multiple choice practice questions
A patient's admission vital signs are: temperature 99.1 degrees F, pulse 75, respirations 16 and unlabored, and blood pressure 185/110. Which of the following vital signs is the most concerning to the nurse? a. Pulse b. Respirations c. Blood pressure d. Temperature
c
nurse is caring for a client with Alzheimer disease who is very confused. which is the most appropriate communication strategy to be used? a. written directions for bathing b. speaking loudly c. gentle touch while providing ADLs d. flat facial expression
c
the nurse determines that a field remains sterile if which of the following conditions exist? a. tips of wet forceps are help upward when help in ungloved hands b. the field was set up 1 hr before c. sterile items are 2 inches from the edge of the field d. the nurse reaches over the field than around the edges
c
the nurse report dyspnea when ambulating. which of the following must have been noted? a. shallow inhalations b. wheezing c. SOB d. coughing up blood
c
which client meets the criteria for apical pulse site for pulse assessment rather than radial pulse? a. a client in shock b. a client whose pulse changes with body composition changes c. client with arrthymia d. client who had surgery less than 24 hrs ago
c
which of the following intervention is highest priority for a client with fall risk? a. keep all side rails up b. review prescribed medications c. place bed in lowest position
c
*The client is unresponsive and requires total care by nursing staff. Which assessment does the nurse check first before providing special oral care to the client? 1. Presence of pain 2. Condition of the skin 3. Gag reflex 4. Range of motion
3
While applying sterile gloves (open method), the cuff of the first glove rolls under itself about 1/4 inch. What is the best action for the nurse to take? 1. Remove the glove and start over with a new pair. 2. Wait until the second glove is in place and then unroll the cuff with the other sterile hand. 3. Ask a colleague to assist by unrolling the cuff. 4. Leave the cuff rolled under.
4
Factors that can affect the body temperature include which of the following? (select all that apply) a. Environment b. Race c. Circadian rhythms d. Exercise e. Hormones
: A, C, D, E
A nurse who is teaching a group of adults ages 20 to 40 years old about safety is going to ensure that which topic is a priority? 1. Automobile crashes 2. Drowning and firearms 3. Falls 4. Suicide and homicide
1
Which charting rule(s) will keep the nurse legally safe? Select all that apply. 1. Use military time. 2. Document worries or concerns expressed by the client. 3. Perform most of the charting at the end of the shift. 4. Record only information that pertains to the client's health problems.
1,2,4
when auscultating the blood pressure, the nurse hears: from 200 to 180: silence... then a thumping sound continuing down to 150...muffled sounds continuing down to 105....muffled sounds down to 95 then silence the nurse records the BP as ___/___/___
180/105/95 systolic/1st diastolic/2nd diastolic
*A client can bathe most of her body except for the back, hands, and feet. She also can walk to and from the bathroom and dress herself when given clothing. Which functional level describes this client? 1. Totally dependent (+4) 2. Moderately dependent (+3) 3. Semidependent (+2) 4. Independent (0)
3
A 74 year old female is brought into ED c/o right hip pain. the right leg is shorter than the left and is ER. during inspection the nurse observes what appears to be cigarette burns on inner thigh. what is the most appropriate way to document? a. six round lesions partically healed, on inner thighs bilaterally b. several burned areas on inner thighs c. multiple lesions on inner thighs possible related to elder abuse d. several lesions on inner thighs similar to cigarette burns
a
A fire is contained to one patient unit on the 7th floor (7 West). The patients on 7 West should be moved to what location? a. 7 East b. 6 South c. The emergency department d. The medical office building
a
A nurse comes across a fire in a patient's room caused by a candle flame and multiple books lying on the bedside table. Which class of fire extinguisher should be used for this type of fire? a. Class A b. Class B c. Class C d. Class ABC
a
A patient diagnosed with tuberculosis is scheduled to go to the radiology department for a chest x-ray. Which nursing intervention would be appropriate when preparing to transport the patient? a. Apply a mask to the patient b. Apply a mask and gown to the patient c. Apply a mask, gown, and gloves to the patient d. Notify the x-ray department so that the personnel can be sure to wear a mask when the patient arrives
a
A sleeping patient has the following vital signs: respiratory rate of 10, temperature 98.5, blood pressure 135/75, heart rate 78, and oxygenation 98%. Which of the following actions should the nurse take? a. Continue to monitor the patient b. Call the physician to report the vital signs c. Arouse the patient from sleep d. Call the charge nurse for assistance
a
The nurse needs vital signs assessed for four patients. Which patient should the nurse assess and not assign to the UAP? a. Patient returning to the nursing unit after cardiac catherization b. Patient on 2 liters of oxygen via nasal cannula c. Pneumonia patient nearing discharge d. Post-operative patient of 2 days from gallbladder surgery
a
When preparing for a bed bath why should the nurse offer the patient a bedpan, urinal, or the commode prior to performing the procedure? a. Warm water and activity can stimulate the need to void b. Increase in air current in the room can promote voiding c. The patient should be offered toileting prior to any procedure d. So the nurse does not have to change the bed linens
