Exam 2 Review Fall 24

Question 1

An RN is performing community safety education, who does the nurse identify at highest risk for choking and suffocation?

Accepted Answer

An infant sleeping in the prone position

Question 2

A school nurse is teaching parents home and fire safety. What information is included in teaching? Select all.....

Accepted Answer

Most people who die in fires die of smoke inhalation, Smoke alarms have caused a decline in fire related injury and death, Fires are more likely to occur in homes without electricity or gas

Question 3

A nurse is justified in independently identifying and documenting which is diagnosis is r/t impaired elimination?

Accepted Answer

Bowel Incontinence

Question 4

A pt tells the RN, "I've never seen that blbue pill before". What is the nurses most appropriate action?

Accepted Answer

Verify the order and double check the drug label

Question 5

An RN notes a pt has dyspnea, tachypnea, tachycardia and pallor with circumoral cyanosis. What action will RN do next?

Accepted Answer

Assess pulse oximetry

Question 6

An easily exhausted pt is scheduled for multiple test; the RN fears it will tire pt. What is appropriate RN action...

Accepted Answer

Coordinate with the other disciplines to schedule tests w/ rest periods

Question 7

Which general teaching will the nurse include with drug education? (select all that apply)

Accepted Answer

Do not share or take medications from someone else, Be sure that you know the name and dose of your medication

Question 8

Which statement reflects the teach back process of patient education?

Accepted Answer

Using your own words, tell me about the drug we just talked about

Question 9

Select all the correct actions the nurse performs administering a subcutaneous injection

Accepted Answer

Removing the needle cap by pulling it straight off, Withdrawing the needle quickly at the same angle at which it was inserted, Injecting the needle quickly at a 45 - 90 degree angle

Question 10

RN administer antihypertensive med as ordered. Which assessment indicates expected pt outcome?

Accepted Answer

Client is normotensive

Question 11

What is the most appropriate example of the assessment phase of the nursing process?

Accepted Answer

Palpating a mass in the right lower quad. of the abd.

Question 12

A LTC facility is conducting safety committee meeting focusing on protecting pts from injury. What is the priority?

Accepted Answer

Maintaining clutter free rooms and hallways

Question 13

What is the best way for a nurse to obtain a full set of data when performing an assessment of a client?

Accepted Answer

Complete a systematic nursing history and nursing examination

Question 14

A pt reports for f/u diabetic care and reports he has done glucose checks regularly as advised. Select best RN response

Accepted Answer

It seems like you are having difficulty with your care regimen

Question 15

A nurse administers pain med. to a post-operative pt. Which nursing intervention will assist with unrelieved pain?

Accepted Answer

Repositioning the client

Question 16

A RN administers a med to the wrong pt. What are the appropriate nursing actions required (select all that apply)

Accepted Answer

Report the error to the healthcare provider, Monitor the pt for adverse reactions, Document the error in a critical incident or occurrence report

Question 17

Pharmacokinetics refers to.... (select all that apply)

Accepted Answer

Absorption of medication, Distribution of medication, Metabolism, Excretion

Question 18

A pt shares with the RN that he smokes in bed at night. What health problem is a priority for this patient?

Accepted Answer

Knowledge deficiency: etiology, risk for burn and suffocation in house fire

Question 19

A RN formulates a care plan for pt. admitted with acute abd. pain. Which nursing diagnosis is the priority for pt?

Accepted Answer

Altered comfort

Question 20

The nurse receives a written medication order MS. Which nursing action is appropriate?

Accepted Answer

Ask the provider to rewrite the order

Question 21

RN is teaching a teen with asthma hot to use a metered-dose inhaler. Which teaching point will the RN include?

Accepted Answer

Be sure to shake the canister before using it

Question 22

A fire alarm sounds in the hospital indicating that is your unit. What is the priority for nurses on your unit?

Accepted Answer

Removing paitents from the room or vicinity

Question 23

Select all the examples of subjective data? (select all that apply)

Accepted Answer

A client reports being cold and requests an extra blanket, A client feels nauseated after eating breakfast, Patient describes pain as an 8 on the pain assessment scale

Question 24

A RN is administering a hepatitis B vaccination to adult patient. What site will the nurse select for this injection?

Accepted Answer

Deltoid muscle

Question 25

Which is an independent (nurse-initiated) action?

Accepted Answer

Helping to allay a pt's fears about surgery

Question 26

A pt's resp, status is deteriorating and VS are taken every shift. Who is responsible for increasing the frequency?

Accepted Answer

The nurse

Question 27

Select all findings of resp. assessment that are normal...

