During the evaluation phase, the nurse may reach which the following conclusions? SATA

The problem was partially resolved, revisions to the care plan are needed., The risk is being prevented but risk factors are still present., The problem was solved, or the risks were eliminated., The goals were met but the actual problem still exists.

Identify signs and symptoms of COPD. SATA

Barrel Chest 1:1 ratio, Rhonchi

Which of the following is an appropriate nursing diagnosis?

Risk for injury related to impaired mobility

What are the three different types of interventions SATA

dependent, collaborative, Independent

When would you take your pts vital signs? SATA

Before and after surgery, Distress symptoms, Per agency routine

What does the RICE acronym stand for?

R: rest I: ice C: compression E: elevation.

Which of the negative reflexes should the nurse be concerned about? SATA

Patellar, Corneal, Gag (most of the time)

Which statement belongs in the evaluation phase of the nursing process?

Goal met: Patient maintained O2 sat >92% on RA consistently.

What are the possible causes of increased tactile fremitus? SATA

Pneumonia, Congestive Heart Failure

A patient’s lab results come back with abnormally high CK and troponin levels. What does this indicate?SATA

Skeletal muscle damage, Cardiac muscle damage

Which principles are used for a decision that is in pt’s best interest while preserving integrity of all involved? SATA

Autonomy, Justice, Beneficence, Veracity

A SMART goal should be? SATA

Time-limited, Measurable, Specific single action, Attainable

Informed consent includes....? SATA

Usually is in writing, Study purpose, length, procedures, risks and benefits, May be withdrawn at any time

Delayed capillary refill indicates...? SATA

Decreased cardiac output, Poor tissue perfusion, Hypotension, Reduced vascular volume

In the evaluation phase of the nursing process, the nurse may do which of the following?

Terminate the plan of care., Modify the plan of care., Continue the plan of care.

studbud

Final quiz fall 2023

99 termsStudBud Administration174 plays

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Questions 99

Answers

1
The Glasgow Coma Scale is used to assess
Amount of CO2 exhaled
Level of consciousness
Ability to keep balance
An individual’s risk of entering a coma
2
In which abdominal quadrant is the liver primarily located?
Right lower quadrant
Left upper quadrant
Right upper quadrant
Left lower quadrant
3
Which auscultation point provides the loudest heart sounds?
Aortic
Erb’s point
Lub-dub
tricuspid
4
The time interval when the ventricles relax and fill with blood is called?
Systole
Peristalsis
Diastole
Stenosis
5
Which valve can be heard closing over the Left 4th intercostal space?
Pulmonic
Aortic
Tricuspid
Mitral
6
Which of the following is an example of an etiology statement?
Symptoms of
AEB
Signs of
Related to
7
What normal heart sound is heard when the semilunar valves close?
whooshing
Lub
Tah-Lub
Dub
8
What disease causes excess hair growth in women?
PCOS
Winter
Hirsutism
Alopecia
9
During the evaluation phase, the nurse may reach which the following conclusions? SATA
The problem was partially resolved, revisions to the care plan are needed.
The risk is being prevented but risk factors are still present.
The problem was solved, or the risks were eliminated.
The goals were met but the actual problem still exists.
10
What expected abnormal breath sound would you hear in a patient with COPD and Pneumonia?
Stridor
Rales
Wheezing
Rhonchi
11
When listening, you hear blowing sounds moving through larger airways, which breath sounds are you hearing?
Vesicular
Bronchial
Bronchovesicular
Rubs
12
Implementation is the ______ phase of the nursing process
last
investigation
education
Action
13
Woods lamp test requires (SATA)
Sunscreen
Heat resistant glove
Dark room
Cleansed skin
14
Identify signs and symptoms of COPD. SATA
Barrel Chest 1:1 ratio
Rhonchi
Wheezing
Barrel Chest 1:2 ratio
15
Which of the following is an appropriate nursing diagnosis?
Type 2 diabetes mellitus related to obesity AEB BMI of 32
Constipation AEB no bowel movement for 3 days
Acute confusion AEB morse fall risk score of 85
Risk for injury related to impaired mobility
16
What are the three different types of interventions SATA
dependent
collaborative
combine
Independent
17
Your Patient needs and ABG, what test will you do?
Romberg Test
Allen’s test
Guaiac Test
Homan’s Test
18
True or False: It is important to eat a hearty meal 6 hours before an endoscopy to ensure energy for the procedure?
False
True
19
How often should a patient change positions?
6 hours
1 hour
2 hours
4 hours
20
True or False: In a normal/healthy adult, the kidneys should be palpable.
False
True
21
True or False EBP studies are always quantitative
False
True
22
When would you take your pts vital signs? SATA
Before and after surgery
Distress symptoms
Per agency routine
Every time they come back from the bathroom
23
What does the RICE acronym stand for?
R: reality I: injury C: cast E: eye-opening response.
R: really I: icy C: coldy E: evalve.
R: rest I: ice C: compression E: elevation.
R: referral I: instance C: coldness E: evaluation.
24
An electrocardiogram is a diagnostic test for cardiac rhythms. T/F?
False
True
25
Which patient can raise the arm against gravity, but not resistance?
Grade muscle strength of 4
Grade muscle strength of 5
Grade muscle strength of 2
Grade muscle strength of 3
26
What is the name of a 3 part nursing diagnosis?
Risk
Problem centered
Syndrome
Health promotion
27
You take your pts temperature at 0400, would the temp be at the coldest or warmest part of theday?
Warmest
Coldest
28
What abnormal breath sound would you find with fluid filled/ collapsed small airways?
Crackles
Rhonchi
Wheezes
Stridor
29
What is the normal respiratory percussive sound?
Dullness
Stony dullness
Resonance
Hyperresonance
30
Where would a nurse percuss to assess kidney tenderness?
Over the liver
Over the costovertebral angle
Over the bladder
Over the spleen
31
“I wish I could afford a new car like yours, but all my money goes to my student loans" Is what type of communication?
Assertive
Passive Aggressive
Passive
Aggressive
32
Which of the negative reflexes should the nurse be concerned about? SATA
Blinking of the eyes
Babinski
Patellar
Corneal
Snout
Gag (most of the time)
33
Which statement belongs in the evaluation phase of the nursing process?
Risk for infection R/T indwelling urinary catheter.
Lungs clear to auscultation bilaterally.
Patient will consume greater than 75% of meals today.
Goal met: Patient maintained O2 sat >92% on RA consistently.
34
What is an abnormal finding?
Skin folds intact
Skin warm & dry
Even hair distribution
Yellowing of skin
35
When establishing goals, collaboratively with a patient, it provides direction and selecting interventions. T/F
False
True
36
What stage of the 5 part nursing process is diagnosing?
1
5
3
2
37
What are the possible causes of increased tactile fremitus? SATA
Pneumonia
Congestive Heart Failure
Pneumothorax
Pleural Effusion
38
When reporting SHARE, the S stands for “Standardize all content” ? T/F
True
False
39
A patient’s lab results come back with abnormally high CK and troponin levels. What does this indicate?SATA
Cardiac stretch
Skeletal muscle damage
Cardiac muscle damage
Inflammation
40
Someone who is A&O x2 would answer which questions correctly?
Place, Time
Person, Situation
Person, Place
Person, Time
41
The nurse completes the implementation phase by charting True or False?
false
true
42
Which principles are used for a decision that is in pt’s best interest while preserving integrity of all involved? SATA
Autonomy
Justice
Beneficence
Veracity
43
Which theorist does the “Human Need Theory” belong to?
Madeline Leininger
Jean Watson
Dorothea Orem
Virginia Henderson
44
A SMART goal should be? SATA
Rounded
Time-limited
Measurable
Specific single action
Attainable
45
Informed consent includes....? SATA
Usually is in writing
Study purpose, length, procedures, risks and benefits
Terms of payment for participation
May be withdrawn at any time
46
Which theorist does the “Theory of Human Caring” belong to?
Madeline Leininger
Virginia Henderson
Jean Watson
Dorothea Orem
47
When assessing a pt w/ absent bowel sounds, what is the minimum listening per quadrant to confirm absent tones?
7 minutes per quadrant
2 minutes per quadrant
3 minutes per quadrant
5 minutes per quadrant
48
Delayed capillary refill indicates...? SATA
Decreased cardiac output
Poor tissue perfusion
Hypotension
Reduced vascular volume
49
In the evaluation phase of the nursing process, the nurse may do which of the following?
Terminate the plan of care.
Describe the human response to an illness or condition.
Modify the plan of care.
Continue the plan of care.
50
PERRLA is used to assess which cranial nerve?
Oculomotor (III)
Optic Nerve (II)
Vestibulocochlear (VIII)
Trigeminal (V)
51
“Goal met: The patient consumed 75-100% of meal trays today” belongs in which phase of the nursing process?
Evaluation
Planning
Implementation
Diagnosis
52
Avoid __________ whenever possible
Confronting others
Apologizing
Conflict
Assertiveness
53
What could cause a false high blood pressure? SATA
Arm above heart
Arm below heart
Cuff too wide
Cuff too narrow
54
How long should it take for 2+ pitting edema to rebound?
15-30 sec
>30sec
Immediately
10-15 sec
55
Which theorist does the “Sunrise Model” belong to?
Virginia Henderson
Dorothea Orem
Madeline Leininger
Jean Watson
56
A goal will always start with?
Patient should
Patient must
Patient won’t
Patient will
57
Select all the P’s that are used to assess neurovascular compromise. SATA
Pain
Paralysis
Pallor
Paresthesia
Pulselessness
Poikilothermia
58
Select the appropriate instructions for preparing for a colonoscopy, SATA
Solid, greasy foods are recommended the day before the procedure.
Drinking red liquids is highly recommended.
The colon should be cleared
Clear liquids are permitted the day before procedure
59
Which of the following is likely indicated by elevated levels of BUN (blood urea nitrogen) and creatinine?
Kidney dysfunction
Kidneys functioning properly
Hyperthyroidism
Liver cirrhosis
60
The MAIN reason for documentation is…?
Legal
None of the above
Communication
Education
61
10. What categories are included in Braden Risk scale? (SATA)
Friction & shearing
Mobility
Activity
Nutrition
Sensory & perception
Moisture
62
3+ pitting edema is how many millimeters deep?
8
6
2
4
63
Which is the incorrect example of a nursing plan?
The Patient will consume over 80% of their meals today 11/28/23
The Pt will demonstrate the use of an IS ten times within every hour
The Pt must demonstrate the correct use of a cane and walker
The Patient will be accounted for all meals within 7 days
64
Which of these are direct interventions? SATA
Medication administration
ADL’s
Calling a provider
restocking supplies
65
an ethical theory that determines the morality of an action based on a set of rules and principles.
Deontology
Consequentialsim
utilitarianism
Contractualism
66
Which of the following is NOT a proper NANDA nursing diagnosis label?
Situational low self esteem
Impaired oral mucous membrane
Hyperthermia
Pneumonia
67
Your patient has SOB that is relieved by lying down, they have...
Bradypnea
Platypnea
Orthopnea
Dyspnea
68
What is the 6th vital sign?
Pulse
Oxygen
Temperature
Pain
Respiration rate
69
What information would a capnography reading give?
A device placed on the patient’s head to measure circumference.
CO2 Levels measured on expiration
CO2 levels measured on inspiration
Measures Broncholvesicular dilation
70
Nursing interventions focus on? SATA
improving health via health promotion
teaching, treating &providing physical care
Preventing complications& reducing risk factors.
assessing to observe change incondition
71
Which term is NOT in the Musculoskeletal assessment? SATA
Stent
Effusion
Subluxation
Lesion
Tremors
Friction rub
72
Which assessment takes two people?
Pulse Pressure
Manual Blood Pressure
Proctalgia ID
Pulse Deficit
73
Your pt is in a hypertensive crisis, what would you expect their blood pressure to be?
120/80
160/100
90/60
210/130
74
Professional dress code consisted of sweatpants, strong cologne, exposed tattoos, open toe shoes. T/F?
False
True
75
What could JVD indicate?
Thyroid cancer
Tracheal displacement
Parkinson’s disease
Cardiopulmonary disease
76
The evaluation phase of the nursing process includes which of the following?
Administering medications ordered by the doctor.
Describing the human response to an illness or condition.
Establishing SMART goals collaboratively with the patient.
Determining the patient’s progress towards goals.
77
What are the main sites you might assess for a bruit? SATA
Radial
Carotid
Aortic
Posterior tibial
78
Which of the following vital signs is under both voluntary and autonomic control?
SP02
Pain
Pulse
Respiration
79
Which of the following could describe the following vitals? SATA BP-180/100 Pulse:45RR-18 T-102.9 SPO2-98%
Hyperthermia
Tachycardia
Hypertension
Hypoxia
80
Define dysphagia
Impaired speech and language understanding
Difficulty swallowing
Difficulty speaking
Poor muscle coordination
81
What step is planning in the nursing process
First step
Second step
Fourth step
Third step
82
Pt. has an Apical pulse of 130, Radial pulse of 100 and BP 120/100 what is their pulsepressure?
10
29.5
20
30
83
Stage 4 PI include full thickness with tendon or bone exposed ( true or false)
True
False
84
Erythema is.....
Yellowing of skin
Superficial redness
Bluish color
Pale color
85
What does a Type 4 on the Bristol Stool Chart indicate?
Severe constipation
Normal, healthy stool
Diarrhea
Unhealthy dietary habits
86
What is the first step to take when assessing the abdomen?
Palpate for tenderness
Percuss to assess for resonance
Inspect for any visible abnormalities
Auscultate bowel sounds
87
Which theorist does the “Self-Care Theory” belong to?
Madeline Leininger
Virginia Henderson
Dorothea Orem
Jean Watson
88
Which of these is not part of the “5 Rights of Delegation”?
Circumstance
Medication
Person
Supervision
89
A pt leaves the unit for an MRI study. Upon return, the UAP completes an assessment, this IS appropriate delegation T/F?
False
True
90
What are some nursing considerations for your cardiac cath patient? SATA
Early ambulation
Lie flat for at least 2 hours
Assess the 6 P’s
Massage cath site
91
True/False: Over-delegation a form of ineffective delegation?
False
True
92
Which of the following could describe the following vitals? SATA BP-88/54 Pulse-145 RR-14T-98.9 SPO2-98%’
Hypotension
Eupnea
Hypertension
Tachycardia
93
A positive Romberg Test looks like
Radioactive substances that detect hotspots.
Cannot maintain foot stance; moves feet apart to maintain stance.
Sway slightly, and maintains an upright posture and foot stance.
For both legs, able to rub their heels to the shin.
94
Protect PHI by logging out of computer, trashing important documents before leaving, etc. T/F?
True
False
95
What tasks are delegable to a UAP? Select all that apply.
gastrostomy feeding
Post mortem care
Vitals
Suction chronic trachs
96
When can a UAP complete blood glucose checks?
Never
When trained and allowed by the facility
Only on patients who are diabetic
Always
97
What are the possible causes of decreased tactile fremitus? SATA
Congestive Heart Failure
Pleural Effusion
Pneumonia
Pneumothorax
98
Which region of the abdomen is the bladder primarily located?
Hypogastric
Umbilical
Lumbar
Epigastric
99
Where should you check skin turgor on elderly patient?
Foot
Elbow
Hand
Clavicle

Final quiz fall 2023 Flashcards | StudBud