What occurs during the last phase of the nursing process?

the nurse compares desired outcome to actual outcome

What is a potential complication of immobility related to the gastrointestinal system?

Constipation and bowel impaction

Cultural competence is the process of:

Acquiring specific knowledge, skills, and attitudes.

What is the purpose of a sterile dressing in wound care?

To protect the wound from contamination

What are the advantages of administering medication using the Z-track method? (SATA)

Prevents the drug from irritating sensitive tissue., Prevents leakage of the medication into subcutaneous tissue.

The nurse is tasked with giving a client 4ml of an antibiotic. Where and how should the injection be given?

2mL in the left ventrogluteal, 2mL in the right ventrogluteal

A patient with COPD. Which intervention for airway management should you delegate to a nursing assistant?

Assisting the patient to sit up on the side of the bed.

When taking a radial pulse there are interruptions in rhythm. what is the next action of nurse

measure a 60 second apical pulse

For which procedure does the nurse use surgical aspesis (select all that apply)

inserting an indwelling catheter, inserting an IV line

hat is the purpose of a post-void residual (PVR) measurement?

To assess the volume of urine left in the bladder after voiding

A normal physiological response to a perceived threat

Nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do?

Return after a few minutes and do not leave until patient takes meds

The nurse is preparing to administer an immunization to a toddler. Which action by the nurse is appropriate?

Grasp the body of the muscle during injection.

A patient with COPD. Which intervention for airway management should you delegate to a nursing assistant?

Assisting the patient to sit up on the side of the bed.

Which priority assessment(s) will the nurse perform on a patient receiving continuous TPN? (SATA)

Monitor glucose levels, Monitor daily weights, Monitor output

A nurse is preparing to administer an intradermal injection to an adult patient. Which action should be taken?

Insert needle at 5-15 degree angle 3 fingers below the antecubital space.

After giving meds in ventrogluteal muscle, the nurse aspirates & notices blood in syringe. What action should be taken?

Withdraw needle, dispose of meds & syringe, prepare new dose of meds

What is the primary purpose of wound irrigation?

To remove debris and bacteria from the wound

organs go outside of the body through surgical incision

Which behavior indicates a child has reached Piaget's formal operations stage of cognitive dev

utilizes deductive reasoning to examine alternatives

What is the nurse's responsibility after administering a medication to a patient?

Document the administration promptly and accurately

A client will receive a 2mL injection of ceftriaxone. Which sites can the nurse administer this medication? (SATA)

Vastus lateralis, Ventrogluteal

What is the primary purpose of the "Five Rights" of medication administration?

To improve patient outcomesTo improve patient outcomes

Which of the following is a key aspect of the "Right Patient" when administering medications?

Confirming the patient's identity using two patient identifiers

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Fundamentals Final Review Part 1