Accepted Answer

Bronchial, vesicular and bronchovesicular breath sounds, Anteroposterior diameter of the chest is less than the transverse diameter, Slightly contoured chest with no sternal depression

Question 28

The MD order is for azithromycin 500 mg q 6 hrs. How many capsules does RN administer if available in 250 mg capsules

Accepted Answer

2 capsules

Question 29

RN evaluate pt. prior to d/c from hospital. Which action is the MOST important act of evaluation by RN

Accepted Answer

The nurse evaluates the client's goal/outcome achievement

Question 30

An RN auscultates an asthmatic pt's lungs. Which lung sound does the RN anticipate during an asthmatic exacerbation?

Accepted Answer

Wheezes

Question 31

An experienced RN is orienting a new RN to the unit. Which activity demonstrates the nurse is an effective caregiver?

Accepted Answer

The nurse uses open-ended questions when working with a crying pt.

Question 32

Which is a psychomotor client goal?

Accepted Answer

By 8/18/24, the pt will demonstrate improved motion (raising arm overhead)

Question 33

A black box warning is the Food and Drug Administration's strongest warning about drugs

Accepted Answer

True

Question 34

During respiratory assessment the RN notes pt. with decreased resp. expansion. What action should the RN take next?

Accepted Answer

Place the pt. in a high Fowler's position

Question 35

Which is an example of a nurse-initiated intervention?

Accepted Answer

Teach pt. to splint an abdominal incision when coughing and deep breathing

Question 36

During which step of the nursing process does the nurse determine whether outcomes of care are met?

Accepted Answer

evaluation

Question 37

A pt. returns after major abdominal surgery to your unit. The nursing priority is to:

Accepted Answer

Complete the post-operative assessment

Question 38

A nurse administering a subq injection of insulin to a pt. After agreeing on the injection site, which action is next?

Accepted Answer

Identify the appropriate landmarks for the site chosen

Question 39

There are 2 pts with the name John Smith on the unit. The RN must take which action when administering meds?

Accepted Answer

Ensure the medications are appropriate to the patient's condition, Check each patient's armband for the patient's name, Ask each patient their date of birth

Question 40

A pt. uses portable O2 at home and tells RN "I still like to smoke every once in awhile" What is the best RN response?

Accepted Answer

You should never smoke when oxygen is in use

Question 41

The nurse identifies which types of data when performing an assessment?

Accepted Answer

Objective, Subjective

Question 42

The nursing process is (select all that apply)

Accepted Answer

Diagnosing: nurse problems that id patient's health actual/potential issues, Implementating: executing the nursing plan of care and interventions, Assessing; gathering cues, Evaluating: Assessing the plan of action measures

Question 43

A RN enters patient room to assess VS and pt asks RN to do hand hygiene. What is the nurse most appropriate response?

Accepted Answer

Praise the pt. for taking an active role in client's care

Question 44

A new RN and preceptor are administering and intradermal tuberculin test. Which action requires correction?

Accepted Answer

Placing pressure on the site when a wheal or blister appears

Question 45

What assessment findings are normal for cardiopulmonary functioning and oxygenation based on developmental variations.

Accepted Answer

An infant's chest is small, airways are short, causing potential aspiration, Elderly's poor resp. and abd. muscles strength = diaphragm to move less, Infants resp. rates are rapid until the alveoli increase in number and size, Older adults have increase risk for pneumonia and infections d/t aging

Question 46

Which effect is considered an adverse effect of a medication? (select all that apply)

Accepted Answer

Angioedema, Rapid heart rate, Chest pain

Question 47

A nurse unit is performing a safety huggle to id pts at risk for falling. Select all pts at risk needing follow up...

Accepted Answer

Transferred from long-term care, Presence of postural hypotension, History of falling

Question 48

The RN is using a standardized plan of care for a pt. Which action would be most important for the nurse to do?

Accepted Answer

Expect to modify the plan significantly

Question 49

Which process will the nurse use to provide information to other members of the health care team?

Accepted Answer

SBAR

Question 50

The RN auscultate a pt finding soft, high-pitch popping breath sounds on inspiration. What is this breath sound called?

Accepted Answer

Crackles

Question 51

RN can't read the dose as it could be 0.25, 0.125 or 125 mgs. as the decimal may be a 1? The best RN safety action is...

Accepted Answer

Contact the healthcare provider to clarify the illegible order

Question 52

Select the "rights" of medication administration (select all that apply)

Accepted Answer

Right patient, Right dose, Right route, Right drug, Right time

Question 53

A RN documents an intervention for a one person assist of moving client to chair; the nursing intervention represents?

Accepted Answer

Psychomotor

Exam 2 Review Fall 24

Questions 53

Exam 2 Review Fall 24

Questions 53