water to remove the crusts and teach not to pick it b) Document lesion's location, size, and characteristics and request a dermatology consult c) Reassure that the lesion is a common occurrence with aging, especially in sun exposed areas d) Ask the patient about exposure to new lotions or perfumes that could cause an allergic reaction

b) Document lesion's location, size, and characteristics and request a dermatology consult

A nurse prepares a patient who is schedule for an arthroscopy of the shoulder. Which action by the nurse is most important? a) Reinforce the dressing if it becomes saturated b) Ensure the informed consent is on the chart c) Assess serum asperate aminotransferase (AST) levels d) Position the patient flat after the procedure

b) Ensure the informed consent is on the chart

During a client's physical assessment, the nurse notes that the client has conductive hearing loss. Which finding does the nurse expect to see in the client's medical history? a) Frequent impactions of cerumen in the ear canals b) Frequent episodes of otitis media in childhood c) History of osteomyelitis treated with IV gentamicin d) History of diabetes with peripheral neuropathy

b) Frequent episodes of otitis media in childhood

Which of the following is not a cause of venous stasis? a) Lengthy surgery b) Indwelling IV catheter c) Prolonged bed rest d) Decreased cardiac output due to heart failure

b) Indwelling IV catheter

The nurse is caring for the client who had a stroke affecting the right hemisphere of the brain. The nurse should assess for which problem initially? a) Right hemiparesis b) Poor impulse control c) Tetraplegia d) Expressive aphasia

b) Poor impulse control

This structure of the eye mostly contains rods and cones a) Pupil b) Retina c) Cornea d) Iris

b) Retina

The diagnostic exam used to diagnose and screen glaucoma is a) Opthalmoscopy b) Tonometry c) Gonioscopy d) Cardinal gazes

b) Tonometry

Your patient has been diagnosed with macular degeneration. All of the following statements are true except: a) It is described as wet or dry b) There is no effective prevention c) You will see straight lines on the Amsler grid exam d) You will not be able to see centrally

c) You will see straight lines on an Amsler grid exam

A postoperative client is requesting medication for pain every 4 hours. In planning effective pain management, what assessment question does the nurse ask the client before administering the medication? a) "Are you bleeding?" b) "Are you really hurting every 4 hours?" c) "Is your pain controlled between doses?" d) "What do you do for pain when you're at home?"

c) "Is your pain controlled between doses?"

Which of the following interventions is considered the most effective to reduce DVT risk? a) Sequential compression device b) Venous foot pump c) Anticoagulation medication d) Graduate compression stockings

c) Anticoagulation medication

The nurse is caring for four hypertensive patients. Which drug-laboratory value combination would the nurse report immediately to the healthcare provider? a) Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L b) Spironolactone (Aldactone)/potassium: 4.8 mEq/L c) Furosemide (Lasix)/potassium: 2.1 mEq/L d) Torsemide (Demadex)/sodium: 142 mEq/L

c) Furosemide (Lasix)/potassium: 2.1 mEq/L

A postoperative client has an epidural infusion of morphine and bupivacaine (Marcaine). What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a) Ask the client to point out any areas of numbness or tingling b) Determine how many people are needed to ambulate the client. c) Perform a bladder scan if the client is unable to void after 4 hours. d) Remind the client to use the incentive spirometer every hour. e) Take and record the client's vital signs per agency protocol.

c) Perform a bladder scan if the client is unable to void after 4 hours d) Remind the client to use the incentive spirometer every hour e) Take and record the client's vital signs per agency protocol

A client is at risk for increased intracranial pressure (ICP). Which findings is the priority for the nurse to monitor? a) Tachycardia b) Decreasing body temperature c) Unequal pupil szie d) Decreasing systolic blood pressure

c) Unequal pupil size

A family member asks the nurse about whether there would be any long-term psychological effects from a client's mild traumatic brain injury (TBI). What is the nurse's best response? a) "You should expect a change in the client's personality." b) "You need to talk with the patient's healthcare provider." c) "Usually the effects last for only a few weeks or months." d) "Each person's reaction to brain injury is different."

d) "Each person's reaction to a brain injury is different."

The client with a ruptured tympanic membrane asks the nurse whether hearing will be affected permanently. Which is the nurse's best response? a) "No. Antibiotics will help resolve the infection and cure hearing impairment." b) "Yes. It will be important for your to be fitted with a hearing aid as soon as possible." c) "Yes. Any time the eardrum is ruptured it will form a scar, which will cause some degree of permanent hearing loss." d) "Possibly. The eardrum usually heals in 1-2 weeks. Any persistent hearing problem should be evaluated."

d) "Possibly. The eardrum usually heals in 1-2 weeks. Any persistent hearing problem should be evaluated."

The client with Meniere's disease asks the nurse how to prevent another acute episode from occurring. Which is the nurse's best response? a) "Reduce the quantity of saturated fats in your diet." b) "Avoid crowds and people with upper respiratory infection." c) "Use aspirin instead of acetaminophen (tylenol) for pain." d) "Stop or reduce cigarette smoking."

d) "Stop or reduce cigarette smoking."

This client who had a stroke follows instructions given by the nurse without any problems. However, when the client responded verbally, his/her response was garbled. The nurse identities that the client has which type of aphasia? a) Global aphasia b) Anomic aphasia c) Receptive aphasia d) Expressive aphasia

d) Expressive aphasia

A nurse is caring for a patient who is recovering from an above-the-knee amputation. The patient reports pain in the limb that was removed. How would the nurse respond? a) This type of pain is common and will eventually go away b) Would you like to learn how to use imagery to minimize your pain? c) The pain you are feeling does not actually exist d) How would you describe the pain you are feeling?

d) How would you describe the pain you are feeling?

Which of the following types of stroke is most commonly occurring? a) Hemorrhagic strokes b) TIA c) Cryptogenic strokes d) Ischemic Strokes

d) Ischemic strokes

Which assessment finding is cause for concern in a client who has taken 4 grams of acetaminophen (Tylenol) to relieve back pain? a) Difficulty with urination b) Decreased respiratory rate c) Gastrointestinal bleeding d) Liver function tests

d) Liver function tests

A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a) Assessing blood pressure in both upper extremities b) Auscultating the carotid arteries for any bruits c) Classify capillary refill of 4 seconds as normal d) Palpating both carotid arteries at the same time

d) Palpating both carotid arteries at the same

A hospitalized patient's strength of the upper extremities is rated 3. What does the nurse understand about this patient's ability to perform activities of daily living (ADLs)? a) No difficulties are expected with ADLs b) The patient would need near-total assistance with ADLs c) The patient is unable to perform ADLs alone d) The patient is able to perform ADLs but not lift some items

d) The patient will be able to perform ADLs but not lift some items