Download NURS 320 Quiz 1 and more Exams Nursing in PDF only on Docsity!
NURS 320 Quiz 1
A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient's care? A Perform postural drainage and chest physiotherapy every 4 hours B Allow the patient to decide whether she needs aerosolized medications C Place the patient in a private room to decrease the risk of further infection D Plan activities to allow at least 8 hours of uninterrupted sleep - ansA A boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The school nurse was called and found him alert and conscious, but in severe pain with a possible fracture of the right femur. Which of the following is the FIRST action that the nurse should take?
- Immobilize the affected limb with a splint and ask him not to move.
- Make a thorough assessment of the circumstances surrounding the accident.
- Put him in semi-Fowler's position for comfort.
- Check the pedal pulse and blanching sign in both legs. - ans A child undergoes a tonsillectomy for treatment of chronic tonsillitis unresponsive to antibiotic therapy. After surgery, the child is brought to the recovery room. Which of the following actions should the nurse include in the child's plan of care?
- Institute measures to minimize crying.
- Perform postural drainage every 2 hours.
- Cough and deep-breathe every hour.
- Give ice cream as tolerated. - ans A client admitted for a myocardial infarction is now stable. Appropriate activities to assign to unlicensed personnel would include all the following EXCEPT: A. Teaching about what foods are high in sodium B. Recording intake and output (I/O) C. Assisting with ambulation to the restroom D. Reporting to the nurse that the patient complained of chest pain - ansA A client admitted to the hospital with a diagnosis of cirrhosis has massive ascites and difficulty breathing. The nurse performs which intervention as a priority measure to assist the client with breathing? a) repositions side to side every 2 hours b) elevates the head of the bed 60 degrees c) auscultates the lung field every 4 hours d) encourages deep breathing exercises every 2 hours - ansB
A client arrives at the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. The priority nursing action is to: a) obtain vital signs b) ask the client about the precipitating events c) complete an abdominal physical assessment d) insert a nasogastric (NG) tube and Hematest the emesis - ansA A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)? Discuss o A. Teach the client how to cough up secretions o B. Changes the tracheostomy trach ties o C. Monitor if client has shortness of breath o D. Perform routine tracheostomy dressing care - ansD A client in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper GI series and endoscopies. Upon return to the long-term care facility, the priority nursing assessment should focus on: a) the comfort level b) activity tolerance c) the level of consciousness d) the hydration and nutrition status - ansD A client is 3 hours postoperative following a right upper lobectomy. The collection chamber of the closed pleural drainage system contains 400 ml of bloody drainage. The client's vital signs are blood pressure 100/50 mmHg, heart rate of 100 beats per minute, and respiratory rate 26 breaths per minute. There is intermittent bubbling in the water seal chamber. One hour following the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant and the client appears dyspneic. The nurse should first check: a) lung sounds b) vital signs c) the chest tube connections d) the amount of drainage - ansC A client is brought to the emergency department by the police after having lacerated both wrists in a suicide attempt. The nurse should take which initial action?
A client's total parenteral nutrition (TPN) infusion rate was too slow, and is now 3 hours behind schedule. The nurse should: A. Contact the health care provider B. Increase the rate to catch up to schedule C. Run the next bag of infusion at a slightly higher rate to make up the volume deficit D. Double the infusion rate until desired amount has infused - ansA A community health nurse is working with older residents who were involved in a recent flood. Many of the residents are emotionally despondent, and they refused to leave their homes for days. When planning forth rescue and relocation of these older residents, what is the first item that the nurse needs to consider? a) contacting the older resident's families b) attending to the emotional needs of the older residents c) arranging for ambulance transportation for the oldest residents d) attending to the nutritional status and basic needs of the older residents - ansD A group of health nurse is caring for a group of homeless people. When planning for the potential needs of this group, what is the most immediate concern? a) peer support through structured groups b) finding affordable housing for the group c) setting up a 24-hour crisis center and hotline d) meeting the basic needs to ensure that adequate food, shelter, and clothing are available - ansD A labor room nurse is caring for a client in labor with a known history of sickle cell anemia. Which priority action would the nurse implement to assist in preventing a sickle cell crisis from occurring during labor? a) continually reassure and coach the client b) administer the prescribed oxygen throughout labor c) maintain strict asepsis throughout the labor process d) increase the intravenous (IV) fluids if the client complains of feeling thirsty - ansB A major hospital has received notification of a mass casualty event in the area. Which of the following actions should a charge nurse of an inpatient neurovascular floor do FIRST? A. Expedite discharge of appropriate clients B. Reallocate staff according to mass casualty plan of action C. Initiate paper charting methods for consistency D. Reduce vital sign frequency to every 8 hours for patients currently on the unit - ansB
