Which of the following statements would indicate an understanding of the nature of pneumonia

pneumonia may not pose a risk to others

Pt who is taking meds for ED is most at risk for

Impaired circulation due to medication.

RN is admitting a pt w/an infectious disease process. What would the RN ask the pt

Do you have a chronic disease, and how long have you had it?

A 68yo female asks RN if a contraceptive is still necessary.

Lets discuss this what your current level of sexual activity

When eval a pt risk for spiritual crises which are part of the evaluation process? SATA

Discuss with family and associates the pts connectedness., Review the patients view of his/her purpose in life., Ask whether the patients expectations are being met., Review the pts self-perception regarding spiritual health

Pt is a member of the 7th Day Adventist religion is to get a test done on a saturday RN should

Discuss the patients beliefs about the Sabbath.

In a cardiac dysrhythmia clinic, a pt asks about using acupuncture to help alleviate stress

It is acceptable, but do not use electro-acupuncture.

The pt has dysuria and hematuria. How does the RN proceed to assess for kidney inflammation

Percuss posteriorly costovertebral angle @ the scapular line

The RN assesses for equipment-related accidents when using

Sequential compression devices.

Which are appropriate for the dx of Spiritual distress? Select all that apply

Offer to pray with the patient., Develop activities to heal body, mind, and spirit, Teach relaxation, guided imagery, and meditation.

pt states I just dont feel like going to work I have no energy and I cant eat or sleep

Assess the potential for suicide and make referrals

Based on the following data, which person is likely to have the highest self-esteem?

Latino adolescent female who has strong ethnic pride

Which pt statement indicates understanding regarding the mode of transmission of this disease

When I go camping, I will be sure to wear insect repellent.

Which information should the nurse include in teaching staff about health care reimbursement

Home health, long-term care RNs docum. affects reimbursement

a new RN has a strategy to prevent burnout. The best strategy would be for the new RN to

Identify limits and scope of work responsibilities.

Which of the following nursing interventions will assist in decreasing the risk of infection?

Teaching the patient to select nutritious foods

Which of the following statement about religion and spirituality is true?

Spirituality is unique to the individual.

A teen with celiac disease continues to eat food she knows will make her ill. RN should

Assist teen in meeting diet restrictions

In caring for the patients spiritual needs, the nurse understands that

Establishing presence is part of the art of nursing.

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Nursing 2 Quiz Flashcards | StudBud

