Exam 2 Flashcards
(135 cards)
0
Q
After the end of 700 shift report the registered nurse delegates three tasks to the nursing assistant at 1300 the RN tells a nursing assistant that he would like to talk to her about the first task that was delegated which was walking the patient Mrs. Taylor earlier that morning. The RN says you did a good job walking Mrs. Taylor by 930. I saw that you recorded her pulse before and after the walk. I saw that Mrs. Taylor walked in the hallway barefoot. For safety, the next time you walk the patient, you need to make sure the patient wears slippers or shoes. Please walk Mrs. Taylor again by 1500. Which characteristics of good feedback did the RN use when talking to the nursing assistant (select all that apply)
1. Feedback is given immediately 2. Feedback focuses on one issue 3. Feedback offers concrete details 4.Feedback identifies ways to improve 5.Feedback focuses on changeable things 6. Feedback is specific about what is done incorrectly only
A
2 3 4 5
1
Q
As the nurse, you need to complete all of the following. Which task do you complete first? 1. Administer the oral pain medication to the patient who had a surgery three days ago
2. Make a referral to the home care nurse for a patient who is being discharged in two days 3. Complete wound care for a patient with a wound drain that has an increased amount of drainage since last shift 4. Notify the healthcare provider of the decreased level of consciousness in the patient who had surgery two days ago
A
4.
2
Q
You are the charge nurse on a surgical unit. You are doing staff assignments for the 3 to 11 shift. Which patient do you a sign to the licensed practical nurse? 1. The patient they transferred out of intensive care an hour again 2. The patient who requires teaching on new medications before discharge 3. The patient who had a vaginal hysterectomy two days ago and is being discharged tomorrow 4. The patient who is experiencing some bleeding problems following surgery earlier today
A
3.
3
Q
The type of care management approach that coordinates and links Healthcare Services too patients and their families while streamlining costs and maintaining quality is 1.Primary nursing 2.Total patient care 3. Functional nursing 4. Case management
A
4.
4
Q
While administering medications, the nurse realizes that she has given the wrong dose of medication to the patient. She acts by completing an incident report and notifying the patient’s health care provider. The nurse is exercising: 1. Authority 2.. Responsibility 3. Accountability 4. Decision-making
A
3.
5
Q
Your nursing manager distributes biweekly newsletters of ongoing unit or health care agency activities and posts minutes of committee meetings on a bulletin board in the staff break room. This is an example of: 1. Staff communication 2. Problem-solving committees 3. Interdisciplinary collaboration 4. Nurse physician collaborative practice
A
1.
6
Q
The nurse asks the nursing assistant to hold the legs of a female patient during a Foley catheter insertion. This is an example of a nurse displaying: 1. Organizational skills 2. Use of resources 3. Time management 4. Evaluation
A
2.
7
Q
The nurse is assisting the patient with coughing and deep breathing exercises following abdominal surgery. This is which priority nursing need for this patient? 1. Low priority number 2. High priority number 3. Intermediate priority 4. non-emergency priority
A
3.
8
Q
The registered nurse checks on a patient who was admitted to the hospital with pneumonia. The patient is coughing profusely and requires nasotracheal suctioning. Orders include an IV infusion of antibiotics. The patient is febrile and asks the RN if he can have a bath because he has been perspiring profusely. Which task is appropriate to delegate to the nursing assistant? 1. Assessing vital signs 2. Changing IV dressing 3. Nasotracheal suctioning 4. Administering a bed bath
A
4.
9
Q
Which task is appropriate for a registered nurse to delegate to the nursing assistant? 1. Explaining to the patient the preoperative preparation before the surgery in the morning 2. Administering the ordered antibiotic to the patient before surgery 3. Obtaining the patient signature on the surgical informed consent 4. Assisting the patient to the bathroom before leaving the operating room
A
4.
10
Q
Which of the following strategies focus on improving nurse physician collaborative practice? (select all that apply) 1. Inviting the physician to attend the practice Council meeting 2. Participating in physician morning rounds 3. Placing physician photos and names in unit newsletter 4. Contacting physician promptly to discuss patient problems 5. Providing a list of physician contact numbers to all staff nurses
A
1 2 4
11
Q
The nurses on the unit developed a system for self scheduling of work shifts. This is an example of: 1. Responsibility 2. autonomy 3. accountability 4. authority
A
2.
12
Q
Which example demonstrates the nurse performing the skill of the evaluation? 1.The nurse explains the side effects of the new blood pressure medication ordered for the patient 2. the nurse asks the patient to rate pain on a scale of 0 to 10 before administering the pain medication 3. after completing the teaching, the nurse observes the patient draw up and administer an insulin injection 4. The nurse changes the patient’s leg ulcer dressing using aseptic technique
A
3.
