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NUR 171 Final review
NUR 171 Final review
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1
You are caring for a pt immediately after a paracentesis. Which finding is most concerning?
Pt c/o discomfort at the puncture site
Blood sugar of 102 mg/dL
A blood pressure of 92/60
Oxygen saturation of 92% with a poor waveform
2
Which pt would you assess first?
A pt with a blood glucose of 42 mg/dL
A pt who reports a pain level of 2
A pt who has a respiratory rate of 22
A pt who has just received a diagnosis of cancer
3
A wound that was surgically made and is not infected but has more potential to become infected due to it's location
Colonized
Contaminated
Infected
Clean-contaminated
4
If a nurse delegates a task to a pt care tech and it doesn't get completed who is held accountable?
The nurse that delegated the task
The primary physician
The pt care tech
The charge nurse
5
What lab result would you expect to find on a pt that is dehydrated
Decreased hemoglobin
Increased hematocrit
Increased red blood cells
No abnormalities
6
Presenting infor about the prevention of STD's to a group of high school kids is an example of which type of prevention
Quaternary prevention
Tertiary prevention
Secondary prevention
Primary prevention is
7
Which pt finding would necessitate a CT scan
without
contrast?
GFR of 90 or below
Allergy to shellfish
BUN 10 mg/dL
Allergy to eggs
8
When teaching a pt who is cognitively impaired which of the following actions should the nurse include in the plan?
Speak quickly
Provide long educational sessions
Involve the pt's family in the education
Avoid making eye contact
9
Which action by the nurse would cause concern when performing a head-to-toe assessment?
Examine the genitalia last
Palpate both carotid pulses simultaneously
Inspect the scalp using gloved hands
Perform bilateral comparison of the extremities
10
Which statement by the nurse reflects an attempt to minimize judgment and bias when caring for pt's
"I will review my actions at the end of the day in the team huddle"
"I will make all comments in a private setting away from pt's"
"I will watch for evidence of bias by members of the health care team"
"I will reflect on my responses and thoughts when meeting new pt's"
11
Which of the following examples demonstrates adherence to HIPAA
Taking a photo of a patient for Instagram
Logging out of a computer after documenting pt care
Discussing a pt's status with a friend
Posting details about the pt without using their name on Facebook
12
A pt who refuses invasive treatments is practicing which pt right?
Right to autonomy
Right of confidentiality
Right of justice
Right to medical records
13
Which of the following plans would help to elicit accountability to a pt wanting to increase daily exercise?
The pt will exercise daily for the next 2 weeks
The pt provides a list of exercises that they are interested in
The pt will mark a calendar on the days they exercise
The pt will share their exercise log with an identified support person
14
Which wound complication is more serious?
Evisceration
Fistula
Sinus tracts
Dehiscence
15
A technique to alleviate pain that involves pressure and kneading of the body is what?
Guided imagery
Massage therapy
Biofeedback
Aqua therapy
16
This law serves to protect citizens from legal liability when rendering emergency care to someone outside a hospital
Statute
Liability
Good Samaritan
tort
17
When documenting in a pt's EMR which statement is most appropriate?
Copy and paste pertinent data from the previous note
Avoid using abbreviations within the note
Quantify statements using the words "average" or "normal"
Document N/A or "not observed" to prevent any blank entries
18
What is a normal finding when assessing an older pt's eyes?
Bloodshot appearance
Yellow tint to sclera
Opaque white ring around cornea
Cloudy appearance
19
Which statement accurately describes an alternative modality?
It is a therapy used instead of conventional modalities
They are used in addition to a conventional modality
Only hippies use alternative modalities
They are not effective
20
When assessing a pt with a head injury you find that the GCS was initially 13 and is now 10. What do you do?
Assess the pt for pain
Contact the physician
Continue to monitor for any changes
Raise the head of the bed
21
Which of the following actions by the nurse exemplifies compassion?
