Exam 1 Review

Question 1

Which organization defines nursing with a framework that clarifies what nursing involves and the responsibilities of the nurse as a professional?

Answer 1

American Nursing Association (ANA)

Question 2

a legal and regulatory body that is created by, and applicable in, each individual state. It establishes common definitions, rules, and regulations to guide the practice of a licensed nurse and thereby promote quality of care and safety when caring for a client?

Answer 2

A Nurse Practice Act

Question 3

The _______ Scope of Nursing Practice provides the nurse with a clear definition of the complex and dynamic role of the nurse and the expectations of the nurse in that role

Answer 3

ANA’s

Question 4

The _______ standards of Nursing Practice are explanatory statements that describe a competent level of care and professionalism that all nurses should achieve.

Answer 4

ANA’s

Question 5

Which of the following are Florence Nightingale’s contributions that are still used today…
A. Documentation
B. Hand hygiene
C. Evidence-based practice
D. Data collection
E. American Red Cross

Answer 5

A, B, C, D

Question 6

A patient has measles. Which type of precaution would they be on?

Answer 6

Airborne

Question 7

A patient has varicella. Which type of precaution would they be on?

Answer 7

Airborne

Question 8

A cancer patient has a CBC done which shows a very weak immune system. Which precaution would they be on?

Answer 8

Neutropenic

Question 9

A patient has meningitis. Which precaution would they be on?

Answer 9

Droplet

Question 10

A patient comes in feeling sick, has a temperature and we need to run tests, but none of the results are back yet. Which precaution would you use?

Answer 10

Standard

Question 11

A patient tests positive for C. diff and you need to put a precaution sign on the door. Which precaution would you use?

Answer 11

Contact precautions

Question 12

What PPE would you use for contact precaution patients?

Answer 12

Gloves and Gown

Question 13

What PPE would you use for droplet precautions?

Answer 13

mask

Question 14

What PPE would you use for airborne precautions?

Answer 14

gown, gloves, N95

Question 15

For which adult client should the nurse make follow-up observations and monitor the vital signs closely?
A. Resting morning BP is 128/78mm Hg, whereas the afternoon BP is 122/76 mm Hg
B. Oral temp is 97.9 in AM and 99.8 in evening
C. Heart rate is 76 beats/min before eating and 88 bpm after eating
D. Respiratory rate is 16 breaths per min when standing and 18 breaths/min lying down

Answer 15

A. Because both blood pressures are higher and the resting rate was even higher than afternoon blood pressure.

Question 16

If a test question refers to a nurse following up, which step of the nursing process is this?

Answer 16

Evaluation

Question 17

If someone is eating it could make their HR go up or down?

Answer 17

Up

Question 18

When a question asks what the ‘best action’ is what part of the nursing process is it referring to?

Answer 18

Intervention

Question 19

What do we expect a temperature to do in the afternoon? Go up or down?

Answer 19

Go up

Question 20

If a respiratory rate goes from 16 breaths/min when standing to 18 breaths/min when lying down is that an expected change or not?

Answer 20

Yes, it is an expected change

Question 21

What is an antipyretic?

Answer 21

Medication used to reduce fever

Question 22

A client’s vital signs 4 hours ago: oral temperature 101.4, HR 110 beats/min, RR 26 breaths/min, and BP 124/78 mm Hg. The temp is now 99.4 - based only on the expected relationship between temperature and respiratory rate, which respiratory rate would the nurse expect to find?
1. 16
2. 18
3. 20
4. 22

Answer 22

18 - for every degree the temperature falls the respiratory rate should fall 4 beats

Question 23

For every degree a temperature drops, the respiration rates drop how many beats per minute?

Answer 23

4

Question 24

The nurse is planning to initiate a research project that involves adult patients as participants. The nurse accepts moral and legal responsibility to protect research participants from physical or emotional harm. Which mechanism will the nurse utilize for participant protection?

Answer 24

IRB - The institutional review board at the research facility.

Question 25

The nurse makes the following entry regarding the patient's outcome, goal not met. "Patient's pain remained the same after administering Acetaminophen." What should the nurse do next?

Answer 25

Goal not met - create a new intervention

Question 26

'Goal not met' in a question is referring to which part of the nursing process?

