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NURS 113 proctored Flashcards | StudBud
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NURS 113 proctored
NURS 113 proctored
61 terms
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1
To reduce
orthostatic hypotension
risk after surgery, teach the client to:
Hyperextend knees when standing
Restrict fluids
Dangle feet before standing
Stand up quickly
2
Clean-catch urine for female—FIRST instruction:
Cleanse perineum front-to-back
Drink 1 L water beforehand
Refrigerate sample immediately
Collect first urine in cup
3
Unilateral calf circumference ↑2 cm versus yesterday suggests:
Fluid deficit
Dependent edema
DVT
Normal postop swelling
4
Aspiration prevention when feeding stroke client:
Use a straw for thin liquids
Upright 90° during & 30 min after meals
Feed quickly while alert
Tilt head back to swallow
5
Order: Enoxaparin 40 mg SQ daily. Prefilled syringe 60 mg/0.6 mL.
mL to give?
0.4ml
0.6ml
0.2ml
0.8ml
6
C. diff client asks for alcohol gel. The best reply is:
“Soap-and-water is safer because gel doesn’t kill spores.”
“Hand hygiene isn’t needed right now.”
“Here you go.”
“We’ll use bleach wipes instead.”
7
BMI for 70 kg, 1.8 m adult is:
28
19
25
22
8
A client signs informed consent but then says, “I’m still unsure.” Nurse’s action?
Ask family to reassure client
Explain procedure risks again in detail
Cancel surgery and chart refusal
Inform surgeon the client has more questions
9
Child temp 102 °F (38.9 °C); first nursing step:
Ice bath
Remove extra blankets and encourage fluids
Start antibiotics
Call rapid response
10
Positive orthostatic change = SBP drop ≥20 mm Hg
with
:
Temperature increase
No HR change
HR decrease
HR increase ≥10–20 bpm
11
Proper N95 mask use is demonstrated when the nurse states, “I _____.”
Skip the seal check if busy
Perform a user seal check every time
Reuse it indefinitely
Wear lipstick under it
12
Before applying a vest restraint, the nurse should FIRST:
Pad bony prominences
Tie straps to side rails
bed alarm
Obtain a PRN order
13
Supportive statement to client grieving limb loss:
“Others have it worse.”
“Losing a limb is hard; your feelings are valid.”
“Try not to think about it.”
“At least you’re alive.”
14
Influenza A
precautions require:
Droplet + surgical mask
Airborne N95
No special precautions
Contact only
15
Most complete entry for late documentation at 1430:
“Late meds, no issues.”
“Forgot to chart earlier meds.
“2 PM meds given.”
“Late entry 1430: furosemide 40 mg PO given at 1000; client voided 500 mL.
16
A central-line dressing change requires which item to remain
sterile
?
Tape strips
Outer gauze roll
Alcohol swab packet
Chlorhexidine Biopatch disc
17
Key step to prevent CAUTI:
Keep bag above bladder
Clean meatus with iodine every 6 h
Irrigate catheter daily
Maintain closed drainage system
18
Therapeutic reply to “I’m terrified of tomorrow’s biopsy”:
“Why are you scared?”
"Tell me more about what scares you.”
“Don’t worry about it.”
“Everything will be fine.”
19
A 600-kcal daily deficit equals ~_____ lb lost per week.
0.5
1
2
3
20
After a
near-miss
medication error (caught before reaching the client), the nurse should:
Ignore because no harm occurred
File an incident/variance report
Tell the client it happened
Call pharmacy only
21
COPD exacerbation needs precise
28 % FiO₂
; choose device:
Nasal cannula 6 L/min
Venturi mask at 28 % setting
Non-rebreather 15 L/min
Simple mask 10 L/min
22
Strategy for expressive aphasia:
Rapid-fire questions
Finish sentences for client
Yes/no questions
Speak loudly
23
Home safety for a legally blind client includes:
Scatter rugs for warmth
Rearranging furniture weekly
Dim lighting to cut glare
High-contrast tape on stair edges
24
Best low-residue snack after bowel surgery:
Raw carrots
Vanilla pudding
Apple with peel
Popcorn
25
Wheelchair-to-bed transfer safest setup:
Directly behind the client
Parallel, brakes off
At foot of bed, brakes on
45° angle to bed, brakes on, footrests up
26
Muslim end-of-life care—respectful action:
Play spiritual music unasked
Remove headscarf
Turn bed toward Mecca
Offer pork-free meals
27
Which situation requires an incident report?
Family complains about food
IV pump alarm sounds
Blood pressure 88/50 mm Hg
Client falls but is uninjured
28
Which is
subjective data
?
HR 110 bpm
I feel nauseous
BP 118/72
5-cm incision
29
Non-English discharge teaching requires:
Bilingual family member interpreter
Certified medical interpreter
“Google Translate” app alone
English handouts only
30
Dying client with “death rattle” secretions—comfort measure:
Deep suction q15 min
Panic family by explaining noise
Bolus IV fluids
Reposition on side
31
Statement indicating
positive coping
:
“I bottle up my feelings.”
