Download NURS 204 Final Exam: Questions and Answers and more Exams Physics in PDF only on Docsity!
NURS 204 Final Exam Latest Update
Questions with Answers
what demonstrates ineffective communication? - Correct Ans: โโGiving your personal opinion While the patient is talking, which of the following demonstrates the nurse is actively listening? a. the nurses arms are crossed while the patient is talking b. the nurse is sitting, facing the patient c. the nurse is standing at the foot of the patient's bed d. the nurse is leaning away from the patient - Correct Ans: โโb. the nurse is sitting, facing the patient which of the following demonstrates effective communication, when caring for a patient who is hearing impaired? a. checking the patient for hearing aids and /or glasses b. asks closed ended questions c. speak to the patient at a higher volume d. heave a family member with the patient at all times - Correct Ans: โโa. checking the patient for hearing aids and/or glasses
during an assessment, an abdominal heart rate is heard. the nurse needs to perform which of the following documentation? a. the nurse will chart by exception b. a new care plan will be created c. an incident report will be made d. past history will be included in notes - Correct Ans: โโa. chart by exception Which of the following does the nurse recognize as part of QSEN? a. the nurse is the source of control in patient centered care b. use past evidence based practice to deliver care c. examine commonly used unsafe practices d. only collaborate with nurses on the same unit - Correct Ans: โโc. examine commonly used unsafe practices proper sequence of donning ppe - Correct Ans: โโgown, mask, goggles, gloves proper sequence of doffing ppe - Correct Ans: โโgloves, goggles, gown mask
a. the patient with a foley catheter in place for the past 5 days b. the patient who was admitted to the hospital with hypertension c. the pediatric patient who had an outpatient tonsillectomy d. the patient who is NPO prior to a colonoscopy - Correct Ans: โโa. the patient with a foley catheter in place for the past 5 days which patient will be most likely to have anti-embolism stockings ordered by the healthcare provider? a. the patient post surgical on bedrest b. the patient with severe peripheral neuropathy c. the patient out of bed with no restrictions d. the patient with a recent skin graft - Correct Ans: โโa. the patient post surgical bed rest the patient is performing self-care. which of the following would the nurse recognize as improper hygiene? a. the patient places their dentures in warm water b. the patient wipes their eyes from inner to outer with a washcloth c. the patient cleans their hands with a hand sanitizer, before they eat
d. the patient wipes their perineum from back to front - Correct Ans: โโd. the patient wipes their perineum from back to front which of the following precautions would the nurse adhere to, when caring for a patient with Tuberculosis? a. contact b. standard c. airborne d. droplet - Correct Ans: โโc. airborne VITAL SIGNS which of the following vital signs would be of concern to the nurse? a. temp-100.2 orally, patient started antibiotics 2 hours ago b. respiratory rate- 36 one day after surgery c. pulse-100, patient complaining of pain scale 8/ d. BP-110/60, patient positioned on their left side - Correct Ans: โโb. respiratory rate- 36 one day after surgery the patient has an irregular radial pulse after 30 seconds. which of the following would the nurse do next?
SKIN AND WOUND CARE
which abnormal skin color finding would indicate redness in face or areas of pressure ulcers? a. pallor b. ecchymosis c. erythema d. petechiae - Correct Ans: โโc. erythema a nurse suspects a wound infection after noting what type of drainage? a. sanguineous b. serous c. serosanguineous d. purulent - Correct Ans: โโd. purulent a wound fails to heal properly and begins to separate. the nurse documents this as a. dehiscence b. granulation tissue
c. evisceration d. approximation - Correct Ans: โโa. dehiscence which of the following is recommended for wound healing? a. Protein and Vit C b. Vit D and zinc c. Vit C and Potassium d. Vit D and Magnesium - Correct Ans: โโa. protein and Vit C a pressure ulcer with full thickness skin loss, but no visible bone, tendon, or muscle exposed, is classified as: a. stage 2 pressure ulcer b. stage 4 pressure ulcer c. stage 1 pressure ulcer d. stage 3 pressure ulcer - Correct Ans: โโd. stage 3 pressure ulcer redness and swelling to a wound with serous exudate are which part of the healing process in tissue trauma? a. inflammatory response
the nurse demonstrates good body mechanics in which situation? a. raising the bed to her waist level b. keeping feet firmly together c. locking her knees d. bending at the waist - Correct Ans: โโa. raising the bed to her waist level what nursing diagnosis takes highest priority for a patient who is immobile? a. impaired skin integrity b. risk for injury c. ineffective airway clearance d. social isolation - Correct Ans: โโc. ineffective airway clearance what is the best nursing intervention to maintain skin integrity for a patient on bedrest? a. changing the bed linens every two hours b. maintaining good oral care c. encouraging 1000mL fluid intake daily