A nurse from medical-surgical unit is asked to work on the orthopedic unit. The medical- surgical nurse has no orthopedic nursing experience. Which client should be assigned to the medical-surgical nurse? Discuss o A. A client with a cast for a fractured femur and who has numbness and discoloration of the toes o B. A client with balanced skeletal traction and who needs assistance with morning care o C. a client who had an above-the-knee amputation yesterday and has a temperature of 101.4F o D. a client who had a total hip replacement 2 days ago and needs blood glucose monitoring - ansD A nurse has just administered a dose of hydralazine hydrochloride (Apresoline) intravenously to a client. Based on the action of this medication, the nurse would initially assess the client's: a) cardiac rhythm b) oxygen saturation c) blood pressure d) respiratory rate - ansC A nurse in a postanesthesia care unit (PACU) receives a client transferred from the operating room. The PACU nurse assesses the client for which of the following first? a) active bowel sounds b) adequate urine output c) orientation to the surroundings d) a patent airway - ansD A nurse is assessing a 39 year old Caucasian female client. The client has a blood pressure (BP) of 152/92 mm Hg at rest, a total cholesterol of level of 190 mg/dL, and a fasting blood glucose level of 110 mg/dL. The nurse would place priority on which risk factor for coronary heart disease (CHD) in this client? a) age b) hypertension c) hyperlipidemia d) glucose intolerance - ansB A nurse is assigned to provide care to a client in labor and will care for the client throughout labor and into the postpartum period. The nurse assists in developing a plan
d) computed tomography - ansC A nurse manager is planning the client assignments for the day. Which of the following clients would the nurse assign to the nursing assistant? a) a 2-day postoperative client who had a below-the-knee amputation b) a client on a 24-hour urine collection who is on strict bedrest c) a cleint scheduled to be discharged after coronary artery bypass surgery d) a client scheduled for a cardiac catheterization - ansB A nurse manager of a medical-surgical unit returns to work after being on vacation for a week. It is the beginning of the shift, and the nurse manager is faced with several activities that need attention. Which activity will the nurse manager attend to first? a) a crash cart needs checking b) client assignments for the day c) a phone message that indicates that the charge nurse of the next shift is ill and will not be reporting to work d) a stack of mail from the education department and administrative services - ansB A nurse preceptor is working with a new nurse and notes that the new nurse is reluctant to delegate tasks to members of the care team. The nurse preceptor recognizes that this reluctance most likely is due to Discuss o A. Role modeling behaviors of the preceptor o B. The philosophy of the new nurse's school of nursing o C. The orientation provided to the new nurse o D. Lack of trust in the team members - ansD A nurse responds to an external disaster that occurred in a large city when a building collapsed. Numerous victims require treatment. Which victim will the nurse attend to first? a) an alert victim who has numerous bruises on the arms and legs b) a victim with a partial amputation of a leg who is bleeding profusely c) a hysterical victim who received a head injury d) a victim who sustained multiple serious injuries and is deceased - ansB A patient arrives at the emergency department complaining of mid-sternal chest pain. Which of the following nursing actions should take priority? a. A complete history with emphasis on preceding events b. An electrocardiogram (EKG)
c. Careful assessment of vital signs d. Chest exam with auscultation - ansC A patient is 6 days post-opt from abdominal surgery. The patient is to be discharged later today. The patient uses the call light and asks you to come to his room and look at his surgical site. On arrival, you see that approximately 2 inches of internal organs are protruding through the incision. What intervention would you NOT do?* A. Put the patient in prone position with knees extended to put pressure on the site B. Cover the wound with sterile normal saline dressing C. Monitor for signs of shock D. Notify the MD and administer as prescribed antiemetic to prevent vomiting - ansA A patient is now in the recovery room after having vaginal surgery. Due to the positioning of the procedure, you would want to assess for what while the patient is in recovery? A. Bowel Sounds B. Dysrhythmia C. Homan's Sign D. Hemoglobin Level - ansC A patient is recovering from surgery. The patient is very restless, heart rate is 120 bpm and blood pressure is 70/53, skin is cool/clammy. As the nurse you would?* A. Continue to monitor the patient B. Notify the MD C. Obtain an EKG D. Check the patient's blood glucose - ansB A patient is taking Aspirin 325 mg PO by mouth daily. The patient is scheduled for surgery in a week. What education do you provide the patient with before surgery?* A. Educate the patient to take the scheduled dose of Aspirin the day of surgery to help prevent blood clots B. To hold his morning dose of Aspirin because the nurse will give it to him before surgery C. None of the above are correct D. The medication should be discontinued for 48 hours prior to the scheduled surgery date - ansD A patient reports he hasn't had a bowel movement or passed gas since surgery. On assessment, you note the abdomen is distended and no bowel sounds are noted in the four quadrants. You notify the MD. What non-invasive nursing interventions can you perform without a MD order? A. Insert a nasogastric attached to intermittent suction B. Administer IV fluids C. Encourage ambulation, maintain NPO status, and monitor intake & output D. Encourage at least 3000 ml of fluids per day - ansC