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Questions 188

Answers

1
what respiratory rate is considered normal
12 to 20
30 to 60
24 to 30
16 to 22
2
What occurs during the last phase of the nursing process?
the nurse compares desired outcome to actual outcome
the nurse gathers data to use in planning care
the nurse prioritizes nursing interventions
the nurse selects nursing interventions
3
What is a potential complication of immobility related to the gastrointestinal system?
Rapid digestion and absorption of nutrients
Increased appetite
Constipation and bowel impaction
Decreased peristalsis
4
Cultural competence is the process of:
Influencing treatment and care of clients.
Learning about vast cultures.
Acquiring specific knowledge, skills, and attitudes.
Motivation and commitment to caring.
5
What is the purpose of a sterile dressing in wound care?
To promote scab formation
To minimize blood flow to the wound
To absorb excessive wound drainage
To protect the wound from contamination
6
A document that lists the medical treatment a person chooses to refuse if unable to make decisions is the:
Living will
Informed consent
Durable power of attorney
Advance directives
7
the most important action to provide protection against infection to each patient is
placing each patient in isolation
hand hygiene
wearing gloves
wearing a gown
8
What are the advantages of administering medication using the Z-track method? (SATA)
Reduces discomfort from the needle.
Prevents the drug from irritating sensitive tissue.
Provides faster absorption of the medication.
Prevents leakage of the medication into subcutaneous tissue.
9
The nurse is tasked with giving a client 4ml of an antibiotic. Where and how should the injection be given?
In the deltoid using a 1in 22gauge needle
2mL in the left ventrogluteal, 2mL in the right ventrogluteal
In the vistas laterals using a 1.5in 20gauge needle
1mL in the left deltoid, 3ml in the left vistas laterals
10
A patient with COPD. Which intervention for airway management should you delegate to a nursing assistant?
Auscultation of breath sounds every 4 hours.
Assisting the patient to sit up on the side of the bed.
Teaching the patient to use incentive spirometry.
Instructing the patient to cough effectively.
11
What is the preferred angle for administering a subcutaneous injection?
90 degrees
180 degrees
30 degrees
45 degrees
12
Which of the following is NOT a preventative measure for fall risk patients?
All 4 side rails up
Bed alarm
Non-skid socks
Yellow wristband
13
When taking a radial pulse there are interruptions in rhythm. what is the next action of nurse
obtain a 60 second apical radial pulse
measure a 60 second apical pulse
report the findings to a health care provider
connect the patient to a cardiac monitor
14
A pt admitted with cellulitis develops bacterial pneumonia 3 days later, this infection is
interstitial
health care associated
mycoplasmic
acute primary
15
Which element of ethical practice is associated with fairness regarding organ transplantation
justice
veracity
nonmaleficence
fidelity
16
What developmental task is a priority for young adults according to Erikson's stages of psychosocial development?
Autonomy vs. Shame and Doubt
Intimacy vs. Isolation
Trust vs. Mistrust
Initiative vs. Guilt
17
During the client’s medical records review, what condition can put the client at risk for developing hypokalemia?
Burn
Has a history of Addison’s disease
Nasogastric suction
Uric acid level of 10.2 mg/dL
18
For which procedure does the nurse use surgical aspesis (select all that apply)
inserting an indwelling catheter
performing perineal care
performing oral care
inserting an IV line
19
Which assessment finding indicates a potential problem with tissue integrity?
Strong peripheral pulses
Dry and pale mucous membranes
Warm and erythematous skin
Intact skin with normal sensation
20
hat is the purpose of a post-void residual (PVR) measurement?
To measure urinary output over a 24-hour period
To assess the volume of urine left in the bladder after voiding
To determine the pH of urine
To evaluate the color and clarity of urine
21
Which lab result indicates infection?
WBC
BNP
BUN
Sodium
22
What is stress?
A sign of emotional weakness
An abnormal mental disorder
A normal physiological response to a perceived threat
A state of complete relaxation
23
What is the potential cause of black, tarry stools?
High fiber diet
Adequate fluid intake
Dehydration
Iron supplementation
24
Nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do?
Instruct patient to take medication and leave it at bedside
Leave medication at bedside for patient and leave the room.
Wait for patient to return and leave med on bedside table.
Return after a few minutes and do not leave until patient takes meds
25
A confused client who fell out of bed because side rails were not used is an example of which type of liability?
Felony
Battery
Assault
Negligence
26
The nurse is preparing to administer an immunization to a toddler. Which action by the nurse is appropriate?
Have the patient’s knee flexed with the foot internally rotated.
Place one hand above the knee and one below the knee to find the site.
Ask the mother to hold the toddler on his side.
Grasp the body of the muscle during injection.
27
when using restraints
attach to the mattress
