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NUR 104 Midterm Exam(RN) 2023 New Module (Excelsior Univ)
1.Which evaluative statement demonstrates achievement of a patient behavior or outcome in the psychomotor domain of learning? The mother expresses a strong connection to her baby. The parents describe situations that should be reported to the pediatrician. The parents report that the baby sleeps six hours per night. The parents demonstrate safe techniques for feeding their newborn. 2.What is the first action the RN takes when a fire occurs in a patient’s room? Extinguish the fire. Activate the fire alarm. Contain the fire quickly. Remove patient from harm. 3.Which patient does the RN assess to be at highest risk for injury? An older client with an infection. A client who has a saline well in the arm. A client who is restrained. A young client with pneumonia. 4.While caring for a patient with the Impaired skin integrity problem(s), which patient outcome or behavior should the RN work towards to resolve the problem most effectively?
Understands the need to apply the dressing daily. Experience no further skin breakdown by the next clinic visit. Utilizes appropriate skin ointment when redness occurs. Increases moisturizer use on skin by the next clinic visit. 5.The RN is assessing an open area on the patient’s sacrum and documents “a one-inch shallow woundwith a pink appearance. No slough is noted.” Which stage is the pressure injury? Stage 1 Stage 4 Stage 3 Stage 2 submitted 6.The RN assesses a patient’s radial pulse and notes it is 50 beats per minute, evenly spaced. How doesthe RN describe it when reporting to the team? irregularly irregular regularly irregular
9.Which is an appropriate method for the RN to evaluate the effectiveness of a patient teaching-learning interaction? Direct the patient to repeat the information that was learned. Verify with family members whether the patient understands. Ask the patient to verbalize if the information was understood. Follow up to determine if patient was readmitted again. 10.Which statement by the school age child allows the RN to determine that safety education has been effective? “I avoid talking to strangers when walking to school.” “I like to use the trampoline by myself at home.” “When I cross the street, I make sure to run fast.” “My friend likes to ride on my bicycle with me.”
10.Which factors support the RN’s determining an older adult is at risk of injury from aging? Select all thatapply. Motivation. Hearing loss. Slowing of reflexes. Reduced muscle strength. Decreased physical stamina. 11.When repositioning a patient in bed, which intervention demonstrates best practice by the RN? Elevates the head of the bed to forty-five degrees. Places a donut type device under the patient’s heels. Slides the patient up in the bed with the assistance of another person. Uses a draw sheet when moving the patient up in the bed.
14.The RN is checking a patient’s BP in the thigh related to new inability to assess BP in arms. The last BP reading in the right arm was 120/50. What reading does the RN anticipate auscultating? 120/ 150/ 100/ 140/ submitted 15.Which strategy demonstrates the RN providing culturally competent patient teaching? Obtains feedback from the patient. Evaluates teaching at end of session. Uses humor appropriately. Presents self as culturally aware. 16.The patient has a learning style preference for manipulating equipment and doing return demonstrations. The RN recognizes the patient learns best in which domain?
Tactile Affective Cognitive Psychomotor submitted 17.The RN is caring for a patient who is confused and attempting to pull out a urinary drainage catheter andintravenous lines. According to The Joint Commission, which must be considered/carried out to use restraints for this patient? Use of less restrictive interventions have not been effective. Restraints can be applied temporarily without a prescription from the primary provider. Family acknowledgment that the use of restraints contributes to safety. Reasons for the use of restraints should be clearly identified. 18.During a mass casualty incident, a representative from the media comes to the emergency departmentrequesting information about the victims. Which is an appropriate action for the RN to take?
Bend patient’s knees and cover the wound with a sterile saline dressing. Sit the patient in high fowlers position and splint the wound. Assess the vital signs and administer pain medication as prescribed. 21.Which assessment technique is the second step when assessing the abdomen? Percussion Auscultation Palpitation Inspection submitted 22.Which focused respiratory assessment patient data should the RN interpret as a significant concern foran adult? Bronchovesicular breath sounds near and over the sternum Bronchial breath sounds over the lower lobes bilaterally Vesicular breath sounds over the lower lobes bilaterally Tubular breath sounds over the trachea anteriorly
Which statement made by a parent of an infant would cause the RN to revise the teaching plan regarding infant safety? “The same immunizations are recommended here as in our country of origin.” “My baby is at greater risk for health acquired infections with multiple antibiotic use.” “I plan to get the recommended immunizations for my baby.” “Scarlet fever can put my baby at risk for a secondary infection.” Which intervention by the RN promotes health literacy with patients? Includes specific medical terms in explanations. Organizes information so the most important information stands out. Provides information mainly in written form. Asks “yes” and “no” questions of learners.
