question

During an initial inspection of a patient with subacute bacterial endocarditis, which changes to the patient's nails should the nurse expect to find?

answer

Red or brown linear streaks in the nail bed

question

The patient wears full dentures during the day and removes them overnight. The patient's usual denture care includes taking the teeth out once a day to brush.. The nurse is concerned that the patient might be at risk for developing denture-induced stomatitis. Which points should the nurse include in a teaching plan for denture care?

answer

- Do not wear damaged or poorly fitting dentures. - Observe mouth for reddened areas under the dentures and small red sores on the roof of the mouth. - See dentist regularly. - Rinse dentures after meals.

question

The primary health care provider ordered the nurse to administer nasal drops to a patient with a sinus infection. Which nursing interventions would be beneficial for the patient?

answer

- Holding dropper 1 cm (½ inch) above the nares - Instructing the patient to breathe through the mouth - Tilting the patient's head back over the edge of the bed for access to the ethmoid bone

question

The child's birth weight was 8 lb. What would the infant's weight be at 1 year? Record your answer using a whole number.

answer

24 lbs. - Infants usually double their birth weight by 5 months of age. The weight should be 16 lb at 5 months. By 1 year, they triple their birth weight; therefore, the weight should be 24 lb.

question

The registered nurse is evaluating the performance of a student nurse who is performing a back massage for a patient with back pain. Which action by the student nurse needs correction?

answer

Kneading downward along one side of the spine from the shoulders to the buttocks - The nurse should knead upward along one side of the spine from buttocks to shoulders, not downward from the shoulders to the buttocks.

question

The registered nurse is teaching a nursing student about precautions to be followed while measuring blood pressure (BP). Which statements made by the nursing student indicate a need for further learning?

answer

- "I should ask the patient to take deep breaths." - "I should make the patient talk while taking readings." - "I should apply the cuff to an extremity where intravenous fluids are infusing."

question

A patient admitted to the hospital wants to know about respite care. What does the nurse explain to this patient about respite care?

answer

- Respite care gives the caregiver time to run errands or socialize. - Respite care provides the caregiver some time off from providing care to the ill person. - Respite care can include overnight care.

question

After assessing the patient's foot, the primary health care provider concludes that the patient has Morton's neuroma. Which symptoms are associated with this condition?

answer

- Pain in the foot - Burning of the foot - Numbness of the foot

question

The nurse is using a chlorine compound at room temperature to clean surgical instruments contaminated by blood, pus, urine, and saliva. Which factors would reduce the efficacy of the disinfectant?

answer

- Pus, blood, urine, and saliva were not rinsed off the instruments before application of the disinfectant. - Soap and water were used to clean the instruments before application of the disinfectant. - The chlorine solution is diluted.

question

An 82-year-old patient visits the primary health care provider with a complaint of dry feet. Which conditions are responsible for the patient's condition?

answer

- Dehydration of epidermal cells - Decrease in sebaceous gland secretions

question

The nurse is caring for different patients with disabilities. Which patient would benefit from the use of a picture or gestures that mimic the desired action? A - hearing impairment B - visual impairment C - speaking disability D - cognitive impairment

answer

Patient D - The nurse should use pictures or gestures to communicate with Patient D, who is cognitively impaired. Patient A has hearing impairment, so the nurse should speak facing the patient with the mouth visible and arrange for a sign language interpreter if indicated. Patient B has a visual impairment, so the nurse should avoid relying on gestures or nonverbal communication. Patient C has a speaking disability, so the nurse should use visual cues to communicate.

question

Which drug is unsafe for the central nervous system as a supplement to epidural anesthesia? - aspirin - naloxone - ibuprofen - oxycodone

answer

Oxycodone

question

A primary health care provider prescribed an antihistamine to a pediatric patient and informed the caretakers that the child may become drowsy after taking this medication. However, on the contrary, the child became extremely agitated and excited after taking the medication. What is this reaction called?

answer

Idiosyncratic reaction

question

Which value indicates normal pulse pressure?

answer

36 mm Hg - The normal pulse pressure of an adult is 30 to 50 mm Hg. Therefore, 36 mm Hg is the normal finding.

question

The nurse administers a potent medication to a patient through the IV. What is the most appropriate intervention followed by the nurse?

answer

Assessing the vital signs before, during, and after infusion

question

Which nursing action is contraindicated when performing oral and foot care to a patient receiving anticoagulant therapy?

answer

Shaping the corners of the toenails - Shaping the corners of the toenails damages tissues and may cause bleeding. Therefore, this action should be avoided in patients receiving anticoagulant therapy.