d. Turning the patient every two hours - Correct Ans: โโd. turning the patient every 2 hours What type of range-of-motion exercises are performed for an unconscious patient? a. active ROM b. active-assistive ROM c. passive ROM - Correct Ans: โโc. passive ROM the nurse observes a patient walking with a cane. which of the following would indicate the need for further teaching? a. the patient walks with the cane 6-12 inches in front of them b. the patient walks with the cane on their weaker side c. the patient moves the cane forward before the weaker leg d. the patient advances the stronger leg past the cane - Correct Ans: โโb. the patient walks with the cane on their weaker side prior to assisting a patient out of bed, the nurse identifies the patient by which of the following identifiers? a. date of birth and room number
d. prone and supine - Correct Ans: โโa. sitting and supine which of the following would the nurse perform as the first part of a physical assessment? a. auscultation b. palpation c. inspection d. percussion - Correct Ans: โโc. inspection the dorsal part of the nurse's hand can detect which characteristic on a patient? a. temperature changes b. turgor and elasticity c. presence of masses d. symmetry and mobility - Correct Ans: โโa. temperature changes the nurse notes loss of pigmentation on the patient's hands and arms. the nurse recognizes this skin variation as: a. pallor b. vitiligo
c. erythema d. cyanosis - Correct Ans: โโb. vitiligo which of the following does the nurse recognize as an indicator of poor skin turgor? a. vascularity b. pigmentation c. infection d. dehydration - Correct Ans: โโd. dehydration the nurse is. performing an eye exam on her patient. how would the nurse test for visual acuity? a. ask the patient to gaze at a distant object then a close one b. ask the patient to cover one eye and follow your hand as it moves c. have the patient read the snellen eye chart d. bring a penlight from side of face directing the light onto the pupil - Correct Ans: โโc. have the patient read the snellen eye chart a patient comes into the ED very intoxicated. which of the following reflexes will the patient exhibit during exam?
CARDIAC
which of the following occurs during the S1 phase of the cardiac cycle? a. the mitral and tricuspid valve close b. the pulmonic and aortic valve close c. the ventricular pressure falls d. blood fills the coronary arteries - Correct Ans: โโa. the mitral and tricuspid valve close which of the following areas will the nurse place her stethoscope to assess for tricuspid heart sounds? a. 3rd intercostal, mid sternal border b. 4th intercostal, left sternal border c. 2nd intercostal, right sternal border d. 5th intercostal, mid-clavicular - Correct Ans: โโb. 4th intercostal, left sternal border which of the following is the correct sequence when performing a cardiac assessment? a. inspection, palpation, auscultation
b. inspection, auscultation, palpation c. palpation, percussion, auscultation d. inspection, percussion, auscultation - Correct Ans: โโa. inspection, palpation, auscultation which of the following positions are best to auscultate heart sounds? a. supine, prone, right lateral b. supine, right lateral, standing c. semi fowlers, supine, left lateral d. prone, left lateral, sims - Correct Ans: โโc. semi fowlers, supine, left lateral the nurse assesses an abnormal radial pulse. which of the following would the nurse perform next? a. palpate all of the peripheral pulses b. obtain a pulse oximetry reading c. notify the healthcare provider d. auscultate the apical pulse - Correct Ans: โโd. auscultate the apical pulse
c. auscultate the carotid artery with the diaphragm of the stethoscope d. encourage the patient to take deep breaths during auscultation - Correct Ans: โโa. ask the patient to hold their breath for a few seconds during auscultation the nurse is palpating the femoral arteries and notes a decrease pulse. the nurse would document this finding as: a. + b. + c.+ d. +2 - Correct Ans: โโa. + the nurse is using a doppler to assess pedal pulses. which of the following indicates need for further teaching? a. the nurse applies a thin layer of transducer gel to the site of the pulse b. the nurse turns the volume on the doppler before she places in onto the skin c. the nurse moves the transducer until she hears a pulsating sound d. the tip of the transducer is held at a 25 degree angle during assessment - Correct Ans: โโd. the tip of the transducer is held at a 25 degree angle
the nurse is assessing the patient for DVT. which of the following would indicate suspicion of a DVT? a. warmth at site, redness, pain b. bruising, bounding pulse, shiny skin c. cool to touch, pale skin, increased pulse d. absent pulse, pale skin, tenderness - Correct Ans: โโa. warmth at site, redness, pain which of the following does the nurse recognize as a reason for a patient's blood pressure to be elevated? a. eating a well balanced diet b. a diet low in sodium c. family history d. daily exercise - Correct Ans: โโc. family exercise the nurse is reviewing the lab results. which lab result would indicate if a patient was experiencing a heart attack? a. complete blood count b. troponin c. triglycerides
