Vancomycin requires monitoring of trough levels. The optimal time to draw a trough level is:

30 minutes before the next scheduled dose

Which action is an example of primary prevention rather than secondary prevention?

Administering influenza vaccines at a community health fair

Which meal option would be best for a client with FVE who is placed on a low-sodium diet?

Baked chicken with corn on the cob

Which order should the nurse question on a client with hypervolemia?

Administer hypertonic IV solution as ordered

For which situation would EMTALA be important?

A patient without insurance comes to the ED with chest pain

Which of the following is true regarding respite care services?

gives the caregiver the opportunity to go on a short vacation

What are some socioeconomic factors that impact vulnerable populations? Select All that apply

Poverty status, Employment status, Education level, Household income

How do the lungs respond to acidosis?

Increasing rate and depth of breathing

A nurse has delegated morning vital signs to a UAP. Which action requires the nurse to intervene?

Takes a radial pulse by placing her thumb over the radial artery

Evidence-based practice

Involves the integration of evidence from research.

impaired tissue integrity can affect

temperature regulation, protection of the body and body image

Which patient should the RN assess first?

A patient receiving a new antibiotic complaining of lip swelling

The nurse anticipates which fluid movement when administering a hypertonic IV solution to a client?

Fluid moves from the cells into the intravascular space

What does EBP ensure in nursing practice?

Effective and safe patient care

A hypertonic solution that is administered to a patient causes what fluid & electrolyte shift?

movement of water into the intravascular space

What is the primary nursing consideration when administering beta blockers such as metoprolol?

Monitor for bradycardia and hypotension

A patient is receiving nutrition through a nasogastric tube. Which assessment is the RN's priority?

The patient is regurgitating the formula

What does HIPAA stand for?

Health Insurance Portability and Accountability Act

Which of the following clients should the RN refer to a social worker? Select All that Apply

Client who needs help setting up an emergency notification system at home, Client who requires placement in an assisted living facility, Client who needs to get school assignments while hospitalized on a ped unit

Which statement is an example of therapeutic communication?

"Tell me more about how you’re feeling."

Which of the following best describes the difference between an agonist and an antagonist medication?

An agonist triggers a response and an antagonist blocks the response

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NUR 112 Final Exam Review Part I