use along with pharmaceuticals
assess site every shift
use the least restrictive
28
A patient with COPD. Which intervention for airway management should you delegate to a nursing assistant?
Auscultation of breath sounds every 4 hours.
Instructing the patient to cough effectively.
Assisting the patient to sit up on the side of the bed.
Teaching the patient to use incentive spirometry.
29
Which priority assessment(s) will the nurse perform on a patient receiving continuous TPN? (SATA)
Monitor glucose levels
Monitor oral intake
Monitor daily gait
Monitor daily weights
Monitor output
30
Which word reflects the ability of a person to perceive another person's emotions accurately
empathy
trust
autonomy
sympathy
31
A nurse is preparing to administer an intradermal injection to an adult patient. Which action should be taken?
Inject no more than 1 mL of solution at one site.
Use a tuberculin syringe with a 1-inch 25-gauge needle.
Expect a bleb and a small amount of bleeding after injection
Insert needle at 5-15 degree angle 3 fingers below the antecubital space.
32
After giving meds in ventrogluteal muscle, the nurse aspirates & notices blood in syringe. What action should be taken?
Inject the medication slowly but smoothly
Withdraw needle, expel blood from syringe, insert needle, inject meds
Withdraw needle, change needle, insert needle, inject meds
Withdraw needle, dispose of meds & syringe, prepare new dose of meds
33
Which of the following is allowed on full liquid diet?
Oatmeal
Apple juice
Noodle soup
Pancakes
34
What is the primary purpose of wound irrigation?
To remove debris and bacteria from the wound
To minimize pain during dressing changes
To speed up the healing process
To promote scab formation
35
eviseration
nosocomial
organs go outside of the body through surgical incision
enuresis
wound stitches open up
36
The nurse listens to Mrs. Sullen’s lungs and notes a hissing sound or musical sound. The nurse documents this as:
Rhonchi
Vesicular
Gurgles
Wheezes
37
What is the term for the involuntary passage of stool?
Incontinence
Fecal impaction
Constipation
Diarrhea
38
Which administration route typically has the fastest onset of action for medications?
Subcutaneous
Intramuscular
Oral
Intravenous
39
Which is an example of secondary prevention?
Screenings
Immunizations
Education
None of the above
40
Nurse is administering cleansing enema to client with severe constipation. She will place the client in which position?
Left Sim's position.
Right Sim's position.
High Fowler's position.
Low Fowler's position.
41
A nurse is changing a dressing, which level of pt space is the nurse in
intimate
personal
social
public
42
Which behavior indicates a child has reached Piaget's formal operations stage of cognitive dev
employs logical thought to organize collected information
explore objects by placing them in the mouth
uses language to communicate with others
utilizes deductive reasoning to examine alternatives
43
When using sterile technique the student knows to hold sterile objects in which location
above waist level
anywhere as long as they are handled with sterile gloves
close to shoulder level
just below waist level
44
Order: 4 units regular insulin; 10 units NPH insulin. When finished, the syringe should contain how many units?
10
14
4
6
45
What is a common complication of using a soapsuds enema?
Dehydration
Bowel obstruction
Rapid evacuation of stool
Electrolyte imbalance
46
What is the nurse's responsibility after administering a medication to a patient?
Ask the patient to sign a consent form for each medication
Discard the medication packaging in the patient's room trash
Document the administration promptly and accurately
Share the patient's medication information with colleagues without consent
47
A client will receive a 2mL injection of ceftriaxone. Which sites can the nurse administer this medication? (SATA)
Dorsogluteal
Vastus lateralis
Anterior adipose tissue on thighs
Deltoid
Ventrogluteal
Abdomen; 2in away from umbilicus
48
What is the primary purpose of the "Five Rights" of medication administration?
To ensure cost-effectiveness
To minimize documentation
To expedite the administration process
To improve patient outcomesTo improve patient outcomes
49
Which of the following is an isometric exercise?
Weight training
Walking
Washing dishes
Running
50
The nurse listens to Mrs. Sullen’s lungs and notes a hissing sound or musical sound. The nurse documents this as:
Gurgles
Wheezes
Vesicular
Rhonchi
51
Which of the following is a key aspect of the "Right Patient" when administering medications?
Ignoring discrepancies in patient identification
Administering medications without verifying the patient's identity
Relying solely on the patient's verbal confirmation
Confirming the patient's identity using two patient identifiers
52
What is the primary purpose of the valsalva maneuver during defecation?
To enhance blood flow to the brain
To minimize strain on the cardiovascular system
To increase peristalsis in the colon
To promote relaxation of the anal sphincter
53
What is the primary nursing intervention for promoting regular bowel habits in patients?
Providing a consistent time for toileting
Encouraging a sedentary lifestyle
Administering laxatives daily
Restricting fluid intake
54
What is the recommended fluid intake per day for maintaining proper urinary function?