Providing care that affirms and upholds a code of ethics
Providing care that demonstrates caring service
Care that collaborates with other health professions and disciplines
Providing care that uses knowledge development from scientific advances
22
Any abnormal assessment finding should be reassessed within what time frame of an intervention
In 1-2 hours
At the beginning of the next shift
Every 4 hours
In 15 minutes
23
Which of the following statements best represents the government's legal responsibilities for health care?
The government provides a health care savings account
The government provides unlimited funding for health care programs
The government produces an anual budget
the government pursues investors for funding
24
Which documentation method is used when the nurse only documents the unexpected findings related to the pt's condition?
Problem-oriented medical record
SOAP charting
Focus charting (DAR)
Charting by exception
25
What is the most appropriate nursing intervention when you enter a pt's room and find them to have a drooping right eye?
Check the pt's blood pressure
Assess the pt for pain
Auscultate the lungs
Palpate the abdomen
26
Which intervention best represents the planning step in the nursing process?
Obtaining blood pressure reading
Reviewing medication record
Trending lab results
Weight loss to be achieved
27
Which of the following is
not
a nursing diagnosis?
Altered sensory perception related to surgery
Chronic fatigue syndrome related to poor diet
Altered nutrition related to nausea and vomiting
Pain related to abdominal incision
28
This type of learner prefers to learn through physical activity or learning though doing?
Auditory
Verbal
Visual
Kinesthetic
29
A 16 year old pt is admitted to the hospital. Which situation allows the pt to sign admission papers?
The pt is an emancipated minor
The pt has a baby of their own
The pt states they understand informed consent
The pt's family is out of town
30
Discharge planning should be initiated at which point in a pt's hospital stay?
During the admission process
Immediately before discharging the pt
After the pt has been an inpatient for 24 hours
Before the pt is admitted to the hospital
31
Which patient is eligible to receive health insurance under the Medicare program?
A pt who does not have any other kind of health insurance
A pt whose income is below the poverty line
A pt who is age 65 or older
A pt who is below the age of 18
32
A nurse who fails to recognize vital symptoms of a decline in a pt's condition is guilty of what?
Malpractice
Tort
Negligence
Liability
33
When making a correction in a pt's paper chart what is the appropriate action to take?
Scribble over the information so no one else can read it
Use "white out" to blank out the mistaken entry
Draw a line through the entry, write error and initial just above the entry
Write over the incorrect letters with a different color ink
34
In order to help build rapport and trust with a patient which action could the nurse take?
Minimize contact with the pt that is angry
Fulfill a promise by allowing a pt to visit with family members
Reinforce the importance of treatment to a pt who speaks a foreign language
Use clinical terminology to help the pt better understand their diagnosis
35
What term would you use to document a pt who is having difficulty verbalizing due to a stroke
Aphasia
Dysphasia
Dysphagic
Dyspneic
36
Which assessment finding would be most alarming if found on an 82 yr old admitted for a UTI?
Hypoactive bowel sounds
O2 Sat of 96% on room air without dyspnea
Presence of an S3 heart sound
A diastolic pressure of 62 mm Hg
37
Using the ABC priority framework which pt should be seen first?
A pt who has pneumonia and has developed difficulty breathing and stridor
A pt scheduled for discharge who has a 101.1 temp this morning
A pt who has early dementia and awoke confused to their location
A postop pt with a urine output of 50 ml over the last 3 hrs
38
Who is responsible for determining the scope of practice for LPN's
State legislators
Federal legislators
US Dept of Health and Human Services
American Nurses Association
39
while reviewing lab results of a pt with a known bacterial infection you would expect to find what?
Decreased white blood cells
Increased lymphocytes
Decreased monocytes
Increased neutrophils
40
In which step of the nursing process would you formulate goals?
Evaluation
Data collection
Implementation
Planning
41
Reflecting on unconscious feelings towards a pt is an example of what concept of cultural competence?
Color discrimination
Implicit bias is
Explicit bias
Sterotyping
42
This protective response triggers the endocrine glands to pump cortisol and adrenaline into the blood stream.
Stress response
Exacerbation
Adaptation response
Fight-or-flight response
43
Which statement is the best example of therapeutic communication?