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Questions 199

Answers

1
Vancomycin requires monitoring of trough levels. The optimal time to draw a trough level is:
30 minutes before the next scheduled dose
Immediately after administration
At the midpoint between doses
30 minutes after completion of the infusion
2
Which of the following is a therapeutic communication technique?
Offering personal interpretation
Using silence
Providing passive responses
Offering sympathy
3
An RN is assessing a client who has an oral temp of 102.2°F. Which of the following findings should the nurse expect?
respiratory rate 10 breaths/min
dilated pupils
heart rate 108 beats/min
Decreased peripheral pulses
4
An RN administers the wrong medication to the patient. What is her priority action?
Notify the charge nurse
Notify the provider
Assess the patient
Complete an incident report
5
A nurse with some experience but still requires clinical support is in what stage of nursing competence?
Proficient
Advanced Beginner
Novice
Competent
6
Which action is an example of primary prevention rather than secondary prevention?
Screening for hypertension during a clinic visit
Performing colonoscopy for early detection of colorectal cancer
Conducting Pap smears for cervical cancer detection
Administering influenza vaccines at a community health fair
7
Which meal option would be best for a client with FVE who is placed on a low-sodium diet?
Spaghetti with meat sauce and garlic bread
Baked chicken with corn on the cob
Steak and broccoli with cheese sauce
Bologna sandwich on whole bread and potato chips
8
The extracellular fluid compartment consists of all of the following except?
Intravascular compartment
Interstitial compartment
Transcellular compartment
Intracellular compartment
9
Which order should the nurse question on a client with hypervolemia?
Obtain urine sample for urine specific gravity
Record client's weight daily
Administer hypertonic IV solution as ordered
Auscultate the lungs q4h and prn
10
Which type of solution has a higher concentration of solutes compared to the cells in the body?
Hypertonic solution
None of the above
Isotonic solution
Hypotonic solution
11
Which body fluid compartment is the smallest in terms of volume?
Interstitial fluid
Plasma
Extracellular fluid
Intracellular fluid
12
A 13-year-old client is beginning to develop sexual feelings and exploring identity. Which psychosexual stage is this?
Anal stage
phallic stage
Genital stage
Latency stage
13
Which type of solution has a lower concentration of solutes compared to the cells in the body?
Hypertonic solution
Hypotonic solution
None of the above
Isotonic solution
14
What assessment finding of a pt at risk for hypovolemic shock indicates compensatory mechanisms are developing?
Decreased respiratory rate
Decreased blood pressure
Increased heart rate
Increased urine output
15
For which situation would EMTALA be important?
A patient requests a nurse to post a video of them dancing together
A patient without insurance comes to the ED with chest pain
A patient refuses a blood transfusion for religious beliefs
A patient needs disability accommodations, but none are available
16
Which of the following is true regarding respite care services?
is only available for palliative or hospice care
it provides comfort and support measures to a client w/ a terminal illness
gives the caregiver the opportunity to go on a short vacation
is available for caregivers of clients with a 60-month life expectancy
17
What are some socioeconomic factors that impact vulnerable populations? Select All that apply
Poverty status
Employment status
Education level
Household income
18
Which type of solution has a higher concentration of solutes compared to the cells in the body?
Hypotonic solution
Isotonic solution
Hypertonic solution
None of the above
19
How do the lungs respond to acidosis?
Decreasing rate and depth of breathing
Increasing rate and depth of breathing
20
A patient recovering from a stroke participates in PT to regain motor function. What level of prevention is this?
primary
tertiary
secondary
quaternary
21
A nurse has delegated morning vital signs to a UAP. Which action requires the nurse to intervene?
Takes BP in left arm with AV fistula in the right arm
Assessing a rectal temperature on a newborn with a red thermometer
Takes an axillary temperature on a patient who is eating breakfast
Takes a radial pulse by placing her thumb over the radial artery
22
Which of the following represents the Outcome component of a PICOT question?
Improved wound healing rates
Nurses providing wound care
Diabetic patients with foot ulcers
Antibiotic ointment use for wounds
23
What is Evidence-Based Practice (EBP)?
A medical management tool
A patient outcome measure
A nursing research approach
A nursing care technique
24
Which of the following is a modifiable risk factor for heart disease?
Gender
Family history
High blood pressure
Age
25
Evidence-based practice
Involves the integration of evidence from research.
Does not include nursing practice.
All of these answers
Hinders safe nursing practice.
26
Which step of the nursing process involves carrying out the planned interventions?
Diagnosis
Assessment
Implementation
Planning
27
An older adult patient asks why they need to use the restroom more often at night. The RN explains that this is due to:
Decreased bladder capacity
Increased renal blood flow
Increased production of renin
Decreased glomerular filtration rate
28
An RN is caring for a patient with fluid volume excess. What clinical manifestations does she expect?
