Exam 2 practice

A young adult patient is admitted to a medical unit with the diagnosis of hepatitis A and placed in contact precautions. What is the primary goal of this action? 1. To prevent transmission of infectious microorganisms 2. To control the environment of the patient during hospitalization 3. To protect the patient from infectious microorganisms 4. To protect only the family from the transmission of the disease

1

During the 7 a.m. to 3 p.m. shift on the adult surgical unit, the code is announced for an external disaster emergency. Which event best represents this type of situation? 1. A school bus accident 2. A bomb threat in the mail room 3. A hostage-taking event in the emergency department 4. An electrical fire in the maintenance department

1

Prolonged Infrequent or Difficulty With Bowel Elimination, related to the effects of analgesic medications on the bowel as evidenced by statements of straining to have a bowel movement and no bowel movement in 5 days is an example of which type of patient problem statement? 1. An actual patient problem statement 2. A potential patient problem statement 3. A wellness patient problem statement 4. A patient problem statement

1

The LPN/LVN is reviewing the care plan of the patient who has an SRD applied for personal safety. Which is the highest priority goal for this patient? 1. Patient will remain free of injury. 2. Patient will allow SRDs to be used. 3. Nurse will check SRD every 30 minutes. 4. Use least restrictive form of SRD possible.

1

The home health nurse is visiting an older adult patient and her husband. What safety concern is of the highest priority when the nurse is assessing this patient's home environment? 1. Accidental poisoning 2. Electrical shock 3. Accidental falls 4. Thermal burns

1

The nurse discovers smoke in a soiled utility room across the hall from a patient's room. What should the nurse's initial action be? 1. Sound the fire alarm. 2. Disconnect the oxygen supply. 3. Use any extinguisher on the fire. 4. Remove the patient from the area.

1

The nurse is caring for the patient in isolation and plans to wear latex gloves. Which is an important consideration? 1. Assess the patient and the patient's record for potential latex allergy. 2. Vinyl gloves actually provide higher barrier protection than latex. 3. The cost of latex gloves is significantly higher than that of synthetic gloves. 4. Latex gloves are so reliable as barriers that hand hygiene is not required.

1

The nurse is performing a surgical hand scrub. During a surgical hand scrub, how are the hands to be held? 1. Above the elbows 2. With the fingers pointing downward 3. Whichever way is convenient 4. Just below the waist

1

The nurse is preparing to open the outer sterile wrap of a indwelling catheter tray. Which flap of the wrap (in which direction) should be opened first? 1. The flap that opens away from the nurse 2. The flap that opens to the left 3. The flap that opens to the right 4. The flap that opens toward the nurse

1

The patient is experiencing severe respiratory distress that is related to his chronic obstructive pulmonary disease. The patient is alert and oriented and is capable of answering questions. Which source of information is most accurate when performing a nursing history during the admission assessment? 1. The patient 2. The patient's wife 3. The physician 4. The medical record

1

The student nurse is preparing to don sterile gloves. What action by the student indicates understanding of the needed procedure? 1. Touch only the inside surface of the first glove while pulling it onto the hand. 2. Place the fingers of the dominant hand into the outside cuff of the first glove. 3. Let the cuff of the glove roll up over the hand as it is being pulled onto the hand. 4. Begin the procedure by pulling the first glove upward and over the nondominant hand.

1

To practice strict surgical asepsis, the nurse: 1. adheres to principles of sterile technique. 2. performs routine environmental cleaning. 3. disinfects surfaces that come into contact with body fluids. 4. maintains proper hand hygiene before and after patient care.

1

When caring for a patient who speaks a foreign language, the patient problem statement Compromised Verbal Communication would be inappropriate for what reason? 1. An inability to understand each other is the problem, not impaired verbal communication. 2. The patient is using a different health belief system that interferes with communication. 3. The patient is perhaps following acceptable communication guidelines within his or her culture. 4. The patient has deficient knowledge, not impaired verbal communication.

