FUNDAMENTALS (NUR125) EXAM 2

Question 1

A pt has been on bed rest for over 5 days. Which of these findings during a nurse assessment may show immobility issues?

Accepted Answer

Decreased peristalsis

Question 2

A nurse is caring for a pt who is post-op. Which interventions should the nurse do to reduce thrombus risk?

Accepted Answer

Apply elastic stockings, Help the pt change positions often

Question 3

A nurse goes to change a pt's surgical dressing and pt is coughing and sneezing. How does she prepare a sterile field?

Accepted Answer

Place a mask on the pt to eliminate spread of micro-organisms in wound.

Question 4

A nurse is helping create a care plan for a pt with suspected pertussis. What interventions should the nurse suggest?

Accepted Answer

Wear a mask when providing care within 3ft of the pt., Place a surgical mask on the pt if pt needs to move to another unit., Wear a gown during care that might result in contamination via secretions.

Question 5

While planning morning care, which of the following pts would have the highest priority to get a bath first?

Accepted Answer

Pt who is experiencing frequent incontinent diarrheal stools and urine

Question 6

A community health nurse is preparing a seasonal influenza campaign. What plans should she add as secondary prevention?

Accepted Answer

Screening groups of older adults in LTCs for early influenza manifestations

Question 7

A nurse at a LTC is assessing an older pt. What findings should the nurse see as atypical signs of infection in this pt?

Accepted Answer

Acute confusion, Agitation, Urinary incontinence

Question 8

A nurse has a pt w/ a hx of falls. Which of the following actions is a nurse's priority?

Accepted Answer

Complete a fall-risk assessment.

Question 9

During a home health visit a nurse sees a pt making lunch. What are safe practices for food prep and storage?

Accepted Answer

Cook meats to the proper temperature, Refrigerate leftovers as soon as possible, Wash hands thoroughly before food prep

Question 10

An older pt is admitted post hip fx and surgical repair. Before ambulation, what is most important to assess?

Accepted Answer

Preadmission activity tolerance, Baseline HR and BP

Question 11

When showing hand hygiene techniques with a group of AP, what instruction should the nurse include about hand hygiene?

Accepted Answer

Wash hands with soap and water for at least 15 seconds., Use a clean paper towel to turn off hand faucets.

Question 12

The effects of immobility on the cardiac system include what of the following?

Accepted Answer

Increased cardiac workload, Thrombus formation, Orthostatic hypotension

Question 13

A nurse has 21 yr pt saying their last physical exam was in high school. What screening would the provider do for them?

Accepted Answer

Testicular exam

Question 14

Which of the following should the nurse educator include as examples of direct contact mode of transmission?

Accepted Answer

A person fails to wash their hands after using a toilet and touches a pt., Blood from an arterial wound splashing into a nurse's eye.

Question 15

A nurse is admitting a pt who has decreased circulation in his left leg. What actions should the nurse take first?

Accepted Answer

Evaluate pedal pulses

Question 16

A nurse is getting 2 yr pt vitals who is having diarrhea and right ear infection. What route of temp should be used?

Accepted Answer

Temporal

Question 17

A nurse is moving a pt who had a total knee replacement from a chair to bed. What pose potential safety risks?

Accepted Answer

The hospital bed is in the high position, The overbed table with pt's glasses is against the wall, opposite of bed, There is no gait belt at the bedside

Question 18

A nurse is caring for a pt with an infection. What localized manifestations would the nurse expect?

Accepted Answer

Edema, Pain/tenderness

Question 19

A nurse wears sterile gloves in sterile procedure prep. What objects can she touch w/o breaking sterilization?

Accepted Answer

One gloved hand with the other gloved hand., The inner wrapping of an item on the sterile field., An irrigation syringe appropriately placed on the sterile field.

Question 20

What is the removal of devitalized tissue from a wound called?

Accepted Answer

Debridement

Question 21

A nurse is caring for a pt at risk for getting a pressure injury. What interventions could help maintain skin integrity?

Accepted Answer

Have the pt sit on a gel cushion when in a chair, Keep the head of the bed elevated 30 degrees

Question 22

A nurse is planning strategies related to heart disease. Which of these should the nurse include as primary prevention?