13
Q
The nurse is explaining the case management model to a group of nursing students. Which characteristics best describe the model? (select all that apply) 1. Case managers provide all patient care 2. Multidisciplinary care plans are used 3. Case managers coordinate discharge planning 4. Staffing is expensive and may not decrease care costs 5. Communication with healthcare team members is important 6. Model helps to improve patient safety and quality
A
2,3,5,6
14
Q
The nurse collects the supplies for the dressing change for the patient in bed 1 and signs out the capillary blood glucose monitoring equipment to test the glucose of the patient in bed 2 before walking down the hall to the room. The nurse is displaying: 1. Organizational skills 2. Use of resources 3. Priority setting 4. Clinical decision-making
A
1.
15
Q
The nurse summarizes the conversation with the patient to determine if the patient has understood him or her. This is what element of the communication process? 1. Referent 2.Channel 3. Environment 4. Feedback
A
4.
16
Q
Mrs. Jones states that she gets anxious when she thinks about giving herself insulin. How do you use your understanding of intrapersonal communication to help with this? 1. Provide her the opportunity to practice drawing up insulin 2. Coach her to give herself positive messages about her ability to do this 3. Bring her written material that clearly describes the steps of insulin administration 4. Use therapeutic communication to help her express her feelings about giving herself and an injection
A
2.
17
Q
The nurse has a patient who is short of breath and calls the health care provider using SBAR(situation background assessment recommendation) to help with the communication. What does the nurse first address? 1. The respiratory rate is 28 2. The patient has a history of lung cancer 3. The patient is short of breath 4. He or she requests and order for breathing treatment
A
3.
18
Q
You are caring for Mr. Smith, who is facing amputation of his leg. During the orientation phase of the relationship, what would you do? 1. Summarize what you have talked about in the previous sessions 2. Review his medical record and talk to other nurses about how he is reacting 3. Explore his feelings about losing his leg 4. Talk with him about his favorite hobbies
A
4.
19
Q
The nurse states, “when you tell me that you’re having a hard time living up to expectations, are you talking about your family’s expectations?” The nurse is using which therapeutic communication technique? 1. Providing information 2.Clarifying 3. Focusing 4. Paraphrasing
A
2.
20
Q
Which of the following statements would be most likely to block communication? 1. You look kind of tired today 2. Why do you always put so much salt on your food 3. It sounds like this is been a hard time for you 4. If you use your oxygen when you walk, you may be able to walk further
A
2.
21
Q
You are caring for an 80-year-old woman, and you ask her a question while you are across the room washing your hands. She does not answer. What is your next action? 1. Leave the room quietly since she evidently does not want to be bothered right now 2. Repeat the question in a loud voice, speaking very slowly 3. Move to her bedside, get her attention, and repeat the question while facing her 4. Bring her a communication board so she can express her needs
A
3.
22
Q
You ask another nurse how to collect a laboratory specimens. The nurse raises her eyebrows and asks, “why don’t you figure it out?” What would be the best response? 1. Say nothing and walk away. Find a different nurse to help you 2. When you brush me off like that, it takes me even longer to do my job 3. Why do you always put me down like that 4. I guess I just enjoy having you make fun of me
A
2.
23
Q
When the nurse takes the patients nursing history, he or she sits: 1. Next to the patient 2. 4 to 12 feet from the patient 3. 18 inches to 4 feet from the patient 4. 12 inches to 3 feet from the patient
A
3.
24
When working with an older adult, the nurse remembers to avoid: 1. Touching the patient 2. Allowing the patient to reminisce 3. Shifting quickly from subject to subject 4. Asking the patient how he or she feels
3.
25
The statement that best explains the role of collaboration with others for the patient's plan of care is which of the following? 1. The professional nurse consults the health care provider for direction in establishing goals for patients 2. The professional nurse depends on the latest literature to complete an excellent plan of care for patients 3. The professional nurse works independently to plan and deliver care and does not depend on other staff for assistance 4. The professional nurse works with colleagues and the patient's family to provide combined expertise in planning care
4.
26
Identify behaviors that foster the development of trust. (select all that apply) 1. Answer the call Light promptly 2. Call the patient by first name unless requested otherwise 3. Do all the care as quickly as possible and leave the room so that the patient can rest 4. Answer questions honestly 5. Demonstrate competence when doing treatments
1,4,5
27
A patient with limited English proficiency is going to be discharged on new medication. How does the nurse complete the discharge teaching? 1. Uses a dictionary to give directions for medication administration 2. Explain the directions to the patient's 14-year-old daughter 3. Obtain an interpreter to facilitate communication of medication information 4.. Uses a picture board and visual aids to communicate medication administration information
3.