1

A male nurse is assigned to care for a female patient. The patient's husband tells the nurse that he cannot care for his wife due to religious reasons. Which statement best describes the patient's spouse's position? 1. The couple are prejudiced against the nurse's race. 2. The patient's religion requires that women should be assigned to care for her. 3. The nurse is not the same religion as the patient and therefore cannot care for the patient. 4. The couple does not speak English.

2

A middle-aged client is admitted to the hospital with cellulitis of the right foot. Three days later, the patient develops bacterial pneumonia. How would the patient's bacterial pneumonia be classified? 1. Acute primary 2. Health care-associated 3. Interstitial 4. Mycoplasmic

2

A patient isolated for pulmonary tuberculosis is expressing anger at the nurse. What action by the nurse is most appropriate? (Select all that apply.) 1. Provide a dark, quiet room to calm the patient. 2. Explain isolation procedures and provide meaningful stimulation. 3. Reduce the level of precautions to keep the patient from becoming angry. 4. Limit family and other caregiver visits to reduce the risk of spreading the infection. 5. Talk with the patient about how they are feeling.

2

An adult patient is brought to the emergency department for treatment of an unintentional poisoning. What is the nurse's first action in caring for this patient? 1. Induce vomiting. 2. Assess the patient. 3. Place the patient in an upright position. 4. Notify the poison control center.

2

The nurse caring for a Chinese American woman after an appendectomy can anticipate which intervention? 1. Maintaining eye contact with education 2. Sitting side-by-side to communicate 3. Touching the patient frequently to comfort 4. Providing a same-gender caregiver 5. Allowing the patient to keep head, arms, and legs covered

2

The nurse is documenting on a patient with an SRD. What information must the nurse include in this documentation? 1. The nurse's feelings about having used the SRD. 2. The specific type of SRD used and assessment of the patient. 3. Confirmation of a prn order for use of the SRD. 4. Evidence that the patient was assessed every 8 hours.

2

The patient asks the nurse how his skin will be sterilized before his surgery. What is the best response by the nurse? 1. "We will use alcohol to sterilize your skin." 2. "It is not possible to sterilize skin, but we will use an antimicrobial solution to eliminate most microorganisms." 3. "There are a series of steps used in sterilizing your skin to prevent you from getting an infection." 4. "We will use Betadine solution to sterilize your skin."

2

The patient explains to the nurse that he became ill because the natural balance in his body was upset when he moved into a new apartment. He has been taking herbs and rearranging objects to change the environment. The patient is most demonstrating what health belief system? 1. Biomedical 2. Folk 3. Holistic 4. A combination of all three

2

Upon entering a patient's room the nurse realizes that the patient is praying. What action by the nurse is most appropriate? 1. The nurse should stay in the room and wait until the patient is finished with his prayers. 2. The nurse should quietly leave the room and give the patient privacy to pray. 3. The nurse should interrupt the patient and tell him it is time for his care to be given. 4. The nurse should tell the patient that he cannot pray while he is in the hospital.

2

Which is a principle of surgical asepsis? 1. Any sterilized item is considered unsterile once it is allowed to fall below knee height. 2. Sterile fields and sterilized items are no longer sterile if they contact a clean surface. 3. A person not wearing sterile garments can come no closer to a sterile field than 3 ft. 4. The front and back of a sterile gown being worn are considered sterile from shoulders to knees.

2

Before implementation of any newly prescribed procedure, the nurse notices that the family of an older adult patient always consults the eldest son. What is the social organization of this family? (Select all that apply.) 1. Hispanic in origin 2. Patriarchal 3. Male dominated 4. Traditional nuclear 5. Matriarchal

2,3

Which example includes all appropriate components of a potential patient problem statement? (Select all that apply.) 1. Potential for Inability to Tolerate Activity 2. Potential for Aspiration Into Airway, related to difficulty swallowing 3. Potential Complication: Hemorrhage 4. Potential for Inability to Clear Airway, related to accumulation of mucus in trachea 5. Potential for Compromised Skin Integrity, related to immobility as evidenced by 2-cm abrasion

2,4

The student nurse correctly identifies which as a medical diagnosis? (Select all that apply.) 1. Acute pain 2. Pneumonia 3. Inability to tolerate activity 4. Inability to clear airway 5. Neuropathy, secondary to type 2 diabetes mell

2,5

A Mexican American is pregnant with her second child. When the nurse is reviewing her diet, the patient states that she never drinks milk. What culturally related factor may explain this? 1. The patient does not like the taste of milk. 2. Milk is forbidden in her cultural diet. 3. Lactose intolerance occurs often among Mexican Americans. 4. The patient cannot afford to buy milk.

3

A newborn has the nursing diagnosis of Potential for Inability to Regulate Body Temperature. What is the most accurate patient goal for this patient problem statement? 1. Parents state that they will keep the infant's room warm. 2. Parents state that they will wrap their infant in two blankets. 3. Parents state that they will keep their infant's temperature between 97.5°F and 98.6°F. 4. Parents state that they will be sure that their infant wears something on her head at home.

3

A patient is admitted to a hospital for coronary artery bypass graft surgery. His wound continues to drain, and when he is discharged, home health nurses will visit to continue to care for him. Who is most likely responsible for coordinating the patient's discharge plans? 1. RN team leader 2. Social worker 3. Case manager 4. Physician

3

A patient, who speaks a language different from the nurse's, asks that her daughter remain with her while the nurse performs a history and physical examination. What action by the nurse is most appropriate? 1. Ask the daughter to leave to maintain privacy for the patient. 2. Explain to the patient that family members are not allowed to stay in the examining room because of infection control. 3. Consider that the daughter may be there to serve as an interpreter for her mother. 4. Ignore the daughter while performing the history and physical examination.

3

A woman who has had four children comes to the clinic. She tells the nurse that when she laughs or coughs she loses control of some urine. Which nursing intervention is properly written in the care plan? 1. The nurse will teach the patient Kegel exercises. 2. The patient will perform Kegel exercises 10 times a day with four to six repetitions each time. 3. The nurse will teach the patient how to perform Kegel exercises 10 times a day with four to six repetitions each time. 4. The patient will not experience stress incontinence after 2 months of performing Kegel exercises 10 times per day.

3

Based on Maslow's hierarchy of needs, which patient problem statement label has the highest priority? 1. Potential for Aspiration Into Airway 2. Insufficient Knowledge 3. Recent Onset of Pain 4. Inability to Control Urination Due to Physical Stress

3

The nurse is planning to do a cultural assessment of an elderly Chinese American patient. What position of the nurse is most therapeutic? 1. The nurse sits facing the patient. 2. The nurse touches the patient frequently to convey concern. 3. The nurse positions the chair so that the nurse sits at a right angle to the patient. 4. The nurse maintains good eye contact while asking questions.

3

A patient in isolation is experiencing signs of social deprivation. Which intervention by the nurse is appropriate? 1. Allow visitors to remove masks while in the patient's room. 2. Leave the door of the negative-pressure room open slightly. 3. Remind the patient that the isolation is for his or her own benefit. 4. Set specific times when the nurse will return to the patient's room.

4

A type C fire extinguisher is required for which type of fire? 1. Paper 2. Cloth 3. Grease 4. Electrical

4

An elderly patient has been diagnosed with type 2 diabetes and hypertension. The student nurse tells the patient that her vegetables should be steamed and served plain. The patient responds, "I always cook my green beans with ham and salt and pepper. How can I eat them plain?" Which response by the nurse is most culturally sensitive? 1. "I'm sorry, but you will just have to change your method of cooking." 2. "I guess you will just have to give up eating green beans." 3. "You must follow the health care provider's order if you want to get better." 4. "Could you try cooking the beans with half as much ham and not add salt?"

4

The LPN/LVN is reviewing the admission information of a patient. Which information is of most concern to the nurse that this patient is at high risk for falling? 1. The patient has diabetes. 2. The patient had a stroke 3 years ago with no complications. 3. The patient becomes disoriented in the evening hours. 4. The patient wears eyeglasses and a hearing aid.

4

The home health nurse is assessing a child for the risk of injury. Which factor places a child at greatest risk for specific types of injuries? 1. Gender of the child 2. Overall health 3. Educational level 4. Developmental level

4

The nurse is assisting the physician with an irrigation of a draining abdominal wound by preparing the sterile tray. To maintain sterility of the tray, which action by the nurse is correct? 1. Use sterile forceps while reaching across it to move the contents around. 2. Wear clean gloves to open and touch the contents of the tray. 3. Allow the open tray to stand unattended for 20 minutes, then cover it with a towel. 4. Put on sterile gloves before handling the contents of the tray.

4

The nurse is providing home poison control instruction to the parent of a 2-year-old boy. Which statement by the parent indicates the need for further teaching? 1. "I will call the national poison control center if my child ingests a poisonous substance." 2. "I will call 911 immediately if my child ingests medication that is not intended for him." 3. "Child safety caps on household cleaner can still be opened by some children." 4. "I will give my child syrup of ipecac if he ingests a poisonous substance that is not caustic."

4

The nursing instructor is discussing the chain of infection to a group of student nurses. What is the most important information about identifying the chain of infection for the health care provider? 1. Understanding of the chain of infection allows for tests to be performed to assess resistance to communicable diseases. 2. Recognition of the chain of infection provides information about which patients will most benefit from isolation precautions. 3. The need for antibiotic therapy can be determined by assessing the chain of infection. 4. Points at which the infection can be stopped or prevented can be located by identifying the chain of infection.

4

The occupational health nurse learns of a mercury spill that occurred in the factory in which she is employed. Which action by the nurse is correct? 1. The nurse cleans the mercury spill with alcohol and ordinary cleaning cloths. 2. The nurse closes all windows and doors to prevent the mercury spill from spreading out of the area. 3. The nurse instructs the housekeeping staff to vacuum up the spill. 4. The nurse evacuates the area and contacts trained personnel to clean up the spill.

4

The patient is admitted to the hospital with an upper respiratory infection. The nurse writes the following problem statement: Potential for Inadequate Fluid Volume, related to refusal to drink fluids, secondary to a sore throat. Which is the best patient goal statement for the patient? 1. The nurse will offer 2000 mL of fluids per day during hospitalization. 2. The patient will experience a less sore throat in 8 hours. 3. The nurse will maintain an intravenous infusion of fluids for the ordered length of time. 4. The patient will maintain adequate hydration as evidenced by moist mucous membranes, elastic skin turgor, and voiding of clear dilute urine.

4

The student is reviewing sterile technique. When using the technique, the student nurse remembers to hold sterile objects in which location? 1. Close to shoulder level 2. Just below waist level 3. Over the patient's bed 4. Above waist level

4

What occurs during the last phase of the nursing process? 1. The nurse gathers data to use in planning care. 2. The nurse selects nursing interventions to achieve the desired outcomes. 3. The nurse compares the desired outcome with the actual outcome. 4. The nurse prioritizes nursing interventions.

4

What term describes a nurse who is aware of her or his own cultural beliefs and the beliefs and practices of other cultures and who has the ability to interact effectively with people from other cultures? 1. Stereotyping 2. Ethnocentric 3. Culturally aware 4. Culturally competent

4

Which statement best describes a patient problem statement? 1. Statement of the patient's needs according to Maslow's hierarchy 2. Description of the patient's disease process 3. Listing of the required nursing interventions 4. A patient's health-related problem that can be treated by the nurse.

4

Which statement by the student nurse best demonstrates knowledge of the nursing process when describing defining characteristics? 1. "Defining characteristics are a description of the patient problem." 2. "Defining characteristics tell how the nursing diagnosis was determined." 3. "Defining characteristics are a cluster of clinical cues." 4. "Defining characteristics are factors such as signs and symptoms that support the nursing diagnosis."

4

While giving a bath, the nurse notes skin breakdown on a patient's coccyx. What part of the patient problem statement is this observation? 1. The patient problem statement 2. The etiologic or related factor 3. The patient goal 4. The defining characteristic

4

Which patient goal statement is best stated and contains necessary criteria? (Select all that apply.) 1. The patient will identify the types of foods to include in a high-fiber diet. 2. The nurse will teach the patient about constipation prevention. 3. The nurse will increase total fluids during hospitalization. 4. The patient will have a soft, formed bowel movement on the third day after surgery. 5. The patient will ambulate 50 feet three times per day, with the assistance of 1, starting on postoperative day 1.

4,5

The nurse has completed a sterile procedure and is preparing to remove the soiled gloves. Place the steps in the correct order: 1. Grasp the outer surface of the glove. 2. Place the glove in the hand that is still gloved. 3. Peel the second glove off, turn inside out, and discard. 4. Take fingers of bare hand and tuck inside remaining glove cuff.

1, 2, 4, 3

When caring for the patient who requires the use of an SRD, what should be included in the patient's plan of care? (Select all that apply.) 1. Monitor the skin for signs of impairment. 2. Remove the SRD once every 2 hours. 3. Secure the ends of the ties to the side rails. 4. Ensure that the SRD is in place at all times. 5. Reevaluate the need for the SRD frequently.

1, 2, 5

The nurse is observing the UAP who is assisting a resident in a long-term care facility ambulate with a gait belt. Which action by the UAP indicates to the nurse that further instruction is necessary? (Select all that apply.) 1. The UAP loosely fastens the gait belt around the patient's waist. 2. The UAP places the gait belt on the resident before assisting the resident to a standing position. 3. The UAP grasps the gait belt while assisting the resident out of bed. 4. The UAP fastens the belt around the arm of the chair to prevent the resident from slipping out of the chair. 5. The UAP explains to the resident that the gait belt is used to prevent injury to the resident and the UAP when assisting with ambulation.

1, 4

The nurse is planning care for several patients undergoing procedures. For which procedure will the nurse gather supplies to implement surgical asepsis? (Select all that apply.) 1. Inserting an IV line 2. Performing perineal care 3. Performing oral care 4. Obtaining a sputum specimen 5. Inserting an indwelling catheter

1, 5

A 14-year-old patient is admitted to the emergency department with a possible medical diagnosis of acute appendicitis. Who should the nurse interview first when performing the assessment? 1. The patient's parents 2. The patient 3. The physician 4. The admissions nurse

2

A Muslim patient visiting the health care provider's office was told she had to remove her clothes and put on an examination gown. The patient said she preferred to remain in her own clothes. Why should the nurse allow the patient to remain in her clothes? 1. The patient is embarrassed. 2. Her beliefs may require her to keep as much of her body covered as possible during the examination. 3. The patient is being uncooperative. 4. The patient cannot disrobe in front of another female.

2

A female nurse who is black is assigned to care for a new 86-year-old resident in a long-term care facility. When she enters his room, he makes several racially offensive remarks. What is an appropriate response? 1. The nurse should refuse to give care to the patient. 2. The nurse should understand that he is possibly less tolerant of other races because of his own cultural experiences or he perhaps has disturbed cognitive functions. 3. The nurse should become angry and retaliate by making racial statements directed at the patient. 4. The nurse should tell her supervisor that she will not take care of any other white patients.

2

The nurse is presenting an educational program on the CDC's hand hygiene recommendations for implementation in a hospital. Which statement by the nurse demonstrates an understanding of the CDC's recommendation? (Select all that apply.) 1. Health care providers will wear gloves at all times when providing patient care. 2. Disinfecting hands after glove removal is not necessary according to the guidelines. 3. Alcohol-based hand cleaner is effective on hands that are not visibly soiled with blood and body fluids. 4. It is necessary to remove waterless alcohol-based hand cleaner with paper towels to remove pathogens from hands. 5. The nurse should use water and soap to wash hands after caring for a patient diagnosed with Clostridium difficile.

3

The nurse is speaking with a patient about the need to prevent infection. The nurse recognizes the patient understands proper hand hygiene when the patient makes what statement? 1. "The water I wash my hands with should be as hot as I can tolerate to kill all of the germs on my skin." 2. "If there isn't time to completely wash my hands, it will be all right to rinse them quickly in warm water." 3. "After washing my hands with soap for at least 20 seconds, I will rinse them thoroughly under running water." 4. "I will put soap into a basin of warm water, lather my hands for 15 seconds, and then rinse them in the basin."

3

The nurse is working in a clinical medical area with a census of 15. Each patient has a different illness. When planning care, the nurse recognizes which as the most important action to provide protection to each patient from health care-associated infections? 1. Wearing a gown 2. Placing each patient in isolation 3. Hand hygiene 4. Wearing gloves

3

The nurse works in a community with many Mexican American families. What is the best method for the nurse to learn about the Mexican American culture? 1. Eat at Mexican American restaurants in the area. 2. Schedule a home visit with a Mexican American family. 3. Conduct a library study or Internet search of information on the culture. 4. Observe cultural behaviors in a movie theater in the area. Examination!

3

The patient is admitted to the hospital with reports of diffuse symptoms such as nausea, vomiting, weight loss, headaches, insomnia, and chest pain, which she describes by saying, "My heart aches." Which intervention is appropriate for this patient, whose cultural beliefs may differ from the nurse's beliefs about physical illness? 1. Adhere to the philosophy, "I treat all my patients the same." 2. Encourage the patient to describe her symptoms using only English. 3. Contact an adviser who is familiar with the cultural beliefs of the patient. 4. Allow the patient to continue taking herbal preparations while she is hospitalized.

3

The student nurse tells her instructor that she does not understand why a Chinese American family is not grieving for their dying father. What behaviors are being demonstrated by the student nurse? 1. Subculture orientation 2. Stereotyping 3. Ethnocentric 4. Culturally racist

3

To remove the gloves, what action is required of the nurse? 1. Pull each finger from each of the gloves first, then roll the glove back over the hand. 2. Remove the glove from the nondominant hand by reaching inside the glove and pulling it off. 3. Remove one glove, then use the bare fingers to push the remaining glove off from inside the cuff. 4. Hold both gloved hands under running water and roll the gloves down to keep microorganisms contained.

3

Which phrases are most appropriate to use to connect the parts of a patient problem statement? 1. "Related to" and "due to" 2. "Due to" and "as evidenced by" 3. "Related to" and "as evidenced by" 4. "Due to" and "as evidenced by"

3

The nurse is caring for a patient on a ventilator and reads the order "restrain prn." The nurse considers which factor when caring for this patient? (Select all that apply.) 1. SRDs often decrease anxiety because the patient feels safer. 2. All older adult patients need some type of SRD at night. 3. Allow as much freedom of movement as possible when applying SRDs. 4. When using soft SRDs to prevent pulling of the ventilator tubing, tie them to the side rail. 5. Ensure that the nurse's two fingers can be inserted between the SRD and the patient's skin.

3, 5

When the staff's knowledge of the fire safety precautions is assessed, which action indicates the need for further fire safety instruction? (Select all that apply.) 1. Fire exits, and corridors are kept clear. 2. A No Smoking sign is posted when oxygen is in use. 3. A heating pad cord is taped when a frayed area is noted. 4. Facility smoking policies are a part of the admission procedure for patients. 5. An UAP evacuated critically ill patients on the elevator during a fire drill.

3, 5

The student nurse is correct in identifying which statement as objective data? (Select all that apply.) 1. "When I walk to the mailbox, I get very short of breath." 2. "My legs ache when I climb stairs." 3. 4-cm Transverse abdominal incision 4. Report of pain 6 on a scale of 0 to 10 5. B/P 178/90

3,5

Which patient problem statement includes all appropriate components of an actual patient problem statement? (Select all that apply.) 1. Inefficient Oxygenation 2. Potential Complication: Gastric Bleeding, related to gastric ulcer 3. Fearfulness, related to separation from support system as evidenced by statements of being scared, pallor, and increased respirations 4. Potential for Falling, related to confusion as evidenced by calling nurse by name of aunt 5. Anxiousness, related to upcoming surgery as evidenced by the patient stating, "I am very worried that something is going to go wrong."

3,5

____________________ means the nurse is aware of his or her own cultural beliefs and practices and how they relate to those of others.

Cultural competence