MS Ch 1, 8, 9 WB questions – Flashcards

Which one of the following is a nursing diagnosis? 1. Peptic ulcer 2. Pneumonia 3. Ineffective airway clearance 4. Myocardial infarction

Which one of the following is a medical diagnosis? 1. Hiatal hernia 2. Impaired mobility 3. Powerlessness 4. Anxiety

An LPN wishes to learn why a patient's lung sounds have crackles and questions the physician during morning rounds. Which critical thinking attitude is the nurse exhibiting? 1. Intellectual humility 2. Intellectual sense of justice 3. Intellectual empathy 4. Intellectual integrity

The LVN is caring for a patient with diabetes. In what order should the nurse carry out the nursing process? Place all steps in correct sequential order. 1. Implement plan of care 2. Assist with evaluation 3. Collect data 4. Assist with development of nursing diagnoses 5. Assist with planning of outcomes and interventions

Which of the following statements best defines critical thinking? 1. Orderly, goal-directed thinking 2. Clear thinking during critical situations 3. Constructive feedback about nursing actions 4. Critical evaluation of patient responses to care

The LPN is reviewing the nursing care plan for a patient with acute pain related to a fractured ankle. Which of the following would determine whether the care plan is effective? 1. Assessment of the patient's ability to walk 2. Evaluation of the patient's fracture on X-ray 3. Elevating the patient's foot on two pillows 4. Evaluation of the patient's pain rating on a 10-point scale

A patient with a history of cardiac disease reports a feeling of tightness in the chest that radiates down the left arm. Which of the following actions by the LPN should be carried out immediately? 1. Check the patient's vital signs. 2. Formulate nursing diagnoses related to an acute myocardial infarction. 3. Determine the patient's outcome after nitroglycerin has been administered. 4. Plan interventions to reduce long-term cardiac damage.

The LPN is documenting patient data. Which of the following should the nurse document under objective data? 1. Denies nausea 2. Shortness of breath 3. Heart rate 72 beats per minute 4. Midsternal chest pain

A patient is admitted with chest pain, which has resolved. The patient states, "I hope I can live a normal life." According to Maslow's hierarchy of needs, which of the following levels is best reflected by this statement? 1. Physiological needs 2. Safety and security 3. Love and belonging 4. Self-esteem

A patient has a nursing diagnosis of impaired swallowing related to muscle weakness as evidenced by drooling, coughing, and choking. Which of the following outcomes is appropriate for this patient's nursing diagnosis? 1. Improved airway clearance within 8 hours as evidenced by clear lung sounds and productive cough 2. Baseline body weight maintained as evidenced by no weight loss 3. Improved muscle strength as evidenced by ability to sit up while eating 4. Improved swallowing within 48 hours as evidenced by no coughing or choking

The LPN is providing care for a patient with a medical diagnosis of congestive heart failure who is very short of breath. Which of the following is a nursing diagnosis that is correctly stated in the PES (problem, etiology, and signs and symptoms) format? 1. Deficient knowledge related to disease process and self-care for shortness of breath 2. Impaired gas exchange related to excess interstitial fluid as evidenced by respiratory rate of 32 per minute and patient stating he feels short of breath 3. Congestive heart failure related to decreased cardiac output as evidenced by abnormal arterial blood gasses 4. Acute dyspnea related to congestive heart failure as evidenced by swollen lower extremities and confusion

Which of the following would the nurse recognize as a sign of a local infection during data collection? 1. Warm skin 2. Clammy skin 3. Anorexia 4. Paleness

Which of the following does the nurse understand is a sterile technique method? 1. Use of antiseptics 2. Use of autoclaves 3. Frequent hand washing 4. Use of gloves when coming in contact with body fluids

Which of the following infections would the nurse rec- ognize as being a health care-acquired infection? 1. Chronic urinary tract infection for a homebound person 2. A sexually transmitted infection in a healthy young adult 3. Pneumonia in a hospitalized postoperative patient 4. Hospitalization for cellulitis

Which of the following antibiotics would the nurse an- ticipate would be used to treat methicillin-resistant Staphylococcus aureus (MRSA)? 1. Gentamicin 2. Tobramycin 3. Penicillin 4. Vancomycin

A nurse should wear a fit-tested high-efficiency particu- late air filter (HEPA) mask when entering the room of a patient with which disease? 1. Influenza 2. Scabies 3. HIV infection 4. Tuberculosis

Which of the following actions would be MOST appro-priate for the nurse to take while providing patient care to help prevent the spread of infection? 1. Sterilizing hands with a germicide once a day 2. Washing hands at the beginning of patient rounds 3. Performing hand hygiene before and after each patient contact 4. Wearing gloves for all patient care

In planning care for a patient, the nurse understands that surgical asepsis is based on which of the following principles? 1. Destroying organisms before they enter the body 2. Isolating all patients who have infectious diseases 3. Destroying bacteria as they leave the body 4. Maintaining basic cleanliness

Which of the following does the nurse understand is needed by all pathogenic organisms to multiply? Select all that apply. 1. Moisture 2. Light 3. A host 4. Oxygen 5. Warmth 6. Food

Which of the following actions can the nurse take to help prevent a health care-acquired infection in an incontinent patient? 1. Avoiding use of a urinary catheter 2. Applying absorbent briefs 3. Toileting patient every 4 hours 4. Restricting fluids

A patient is to have a sterile urine specimen collected. Which of the following techniques is used to collect this specimen? Select all that apply. 1. Cleansing the patient's external genitalia before the patient voids 2. Having the patient void into a sterile container 3. Straight catheterizing the patient 4. Obtaining a midstream voided specimen 5. Obtaining a second voiding specimen 6. Placing urine specimen from catheter in a sterile container

A patient has been diagnosed recently as having an upper respiratory infection. Which of the following symptoms would indicate to the nurse that the patient is developing a complication? 1. Scratchy throat 2. Clear, watery drainage from the nose 3. Dry cough 4. High fever

The nurse is collecting a culture of wound drainage, and the patient asks what a culture is. Which of the following is the best response by the nurse to explain what a culture is? 1. A culture identifies the presence of pathogens. 2. A culture measures antibiotic levels. 3. A culture identifies an antibiotic's effect on a pathogen. 4. A culture determines the appropriate medication dosage.