28
Your patient has just been told that she has cancer, and she is crying. Which actions facilitate therapeutic communication? (Select all that apply) 1.Turning on the television to her favorite show 2. Pulling the curtain to provide privacy 3. Offering to discuss information about her condition 4. Asking her why she is crying 5. Sitting quietly by her bed and hold her hand
2,3,5
29
Mr. Sakda emigrated from Thailand. When taking care of him, you notice that he looks relaxed and smiles but seldom looks at you directly. How do you respond? 1. Use therapeutic communication to assess for increased anxiety 2. Sit down and position yourself closer so you are at eye level 3. Deflect your eyes downward to show respect 4. Continue to maintain eye contact
3.
30
A patient needs to learn to use a walker. Which domain is required for learning this skill? 1. Affective domain 2. Cognitive domain 3. Attentional domain 4. Psycho motor domain
4.
31
The nurse is planning to teach a patient about the importance of exercise. When is the best time for teaching to occur? (Select all that apply ) 1. When there are visitors in the room 2. When the patient's pain medications are working 3. Just before lunch, when the patient is most awake and alert 4. When the patient is talking about current stressors in his or her life
2,3
32
A patient newly diagnosed with cervical cancer is going home. The patient is avoiding discussion of her illness and post operative orders. What is the nurses best plan in teaching this patient? 1. Teach the patient's spouse 2. Focus on knowledge the patient will need in a few weeks 3. Provide Only the information that the patient needs to go home 4. Convince the patient that learning about her health is necessary
3.
33
The school nurse is about to teach a freshman level high school health class about nutrition. What is the best instructional approach to ensure that the students meet the learning outcomes? 1. Provide information using a lecture 2. Use simple words to promote understanding 3. Develop topics for discussion that require problem-solving 4. Complete an extensive literature search focusing on eating disorders
3.
34
A nurse is going to teach a patient how to perform breast self-examination. Which behavioral objectives does the nurse set to best measure the patient's ability to perform the examination? 1. The patient will verbalize the steps involved in breast self-examination within one week 2. The nurse will explain the importance of performing breast self-examination once a month 3. The patient will perform breast self-examination correctly on herself before the end of the teaching session 4. The nurse will demonstrate breast self-examination on a breast model provided by the American Cancer Society
3.
35
A patient with chest pain is having an emergency cardiac catheterization. Which teaching apprised of the nurse use in this situation? 1. Telling approach 2. Selling approach 3. Entrusting approach 4. Participating approach
1.
36
The nurse is teaching a parenting class to a group of pregnant adolescents and the nurse pretends to be the baby's father, and the adolescent mother is asked to show how she would respond to the father if he gave her a can of beer. Which teaching approach to the nurse use? 1. Role-play 2. Discovery 3. An analogy 4. A demonstration
1.
37
An older adult is being started on a new antihypertensive medication. In teaching the patient about the medication, the nurse: 1. Speaks loudly 2. Presents the information once 3. Expects the patient understand the information quickly 4. Allows the patient time to express himself or herself and ask questions
4.
38
A patient needs to learn how to administer a subcutaneous injection. Which of the following reflects that the patient is ready to learn? 1. Describing difficulties of family member has had in taking insulin 2. Expressing the importance of learning the skill correctly 3. Being able to see and understand the markings on the syringe 4. Having the dexterity needed to prepare and inject medication
2.
39
A patient who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to give himself injections. Which teaching method does the nurse use? 1. Simulation 2. Demonstration 3. Group instruction 4. One on one discussion
2.
40
When a nurse is teaching a patient about how to administer an epinephrine injection in case of a severe allergic reaction, he or she tells the patient to hold the injection like a dart. Which of the following instructional methods did the nurse use? 1. Telling 2. Analogy 3. Demonstration 4. Simulation
2.
41
A nurse needs to teach a young woman newly diagnosed with asthma how to manage her disease. Which of the following topics does the nurse teach first? 1. How to use an inhaler during an asthma attack 2. The need to avoid people who smoke to prevent asthma attacks 3. Where to purchase a medical alert bracelet that says she has asthma 4. The importance of maintaining a healthy diet and exercising regularly
1.
42
A nurse is teaching a group of young college age women the importance of using sunscreen when going out in the sun. What type of content is the nurse providing? 1. Simulation 2. Restoring health 3. Coping with impaired function 4. Health promotion and illness prevention
4.
43
A nurse is planning a teaching session about healthy nutrition with a group of children who are in the first grade. The nurse determined that after the teaching sessions the children will be able to name three examples of foods that are fruits. This is an example of: 1. A teaching plan 2. A learning objective 3. Reinforcement of content 4. Enhancing the children's self efficacy
2.
44
A nurse is teaching a 27-year-old gentleman how to adjust his insulin dosages based on his blood sugar results. What type of learning is this? 1. Cognitive 2. Affective 3. Adaptation 4. Psychomotor
1.
45
The nurse is having difficulty reading a physician order for a medication. He or she knows that the physician is very busy and does not like to be called. What is most appropriate next step for the nurse to take? 1. Call a pharmacist to interpret the order 2. Call the physician to have the order clarified 3. Consult the unit manager to help interpret the order 4. Ask the unit secretary to interpret the physicians handwriting
2.
