Final Exam Review

Question 1

What is the patient describing when they say, “I am in so much pain I cannot sleep?”

Answer 1

perception

Question 2

What will the nurse remove once they have removed their goggles?

Answer 2

gown

Question 3

What precaution is used for a microorganism that is transmitted by small, evaporated particles suspended in the air?

Answer 3

airborne

Question 4

What does delegate mean?

Answer 4

entrust a task to another person

Question 5

What does pallor mean?

Answer 5

decreased hematocrit

Question 6

What does 20/30 mean in terms of eyesight?

Answer 6

the 20/20 person sees the same at 30 feet

Question 7

How do you straighten the ear canal of an adult?

Answer 7

pull up and back

Question 8

How do you straighten the ear canal of a child?

Answer 8

pull down and back

Question 9

What mechanism can be utilized to promote venous return?

Answer 9

ambulation

Question 10

Where do you begin lung auscultation?

Answer 10

above the clavicle

Question 11

How often should an artificial eye be cleaned?

Answer 11

as needed

Question 12

What are the six QSEN competencies?

Answer 12

PCC, team work and collaboration, EBP, quality improvement, safety, and informatics

Question 13

Which QSEN competency focuses on providing individualized care and restores an emphasis on personal relationships?
(respect client’s preferences, values, and needs)

Answer 13

patient centered care

Question 14

The nurse provides a bed bath and asks the client how they feel. Which step of the nursing process is this?

Answer 14

evaluation

Question 15

What do nurses evaluate in ADPIE?

Answer 15

client outcomes

Question 16

Which clinical judgement skill causes the nurse to collect, categorize, and clarify data?

Answer 16

interpretation

Question 17

What organization evaluates clinical judgement abilities of new graduate nurses?

Answer 17

NCSBN (national council of state boards of nursing) aka NCLEX

Question 18

Are responsibility, discipline, creativity, and curiosity are key components of the attitudes of critical thinking?

Answer 18

yes

Question 19

What is an emic worldview?

Answer 19

intercultural encounter from an insider perspective

Question 20

What are the standards of professional performance?

Answer 20

EDUCATION, ethics, culturally congruent practice, communication, collaboration, leadership, EBP and research, quality of practice, professional practice evaluation, resource utilization, and environmental health

Question 21

What are the 5 components of the transcultural care model?

Answer 21

awareness, knowledge, skill, encounter, and desire

Question 22

What should be provided toa client who does not speak English to maintain linguistic competency?

Answer 22

medically licensed interpreter

Question 23

what is the ability to obtain,
process, and understand basic health information and services needed to make
appropriate health decisions called?

Answer 23

health literacy

Question 24

What is a client without health insurance at risk for?

Answer 24

health disparities

Question 25

What should a nurse use to build a therapeutic relationship with a client?

Answer 25

open-ended question

Question 26

What is client describing when they state "my chest feels really tight"?

Answer 26

quality/character

Question 27

What describes where pain is, such as deep, superficial, and radiating?

Answer 27

location

Question 28

What is described with "burning, sharp, dull, crushing, looks like...?"

Answer 28

character/quality

Question 29

What is described with statements like "0/10 pain," "soaked 5 sheets?"

Answer 29

quantity/ severity

Question 30

What is described as onset, duration, or frequency?

Answer 30

timing

Question 31

What is described as when/where symptoms started?

Answer 31

setting

Question 32

What is described as factors that make something better or worse?

Answer 32

aggravating/ relieving factors

Question 33

What is known as additional symptoms to the primary issue?

Answer 33

associated factors

Question 34

What is being described when a client described the effect their condition has on their daily activities?

Answer 34

client's perception

Question 35

Which mode of transmission is person to person, object to person, or fecal to oral?

Answer 35

contact

Question 36

Which mode of transmission is spread through sneezing and travels less than 6ft?

Answer 36

droplet

Question 37

Which mode of transmission is spread through coughing and sneezing with small suspended particles that travel >6 ft?

Answer 37

airborne

Question 38

What PPE is needed for contact precautions?

Answer 38

gown and gloves

Question 39

What is required for droplet precautions?

Answer 39

surgical mask

Question 40

What PPE is required for airborne infection isolation precautions?

Answer 40

particulate respirator (N95) and negative pressure isolation room

Question 41

Which temperature alteration occur when pyrogens trigger the immune system, causing the hypothalamus to raise the set point?

Answer 41

pyrexia

Question 42

What are some objective categories to assess during a skin assessment?

Answer 42

texture, thickness, edema, turgor, color

Question 43

What should be washed first when giving a bath?

Answer 43

face (cleanest to dirtiest)

Question 44

What can be used to assess head for lice?

Answer 44

tongue depressor

Question 45

What is example of normal charting for a head?

Answer 45

normocephalic, no lumps, no lesions, no tenderness

Question 46

How often should an artificial eye be cleaned, and what should you use to clean it?

Answer 46

as needed with soap and water or saline

Question 47

What is clonus?

Answer 47

Very strong deep tendon reflex, +4

Question 48

What is the grade for a weak deep tendon reflex?

Answer 48

1

Question 49

What grade indicates a strong deep tendon reflex?

Answer 49

3

Question 50

What is the graded muscle strength for a client who cannot resist gravity?

Answer 50

2

Question 51

Muscle strength grade 5?

Answer 51

ROM full

Question 52

The nurse is assessing range of motion in a client who is able to actively achieve full range of motion against full resistance. How will the nurse grade this client's muscle strength?

Answer 52

grade 5

Question 53

What is a full ROM against gravity with some resistance graded as?

Answer 53

4

Question 54

What is the graded muscle strength for a client who cannot resist gravity?

Answer 54

2

Question 55

What does a positive Romberg test indicate?

Answer 55

loss of balance

Question 56

How should the nurse manage the effects of immobility on the respiratory system?

Answer 56

teach the client to use an IS (incentive spirometer)

Question 57

How should the nurse manage the effects of immobility on blood flow to the skin?

Answer 57

turn the client every 2 hours

Question 58

How may immobility impact the cardiac system? How will the patient present?

Answer 58

-activity intolerance -light headed, dizzy, increased HR, decreased BP

Question 59

Which interventions will the nurse implement to reduce the impact of immobility on a client's integumentary system?

Answer 59

Turn the client every 1-2 hours, maintain a positive fluid balance, and teach the client to shift every 15 minutes

Question 60

The nurse is caring got four clients with immobility from different conditions. Which client should the nurse place in the side-lying position?

Answer 60

client with pressure ulcers

Question 61

How far should a client move a cane in front of them?

Answer 61

For maximum support when walking, the patient places the cane forward 6-10 inches

Question 62

Which leg should step first when using a cane?

Answer 62

The client moves the weaker leg forward to the cane so the body weight is divided between the cane and the stronger leg

Question 63

Which statement will the nurse include when teaching a client to use a walker?

Answer 63

" Your walker should be as tall as your wrist."

Question 64

How should a client move with a walker?

Answer 64

When walking the client should step with the affected side, then move the walker, then step with the affected or stronger side.

Question 65

How will the nurse fit crutches to prevent nerve damage?

Answer 65

2-3 finger widths from axilla; 15-30 degree elbow angle

Question 66

What kind of breaths are regular wax and wean sleep apnea sounds?

Answer 66

Cheyne-Stokes Respirations

Question 67

What kind of breaths are irregular wax and wean sleep apnea sounds?

Answer 67

Biot Respirations

Question 68

What kind of respirations are characterized with prolonged expirations with dyspneic episodes?

Answer 68

COPD respirations