Exam 2
A nurse is monitoring a 58-year-old patient who is receiving diuretic therapy. Which assessment finding would the nurse interpret as being most significant?
Weight gain of 2 pounds
Which patient action when caring for a natural blind globe prosthesis indicates to the nurse the need to reinforce teaching?
Wiping off the cornea area with a clean, dry cloth
A patient reports waking up frequently during the night and not getting restful sleep. Which response should the nurse make?
"Drinking alcohol can cause you to wake up during the night."
A patient who has pain rated as a 7 on a scale from 1 to 10 continues to have pain despite having medication 2 hours ago. Which response should the nurse make when the patient requests additional medication?
"Let me reposition you and rub your back to help relieve the pain."
Which statement regarding addressing a patient's environmental controls requires the nurse to reinforce education with the patient?
"Lightly scented perfumes, colognes, or body lotions are not appropriate when providing patient care."
A nurse delegates activities of daily living (ADLs) to a certified nursing assistant (CNA). ADLs that can be delegated to a CNA include which of the following? Select all that apply.
-Assisting a patient with denture care -Showering a patient -Assisting a patient with dressing -Shaving a patient
A postoperative patient has been prescribed patient-controlled analgesia (PCA) for pain control. Which actions should the nurse implement related to PCA monitoring? Select all that apply.
-Document narcotic amounts at end of shift. -Assess patient sedation. -Assess pain relief. -Verify prescription.
A patient is admitted with long-standing chronic obstructive pulmonary disease (COPD) and is at risk for respiratory failure. Every 4 hours, the nurse performs a focused respiratory assessment. Which assessment action should the nurse include during each reassessment? Select all that apply.
-Presence of sternal retractions -Color of nail beds -SpOz
When assisting a patient with bedtime care, a nurse demonstrates caring by doing which of the following? Select all that apply.
-Rernoving the patient's hearing aids -Removing the patient's dentures -Dimming the patient's lights
A nurse is assessing a patient's eyes using a penlight. Which findings indicate that consensual reflex is normal? Select all that apply.
-Simultaneous pupillary response -Pupillary constriction in response to light -Pupils returning to same size after light stimuli
A nurse is assessing the fingernails of a 58-year-old male patient. Which findings warrant immediate intervention? Select all that apply.
-There is a bluish hue to nailbeds. -Fingernails are long and curved. -Cracked areas are around cuticles.
A nurse is working in a long-term care facility and preparing to provide a.m. care to patients. Which care should be provided on a daily basis? Select all that apply.
-massage -oral care -perineal
A nurse is preparing to document findings of edema for a patient who has bilateral swelling of both feet up to the level of the ankle. There is prolonged indentation after the nurse touches the area, which lasts several minutes. How should the nurse document this finding?
3+ pitting edema of the feet to ankle bilaterally
A nurse is monitoring a patient who has decreased urinary output despite being on continuous intravenous therapy and drinking fluids. Which assessment should the nurse identify as being a potential cause of this finding?
Abdomen slightly distended
A nurse performing an assessment of the patient's eyes tells the patient, "Focus on my pencil and follow it as I move it away from you and then back toward you." Which specific function is the nurse assessing?
Accommodation response
An unlicensed assistive personnel (UAP) has recorded vital signs on the patient's record. In reviewing the information, the nurse finds a documented temperature of 102.2°F (39°C). What is the next action that the nurse should take?
Administer Tylenol.
A patient asks the nurse if their family member can provide a.m. care to them. What is the best nursing response?
Allow patient and family member privacy during a.m. care.
A nurse provides care for a patient who is 1 day postoperative. The patient reports nausea and is refusing to eat. The nurse assesses the patient by auscultating the abdomen. Which cause would the nurse suspect if assessment reveals hypoactive bowel sounds?
Anesthesia
A nurse is preparing to administer a vaccine injection to a patient who is very nervous. What method should the nurse implement to decrease the patient's anxiety?
Ask the patient about what activities they like to do.
A patient has been using a TENS unit for one hour to help relieve back pain. Which action should the nurse take after removing the unit from the patient?
Assess pain level.
A charge nurse notes a patient's blood pressure at 8:00 a.m. was 124/80 mm Hg. It is now 12:00 p.m., and the patient's blood pressure is 152/94 mm Hg. Which suggestion about the plan of care should the charge nurse make to the graduate nurse?
Because the blood pressure has become elevated, it should be rechecked in 1 to 2 hours.
A nurse provides care to a patient who is lethargic and unable to tolerate standing for long periods. The patient has dyspnea on exertion. Which type of bath is best for the nurse to implement with this patient?
Bed bath
A patient reports having a sore jaw and tooth pain in the mornings. Which sleep disorder should the nurse suspect this patient has?