1500 mL
500 mL
1000 mL
2000 mL
55
Which injection site is the most appropriate when administering an IM injection to a 6 month old patient?
Dorsogluteal injection site
Vastus lateralis
Abdomen 2 inches away from the umbilicus
Deltoid muscle
56
Which of the following findings must be immediately reported to the primary healthcare provider?
Excoriation of the skin around the stoma
Beefy red and shiny stoma.
A semi-formed stool in the ostomy.
The stoma is purple in appearance.
57
Based on Maslow's hierarchy of needs which nursing diagnosis label has the highest priority
a wellness nursing diagnosis
a risk nursing diagnosis
a medical diagnosis
an actual nursing diagnosis
58
Which is an example of secondary prevention?
None of the above
Education
Screenings
Immunizations
59
A nurse is administering a parenteral medication to a patient. Which action by the nurse demonstrates proper technique?
Injecting the medication smoothly but rapidly
Using work-arounds to administer medications in a timely manner
Using strict aseptic technique
Inserting the needle into the patient’s skin smoothly and slowly
60
Which physiological change is commonly associated with prolonged immobility?
Enhanced joint flexibility
Decreased bone density
Increased muscle mass
Improved respiratory function
61
When preparing subQ injections, the nurse is careful not to touch which part of the syringe or needle? (SATA)
The needle shaft
The needle hub
The needle bevel
The syringe outer barrel
62
Trying questionable and experimental forms of therapy is a behavior that is characterized by which stage of dying?
Bargaining
Depression
Anger
Acceptance
63
Which of the following is allowed on full liquid diet?
Pancakes
Noodle soup
Oatmeal
Apple juice
64
Nurse is administering cleansing enema to client with severe constipation. She will place the client in which position?
Right Sim's position.
Left Sim's position.
Low Fowler's position.
High Fowler's position.
65
What age range is typically considered as middle adulthood in the context of nursing care?
25-34 years
35-44 years
35-64 years
55-64 years
66
What size needle is used for IM injections?
0.5-1in
2-2.5in
1-1.5 in
1.5-2in
67
What is a common health promotion focus for middle adults?
Bone density screenings
Immunizations
Falls prevention
Cognitive screenings
68
What is normal range for Potassium?
136-145
3.5-5.0
90-110
9-10.5
69
The UAP reports the patient is feeling funny. what is the nurse's first action
obtain the patient's vital signs herself
have UAP keep assessing the pt and report further symptoms
notify the healthcare provider
delegate the assistant to retake the vital signs
70
Nurse is preparing to give bed bath to a client with tuberculosis. Which should the nurse include when doing procedure?
N95 and protective eyewear
Surgical mask, gown, and protective eyewear
Surgical mask and gloves
N95, gown, and gloves
71
What is a key component of self-care for nurses to manage stress?
Minimizing breaks and leisure activities
Ignoring personal needs for the sake of patient care
Seeking professional help only in times of crisis
Regular exercise, adequate sleep, and engaging in enjoyable activities
72
What is the term for the inability to control the release of urine?
Anuria
Retention
Hematuria
Incontinence
73
What is the purpose of the "Right Time" in medication administration?
To align with the nurse's convenience
To minimize interruptions during patient care
To ensure medications are given within the prescribed timeframe
To expedite the administration process
74
a patient in isolation has signs of social deprivation the most appropriate intervention is
set specific times when the nurse will return to the room
leave the door of the negative-pressure room open slightly
allow visitors to remove masks while in the room
remind the patient that the isolation is for their benefit
75
What is a potential challenge for middle adults related to family dynamics?
Identity exploration
Parental control issues
Peer pressure
Empty nest syndrome
76
What does the acronym MAR stand for in medication administration?
Medical Assessment Report
Medication Authorization Request
Medication Adverse Reaction
Medication Administration Record
77
A nurse is preparing a plan of care for a client who is a Jehovah’s Witness. Which statement is correct?
Blood products can not be administered.
Surgery is strictly prohibited.
Giving any medication is not allowed.
Alternative medicines can be advised.
78
Which route of administration is used for delivering TPN?
Oral
Subcutaneous
Intravenous
Intramuscular
79
A nurse must give IV meds that need to be diluted in 60mL of fluid & given over 45min. Which methods can be used? (SATA)
Volume-control device
Piggyback infusion
Mini-infusion pump
IV bolus injection
80
A nurse should consider which of the following when choosing which size needle & syringe to use to give IM meds? (SATA)
The viscosity of the medication
The size and weight of the patient
Whether or not the syringe has a safety needle
The volume of medication
81
The nurse must administer a medication using the Z-track method. Which option describes the nurse’s action?
Insert needle at a 60-75 degree angle
Pull skin down to one side before inserting needle
Massage the site following the injection
Aspirate before injecting medication