decreased urine output
pitting edema
excessive thirst
syncope
29
impaired tissue integrity can affect
temperature regulation
protection of the body
temperature regulation, protection of the body and body image
body image
30
What does the "A" stand for in SMART goals?
Affective.
Assertive.
Aggressive.
Achievable.
31
Which patient should the RN assess first?
A patient with a respiratory rate of 24 breaths/min
A patient receiving a new antibiotic complaining of lip swelling
A confused 85 year old patient who is trying to get out of bed
A 60 year old patient fresh-postoperative complaining of 8/10 pain
32
What is the fluid compartment that fills the spaces between cells?
Transcellular compartment
Intravascular compartment
Intracellular compartment
Interstitial compartment
33
Which of the following VS documentations is correct?
Radial pulse regular 68/min
Temp 96.8 F
SpO2 95%
BP 148/72 mmHg
34
The nurse anticipates which fluid movement when administering a hypertonic IV solution to a client?
Fluid moves from the intravascular space into the intracellular space
Causes no or equal movement of fluid into or out of cells
Fluid moves from the cells into the intravascular space
Fluid moves from the intravascular space into the interstitial spaces
35
What is the third step of the nursing process?
Planning
Implementation
Assessment
Diagnosis
36
A severe complication of fluid volume excess is?
Myocardial Infarction
Pulmonary edema
COPD
Emphysema
37
What does EBP ensure in nursing practice?
Effective and safe patient care
Professional growth and contribution
Reduced hospital readmissions
Efficient resource utilization
38
What does the "M" stand for in SMART goals?
Major.
Measurable.
Minor.
Mathematics.
39
A patient with an SBO has a metabolic alkalosis on an arterial blood gas (ABG). What is the likely cause?
Diarrhea
Hypoventilation
Vomiting
Ischemia
40
Which laboratory result correlates to a diagnosis of dehydration?
Hematocrit 45%
Serum osolality 350 mOsm/kg
Urine specific gravity 1.015
BUN 20 mg/dL
41
A hypertonic solution that is administered to a patient causes what fluid & electrolyte shift?
movement of water into the intercellular compartment
movement of sodium into the intravascular space
movement of water into the intravascular space
movement of sodium into the intracellular compartment
42
What is the primary nursing consideration when administering beta blockers such as metoprolol?
Expect an increase in heart rate
Monitor for bradycardia and hypotension
Assess for hyperglycemia
Administer on an empty stomach
43
Which action most directly reduces risk for pressure injury development in bed-bound patients?
Applying ice to pressure points
Repositioning every 2 hours
Increasing fluid intake
Applying lotion every 8 hours
44
A patient is receiving nutrition through a nasogastric tube. Which assessment is the RN's priority?
The patient is experiencing abdominal cramping
The patient reports constipation
The patient is regurgitating the formula
The patient complains of irritated skin around his nose
45
What are reliable sources for evidence in EBP?
Government agencies websites
Peer-reviewed journals
Opinion-based content
Google searches
46
What does HIPAA stand for?
Health Insurance Portability and Accountability Act
Health Information Privacy and Protection Act
Healthcare Information and Privacy Act
Healthcare Insurance Portability and Authorization Act
47
Which of the following clients should the RN refer to a social worker? Select All that Apply
Client who needs help setting up an emergency notification system at home
Client who requires placement in an assisted living facility
Client asking about the adverse effects of a med they have been prescribed
Client who needs to get school assignments while hospitalized on a ped unit
Client who needs additional instructions on breastfeeding prior to d/c
48
During which psychosexual stage does Freud propose that a child develops an Oedipus complex or Electra complex?
Oral
Phallic
Latency
Anal
49
Which statement is an example of therapeutic communication?
"Why did you refuse your medication?"
"Tell me more about how you’re feeling."
"I know how you feel."
"Everything will be okay."
50
Which of the following best describes the difference between an agonist and an antagonist medication?
Agonists cause an adverse reaction; antagonists prevent adverse reactions.
An agonist blocks a response and an antagonist enhances the response
An agonist triggers a response and an antagonist blocks the response
An agonist and an antagonist both block responses but in different ways.
51
Stage this pressure injury
Stage 3
Stage 1
Stage 2
Deep Tissue Injury
52
What is the strongest type of evidence in EBP?
Qualitative studies
Case studies
Systematic reviews and meta-analyses
Quantitative studies
53
The "T" in PICOT is often used for defining which of the following?
The tools used to measure the results
The total number of participants in the study
The timeframe for measuring outcomes
The type of treatment used
54
Which situation is considered a sentinel event?
A client developing nausea from medication
A client developing a stage 2 pressure ulcer
A client experiencing a wrong-site surgery
A client receiving the wrong diet tray
55
A pressure injury with visible adipose tissue but no bone exposure is classified as:
Stage I
Stage IV
Stage II
Stage III
56
The nurse anticipates which fluid movement when administering an isotonic IV fluid to a patient?
Fluid moves from the intravascular space into the intracellular space
Fluid moves from the cells into the intravascular space
