week 1 dynamic quiz question
a nurse is teaching a pt who is using a PCA pump to deliver morphine for pain management. which of the following statements should the nurse identify as an indication that the pt understands the instructions? a. "i will limit pushing the button so i don't get an overdose" b. "if i push the button and still have pain after 2 minutes, i'll push it again. c. "i'll ask my niece to push the button when i am sleeping" d. " i can still use my transcutaneous electrical nerve stimulation unit while im pushing the PCA button"
" i can still use my transcutaneous electrical nerve stimulation unit while im pushing the PCA button"
a nurse is caring for a pt who has injuries resulting a motor-vehicle crash. which of the following pt statements should the nurse address first? a. "i'm afraid this injury will cause me to lose my job" b. "i can't sleep well whenever i move in my sleep, the pain wakes me up" c. "i don't know what will i do if my car isn't safe or even drivable after the crash" d. "i wonder how am i going to be able to take care of my family"
"i can't sleep well whenever i move in my sleep, the pain wakes me up"
a nurse is preparing a pt for discharge and providing performing dressing changes at home. which of the following statements should the nurse identify as an indication that the pt understands medical asepsis? a. "i will wrap the old dressing in a paper bag and put it in the trash" b. "i will wash my hands before i remove the old dressing and again before putting on the new one" c.: "i'll need to take a pain pill 30 min before changing the dressing" d. "i'll wear sterile gloves when apply new dressing"
"i will wash my hands before i remove the old dressing and again before putting on the new one"
a nurse is teaching a pt who is post op about the importance of turning , coughing, and breathing deeply. which of the following statements should the nurse identify as the indication that the pt understands the instructions? a. " if i do this often i won't experience muscle wasting" b. "if i do this often, i won't get pneumonia" c. " if i do this often, i won't get constipation" d. " if i do this often, i won't have a fast heartbeat"
"if i do this often, i won't get pneumonia"
a nurse is teaching a assistive personnel (AP) about proper hand hygiene. which of the following statements by the AP indicates and understanding of the teaching? a. "there's times i should use soap and water rather than alcohol-based rub to clean my hands" b. "i will use cold water when i wash my hands to protect my skin from becoming too dry" c. "i will apply friction for at least 10 seconds while washing my hands" d. "after washing my hands, i will dry them from the elbows down"
"there's times i should use soap and water rather than alcohol-based rub to clean my hands"
a nurse on an oncology unit receive report at the beginning of her shift about 4 pts who are post op. which of the following pts should the nurse see first ? a. a pt who is 1 day post op following a lobectomy for a small cell carcinoma and has a chest tube with 35 ml/hr of bright red, bloody drainage b. a pt who is 2 days post op following a colectomy due to colorectal cancer an ostomy bag full of bright red, bloody drainage c. a pt who is 2 days post op following the excision of an abdominal mass and has a portable wound suction device with 20ml/hr of serosanguinous drainage d. a pt who is 1 day post op following the excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300ml/hr reddish-pink urine
a pt who is 2 days post op following a colectomy due to colorectal cancer an ostomy bag full of bright red, bloody drainage
a nurse is admitting a pt who has tuberculosis. in addition to standard precautions, which of the following transmission-based precautions should the nurse add to the pt's plan of care? a. protective b. airborne c. droplet d. contact
airborne
a nurse in a provider's clinic is take a pt's age, height, weight, and vital signs. the nurse should identify this action as part of which of the following components of the nursing process? a. planning b. evaluation c. assessment d. implementation
assessment
a nurse is using I-SBAR communication tool to give a pt's provider information about the pt. the nurse should convey this pt's status in which part of the report? a. assessment b. background c. situation d. recommendation
assessment
A nurse is supervising a newly licensed nurse who is caring for a pt with streptococcal pharyngitis and is on transmission-based precautions. which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? A. shaking soiled linen before putting it in a hamper B. removing a face mask when standing 0.5m (1.6 ft) from the pt C. assigning another pt with the same infection to share the room with the pt D. allowing the pt to visit a family member in the lobby of the facility
assigning another pt with the same infection to share the room with the pt