82
which is being conveyed when the nurse leans forward during a patient interview?
privacy
aggression
interest
anxiety
83
A confused client who fell out of bed because side rails were not used is an example of which type of liability?
Assault
Negligence
Battery
Felony
84
Which of the following are symptoms of hypoglycemia? (SATA)
Diaphoresis
Increased voiding
clammy skin
Loss of consciousness
Increased thirst
Shakiness
85
What action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection?
Aspirate urine from the tubing port using a sterile syringe.
Use sterile gloves when obtaining urine
Open the drainage bag and pour out the urine.
Disconnect the catheter from the tubing and get urine.
86
A nurse is preparing a plan of care for a client who is a Jehovah’s Witness. Which statement is correct?
Surgery is strictly prohibited.
Alternative medicines can be advised.
Giving any medication is not allowed.
Blood products can not be administered.
87
In which position is the patient lying face down or chest down
prone
fowler's
lateral
supine
88
What is a common nursing intervention for preventing infection in a wound?
Delaying dressing changes
Applying excessive ointments to the wound
Exposing the wound to open air
Using sterile gloves during wound care
89
A nurse tells the pt. if you don't let me change the drsg you will not get dinner what is this?
malpractice
negligence
battery
assault
90
What is the minimum number of times the nurse should check the medication label before administering a drug?
5
4
1
3
91
The student nurse correctly identifies which as a medical diagnosis?
Ineffective airway clearance
Activity intolerance
Acute Pain
Pneumonia
92
preparing a med the nurse notes the dose is higher than the standard dose what should nurse do
give the average dose of medication
give the drug as prescribed
inform the supervisor
discuss the prescription with the primary provider
93
What is the minimum number of times the nurse should check the medication label before administering a drug?
1
4
3
5
94
Which of the following findings must be immediately reported to the primary healthcare provider?
A semi-formed stool in the ostomy.
The stoma is purple in appearance.
Excoriation of the skin around the stoma
Beefy red and shiny stoma.
95
What is the legally binding situation between a patient and the nurse caring for him or her
advocacy
standard of care
nurse patient relationship
accountability
96
What is an example of a subjective data?
Heart rate of 68 beats per minute
Noisy breathing
Client verbalized, “I feel pain when urinating.”
Yellowish sputum
97
which statement best reflects a principle common to all theories of health wellness and illness
people are able to control factors that affect health
health is synonymous with a sense of well being
many variables influence a person's perception of health
ability to meet demands of ones role is necessary for health
98
How can medication errors be prevented?
Skipping the documentation step
Speeding up the medication administration process
Double-checking before administration
Guessing the dosage for accuracy
99
Which factor is associated with the development of constipation?
Adequate fluid intake
Inadequate dietary fiber and dehydration
Regular exercise
Adequate fiber intake
100
the pt. says I am nervous about my test tomorrow. the best response by the nurse is
it's alright to be nervous, everyone is
I'll ask the doctor for medication to help you relax
your physician is excellent and will be very careful
Other patients who have had this say it is not uncomfortable
101
A nurse is preparing to administer insulin to a patient. Which of these steps are INCORRECT when preparing insulin?
Injects 5 units of air into regular first & pulls 5 units out
Withdraws 5 units of regular insulin before withdrawing 15 units of NPH
Injects 15 units of air into the NPH but does not withdraw the medication.
Rolls NPH vial gently between hands before inserting needle
102
which factor is unique to malpractice when comparing negligence and malpractice
there is harm to the patient as a result of the care
the inappropriate care is an act of commission
the action did not meet standards of care
there is a contractual relationship between nurse and pt
103
What is tissue integrity in the context of nursing care?
Administering antibiotics
Ensuring proper wound healing
Monitoring vital signs
Maintaining a sterile environment
104
What is a potential consequence of chronic stress on physical health?
Impaired immune response and increased susceptibility to illness
Improved immune function
Enhanced metabolic rate
Reduced risk of cardiovascular diseases
105
What is the term for the strategies individuals use to manage or adapt to stress?
Resistance
Depression
Coping mechanisms
Anxiety
106
Nurse puts a restraint jacket on a client without the client’s permission & physician’s order. Nurse may be guilty of:
Assault
Battery
Neglect
Invasion of privacy
107
The nurse injects the medication into the loose connective tissue just under the dermis when giving a _____ injection.
Subcutaneous
Intradermal
Intravenous
Intramuscular
108
what information must be included when documenting about a safety reminder device
evidence that the patient has assessed every 8 hours
the specific type of SRD used
the nurse's feelings about having used the SRD