46
The patient has an order for 2 tablespoons of milk of magnesia. How much medication does the nurse give him or her? 1. 2 mL 2. 5 mL 3. 16 mL 4. 30 mL
4.
47
A nurse is administering eardrops to an eight-year-old patient with an ear infection. How does the nurse pull the patient's ear when administering medication? 1. Outward 2. Back 3. Upward and back 4. upward and outward
4.
48
A patient is to receive cephalexin 500 mg PO. The pharmacy has sent 250 mg tablets. How many tablets does the nurse administered? 1. 1/2 tablet 2. One tablet 3. 1 1/2 tablet 4. Two tablets
4.
49
A nurse is administering medications to a four year old patient. After he or she explains which medications are being given, the mother states, "I don't remember my child having that medication before" what is the nurses next action? 1. Give medications 2. Identify the patient using two patient identifiers 3. Withhold the medications and verify the medication orders 4. Provide medication education to the mother to help her better understand her child medications
3.
50
A patient is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe medication administration for the discharge nurse? 1. Set up the follow up appointments with the physician for the patient 2. ensure that someone will provide housekeeping for the patient at home 3. ensure that the home care agency is aware of medication and help teaching needs 4. make sure that the patient's family knows how to safely bathe him or her and provide mouth care
3.
51
A nursing student takes a patient's antibiotic to his room. The patient asks the nursing student what it is and why he should take it. Which information does the nursing student include when replying to the patient? 1. Only the patient's physician can give this information 2. The student provides the name of the medication and the description of it's desired effect 3. Information about medications is confidential and cannot be shared 4. You have to speak with his assigned nurse about this
2.
52
The nurse is administering a sustained release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurses next best course of action? 1. Ask the prescriber to change the order 2. Crush the pill with an mortar and pestle 3. Hide the capsule in a piece of solid food 4. Open the capsule and sprinkle over pudding
1.
53
The nurse takes a medication to the patient, and the patient tells him or her to take it away because she is not going to take it. What is the nurses next action? 1. Ask the patient's reason for refusal 2. Explain that she must take medication 3. Take medication away and chart the patient's refusal 4. Tell the patient that her physician knows what is best for her
3.
54
The nurse receives in order to start giving a loop diuretic to The patient to help lower his or her blood pressure. The nurse determines the appropriate route for administrating the diuretic according to 1. Hospital policy 2. The prescribers orders 3. The type of medication ordered 4. The patient size and muscle mass
2.
55
A patient is receiving an intravenous push medication. If the drug infiltrates into the outer tissues, the nurse: 1. continues to let the IV run 2. applies a warm compress to the infiltrated site 3. stops the administration of medication and follows agency policy 4. should not worry about this because vesicant filtration is not a problem
3.
56
If a patient who is receiving intravenous fluids develops tenderness, warm, erythema, and pain at the site, the nurse suspects: 1. Sepsis 2. Phlebitis 3. Infiltration 4. Fluid overload
2.
57
After seeing a patient, the physician gives a nursing student a verbal order for a new medication. The nursing student first needs to: 1. Follow ISMP guidelines for safe medication abbreviations 2. Explain to the physician that the order needs to be given to a registered nurse 3. Write down the order on the patient's order sheet and read it back to the physician 4. Ensure that the six rights of medication administration are followed when giving the medication
2.
58
A nurse accidentally gives a patient the medication at the wrong time. The nurse's first priority is to: 1. Complete an occurrence report 2. Notify the health care provider 3. Inform the charge nurse of the error 4. Assess the patient for adverse effects
4.
59
A patient is taking albuterol through a pressurized metered dose inhaler that contains a total of 200 puffs. The patient takes two puffs every four hours. How many days will the pMDI last?
16 days
60
A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder: 1. Alcoholism and hypertension 2. Obesity and diabetes 3. Stress related illnesses 4. Cardiopulmonary disease and lung cancer
4.
61
A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status? 1. Increased breathlessness but increased activity tolerance 2. decreased breathlessness and decreased activity tolerance 3. Increased activity tolerance and decreased breathlessness 4. Decreased activity tolerance and increased breathlessness
4.
62
A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy, not cyanotic the nurse understands that the patient is a risk for decreased oxygen carrying capacity of blood because carbon monoxide does which of the following: 1. Stimulate hyperventilation, causing respiratory alkalosis 2. Forms a strong bond with hemoglobin, creating a functional anemia 3. Stimulates hypoventilation, causing respiratory acidosis 4. Causes alveoli to over inflate, leading to atelectasis
2.