Answer 26

Evaluation

Question 27

The nurse is using contact precautions to change the soiled bed sheets of a client with C. diff. In the process, the nurses right glove and skin on a finger are torn. After removing soiled gloves what action is priority? A. Hold pressure to stop bleeding B. Use bleach wipes to clean hands C. Wash hands with soap and water D. Cleanse hands using alcohol-based hand rub

Answer 27

C

Question 28

With C. diff should you use soap and water or alcohol based cleanser for your hands after changing patient?

Answer 28

Soap and water

Question 29

When heart rate increases does the respiratory rate increase or decrease?

Answer 29

Increase

Question 30

What is diaphoresis?

Answer 30

Sweating

Question 31

Would you expect temperature to decrease after diaphoresis? Y/N

Answer 31

Yes

Question 32

A nurse is assisting a UAP about caring for a patient who has a low platelet count from chemo. Which of the instructions is the priority for measuring vital signs for this client? A. Do not take the client's temp rectal B. Count the client's radial pulse for 30 seconds and multiply by 2 C. Do not let the client know that you are counting their respirations D. Let the client rest for 5 minutes before taking BP

Answer 32

A

Question 33

If a patient has a low platelet count why wouldn't you want to take rectal temperature?

Answer 33

The bowel could be easily perforated causing bleeding with an already low platelet (clotting) issue.

Question 34

The nurse caring for a post surgical pt obtains an oral temp of 102F. The nurse contacts the surgeon, obtains an order, and administers acetaminophen 650 mg orally. Which clinical data should the nurse document? (Select all that apply) A. Obtained oral temp of 102F B. Called the surgeon to obtain the order C. Administered acetaminophen 650mg orally D. Administered aspirin 650 mg orally E. Obtained rectal temp of 102F

Answer 34

A, B, C

Question 35

TIP: For select all questions -DON'T try to make the answer options make sense together -DO ask if each option is true/false

Answer 35

:)

Question 36

What is the first level of Maslow's hierarchy of needs that must be met before you can move upward?

Answer 36

Physiologic Level

Question 37

What is included in Maslow's physiologic level that must be met?

Answer 37

Sex, food, water, air, shelter, sleep, air

Question 38

What is one factor that will take over all other levels of Maslow's hierarchy and won't allow a person to climb the heirarchy?

Answer 38

Pain

Question 39

What tasks can you delegate to a UAP?

Answer 39

bathe, hygiene, vital signs if not the first time, ambulate, feed (unless stroke pt)

Question 40

What are four things the nurse can't delegate to anyone else?

Answer 40

T.A.P.E Teach, assess, plan, evaluate

Question 41

What are the five stages of Benner's Novice to Expert theory?

Answer 41

Novice, Advanced beginner, competent, proficient, expert

Question 42

How long does it take to go from being a novice to competent nurse?

Answer 42

2-3 years

Question 43

Why do we do the nursing process?

Answer 43

To gain critical thinking skills

Question 44

If a nurse is very task oriented, doesn't have a good nurse intuition they are a _____ nurse.

Answer 44

Novice

Question 45

When writing goals and following SMART. What does 'SMART' stand for?

Answer 45

specific, measurable, attainable, realistic, timely

Question 46

What are the steps of the nursing process in order?

Answer 46

ADPIE: Assess, Diagnose, Plan, Implementation, Evaluation

Question 47

When writing goals and following KISS - what does 'KISS' stand for?

Answer 47

keep it simple specific

Question 48

A nursing home is trying to see how happy the patients are with their new weekly food menu by getting opinions from patients. Would this be quantitative or qualitiative?

Answer 48

Qualitative

Question 49

A hospital is tracking UTIs in patients that had catheters. Would this be quantitative or qualitative data?

Answer 49

Quantitative

Question 50

Interviewing a patient that comes into the ED is which part of the nursing process?

Answer 50

Assessment

Question 51

A patient is having a hard time breathing - the nurse tries to reposition the patient. Which type of intervention is this?

Answer 51

Independent intervention

Question 52

A patient is having a hard time breathing, the nurse tries to reposition but feels they need orders for oxygen. They ask the doctor for orders. This is what type of intervention?