question

At what age can an infant normally place objects into containers?

answer

10 to 12 months - At 10 to 12 months, an infant can place objects into containers. At 4 to 6 months, an infant can grasp an object at will and drop it to pick up another object. At 6 to 8 months, an infant can transfer objects from one hand to the other. At 8 to 10 months, an infant can effectively use the pincer grasp.

question

A patient reports dry and flaky skin. During an assessment, the nurse notices a loss of protective oils from the skin. What are possible reasons for the patient's condition?

answer

- Bathing frequently - Using hot water frequently - If the patient bathes and uses hot water frequently, the skin may become dry and flaky and it may lose protective oils. Using alkaline soaps will neutralize the protective acid condition of the skin. Excessive perspiration can harbor microorganisms. The use of excessive deodorants may cause chemical irritation.

question

The nurse is assessing the pain for an adult patient who has cognitive impairment. Which nursing action is most appropriate?

answer

Observing the facial expressions and body movements for any pain behavior

question

In which phase does the nurse observe blowing and whooshing sounds during blood pressure (BP) measurement?

answer

Phase 2 - Phase 1: a sharp thump - Phase 2: a blowing or whooshing sound - Phase 3: a crisp intense tapping - Phase 4: a softer blowing sound that fades - Phase 5: silence

question

The nurse is assessing an older adult's oral health. How should the nurse assess the oral cavity?

answer

- Observe for cleanliness. - Use olfaction to assess halitosis. - Inspect the mouth for color, hydration, texture, and lesions.

question

During a visit to the clinic, a patient tells the nurse that he has been sick to his stomach for 3 days and he vomited twice yesterday. Which responses by the nurse is an example of probing?

answer

Is anything else bothering you? - A probing question encourages a full description without trying to control the direction of the patient's story

question

Which symptom is associated with an elevated temperature?

answer

Diaphoresis

question

When nurses are communicating with adolescents, what should they do?

answer

Be alert for cues to their emotional state.

question

Which signs indicate scrotal edema?

answer

- Scrotal skin is tightened. - Scrotal skin has lost wrinkling.

question

A 10-year-old child is brought to the hospital with high fever and chills. The nurse records the vital signs and finds that her temperature is 104° F (40° C), blood pressure is 130/85 mm Hg, and pulse rate is 120/min. The fever remains mostly high but is interspersed with periods of normal body temperature. What pattern of fever does the child have?

answer

Intermittent

question

What could be the effect of an incorrect nursing diagnosis?

answer

It could affect the quality of patient care.

question

The nurse is interviewing a 19-year-old pregnant woman. The nurse discovers that the woman is a victim of intimate partner violence (IPV). Which conditions are more likely to occur in this patient?

answer

- high blood pressure - delivery of a pre term baby - delivery of a low birth weight baby

question

The nurse covers the patient's chest and abdomen and places a bath towel under the patient's leg to wash the lower extremities. What are the rationales behind this action?

answer

- To prevent the soiling of bed linen - To prevent unnecessary exposure

question

In which situation would drug administration be considered palliative?

answer

Pain management for a patient with terminal cancer

question

Which policy covers medical expenses for very poor children?

answer

Medicaid

question

Which cranial nerve controls the position of the tongue?

answer

Hypoglossal

question

The nurse receives an order to start giving a loop diuretic to a patient to help lower blood pressure. Which will help the nurse determine the appropriate route for administering the diuretic?

answer

The prescriber's orders

question

A patient has difficulty swallowing a capsule. What is the appropriate nursing intervention?

answer

Notify the primary healthcare giver - try to get med in a different form

question

The nurse is teaching a young mother to palpate her 8-year-old child to quickly evaluate whether the child has a fever. Which information is important for the nurse to include?

answer

Place the back of your hand against the child's forehead

question

During a skin assessment, the nurse observes that the patient's skin lifts easily and falls immediately back to its resting position. What should the nurse interpret from this assessment?

answer

This is a normal skin finding.

question

A parent informs the nurse that her 5-year-old child treats a doll like a real baby. The mother is very worried about this behavior. Which explanation given by the nurse is most appropriate?

answer

The child's behavior is normal

question

A nurse performs hand hygiene before providing direct patient care. Which action made by the nurse may cause an infection?

answer

Wearing rings on both hands

question

Children in which age group are in the industry-versus-inferiority stage of Erikson's psychosocial development?

answer

School-aged children

question

Following an initial assessment of a patient, the nurse is formulating nursing diagnoses. Which guidelines should the nurse follow to reduce errors in the diagnostic statement?