63
A six-year-old boy is admitted to the pediatric unit with chills and a fever of 104°F what physiological process explains why the child is at risk for developing dyspnea? 1. Fever increases metabolic demands, requiring increased oxygen need 2. Blood glucose stores are depleted, and the cells do not have energy to use oxygen 3. Carbon dioxide production increases as a result of hyperventilation 4. Carbon dioxide production decreases as a result of hypoventilation
1.
64
A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds? 1. Sonorous wheezes in the left lower lung 2. rhonchi mid sternum 3. crackles only in Apex of lungs 4. Inspiratory crackles in lung bases
4.
65
The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risk of stasis of pulmonary secretions and decreased Chestwall expansion? 1. Antibiotics 2. Frequent change of position 3. Oxygen humidification 4. Chest physiotherapy
2.
66
A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway sectioning? 1. Coughing up thick sputum only occasionally 2. Coughing up thin, watery sputum easily after nebulization 3. Decreased independent ability to cough. 4. Lung sounds clear only after coughing
3.
67
A patient was admitted after a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs and symptoms of secondary pneumothorax, which includes which of the following? 1. Sharp pleuritic pain that worsens on inspiration 2. crackles over lung bases of effected lung 3. Tracheal deviation towards the effected lung
4. Increased diaphragmatic excursion on side of rib fractures
1.
68
A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his statements would indicate a need for further education? 1. I'll make sure that I rest between activities so I don't get so short of breath 2. I'll rest for 30 minutes before I eat my meal 3. If I have trouble breathing at night, I'll use 2-3 pillows to prop up 4. If I get short of breath, I'll turn up my oxygen level to 6L per minute
4.
69
The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first? 1. Raise the head of the bed to 45° 2. Take his oxygen saturation with a pulse ox summoner 3. Take his blood pressure and respiratory rate 4. Notify the healthcare provider of his shortness of breath
1.
70
The nurse is carrying for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for nurses perform? (Select all that apply) 1. SPO2 levels 2. Amount of sputum production 3. Change in respiratory rate and pattern 4. Pain in lower calf area
1,2,3
71
Which of the following statements made by a student nurse indicates the need for further teaching about suctioning a patient with an Endotracheal tube? 1. Suctioning the patient requires sterile technique 2. I'll apply suction while rotating and withdrawing the suction catheter 3. I'll suction the mouth after I suction the endotracheal tube 4. I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient
4.
72
Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? 1. Record the amount and continue to monitor drainage 2. Notify the healthcare provider 3. Strip the chest tube starting at the chest 4. Increase the suction by 10 mmHg
1.
73
Which nursing intervention is appropriate for preventing atelectasis in the post operative patient? 1. Postural drainage 2. Chest percussion 3. Incentive spirometer 4. Suctioning
3.
74
The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen delivery systems should the nurse select to administer oxygen to the patient? 1. Nasal cannula 2. Venturi mask 3. Simple facemask without inflated reservoir bag 4. Plastic facemask with inflated reservoir bag
1.
75
A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. The probable cause of the symptoms and findings is: 1. Cystitis 2. Hematuria 3. Pyelonephritis 4. Dysuria
1.
76
A male patient returned from the operating room six hours ago with a cast on his right arm. He has not yet voided. Which action would be the most beneficial in assisting the patient to void? 1. Suggest to stand at the bedside 2. Stay with the patient 3. Give him the urinal to use in bed 4. Tell him that, if he doesn't urinate, he will be catheterized
1.
77
Elimination changes that result from inability of the bladder Empty properly may cause which of the following? (Select all that apply) 1. Incontinence 2. Frequency 3. Urgency 4. Urinary retention 5. Urinary tract infection
1,2,3,4,5
78
An older male patient states that he is having problems starting and stopping his stream of urine and he feels the urgency to void. The best way to assist this patient is to: 1. Help him stand avoid 2. Place a condom catheter 3. Have him practice Crede's method 4. Initiate Kegle exercises
4.
79
Since removal of the patients Foley catheter, the patient has voided 50 to 100 mL every 2 to 3 hours. Which action should the nurse take first? 1. Check for bladder distention 2. Encourage fluid intake 3. Obtain an order to recategorize the patient 4. Document the amount of each voiding for 24 hours
1.
80
To minimize the patient experiencing nocturia, the nurse would teach him or her to: 1. Perform perineal hygiene after urinating 2. Set up a toileting schedule 3. Double void 4. Limit fluids before bedtime
4.
81
A patient with a Foley catheter carries the collection bag at waist level when ambulating. The nurse tells the patient that he or she is at risk for: (select all that apply) 1. Infection 2. Retention 3. Stagnant urine 4. Reflux of urine
1.,4,
82
The patient is incontinent, and a condom catheter is placed. The nurse should take which action? 1. Secure the condom with adhesive tape 2. Change the condom every 48 hours 3. Assess the patient for skin irritation 4. Use sterile technique for placement
3.