A primigravida is admitted to the labor unit. During the assessment of the client, her membranes rupture spontaneously. The priority nursing action is which of the following? a) monitor the contraction pattern b) assess the fetal heart rate c) note the amount, color, and odor of the amniotic fluid d) check maternal vital signs - ansB A registered nurse (RN) has delegated care of a newly postoperative client to a licensed practical nurse (LPN). The LPN notifies the RN that the client's blood pressure and respirations are elevated from the baseline readings and that the client is complaining of pain and dyspnea. The RN takes which action next? a) the RN need not to carry out further assessment because the LPN is very experienced and trustworthy b) the RN requests that the LPN offer the client a opioid analgesic, which has ordered postoperatively c) the RN places a call to the attending surgeon and reports that the client is having pain and dyspneic d) the RN assesses the client, checks the client's surgical notes, and gathers addition data before calling the surgeon - ansD A registered nurse (RN) must determine how best to assign coworkers (another RN and one licensed practical nurse LPN) to provide care to a group of clients. Which of the following is the appropriate assignment? a) the RN is assigned to care for an unemployed 26-year old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS), who has four school-age children b) the LPN is assigned to care for a 41-year old male, postresection of an acoustic neuroma 2 days ago, transferred from the intensive care unit (ICU) this morning c) the LPN is assigned to provide discharge teaching about medications and maintenance of nephrostomy tube to a 35-year old man d) the RN is assigned to care for a 65-year old woman hospitalized because of chest pain, being discharged today to home with no medication - ansA A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements? o A. "I will arrange for a conference with you and the UAP within the next week" o B. "I can assure you that I will look into the matter" o C. "I would like for you to approach the UAP about the problem the next time it occurs" o D. "I will add this concern to the agenda for the next unit meeting" - ansC
A telephonic case management nurse notes that a cardiac client's weight has increased 5 pounds in the last two days and the client's blood pressure is elevated, as measured by the client's home telephonic equipment. When calling the client to evaluate, which of the following questions should the nurse ask FIRST? A. "How are you feeling today?" B."Are you experiencing any shortness of breath?" C."How is the swelling in your legs?" D. "When did you last calibrate your equipment?" - ansB After change of shift, you are assigned to care for the following patients. Which patient should you assess first? A A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab B A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation C A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics D A 50-year old with asthma who complains of shortness of breath after using a bronchodilator - ansD After surgery your patient is semicomatose with vital signs within normal limits. As the nurse, what position would be best for this patient? A. Semi-Fowlers B. Prone C. Low-Fowlers D. Side positioning preferably on the left side - ansD After surgery your patient starts to shiver uncontrollably. What nursing intervention would you do FIRST?* A. Apply warm blankets & continue oxygen as prescribed B. Take the patient's rectal temperature C. Page the doctor for further orders D. Adjust the thermostat in the room - ansA After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the RN immediately? A Heart rate of 98 beats/min B Respiratory rate of 24 breaths/min C Blood pressure of 168/90 mm Hg D Tympanic temperature of 101.4 F (38.6 C) - ansD All of the members of the surgical team must perform a "surgical scrub" except which of the following? A. Anesthetist/anesthesiologist
1.) Acute bleeding 2.) Pink serous drainage 3.) Purple drainage 4.) severe pain - ans2 Pink serous drainage (looks like pink lemonade) suddenly gushing is usually the major symptom of wound dehiscence. An adult male is scheduled for surgery and the nurse is assessing for risk factors. Which is the following are the greatest risk factors? 1.) He is 5ft 4 in tall and weighs 125 lb 2.) He expressed a fear of pain in the post-op period. 3.) He is 5ft 4 in tall, weighs 360lb, and is diabetic. 4.) He expresses fear of the unknown. - ans3.)He is 5ft 4 in tall, weighs 360lb, and is diabetic An adult man is in the postanesthesia care unit (PACU) following a hemicolectomy. While in the PACU, the nurse will monitor his vital signs: 1.) continuously 2.) every 5 minutes 3.) every 15 minutes 4.) on a prn basis - ans3 in the PACU, vital signs are assessed every 15 minutes An adult received atropine sulfate (Atropine) as a pre-op medication 30 minutes ago and is now complaining of dry mouth and her pulse rate is higher than before the medication was administered. The nurse's best interpretation of these findings is that: 1.) The client is having an allergic reaction to the drug. 2.) the client needs a higher dose of this drug 3.) this is a normal side effect of Atropine 4.) the client is anxious about the upcoming surgery. - ans3.) These are normal side effects of an anticholinergic drug; adverse side effects would include ECG changes, constipation, and urinary retention. An adult who has had general anesthesia for major surgery is in the PACU. One of the signs that may indicate that his artificial airway should be removed is: 1.) gagging 2.) restlessness 3.) in increase in pain 4.) clear lungs on auscultation. - ans1 Gagging with the return of the gag reflex indicates that the client is able to manage his own secretions and patent airway.