Fluid moves from the intravascular space into the interstitial spaces
Causes no or equal movement of fluid into or out of cells
57
Fluid volume excess can be caused by
heart failure
Excessive intake of sodium
All of these
cirrhosis of the liver
58
Which healthcare professional is responsible for assessing patient's health status and developing care plans?
Unlicensed Assistive Personnel (UAP)
Certified Nursing Assistant (CNA)
Registered Nurse (RN)
Licensed Practical Nurse (LPN)
59
Evidence Based Practice....
Is determined by the American Medical Association
Is determined by nursing students
Is determined by the Nurse Practice Act
Optimizes patient care by integrating best current evidence & expertise
60
Stage 2 Pressure Injury:
Partial thickness skin loss without any slough.
Full thickness tissue loss with or without slough (minimal)
Full thickness tissue loss with no slough or eschar.
Partial thickness skin loss. Can have slough, but minimal
61
What is the purpose of EMTALA?
To provide financial assistance to healthcare providers
To establish standards for medical education and training
To regulate the use of medical equipment in hospitals
To ensure access to emergency medical services for all individuals
62
Which component of the nursing process deals with the identification of client problems?
Assessment
Diagnosis
Implementation
Planning
63
Which of the following scenarios is a violation of HIPAA policy?
Reporting workers' compensation data to a pt's employer
Faxing a pt's demographic info. to a pharmacy
Discussing pt diagnosis in a facility hallway
Including pt name when reporting communicable disease to the health dept.
64
Why is EBP important for nurses? Select all that apply
To improve patient outcomes
To lower the cost of healthcare
To increase professional satisfaction
To reduce malpractice claims
65
A patient is complaining of severe 10/10 pain. Which physiological response in the patient does the nurse expect?
bradycardia
hypoglycemia
hypertension
bradypnea
66
Which hospital-acquired infections are included in the HACRP? Select All that Apply
vancomycin-resistant enterococcus bacteremia
urinary catheters
AV fistulas
clostridium difficile infection
central lines
67
An RN is reviewing laboratory results on his patients. Which of the following results does he report to the MD?
Mg 1.0 mEq/L
Ca 9.8 mg/dL
Na 140 mEq/L
K+ 4.0 mEq/L
68
What is the most important reason for using a framework such as PICOT to formulate clinical questions?
It ensures the right comparison is included within the question
increases chance that best evidence will be identified quickly/efficiently
It helps identify the patient population
It guarantees that all relevant evidence will be identified
69
An RN is interviewing a patient who just lost their house in a fire. What is the priority need according to Maslow?
Self-actualization
Physiological
Safety
Self-esteem
70
What is the largest fluid compartment in the body?
Interstitial fluid
Transcellular fluid
Plasma
Intracellular fluid
71
RN suspects fluid volume excess in a CHF pt. What assessment finding caused the RN's suspicion?
hypotension
new persistent nonproductive cough
flat neck veins
syncope
72
In a patient with fluid volume deficit, increased production of aldosterone & ADH causes a decrease in what parameter?
body temperature
serum sodium
blood pressure
urine output
73
An RN observes a PCT discussing a patient’s condition in a crowded elevator. What ethical principle is being violated?
Veracity
Confidentiality
Autonomy
Nonmaleficence
74
What is a violation of EMTALA?
Billing a patient for emergency medical services
Using outdated medical equipment in a hospital
Refusing to treat a patient in an emergency situation
Failing to provide medical records to a patient
75
What signs are indicative of fluid volume deficit? Select All that Apply
Shortness of breath
Flat neck veins
Skin tenting
Thready pulse
76
What are some factors that may cause health disparities? Select all that apply
Household type and population density
Race and ethnicity
Language
Demographics
77
Which of the following statements made by a newly licensed RN indicates understanding of delegation?
"I am going to ask the LPN to start discharge education with this patient."
"I cannot delegate PO medication administration to an LPN."
"I am responsible for ensuring a delegated task is completed."
"I cannot delegate ADLs to UAPs."
78
What is the primary purpose of electronic health records (EHRs)?
To improve coordination of care and reduce errors
To allow unlimited access to patient information
To limit patient access to their medical records
To replace nurse documentation
79
Which step of the nursing process involves identifying the patient's health problems?
Implementation
Planning
Diagnosis
Assessment
80
Stage 4 Pressure Injury:
Full thickness tissue damage without bone/tendon exposed
Full thickness tissue loss. May be fully covered with slough
Full thickness tissue loss with bone/tendon/muscle exposed.
Full thickness tissue loss. May be fully covered with eschar
81
Which route has the fastest absorption?
intramuscular
oral
topical
intravenous
82
Which of the following is an intervention for hyperkalemia?
IV potassium
Perform ECG
Fluid restriction
IV magnesium
83
Which factors contribute to pressure injury development in immobile clients? (Select all that apply)
Incontinence
Decreased mobility
Frequent repositioning
High-protein diet
Poor nutritional status
84
The nurse has four patients to assess during a shift. Which patient is the priority?
A postoperative patient who has a BPof 88/50 and reports dizziness.