Bruxism
A nurse is assessing a patient's respiratory status and notes periods of apnea alternating with several deep breaths. What priority action should the nurse take?
Call a rapid response.
A patient being treated for chronic pain wants to reduce their intake of opiates and narcotics. What options should the nurse suggest to help support the patient's request?
Carbamazepine
A nurse enters the patient's room and observes a drooped right eyelid. Which assessment should the nurse perform next?
Check blood pressure
A nurse is inquiring about a patient's pain during morning assessment and asks the patient to provide a rating based on a scale of 0 to 10, with O meaning pain free and 10 meaning the worst pain. The patient reports a 9 out of 10. The patient is resting comfortably in bed watching television and does not appear to be in distress. What is the best nursing response?
Check to see when the patient was last medicated for pain.
A patient complaining of persistent shoulder pain is in the clinic for evaluation. Upon examination, vital signs are stable, and the patient appears angry that no one can help. How would the nurse interpret these findings?
Chronic pain patterd
A patient reports feeling pain "only when I move." Which type of pain is this patient experiencing?
Deep somatic
A nurse has determined that a patient's pain is acute and plans to administer pain medication. Which and symptoms of acute pain did the nurse use to make this clinical determination?
Dilated pupils
A student nurse is providing a.m. care to a patient who is receiving IV fluids. Which finding if observed by the nursing instructor warrants immediate action?
Disconnects IV tubing
A postoperative patient has been prescribed patient-controlled analgesia (PCA) for pain control. Which information should the nurse include in the plan of care?
Dosage prescription is programmed into the pump.
A nurse is assessing the patient's respiratory system. Which finding is consistent with normal respiratory function?
Equal thoracic excursion
A nurse is providing a.m, care lo a patient and finds an erythematous area near the sacrum that has scratch marks on the skin. The skin is intact. How should the nurse document this finding?
Excoriated
A nurse who is performing a physical assessment is preparing to auscultate breath sounds. Which position is most favorable for performing the assessment of breath sounds?
High Fowler's position
A nurse performs a focused assessment. Which condition provides the best information through the use of percussion?
Hyperinflated lungs
A nurse has been assigned to care for a patient who has been on the medical unit for 3 days with a clinical diagnosis of uncontrolled hypertension (HT). What type of physical assessment should the nurse perform upon starting the shift?
Initial head-to-toe assessment
A patient with diabetes has an open foot wound but reports no pain. How should the nurse document this finding?
Injury due to neuropathy
A nurse is assessing a patient's skin and notes a bronzed appearance. The nurse understands that the cause of the bronze pigmentation is:
Iron pigments
A nursing instructor is observing a nursing student perform a physical assessment on a simulation mannequin. Which observation warrants immediate action by the nursing instructor?
Palpated abdomen before listening to bowel sounds
A nurse is performing the morning assessment for a patient who is receiving a tube feeding. Which finding warrants immediate intervention?
Patient is lying flat in bed.
A nurse is performing an initial assessment of a 48-year-old patient's sleeping habits. Which warrant further attention? Select all that apply.
Patient sleeps 2 hours a night.
A 58-year-old patient is admitted to the hospital with a ruptured appendix for surgical repair, has poor vascular access, and is mildly dehydrated. What type of pain management would the nurse suspect that the health-care provider will order?
Patient-controlled analgesia (PCA)
A nurse is taking care of a patient with vital signs of BP 90/70, pulse 98, and respirations 24. Which immediate action should the nurse implement?
Place the bed in Trendelenburg position and administer oxygen via nasal cannula.
A nurse is providing a.m. care to a patient who is 3 days postoperative for a knee replacement. This is the first time that the patient wants to participate in the bathing process after the surgery. Which bathing option should the nurse provide to the patient?
Provide water basin and a face cloth so that patient can wash face.
A patient is able to brush their teeth but unable to floss and can bathe herself but can't style her hair. How should the nurse best categorize the patient's care level as it relates to activities of daily living (ADLs)?
Requires partial assist with ADis
An 18-year-old is in the clinic with an arm injury after banging into a doorframe. Upon entering the room, the nurse observes the individual rubbing the area. Based on the gate control theory of pain, how would the nurse interpret this finding?
Stimulation of small nerves to open the gate
A nurse is receiving a postoperative appendectomy patient from the recovery room to the surgical care unit. Which type of bed should the nurse use to prepare for the patient's arrival?
Surgical bed
A nurse is reviewing a patient's medication profile and finds that the patient is taking gabapentin following a motor vehicle accident (MA) in which injuries were sustained. Medical history is negative for disease. How should the nurse interpret this finding?
The medication is used to treat pain from MVA.
A patient is very restless in bed and the nurse finds that the bed linen is constantly coming off the bed. Which priority action should the nurse implement?
Use mitered corners.