a
Which nursing measure is appropriate to break a link in the chain of infection? a. Wash hands before and after caring for a patient b. Place contaminated linens in a yellow paper bag c. Use personal protection equipment sparingly d. Wear gloves at all times
a
a nurse tell a client who is struggling with cancer pain "it is normal to feel frustrated about the discomfort" which is most representative of the skills associated with the working phase of helping relationship? a. respect b. genuineness c. concreteness d. confrontation
a
a nurse tells a client struggling with cancer "it is normal to feel frustrated about the discomfort" which therapeutic technique is this? a. respect b. genuineness c. concreatness d. confortation
a
in what situation can UAP take vitals? a. client being prepared for elective face surgery with history of stable hypertension b. client receiving blood transfusion with history of transfusion reactions c. client who recently started medications for arrthymia d. client who is frequently admitted with asthma attacks
a
the client is complaining of shortness of breath. his respirations are 28 and labored. the bed is currently in the flat position. the nurse puts the bed in what position? a. fowlers b. semi fowlers c. trendelenburg d. reverse tren
a
the client wears an in the ear (ITE) hearing aid and because of arthritis needs someone to insert the hearing aid. which action does the nurse teach the UAP to do before inserting the hearing aid? a. turn the hearing aid off b. soak the hearing aid in a soapy solution c. turn the volume all the way off d. remove the batteries
a
the nurse asks the client "what do you fear most about your surgery tomorrow?" this is an example of which communication technique? a. providing general leads b. seeking clarification c. presenting reality d. summarizing
a
when caring for a single patient during one shift, it is appropriate for the nurse to reuse which PPE? a. goggles b. gloves c. gown d. surgical mask
a
a nurse is caring for a client who has SARS. the nurse knows that health care professionals are required to report communicable and infectious diseases. which illustrate the rationale for reporting? (SAP) a. planning and evaluating control and prevention strategies b. determining public health priorities c. ensuring proper medical treatment d. identifying endemic disease e. monitoring for common source outbreaks
a,b,c,e
a student nurse observes the change of shift report. which behavior(s) by the reporting nurse represents effective nursing practice? sap a. provides medical diagnosis or reason for admission b. states the time the client last received pain medication c. speaks loudly when giving report d. states priorities of care that are due shortly after the report e. reports number of visitors for each client
a,b,d
the nurse is discussing strategies with the UAP for bathing a client with dementia. which strategies would be appropriate for the client? sap a. cover the client as much as possible b. sing or talk to the client c. complete a bath as quickly as possible d. expect the client to protest --- finish quickly
a,b,d
a charge nurse is reviewing the difference in manifestations of localized versus a systemic infection. which are manifestations of a systemic infection? SAP a. fever b. malaise c. edema d. pain or tenderness e. increase in pulse and respiratory rate
a,b,e
the nurse who uses appropriate therapeutic listening skills will display what behavior? a. absorb both the content and the feeling the client is conveying b. presume an understanding of the clients needs c. adopt an open professional posture d. react quickly to message e. resaaure the client that everything will be fine
a,c
the nurse at change of shift report learns that one of the clients had a bilateral soft wrists restraints. the client is confused, is trying to get out of bed and pulled out the IV line, which was reinserted. which action(s) by the nurse is appropriate? sap a. document the behavior(s) that acquire continued use of the restraints b. ensure that the restraints are tied to the side rails c. provide ROM exercises when restraints are removed d. orient the client e. assess the tightness of the restraints
a,c,d,e
the nurse is planning a presentation on oral health at an intergenerational community center. which statement will be important to include? sap a. using a bottle during naps and bedtime can cause dental caries in a toddler b. schedule a visit to the dentist when your child is ready to go to school c. its important for parents to supervise a childs brushing of their teeth d. most older adults have dentures and dont need to worry about oral care e. older adults are at risk for periodontal disease
a,c,e
Before discharge from the hospital a patient is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the patient to monitor to determine whether to increase or decrease the exercise level? a. Blood pressure b. Pulse rate c. Body temperature d. Respiratory rate
b
The nurse determines that a patient has active immunity to a microorganism. Which of the following would cause the patient to develop this type of immunity? a. Becoming ill with tetanus and receiving tetanus toxoid b. Having chickenpox c. Receiving a rabies shot after being bitten by a rabid dog d. Receiving an injection of gamma globulin
b
The nurse has just been stuck with a syringe while dropping it into a sharps container that was too full in a patient's room. What action should the nurse take first for this puncture wound? a. Complete an injury report. b. Allow some bleeding. c. Initiate first aid. d. Wash the area with soap and water.