a nurse is taking a pt's vital signs. which of the following findings should the nurse identify as outside of expected reference range? a. pulse rate 90/min b. rectal temp 38C (100.4F) c. pulse ox 95% d. bp 145/99 mmhg
bp 145/99 mmhg
a nurse is caring for a pt who was transferred to the surgical unit by stretcher from the PACU. which of the following actions should the nurse perform immediately following the transfer? a. administer pain med b. check pts vitals c. instruct the pt to use the incentive spirometer every 1 hr d. provide ice chips as per provider prescription
check pt's vitals ``1
a nurse is caring for a pt who reports muscle pain to the lower back and has persisted for a year after a motor vehicle crash. in which way should the nurse categorize the pt's pain? a. cancer pain b. acute pain c. chronic pain d. neuropathic pain
chronic pain
a nurse is measuring a pt's vital sign's and notices an irregularity in the pulse. which of the following actions should the nurse take? a. measure the pulse using a doppler ultrasound stethoscope b. check the pt's pedal pulses c. count the apical pulse for a full minutes and describe the rhythm in the chart d. take the pulse at each peripheral site and count the rate for 30 sec
count the apical pulse for a full minutes and describe the rhythm in the chart
a nurse is caring for a pt who is unstable and has vital signs every 15 min by an electronic blood pressure machine. the nurse notices the machine begins to measure the bp at varied intervals, and the readings are inconsistent. which of the following actions should the nurse take? a. turn on the machine every 15 min to measure the pt's bp b. record only the bp readings needed for 15min intervals c. obtain manual and automatic readings and compare them d. disconnect the machine and measure the bp manually every 15 min
disconnect the machine and measure the bp manually every 15 min
a nurse is replacing the surgical dressings of a pt who had abdominal surgery. which of the following actions should the nurse take? a. don clean gloves to remove the old dressing b. loosen the dressing by pulling the tape away from the wound c. remove the entire old dressing at once d. open sterile supplies after applying sterile gloves
don clean gloves to remove the old dressing
a nurse is caring for a pt who has a methicillin-resistant staphylococcus aureus (MRSA) infection. a dietary assistant asks the nurse what precautions are necessary for entering the pt's room with the lunch tray. which of the following instructions should the nurse give to the dietary assistant? a. don a gown before entering the room and remove it before exiting b. wear a mask while in the pt's room c. don gloves when entering the room and use hand sanitizer when exiting d. take no special precautions unless engaging in direct contact with the pt
don gloves when entering the room and use hand sanitizer when exiting
a nurse is caring for a pt who has cancer and is experiencing pain. the nurse should implement which of the following interventions to assist the pt with pain relief? a. encourage the pt to listen to soft music b. instruct the pt to practice tai chi c. place a jasmine scented air freshener in the pt's room d. offer the pt ginger tea
encourage the pt to listen to soft music
a nurse is assessing a pt who is post-op. which of the following findings should the nurse identify as an indication that the pt is experiencing pain? a. diarrhea b. pupillary constriction c. flushing d. grimacing
grimacing
which of the following are examples are reservoirs in the chain of infection? (select all that apply) a. health care workers b. clients c. bacteria d. furniture e. equipment f. viruses
health care workers bacteria furnitures
a nurse is changing the bed linens for a pt who is on bed rest. which of the following actions should the nurse perform? a. place the soiled linens on the chair while making the bed b. hold the linens away from the body and clothing c. place the linens on the floor until linen bag is available d. shake the clean linens to unfold
hold the linens away from the body and clothing
a nurse is performing a sterile field for a procedure the provider will perform at the pt's bedside. which of the following actions should the nurse take? a. hold the sterile drape above the waist and away from the body b. drop sterile objects toward the edges of the sterile field c. hold packaged supplies 7.6 (3in) above the sterile field d. hold sterile objects over the field before setting them down on the field
hold the sterile drape above the waist and away from the body
a nurse is assessing a pt who is experiencing stress and anxiety regarding a recent diagnosis. which of the following findings should the nurse expect? a. increase bp b. decrease blood glucose levels c. decrease oxygen use d. increased gastrointestinal motility
increase bp