83
After a transurethral prostatectomy a patient returns to his room with a triple lumen indwelling catheter and continuous bladder irrigation. The irrigation is normal saline at 150 mL per hour. The nurse empties the drainage bag for a total of 2520 mL after an eight hour period. How much of the total is urine output?
1320mL
84
The nurse is planning to remove a Foley catheter at 1300. The nurse would check if the patient has avoided by: 1. 1400 2. 1600 3.1700 4. 2300
3.
85
The postoperative patient has difficulty voiding after surgery and is feeling uncomfortable in the lower abdomen. Which action should the nurse implement first? 1. Encourage fluid intake 2. Administer pain medication 3. Categorize the patient 4. Turn on the bathroom faucet as he tries to void
4.
86
The patient is to have an intravenous pyelogram. Which of the following apply to this procedure? (Select all that apply) 1. Note any allergies 2. Monitor intake and output 3. Provide for perineal hygiene 4. Assess vital signs 5. Encourage fluids after the procedure
1,5
87
The nurse assesses that the patient has a full bladder, and the patient states that he or she is having difficulty voiding. The nurse would teach the patient to: 1. Use the double voiding technique 2. Perform Kegel exercises 3. Use Crede's method 4. Keep a voiding diary
3.
88
The patient states that she loses urine every time she laughs or coughs. The nurse teaches the patient measures to regain urinary control. The nurse recognizes the need for further teaching when the patient states: 1. I will perform my Kegel exercises every day 2. I joined Weight Watchers 3. I drink two glasses of wine with dinner 4. I have tried urinating every three hours
3.
89
The nurse notes that the patients Foley catheter bag has been empty for four hours. The priority action would be to: 1. Irrigate the foley 2. Check for kinks in the tubing 3. Notify the health care provider 4. Assess the patient's intake
2.
90
During the nursing assessment a patient reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that the symptoms are associated with: 1. Food allergy 2. Irritable bowel 3. Lactose intolerance 4. Increased peristalsis
3.
91
When assessing a 55 year old patient who is in the clinic for a routine physical, the nurse instructs the patient about the need to obtain a stool specimen for guaiac fecal occult blood testing: 1. if patient reports rectal bleeding 2. When there is a family history of polyps 3. As part of a routine examination for colon cancer 4. If a palpable mass is detected on digital examination
3.
92
Which of the following medications listed in a patients medication history possibly causes gastrointestinal bleeding? (Select all that apply) 1. Aspirin 2. Cathartics 3. Antidiarrheal opiate agents 4. Nonsteroidal anti-inflammatory drugs
1,4
93
Nurses discourage patients from straining on defecation primarily because it causes: (select all that apply) 1. Pain 2. Impaction 3. Hemorrhoids 4. Dysrhythmias
3,4
94
A cleansing enema is ordered for a 55-year-old patient before intestinal surgery. The nurse understands that the maximum amount of fluid given is: 1. 150 to 200 mL 2. 200 to 400 mL 3. 400 to 750 mL 4. 750 to 1000 mL
4.
95
A patient starts to experience pain while receiving an enema. The nurse notes blood in the return fluid and rectal bleeding. What action does a nurse take first? 1. Administer pain medication 2. Slows down the rate of installation 3. Tells the patient to breathe slowly and relax 4. Stop the installation and obtains vital signs
4.
96
Number the steps to irrigating a nasogastric tube in correct order: 1. Slowly aspirate the syringe 2. Reconnect the NG tube to section 3. Clamp and disconnect the NG tube 4. Perform hand hygiene and apply clean glove 5. Insert tip the syringe into NG tube and slowly inject 30 mL of saline
4,3,5,1,2
97
List the correct order in which to apply an ostomy pouch: 1. Remove the used pouch and skin barrier 2. Perform hand hygiene and apply clean gloves 3. Assess the stoma for color, swelling, and healing 4. Gently cleanse the peristomal skin with warm tapwater 5. Apply nonallergenic tape around the pectin skin barrier 6. Cut an opening on the pouch 0.15 to 0.3 cm larger than the stoma 7. Press the adhesive backing of the pouch smoothly against the skin
2,1,4,3,6,7,5
98
A patient is admitted for lower gastrointestinal bleeding. What color of stool does the nurse anticipate the patient to have? 1. Red 2. Black 3. Green 4. Orange
1.
99
The nurse is caring for a patient with a colostomy. Which intervention is most important? 1. Cleansing the stoma with hot water 2. Inserting a deodorant tablet in the stoma bag 3. Selecting a bag with an appropriate size stoma opening 4. Wearing sterile gloves while caring for the stoma
3.
100
The nurse understands that, when comparing nasogastric tubes used for gastric decompression, a Salem sump is specifically designed to: 1. Minimize the risk of a bowel instruction 2. Ensure drainage of the intestines 3. Prevent gastric mucosal damage 4. Promote resting the gut
3.