Nursing 2 Quiz

254 termsStudBud Administration141 plays

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Questions 254

Answers

1
Meds that are used to manage a pts behavior that are not standard tx for the pts condition
Chemical Restraint
Pharmacologic Restraint
Phyiscal Restraint
Mechanical Restraint
2
A pt who has had several sexual partners in the past month. Which contraceptive should they use
Diaphragm
Spermicide
Oral contraceptive
Condom
3
Which position is this?
Dorsal Recumbent
Left Lateral Recumbent
Right Lateral Recumbent
Supine
4
Best exam position for a complete geriatric physical exam on a weak pt with bilateral pneumonia
Lateral recumbent
Sims position
Prone position
Supine position
5
Story-like format that can be repetitious info and time consuming
Progress Notes
Focus Charting
Critical Pathways
Narrative
6
Which of the following statements would indicate an understanding of the nature of pneumonia
We need to isolate the patient in a negative pressure room.
Clinical signs and symptoms are not present in pneumonia.
pneumonia may not pose a risk to others
The patient will not be able to return home.
7
What is the usual temperature comfort range for most patients?
25 C to 28 C
65 F to 75 F
60 F to 75 F
15 C to 17 C
8
The nurse recognizes a lump on the testis as a potential sign of which of the following?
Diuretic use
Inguinal hernia
Testicular cancer
Sexually transmitted infection
9
Which position is this?
Left Lateral Recumbent
Supine
Dorsal Recumbent
Right Lateral Recumbent
10
Pressing inward 1 cm
Light Palpation
Deep palpation
11
Person states he was not shoplifting despite being caught on camera. This is which ego defense
Conversion
Compensation
Dissociation
Denial
12
Pt who is taking meds for ED is most at risk for
Anxiety related to erectile dysfunction.
Ineffective coping related to chronic illness.
Impaired circulation due to medication.
Sexual dysfunction related to low self-esteem.
13
RN is admitting a pt w/an infectious disease process. What would the RN ask the pt
Do you have a chronic disease, and how long have you had it?
Do you have any religious beliefs that influence care
Do you have any children living in the home?
What is your marital status; single, married, or divorced?
14
A 68yo female asks RN if a contraceptive is still necessary.
Lets discuss this what your current level of sexual activity
A barrier such as a condom is recommended
Yes as long as a barrier doesnt decrease sexual performance
No you have gone through menopause & cant become pregnant
15
Which of the following is not an element in the development or chain of infection
Means of transmission
Reservoir for pathogen growth
Formation of immunoglobulin
Infectious agent or pathogen
16
RN is caring for a pt who claims that he doesnt believe in God. The nurse realizes that this pt
Finds no meaning through relationships with others.
Is devoid of spirituality.
Is an atheist/agnostic.
Believes that what he does is meaningless.
17
Which position is this?
Prone
Sims
Dorsal Recumbent
Right Lateral Recumbent
18
When eval a pt risk for spiritual crises which are part of the evaluation process? SATA
Discuss with family and associates the pts connectedness.
Review the patients view of his/her purpose in life.
Ask whether the patients expectations are being met.
Review the pts self-perception regarding spiritual health
19
RN realizes that entropion places the elderly pt at risk for which of the following
Ectropion
Exophthalmos
Infection
Strabismus
20
Pt is a member of the 7th Day Adventist religion is to get a test done on a saturday RN should
Inform the physician that the tests cannot be performed.
Discuss the patients beliefs about the Sabbath.
Order the tests without questioning.
Reorder the tests for Sunday.
21
In a pt with pneumonia, the nurse hears high-pitched continuous sounds over the bronchi on exp
Crackles
Rhonchi
Friction rubs
Wheezes
22
The cognitive skill of learning to tolerate uncertain and unfamiliar experiences
Passivity.
Focusing.
Receptivity.
Mindfulness.
23
The nurse contacts the patients medical provider over which potential drug-drug interaction?
Echinacea and warfarin
Warfarin and ginkgo biloba
Lisinopril and hydrochlorothiazide
Lisinopril and echinacea
24
First step in a nurses initial assessment is
Deep palpation, light palpation, inspection.
Auscultation, deep palpation, light palpation.
Inspection, light palpation.
Light palpation, deep palpation, inspection.
25
In a cardiac dysrhythmia clinic, a pt asks about using acupuncture to help alleviate stress
It is acceptable, but do not use electro-acupuncture.
It is very clearly contraindicated.
You do not look like you have an infection, so it will be OK
Do not allow needles near the heart.
26
The pt has dysuria and hematuria. How does the RN proceed to assess for kidney inflammation
Uses deep palpation posteriorly
Inspects abdomen for abnormal movement
Lightly palpates each abdominal quadrant
Percuss posteriorly costovertebral angle @ the scapular line
27
The RN assesses for equipment-related accidents when using
A measuring device that measures urine.
Sequential compression devices.
Computer-based documentation.
A manual medication-dispensing device.
28
Which action would indicate a break in sterile technique?
Touching protective eyewear
Accepting sterile supplies from the surgeon
Staying with the sterile table once it is open
Standing with hands folded on chest
29
One of several formats or structured notes within a POMR (Problem-oriented Med Record)
Case management
EMR
Focused Charting
Progress Notes
30
Number of sound wave cycles generated per second by a vibrating object
Quality
Duration
Amplitude
Frequency
31
Focuses on deviations from the est. norm or abnormal findings; highlights trends/changes
Critical pathways
Focus charting
Charting by exception
Progress notes
32
When is the best time the nurse should start discharge planning for a patient?
After the congestion is treated
When the primary care provider writes the order
Right before discharge
Upon admission
33
A class about stress reduction after cardiac bypass surgery is which type of intervention
Primary
Tertiary
Secondary
34
Which are appropriate for the dx of Spiritual distress? Select all that apply
Offer to pray with the patient.
Assess for potential suicide.
Develop activities to heal body, mind, and spirit
Teach relaxation, guided imagery, and meditation.
35
RN is teaching a pt and family about hand hygiene in the home. Teach about handwashing before
And after shaking hands.
And after treatments.
Opening the refrigerator.
And after using a computer.
36
Individuals/familys/communitys relationship to stress and the reaction to stress.
Situational model
Evidence-based practice model
Ego defense model
Neuman systems model
37
pt states I just dont feel like going to work I have no energy and I cant eat or sleep
Assess the potential for suicide and make referrals
Encourage the purchased of OTC sleep aids to help with sleep
Ignore individual pt goals until the current crisis is over
Dont be concerned with self harm, pt has no indication of it
38
Multidisciplinary care plans that include pt problems, key interventions, & expected outcomes
Focus charting
Critical pathways
Progress notes
Charting by exception
39
Based on the following data, which person is likely to have the highest self-esteem?
Latino adolescent female who has strong ethnic pride
Caucasian boy who lives below federal poverty level
Adolescent who was suspended twice from high school
African American adolescent male who has severe acne
40
Which pt statement indicates understanding regarding the mode of transmission of this disease
When I go camping I will be sure to use hand gel on my hands
When I go camping, I will drink bottled water.
When I go camping, I will be sure to wear insect repellent.
When I go camping, I will be sure to wear sunscreen.
41
A circumscribed elevation of skin filled w/serous fluid on upper lip, 4cm in diameter. This is
Macule
Nodule
Pustule
Vesicle
42
After providing care, a nurse charts in the patients record. Which entry should the RN document
Apparently is asleep with eyes closed
Skin pale and cool
Appears restless when sitting in the chair
Drank adequate amounts of water
43
Which information should the nurse include in teaching staff about health care reimbursement
Sentinel events determine reimbursement issues
Home health, long-term care RNs docum. affects reimbursement
HIPAA is the basis for establishing reimbursement
Clinical info system must be installed by 2014
44
a new RN has a strategy to prevent burnout. The best strategy would be for the new RN to
Write for 10 minutes in a journal every day.
Delegate complex nursing tasks to licensed professional RNs
Use progressive muscle relaxation.
Identify limits and scope of work responsibilities.
45
Which of the following nursing interventions will assist in decreasing the risk of infection?
Teaching the patient to take a temperature
Teaching the patient about fall prevention
Teaching the patient about the effects of alcohol
Teaching the patient to select nutritious foods
46
Use of DAR (data, action, and response)
Case management
Charting by exception
Critical Pathways
Focus Charting
47
Which position is this?
Sims
Lithiotomy
Dorsal Recumbent
Knee-Chest
48
Which of the following statement about religion and spirituality is true?
Spirituality is unique to the individual.
Spirituality encompasses religion.
Religion is a unifying theme in peoples lives.
Religion and spirituality are synonymous.
49
For a rectal examination of a nonambulatory male pt, he needs to be placed in which position?
Knee-chest
Dorsal recumbent
Forward bending with flexed hips
Sims position
50
A teen with celiac disease continues to eat food she knows will make her ill. RN should
Administer antidiarrheal medications with meals.
Admonish the teen regarding her poor diet choices
Teach the patient about the food pyramid.
Assist teen in meeting diet restrictions
51
In caring for the patients spiritual needs, the nurse understands that
A caring presence involves listening to the pts wishes only.
RN must use her expertise to make decisions for the pt
Presence involves doing for the patient.
Establishing presence is part of the art of nursing.
52
Which position is this?
Dorsal Recumbent
Lithiotomy
Prone
Supine
53
The developmental stage that carries the highest risk of injury from a fall
Adulthood
School age
Older adulthood
Preschool
54
Infection comes from microorganisms outside the individual that do not exist in normal flora
Exogenous
Endogenous
55
Level is based on the type and number of nursing interventions required over a 24 hr period
Flow Sheets
Patient care summary
Acuity Records
Discharge summary forms
56
To perform a proper gynecological assessment, the RN would place the pt in which position
Dorsal Recumbent
Litotomy
Knee-chest
Sitting
57
The most appropriate CAM therapy that the nurse can recommend for excessive worry & work stress
Meditation
Acupuncture
Chiropractic therapy
Ayurvedic herbs
58
A pt asks RN what signs and symptoms are associated with chlamydia. How should the RN respond?
Dementia results if chlamydia goes untreated too long.
Small red blisters appear first and then multiply.
1st sign is frequency and burning with urination
Symptoms usually only affect women
59
The 1994 Dietary Supplement Health and Education Act impacted herbal therapies in what way?
Classified herbs as beneficial, harmful, or neutral
Allowed herbs to be sold as dietary supplements
Allowed for labeling of herbal medicines as safe
Classified herbs as natural foods
60
The nurse knows that children in late infancy and toddlerhood are at risk for injury owing to
Growing ability to explore and oral activity.
Trying to pull up on furniture
Being dropped by a caregiver.
Learning to walk.
61
When Pt on respiratory isolation must be transported, the RN
Advises other health care team members to wear masks& gowns
Places a mask on the pt before leaving the room
Get an order to prohibit pt from transport
Instruct pt to cover his mouth with tissue when sneezing
62
Acute symptoms of infection disappear
Incubation period
Convalescence
Prodromal Stage
Illness stage
63
Today, spirituality is
Equated to formal religious practice
Awareness of inner self & sense of connection w/higher being
Less important than coping with the patients illness.
Pt centered and has no bearing on the RNs belief patterns
64
Pt has a small amount of a white, thick substance on the patients uncircumcised glans penis
Tell the patient to avoid doing self-examinations
Notify his provider about a suspected STI.
Recognize this as a normal finding.
Avoid embarrassing questions about sexual activity.
65
The school nurse is assessing the tympanic membranes of a 3-year-old child by
Using an otoscope grip while pulling the auricle upward
Using an otoscope grip while pulling the auricle downward
Pulling the auricle upward and backward
66
Which advantage is there of standardized documentation forms in nursing info systems
More time to read charts
Varied clinical databases
Reduced errors of omission
Increased hospital costs
67
Which of the following preventive screenings does the RN recommend for a 50y/o male pt
Colonoscopy every 3 years
Digital rectal examination of the prostate (DRE) annually
Complete eye examination every year
Ca125 blood test once a year
68
The nursing student can help geriatric patients self-concept by using which technique?
Allowing patients extra computer time
Encouraging patients to sing
Reviewing old photos with patients
Discussing current weather
69
Includes meds, diet, community resources, and follow-up care
Standardized care plan
Patient care summary
Discharge summary forms
Flow sheets
70
A 12yo female pt complains that her periods are making her fat. RN should say
Stop snacking on sweets and replace them with vegetables
Does the weight fluctuate throughout the month?
Changes are normal with menstration; try not to get upset
i promise no one notices this but you
71
All herbal supplements should be evaluated with current pharmacological medications
True
False
72
Stroke pt is having difficulty eating. The RN includes which intervention in the plan of care
Obtain an order for antidepressant meds
Teach pt about special devices to assist with eating meals
Order the pt food that does not require utensils
Place a consult for a home health nurse
73
Clinic that is staffed by allopathic and complementary practitioners
Ayurvedic clinic
Integrative medical clinic
Naturopathic medical clinic
Healing intention clinic
74
The second heart sound (S2) occurs when
There is rapid ventricular filling
The aortic and pulmonic valves close
Systole begins
The mitral and tricuspid valves close
75
Aware of the need for Standard Precautions, the nurse is careful to
Wear eyewear when emptying a urinary drainage bag.
Don gloves when wearing artificial nails.ANS: B
Teach the patient about good nutrition.
Avoid contact with intact skin without wearing gloves.
76
