Unit 1 NUR 155 Wessling

Which of the following is the best information to put in a flow sheet format?

Myopia: Near is clear, far is fuzzy

A slow heart rate

Freedom from & prevention of the contamination that causes infection

Which must be performed under surgical asepsis? SATA

When assessing your pts lungs for egophony, you ask them to say "E" but it sounds like the letter A. This indicates?

Which one of the following is associated with specifically meeting the Quality & Safety Education Teamwork & Colab

Treatment of COVID-19 with antibodies from donors is an example of which type of immunity?

Which of the following physical assessment technique is used to determine skin moisture?

What does strabismus mean?

Which of the following are accurate palpation techniques? Select all that apply.

People with access to the care plan include:

In preparing to conduct a physical exam on a pt, the RN plans to

RN is observing a new staff nurse. Of the following activities, which needs correction d/t ^HAI?

To test fine motor skills, what does the RN ask the patient to do?

Appropriate to Use? TID

The new nursing staff is observed by the unit manager during a patient interview. Which should be avoided in the future?

On entering the room, the nurse observes that the patient appears to be tachypneic. The nurse should first:

Which of the following actions can be safely delegated to unlicensed assistive personnel (CNA)?

As part of the exam, the RN will be assessing the patient's balances. Which test should RN administer?

Lung sounds that will become course if untreated

Can opioids & medications for glaucoma cause pupils to measure less than 2mm & not dilate?

Which of the following are accurate for pulse measurement? Select all that apply.

Match to the correct condition: Isolation Precautions

When you auscultate the lower lobes of a health patient's lungs, you would expect to hear

RN makes HHC visit for a patient s/p total hip replacement 1 week ago. Which part of ADPIE does RN determine outcomes?

The nurse is unable to locate the point of maximal impulse (PMI). What action should the nurse take?

A student nurse is working with a pt who has asthma. The RN tells the student wheezes can be heard. What's expected?

RN is evaluating a pt for conduction deafness in the R ear. In using the Weber test, the RN places the tuning fork &

Which are contact precautions? SATA

What is considered unexpected findings when assessing chest? SATA

Which of the following is BEST measurable patient goal? The patient will:

The nurse instructs the aide that a falsely low blood pressure reading will be obtained by which method?

What are expected findings for mouth, throat & neck assessment? SATA

You're the nurse caring for the patient who needs an assessment. You notice the patient has 6mm indentation on BLE.

Pt tells nurse she is not confident with self injection of insulin. RN should use which to validate information?

Appropriate to Use: mL?

Appropriate? Taking a rectal temperature on an infant

When you're evaluating a patient's breathing, you should note

For a patient with a nursing diagnosis of Restricted Physical Mobility Associated with Bilateral Arm Casts, direct care?

The nurse receives the patient assignment in the morning. Which of the patients should be seen first? The patient who

Appropriate? Counting an irregular apical pulse for 30 seconds?

Which one of the following interventions is considered independent or nurse-initiated?

The pt has been on MS for 2 days w/dx of asthma. She has been stable & her d/c is planned for tomorrow. She reports SOB

Which of the following best meets the criteria for a goal statement?

For the patient with the NANDA Activity Intolerance, the nurse expects that the patient will specifically demonstrate

Which should be performed using medical asepsis? SATA

The RN is auscultating the patient's lungs & notes normal vesicular sounds as

Why is it important for proper body mechanics?

Before 1991, the nursing care plan was commonly

Difficulty in breathing in positions other than upright

The patient is experiencing pain & asks for medication which was ordered. The nurse assessed bp 144/82, HR 88/min, RR 24

Nurses can be held liable for not monitoring vital signs appropriately

A physical exam is to be performed by the RN on a pt who has cardiopulmonary disease. What nails are expected?

During inspection of the patient's skin, the RN finds a brown, flat lesion with irregular borders. The RN suspects

What disease processes would you put a patient on droplet precautions for? SATA

A bluish discoloration of the skin & mucous membranes

The patient works in a tailor shop & is having surgery to correct bilateral cataracts. What is the long term goal?

A patient with a 2+ pulse is

A process used to destroy all microorganisms, including their spores

During physical exam, the pt tells the RN that he has been told he has myopia. The RN expects to find that the pt

An adult female has been undergoing testing. Which is abnormal?

Capillary refill time is normally

Which of the following information is classified by RN as subjective data from the patient?

A primary concern for a patient with orthostatic hypotension is

For patients with no pathology, respiration is stimulated by changes in oxygen levels in the body.

Which of the following actions is considered direct patient care?

Which actions are considered part of standard precautions rather than transmission based precautions? SATA

Compared with a standardized care plan, a traditional care plan is

The RN is examining a patient with a deep skin tone. In assessing for jaundice, the nurse will specifically look at the

RN employs surgical aseptic technique when

How long should irregular respirations & pulses be listened to?

A pt w/a large, deep abdominal incision requires a dressing. When changing, the RN drops packing into the cavity.

What is myopia

A pt w/active TB is admitted. The RN recognizes they need to be placed on which transmission precautions

Any disease-causing agent

Which vitals are WNL for a 72 year old

For a patient w/COPD with an excess of secretion in the bronchioles, which NANDA is MOST appropriate?