b
What is the most effective nursing action for preventing and controlling the spread of infection? a. Always wearing gloves when completing patient care b. Thorough handwashing c. Placing patients in isolation as appropriate d. Widespread use of antibiotics
b
When preparing a patient for discharge the nurse notes that the patient has a temperature of 101.8. Which phrase is most appropriate for the nurse to use when speaking with the healthcare provider? a. "This patient should not be discharged because he has a temperature of 101.8." b. "I am concerned about the patient's readiness for discharge because his most recent temperature was 101.8." c. "I called the nursing home and cancelled this patient's discharge because he has a temperature of 101.8." d. "This patient has a temperature of 101.8. Don't you think we should cancel his discharge?"
b
Which is the primary reason why the nurse should avoid wearing artificial nails? a. They interfere with typing b. They could harbor microorganisms c. They could fall off in a patient's bed d. They can scratch the patient
b
While the nurse is performing morning care, a patient begins to have a seizure. What should the nurse do to help this patient? a. Insert a tongue blade into the patient's mouth. b. Loosen any clothing around the neck and chest. c. Restrain the patient. d. Turn the patient to the supine position if possible.
b
a client with diabetes has very dry skin on her feet and lower extremities. the nurse plans to inform the client to do which of the following to maintain intact skin? a. soak feet frequently b. use a non-perfumed lotion c. apply foot powder d. avoid knee high elastic stockings
b
a depressed client who has not bathed or dressed in clean clothes is reading the lunch menu and is unable to make a decision. what would be the diagnosis? a. anxiety b. powerlessness c. chronic low self esteem d. social isolation
b
after teaching a client and family strategies tp prevent infection prevention, which statement by the client would indicate effective learning has occurred? a. we will use antimicrobial soap and hot water to wash hands 3 times per day b. we must wash or peel all raw fruits and vegetables before eating c. a wound or sore is not infected unless we see drainage
b
during the first day a nurse is caring for a client who has been in the hospital for 2 days, the nurse thinks the BP seems high. what is the next step? a. ask client about past BP ranges b. review the graphic record on the clients record c. examine medication record for antohypertentive medications d. review the progress notes included in the clients record
b
for a client with a previous BP of 138/74 and pulse of 64 bpm, how long should the nurse take to release the BP cuff in order to obtain an accurate reading? a. 10-20 sec b. 30-45 sec c. 1-1.5 min d. 3-3.5 min
b
is discussing foot care with a client who has recently was diagnosed with diabetes. which statement by the client indicates a need for further teaching? a. i am going to use a mirror to check my feet b. i enjoy walking barefoot around the house c. i will file my nails d. i will increase the time that I wear my shoes everyday
b
the client is a chronic carrier of infection. to prevent spread of the infection or other clients or health care providers, the nurse emphasizes interventions that do which of the following? a. eliminate the reservoir b. block the portal of exit from the reservoir c. block the portal of entry to host d. decrease the susceptibility of the host
b
the clients temp at 8am using an oral electronic thermometer is 36.1c (97.2F). if the respirations, pulse and BP were within normal range, what would the nurse do next? a. wait 15 min and retake it b. check the clients temp the last time is was taken c. retake it using a different thermometer d. chart the temp; its normal
b
a client just returned from PAR. which communication intervention is most likely to facilitate effective communication? sap a. ask the client if they known where they are b. ask the client or support the person about visual or learning problems c. inform the client and the person about the events that might occur in the next 2 hours d. provide the client with instructions about discharge
b,c
Nurse has prepared sterile field for assisting provider with chest tube insertion. Which should nurse recognize as contaminating sterile field? (Select all that apply.) A: provider drops sterile instrument onto near side of sterile field B: nurse moistens cotton ball with sterile NS & places it on sterile field C: procedure is delayed 1h b/c provider receives emergency call D: nurse turns to speak to someone who enters through door behind nurse E: client's hand brushes against outer edge of sterile field
b,c,d
the nurse evaluates the chart of a 65 year old with no apparent risk factors and concludes which immunizations are current? sap a. last tetanus booster was at age 50 b. receives flu shot every year c. has not received Hep B d. has not received Hep A e. has not received herpes zoster
b,c,d
a nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. which interventions should the nurse include? sap a. place client in room with negative air pressure with at least 6 exchanges per hour b. wear a mask when providing care within 3ft from client c. place a surgical mask on the client if transportation to another department is unavailable d. use sterile gloves when handling soiled linens e. wear a gown when preforming care that might result in contamination from secretions
b,c,e
which are written correctly? a. MS 5 gr given IV c/o abdominal pain b. lanoxin 0.25 mg given orally per Dr. Smith's stat order c. KCL 15 mL given orally for K+ level of 3.9 d. regular insulin 10.0 u given SQ for capillary blood glucose of 180 e. ambien 5 mg given orally at bedtime per request
b,c,e
a client is being admitted to the hospital because of a seizure that occurred at his home.the client has no previous history of seizures. in planning the clients nursing care, which of the following measures is most essential at the time of admission? sap a. place padded tongue depressor at head of bed b. pad the bed with blankets c. inform the client about the importance of wearing medical identification tag d. teach the client about epilepsy e. test oral suction equipment
b,e
A nurse sees smoke emerging from the suction equipment being used. Which is the greatest priority in the event of a fire? a.Report the fire. b. Extinguish the fire. c. Protect the clients. d. Contain the fire.
c
The nurse has delegated the making of unoccupied beds to unlicensed assistive personnel. What should the nurse assess regarding patient safety once the beds are completed? a. Folding of the top sheet b. Direction of the pillow c. Call light being readily available d. Presence of mitered corners
c
The nurse is caring for a patient with Clostridium difficile infection. Which behavior indicates that the nurse needs additional information about this disease? a. Wears gloves during a physical assessment b. Enters room without first putting on a mask c. Performs hand hygiene with an alcohol-based disinfectant d. Wears a gown while providing incontinent care
c
The nurse is educating a patient about proper handwashing techniques. She instructs the patient to use which of the following in order to better protect the skin? a. Cold water b. Hot water c. Warm water d. Water-based sanitizer
c
The nurse is shampooing a patient's hair. Which assessment finding should the nurse consider as expected? a. Dry, dark, thin b. Smooth, taut, shiny c. Smooth texture and not oily or dry d. Tender, warm scalp
c
The nurse notices the pulse oximetry of the client is 85% oxygen saturation. What is the first action the nurse should take? a. Notify the physician b. Call the respiratory therapist c. Ensure that the pulse oximeter is working correctly d. Assess the pulse at the oximeter site for one minute
c
The nurse understands that redness of the skin associated with a variety of conditions is described as which of the following? a. Excessive dryness b. Abrasion c. Erythema d. Hirsutism
c
When entering client's room to change dressing, nurse notes client is coughing & sneezing. When preparing sterile field, it's important the nurse... A: keep sterile field at least 6 ft away from client's bedside B: instruct client to not cough/sneeze during dressing change C: place mask on client to limit spread of microorganisms into surgical wound D: keep box of Kleenex nearby for client to use during dressing change
c
a mother and her child live in a home built in 1932. which NADA nursing diagnosis is most applicable for this child? a. risk for suffocation b. risk for injury c. risk for poisoning d. risk for disuse syndrome
c
a nurse in communicating with a well orientated long term care client. which statement best reflects respectful and caring communication? a. are we ready for our shower? b. its time to go to the dining room, honey c. are you comfortable Mr. smith? d. you would rather wears the slacks, wouldnt you?