confirmation of a prn order for use of the SRD
109
What is the primary purpose of range of motion (ROM) exercises for immobile patients?
To induce fatigue and encourage rest
To minimize oxygen consumption
To increase muscle strength
To promote joint flexibility and prevent contractures
110
Which of the following is an isometric exercise?
Washing dishes
Weight training
Walking
Running
111
What is the purpose of antiembolic stockings for immobile patients?
To reduce the risk of deep vein thrombosis (DVT)
To maintain skin integrity
To prevent joint contractures
To promote muscle strength
112
During the client’s medical records review, what condition can put the client at risk for developing hypokalemia?
Uric acid level of 10.2 mg/dL
Burn
Has a history of Addison’s disease
Nasogastric suction
113
Which statement is considered aggressive communication
complaining behind someones back about them not to them
I would like to set up an appointment to discuss this
avoiding eye contact
"You failed to tell me why you graded my paper this way"
114
Even though the nurse may obtain the client’s signature on a form, obtaining informed consent responsibility of the:
Supervising nurse
Physician
Client
Student nurse
115
When administering multiple medications, what is the best practice for preventing medication errors?
Administer meds separately, checking each one before moving to the next
Rely on the healthcare provider's prescription without question
Administer all medications at once to save time
Use memory aids and avoid cross-checking with references
116
Nurse is preparing to give bed bath to a client with tuberculosis. Which should the nurse include when doing procedure?
Surgical mask and gloves
Surgical mask, gown, and protective eyewear
N95, gown, and gloves
N95 and protective eyewear
117
A pt is upset and mentions a work issue that the nurse doesn't understand the best response is
calm down so that I can understand what you are saying
I'm not quite sure I heard what you were saying about work
your job must be very important to you
it's natural to worry about your job
118
Which of the following food items would be appropriate for a Jewish client who follows a kosher diet?
Tuna and salmon.
Beef and pork.
Shrimp and mussels.
Cheese and milk.
119
Which of the following food items would be appropriate for a Jewish client who follows a kosher diet?
Cheese and milk.
Beef and pork.
Shrimp and mussels.
Tuna and salmon.
120
The nurse must administer a medication using the Z-track method. Which option describes the nurse’s action?
Massage the site following the injection
Insert needle at a 60-75 degree angle
Pull skin down to one side before inserting needle
Aspirate before injecting medication
121
According to Erikson's stages of psychosocial development, what is the primary developmental task for older adults?
Generativity vs. Stagnation
Autonomy vs. Shame and Doubt
Integrity vs. Despair
Identity vs. Role Confusion
122
Which type of injection deposits meds into deep muscle tissue causing meds to be absorbed rapidly?
Intramuscular
Intravenous
Subcutaneous
Intradermal
123
Which nursing intervention is essential for promoting urinary elimination in immobile patients?
Ignoring signs of urinary retention
Encouraging a sedentary lifestyle
Providing a bedside commode or bedpan
Limiting fluid intake
124
Which sites are acceptable for giving subcutaneous injections? (SATA)
Outer aspect of the upper arms
Anterior thighs
Ventrogluteal area between the greater trochanter and the iliac crest
Abdomen from below the costal margins to the iliac crests
125
giving meds to confused pt. what should the nurse do if pt says it looks different than before
encourage the patient to take the medication
explain the purpose of the medication
check the original medication prescription
ask what the other pill looked like
126
patient goals are best met when
nurses delegate education tasks
nurses use aggressive communication
assessment data is accurate
goals are determined alone
127
Which of the following are symptoms of hypoglycemia? (SATA)
Shakiness
Increased voiding
Diaphoresis
Increased thirst
clammy skin
Loss of consciousness
128
A 52 year old patient has a heart rate of 110. what is the definition of this type of heartrate
bradycardia
hypertension
tachypnea
tachycardia
129
What is a common physiological response to stress?
Constricted pupils
Elevated blood pressure
Decreased heart rate
Slowed digestion
130
At what angle do you administer an IM injection?
15
35
90
45
131
Which assessment finding may indicate dehydration in a patient?
Clear urine color
Normal blood pressure
Decreased skin turgor
Moist mucous membranes
132
What is a potential complication of impaired tissue integrity in wounds that heal by secondary intention?
Excessive granulation tissue
Reduced risk of infection
Rapid healing process
Minimal scar formation
133
A nurse notices that an IV insertion site is warm, reddened, & tender. What action should the nurse take first?
Apply warm compresses over the insertion site.
Slow the infusion rate and slowly inject the medication.
Inject a local anesthetic to relieve the tenderness.
Discontinue the IV infusion
134
Which action should be questioned when a student nurse is giving an IM injection in the ventrogluteal muscle?
Asking the patient to assume a sitting position