A patient with a history of heart failure with clear lung sounds
A diabetic patient with a blood glucose of 250 requesting insulin
A patient with a COPD who is stable on 2L of oxygen via nasal cannula.
85
What does the "S" in SMART Goals Represent?
Specific
Snapchatable
Short
Simple
86
What is health literacy?
The ability to make healthy lifestyle choices
The ability to perform physical activities
The ability to understand and use health information
The ability to communicate effectively with healthcare professionals
87
What is the largest fluid compartment in the body?
Interstitial fluid
Plasma
Transcellular fluid
Intracellular fluid
88
Which step of the nursing process involves creating a plan of care for the patient?
Diagnosis
Planning
Assessment
Implementation
89
A nurse accesses a coworker’s medical record without permission. What violation has occurred?
Violation of EMTALA
Violation of HIPAA
Breach of autonomy
Defamation
90
Which fluid compartment is found within the cells?
Intracellular fluid
Plasma
Interstitial fluid
Extracellular fluid
91
The RAAS system alters blood in response to?
Hyperkalemia
Decrease perfusion of the kidneys
Hypophosphotemia
Hypoglycemia
92
Characteristics of a Stage 3 pressure injury include: (Select all that apply.)
Rolled wound edges
Visible adipose tissue
Bone exposure
Slough
Eschar
93
Which of the following is a non-modifiable risk factor for hypertension?
obesity
sedentary lifestyle
high salt intake
advancing age
94
A pt receiving IV fluids at 150 mL/hr develops crackles and dyspnea. What should be the nurse's first action?
Lay the client flat
Encourage the client to turn, cough, & deep breathe
Administer oxygen via nasal cannula at 2L
Stop the infusion and notify MD
95
A nurse is assigned four patients. Which patient should the nurse assess first?
pt with diabetes requesting help with their insulin injection
pt with BP of 180/100 who reports a mild headache
pt with sudden onset of chest pain and shortness of breath
pt who has been discharged and is demanding their paperwork ASAP
96
Which of the following is an example of nontherapeutic communication?
"Tell me how you’re feeling."
"What concerns do you have?"
"I understand this is difficult for you."
"You shouldn't worry."
97
Which type of solution has the same concentration of solutes as the cells in the body?
Hypertonic solution
Hypotonic solution
None of the above
Isotonic solution
98
A client has been prescribed an opioid for pain. Which side effect should the nurse monitor for?
bradycardia
hypertension
polyuria
respiratory depression
99
In caring for a patient with fluid deficit, which prescribed IV solution is most effective in expanding plasma volume?
Albumin
0.45 % Normal saline
Dextrose 10%
0.9 % Normal saline
100
Which urine output value indicates the development of fluid volume deficit?
60 mL/hr
80 mL/hr
20 mL/hr
40 mL/hr
101
How does acidosis affect potassium levels?
Increases potassium
Decreases potassium
Fluctuates potassium
No effect
102
Which type of IV fluid is most commonly used to replace fluid losses and maintain hydration?
0.9% Sodium chloride
Lactated Ringer's solution
Potassium chloride
Dextrose 5% in water
103
A nurse is explaining medication half-life to a student nurse. Which description is correct?
"The time required for the serum drug concentration to be reduced by half."
"The amount of drug needed to reach peak effect."
"The duration of the medication’s therapeutic effect."
"The time it takes for the medication to be eliminated from the body."
104
Which level of prevention focuses on early detection and treatment of disease?
Secondary prevention
Primary prevention
Quaternary prevention
Tertiary prevention
105
What is the main purpose of the Hospital-Acquired Condition Reduction Program (HACRP)?
To reduce patient length of stay
To ensure all hospitals follow the same infection control policies
To financially penalize hospitals for preventable infections
To prevent all infections in hospital settings
106
Tissue Integrity
Pressure injury stage 3
Unstageable pressure injury
Pressure injury stage 4
Deep tissue injury
107
Which body fluid is found in the blood vessels?
Plasma
Intracellular fluid
Extracellular fluid
Interstitial fluid
108
Which team member coordinates discharge planning?
physician
case manager
pharmacist
occupational therapist
109
What is the role of each state's board of nursing?
Promotes excellence in nursing education
Regulate and monitors laws set by the Nurse Practice Act
Determines competencies for nurses to achieve before licensure
Establishes a protocol for care for a specific health problem
110
EMTALA mandates the following must be performed on all patients arriving in the ED
Urine Drug Screen
Full Assessment of Needs
Medical Screening Exam
Collection of Insurance Info
111
What is the relationship between calcium and phosphorus?
Direct relationship
No relationship
Fluctuating relationship
Inverse relationship
112
According to the Maslow hierarchy of needs, which of the following is the highest level of needs?
Self-esteem
Love and belonging
Safety and security
Self-actualization
113
The "R" in SMART goals stands for...
Ridiculous.
Revolution.
Realistic.
Ready.
114
The primary function of aldosterone is the protection of sodium and fluid balance by what mechanism?
suppressing the adrenal cortex
increasing sodium reabsorption from the renal tubules
increasing fluid excretion
constricting the afferent arteriole
115
What is the normal pH range of arterial blood?
5.62-6.87
8.21-8.98
6.98-7.79
7.35-7.45
116