Accepted Answer

Teaching about a healthy diet

Question 23

A nurse is caring for a pt who has been sitting in a chair for an hour. Which complication is greatest risk to the pt?

Accepted Answer

Pressure injury

Question 24

A nurse has a pt that had extreme exposure to heat, w/ a temp: 104 F. The nurse should expect the pt will show what?

Accepted Answer

Hypotension

Question 25

A nurse has a pt who has enteral tube feeds due to dysphagia. Which bed position should the nurse use for safe care?

Accepted Answer

Semi-Fowlers

Question 26

A nurse delegates hygiene care for 2 pts w/ different cultures to AP. What cultural information should be communicated?

Accepted Answer

Religious practices, Timing of hygiene care, The need for gender congruent caregiver, Specific hygiene products

Question 27

A nurse has a sterile field ready for a chest tube insertion. What could contaminate the sterile field?

Accepted Answer

A nurse moistens cotton ball with sterile saline; places on sterile field., The procedure is delayed 1 hour due to provider receiving emergency call., A nurse turns to speak to someone entering through the door behind them.

Question 28

A nurse is preparing to provide tracheostomy care for a pt. Which action should the nurse take first?

Accepted Answer

Perform hand hygiene

Question 29

A nurse is obtaining the blood pressure in a pts lower extremity. What action should the nurse take?

Accepted Answer

Place the bladder of the cuff over the posterior aspect of the thigh

Question 30

A pt has low mobility after a total knee arthroplasty. What assessment data supports a lung issue related to immobility?

Accepted Answer

Oxygen saturation of 89%, Diminished breath sounds in bilateral bases of lungs, Respiratory rate of 26

Question 31

The nurse checks the surgical wound and it's separated with visceral protruding. What actions should the nurse take?

Accepted Answer

Position the client supine with the hips and knees bent., Cover the area with saline-soaked sterile dressings

Question 32

A nurse delegates to AP hygiene care for an older pt who had a stroke. What action would be good to do during the bath?

Accepted Answer

Providing ROM exercises to extremities, Providing special skin care as indicated by the nurse

Question 33

What type of precaution measures are taken with a pt that has influenza?

Accepted Answer

Droplet

Question 34

A pt has a hx of heart murmur via aortic valve stenosis. Where does a nurse put a stethoscope to listen to aortic valve?

Accepted Answer

Second intercostal space to the right of the sternum

Question 35

A nurse is taking a sterile back out of its' cover. Which of the following flaps should be unfolded first?

Accepted Answer

The flap furthest from the body.

Question 36

A nurse is going over wound healing and should include what alterations for secondary intention wound healing?

Accepted Answer

Stage 3 pressure injury, Open burn area

Question 37

That same pt with an infection is showing the same signs/symptoms. Which of them are systemic?

Accepted Answer

Malaise, Fever, Tachypnea, Tachycardia

Question 38

A surgeon suspects an incision wound infection post-op abdominal surgery. Prescribes abx. What findings are expected?

Accepted Answer

Increase in incisional pain, Fever and chills, Reddened wound edges

Question 39

A nurse sees an AP prepare to take BP with a regular size cuff for an obese pt. What explanation should the nurse give?

Accepted Answer

"Using a cuff too small will result in an inaccurately high reading"

Question 40

A nurse has a pt who needs a x-ray. Prior to the pt being transported, what action should the nurse take first?

Accepted Answer

Identify the pt using 2 identifiers

Question 41

Which of the following is an indication for a binder to be placed around a surgical pt with new abdominal wound?

Accepted Answer

Provision of support to abdominal tissues when coughing or walking, Reduction of stress on abdominal incision

Question 42

A nurse is helping a pt who has a left lower extremity injury about cane use. Which instructions should the nurse give?

Accepted Answer

Hold the cane tight on the right side., Keep two points of support on the floor., After advancing the cane, move the weaker leg forward

Question 43

A nurse is teaching family foot care for their mom w/ DM. What safety precautions are important in infection prevention?

Accepted Answer

Assess skin for redness, abrasions, and open areas daily, Clean between toes after bathing, Apply lotion to feet daily

Question 44

Medical adhesives, such as tape securing a wound dressing, cause MARSI. Which interventions reduce the risk of MARSI?