“I call friends when I feel low.”
"I use alcohol to relax.”
“I quit all hobbies.”
32
Best electronic documentation for a dysphagic client refusing thickened liquids:
Dysphagia diet unsuccessful.”
Refused thickened liquids; no distress.”
“Client states, ‘I hate this slime,’ coughed after sip of water.”
“Non-compliant with diet.”
33
First sign of
phlebitis
at IV site:
Pitting edema
Warmth and redness along vein
Cool, blanched skin
Sudden chest pain
34
A
sterilized
surgical pack is verified by chemical tape that turns:
Red
Green
Dark/black
White
35
Pulse-ox alarm 82 % on sleeping client—FIRST nursing action:
Call rapid response
Re-check sensor placement and client status
Draw arterial blood gas
Increase O₂ to 10 L/min
36
High-protein snack for malnourished older adult:
Apple slices
Greek yogurt with nuts
Plain toast
Rice cakes
37
Angry family member in hallway—first nursing response:
Invite to private area to talk
Walk away
“Calm down!”
Threaten security immediately
38
Which principle is upheld by locking the computer when leaving the workstation?
Non-maleficence
Confidentiality
Fidelity
Justice
39
Priority element before a procedure consent is valid:
Client understands risks/benefits
Provider’s signature
Date and time
Witness nurse’s signature
40
how was your day?
meh
eventful
good
slow
41
Compression (TED) stockings should be removed:
Once every 24 h for skin check
Only during sleep
Whenever ankles feel warm
After first ambulation only
42
Correct walker gait for weak left leg:
Walker 12 in, strong leg first
Walker and right leg together
Use walker to climb stairs
Advance walker, step with left (weak) leg, then right leg
43
For right-hemiparesis, the cane should be held in the:
Left hand
Dominant hand always
Right hand
Both hands alternately
44
Greatest fall hazard in a dementia client’s room is:
Night-light on
Nonskid socks
IV pump cords across walkway
Bed in low position
45
Which part of the record gets charted when using “charting-by-exception”?
Only abnormal or variances
All medication times
Every normal finding
A full narrative each shift
46
Which client needs
airborne
isolation?
RSV bronchiolitis
Pertussis cough
C. diff diarrhea
Disseminated shingles (varicella)
47
Proper
body mechanics
when lifting a 15 kg box:
Bend from hips with straight arms
Bend knees, keep back straight, hold load close
Feet together, knees locked
Twist at the waist while lifting
48
Missed antibiotic dose discovered 2 h late—best action:
Document only
Skip dose, resume schedule
Give dose now, adjust times forward
Double next dose
49
Extra 2 units of insulin drawn accidentally—nurse should:
Discard syringe, redraw correct dose
Squirt extra into sink, give rest
Administer full syringe
Ask provider to adjust order
50
First step when a competent adult refuses a PEG-tube insertion:
Document refusal and stop prep
Notify ethics committee
Ask family to persuade client
Restrain for life-saving care
51
Cultural humility means the nurse should:
Avoid discussing culture
Assume all Latinos prefer spicy food
Ask each client about personal health beliefs
Memorize every cultural holiday
52
High-alert med requiring independent double-check:
Lorazepam 1 mg PO
Ondansetron 4 mg IV
Cefazolin 1 g IV
Potassium chloride 10 mEq/100 mL IV
53
After removing soiled gloves, the nurse’s
immediate
action is to:
Don new gloves
Wipe countertop
Document procedure
Perform hand hygiene
54
Sign of fluid
overload
on IV therapy:
Flat neck veins
Crackles at lung bases
Orthostatic hypotension
Dry mucous membranes
55
Lab best reflecting
short-term
nutrition:
Albumin
Hemoglobin
Calcium
Potassium
56
HIPAA Privacy Rule allows faxing PHI ONLY when:
The receiving fax is in a restricted area
Cover sheet is omitted
It’s faster than mailing
Client gives verbal okay
57
Client says, “Life isn’t worth it.” Priority:
Offer sedative
Provide false reassurance
Encourage hobbies
Ask about suicidal thoughts/plan
58
Morphine 3 mg IV ordered. Vial 2 mg/mL.
mL to draw?
1.5ml
1ml
2ml
3ml
59
Which client need is best handled by the social worker on the care team?
Adjusting pain meds
Teaching incentive spirometry
Arranging home-meal delivery
Assessing IV patency
60
Appropriate hand-gel technique is to rub until:
Next client is reached
Hands feel dry (≈15-20 s)
Foam drips off fingertips
5 seconds elapse
61
Which client may legally sign his or her own surgical consent?
15-year-old in foster care
17-year-old single mother
70-year-old with advanced dementia
18-year-old college student with mild autism