101
Before collecting a stool sample for occult blood, the nurse instructs the nursing assistant personnel to: 1. Ask the patient to void 2. Wash the patient's perineum 3. Secure a sterile, specimen container 4. Plan to collect the first specimen of the day
1.
102
The nurse is taking a health history of a newly admitted patient with a diagnosis rule/out bowel obstruction. Which of the following is a priority question to ask the patient? 1. Describe your bowel movements 2. How often do you have a bowel movement 3. When was the last time you moved your bowels 4. Do you routinely use stool softeners, laxatives, or Enemas
3.
103
The nurse is caring for a 78-year-old man with diarrhea. Of the following problems, which is the most important to consider? 1. Malnutrition 2. Dehydration 3. Skin breakdown 4. Incontinence
2.
104
The nurse recognizes which patient needs to use a fracture pan for a bowel movement? 1. The patient who is obese 2. The patient experiencing confusion 3. The patient on bed rest 4. A patient recovering from hip surgery
4.
105
A patient on bedrest for several days attempts to walk with assistance. He becomes dizzy and nauseated. His pulse rate jumps from 85 to 110 bpm. These are most likely symptoms of which of the following? 1. Rebound hypertension 2. Orthostatic hypotension 3. Dysfunctional proprioception 4. Central nervous system rebound hypotension
2.
106
Which actions are appropriate for the nurse to implement when a patient experiences orthostatic hypotension? (Select all that apply) 1. Call for assistance 2. Allow patient to sit down 3. Take patient's blood pressure and pulse 4. Continue to ambulate patient to build endurance 5. If patient begins to faint, allow him to slide against the nurses leg to the floor
1,2,3,5
107
Which of the following best motivates a patient to participate in an exercise program? 1. Giving a patient information on exercise 2. Providing information to the patient when the patient is ready to change behavior 3. Explaining the importance of exercise when a patient is diagnosed with a chronic disease such as diabetes 4. Following up with instructions after the health care provider tells a patient to begin an exercise program
2.
108
Which of the following is a principle of proper body mechanics when lifting or carrying objects? 1. Keep the knees in a locked position 2. Bend at the waist to maintain a center of gravity 3. Maintain a wide base of support 4. Hold objects away from the body for improved leverage
3.
109
Which group of patients is at most at risk for severe injuries related to Falls? 1. Adolescents 2. Older adults 3. Toddlers 4. Young children
2.
110
A nurse plans to provide education to the parents of school aged children and includes which of the following result of children being less physically active outside of school? 1. An increase in obesity 2. An increase in heart disease 3. Higher computer literacy 4. Improved school attendance and grades
1.
111
A nursing assistant personnel asks for help to transfer a patient who is 125 pounds from the bed to a wheelchair. The patient is unable to assist what is the nurses best response? 1. As long as we use proper make body mechanics, no one will get hurt 2. The patient only weighs 125 pounds you don't need my assistance 3. Call the lift team for additional assistance 4. The two of us can easily lift the patient
3.
112
You are transferring a patient who raise 320 pounds from his bed to a chair. The patient has an order for partial weight bearing as a result of bilateral reconstructive knee surgery. Which of the following is the best technique for transfer? 1. Use a transfer board 2. Obtain a stand assist device 3. Implement a three person carry 4. Use the ceiling mounted lift
4.
113
Which is the correct gait when a patient is ascending stairs on crutches? 1. A modified two point gait. The affected leg is advanced between the crutches to the stairs 2. A modified three-point gait the unaffected leg is advanced between the crutches to the stairs 3. A swing through gait 4. A modified four-point gait both legs advance between the crutches to the stairs
2.
114
A patient recovering from bilateral knee replacements is prescribed bilateral partial weight bearing. You reinforce crutch walking knowing that which of the following crunch gaits is most appropriate for this patient? 1. Two point gait 2. Three point gait 3. Four point gait 4. Swing through gait
1.
115
A patient with a right knee replacement is prescribed no weight-bearing on the right leg. You reinforce crutch walking knowing that which of the following crutch gaits is most appropriate for this patient? 1. Two point gait 2.Three point gait 3. Four point gait 4. Swing through gait
2.
116
A patient on week long bed rest is now performing isometric exercises. Which nursing diagnosis best addresses the safety of this patient? 1. Disturbed thought processes 2. Impaired skin integrity 3. Disturbed body image 4. Risk for activity intolerance
4.