Using the right hand to locate the injection site on patient’s left side
Asking the patient to flex the knee and hip
Placing the heel of the hand over the patient’s greater trochanter
135
What is the advantage of administering medication via Intravenous Bolus?
Small volumes are used, so fluid overload can be avoided.
Medications are given over a longer time frame.
There is a slower onset of medication effects.
Medications given by IV bolus are less irritating to the veins.
136
Which medication administration site is used for insulin?
Intravenous
Intradermal
Intramuscular
Subcutaneous
137
What is the first action of the nurse for a patient on continuous TPN with increased urine output?
Assess blood glucose level
Decrease IV infusion rate
Assess diuresis level
Decrease TPN infusion rate
138
What is a potential barrier to seeking healthcare for young adults?
High levels of health literacy
Availability of time for medical appointments
Limited access to affordable healthcare
Strong social support networks
139
What is the primary purpose of a cleansing enema?
To provide nutrients and electrolytes
To soften and lubricate the stool
To remove fecal material from the colon
To stimulate bowel peristalsis
140
The nurse notes smoke in the utility room across the hall from a pt room the first action is
remove the patient from the area
sound the fire alarm
use any extinguisher
disconnect the oxygen supply
141
A document that lists the medical treatment a person chooses to refuse if unable to make decisions is the:
Advance directives
Living will
Durable power of attorney
Informed consent
142
Which instruction should be given when teaching a family member of an obese patient about giving a subQ injection?
Insert the needle quickly and firmly at a 90-degree angle.
Draw the medication into a tuberculin syringe with a 27-gauge needle.
Rotate injection sites between the abdomen, thighs, and upper arms.
Carefully massage the site after the injection to aid absorption.
143
What is normal range for Potassium?
9-10.5
3.5-5.0
90-110
136-145
144
How should a nurse dispose of a used syringe and needle after administering an injection?
Place the entire syringe and needle in a biohazard container.
Dispose needle in a sharps container and the syringe in the regular trash.
Flush needle down toilet and discard the syringe in a regular trash bin.
Recap the needle and dispose of the syringe in the regular trash.
145
The Code of Ethics for nurses is composed and published by:
The National Institutes of Health, Nursing Division
The Medical American Association
The American Nurses Association
The National League for Nursing
146
What age range is typically considered as older adulthood in the context of nursing care?
65 years and older
45-60 years
50-60 years
55-64 years
147
What is the recommended site for intramuscular injections in adults?
Dorsogluteal muscle
Vastus lateralis muscle
Ventrogluteal muscle
Deltoid muscle
148
What term is for the involuntary loss of urine during activities that increase intra-abdominal pressure?
Stress incontinence
Overflow incontinence
Urge incontinence
Reflex incontinence
149
At what angle do you administer an IM injection?
90
15
35
45
150
What size needle is used for IM injections?
2-2.5in
0.5-1in
1-1.5 in
1.5-2in
151
Which Maslow level need does giving a choice of which color shirt to wear meet?
safety and security
self esteem
love and belonging
physiological
152
Freedom from which situation demonstrates a safety and security need according to maslow
ridicule
lonliness
hunger
pain
153
Which medication will be given through an intradermal injection?
Opioid
Medication for allergy testing
Low-molecular-weight heparin
Glargine insulin
154
Trying questionable and experimental forms of therapy is a behavior that is characterized by which stage of dying?
Acceptance
Anger
Bargaining
Depression
155
What is the primary goal of placing a patient with hepatitis A on contact precautions
to control the environment of the patient
to protect only the family
to prevent transmission of infectious microorganisms
to protect the patient from infectious microorganisms
156
What is an example of a subjective data?
Yellowish sputum
Heart rate of 68 beats per minute
Client verbalized, “I feel pain when urinating.”
Noisy breathing
157
What action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection?
Open the drainage bag and pour out the urine.
Aspirate urine from the tubing port using a sterile syringe.
Use sterile gloves when obtaining urine
Disconnect the catheter from the tubing and get urine.
158
What is a potential challenge for older adults related to social well-being?
Loss of friends and family
Financial instability
Overwhelming work responsibilities
Child-rearing responsibilities
159
Which factor is crucial for the prevention of pressure ulcers in immobile patients?
Limited nutritional support
Restricted fluid intake
Frequent turning and repositioning
Use of tight dressings
160
A nurse is preparing an injection of 0.45 mL of medication for a pediatric patient. Which syringe is most appropriate?
Tuberculin syringe
Insulin syringe
10-mL syringe
3-mL syringe
161
The Code of Ethics for nurses is composed and published by:
The American Nurses Association
The Medical American Association
The National Institutes of Health, Nursing Division