Which medication could cause an abnormal drug interaction in a pt taking an antidepressant med
Ginger
Aspirin
Chamomile
Digoxin
77
The component that should receive the highest priority before a physical exam is
Preparation of the equipment
Preparation of the enviornment
Physical preparation of the patient
Psychological preparation of the patient
78
Describes the loudness, soft to loud
Duration
Amplitude
Frequency
Quality
79
A therapeutic touch practitioner scans the patients body to identify what?
The flow of Qi
Blocked chakra
Accumulated tension
Structural and functional imbalance
80
The best equipment to test central vision for preschoolers is which of the following?
Snellen test
E chart
Penlight
Reading test
81
Onset of nonspecific signs and symptoms to more specific symptoms
Prodromal Stage
Incubation stage
Illness stage
Convalescence
82
Identify a sociocultural factor that can lead to developmental problems.
Loss of stamina
Prolonged poverty
Family relocation
Childhood obesity
83
Sounds are created by air moving through smaller airways
Bronchialvesicular
Bronchial
Rhonchi
Vesicular
84
Different reactions to the same situation would be explained best by which of the following
Maturational and sociocultural factors
Restorative care
Strong financial resources
Immaturity and intelligence factors
85
Which patient is most in need of a nurses referral to adoption services?
A patient considering abortion for an unwanted pregnancy
infertile couple opposed to artificial insemination
A couple who has been attempting conception for 3 months
A woman who suffered miscarriage during her first pregnancy
86
Which interventions would take priority in a plan of care for a pt who presents with pneumonia
Assume that the patient is in pain and treat accordingly.
Observe the patient for decreased activity tolerance.
Provide the patient ice chips as requested.
Maintain the temperature at 65 F.
87
The RN sets up a nonbarrier sterile field on the pts table. Which would be contamination
RN keeps the top of the table above her waist
Sterile objects are kept within the 1 inch border
Sterile saline solution is spilled on the field
RN, who has a cold, wears a double mask
88
Depressing the area 4 cm to assess the conditions of organs
Light palpation
Deep palpation
89
Upon suspecting abuse, the school nurses best next action is which of the following?
Ignoring the findings, child abuse is a declining problem
Realizing that abuse victim usually report abusive situation
Interviewing the patient in the presence of his/her teacher
Contacting Social Services and reporting suspected abuse
90
Sounds are created by air moving through the trachea close to the chest wall
Bronchialvesicular
Bronchial
Bruit
Rhonci
91
What type of breath sound is this?
Rhonci
Normal
Wheezing
Bronchial/Vesicular breathing
92
While assessing the skin of an 82y/o male patient, nonpainful ruby red papules on the pts trunk
Tell the pt that he has a benign squamous cell carcinoma
Tell them he has basal cell carcinoma
Document cherry angiomas as a normal geriatric skin finding.
Document the presence of edema.
93
A terminally ill patient is experiencing constipation secondary to pain medication. The RN will
Contact the provider to discontinue pain medication.
Administer enemas twice daily for 7 days.
Massage the patients abdomen.
Use a stimulant laxative and increase fluid intake.
94
The nurse assesses the skin turgor of the pt by
Palpating the skin with the dorsum of the hand
Pressing the skin for 5 secs, releasing, and noting depth
Grasping skin on the back of the forearm & releasing
Inspecting the buccal mucosa with a penlight
95
RN is using the source record and wants to find the daily weights. Where should the RN look
Database
Graphic sheet and flow sheet
Medical history and examination
Progress notes
96
Which of the following best describes iatrogenic infection
Results from diagnostic or therapeutic procedure
Occurs when pt are infected with their own organisms
Involves an incubation period of 3-4 weeks before detection
Results from extended infection of the urinary tract
97
RN assists pt to ID several activities that the pt is looking forward to in life. This is
Charity
Faith
Time management
Hope
98
Provides current info that is accessible to all members of the health care team
Flow sheet
Admission nursing history forms
Discharge planning sheet
Admission sheet
99
Which information is critical for the RN to report during hand-off
The family is demanding and argumentative.
The patient has a new pain medication, Lortab.
The patient had a good day with no complaints.
The family is poor and had to go on welfare.
100
What nursing action is appropriate for a pt with C. Diff
Teach the patient cough etiquette.
Wear an N95 respirator when entering the patient room.
Place the patient on Droplet Precautions.
Use soap and water instead of hand sanitizer
101
A cancer pt asks the RN what the criteria are for hospice care. What should the nurse answer?
Completion of an advance directive
Needing assistance with pain management
Expected to live less than 6 to 12 more months
Having a terminal illness, such as cancer
102
All of this info needs to documented for a telephone report except
Who was called
Where the call was made
When the call was made
Who made it
103
Which of the following sensory changes are normal with aging?
Heightened sense of smell
Difficulty hearing low pitch
Impaired night vision
Increase in taste discrimination
104
A blowing sound is auscultated over the carotid artery. This finding is called
Right-sided heart failure.
Bruit.
Phlebitis
Clubbing.
105
Any manual method, physical or mechanical device, material that immobilizes a pt is a
Chemical restraint
Mechanical restraint
Physical restraint
106
Which position is this?
Dorsal Recumbent
Lithiotomy
Prone
Sims
107
The comprehensive abdominal examination would include, in proper order, which of the following?
Inspection, palpation, auscultation
Inspection, auscultation, palpation
Inspection, palpation, percussion
Percussion, inspection, auscultation
108
Pt is weak but refuses to use a bedpan & wants to get up to use the commode. RN should
Insert rectal tube so pt doesnt need to actively defecate
Tell the pt that he is too weak & needs to use the bedpan
Assistance from family & assist pt to get up
Put the pt on a bedpan and stay with him until finished
109
Which statement requires a professor to intervene
Older adults dont need to worry about STIs
Avoiding alcohol use will enhance your sexual functioning.
Using pillows & pain meds PRN before sex often helps w/pain
You need to tell your partner how you feel about sex
110
In assessing the spiritual health of her patients, the nurse understands that
Basis of beliefs of older people focuses on 1 or 2 factors
Spiritual beliefs change as patients grow and develop.
Spiritual health in older adults leads to peace
Older adults express spirituality by focusing on themselves
111
Female pt has brittle hair. Based on these findings, which lab test would be ordered?
Lead level
Complete blood count
Liver function test
Thyroid-stimulating hormone test
112
The step after inspection when assessing the abdomen is
Palpation
Auscultation
Deep palpation
Percussion
113
The nursing student can help geriatric patients self-concept by using which technique?
Allowing patients extra computer time
Discussing current weather
Reviewing old photos with patients
Encouraging patients to sing
114
small, circumscribed skin lesions filled with serous fluid
Pustule
Wheal
Vesicle
Papule