answer

- Identify a treatable etiology or risk factor. - Identify the problem caused by the treatment, not the treatment itself. - Identify the patient's response to the equipment rather than the equipment itself.

question

According to Robert Havighurst, what should adults do as they grow older to foster greater satisfaction and well-being as they age?

answer

They should continue to be active in society

question

A patient who is receiving chemotherapy has inflamed gums, oral mucosa, and painful sores in the mouth. Which oral care actions are appropriate?

answer

- Applying water-soluble moisturizing gel on the oral mucosa - Encouraging intake of soft foods - Using normal saline rinses

question

The nurse is preparing the bed of a patient. Which of the nurse's actions are appropriate in this situation?

answer

- Keeping the linen away from the uniform - Placing the clean linen in a dirty-linen container if it touches the floor

question

A registered nurse is explaining the Health Insurance Portability and Accountability Act (HIPAA) regulations to a student nurse. Which response by the student nurse regarding HIPAA regulations needs correction?

answer

HIPAA allows health care professionals to print data about the patient's health information and identification for personal use.

question

Which of a nurse's statements made regarding the assessment of the thyroid gland is correct?

answer

"I should inspect the lower neck for the presence of obvious masses."

question

The caregiver of an older adult patient complains of fragmented sleep cycle and worsened recent memory in the patient. The nurse performs an assessment of the patient and suspects dementia. Which other characteristics observed in the patient supports the nurse suspicion?

answer

- Apraxia - Poor judgement

question

A registered nurse is teaching a nursing student about acetaminophen for pain management. Which statements if made by the nursing student indicate the need for further teaching?

answer

- "Naloxone is an acetaminophen antagonist." - "The maximum 24-hour dose of acetaminophen is 325 mg."

question

What is myopia?

answer

Nearsightedness

question

Which conditions may alter pupillary reaction

answer

- Direct trauma to the eye - Changes in intracranial pressure - Lesions along the nerve pathways

question

The nurse is assessing a patient who is admitted to the hospital. For which ocular symptoms should the nurse consult an ophthalmologist?

answer

- Floaters - Headache - Halos around lights - Diplopia

question

The nurse finds that a patient is a chain smoker and bathes more than five times a day. On assessing medical reports, the nurse finds that the patient is on contraceptive therapy. Based on the nurse's findings, which of the patient's body defense mechanisms may weaken?

answer

- Saliva - Sebum - Flora of the vagina - Macrophages in the respiratory tracts

question

A pregnant woman in her first trimester approaches the nurse for a regular checkup. Which are covered in health screenings during prenatal care?

answer

- Counseling about child care - Counseling about exercise and diet - Screening for sexually transmitted diseases and vaginal infections - Physical assessment at scheduled intervals

question

Which shows that the nurse lacks critical thinking skills in practice?

answer

The nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care.

question

After teaching breathing exercises to a postoperative patient who underwent leg surgery, the nurse suspects that the patient has not fully understood the instruction. Which approach by the nurse helps to assess the patient's retention of information?

answer

Teach back

question

A patient in the emergency department has developed wheezing and shortness of breath. The nurse gives the ordered medicated nebulizer treatment now and in 4 hours. Which standard of practice is performed?

answer

Implementation

question

While assessing a preschool-age child, the nurse concludes that the child has normal cognitive development. Which of the child's behaviors support the nurse's conclusion?

answer

- Offering snacks to a child who is hungry - Arranging the playing blocks in ascending to descending order - Understanding that an accident occurred because of his or her actions

question

A 50-year-old male patient is seen in the clinic. He tells the nurse that he has recently lost his job, and his wife of 26 years has asked for a divorce. He has a flat affect. Family history reveals that his father committed suicide at the age of 53. The nurse should assess for which of the following?

answer

Depression

question

The nurse is assessing a patient who was diagnosed with diabetes 5 years ago. During the assessment, the nurse finds out that the patient does not log daily blood sugar levels because he cannot operate the home glucometer properly even though he tries. What does this finding indicate?

answer

The patient needs further teaching on glucose testing

question

Which instruction of the nurse would be appropriate for a patient while applying ointment to an affected area?

answer

Spread the medication evenly over the involved surface and cover the area well

question

During the assessment, the nurse asks about the patient's history of hemodialysis. What is the rationale behind the nurse's question?

answer

To identify the risk factor of hepatitis B virus

question

Which phase of a helping relationship involves activities such as reviewing available medical and nursing history?