Accepted Answer

Use Montgomery ties to secure the dressing, Loosen ends of tape, pull the outer end parallel w/ skin surface to wound, Apply adhesive remover

Question 45

Which pt is most at risk for developing skin problems requiring bathing/skin care?

Accepted Answer

70 yr female pt, diabetes and dementia, incontinent or urine and stool, 60 yr female pt, stroke w/ right side paralysis, brace on left leg

Question 46

A nurse is teaching an AP proper hand hygiene. Which of the following statements by the AP indicates an understanding?

Accepted Answer

"I should use soap w/ water rather than an alcohol-based hand rub at times"

Question 47

A nurse tells a pt with COPD about the orthopneic position to help SOB. What statement should the nurse make?

Accepted Answer

"Use a table by your bed. You can sit on the bed and rest your arms on it."

Question 48

A nurse on meg-surg is washing hands prior to helping w/ a surgical procedure. What action is surgical hand washing?

Accepted Answer

The nurse washes with her hands help higher than her elbows

Question 49

What factors directly impair salivary gland secretion?

Accepted Answer

Dehydration, Radiation therapy

Question 50

What type of precautions are necessary with C. Diff or MRSA pts?

Accepted Answer

Contact

Question 51

A nurse is helping a pt do active assisted ROM in the right elbow. Which statement describes the right technique?

Accepted Answer

Support elbow by holding distal part of extremity

Question 52

A nurse is planning care for a pt on bed rest. Which interventions should the nurse plan to implement?

Accepted Answer

Encourage pt to perform antiembolic exercises every 2 hours

Question 53

What technique should a nurse use to find the correct stocking size?

Accepted Answer

Measuring around the largest part of the thigh

Question 54

A pt in the ICU pulled out his IV line. You tried nonrestraint options . What do you assess for reason of restraint?

Accepted Answer

Current medications, Prescence of fever, Serum electrolytes, Health care provider's order, Pt's current behavior

Question 55

A nurse has a pt that fell at a nursing home. Pt is oriented x3 and can follow direction. What can reduce the fall risk?

Accepted Answer

Make sure call light is within pts' reach., Provide pt with nonskid footwear., Complete a fall-risk assessment.

Question 56

A nurse determines a pt is a high fall risk after assessment. What measures are targeted to high fall risk status?

Accepted Answer

Using a bed exit alarm, Providing pt with a protective head helmet when in chair or walking, Scheduling any oral medications at least two hours before bedtime, Placing a low bed in room

Question 57

A nurse manager is educating on infant safety to guardians. Which statement by a guardian shows understanding?

Accepted Answer

"I should place the baby on their back when sleeping."

Question 58

45 yr pt, 2 days postop appendectomy w/ type 1 DM. HGB is 12g/dL and BMI 17.1. What risks impair wound healing?

Accepted Answer

Chronic Illness, Low hemoglobin, Malnutrition

Question 59

A nurse manager is reviewing care of a pt who had a seizure. Which statement from a nurse requires more teaching?

Accepted Answer

"I will go to the nurses' station for assistance."

Question 60

What type of precautions are taken for pts with TB or COVID-19?

Accepted Answer

Airborne

Question 61

A nurse has a pt in the terminal stage of cancer and sees pt crying. What action should the nurse take?

Accepted Answer

Sit and hold the pts hand

Question 62

Postop pt w/ closed abdominal wound hears pop when coughing. A nurse sees sutures open and open wound. What is priority?

Accepted Answer

Cover the area with sterile gauze and apply abdominal binder, Notify healthcare provider

Question 63

When repositioning an immobile pt, a nurse sees redness on the hip bone that blanches w/ touch. What is this indicating?

Accepted Answer

Blanching hyperemia; body trying to overcome ischemic episode

Question 64

A nurse is admitting a pt who is suspected to have pulmonary TB. What actions should the nurse plan to perform first?

Accepted Answer

Implement airborne precautions

FUNDAMENTALS (NUR125) EXAM 2

Questions 70

FUNDAMENTALS (NUR125) EXAM 2

Questions 70