Concepts Sim quiz questions

the nurse has received an order to collect a urine sample. which characteristics would the nurse observe for when assessing the patients specimen? (select all that apply) a. odor b. sediment c. color d. pH e. clarity

a. odor b. sediment c. color e. clarity

during her hospitalization for pneumonia, the provider orders arterial blood gases for Mona Hernandez. what is the best explanation for why this is ordered? a. patient has shallow, ineffective breathing b. patient has a history of smoking 1/2 pack of cigarettes per day c. patient has fever and malaise d. patient has a productive cough with rust colored sputum

a. patient has shallow, ineffective breathing

the nurse is completing documentation following the insertion of an intermittent urinary catheter. what should be included in the documentation? (select all that apply.) a. patients tolerance of the procedure b. size of the catheter c. time the procedure was performed d. date the procedure was performed e. the length of time for completion of the procedure

a. patients tolerance of the procedure b. size of the catheter c. time the procedure was performed d. date the procedure was performed

mona hernandez's blood gas results indicate respiratory acidosis. her oxygen saturation is 95% per the pulse oximeter. which interventions should the nurse provide. (select all that apply) a. promote voluntary coughing activities to clear secretions. b. none; the patient has a 95% oxygenation c. provide supplemental oxygen as ordered. d. assist the patient with adequate ventilation e. ensure the patient is well hydrated

a. promote voluntary coughing activities to clear secretions. c. provide supplemental oxygen as ordered. d. assist the patient with adequate ventilation e. ensure the patient is well hydrated

Mr. Russell has been placed on fall precautions. what actions should the nurse take to keep the patient safe? (select all that apply) a. provide non-skid socks for ambulation b. instruct patient to call for assistance when out of bed c. place the call bell within reach d. maintain be in low position at all times e. keep side rails up x4 at all times

a. provide non-skid socks for ambulation b. instruct patient to call for assistance when out of bed c. place the call bell within reach d. maintain be in low position at all times

Ms. Johnson asks: why do i need to self-catheterize at regular intervals? what would be the appropriate response by the nurse? a. this helps prevent your bladder from becoming over-distended b. this allows you to accurately measure your urine c. you will only need to self-catheterize once daily d. self-catheterization helps reduce your risk of infection

a. this helps prevent your bladder from becoming over-distended

Ms. Johnsom is being discharged with an order to continue the medication oxybutynin. what information should be included in the teaching session? a. this medication helps reduce bladder spasms. b. you may experience excess saliva production while taking this medication c. your urine may appear reddish-orange d. you may have to urinate more frequently while taking this medication

a. this medication helps reduce bladder spasms.

Mr. Russell has an order for vital signs and neurochecks every four hours. which assessment findings, if made by the nurse, would indicate potential neurologic compromise? (select all that apply.) a. unequal pupils b. left-sided weakness c. decreasing level of consciousness d. difficulty swallowing e. unsteady gait

a. unequal pupils c. decreasing level of consciousness

Mr. Russell experienced dysphagia and mild left-sided weakness following his stroke. for which additional symptoms of stroke should the nurse assess? (select all that apply) a. urinary incontinence b. communication difficulties c. hearing loss d. sensory deficits e. decreased peristalsis

a. urinary incontinence b. communication difficulties d. sensory deficits

the nurse is caring for a patient who has experienced a sudden change in level of consciousness and has difficulty speaking. what is the priority action of the nurse? a. notify the charge nurse b. assess the patent c. document the findings d. wait 15 minutes to see if the problem resolves

b. assess the patent

the nurse is caring for a stroke patient with mild dysphagia. what would be an appropriate nursing intervention for this patient in order to minimize risk for injury? (select all that apply.) a. providing mouth care immediately before meals b. placing food in an easily accessible position c. educating the patient about the importance of alternating liquids and solids d. providing a 30-minute rest period prior to mealtimes e. positioning patient upright in chair if not contraindicated

c. educating the patient about the importance of alternating liquids and solids d. providing a 30-minute rest period prior to mealtimes e. positioning patient upright in chair if not contraindicated

the nurse is providing patient education of self-catheterization. what statement by Ms. Johnson indicated the need for additional teaching? a. i should report signs and symptoms of potential complications to the provider immediately b. i should store my reusable catheters in a clean, dry container c. i can use either an indwelling or intermittent catheter d. i may by eligible for free catheters through Medicare

c. i can use either an indwelling or intermittent catheter

the nurse has created a sterile field and is preparing to catheterize a patient. while using sterile cotton balls to clean the patient prior to the procedure, the nurse drops a contaminated cotton ball in the middle of the sterile field. what is the correct action of the nurse at this time? a. remove the contaminated cotton ball from the field with the non-dominant hand b. continue with the procedure while avoiding the contaminated cotton ball c. obtain a new catheter kit and restart the procedure d. ask a co-worker to remove the contaminated cotton ball from the field

c. obtain a new catheter kit and restart the procedure

the nurse is calling in report to the provider using the SBAR format. Which statement by the nurse would by the "S" when using this reproting technique? a. the patients lungs are clear to auscultation b. the patient was admitted with stroke and mild left hemiplegia c. the patient began coughing when eating breakfast this morning d. i recommend the patient be sent for a swallow study

c. the patient began coughing when eating breakfast this morning

Mona hernandez's laboratory work indicates an elevated white blood cell count with a left shift in the different. the nurse interprets this to mean which of the following? a. there is high number of white blood cells to fight the infection, and the red blood cells are compensating b. a left shift in the differential means that there is not infection present c. there is a high number of white blood cells and immature white blood cells present to fight the infection d. there is a high number of white blood cells, but not immature white blood cells, present in the circulation

c. there is a high number of white blood cells and immature white blood cells present to fight the infection

as the nurse administers Mona Hernandez's prescribed medication, guaifenesin, the patent states: "i dont like this medication. it makes me cough too much." how should the nurse respond? a. this medication is given to you because of your pneumonia b. i will let your provider know you have questions about your medications c. when you cough out secretions, oxygenation is more effective. d. this medication will help make your breathing easier.