The home care patient has a pressure injury on their heel and asks to wear compression stockings to improve blood supply to the wound. The wound is being dressed with a hydrocolloidal dressing. Which statement made by the RN to the patient demonstrates use of evidence-based practice re: wound care? Thigh-high elastic stockings are best at improving circulation. Assessing your leg for edema is important before we consider this. Do you think that the heel wound is slow in healing and improving? Elevation of the limb is the most effective way to increase blood supply. The RN assesses that the patient has a risk for impaired skin integrity and a Braden scale score of 16. What would be the best outcome or behavior for this patient? The patient will turn and position frequently. The patient will have intact skin when discharged. The patient will be toileted every 2 hours while awake. The patient will eat more protein at each meal.
The RN auscultates high pitched squeaking sounds on expiration over the upper lobes and recognizes it is abnormal for the patient? How does the RN document this? Crackles Stridor Rhonchi Wheezes submitted Which pulse location does the RN use for distal bilateral comparison when performing a peripheral vascular assessment on a patient with a right leg cast from toes to mid-thigh? Popliteal Femoral Dorsalis pedis Posterior tibial Which intervention should the RN implement to increase a patient’s motivation to learn?
The patient will have a normal blood pressure at next clinic appointment. The patient will state their blood pressure is good when systolic is below 140. The patient will have a systolic blood pressure less than 120 at next office visit. The patient will call the physician when the blood pressure is high. At what age does the RN begin to routinely assess blood pressure in a child? 2 years 5 years 3 years 2.5 years The RN is working with a patient who requires self-injection of daily medication. The RN must perform which assessment to determine the patient’s ability to learn this skill? hearing and attitude. muscle strength and skin sensitivity. vision and motor coordination.
knowledge and energy. The nurse would obtain information from a material safety data sheet (MSDS) for which situation? A fall on the floor that had just been washed. A vial of antineoplastic medication broke on the floor. A chemical solvent spilled in the hallway. An injury with a contaminated needle. What precautions should be taken by the family of a toddler when the grandmother with multiple prescription medications comes to visit? Provide a medicine case that locks and place it on a high shelf. Be sure that all the medication bottles have childproof caps. Ask the grandmother to keep the medication bottles in her closed purse. Show the medications to the toddler and emphasize not to touch them.
The RN is caring for a patient with at risk for impaired skin integrity. Delegating which intervention to the Nursing Assistive Personnel (NAP) would indicate the RN needs additional education? “Notify me if you see any areas of reddened skin.” “When you feed the patient, encourage protein intake.” “Turn and position the patient every 2 hours.” “Measure any new reddened skin areas.” When carrying out a general survey on a middle-aged adult male, which of the following would the RN assess? Select all that apply. Gait and abnormal movements Speech pattern, quality, and tone Dress, grooming, and hygiene Function of the 12 cranial nerves Vital signs (BP, P, R, T) When assessing the first cranial nerve, how should RN assess this? Ask patient to identify a coffee odor Assess with the Snellen vision test Assess ability to talk and swallow Ask patient to make faces, smile During a skin assessment of a cold patient, the RN assesses a bluish marbeling to the patient’s skin. Which nursing action would be most appropriate considering this assessment data? Apply ordered oxygen. Provide a warm blanket. Assess bleeding lab values. Consider potential abuse. Which behavior would clearly demonstrate to the RN that the patient learned their new diet plan?
The RN will teach the patient about low salt foods. The client will understand to select low salt foods. The client will know the benefits of a low salt diet by the next visit. The client will identify low salt foods at the next session. By which patient behavior or action should the RN determine that the patient has achieved affective learning effectively? The patient will demonstrate how to change the sterile dressing by the end of the shift. The patient will make a chart for daily medications by the end of class. The patient will share a positive coping strategy by end of the group meeting. The patient will verbalize the symptoms requiring contact with the health care provider. Which action should the RN take first when beginning to teach a client who is newly diagnosed with Type I diabetes? Implement teaching plan.
