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Skills II Midterm Review Modules 1-7 Flashcards | StudBud
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Skills II Midterm Review Modules 1-7
Skills II Midterm Review Modules 1-7
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1
A patient reports pain as 8/10 on the pain scale. Which of the following changes in vital signs would you expect?
No change in vital signs.
Decreased respiratory rate and normal blood pressure.
Decreased heart rate and blood pressure.
Increased heart rate, blood pressure, and respiratory rate.
2
Which practice is a violation of patient confidentiality?
Logging out after charting
Documenting in a private location
Sharing your password with a colleague
Using approved software
3
The patient has chronic heart failure and a new admission for acute chest pain. Which principle should guide you?
Chronic before acute.
Potential before actual.
Acute before chronic.
Localized before systemic.
4
A higher score on the Morse Fall Scale indicates?
Improved mental status
Greater risk of falling
No change in fall risk
Lower risk of falling
5
If a weak or absent dorsalis pedis pulse is palpated, what should you do next?
Ignore the finding if the patient has no pain.
Attempt to locate the posterior tibial pulse for comparison.
Perform capillary refill testing on the upper extremities.
Immediately apply a cast to immobilize the limb.
6
Which of the following arms should
NOT
be used for blood pressure measurement?
All options apply.
An arm with bruising.
An arm on the same side as a mastectomy.
An arm with an IV.
7
What does the term “accommodation” in the PERRLA test refer to?
The equality of pupil size.
The pupils’ response to a distant-to-near object shift.
The shape of the pupils.
The pupils’ response to light.
8
If a patient is NPO (nothing by mouth), how should intake be monitored?
Exclude intake completely since the patient is NPO.
Include estimated oral intake based on previous days.
Only monitor output, as intake is irrelevant.
Record only tube feedings or IV fluids.
9
Which technique is used to assess for pitting edema?
Palpate the skin for warmth and redness.
Apply firm pressure with both hands and observe for fluid leakage.
Lightly stroke the affected area and assess for swelling.
Press affected area with a finger for 5 seconds, observe for an indentation
10
Which of the following is NOT a risk factor for pressure injuries?
Immobility
Vascular insufficiency
Friction and shear
High protein diet
11
What does cyanosis indicate in a patient’s extremities?
Increased oxygenation in the blood
Decreased peripheral blood flow and oxygenation
Excess fluid retention in the extremities
Low levels of circulating hemoglobin
12
What is a normal finding for a capillary refill test?
Color takes 3-5 seconds to return after pressure is released.
Color returns within 1-2 seconds after releasing pressure.
Capillary refill is normal only if the skin is warm and moist.
The nailbed remains blanched after releasing pressure.
13
What is the primary purpose of using an incentive spirometer?
To monitor SpO2 levels continuously
To promote deep breathing and prevent atelectasis
To assist with controlled exhalation
To deliver supplemental oxygen effectively
14
What is the primary cause of pressure injuries?
Bacterial infection
Exposure to high temperatures
Prolonged pressure reducing blood flow
Allergic reaction to moisture
15
Why should pulse oximetry not be used as the sole assessment of a patient’s respiratory status?
It requires blood samples for accurate readings.
It cannot be used with oxygen delivery devices.
It only measures oxygen saturation, not ventilation or perfusion.
It is unreliable in detecting low oxygen levels.
16
Why is it essential to provide patient education before collecting a sputum sample?
To guarantee the specimen is collected from deep in the lungs
To prevent the need for multiple collections
To ensure the patient knows how to avoid swallowing mucus
To reduce contamination from saliva
17
A patient has a blood pressure reading of 88/56 mmHg. This is classified as:
Hypertension.
Normal blood pressure.
Hypotension.
Orthostatic hypotension.
18
You are performing a quick ABCDE priority assessment. Which finding would require immediate intervention?
IV tubing is kinked but no issues with fluid flow.
Patient is lethargic but able to answer questions.
Respiratory rate of 10 breaths per minute and shallow.
Pulse is regular and 88 beats per minute.
19
Auscultation is most effectively used to assess which body systems?
Cardiovascular, respiratory, and gastrointestinal.
Reproductive and endocrine.
Neurological and musculoskeletal.
Integumentary and lymphatic.
20
How should the Morse Fall Scale be used in patient care?
To prevent falls through targeted interventions
To track medication compliance
To determine a patient's hydration status
To calculate nutritional requirements
21
A wound covered with eschar & slough, making the tissue beneath unassessable, is this type of pressure injury:
Unstageable
Healing Stage IV
Stage 3
Deep tissue injury
22
What is the primary purpose of end-of-shift reporting?
To evaluate staff performance
To provide continuity of care
To prepare for the next patient admission
To review hospital policies
23
Which of the following is an indicator of airway compromise?
Respiratory rate of 18 breaths per minute.
Bilateral lung sounds.
Patient able to speak in full sentences.
Stridor heard upon inspiration.
24
When assessing pupils for the PERRLA test, which of the following abnormalities could indicate a neurological issue?
Irregularly shaped pupils.
Pupils that do not constrict in response to light.
All options apply.
Pupils unequal in size.
25
How does a focused assessment differ from a head-to-toe assessment?
A head-to-toe assessment is only performed in emergency situations.
A focused assessment always includes a full general survey.
Focused targets a specific system, a head-to-toe is comprehensive
A focused assessment is performed only on healthy patients.
26
Which sign suggests worsening respiratory status in a patient receiving oxygen therapy?