The National League for Nursing
162
Nurse puts a restraint jacket on a client without the client’s permission & physician’s order. Nurse may be guilty of:
Neglect
Battery
Assault
Invasion of privacy
163
During which step of the nursing process does the nurse determine if outcomes are achieved
planning
implementation
evaluation
analysis
164
Even though the nurse may obtain the client’s signature on a form, obtaining informed consent responsibility of the:
Physician
Client
Student nurse
Supervising nurse
165
How does immobility affect the respiratory system?
Enhances lung capacity
Promotes deeper breathing
Decreases lung expansion and predisposes to pneumonia
Increases respiratory rate
166
Which factor contributes to impaired tissue integrity?
Regular exercise
Adequate blood supply
Inadequate oxygenation
Proper nutrition
167
What does TPN stand for in nursing?
Total Procedural Nutrition
Total Patient Nutrition
Total Parenteral Nutrition
Total Preoperative Nutrition
168
The nurse is asked to perform a procedure she has never done before, what should she do
refuse to perform it, citing lack of knowledge
go ahead and do it
ask another nurse who has performed the procedure.
discuss it with the charge nurse asking for direction
169
Which lab result indicates infection?
BUN
WBC
Sodium
BNP
170
A nurse is preparing an IM injection for a thin, elderly patient. What is the max volume that may be tolerated?
1 mL
3 mL
2 mL
5 mL
171
When a TB test is read for a patient that has no risk factors for TB, which of these results would be positive?
Induration of 2 mm or more
Induration of 5 mm or more
Induration of 10 mm or more
Induration of 15 mm or more
172
What should the nurse do if a patient refuses to take a prescribed medication?
Respect patient's decision, document refusal, & explore reasons behind it
Discard the medication and inform the healthcare provider
Encourage the patient to take the medication, emphasizing its importance
Document the refusal and administer the medication anyway
173
What is a key consideration when providing health education to young adults?
Focus on short-term health goals.
Use complex medical terminology for accuracy.
Provide information only to parents or guardians.
Emphasize preventive care and healthy lifestyle choices.
174
Which of the following is NOT a preventative measure for fall risk patients?
Non-skid socks
Yellow wristband
Bed alarm
All 4 side rails up
175
A nurse is preparing to give an IM injection via the Z-track method. Which action should be taken by the nurse?
Immediately remove the needle after injecting the medication.
Insert the needle at a 90-degree angle.
Pinch the skin between the thumb and the first finger.
Release the skin before removing the needle from the site.
176
What regulates standards for long term care documentation?
Title XXII
OBRA
the care plan
Nursing diagnoses
177
What is the first step in the nursing process when addressing impaired tissue integrity?
Planning
Evaluation
Assessment
Implementation
178
The nurse is preparing a medication that comes in an ampule. Which action by the nurse is appropriate?
Guiding the needle against the rim of the ampule to access the medication
Using a filter needle long enough to reach the bottom of the ampule
Avoiding inversion of the ampule after opening to prevent spillage of med
Tapping the ampule so fluid moves from bottom of the ampule to the neck
179
Red, bloody drainage
serosanguinous
purulent
serous
sanguinous
180
Cultural competence is the process of:
Acquiring specific knowledge, skills, and attitudes.
Influencing treatment and care of clients.
Learning about vast cultures.
Motivation and commitment to caring.
181
A nurse follows guidelines when administering injections to a patient to avoid which possible complications? (SATA)
Drug response that is too rapid or too slow
Death of the patient
Death of tissue surrounding the injection site
Nerve injury with possible pain or paralysis
182
When is Total Parenteral Nutrition (TPN) typically indicated for a patient?
Stable oral intake
Difficulty swallowing
Mild malnutrition
Mild dehydration
183
Nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do?
Leave medication at bedside for patient and leave the room.
Return after a few minutes and do not leave until patient takes meds
Wait for patient to return and leave med on bedside table.
Instruct patient to take medication and leave it at bedside
184
Which psychological effect is commonly associated with prolonged immobility?
Enhanced sense of independence
Increased self-esteem
Improved sleep quality
Feelings of depression and anxiety
185
a 65 yr old man has a history of emphysema and reports dyspnea. What is dyspnea
pallor
cyanosis
difficulty breathing
absence of retractions
186
according to Maslow which characteristic is least associated with someone whos self actualized
has an external locus of control
is autonomous
is able to see the good in others
has the ability to problem solve
187
Where is a buccal medication given?
Inside ear
Inside nostril
Under tongue
In between gums and cheek
188
Which type of wound healing occurs when there's minimal tissue loss, and the edges of the wound can be brought together?
Secondary intention
Tertiary intention
Primary intention
Inflammatory intention

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