Which of the following interventions is most clearly stated & will assist other staff to provide safe care?

RN observes a student put on sterile gloves. Which action contaminated the gloves?

Which is an abnormal finding for eye inspection?

What is the single most important technique to prevent & control the transmission of infections is

Abnormal assessment findings with occular assessment? SATA

For integumentary assessment which are expected findings?

It is the current belief that patient hand-offs can be improved with which of the following actions?

For a patient-related incident report, which of the following is correct

What are unexpected findings or mouth, throat & neck on assessment? SATA

Pt comes to ED p having been in the sun all day. RN determines the pt is taking diuretic. Heat stroke is suspected.

In a patient with COPD, a barrel chest indicates

Appropriate? Having a patient who exercised rest 5 minutes before measuring RR?

The expected appearance of the oral mucosa in a light-skinned adult is

The use of telephone & verbal orders has been reduced as a result of which of the following?

Identify which of the following vital signs are within the expected range for a 40 year old? SATA

In evaluating the infection control measures used by the patient & family which indicates additional teaching is needed?

Difficult, labored breathing

If the nurse alters a patient's electronic medical information, there is no record of the change

Which are expected findings for integumentary health assessment? SATA

Appropriate to Use? QOD

The percussion sound usually heard over most of the lungs is

For health promotion NANDA Ability to comprehend the need for enhanced nutrition, which is most appropriate

Appropriate? Placing a dyspneic patient in a supine position.

A patient asks RN whether her bp is too high. Which is associated with stage II HTN

RN recognizes special care must be taken in handling which of the following to prevent transmission of Hepatitis C?

For patient w/a NANDA of potential for aspiration, RN anticipates there will be goals & interventions observation during

Which of the following questions will elicit the most information from the patient during an interview?

The patient gets out of bed to go to the bathroom & tells the nurse that he "feels dizzy." What should RN do first?

In planning for the pt assignment, RN prioritizes a schedule on basis of pt needs. Which NANDA should be prioritized?

RN works in a small rural hospital with a wide variety of pts. The pt w/^ susceptibility to infection is

Patient had abdominal surgery this morning. Current vs: bp110/60, P 110, R 32/min. What should RN do?

Which of the following is the best example of a measurable patient goal? The patient will:

Which of the following are demographic data? Select all that apply

What is expected during nose & ear assessment? SATA

For baby boomers, which is a generational factor that may influence behavior?

Which of the following NANDAs best meets criteria for diagnostic statement?

The RN suspects the pt may have vascular disease. The RN is alert to which s/sx?

During the termination phase of the patient interview, the RN does what

The RN is aware that which of the following are true regarding patients seeing their medical records?

Protein molecules on the surface of foreign invaders/nonliving substances such as toxins, chemicals, drugs, or particles

Apical pulse exceeds the radial pulse

Appropriate? Removing polish or artificial nails before measuring SpO2?

What are expected findings of the chest? SATA

What are abnormal assessment findings with nose & ears? SATA

What disease processes would you put a patient on airborne precautions for? SATA

Farsightedness: Far is clear, near is fuzzy.

NANDA are primarily used to do what

The patient has a 6in laceration on his R FA. An infection develops. Which is a sign of a local inflammation?

The unit manager sees the new RN come out of an isolation precaution room? Which needs correction?

In auscultation of the thorax, the nurse notes that the sounds heard over the trachea are expected to be

RN is working w/post op pt on MS. Which aspect demonstrates a manipulation of environment?

Using a multidisciplinary team, who do you call if the patient needs resources in the community?

The adult patient is seen for heat exhaustion. The nurse anticipates that tx will include what

Which of the following nursing actions is identified as indirect nursing care?

NANDA of Altered speech associated with recent neurological disturbances as observed by an inability to speak coherently

The adolescent pt is found to have an S-shaped curvature of the spine. The RN documents this finding as

For blood pressure measurement, identify the correct information. Select all that apply

RN is working with a patient who has the following s/sx. ^wt, bilat lower edema, ^bp, & abdominal distention. NANDA?

The nurse is aware that which of the following is an accurate statement about the respiratory rate?

Peak of the pressure wave on arterial walls

RN is aware it's important to break the chain of infection. What's an example of intervention to control portal of exit

RN is concerned patient has developed atelectasis after sx. Which is an appropriate NANDA?

Which of the following is a vector-borne disease?

Appropriate to Use: MS?

Which of the following factors will result in a decrease in a patient's blood pressure?

Appropriate to Use? IU

A patient has MRSA. An appropriate isolation procedure for the RN to implement when working with the patient

Indicate the accurate statements related to body temperature. Select all tat applyh

A 21-year-old woman asks when she should perform a breast self-examination during the month. The RN should inform the pt

Which of the following are signs of hyperthermia (fever)? Select all that apply

As you auscultate heart sounds in a 53 year old patient you hear an S4. This sound may indicate

Which one of the following is the most correct notation for the nurse to make in the record?

For a NANDA of Insufficient Gas Exchange, indicate which defining characteristics are most appropriate to include? SATA

What would be considered out of normal parameters for a 34 YO

When listening to heart sounds, you can hear S1 best at the

Which of the following statements are accurate in relation to infectious control? Select all that apply