RN suspects fluid volume excess in a CHF pt. What assessment finding caused the RN's suspicion?

new persistent nonproductive cough

Characteristics of a Stage 3 pressure injury include: (Select all that apply.)

Slough, Eschar, Visible adipose tissue, Rolled wound edges

Which of the following statements made by a newly licensed RN indicates understanding of delegation?

"I am responsible for ensuring a delegated task is completed."

Which hospital-acquired infections are included in the HACRP? Select All that Apply

central lines, clostridium difficile infection, urinary catheters

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

A nurse assesses a patient c/o vomiting and diarrhea. What info is most important for the nurse to obtain?

how long the patient has had these symptoms

For which situation would EMTALA be important?

A patient without insurance comes to the ED with chest pain

Among other things, HIPAA is concerned with

protecting personal health information

When completing an incident report, which of the following actions should the nurse take?

document objective facts and actions taken

A nurse is obtaining an oxygen saturation on a client. Which of the following actions should the nurse take?

choose a finger with capillary refill <2 seconds, Wait 10 sec after placing the probe before obtaining the O2 sat reading

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

Administer hypertonic IV solution as ordered

How do the lungs respond to acidosis?

Increasing rate and depth of breathing

RN is documenting information in an EHR. Which of the following actions jeopardizes client confidentiality?

sharing passwords with a fellow RN participating in the client's care

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

The patient is regurgitating the formula

What are effects of the Renin-angiotensin-aldosterone (RAAS) system?

vasoconstriction and increased blood pressure

Compared with an adult, an infant has which amount of fluid per total body weight?

More fluid per total body weight

The primary function of aldosterone is the protection of sodium and fluid balance by what mechanism?

increasing sodium reabsorption from the renal tubules

Which best describes a deep tissue pressure injury?

Blood-filled blister or maroon discoloration

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

Administering influenza vaccines at a community health fair

Who is protected under EMTALA?

All individuals seeking emergency medical treatment

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NUR 112 Final Exam Review Part I

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Questions 199

Answers

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

NUR 112 Final Exam Review Part I Flashcards | StudBud