An adult with COPD is scheduled for surgery and the physician has recommended an epidural anesthetic. The nurse should know that general anesthesia was not recommended for this client because: 1.)there is too high a risk for pressure sores to develop 2.) there is less effect on the respiratory system with epidural anesthesia. 3.) CNS control of the vascular constriction would be affected with general anesthesia. 4.) there is too high a risk of lacerations to the mouth, bruising of lips, and damage to teeth. - ans2.) Epidural anesthesia does not cause resp. depression, but general anesthesia can. especially in a client with COPD. An emergency nurse is injured while restraining a client. The nurse manager debriefs uninjured personnel, and addresses which of the following about the injured coworker? A. Resignation of the coworker is expected B. Legal action against the client would be time-consuming C. The injured coworker can only return to work after a debriefing between client and coworker D. The coworker's emotional response may be similar to a crime victim's reponse - ansD An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply. A Auscultate breath sounds B Administer medications via metered-dose inhaler (MDI) C Complete in-depth admission assessment D Initiate the nursing care plan E Evaluate the patient's technique for using MDI's - ansA, B An RN from the women's health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse? o A. A newly diagnosed client with type 2 diabetes mellitus who is learning foot care o B. A client from a motor vehicle accident with an external fixation device on the leg o C. A client admitted for a barium swallow after a transient ischemic attack o D. A newly admitted client with a diagnosis of pancreatic cancer - ansB As a nurse, which statement is incorrect regarding an informed consent signed by a patient?* A. The nurse is responsible for obtaining the consent for surgery B. Patients under 18 years of age may need a parent or legal guardian to sign a consent form
In the Per-op phase, a physicial orders a patient taken off of Coumadin (warfarin) and put on IV heparin. This change in medication will: 1.) Help the patient be more relaxed before her surgical procedure. 2.) Prevent blood clots. 3.) be more quickly reversible during surgery if needed. 4.) shortens the length of recovery time for post-op patients. - ans3.) Heparin is quickly reversible in the event of hemorrhage with Protamine sulfate, (Coumadin can be reversed with Vitamin K, but the results are much slower than with the heparin/protamine reversal) In the recovery room, the postoperative client suddenly becomes cyanotic. What is the most appropriate nursing action? Discuss A. Start administration of oxygen through a nasal cannula B. Call for assistance C. Reposition the head and determine patency of airway D. Insert an oral airway and suction the nasopharynx - ansC The anesthetized client with an open abdomen suddenly develops malignant hyperthermia. What intervention should the nurse be prepared to initiate or assist with? A. Discontinue mechanical ventilation. B. Administer intravenous potassium chloride. C. Administer intravenous calcium chloride. D. Administer intravenous dantrolene (Dantrium). - ansD The best position for kidney, chest, or hip surgery is: A. Supine B. Trendelenburg C. Lithotomy D. Lateral - ansD The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit? A A 58-year old on airborne precautions for tuberculosis (TB) B A 68-year old just returned from bronchoscopy and biopsy C A 72-year old who needs teaching about the use of incentive spirometry
D A 69-year old with COPD who is ventilator dependent - ansC The charge nurse is working with a licensed practice nurse (LPN), unlicensed assistive personnel (UAP) and another registered nurse (RN). Which patient assignment is appropriate to delegate to the other RN? A Patient A with an arm fracture needs assisting with feeding and bathing B Patient B with diabetes and a wound infection needs the daily insulin injection C Patient C needs his chest pain re-assessed before giving a second dose of medication D Patient D with chronic bronchitis needs transportation to radiology for a chest X-Ray - ansC The client is admitted to the postanesthesia care unit (PACU) after surgery that took place with the client in the lithotomy position. Which change in assessment findings alerts the nurse to a possible complication of this surgical position? A. The electrocardiogram (ECG) shows tall, peaked T waves and wide QRS complexes. B. The client only arouses in response to light shaking. C. The pulse pressure has increased from 28 to 40 mm Hg. D. The dorsalis pedis pulses are not palpable bilaterally. - ansD The client is postoperative from surgery performed to determine whether a growth in her colon is cancerous. She