115
If an RN gets stuck with a needle in her hand, she is at risk for
Clostridium difficile.
Hepatitis B.
Diphtheria.
MRSA
116
Which of the following findings requires the nurse to contact the pt Dr for further exam?
Dilated pupils
A black pupil
A thin white ring along the margin of the iris
A black fundus of the eye
117
The nurse should include which of the following teaching points in the safety of adolescents
Need to be reminded to use seatbelts on long trips
Adolescents need info about the effects of beer on the liver
Parents and friends should teach adolescents how to drive.
Need unsupervised time with friends two-three times a week
118
When pt is first admit, they weigh 250lbs. The next day they weigh 256lbs. The RN should eval
Fluid loss.
Decreased nutritional reserves.
Fluid retention.
Anorexia.
119
Classification system on pts medical diagnoses that support reimbursement
Minorities
Legal Documentation
Patient Groups
Diagnostic-Related Groups
120
A pt admits that he knew for months that he had an STI but didnt report it. RN knows that pts
Do not acknowledge the importance of STI testing & treatment
Have lifestyles that subject them to repeated exposure.
Are hesitant to admit they contracted an STI.
Are uncomfortable discussing sexual health issues
121
RN knows to not use which of the following treatment products for Pediculosis humananus capitis
Fine-toothed comb
Lindane-based shampoo
Vinegar hair rinse
Pediculicide
122
Provides the most current info that has been entered into the EHR
Admission history
Admission flow sheet
Patient care summary
EMR
123
RN caring for Pt who has had unprotected sex with HIV+ partner. RN informs pt
Antiretroviral therapy has been effective in slowing disease
You may have flulike symptoms in 6 months
Have your blood drawn today to see if you were infected
I will set you up with a support group to help cope w/dying
124
Pts choose to use unconventional therapy because
They are dissatisfied with conventional medicine
It is now widely accepted by the FDA
They are willing to pay more to feel better
They want religious approval for the remedies they use
125
Which position is this?
Sims
Supine
Dorsal Recumbent
Prone
126
An incident report is
A summary report of all falls occurring on a nursing unit
Report of an RN's behavior submitted to the hospital admin.
A legal claim against a nurse for negligent care
A report of an event inconsistent with routine pt care
127
The severity of a patient's illness depends on all of the following except
Pathogenicity of the microorganism
Extent of infection
Incubation period
Susceptibility of the host
128
A basic foundational principle of chiropractic care is that
Structure and function coexist.
Subluxation will cause permanently restricted joint movement
Human beings need external hands-on care to be healthiest.
Chiropractic care is risk free.
129
When caring for a terminally ill patient, the nurse should focus on the fact that
Spiritual care is the least important nursing intervention.
Members of church or synagogue play no part in the pts care
RNs relationship w/pt allows understanding of pt priorities
Spiritual needs need to be sacrificed for physical priority
130
Which position is this?
Supine
Prone
Dorsal
Laying
131
Pt informs RN that she often becomes nauseated when riding in cars. This is a
Balance deficit
Neurological deficit
Visual deficit
Hearing deficit
132
Which of the following statements made by the new graduate nurse requires the RN to intervene?
Assessment only provide info about the effectiveness of care
Uses assessment data to see if medication is working
use data from pt assessment to determine educational needs.
Assessment helps understand their pts emotional needs.
133
The nurse explains to the patient that interventions for fall precautions include
Placing all four side rails in the up position.
Encouraging visitors in the early evening.
Placing a high risk for falls armband on the patient.
Checking on the patient once a shift.
134
The best term for breath sounds created by air moving through large lung airways is
Rhonchi.
Bronchovesicular.
Vesicular.
Bronchial.
135
Dependent upon a persons culture, development life experiences beliefs & ideas about life
Religion.
Faith.
Self-transcendence.
Spirituality.
136
To perform an examination of female genitalia the nurse would put the pt in which position
Dorsal recumbent
Sitting
Lithotomy
Knee-chest
137
During change of shift...
2 or more RNs always visit pts to review plan of care
Pt info is communicated from one RN to another
RN should ID nursing dx and clarify pt priorities
RN should exchange judgements about pt attitudes
138
Which actions would be appropriate to prevent the spread of disease using contact precautions
Transport pt quickly when going to radiology
Place pt in a room with negative airflow
Use dedicated BP cuff that stays in pts room for that pt
Wear gown, gloves, face mask, and goggles
139
The developmental self concept task known as initiative versus guilt would occur in
11-year-old student
15-year-old high school student
5-year-old kindergarten student
3-week-old neonate
140
which priority concern would require collaboration with social services to address the pt needs
The electricity was turned off 2 days ago.
The water comes from the county water supply.
The home is not furnished with a microwave oven.
A son and family recently moved into the home.
141
Which is an indication that the pt understands the directions regarding the antibiotic meds
The patient states, I will finish the antibiotic in ten days
The patient asks where to get the prescription filled.
The patient nods throughout the educational session.
The patient reads the medication prescription out loud.
142
What should the nurse ask to understand how visual alterations affect pts self-care ability
Are you able to prepare a meal or write a check?
How does your vision impairment make you feel?
Have you stopped reading books?
How do you protect yourself from injury at work?
143
A spike in postop infection; this type of health care-associated infection is
Exogenous
Iatrogenic
Endogenous
Nosocomial
144
The reason for writing in indelible ink on the surgical site the word correct is to
Label the correct patient.
Comply with the surgeons preference.
Distinguish the correct surgical site.
Adhere to the correct regulatory standard.
145
Which of these should be reviewed when observing a patient? (Select all that apply)
Body type/movements/Gait
Age
Gender/Race
Body color, odor, hygiene and grooming
146
Female Pt of muslim faith is on hospice. The plan of care would include
Female health care workers care for the body after death
Male health care workers care for the body after death
Body preparation for cremation.
Body preparation for autopsy.
147
Infection that occurs when part of the pts flora becomes altered and overgrowth results
Exogenous
Endogenous
148
The pt states that he is a spiritual person but doesnt practice any specific religion. This is
Indicate a strong religious affiliation.
Indicate a lack of faith.
contradictory
Reasonable.
149
RN recognizes the new RN ability to determine pt safety risks when which behavior is observe
Disposing of used needles in a red needle container
Raising all four side rails per family request
Checking patient identification once every shift
Multitasking by gathering two patients medications
150
A nurse has provided care to a patient. Which entry should the nurse document in the pt record?
Incision 1in in length w/out redness drainage or edema