SpO2 consistently above 95%
Respiratory rate of 14 breaths per minute
Cyanosis and increased shortness of breath
Regular breathing pattern with nasal flaring
27
Which criteria is NOT part of the Morse Fall Scale?
Body mass index
History of falling
Mental status
Ambulatory aid
28
What is the most important characteristic to assess during a peripheral vascular pulse examination?
Location of the strongest pulse point
Temperature and moisture of the skin
Rate and rhythm only
Strength and symmetry bilaterally
29
Why is hair loss on the extremities clinically significant in a vascular assessment?
It is an early sign of deep vein thrombosis (DVT).
It indicates a normal aging process.
It is primarily a cosmetic concern.
It may suggest poor arterial blood flow to the area.
30
A blood pressure reading should be documented:
As an even number fraction with the patient’s position and arm used.
Only when systolic pressure is below 100 mmHg.
In whole numbers with no mention of patient position.
As an odd number fraction with no additional details.
31
A patient complains of right-sided abdominal pain. What is the nurse's priority during a focused assessment?
Completing a head-to-toe assessment first.
Checking the patient’s vital signs only.
Performing a general survey to assess the patient’s posture.
Inspecting the entire abdomen and palpating the painful area last.
32
A patient using a nasal cannula complains of dryness in the nasal passages. What is the most appropriate action?
Remove the nasal cannula for a few hours
Add humidification to the system
Reduce the oxygen flow rate to below 1 L/min
Increase the oxygen flow rate
33
A nurse has four patients. Who should the nurse assess first?
A post-operative patient requesting pain medication.
A patient who reports shortness of breath and an oxygen saturation of 86%.
A patient complaining of severe abdominal pain with a low-grade fever.
A patient receiving IV fluids with no reported issues.
34
What is the primary goal of monitoring a patient’s calorie count?
To track weight changes
To support healing and nutritional needs
To prevent falls
To assess fluid balance
35
What is the primary purpose of conducting a general survey?
To focus exclusively on the physical appearance of the patient.
To measure vital signs before beginning a head-to-toe assessment.
To establish a detailed diagnosis for the patient.
To provide an overall impression of the patient’s health state.
36
Which type of assessment is most appropriate during a sudden change in a patient's condition?
Comprehensive assessment
Focused assessment
Priority assessment
Shift assessment
37
During a physical assessment, palpation is used primarily to assess:
Skin temperature and masses.
Heart and lung sounds.
Visual symmetry of body parts.
Patient behavior and mood.
38
Significant discrepancies between intake and output should be:
Ignored if the patient looks fine.
Reported and documented as they may indicate a complication.
Reviewed only during the next 24-hour assessment.
Adjusted manually to match expected values.
39
What is the primary purpose of the nursing process?
To develop individualized nursing care plans.
To diagnose diseases.
To treat medical conditions directly.
To delegate patient care to other healthcare professionals.
40
Where should shift reports ideally be conducted?
In the patient’s room
In the break room
At the nurse’s station
In a private, interruption-free area
41
When conducting a shift assessment, which of the following should the nurse include?
Focus only on the cardiovascular system
Reassess only what was previously reported
A brief summary of patient priorities only
A full head-to-toe assessment
42
Which of the following is an accurate description of a Stage 2 pressure injury?
Partial-thickness skin erosion resembling an open blister
Intact, red skin that does not blanch
Full-thickness loss exposing muscle or bone
Deep maroon discoloration with an unidentifiable wound bed
43
Why is it essential to balance intake and output?
To assess dietary calorie count
To monitor wound healing
To improve patient appetite
To prevent dehydration or fluid overload
44
What is the most effective method for preventing pressure injuries in immobile patients?
Repositioning the patient every 2 hours
Using assistive devices without assessing skin integrity
Applying medicated creams daily
Providing high-protein snacks only
45
A nurse is performing a head-to-toe assessment. Which of the following is subjective data that may be collected?
The patient has clear lung sounds upon auscultation.
The patient’s respiratory rate is 18 breaths per minute.
The patient’s skin appears red and swollen.
The patient reports, “I have pain in my lower back.”
46
Which patient statement indicates understanding of incentive spirometry instructions?
"I only need to use the spirometer once a day."
"The spirometer measures my oxygen levels directly."
"I should hold my breath for a few seconds after inhaling deeply."
"I need to blow out hard to raise the ball in the spirometer."
47
While performing the "D" portion of the ABCDE assessment, what should the nurse focus on?
Inspecting and managing any equipment attached to the patient.
Checking the patient’s respiratory effort and oxygen saturation.
Assessing circulation status and capillary refill.
Evaluating body systems related to the patient’s admitting diagnosis.
48
When using the 2-step method to measure blood pressure, what is the next step after palpating the radial pulse?
Immediately place stethoscope on the brachial artery and deflate the cuff.
Locate the brachial artery and inflate the cuff to 200 mmHg.
Inflate the cuff to 30 mmHg above the systolic reading obtained.
Inflate cuff until the radial pulse is not palpable, + 30mmHg to the value.
49
Which finding would likely accompany cyanosis due to poor circulation?
Pale or mottled skin with weak peripheral pulses
Increased hair distribution on the extremities
Red, flushed skin and strong bounding pulses
Absence of edema with normal capillary refill
50
What is the primary reason for performing a focused assessment?
To document baseline information for a new patient.
To quickly address a specific problem or change in the patient's condition.
To evaluate the effectiveness of a patient's medication regimen.
To gather comprehensive information about all body systems.