'You feel like you have the support needed to be successful?"
"Do you need any more resources of information?"
"Tell me what kind of coping skills you have"
"Do you understand your next step in the treatment?"
44
Which definition best describes the allopathic philosophy of health care?
Remedies that produce effects different from what caused them
Illness is the result of falling out of balance with nature
Giving small doses of a substance that creates the disease symptoms
Disease is a result of nerve dysfunction
45
Which statement is most true regarding the electronic medical record is it...
provides evidence of care provided
allows less time for direct pt care
Decreases the amount of paperwork
increases the number of medication errors
46
What statement best describes the major effects the Affordable Care Act (ACA) had on health inequities
Has enabled pt's with pre-existing conditions to obtain health insurance
Allows hospitals to receive less reimbursement for preventable re-admits
Allows for quality performance measures to be used to reimburse hospitals
Has improved quality and safety in hospitals
47
this is set in place by each state to define the scope of nursing practice. It is regulated by the Board of Nursing
Nurse Practice Act
American Nursing Association
Health Insurance Portability And Accountability Act
The National Council of State Boards of Nursing
48
While providing care to a pt from a different culture what action indicates cultural competence?
Develops communication skills
Assesses the pt for chronic illness
Speaks a different language
Interacts effectively in a multicultural context
49
Which of Maslow's hierarchy of needs represents the highest level of human need
Feeling safe
Homeostasis
Self-actualization
Feeling loved
50
Which type of assessment should a nurse perform upon starting their shift?
Vital signs and bowel sounds
A neuro assessment
Complete head to toe assessment
Focused assessment of the system related to the pt's primary diagnosis
51
When reviewing a pt's plan of care you determine that they have not met the goal what is the most appropriate plan?
Review the plan of care
Assess for patient noncompliance
Collect additional assessment data
Add more interventions
52
According to the law, you must initiate resuscitative measures if this order is not provided
Advance directives
Durable medical power of attorney
DNAR
Consent
53
A pt care tech reported a pts temperature as 102.2 F. What is the
next
action the nurse should take?
Continue to monitor
Encourage the pt to drink more fluids
Retake the temperature for yourself to verify it was done correctly
Check for an order and administer Tylenol
54
Which statement is most accurate when accessing a pt's medical records?
A nurse can only access the records of pts they are actively caring for
A nurse can only access the records of a pt within the facility
A nurse can share information about a pt with the pt's who have the same dx
pt information can only be shared with the immediate family
55
This type of nursing care empowers the pt to take control of and manage their health care
Primary care nursing
Patient centered care
Team nursing
Case management
56
Which type of teaching method asks the pt to explain the information received in their own words back to the nurse?
Lecture
Question and answer
Teach back
Role play
57
What statement best describes a tort?
False imprisonment does not apply to the use of chemical restraints
Battery occurs when a person verbally threatens to harm another person
Assault is a tort that only occurs if a pt is physically harmed
Negligence is the most common unintentional tort
58
To threaten a pt with harm is an example of what type of offense?
Battery
Harassment
Assault
Negligence
59
When assessing the respiratory system which finding is consistent with normal respiratory function?
Circumoral cyanosis
Productive cough
Barrel-shaped chest
Equal thoracic excursion
60
This nurse has completed a 4-year degree at a university and sits for the NCLEX-RN
Doctorate nurse
RN diploma nurse
RN bachelors degree nurse
LPN
61
Which of the following resources are considered reliable tools for obtaining pt teaching?
Wikipedia
City or County health department
You-Tube
Associations
Google MD
Foundations
62
What factors help guide decisions about pt care to ensure they get the care they need at the appropriate place?
Medical necessity and reasonable delivery of care
Medical necessity and appropriate level of care
Medical necessity and interprofessional collaboration
Managed care and critical access
63
When auscultating breath sounds which position is best?
Semi Fowler's
Low Fowler's
High Fowler's
Supine
64
While caring for a pt with suspected untreated/uncontrolled diabetes what is the best action for the nurse to take?