a nurse is caring for a pt who is schedule to receive transcutaneous electrical nerve stimulation (TENs) for pain management. the pt asks the nurse how a TENs unit helps to relieve pain. which of the following the responses should the nurse make? a. "it provides a distraction from the pain" b. "it modulates the transmission of the pain impulse" c. "it promotes increased circulation to the painful area." d. "it elicits a relaxation response"
it modulates the transmission of the pain impulse
a nurse in a provider's office is collecting info from an older adult pt who reports taking acetaminophen 500mg/day for severe joint pain. the nurse should instruct the pt that large doses of acetaminophen could cause which of the following adverse effects? a. constipation b. gastric ulcer c. respiratory depression d. liver damage
liver damage
a nurse is measuring a pt's vital signs. the pt's resting radial pulse rate is 55/min. which of the following actions should the nurse take next? a. document the finding b. measure the pt's apical pulse rate c. talk with the pt about factors that affect the pulse rate d. notify the provider about the pt's radial pulse rate
measure the pt's apical pulse rate
during the insertion of a urinary catheter for a pt, the tip of the catheter brushes against the nurse's arm. which of the following actions should the nurse take? a. wipe the catheter with providone-iodine and continue the catheter insertion b. soak the catheter in chlorhexidine for 15 min and reattempt insertion c. continue with the catheter insertion d. obtain a new catheter and reattempt insertion
obtain a new catheter and reattempt insertion
a nurse is assessing a pt's peripheral pulses. which of the following descriptions should the nurse use to document findings? a. peripheral pulses equal bilaterally at rate of 60/min b. radial, brachial, and pedal pulses bilaterally weak c. peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities d. brachial, radial, popliteal, and dorsalis pedis pulses regular, 58 and bilaterally palpable
peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities
a nurse is teaching a newly licensed nurse about pain management in the pt age 65 and older. which of the following pieces of information should the nurse include the teaching? a. pt who are age 65 or older experience a decreased ability to perceive pain compared to young adult pts b. pts who are are age 65 or older are reluctant to report pain c. pt who are age 65 or older should not receive opioid narcotics d. pts who are age 65 or older experience a shorter duration of action with medications than younger adults
pts who are age 65 or older are reluctant to report pain
a nurse is caring for a pt who is hospitalized and has a new tracheostomy. which of the following should the nurse take when performing a tracheostomy care for a pt? a. perform tracheotomy care using medical asepsis b. allow enough slack under the tracheotomy ties insert 3 fingers c. soak the inner cannula of the tracheotomy tube in normal saline d. cut a sterile gauze pad to place between the neck and tracheotomy tube
soak the inner cannula of the tracheotomy tube in normal saline
a nurse is measuring a pt's vital signs. the pt's heart rate is 105bpm. the nurse should document this finding as which of the following alterations? a. palpation b. bradycardia c. tachycardia d. dysrhythmia
tachycardia
a nurse is planning to obtain vital signs for a 2 year old who is experiencing diarrhea and may have a right ear infection. which of the following routes should the nurse use to obtain the child's temp? a. rectal b. Tympanic c. oral d. temporal
temporal
a nurse on a med-surg unit is washing her hands prior to assisting with a surgical procedure. which of the following actions should the nurse demonstrates proper surgical handwashing technique? a. the nurse washes each part of her hands with 5 strokes b. the nurse washes from the elbows down to the hands c. the nurse holds her hands higher than her elbows while washing d. the nurse uses minimal friction when washing hands
the nurse holds her hands higher than her elbows while washing
a home health nurse is caring for a pt who had knee placement surgery 5 days ago. which of the following finding should the nurse report to the provider? a. the pt can walk 40 ft with the walker b. the pt elevates the left leg when sitting and sleeping c. the pt temp is 98.6F (37C) d. the pt left knee is warm to touch and erythematous
the pt left knee is warm to touch and erythematous
a nurse is planning to administer pain medication to a pt following abdominal surgery. which of the following actions should the nurse take first? a. use the pain scale to determine the pt's pain level b. discuss the adverse effects of pain meds to the pt c. obtain the pt's vital signs d. check pt's allergies
use the pain scale to determine the pt's pain level
a nurse is caring for a pt who has methicillin-resistant staphylococcus (MRSA). which of the following precautions should the nurse implement? a. place the pt in a semi-private room b. wear a mask when providing care c. wear a gown when in a pt's room d. dispose of all bed linens by the pt
wear a gown when in a pt's room