Which of the following data collection findings should the nurse recognize and report as a possible sign of infection in the older adult? Select all that apply. 1. Poor skin turgor 2. Irritability 3. Hypertension 4. Bradycardia 5. Pacing behavior 6. Hunger

The nurse observes a nursing assistant providing oral care to an immunocompromised patient. The use of which of the following by the nursing assistant would require further instruction for patient safety? 1. Sterile water 2. Tap water 3. Fluoride toothpaste 4. Soft toothbrush

Which of the following nursing interventions would the nurse use to collect data to determine status of periph- eral tissue perfusion in a 48-year-old patient in shock? 1. Obtain apical pulse. 2. Check capillary refill. 3. Check for sacral edema. 4. Monitor level of consciousness.

Which of the following does the nurse understand is the primary reason that respirations increase in compensated shock? 1. Anxiety causes hyperventilation. 2. Retention of carbon dioxide is decreased. 3. Normal Oxygen levels maintained 4. Cardiac output is increased.

With which of the following types of shock would the nurse anticipate the skin to be cold and moist during data collection? 1. Compensating 2. Progressive 3. Irreversible

The nurse is caring for a hypertensive patient whose blood pressure is usually 156/86. Which of the following blood pressures is considered a progressive shock blood pressure finding for this patient? 1. 90/44 2. 140/80 3. 114/64 4. 130/72

Which of the following outcomes for the nursing diagnosis Deficient Knowledge is appropriate for the patient recovering from shock? 1. Accepts responsibility for shock 2. States understanding of shock 3. Interacts with others 4. Verbalizes fears

The nurse monitors a patient with chronic kidney disease who has just returned from completing a hemodialysis session. The patient's data before dialysis is as follows: blood pressure 150/88 mm Hg, pulse 90 beats per minute, respiration's 18 per minute, temperature 98.9°F (37°C), and weight 168 lb. Patient data obtained after dialysis is as follows: blood pressure 98/50 mm Hg, pulse 110 beats per minute, respiration's 18 per minute, temperature 99°F (37°C), and weight 165 lb. Which of the following actions should the nurse take after comparing the data? 1. Reweigh the patient. 2. Provide a quiet environment so patient may rest. 3. Have the health care provider notified of the post- dialysis data. 4. Check on the patient in 10 minutes.

A 47-year-old patient is admitted with hypovolemic shock from trauma injuries resulting from an automobile accident. The patient remains oliguric 2 days later. Which of the following assessments of the patient indi- cates to the nurse that the patient is experiencing a com- plication of shock that requires follow-up treatment? 1. Hematocrit 42% (normal = 38%-47%) 2. Creatinine 2.2 mg/dL (normal = 0.6-1.3 mg/dL) 3. Blood urea nitrogen 24 mg/dL (normal = 6-25 mg/dL) 4. Hemoglobin 13.4 g/dL (normal = 13.5-18 g/dL)

The nurse is caring for a patient with a bowel obstruction. Which of the following is the earliest indication that the patient is developing symptoms of shock? 1. Blood pressure 88/50 mm Hg 2. Pulse 110 beats per minute 3. Lethargy 4. Urine 18 mL/hr

The nurse is caring for a postoperative patient following a splenectomy. Which of the following symptoms is of highest priority for the nurse to report? 1. Blood pressure 86/52 mm Hg 2. Pulse 100 beats per minute 3. Cool, pale skin 4. Urine 40 mL/hr

The nurse is caring for a patient with gastrointestinal bleeding who has an intravenous (IV) infusion of 0.9% normal saline at 50 mL/hr. The patient has a large, red, bloody stool and reports dizziness. The nurse assists the patient back to bed and obtains vital signs of blood pressure 90/52 mm Hg, pulse 118 beats per minute, and respirations 22 per minute. Which of the following actions should the nurse take? 1. Continue monitoring vital signs. 2. Inform the registered nurse now. 3. Decrease the IV flow rate. 4. Elevate the head of the bed.

Which of the following medications would the nurse anticipate the health care provider may order to increase blood pressure for a patient with septic shock? 1. Atropine 2. Dopamine 3. Digoxin (Lanoxin) 4. Nitroglycerin

For the patient in hypovolemic shock, place the following interventions in the order of priority in which the nurse should perform them. 1. Record hourly urine output. 2. Apply oxygen. 3. Provide restful environment. 4. Ensure patent airway. 5. Obtain vital signs. 6. Monitor IV fluids.

The nurse is providing care for a patient with pericardial effusion who is at risk for pericardial tamponade. Which of the following symptoms would indicate the patient was developing obstructive shock? Select all that apply. 1. BP 88/56 mm Hg 2. Urine output 100 mL over 6 hours 3. Pulse 66 beats per minute 4. Respirations 12 per minute 5. Jugular vein distension 6. Confusion and lethargy