Suggest the pt go home and return if symptoms get worse
Begin test while asking about other social concerns
Refer the pt to an endocrinologist to address the diabetes
Treat the symptoms and give the pt medication to take home
65
This initiative was developed to provide science-based health goals to improve health and prevent disease.
The Office of Disease Prevention and Health Promotions
The Affordable Care Act
The Nursing Practice Act
Healthy People 2030
66
When working with a pt to set goals for an identified problem it is important for the nurse to remember what?
Family input is important for goals to be realistic and
Only the adults in the family should set the goals
Only a provider should set the goals for the family
the nurse needs to take the lead
67
Which definition best describes a subculture?
A variation within an ethnic or cultural group
An ability to practice openness to new ways of thinking
An appreciation of someone from another culture
Differences that occur in race, color, ethnicity, and national origin
68
Which nurse was instrumental in establishing modern nursing. She founded the school of nursing
Florence Nightingale
Dorothea Dix
Clara Barton
Linda Richards
69
When caring for a pt who has reported experiencing abuse at home the nurse should do what?
Implement a safety plan
Assess the pt's risk for immediate harm
Refer the pt to a community support group
Instruct the pt on how to leave the relationship
70
In order for a hospital to receive reimbursement for services rendered a nurse must do what?
Document care and appropriate interventions provided during hospitalization
Be careful not to mention adverse reactions in the documentation
Notify the pt's insurance of the pt's admission
Tell the pt his care will not be covered by insurance
71
When performing a neuro exam on a 65 yr old pt which finding is considered a normal based on the pt's age?
Inability to distinguish certain tones or voices
Uneven grip strength of arms
Limited ability to fully extend right leg
Drooping smile
72
Which of the following actions demonstrates active listening skills?
Show emotion when a pt is disclosing sensitive information
Interrupt the pt's statement to clarify thoughts or ideas
Keep direct eye contact to a minimum
Avoid looking at other pt's on the unit
73
Which of the following has had the greatest impact on the ability of obtaining health insurance?
Medicaid
The Affordable Care Act (ACA)
The Children's Health Insurance Program (CHIP)
Medicare Prescription Drug, Improvement, and Modernization Act (MMA)
74
This physical change associated with the dying process often causes a pt's family distress and concern
Accumulation of secretions in the trachea
Restlessness and difficulty sleeping
Pallor and circumoral cyanosis
Conjunctival dryness that causes tearing of the eyes
75
Which of the following describes a team of mental health professionals who work together to provide client care?
A professional organization
A shared governance
Inter-professional team
Intra-professional team
76
You enter a pt's room and find they are apneic and pale. should your first response be?
Notify the Dr
Check the chart for a code status
Auscultate the lung sounds
Call a rapid response
77
Which type of goals would you expect to be completed by time of discharge from the hospital?
Long term goals
Teaching goals
Short term goals
Long term and short term goals
78
Which statement about the legal guidelines for documentation is false?
Any information recorded in the chart must be accurate and true
It should be organized and completed in a timely fashion
It should include the nurse's interpretation of the situation
A medical record can be used as evidence in a court of law
79
What are indications of cold therapy?
Pain relief
Decrease edema
Hemostasis
Reduction of muscle spasms
Increased blood flow to the site
Vasodilation
80
Which of the following
would not
be submitted in an incident report?
Patient complaints about dietary services
Visitor falling in the hallway
Patient lost dentures
Patient given the wrong medication
81
Why is evidence based nursing important?
Helps validate the difference nurses really make
It helps ensure nurses can demand more pay
It makes nursing more professional
Guides nursing decisions to optimize effective care
82
To develop cultural competence, a nurse should understand which of the following characteristics of their pt's
Professional roles
Diversity
Self-esteem
Social status
83
This is a form of rude, disrespectful, or intimidating behavior that violates social norms of mutual respect?
Incivility
Harassment
Anger
Abuse
84
When a pt is actively dying and the nurse is performing a shift assessment which action should take priority?
Auscultate lung fields
Provide oral care
Observe for cyanosis
Obtain a pulse ox reading
85
Which of the following interprofessional team members can help a pt with a mental illness find housing?
Psychologist
Social worker
Behavioral therapist
Psychiatrist
86
What assessment finding would be most alarming if found on a pt who is on diuretic therapy?
Weight gain of 2 pounds
Pulse rate of 100
BP 130/80
Respiratory rate of 24
87
This quick pt reference summary is updated each shift and used to provide pt report and summarize pt care
Medication administration record (MAR)
Narrative chart note
Kardex
Personal notes
88
This Act was implemented to provide confidential maintenance of protected health information
Health Insurance Portability and Accountability Act
Health Security Act
Health Privacy Act
Health Information Technology for Economic and Clinical Health Act
89
Which function is the nurse assessing when asking a pt to focus on an object close up and moving it farther away
Accommodation response
Consensual pupil reflex
Anisocoric pupil response
Direct pupil response
90
All are contraindications to heat application
except
what?
Bleeding wound
Phlebitis
Suspected appendicitis
Newly injured joints
91
This designates legal written permission to appoint another person responsible for medical decisions on your behalf
Emancipation
Advance directives
Civil law
Durable medical power of attorney
92
This type of facility can perform minor surgical procedures in which the pt is discharged home the same day
Health department
Rehabilitation facility
Ambulatory surgery center
Ambulatory care clinic
93
This is a common modifiable risk factor of many illnesses. It is a response of the body to a demand made of it.
Anxiety
Stress
Smoking
High fat diet
94
When performing a focused assessment which condition provides the best information through the use of palpitation?
Cardiac arrhythmia
Rebound tenderness
An enlarged heart
Hyperinflated lungs
95
This type of communication is pt centered and promotes a greater understanding of the pt's needs, concerns and feelings
Therapeutic communication
Aggressive communication
Passive communication
Assertive communication
96
You witness a co-worker put a pain pill in their pocket before leaving the hospital. What should you do?
Ask an RN what to do
Call the police and report the incident
Notify the nurse manager of the unit
Confront the co-worker about what happened
97
What strategy would you enforce to help decrease health care disparities among vulnerable groups
Compile a list of resources available in the community
Update pt's charts to reflect socioeconomic status
Teach staff to recognize discrimination in vulnerable populations
Provide low-cost medications
98
Pt is back from an EGD & is c/o sob, abd & shoulder pain that increases with movement of the torso. What do you suspect?
Pulmonary embolism
Myocardial infarct
A perforation
Hematoma
99
A nurse experiencing moral conflicts when providing pt care places them at risk for which of the following actions?
Using nonverbal cues when caring for pt's
PBecoming too involved with the pt
Initiating inclusion when planning care for the pt
Providing a lower quality of care to the pt
100
When total protein values are significantly below normal what physical manifestation would you expect the pt to have?
Poor skin turgor
Edema
Dry mucous membranes
Pallor
101
A pt with a low hemoglobin is at risk for what?
Poor nutrition
Infection
Alteration in skin integrity
Altered tissue perfusion
102
What factor places immigrant populations at an increased risk for negative health outcomes
Poverty
Language barriers
Genetics
Transporation access
103
Which of the following assessments is considered subjective?
Respiratory rate of 26 bpm
Patient reports shortness of breath
Coarse lung sounds billaterally
Cough producing green sputum
104
This type of charting provides a continual description of a pt's care from admission through discharge
Focused charting
Charting by exception
Narrative charting
PIE charting
105
Which cause would you suspect if a pt has hypoactive bowel sounds, c/o nausea and refuses to eat 12 hours after surgery
Paralytic ileus
Anesthesia
Obstruction
Peritonitis
106
Which of the following areas is an example of an environmental risk factor of health
Ethnicity
Work Stress
Sexual practices
Age
107
Which of the following statements is true regarding the cultural care theory?
The nurse should aim to provide culturally competent and congruent care
The nurse should be fair and treat everyone the same
It is possible for the nurse to separate a pt's culture from their care
The nurse should know everything about the client's culture