Patient seems to be in pain and states, I feel uncomfortable
Patient is hard to care for and refuses all tx and meds
Status unchanged, doing well
151
RN determines that it is especially important to perform which focused exam for a premature pt
Cardiac
Hearing acuity
Ophthalmic
Respiratory
152
pt needs and process, individual therapies, pt education, & discharge planning are conveyed
Communication
Report
Diagnostic-Related Groups
Education
153
The nurse knows that the ability to recognize and interpret stimuli is known as
Reception
Perception
Reaction
Sensation
154
Provides baseline data to compare with changes in the pts condition
Admission nursing history forms
Pt care summary
EMR
Flow sheets
155
Which statement indicates that the staff needs more education about informatics
The RN should be able to discover, retrieve, and use info
Computer competency means the RN is competent in informatics
Need to know how to apply scientific evidences from database
156
While caring for a pt who vomits without warning, the nurse has contaminated hands Next the RN
Wash hands with an antimicrobial soap and water.
Use an alcohol-based waterless hand gel.
Instruct the patient to wash his face and hands.
Clean hands with wipes from the bedside table.
157
Which behavior should the nurse implement to reduce data entry errors in the computer system
Share password with only one other staff member.
Chart on the computer immediately after care is provided.
Print out and review computer nursing notes at home.
Use the same password all the time
158
Individual risk factors that can threaten safety are (Select all that apply)
Sensory or communication impairment
Lack of sensory awareness
Impaired mobility
Lifestyle
159
Which of the following is correctly charted according to the 6 guidelines for quality recording
Respirations rapid; lung sounds clear
Crying, states she doesnt want visitors to see her like this
Had a good day. Up and about in room
Was depressed today
160
RN is preparing to assess the external genitalia of a 25y/o woman of Chinese descent. First
Drape the patient to enhance patient comfort.
Place the patient in the lithotomy position.
Assess the pts feelings and explain the purpose of the exam
Ask the pt if she would like her mom to be present
161
When observing a fire, a nurse should immediately
Assist the pt to a safe place
Close all windows and doors to contain the fire
Attempt to extinguish the fire
Report the fire
162
Lumps on the testis is a sign of
Sexually transmitted infection
Testicular cancer
Diuretic use
Inguinal hernia
163
The pt is having a difficulty dealing with AIDS dx. States Im isolated from my family RN should
Tell pt if your father cant get over it, forget it, move on
Assure the pt that his father will accept his situation soon
Tell the pt has no control & has to face consequences
Use therapeutic communication to establish trust and caring.
164
RN prepared an audiotaped exchange with another RN of info about a pt. This is
Record.
Referral.
Report.
Consultation.
165
Manifests signs and symptoms to types of infection
Prodromal stage
illness stage
Convalescence
incubation stage
166
The CAM therapy that is known to alter immune function is which of the following
Breath work
Imagery
Biofeedback
Acupuncture
167
During the eval stage of the critical thinking model applied to a pt coping with stress RN will
Reassess stress related symptoms compare w/expected outcomes
Establish short- and longterm goals w/pt experiencing stress
nursing interventions to promote the pt adaptation to stress
ID stress management interventions for achieving outcomes
168
The organization that facilitates the evaluation of alternative medical treatments is the
U.S. Department of Health and Human Services.
National Center for Complementary and Alternative Medicine.
Food and Drug Administration.
American Holistic Nurses Association.
169
Focusing on breathing and one part of the body at a time
Progressive relaxation training
Group psychotherapy
Group biofeedback
Meditation
170
Important skin cancer prevention for a pt who is taking oral contraceptives
Applying water-based sunscreen only before swimming
Extra precautions in the sun secondary to the prescription
Using tanning bed daily for 7 days before college break trip
Applying broad-spectrum sunscreen of SPF 5
171
Which action would most likely increase the risk of a pt contracting a UTI
Providing perineal hygiene at least once a shift
Reusing the pt graduated receptacle to empty the bag
Emptying the urinary drainage bag once a shift
Allow drainage bag port to touch the graduated receptacle
172
Pt wants to have an elective abortion. RNs religious values are strongly opposed. RN should
Continue to care for the pt limit conversation
Refer pt to a family planning center
Attempt to educate pt about the consequences
Because of moral issues, another RN will care for Pt
173
Describes sounds of similar frequency and loudness
Quality
Amplitude
Frequency
Duration
174
A long-term outcome for an individual who is learning relaxation therapy is
Increasing delta brain activity.
Having no tension in his life.
Increasing the focus on himself.
Identifying tension in body & consciously releasing tension
175
Drawbacks of complementary and alternative therapies would be all of the following except
Minimal supportive research studies.
Strong support by allopathic medical providers.
Lack of evidence-based guidelines.
Lack of long tradition of therapies taught in education
176
Subjective, objective, assessment, and plan
PIE
Progress Note
SOAP Note
POAS Note
177
Physical injury, neglect, malnutrition, bruising, fear of care giver are all signs of
Pneumonia
Abuse
Mental illness
Risk for falls
178
Which interventions would indicate the ability to recognize the inflammatory response
Rest, ice, compression, and elevation
Orient to date, time, and place
Passive range-of-motion exercises
Turn, cough, and deep breathe
179
The primary purpose of a pts med record is to
Provide the nurse with a defense against malpractice
Satisfy requirements of accreditation agencies
Communicate accurate, timely info about the pt
Provide validation for hospital charges
180
Describes length of time that vibrations last
Quality
Amplitude
Frequency
Duration
181
A patient is being discharged home. Which information should the nurse include?
Acuity level
Community resources
Standardized care plan
Kardex
182
Medical hx of asthma, eczema, and allergic rhinitis. Physical finding on nasal exam is
Yellow discharge
Puffiness of nasal mucosa
Pale nasal mucosa
Polyp
183
An elderly pt has been on high doses of antibiotics & is experiencing a sudden loss of hearing
Tell the pt that rapid hearing loss is normal in the elderly
Hearing loss usually occurs with thinning of the eardrum
Stop antibiotic use until the physician responds.
Tell the pt that older pts often lose low-frequency hearing
184
Older adults may have changes in sexual functioning. What can increase sexual stamina. SATA
Plan sexual activity around when the couple feels rested
Eat well balanced meals and eliminate excess fats and sugars
Encourage intimate touching, such as hugging and kissing.
Avoid alcohol and tobacco.
185
Purpose of unconscious ego defense mechanisms is which of the following for the individual
Evaluate an event for its personal meaning.
Facilitate the use of problem-focused coping.
Protect against feelings of worthlessness and anxiety.
Trigger the stress control functions of medulla oblongata
186