117
Which of the following activities does the nurse delegate to nursing assistant personnel in regard to crutch walking? (Select all that apply) 1. Notify nurse if patient reports pain before, during, or after exercise 2. Notify nurse of patient complaints of increased fatigue, dizziness, lightheadedness when obtaining vital signs before and/or after exercise 3. Notify nurse of vital sign values 4. Evaluate the patient's ability to use crutches properly 5. Prepare the patient for exercise by assisting and dressing and putting on shoes
1,2,3,5
118
Select statements that apply to the proper use of a cane, select all that apply 1. For maximum support when walking, the patient places the cane forward 15 to 25 cm, keeping bodyweight on both legs. The weaker leg is moved forward to the cane the bodyweight is divided between The cane and the stronger leg 2. A person's cane length is equal to the distance between the elbow and the floor 3. Canes provide less support than a walker and are less stable 4. The patient needs to learn that two points of support such as both feet or 1 foot and the need to be present at all times
1,3,4
119
A patient is discharged after an exacerbation of chronic obstructive pulmonary disease, she states I'm afraid to go to pulmonary rehabilitation. What is your best response? 1. Pulmonary rehabilitation provides a safe environment for monitoring your progress 2. You have to participate or you will be back in the hospital 3. Tell me more about your concerns with going to pulmonary rehabilitation 4. The staff at our pulmonary rehabilitation facility are professionals and will not cause you any harm
1.
120
The nurses first action after discovering an electrical fire in a patient's room is to: 1. Activate the fire alarm 2. Confine the fire by closing all doors and windows 3. Remove all patients in immediate danger 4. Extinguish the fire by using the nearest fire extinguisher
3.
121
A parent called the pediatricians office frantic about the bottle of cleaner that her two-year-old son drink. Which of the following is the most important instruction the nurse gives to this parent? 1. Give the child milk 2. Give the child Syrup of ipecac 3. Call poison control Center 4. Take the child to the emergency department
3.
122
The nursing assessment on the 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnosis indicates an understanding of the assessment findings? 1. Activity intolerance 2. impaired bed mobility 3. Acute pain 4. Risk for falls
4.
123
A couple is with their adolescent daughter for a school physical and state that they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent? 1. Home accidents 2. Physiological changes of aging 3. Poisoning and child abduction 4. Automobile accidents, suicide, and substance abuse
4.
124
The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply) 1. Insert a urinary catheter 2. Leave a night light on in the bathroom 3. Ask the physician to order a restraint 4. Keep the bed in low position with upper and lower side rails up 5. Assign a staff member to stay with the patient 6. Provide scheduled toileting times during the night shift 7. Keep the pathway from the bed to the bathroom clear
2,6,7
125
The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply) 1. Contact the nursing supervisor 2. Restrict the families visiting privileges 3. Ask the family to stay with the patient if possible 4. Inform the family of the risks associated with side rail use 5. Thank the family for being conscientious and put the side rails up 6. Discuss alternatives with the family that are appropriate for this patient
3,4,6
126
A physician writes an order to apply a wrist restraint to a patient who has been pulling out a surgical wound drain. Place the following steps for applying the restraint in the correct order 1. Explain what you plan today 2. Wrap a limb restraint around wrist or ankle with soft part towards skin and secure 3. Determine that restraint alternatives failed to ensure patient safety 4. Identify the patient using proper identifier 5. Pad the patient's wrist
3,4,1,5,2
127
A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing interventions during the situation? 1. Begin cardio pulmonary respiration 2. Restrain the child to prevent injury 3. Place a tongue blade over the tongue to prevent aspiration 4. Clear the area around the child to protect the child from injury
4.
128
A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that: 1. A safe environment promotes patient activity 2. Assessment focuses on environmental factors only 3. Teaching home safety is difficult to do in the hospital setting 4. Most accidents in the older adult are caused by lifestyle factors
1.
129
A fragile, 87-year-old nursing home resident is admitted to the hospital with dehydration and increased confusion. The patient has upper limb restraints to prevent her from pulling out her nasogastric tube. What instructions does the nurse gives to nursing assistant personnel?
See evolve
130
The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: 1. Place a bed alarm device on the bed 2. Place the patient in a belt restraints 3. Provide one on one observation of the patient 4. Apply wrist restraints
1.
131
To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include? (Select all that apply) 1. Smoking is prohibited around oxygen 2. Demonstrate how to adjust the oxygen flow rate based on patient symptoms 3. Do not use electrical equipment around oxygen 4. Special precautions may be required when traveling with oxygen
1,3,4
132
How does the nurse support a culture of safety? (Select all that apply) 1. Completing incident reports when appropriate 2. Completing incident reports for a near miss 3. Communicating product concerns to immediate supervisor 4. Identifying the person responsible for an incident
1,2,3
133
You are admitting Mr. James, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with facial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an IV line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply) 1. Smoked a pack a day 2. Used a cane to walk at home 3. Take antihypertensive and diuretics 4. History of recent fall 5. Neglect, spatial and perceptual abilities, impulsive 6. Requires assistance with activity, unsteady gait 7. IV line, urinary catheter
3,4,5,6,7
134
At 3 AM the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first? 1. Prepare for an influx of patients 2. Contract the American Red Cross 3. Determine how to restore essential services 4. Evacuate patients per the disaster plan
1.