Answer 52

Dependent intervention

Question 53

A patient comes back from surgery after having a skin graft and needs to have their wound assessed. The nurse performs this assessment. Which type of care? Indirect or Direct

Answer 53

Direct care

Question 54

What does the State Board of Nursing do?

Answer 54

They make the nursing laws regarding each state.

Question 55

What does the ANA do?

Answer 55

Create guidelines based on what the board of nurses has stated.

Question 56

What does JCO do?

Answer 56

They set guidelines for patient safety. (Scanning armbands, two forms or identification, protecting patient rights)

Question 57

What does NLN (National League of Nurses) do?

Answer 57

Sets guidelines, mostly for education of nurses.

Question 58

If you are a nurse and you have an order for something that doesn't seem quite right, do you do it?

Answer 58

No - be an assertive nurse - question it

Question 59

What characteristics should you have as a nurse?

Answer 59

be a leader, advocate, be accountable

Question 60

Which precaution would require a patient to be in a negative pressure room?

Answer 60

Airborne precaution

Question 61

TIP: Know the appropriate way to don and doff PPE

Answer 61

:-)

Question 62

An increase in heart rate and decrease in blood pressure are consistent with?

Answer 62

Fluid volume deficit

Question 63

A nursing supervisor is determining bed placement for four clients. Which of the following clients should be placed on droplet precaution? 1. Client with rubella 2. Client who has measles 3. Client who has hepatitis A 4. Client who has Rocky Mountain spotted fever

Answer 63

Client who has rubella

Question 64

PIMP (surgical mask & eye protection) patient placed in a single room: P (pertussis) I (influenza) M (meningitis) P (pneumonia)

Answer 64

droplet precautions

Question 65

MTV on air M (measles, mumps, & rubella) TB (tuberculosis) V (varicella) turn on room air

Answer 65

airborne precautions

Question 66

TAPE

Answer 66

teaching, assessment, planning, education

Question 67

what precautions should a patient be placed on if they have rubella?

Answer 67

airborne

Question 68

what precautions should a patient be placed on if they have measles?

Answer 68

airborne

Question 69

what precautions should a patient be placed on if they have mumps?

Answer 69

airborne

Question 70

A nurse is teaching a newly licensed nurse about documenting vital signs. Which of the following documentations made by the new nurse indicates an understanding of the teaching? A. Radial pulse regular 68/min B. BP 148/72 mm Hg C. Temp 36 degrees D. SpO2 95%

Answer 70

A - the nurse documented location where it was taken and if it was regular or irregular.

Question 71

A nurse is providing care to a client. Prior to exiting the client's room, the nurse ensures the client's bed is locked and their call light is within reach. Which of the following QSEN competencies is the nurse demonstrating?

Answer 71

Safety

Question 72

A nurse is obtaining an oxygen saturation on a client. Which action should the nurse take?

Answer 72

Choose a finger with a capillary refill less than 2 sec

Question 73

An infection control nurse is teaching a class about transmission of infectious agents. The nurse should include that which of the following diseases is transmitted via airborne transmission? Select all that apply A. Varicella B. C. diff C. Rubella D. Staphylococcus aureus E. Tuberculosis

Answer 73

A, C, E

Question 74

Which of the following is a component of clinical decision-making that the nurse should use to make an evidence-based decision? A. Critical Thinking B. Clinical Reasoning C. Concept Mapping D. Clinical Judgement

Answer 74

D

Question 75

A nurse wants to become more involved in nursing on a national level. Which of the following organization should the nurse join? A. American Nursing Association B. National Student Nurses Association C. National League for Nursing D. National Academy of Medicine

Answer 75

A

Question 76

During which of the following situations should a nurse wear eye protection? A. Providing hygiene care to a client who is HIV positive B. Emptying urinary drainage bag for a client who has pneumonia C. Irrigating a client's abdominal wound D. Transporting cerebrospinal fluid specimen to the lab E. Suctioning a client's tracheostomy tube

Answer 76

C and E

Question 77

A nurse is discussing the effect of low health literacy with a group of community members. Which of the following statements should the nurse include? A. "Clients who have low health literacy have lower mortality rates than others" B. "Low health literacy leads to an increase in preventative services." C. "Low health literacy leads to increased use of emergency services."