answer

Preinteraction - In the preinteraction phase, the nurse reviews the available medical and nursing history of a patient and collects information from caregivers before meeting the patient. The orientation phase is when the nurse and patient meet each other. In the working phase, they work with each other to solve problems. The termination phase occurs at the end of the relationship process where evaluation occurs.

question

The nurse manager is providing a verbal report to a group of team members. Which zone of personal space is indicated in the nurse's action?

answer

Socio-consultative zone - In the public zone, the nurse speaks at a community forum and delivers a lecture to a class of students. In the intimate zone, the nurse performs physical assessment and changes a patient's surgical dressing. In the personal zone, the nurse sits at the patient's bedside.

question

The nurse is attending to a postsurgical patient who underwent a nephrectomy. What observations would tell the nurse the patient is in severe pain?

answer

- The patient has a reduced attention span - The patient is constantly asking for pain medication - The patient is clenching teeth and biting lips

question

A student nurse is caring for a 78-year-old patient with multiple sclerosis. The patient has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient's temperature was 37.1° C (98.8° F). The student reports this recent assessment to the registered nurse (RN): the patient's temperature is 37.2° C (99° F); the Foley catheter is still in place, draining dark urine; and the patient is uncertain what time of day it is. Based on knowledge about presentation of symptoms in older adults, what should the RN tell the student?

answer

The nurse will notify the physician of the findings.

question

Who can legally use a pill-splitting device to split tablets in half?

answer

Pharmacist

question

A 55-year-old patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. What sites do you instruct the nursing assistant to use for obtaining the patient's blood pressure and temperature?

answer

Right popliteal and right axillae

question

The nurse is comparing the temperature reading with the patient's previous baseline temperature range. Which step of the nursing process is involved in this situation?

answer

Evaluation

question

The nurse is caring for a 50-year-old patient. The patient has had the gall bladder removed, and it is the second postoperative day. The nurse finds that the patient is uncomfortable and in pain. After collecting data from the patient, the nurse examines the patient and collects subjective as well as objective data. Which data should the nurse categorize as objective data?

answer

- Minimal oozing at the incision site - Fever of 104 o F

question

A registered nurse teaches a nursing student about the use of spacers for inhalers. Which statement made by the nursing student indicates the need for further teaching?

answer

"Breath-actuated metered-dose inhalers require use of spacers."

question

The nurse assists the primary health care provider while administering an intravenous bolus to a patient. Which interventions are beneficial for the patient?

answer

- Assessing the intravenous site for signs of infiltration or phlebitis - Injecting normal saline flush at the same rate medication was delivered

question

A patient diagnosed with pancreatitis complains of pain in the abdomen. Following an initial interview and the assessment, the nurse prepares a nursing care plan. Which guidelines should the nurse follow to reduce errors in the diagnostic statement?

answer

- Identify treatable etiology or risk factors. - Identify the problems caused by the treatment. - Identify the patient's response.

question

Which type of muscles do women commonly use to breathe?

answer

Costal - The trapezius and abdominal muscles are not used for breathing in healthy patients. Men, not women, tend to use their diaphragms to breathe.

question

A patient returns to your postoperative unit following surgery for right shoulder rotator cuff repair. The licensed practical nurse (LPN) reports that she had difficulty obtaining the patient's heart rate from his right radial pulse. What is your best response?

answer

Perform a complete assessment of all pulses

question

Which statements about opioid analgesics for pain management are correct?

answer

- Opioid analgesics act on higher centers of the brain. - The short-acting forms of opioids provide pain relief for approximately 4 hours.

question

On assessment, the nurse finds that the patient has bad breath. Which condition should the nurse document?

answer

Halitosis

question

A primary health care provider ordered a rectal suppository for a patient with severe constipation. Which instruction would the registered nurse exclude while delegating the work to the nursing assistive person (NAP)?

answer

"Administer the rectal suppository." - The skill of administering rectal suppositories cannot be delegated to nursing assistive personnel (NAP), because it is not within the scope of practice of NAP. NAP can watch and report fecal discharge or bowel movement. NAP can also report the occurrence of medication side effects. NAP can be delegated the task of providing perineal care that involves cleaning the perineum, the external genitalia, and the surrounding skin.

question

A patient with lung cancer is emotionally, economically, and socially disturbed. What is the role of the nurse as a caregiver?

answer

- Manage the disease and symptoms. - Help the patient establish and achieve goals. - Implement measures to restore emotional and social well-being.

question

Which equipment used while making an unoccupied bed is considered optional?

answer

- Waterproof pads - Clean gloves - Drawsheet

question

A patient is admitted to the hospital for abdominal pain. The patient is instructed not to eat or drink anything by mouth for the next 24 hours. The patient also complains of nausea and vomiting. The healthcare provider orders an antiemetic drug for the patient. Following the administration of the drug, the patient develops adverse reactions. What should the nurse do? .

