Which response by the nurse is most effective in establishing an open rapport with a patient?

Inform the patient that all encounters are confidential.

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

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.

The 1994 Dietary Supplement Health and Education Act impacted herbal therapies in what way?

Allowed herbs to be sold as dietary supplements

Which statement indicates that the staff needs more education about informatics

Computer competency means the RN is competent in informatics

When Pt on respiratory isolation must be transported, the RN

Places a mask on the pt before leaving the room

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

Impaired circulation due to medication.

Female pt has brittle hair. Based on these findings, which lab test would be ordered?

Thyroid-stimulating hormone test

In assessing the spiritual health of her patients, the nurse understands that

Spiritual beliefs change as patients grow and develop.

The RN assesses for equipment-related accidents when using

Sequential compression devices.

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

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

While washing hands, the nurse touches the sink. What is the next action the nurse should take?

Repeat handwashing using antiseptic soap,

Whats required after exposure to blood by a cut from a scalpel in the perioperative area

Testing the patient and offering treatment to the nurse

The nurse should include which of the following teaching points in the safety of adolescents

Adolescents need info about the effects of beer on the liver

An assessment finding example for caregiver strain would be which of the following?

Caregiver has not received medical care when ill.

A holistic nurse would be a nurse who

Recognizes the mind-body-spirit connection.

Pt tells RN that he wants to have sex with his spouse but is afraid to in a hospital. RN should

Arrange a schedule for intimacy when pt is well rested

which priority concern would require collaboration with social services to address the pt needs

The electricity was turned off 2 days ago.

The pt is having a difficulty dealing with AIDS dx. States Im isolated from my family RN should

Use therapeutic communication to establish trust and caring.

Aware of the potential for health care associated infection R/T a PICC, the nurse is careful to

Prepare the skin with 2% chlorhexidine gluconate.

The nurse assesses the skin turgor of the pt by

Grasping skin on the back of the forearm & releasing

If an error is made while recording, the nurse should

Draw a single line through the error and initial it

Stroke pt is having difficulty eating. The RN includes which intervention in the plan of care

Teach pt about special devices to assist with eating meals

The primary purpose of a pts med record is to

Communicate accurate, timely info about the pt

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.

Female Pt of muslim faith is on hospice. The plan of care would include

Female health care workers care for the body after death

Which situation shows the RN has a good understanding about auditing & monitoring pt HR

Determines that standards of care are met by reviewing pt HR

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

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

Spirituality is unique to the individual.

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

Individual risk factors that can threaten safety are (Select all that apply)

Lifestyle, Sensory or communication impairment, Impaired mobility, Lack of sensory awareness

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Nursing 2 Quiz Flashcards | StudBud

Nursing 2 Quiz

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Questions 254

Answers

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