Answer 77

C

Question 78

Which precaution should the nurse use when setting up a client's food tray? -Transmission-based -Handwashing only -Standard

Answer 78

Handwashing Only

Question 79

Which precaution should the nurse use when starting an IV for a client with a high fever and productive couch of unknown origin? -Handwashing only -Standard -Transmission-based

Answer 79

Transmission-based

Question 80

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented? A. I will begin 48 hours before the client's discharge B. I will begin once the client's discharge order is written C. I will begin upon the client's admission to the facility D. I will begin once the client's insurance company approves discharge coverage

Answer 80

C

Question 81

A nurse is teaching a newly licensed nurse about measuring body temperature in clients. The nurse should instruct to obtain an oral temperature in which of the following clients? A. A client who has hemorrhoids B. A client who had recent oral surgery C. A client who breaths through the mouth D. A client who is drinking ice water E. A client who has a coagulation disorder

Answer 81

A, E

Question 82

A nurse in a long-term care facility has assigned a task to an assistive personnel. The AP refuses to perform the task. Which of the following is an appropriate statement for the nurse to make? A. I feel you are being inconsiderate of the other team members B. I have to let the director of nursing know about this situation C. I need to talk to you about the unit policies regarding client assignments

Answer 82

C

Question 83

A patient has tuberculosis. What PPE should be worn when entering the room?

Answer 83

N-95 mask

Question 84

What precaution would require a negative pressure room?

Answer 84

Airborne precautions

Question 85

With which precaution would you mask when within 3 ft of the patient?

Answer 85

Droplet

Question 86

Which precaution requires for the door to be kept closed?

Answer 86

Airborne

Question 87

A nurse is assessing a client who reports acute pain at a level of 7 on a scale of 10. Which of the following findings should the nurse expect? A. Hypertension B. Decreased respiratory rate C. Hypoglycemia D. Bradycardia

Answer 87

C.

Question 88

A nurse is caring for a client who reports bilateral knee pain after hiking this past weekend in the mountains on rough ground. He says he is concerned because his cousin died from bone cancer recently. Which of the following actions should the nurse take? 1. Tell the client that it is unlikely that he has bone cancer 2. Ask the client why he thinks his pain isn't a result of hiking 3. Suggest genetic testing so the client can understand his risks 4. Explain that the provider will see him and determine a course of action

Answer 88

4. This illustrates the therapeutic communication technique of focusing the client on the usual course of action that must proceed drawing any conclusions about the cause of a client's pain.

Question 89

A nurse is assessing a client who has a heart rate of 56/min. Which of the following findings should the nurse expect? A. Dizziness B. Hypoglycemia C. Temp of 39 degrees D. History of cigarette smoking

Answer 89

A. Bradycardia can cause dizziness due to decreased perfusion to the brain

Question 90

A nurse is caring for a client who has MRSA in an abdominal would. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take? A. Wear an N-95 respirator B. Wear sterile gloves C. Wear clean gloves D. Wear protective eyewear

Answer 90

C. Clean gloves

Question 91

A nurse is admitting a new client. Which of the following steps of the nursing process is the nurse performing when formulating goals for a positive outcome? A. Planning B. Implementation C. Evaluation D. Assessment

Answer 91

A

Question 92

A nurse is assessing a client who has an oral temperature of 102.2F. Which of the following findings should the nurse expect? A. Respiratory rate 10/min B. Dilated pupils C. Heart rate 108/min D. Decreased peripheral pulses

Answer 92

C. Heart rate of 108/min A heart rate is greater than the normal 60-100 bpm. A fever causes an increase in metabolic demands and an increased heart rate.

Question 93

ABC

Answer 93

airway, breathing, & circulation

Question 94

Implementation step of the Nursing Process

Answer 94

How the nurse carries out nursing actions

Question 95

Evaluation step of the of the Nursing Process

Answer 95

Determining whether patient goals have been achieved and interventions have been successful

Question 96

Evaluation step of the of the Nursing Process

Answer 96

Determining whether patient goals have been achieved and interventions have been successful

Question 97

If a patient experiences a fall, is the event documented on an incident report?

Answer 97

NO, this is not part of the health record and is a separate document

Question 98

SBAR (documentation)

Answer 98

situation, background, assessment, & recommendation

Question 99

Informatics

Answer 99

managing and processing information necessary to make decisions