A nurse is screening clients' BP at a clinic. At what level of preventative care is the nurse engaging?
Tertiary
Quaternary
Primary
Secondary
117
The primary function of the RAAS is:
Synthesis of Vitamin D
Increase water and Na reabsorption
Activation of Cortisol
Vasodilation
118
How does acidosis affect potassium levels?
Decreases potassium
Fluctuates potassium
No effect
Increases potassium
119
A pro athlete has a resting heart rate of 52 bpm. Which of the following clinical manifestations does the nurse expect?
dizziness
headache
none
blurred vision
120
Which of the following is a potential cause of fluid volume deficit?
End-stage renal disease
Severe burns over 50% of the body
Excessive use of hypotonic solutions
Congestive Heart Failure
121
Stage 1 pressure injury is characterized by:
Non-blanchable erythema of intact skin
Visible adipose tissue
Full-thickness skin loss
Partial-thickness skin loss
122
How do the kidneys respond to elevated levels of metabolic acid in the blood?
The kidneys secrete less bicarbonate
The kidneys secrete more carbonic acid
The kidneys secrete less carbonic acid
The kidneys excrete more bicarbonate
123
Which nutrient is essential for calcium absorption in osteoporosis management?
Magnesium
Potassium
Phosphorus
Vitamin D
124
Which best describes a deep tissue pressure injury?
Pink moist wound bed
Blood-filled blister or maroon discoloration
Bone exposure
Full-thickness tissue loss with visible adipose
125
A pt with diabetes mellitus attends a program to learn to properly manage his diet. What level of prevention is this?
Secondary
Quaternary
Primary
Tertiary
126
Which lab result would you expect in a patient with fluid volume deficit?
Na 130 mEq/L
Hgb 14.2 g/dL
BUN 19 mg/dL
Hct 55%
127
RN is planning discharge for a client with an Rx for daily dressing changes. Which referral should the RN anticipate?
Assisted living
Long-term care
Hospice care
Home care
128
Stage 3 Pressure Injury:
Partial thickness loss of dermis. May have slough, minimal.
Partial thickness skin loss. May be shallow or open wound
Full thickness tissue loss. Some slough, but no bone/tendon
Full thickness tissue loss. Bone/tendon may be exposed
129
What is the generic name of this medication?
Motrin
Ibuprofen
130
Which patient should the nurse prioritize?
A patient requesting their daily scheduled dressing change for a wound.
A patient with a low-grade fever and mild productive cough for two days.
A patient reporting severe abdominal pain after falling earlier today.
A patient who reports nausea after receiving chemotherapy this morning.
131
Which patient is at highest risk for a pressure injury?
Elderly patient with impaired mobility and poor nutrition
Young adult with a fracture in the arm
Middle-aged adult with seasonal allergies
School-aged child with a rash
132
RN is caring for a client receiving diuretics for FVE; Which finding indicates treatment is effective?
decrease in body weight
increase in blood pressure
decrease in urine output
increase in respiratory rate
133
What does EMTALA stand for?
Emergency Medical Training and Legal Assistance
Emergency Medical Transportation and Liability Act
Emergency Medical Treatment and Labor Act
Emergency Management and Technical Assistance
134
An RN is admitting a client who does not speak English. The client's wife is fluent in English. What action is correct?
Obtain a translator to assist with interpretation during admission
Omit assessments on the admission that require communication with client
Ask the client's wife to assist with interpretation during the admission
Complete the admission assessment and document the language barrier
135
Which of the following patients is at the highest risk for medication toxicity?
A 55-year-old with controlled hypertension
A 78-year-old with renal impairment
A 25-year-old with no medical history
A 40-year-old with seasonal allergies
136
RN is discharge planning for a pt who will need to be on supplemental oxygen at night. Who should be consulted?
physical therapist
occupational therapist
speech pathologist
respiratory therapist
137
A nurse assesses a patient c/o vomiting and diarrhea. What info is most important for the nurse to obtain?
what medications the patient is taking
who has been exposed to the patient
when the patient last ate or drank
how long the patient has had these symptoms
138
In a stage 2 pressure injury, you would expect:
Full-thickness skin loss
Partial-thickness skin loss involving dermis
Presence of rolled wound edges
Exposure of fascia
139
Which of the following is a hypotonic solution?
3% Sodium chloride
Lactated Ringers
0.45% Sodium chloride
D5W
140
Which documentation format organizes data based on the nursing process?
PIE
Narrative
SOAP
Charting by exception
141
Compared with an adult, an infant has which amount of fluid per total body weight?
Double the fluid per total body weight
Less fluid per total body weight
Equal amount of fluid per total body weight
More fluid per total body weight
142
Which task can an RN delegate to a LPN?
Teaching a client about a new diagnosis
Administering IV push medication
Administering oral medications
Developing a care plan
143
Order is digoxin 0.25 mg PO daily. Available is digoxin 0.125 mg tablets. How many tablets should the RN administer?
4 tabs
1 tab
0.5 tab
2 tabs
144
Select the abnormal assessment findings
RR 22
BP 110/80
Temp 99.0
HR 105
145
Differentiate between normal and abnormal assessment findings
Nail beds pink, capillary refill 5 seconds
Nail beds cyanotic, capillary refill 4 seconds
Nail beds blanched, capillary refill 3 seconds
Nail beds pink, capillary refill 6 seconds
146