RN encourages which of the following to reduce childrens stress regarding homework assignments
Prevention of iron deficiency anemia
Speech articulation skills
Time management skills
Routine preventative health visits
187
Which info is critical for the nurse to include during hand-off about a pt with chest pain
Had poor results from the pain medication
Sharp pain of 8 on a scale of 1 to 10
Pupils equal and reactive to light
The family is a pain
188
Pt has a urinary cath. After the RN empties the collection bag and disposes of the urine, next
Remove gloves and dispose of in garbage.
Use alcohol-based gel on hands.
Remove eye protection and dispose of in garbage.
Wash hands with soap and water.
189
A holistic nurse would be a nurse who
Knows about resources for fresh herbs.
Provides spiritual literature to patients.
Recognizes the mind-body-spirit connection.
Recommends a vegan diet for all patients.
190
RN would be most concerned about risk of malnutrition for a pt with which sensory deficit
Disequilibrium
Xerostomia
Cataracts
Peripheral neuropathy
191
The nurse knows that a patient does not fully understand the changes of aging when the pt says
Hormones of sexual regulation decrease with age
Orgasms are no longer achievable after menopause.
I will no longer ovulate after menopause.
As men age, their ability to sexually perform may decrease.
192
How should you clean the stethoscope
Running warm water over stethoscope for patient comfort
Cleaning stethoscope with alcohol
Cleaning stethoscope with Betadine
Using alcohol-based hand disinfectant
193
Based on the following data, which person is likely to have the highest self-esteem?
Caucasian boy who lives below federal poverty level
Adolescent who was suspended twice from high school
African American adolescent male who has severe acne
Latino adolescent female who has strong ethnic pride
194
Whats required after exposure to blood by a cut from a scalpel in the perioperative area
Removing sterile gloves and disposing of in kick bucket
Providing a medical evaluation of the nurse to the manager
Placing the scalpel in a needle safe container
Testing the patient and offering treatment to the nurse
195
Which of the following would most immediately threaten an individuals safety
70% Humidity
A sprained ankle
Lack of water
unrefrigerated fresh vegetables
196
Abnormal thyroid shape during the physical exam. RN offers the pt and observes her drinking to
Visualize the uvula and soft palate.
Test the patients gag reflex.
Evaluate for exostosis.
Visualize an enlarged thyroid gland.
197
15yo pt is unsure about getting the HPV vaccine. The RN should respond by saying
Ask the pt how many sexual partners shes had in the past
Remind her that her mother knows best
Promote importance of the vaccine, she should get it asap
Ask the pt what concerns she may have about the vaccination
198
Blowing sound over the carotid artery
Bruit
Phlebitis
Clubbing
Right-sided heart failure
199
Integrating all pt info into one record regardless of the # of times a pt is treated
Electronic medical record
Electronic problem record
Electronic charting record
Electronic health record
200
Biofeedback will
Allow me to manipulate my stressed out joints.
Direct my energies in an intentional way when stressed
Help w/thoughts feelings & physiological response to stress.
Let me assess and redirect my energy fields.
201
Sites for HAI: Urinary tract, surgical or traumatic wounds, respiratory tract, bloodstream
False
True
202
The nurse and the patient have the same religious affiliation. Because of this, the nurse
Can assume that they have the same spiritual beliefs.
Must use an assessment tool to assess the patients beliefs.
Can skip the spiritual belief assessment.
Should not impose her personal values on the patient.
203
Pt on antidepressants states I feel happier but my sex drive is gone. Which RN dx is priority
Ineffective coping
Sexual dysfunction
Deficient knowledge about contraception
Risk for self-directed violence
204
Involves repressing an anxiety-producing conflict & transforming it into a nonorganic symptoms
Dissociation
Compensation
Denial
Conversion
205
A nurse is charting on a patients record. Which action is most accurate legally?
Uses correction fluid to correct error
Charts legibly
States the patient is belligerent
Writes entry for another nurse
206
Aware of the potential for health care associated infection R/T a PICC, the nurse is careful to
Use nonallergenic tape and dressings on the patient.
Utilize local anesthetic on the site as ordered.
Prepare the skin with 2% chlorhexidine gluconate.
Select catheter of appropriate size for the appropriate vein
207
Learning the nature of an illness and the individual patient's response
Auditing
Education
Legal documentation
Research
208
A preceptor is working with a new RN on documentation. Which requires intervention
The new nurse ends each entry with signature and title
The new nurse uses a black ink pen to chart
The new nurse keeps the password secure.
The new nurse charts consecutively on every other line
209
When considering the ego defense mechanism of conversion, the nurses next best action is
Recommend a regular exercise program.
Recommend acupuncture.
Confront the patient on malingering.
Obtain history of any recent life stressors.
210
Teen pt informs RN that hes unsure about his sexuality. RN est. a trusting relationship by
Dont worry. Its just a phase you will grow out of.
Having questions about sexuality is normal.
Those are abnormal impulses. You should seek therapy.
At your age, it is normal to be curious about both genders.
211
hx of asthma, eczema, & allergic rhinitis, the RN expects which physical finding on nasal exam?
Pale nasal mucosa
Polyp
Yellow discharge
Puffiness of nasal mucosa
212
Which of the following comments by the patient would indicate a need for further education?
I will schedule an appt with a chimney inspector next week
when its cold out, i can warm up my car in the garage
Change the CO detector batteries at daylight savings time
If dizzy while using the heater, have it inspected
213
If an error is made while recording, the nurse should
Obtain a new RN's note and rewrite the entries
Leave a blank space in the note
Erase it or scratch it out
Draw a single line through the error and initial it
214
SOAP with intervention and evaluation added
PIE
Progress note
SOAPIE
Focus Charting
215
One benefit of meditation over other forms of behavioral therapy is that meditation
Balances insulin and other body hormones.
Improves communication skills.
Cures hypertension.
Does not require memorization.
216
Which position is this?
Standing
Sitting
Knee-Chest
Prone
217
Database, problem list, care plan, and progress notes
EHR
EMR
POMR
CAT
218
HPV vaccines are recommended to prevent
Vaginal discharge.
Swollen perianal tissues.
Cervical cancer.
Genital lesions.
219
How does the nurse proceed to assess for kidney inflammation?
Uses deep palpation posteriorly
Inspects abdomen for abnormal movement
Lightly palpates each abdominal quadrant
Percusses posteriorly costovertebral angle at scapular line
220
Family cry and scream after learning of pts death. This is Bowlby Attachment Theory stage of
Disorganization and despair
Yearning and searching
Bargaining
Numbing
221
Which assessment of the pt would indicate an adaptation to a hearing deficit r/t presbcusis
The pt turns one ear toward the nurse during conversation
The pt asks the nurse to speak loudly during conversations.
The pt frequently cleans out his ears with a cotton swab