asks the nurse what the pathology report shows. The pathology report indicates that the growth is benign. What is the nurse's best response? A. "Congratulations! The growth was not cancerous." B. "You will have to wait for your doctor to tell you the results." C. "You shouldn't worry. Most tumors of this sort are benign." D. "I will call your doctor to let her know you are awake and are concerned about the results." - ansD The client receiving preoperative medication tells the nurse that all of the following medications (drugs or herbs) were ingested yesterday. Which one should the nurse report to the surgical team? A. Acetaminophen (Tylenol) B. Vitamin C C. Motherwort D. Diphenhydramine (Benadryl) - ansC The client tells the nurse during the preoperative history that he is a three-pack a day cigarette smoker. This information alerts the nurse to which potential complication during the intraoperative and postoperative periods? A. A decreased tolerance to pain B. A decreased clotting ability C. An increased risk for atelectasis and hypoxia
B Manually ventilate the patient while assessing possible reasons for the high-pressure alarm C Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning D Insert an oral airway to prevent the patient from biting on the endotracheal tube - ansB The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client? o A. Ask the client and family if they are satisfied with the care given o B. Determine if the home health aide's care is consistent with the plan of care o C. Investigate if the home health aide is prompt and stays an appropriate length of time for care o D. Check the documentation of the aide for appropriateness and comprehensiveness - ansB The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to? Discuss o A. Practical nurse (PN) o B. Registered Nurse (RN) o C. Unlicensed assistive personnel (UAP) o D. Volunteer - ansC The nurse administers 10mg IM morphine as a pre-op medication, and then discovers that there is no signed operative permit. The best action for the nurse to take is to: 1.) Send the client to surgery as scheduled. 2.) notify the nursing supervisor, the OR, and the physician. 3.) cancel surgery immediately 4.) obtain the needed constent. - ans2.)is a narcotic, sedative, or tranquilizing drug has been administered before signing of the consent, the drug's effects must be allowed to wear off before consent can be given. The nurse advises unlicensed personnel to provide oral hygiene for clients who are unable to perform it for themselves. Which technique should be emphasized?
A. Soft bristle brushing of teeth and tongue after every meal B. Moistened foam applicator swabbing of tongue, gums, and lips every 4 hours C. Frequent rinsing of the client's oral cavity with mouthwash D. Record observations about the client's oral cavity after each instance of oral care - ansA The nurse empties 80 mL of sanguineous drainage from the Jackson-Pratt drain in the client's hip after hip surgery. What other actions regarding the drain should the nurse take? A. Flush the tubing with urokinase to ensure patency. B. Compress and close the drain to ensure suction. C. Advance the tubing ½ inch from the insertion site. D. Clamp the drain for 2 hours and release the clamp for 2 hours. - ansB The nurse enters a woman's room to administer 10mg Valium PO, the ordered pre-op medication for her hysterectomy. During the conversation, the client tells the nurse that she and her husband are planning to have another child in the coming year. The best action for the nurse to take is which of the following? 1.) Do not administer the pre-op medication. NOtify the nursing supervisor and the physician. 2.) Go ahead and administer the medication as ordered. 3.) Check to see if the client has signed a surgical consent. 4.)Send the client to the OR without the medication. - ans1.)no client should be administered the per-op med until the informed consent has been obtained. Even if the consent form is signed, the nurse should withhold sedating meds because this client clearly does not understand the planned procedure. The nurse in a same-day surgery unit assigns the unlicensed assistive personnel (UAP) to provide a hernia patient with a lunch tray. Which statement by the nurse is most appropriate? Discuss o A. "Tell the family they can bring in a pizza if the patient would prefer that." o B. "Make sure the patient gets at least 2 cartons of milk." o C. "Stop the IV if the patient is able to eat solid food." o D. "Encourage the patient to eat slowly to prevent gas." - ansD The nurse in an outclient department is interviewing an adult one week prior to her scheduled elective surgery. In planning for the surgery, which of the following should the nurse include in her teaching? 1.) The client will be able to return home alone following the surgery.