Which type of solution has a lower concentration of solutes compared to the cells in the body?
None of the above
Isotonic solution
Hypotonic solution
Hypertonic solution
147
When completing an incident report, which of the following actions should the nurse take?
document objective facts and actions taken
use pseudonyms to protect the client's health information
wait 24 hours to document the incident to ensure client stability
document the incident report in the client's EHR
148
Stage this pressure injury.
Unstageable
Deep tissue injury
Stage 3
Stage 4
149
Which of these professional standards should you refer to when teaching about the importance of client confidentiality?
Code of Ethics for Nurses
American Nurses Association Position Statements
Nursing Scope and Standards of Practice
Principles of Nursing Practice
150
TJC survey team arrives at the hospital for an inspection. What is the purpose of this survey?
To evaluate compliance with established standards of safety and care.
To monitor how well nurses follow hospital-specific policies.
To investigate patient complaints against specific providers.
To provide recommendations for cost reduction in the facility.
151
Stage this pressure injury.
Stage 1
Stage 4
Not pressure injury
Stage 2
152
Among other things, HIPAA is concerned with
patient compliance
patient safety
patient advocacy
protecting personal health information
153
An RN is reviewing a new prescription and notes it lacks the dosage of the medication. What is the appropriate action?
Contact the healthcare provider to clarify the prescription.
Refer to the facility’s protocol for standard dosages.
Ask the pharmacist to determine the appropriate dosage.
Administer the medication at the lowest possible dose.
154
Which of the following is a sign of fluid volume excess?
Extreme thirst
Sudden increase in weight
Increased BUN
Urine specific gravity > 1.020
155
What are risk factors for impaired tissue integrity?
old age
bed rest
malnutrition
alert and walking around
156
What are effects of the Renin-angiotensin-aldosterone (RAAS) system?
vasoconstriction and increased blood pressure
increased heart rate and pupil dilation
water retention and sodium elimination
vasodilation and decreased blood pressure
157
Compared with an adult, an infant has which amount of fluid per total body weight?
More fluid per total body weight
Less fluid per total body weight
Double the fluid per total body weight
Equal amount of fluid per total body weight
158
The nurse monitors for which clinical manifestations in the patient admitted with hyperkalemia?
Excessive energy
Hyperactive reflexes
Diarrhea
Dysrhythmias
159
Which laboratory result should the nurse associate with the development of fluid volume excess?
increased urine specific gravity
decreased hematocrit
decreased hemoglobin
increased BUN
160
The teach-back method is used to:
Test a client's knowledge
Evaluate the client’s understanding
Provide passive learning
Replace written education materials
161
The time required for a drug to reach its maximum therapeutic effect is known as:
peak
onset of action
duration of action
half-life
162
The PICOT format can be used to construct a clinical question. The acronym “PICOT” stands for which of the following?
Purpose, Implementation, Clientele, Outcome(s), Time of Study
Patient, Intervention, Comparison of Issue of Intervention, Outcome, Time
Plan, Implementation, Clinical Hypothesis, Outcome(s) Type of Interest
Population, Intervention of Interest on Issue, Outcome(s) of Interest, Type
163
What is acid excretion?
Resisting pH changes
Removal of acid from the body
Generation of acid through metabolism
Binding with hydrogen ions
164
RN is caring for a patient who has difficulty performing ADLs. Who should be consulted?
clinical nurse specialist
recreational therapist
occupational therapist
physical therapist
165
Which of the following is an expected finding in a patient in hypovolemic shock?
Flushing of skin
Pulmonary edema
Oliguria
Bradycardia
166
What does PICOT stand for?
patient, intervention, comparison, outcome and (sometimes) time
parents, intervention, comparison, outcome and (sometimes) time
patient, investing, comparison, outcome and (sometimes) time
patient, intervention, comparison, outcome and (sometimes) testing
167
A pressure injury with exposed bone would be classified as:
Stage 4
Stage 3
Deep Tissue Injury
Unstageable
168
A pt receiving a hypertonic IV solution may experience FVO secondary to fluids shifts caused by what type of pressure?
Hydrostatic pressure
Diffusion pressure
Osmotic pressure
Filtration pressure
169
The nurse knows which of the following cardiovascular changes is most commonly seen in older adults?
Increased resting heart rate
Increased elasticity of the arteries
Decreased peripheral vascular resistance
An
170
Which type of solution has the same concentration of solutes as the cells in the body?
None of the above
Isotonic solution
Hypotonic solution
Hypertonic solution
171
Who is protected under EMTALA?
Only U.S. citizens
All individuals seeking emergency medical treatment
Healthcare providers and hospital staff
Children under the age of 18
172
A patient with peripheral vascular disease has increased peripheral vascular resistance. How will this affect patient?
Decrease O2 saturation
Increase RR
Increase BP
Decrease HR
173
Which of the following is an example of a secondary prevention strategy?
Educating a patient on medication adherence
Encouraging daily physical activity to prevent heart disease
Performing mammograms for early detection of breast cancer
Providing cardiac rehabilitation to a patient post-myocardial infarction
174
Which body fluid compartment is the smallest in terms of volume?
Interstitial fluid
Plasma
Extracellular fluid
Intracellular fluid
175
Which is an example of a sentinel event?
administering enteral nutrition through the intravenous line
administering a client's medication 45 minutes past the due time
documenting intake and output at the incorrect time
administering a prescribed opioid for pain control
176
For gentamicin therapy, both peak and trough levels are monitored. The optimal time to collect a peak level is:
1 hour after IM administration
At the midpoint between doses
30 minutes after IV administration
Immediately before the dose is administered
177
A nurse is obtaining an oxygen saturation on a client. Which of the following actions should the nurse take?
Place the sensor probe on the same extremity as an electronic bp cuff.
choose a finger with capillary refill <2 seconds
Relocate the sensor every 12 hours
Wait 10 sec after placing the probe before obtaining the O2 sat reading
178
RN is documenting information in an EHR. Which of the following actions jeopardizes client confidentiality?
Logging out of the computer before leaving a terminal
sharing passwords with a fellow RN participating in the client's care
Only accessing information on a need-to-know basis
using a computer terminal in a non-public area
179
According to HIPAA all of the following information can used to identify a patient:
all of the above
pt. phone number
pt. social security number
pt address
180
What is the purpose of an incident report in healthcare?
To provide a basis for employee punishment
To be included in the patient’s medical record
To assign blame for errors
To document and track events for quality improvement
181
A nurse is preparing to administer cefotaxime 1,000 mg IM to a client. How many grams (g) should the nurse administer?
100 g
1 g
0.1 g
10 g
182
Which is the principal base in the body?
Sulfuric Acid
Bicarbonate (HCO₃-)
Lactic Acid
Carbonic Acid (H₂CO₃)
183
Which tissue type is primarily focused on in tissue integrity?
Muscle
Epithelial
Neural
Connective
184
Which laboratory result should the nurse associate with the development of fluid volume excess?
decreased hemoglobin
increased urine specific gravity
increased BUN
decreased hematocrit
185
What is the purpose of HIPAA?
To regulate healthcare costs
To provide universal healthcare coverage
To protect the privacy and security of individuals' health information
To enforce medical malpractice laws
186
What is a breach of protected health information (PHI) under HIPAA?
An unauthorized acquisition, access, use, or disclosure of PHI
A loss of physical medical records
A delay in providing medical treatment
A violation of medical billing practices
187
A nurse has delegated morning vital signs to a UAP. Which action requires the nurse to intervene?
Assessing a rectal temperature on a newborn with a red thermometer
Takes BP in left arm with AV fistula in the right arm
Takes an axillary temperature on a patient who is eating breakfast
Takes a radial pulse by placing her thumb over the radial artery
188
A nurse is using the "OARS" method in motivational interviewing. What does "R" stand for?
Reflective listening
Reinforce behavior
Recommend a solution
Restate information
189
RN is administering meds to a client. Which of the following demonstrates adherence to the 10 rights of med admin?
Asking the PCT to verify the client's identity before administration
Checking the expiration date before administration
Documenting the medication before giving it to the client
Administering a medication prepared by another nurse
190
A pt reports difficulty breathing and has a RR of 30 breaths/min. What is the RN's priority action?
Place the patient sitting up straight in bed
Administer an ordered bronchodilator.
Assist the patient to lie down to rest
Provide emotional reassurance to reduce anxiety.
191
What are the potential consequences of a HIPAA breach?
Fines, penalties, and legal action
Decreased patient satisfaction
Loss of medical license
Increased healthcare costs
192
What is the primary cause of respiratory alkalosis?
The kidneys excrete too much metabolic acid
Hyperventilation
Hypoventilation
The kidneys excrete too little metabolic acid
193
RN is teaching a client about a new medication. Which action should the nurse take during education?
Use active listening during the teaching session
Provide reading material at a 9th-grade level
End the teaching session with the most important information
Ask the client closed-ended questions
194
Which teaching methods requires the client to explain the information being covered in their own words?
Teach-back
Lecture
Role-play
Question-and-answer
195
A nurse is checking orthostatic blood pressures. Which BP does she take first?
prone
sitting
standing
supine
196
A client s/p stroke has difficulty feeding himself with adaptive devices. The nurse should initiate a referral with who?
registered dietician
social worker
occupational therapist
physical therapist
197
What does the "S" stand for in SBAR communication?
Subject
Standard
Safety
Situation
198
How do the lungs respond to an elevated pH?
Increased rate and depth of respirations
Decreased rate and depth of respirations
Decreased lung compliance
Increased lung compliance
199
Based on HIPAA guidelines, when leaving a workstation an MA should take which safeguard?
Lock the computer.
Exit the program.
Turn off the computer monitor.
Minimize open programs.

NUR 112 Final Exam Review Part I Flashcards | StudBud