Exam 2 Study Guide
Convert this value from milliliters to liters 250mL= _________ L
0.25 L
Owen is a 15 year old client who is waking up postoperatively. He became combative and tried to strangle one of the nurses. Security assisted in placing Owen into 4-point restraints. How soon does a licensed provider need to assess the client and place the restraint order?
1 hour
Order: Acetaminophen 500 mg PO Q4 hours On hand: Acetaminophen 250 mg in 5 mL How much will you administer to your patient?
10 mL
What is the corresponding military time for the traditional time 4pm?
1600
Convert this value from milligrams to micrograms: 0.02 mg= __________mcg
20 mcg
How many tablespoons are in one half cup?
8 tbsp
What is the most appropriate outcome for the patient who has a nursing diagnosis of "Risk for Injury related to the use of assistive mobility devices in an unfamiliar environment?" A. The patient will demonstrate safety measures to prevent falls B. The patient will establish safety priorities with family members C. The nurse will identify resources for safety information D. The nurse will identify unsafe situations in the patients room.
A. The patient will demonstrate safety measures to prevent falls
A 6 year old female is diagnosed with Varicella. What type of isolation precautions will be initiated for this patient?
Airborne
What are the 5 steps involved in the nursing process?
Assess, diagnose, plan, intervene, evaluate
A child has third-degree burns of the hands, face, and chest. Which nursing diagnosis takes priority? A. Impaired urinary elimination related to fluid loss B. Ineffective airway clearance related to edema C. Disturbed body image related to physical appearance D. Risk for infection related to epidermal disruption
B. Ineffective airway clearance related to edema
A client with multiple injuries is rushed to the ED after a head-on car collision. Which assessment takes priority? A. Irregular apical pulse B. Ecchymosis in the flank area C. A deviated trachea D. Unequal pupils
C. A deviated trachea
The registered nurse on a busy telemetry floor is delegating tasks to a UAP. Which task is appropriate for the UAP to complete? A. Inserting an indwelling urinary catheter B. Recording an order over the phone from a physician C. Bathing a combative patient D. Assessing a client's wound
C. Bathing a combative client
A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? A. Obtaining history information from the parents B. Administering acetaminophen (Tylenol) C. Instituting droplet precautions D. Orienting the parents to the pediatric unit
C. Instituting droplet precautions
Which task is the most appropriate to assign to the nursing assistant when an uncertain death occurs in the ED? A. Go with the organ donor specialist to talk to the family B. Helping the family to collect belongings C. Escorting the family to a place of privacy D. Assist with postmortem care
D. Assisting with postmortem care
True or False: An RN delegates to the LPN to administer a scheduled tube feeding to a patient. The RN has now transferred full accountability to the LPN for the task getting done, and the RN is no longer accountable for the task.
FALSE
An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection?
Healthcare-associated infection (HAI)
After a client falls out of bed, the nurse should complete what?
Incident Report
Eye contact, physical appearance, gestures and posture are types of what kind of communication?
Non verbal
The nurse is completing a sterile dressing change on a confused client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What is the nurse's next action?
Open a new sterile dressing kit
The nurse is caring for an older adult who states the need to use the restroom. Which safety intervention must the nurse perform first?
assess the need for assistance with ambulation
Which type of health problem requires both physician and nurse prescribed actions to address?
collaborative health problems
A patient is diagnosed with Hepatitis A and is incontinent of stool. What type of precautions would be initiated?
contact/enteric
What is the leading cause of injury-related deaths in adults 65 and older?
falls
A 10 year old client contracted severe acute respiratory syndrome (SARS) when traveling abroad with her parents. The nurse knows she must put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective equipment should the nurse wear?
gown, gloves, mask, and shield
What is one of the most difficult therapeutic communication skills to master?
listening
The nurse is caring for a client in protective isolation due to neutropenia as a result of chemotherapy. Which priority intervention should the nurse implement in this client?
monitor client for infection
The registered nurse asks an LNA to check the infusion rate on an infusing intravenous medication. Can this task be delegated?
no
Before implementing any planned intervention, which action should the nurse take first?
reassess the client to determine whether the action is needed
What is another term for subjective data?
signs and symptoms
You are providing care to a patient with C. Diff. After removing the appropriate PPE, you would perform hand hygiene.
using soap and water
The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which piece of the assessment should the nurse obtain first in the comprehensive assessment?
vital signs