The patient isolates himself from social situations.
222
A trauma survivor is requesting sleep meds because of bad dreams. Concerned about PTSD RN asks
Can you tell me when you wake up?
Are you reliving your trauma?
Can you describe your phobias?
Are you having chest pain?
223
RN creates a referral to pastoral care when he/she realizes that the patient is in need of
Spiritual care.
Transfer to the psychiatric unit.
Return to religious affiliation.
Psychiatric care.
224
Interval between entrance of the pathogen into the body and appearance of the symptoms
Convalescence
Incubation period
illness stage
Prodromal stage
225
The pt most at risk for developing an infection is the pt who
Is recovering from a right total hip arthroplasty.
Has been admitted for stabilization of atrial fibrillation.
Has been admitted with dehydration.
Is in observation for chest pain.
226
Loud low-pitched rumbling coarse sounds during insp or exp that sometimes clear by coughing
Stridor
Rhonchi
Bronchial
Crackles
227
Which situation shows the RN has a good understanding about auditing & monitoring pt HR
Care not documented is still care provided
Compares tx to find the best outcome
Determines that standards of care are met by reviewing pt HR
reimbursement is based on the DRG documented in pts records
228
An assessment finding example for caregiver strain would be which of the following?
Caregiver can identify respite care provider.
Caregiver routinely creates a weekly menu plan.
Caregiver attends religious service.
Caregiver has not received medical care when ill.
229
The HPV vaccine
Requires a three-injection series to be fully effective.
Is safe for children over the age of 5 and lasts 10 years.
Is recommended only after a female becomes sexually active.
Will prevent a female from ever getting cervical cancer.
230
Physiological symptoms of a stress response include all of the following except
Constricted pupils.
Tachycardia.
Tachypnea.
Elevated blood pressure.
231
Which of the following behaviors alerts the nurse to consider the need for restraint?
The patient does not sleep and continues to ask for items.
The patient refuses to call for help to go to the bathroom.
The patient gets confused regarding the time at night.
The patient continues to remove the nasogastric tube.
232
Which RN dx for psychological concerns for a pt with both hearing and visual sensory impairment
Social isolation
Impaired physical mobility
Risk for falls
Self-care deficit
233
Pt responds correctly to questions and instructions but cannot form words coherently. This is
Sensory Aphasia
Combination Aphasia
Expressive Aphasia
Receptive Aphasia
234
Which of the following is the most important point to be included in education about smoking
It affects the cilia lining the upper airways in the lungs
Smoking tobacco products can be very expensive.
Smoke from tobacco products clings to your clothing and hair
Smoking can affect the color of the patients fingernails.
235
The therapy that is more effective in tx physical ailments than preventing disease
Alternative
Allopathic
Complementary
Mind-body
236
While washing hands, the nurse touches the sink. What is the next action the nurse should take?
Extend the handwashing procedure to 5 minutes.
Rinse and dry hands, and begin assisting the physician
Repeat handwashing using antiseptic soap,
Inform the physician and recruit another nurse to assist.
237
nursing action that would increase a pt risk for developing a health care associated infection
Urinary cath bag placed below the level of the bladder
Clean technique for inserting a urinary catheter
Use a sterile bottled solution more than once in 24 hrs
Use of surgical aseptic technique to suction an airway
238
Pt is 54y/o, 148lbs, 5ft 8in tall. The nurse realizes that this pt is
Underweight.
Overweight.
Obese.
At his desired weight.
239
Which behavior by a student nurse will require intervention
The student nurse reads the patients plan of care.
The student nurse shares patient information with a friend.
The student nurse documents meds administered to the pt
The student nurse reviews the patients medical record.
240
Which intervention will be most effective in helping pt resume sexual activity after ostomy
Teach about intimate activities that incorporate the ostomy
Reassure the pt that people resume sex the same week
Inform pt about a support group for people with ostomies
Discuss ways to adapt to new body image
241
Which type of breath sound is this?
Wheeze
Amphoric
Rhonci
Pulmonary Friction Rub
242
Pt tells RN that he wants to have sex with his spouse but is afraid to in a hospital. RN should
Stress importance of using contraceptives
Arrange a schedule for intimacy when pt is well rested
Ask pt if it would be ok to have a monitor on in the room
Educate pt about dangers of strenuous activity
243
In discussing spiritual well-being, the nurse identifies that the vertical dimension involves
Providing an attitude of something to live for
Confidence in something for which there is no proof.
The positive relationships/connections people have w/others
The transcendent relationship between a person and God.
244
Objective, ongoing reviews to determine the degree to which quality improvement standards R met
Auditing
Legal Documentation
Research
Communication
245
Pt asks the RN for her phone number. How should the RN handle this situation
Give the patient false information to appease him.
Ask a coworker to take over care for this patient.
Redefine the boundaries of professionalism.
Give the pt her number but ask that he call after work hours
246
What is the involuntary motion of retracting the body from painful stimuli?
Perception
Reception
Reaction
Sensation
247
The patient is admitted with chronic back pain. The nurse who is caring for this patient should
Look at how pain influences the patients ability to function
Realize that the pts only goal is relief of the back pain
Help pt realize that theres no hope of relief from pain
Focus on finding quick remedies for the back pain.
248
The expected inspiratory-to-expiratory phase of this normal vesicular breath sound is
The expiration phase is 2times longer than the inspiration
Inspiratory phase is 3times longer than the expiratory phase
The expiration phase is longer than the inspiration phase.
The inspiratory and expiratory phase are exactly the same
249
Which type of breath sound is this?
Wheezing
Rhonci
Plural rub
Stridor
250
RN is teaching guided imagery to a prenatal class. ID an example of guided imagery
Listening to music
Sensory peaceful words
Singing
Back massage
251
Which response by the nurse is most effective in establishing an open rapport with a patient?
Share an anecdote.
Inform the patient that all encounters are confidential.
Ask the pt what concerns/fears she has related to the visit
Tell pt she must be honest about sexual experience shes had
252
Pt says they believe in life after death, now im not sure The RN says here is. RN is trying to
Provide hope.
Strengthen the patients religion.
Support the horizontal dimension of spiritual well-being.
Support the patients agnostic beliefs.
253
When assessing the pts thorax, the nurse should
Compare symmetrical areas from side to side
Change the position of the stethoscope between insp. and exp
Complete the left side and then the right side
Begin with the posterior lobes on the right side
254
Pediatric stressors related to self-esteem reflect which maturational school age category
Preadolescence
Elementary school age
Early adulthood
Adolescence