c. when you cough out secretions, oxygenation is more effective.

a patient has been admitted with a diagnosis of stroke, and the nurse has received orders to hold warfarin until lab results are received. what lab results does the nurse anticipate reviewing prior to administering this medication? a. platelets b. d-dimer c. hemoglobin and hematocrit d. PT/INR

d. PT/INR

Upon entering the room, the nurse observes Mona Hernandez slumped over in a semi-Fowler's position, struggling to catch her breath. What is the priority nursing action at this time? a. titrate her oxygen so that her oxygen is greater than or equal to 95% b. obtain vital signs c. obtain an oxygen saturation level. d. assist the patient into a high Fowler's position

d. assist the patient into a high Fowler's position

Mona Hernandez complains of shortness of breath with activity and does not want to exacerbate her condition by moving to the chair or ambulating three times a day as ordered. How should the nurse respond? a. pneumonia causes thick secretions in your lungs, making it difficult to breathe b. you really need to walk as much as possible in order to prevent your pneumonia from getting worse c. you should wait until your breathing improves to try to get out of bed again, because it makes you short of breath d. even short activities such as moving to the chair will help you cough mucus out of your lungs

d. even short activities such as moving to the chair will help you cough mucus out of your lungs

identify the following potential problems or actual problems that the nurse should include when planning care for the patient diagnosed with pneumonia? (select all that apply.) a. acute pain b. ineffective respiratory gas exchange c. not able to tolerate activity d. difficulty breathing e. metabolic acidosis

a. acute pain b. ineffective respiratory gas exchange c. not able to tolerate activity d. difficulty breathing

the nurse is preparing to insert an intermittent urinary catheter in a paralyzed female patient. what would be the appropriate action by the nurse? a. call for a co-worker to help the patients legs in position b. ask a family member to assist you with the catheterization c. notify the provider that the procedure could not be completed because the patient is paralyzed d. instruct the patient to turn over on her side

a. call for a co-worker to help the patients legs in position

a nurse rounding on a patient with pneumonia notices the patient is more confused than at the beginning of the shift. what is the best response by the nurse? a. check oxygen saturation level b. ensure a sitter is available to watch the patient c. notify the provider d. document findings in the medical record

a. check oxygen saturation level

The nurse is preparing the discharge Mona Hernandez from he hospital. Which of the following instructions should the nurse include in the discharge education? (select all that apply) a. continue to focus on ambulating several times per day b. quitting smoking will improve your recovery c. stop taking your antibiotics once you are feeling better d. take your antibiotics as directed, even if you feel better e. use the incentive spirometer every one to two hours to move secretions out of your lungs.

a. continue to focus on ambulating several times per day b. quitting smoking will improve your recovery d. take your antibiotics as directed, even if you feel better e. use the incentive spirometer every one to two hours to move secretions out of your lungs.

the nurse is recording fluid intake for Ms. Johnson. which items on the dinner tray should the nurse include when completing this documentation? (select all that apply.) a. iced yea b. tomato soup c. ice cream d. applesauce e. creamed corn

a. iced yea b. tomato soup c. ice cream

the nurse is assessing a patient using the Glasgow Coma Scale. which of the following are components of that scale? (select all that apply) a. motor response b. eye opening c. respiration d. brain stem reflexes e. verbal response

a. motor response b. eye opening e. verbal response

after completing an intermittent catheterization, what information concerning the procedure will the nurse include in Ms. Johnsons medical record? (select all that apply) a. description of the cleansing process preceding the procedure b. description of the patients tolerance of the procedure c. size of catheter used d. time procedure was performed e. characteristics of the urine obtained

b. description of the patients tolerance of the procedure c. size of catheter used d. time procedure was performed e. characteristics of the urine obtained

Mr. Russell is being discharged from the hospital following a mild stroke. what instruction would the nurse include in discharge education? a. you only need to take your medication when symptoms are present b. it is important that you begin smoking cessation program c. be sure to weigh yourself at the same time each day d. a low-protein diet is necessary to maintain your heath

b. it is important that you begin smoking cessation program

the nurse is providing Ms. Johnson discharge education about intermittent self-catheterization. what statement, if made by the patient, would indicate the need for further instruction? a. if i do not catheterize myself, i may develop urinary problems b. there are risks associated with self-catheterization, such as bleeding and infection c. i should maintain sterile technique throughout the procedure d. it is important that i self-catheterize at regular intervals

c. i should maintain sterile technique throughout the procedure

Mona Hernandez asks the nurse why it is necessary to use the incentive spirometer when she is already having difficulty breathing. what is the best response by the nurse? a. it increases the oxygen taken in by the lungs when you inhale b. it decreases cardiac workload during inspiration c. it helps prevent atelectasis or collapsing of the alveoli

c. it helps prevent atelectasis or collapsing of the alveoli