c
an 87-year-old man is admitted to the hospital for cellulitis of the left arm. he ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. which intervention is most important to protect him from injury? a. leave the bathroom light on b. with hold the client from diuretic meds c. provide a bedside commode d. keep the side rails up
c
place in helping relationship sequence in order a. after introductions, "what plan do you have coming up for the holiday weekend" b. the nurse states "it sounds like you are concerned about the complications of having diabetes. what would be must helpful to you?" c. the nurse reads the medical history that the client was diagnosed with diabetes type 1 a week ago d. the nurse states "when we met, you knew very little about diabetes and now you are able to you this new info and apply it"
c,a,b,d
85 year old client has had a stroke resulting in right sided facial dropping, difficultly swallowing, and the inability to move self of maintain position unaided. which sites are most appropriate for temperature? sap a. oral b. rectal c. axillary d. tympanic e. temporal artery
c,d,e
A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand
c,d,e
medication errors can place the client at significant risk. which practice(s) will decrease the possibility of error? sap a. hire only competent nurses b. improve the nurses ability to multitask c. establish a reporting system for "near misses" d. communicate effectively e. create a culture of trust
c,d,e
A nurse employed in a preschool agency is planning a staff education program to prevent the spread of an outbreak of an intestinal parasitic disease. The nurse includes which priority prevention measure in the educational session? a. All food will be cooked before eating b. Only bottled water will be used for drinking c. All toileting areas will be cleaned daily with soap and water d. Staff will practice standard precautions when changing diapers and assisting children with toileting
d
A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body
d
An older patient has an oral temperature reading of 97.2 degrees F. The nurse realizes that this patient's low temperature could be due to which observation? a. The anxiety level of the patient has increased. b. Hormones have fluctuated in this patient. c. Muscle activity has increased during the patient's therapy session. d. Loss of subcutaneous fat is noted.
d
Body temperature may be measured in all of the following ways except which of the following? a. Axillary b. Rectal c. Temporal d. Radial
d
The nurse is concerned that a break occurred in a sterile field. Which of the following would cause such a break? a. Grasping the edge of the outermost flap and opening it away from oneself b. Keeping objects on the field 1 inch from the edge c. Keeping the sterile field in eyesight d. Transferring a sterile object to a sterile field with a clean gloved hand
d
The nurse is setting up a sterile field. Which action by the nurse best exhibits surgical asepsis? a. Disinfecting an item before adding it to a sterile field b. Allowing sterile gloved hands to fall below the waist c. Suctioning the oral cavity of an unconscious patient d. Touching only the inside surface of the first glove while pulling it onto the hand
d
Which determinant of blood pressure would best explain a patient's blood pressure reading of 120/100? a. Blood viscosity b. Blood volume c. Pumping action of the heart d. Peripheral vascular resistance
d
While assessing the dorsalis pedis pulse of a patient, the nurse determines that the pulse is not palpable. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds of capillary refilling time. Which of the following is likely cause of these findings? a. A change in the patient's health status has occurred. b. The patient has thrown a blood clot in that extremity. c. The nurse's watch has stopped working. d. Too much pressure was applied over the pulse site
d
a 75 year old, hospitalized with a stroke becomes disorientated at times and tries to get out of bed, but is unable to ambulate without help. what is the most appropriate safety measure? a. restrain client in bed b. ask family member to stay with client c. check on client every 15 min d. use a bed exit safety monitoring device
d
a nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. the client has manifestations of which of the following? a. allergic reaction b. ringworm c. systemic lupus erythematosus d. TB
d
a nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. the client is experiencing what? a. prodromal b. incubation c. concalescence d. illness
d
a nursing diagnosis of ineffective peripheral tissue perfusion would be validated by which one of the following? a. bouding radial pulse b. irregular apical pulse c. carotid pulse stronger on L than R d. absent posterior tibial and pedal pulses
d
after making a documentation error, which action should the nurse take? a. use correcting liquid to cover the mistake and new entry b. draw a line through it and write error above the entry c. draw a line through it and write mistaken above it d. draw a line through the mistake and write mistaken entry with intitals above it
d
the client is in surgery and will be returning to his bed via a stretcher. which bed option reflects that the nurse appropriately planned ahead for this client? a. open bed in low position b. occupied bed in low position c. closed bed in high position d. surgical bed in high position
d
the nurse is observing the UAP preform peri hygiene for a client. which action indicates that the nurse needs to discuss additional teaching with the UAP? a. uses a clean portion of the washcloth for each stroke b. wipes from pubis to rectum c. uses clean gloves d. does not retract foreskin
d
A client with poor nutrition enters the hospital for treatment of a puncture wound. An appropriate nursing diagnosis would be _____________________.
risk for infection