answer

- Record the reaction - Stop administration of the drug immediately - Call the provider

question

The nurse provides a semi-solid diet to a patient, but the patient wants to have a solid diet. The nurse convinces the patient that having a solid diet would delay recovery and the patient ultimately agrees to the semi-solid diet. Which attitude does the nurse exhibit that promotes effective communication?

answer

Integrity

question

Which form of medication used topically releases the medication slowly over a long period?

answer

Transdermal Patch

question

The nurse is assessing a patient who was brought to the hospital with a body temperature of 41.1° C (106° F). Which signs and symptoms would the nurse likely find in the patient? .

answer

- Delirium - Visual disturbances - Increased heart rate - The condition of heatstroke is defined as a body temperature of 41.1° C (106° F) or more. The common signs and symptoms of heatstroke include the patient showing a state of delirium, as well as disturbances related to vision. The heart rate would also be increased.

question

A patient is being assessed for cutaneous reflexes. The nurse is aware that the normal reflex for the site being assessed is plantar flexion of all toes. Which steps will the nurse follow while assessing this reflex?

answer

- Stroke the lateral aspect of the patient's sole from heel to ball of foot with the reflex hammer - Have the patient lie supine with legs straight and feet relaxed

question

The nurse provides dietary instructions to a patient to help to prevent tooth decay. Which of the patient's statements indicate effective learning?

answer

- "I will drink orange juice regularly." - "I will eat apples regularly."

question

In which of the examples is the nurse applying critical thinking skills when preparing to insert an intravenous (IV) catheter?

answer

- Showing confidence in performing the correct IV insertion technique - Seeking necessary knowledge about the steps of the procedure from a more experienced nurse

question

The nurse cares for a patient with a history of tuberculosis who underwent surgery. Which laboratory parameters would indicate the absence of infection in the patient?

answer

- Monocyte count: 4% - A monocyte count of 4% indicates the absence of infection. Although the normal range of basophils is 0.5 to 1.5%, a reading of 1% may not indicate the absence of infection. The normal range of neutrophils is between 55 and 70%. This count may increase during acute suppurative infection. The normal range of lymphocytes is between 20 and 40%. This count may decrease in sepsis, which may occur postoperatively.

question

Which patient-related factors fall under health promotion nursing diagnosis?

answer

- The patient is willing to eat nutritious foods. - The patient is ready to increase his or her coping skills. - The patient is ready to perform regular exercises.

question

The nurse performs psychosocial assessments in young adults. Which findings would indicate that a patient is mature for the developmental age?

answer

- Not sensitive to criticism - Satisfied with friends and family - Satisfied with personal growth and development

question

When assessing a patient who was prescribed a new dry powder inhaler, the nurse asks for the patient's previous experiences with inhalers. The nurse learns that the patient has a family history of asthma and the patient's mother uses metered dose inhalers. Which teaching and learning principle will most effectively benefit the patient?

answer

Building care plan on existing knowledge

question

The nurse is explaining the levels of prevention to a group of nursing students. Which information should the nurse include?

answer

- Primary prevention involves immunizations, health education programs, nutrition, and physical activities. - Secondary prevention involves early diagnosis and prompt treatment.Secondary prevention involves early diagnosis and prompt treatment. - Tertiary prevention involves minimizing the effects of long-term illness or disability, including rehabilitation. - Secondary prevention focuses on people who are experiencing health problems or illnesses.

question

An older adult has had several bouts of diarrhea. The nurse finds that the patient is exhibiting a sudden onset of altered behavior. The patient is also suffering from hearing and visual impairment. The patient recovered after interventions aimed at maintaining the fluid and electrolyte balance and is being discharged. To assess the home environment, the nurse visits the patient's house. Which suggestions should the nurse provide for making the home environment safe for the patient?

answer

- Furnishings should be red, yellow, or orange. - Stairs should have a color contrast at the edge of the step. - Door frames and baseboards should be a color that contrasts with the color of the wall.

question

The nurse teaching a family member caregiver how to bathe the patient explains the importance of using long strokes on the patient's extremities, moving from distal to proximal. Why is this bathing technique used?

answer

To promote venous return

question

The school nurse is about to teach a freshman-level high school health class about nutrition. What is the best instructional approach to ensure that the students meet the learning outcomes?

answer

Develop topics for discussion that require problem solving.

Phoenix College Nursing Exam 1 2018 – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards