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Nursing 130 - Practice Test 2 Questions
With Correct Detailed Answers.
C - ANSWER- The nurse's first action after discovering an electrical fire in a patient's room is to: a. Activate the fire alarm b. Confine the fire by closing all doors and windows. c. Remove all patients in immediate danger. d. Extinguish the fire by using the nearest fire extinguisher. C - ANSWER- The parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent? a. Give the child milk. b. Give the child syrup of ipecac. c. Call the poison control center. d. Take the child to the emergency department. D - ANSWER- The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? a. Activity to intolerance b. Impaired bed mobility c. Acute pain d. Risk for falls D - ANSWER- A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent? a. Home accidents b. Physiological changes of aging c. Poisoning and child abduction d. Automobile accidents, suicide, and substance abuse B F G - ANSWER- The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply) a. Insert a urinary catheter.
b. Leave a night light on in the bathroom. c. Ask the physician to order a restraint. d. Keep the bed in low position with upper and lower side rails up. e. Assign a staff member to stay with the patient. f. Provide scheduled toileting during the night shift. g. Keep the pathway from the bed to the bathroom clear. C D F - ANSWER- The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select 3) a. Contact the nursing supervisor. b. Restrict the family's visiting privileges. c. Ask the family to stay with the patient if possible. d. Inform the family of the risks associated with side-rail use. e. Thank the family for being conscientious and put the four rails up. f. Discuss alternatives with the family that are appropriate for this patient. D - ANSWER- A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation? a. Being cardiopulmonary respiration. b. Restrain the child to prevent injury. c. Place a tongue blade over the tongue to prevent aspiration. d. Clear the area around the child to protect the child from injury. A - ANSWER- A 62-year-old woman is being discharged to home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that: a. A safe environment promotes patient activity. b. Assessment focuses on environmental factors only. c. Teaching home safety is difficult to do in the hospital setting. d. Most accidents in the older adult are caused by lifestyle factors. A - ANSWER- The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: a. Place a bed alarm device on the bed. b. Place the patient in a belt restraint. c. Provide one-on-one observation of the patient. d. Apply wrist restraints.
B - ANSWER- A 26-year-old married woman recently discovered that she is pregnant and is at her first prenatal visit. While assessing the patient, the woman's health nurse practitioner discovers that she has purulent vaginal discharge. The patient states, "It burns when I urinate, and I seem to have to go to the bathroom frequently." Based on these symptoms, the nurse practitioner determines that further follow-up is needed because the patient: a. Should be tested for human immunodeficiency virus (HIV). b. May have a sexually transmitted infection (STI) such as chlamydia. c. Is experiencing normal signs of pregnancy. d. Needs education on proper perineal hygiene. A B C - ANSWER- A new graduate nurse is working in a rehabilitation center that specializes in the care of patients with spinal cord injuries (SCIs). The new graduate knows that sexual issues are common among patients with SCIs. Which of the following actions enhances the nurse's comfort in discussing sexual issues with the patients? (Select 3) a. Clarifying personal values related to sexuality. b. Role playing discussion of sexual concerns with another nurse. c. Attending a conference to enhance knowledge about sexuality. d. Avoiding a discussion of sexual concerns until after completing new nurse orientation. B - ANSWER- The nurse is gathering a sexual history from a 68-year-old man in a nursing home. It is important for the nurse to keep in mind that: a. Older adults are usually not part of a sexual minority group. b. Older adults sometimes do not reveal intimate details. c. Older men and women lose their interest in sex. d. Older adults in nursing homes do not usually participate in sexual activity. A D - ANSWER- Certain cultural groups in the United States are disproportionately affected by diseases such as HIV and AIDS. The nurse understands that this is most likely caused by: (Select 2) a. Expectations about behavior by men or women in the culture. b. Higher percentages of lesbian, gay, bisexual, or transgender individuals in the culture. c. Genetic predisposition to the disease in the culture. d. Communication patterns and language practiced by the culture. A - ANSWER- Since the majority of sexually transmitted infections (STIs) have few if any symptoms, it is important for the nurse to: a. Encourage regular screenings in all sexually active individuals. b. Provide information about contraception options.
c. Administer prescribed antibiotics for human papillomavirus (HPV) or genital herpes outbreaks. d. Ask all patients if they are experiencing any symptoms. C - ANSWER- Establishing trust and encouraging disclosure about sexuality are often facilitated if the nurse begins by asking the patient: a. How often he or she has sexual intercourse. b. To disrobe in preparation for the physical assessment. c. For permission to discuss sexual issues. d. For specific examples of sexual practices and problems. B C - ANSWER- A 15-year-old girl states that she is having unprotected intercourse with her boyfriend. She asks for more information about birth control methods. The nurse informs the patient that: (Select 2) a. Condoms or diaphragms must be used with each sexual encounter. b. Hormonal methods offer little protection against STIs. c. Barrier methods offer some protections against STIs. d. Sterilization is an effective option that she should consider. C - ANSWER- The nurse reviews the health history of a 24-year-old woman who indicates that she has had three new sexual partners since her previous examination 2 years ago. The nurse discusses the need for sexually transmitted infection (STI) screening with the patient even though she denies symptoms or discomfort. The nurse realizes that the most serious complication from untreated STIs in females is: a. Genital discharge and dyspareunia. b. Painful menstrual cycles. c. Infertility and pelvic inflammatory disease. d. Genital warts. B C - ANSWER- The nurse is providing education about condom use at a community clinic for older adults. Which of the following statements demonstrates that the adults understand correct use of condoms? (Select 2) a. "I can use any kind of lubricant such as lotions or baby oil." b. "Before using the condom, I should check the package for damage or expiration." c. "I need to use a condom to help reduce the risk of sexually transmitted infections." d. "A good place to store condoms is in the bathroom so they don't dry out." B - ANSWER- Which of the following represents a nonjudgmental approach when gathering a sexual health history? a. How do you and your wife/husband feel about intimacy? b. Do you have sex with men, women, or both?
b. Protein c. Vitamin d. Carbohydrate A C E - ANSWER- The nurse is caring for a patient experiencing dysphagia. Which interventions help decrease the risk of aspiration during feeding? (Select 3) a. Sit the patient upright in a chair. b. Give liquids at the end of the meal. c. Place food in the strong side of the mouth. d. Provide thin foods to make it easier to swallow. e. Feed the patient slowly, allowing time to chew and swallow. f. Encourage patient to lie down to rest for 30 minutes after eating. B - ANSWER- The nurse suspects that the patient receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What action does the nurse need to take first? a. Raise the head of bed to 90 degrees. b. Turn patient to left lateral decubitus position. c. Notify health care provider immediately. d. Have patient perform the Valsalva maneuver. A - ANSWER- Which action is initially taken by the nurse to verify correct position of a newly placed small-bore feeding tube? a. Placing an order for x-ray film examination to check position. b. Confirming the distal mark on the feeding tube after taping. c. Testing the pH of gastric contents and observing the color. d. Auscultating over the gastric area as air is injected into the tube. 2 3 1 4 - ANSWER- The catheter of a patient receiving parenteral nutrition (PN) becomes occluded. Place the steps for caring for the occluded catheter in the order in which the nurse would perform them:
- Attempt to aspirate a clot.
- Temporarily stop the infusion.
- Flush the line with saline or heparin.
- Use a thrombolytic agent if ordered or per protocol. D - ANSWER- Based on knowledge of peptic ulcer disease (PUD), the nurse anticipates the presence of which bacteria when reviewing the laboratory data for a patient suspected of having PUD? a. Micrococcus b. Staphylococcus
c. Corynebacterium d. Helicobacter pylori D - ANSWER- The nurse is assessing a patient receiving enteral feedings via a small- bore nasogastric tube. Which assessment findings need further intervention? a. Gastric pH of 4.0 during placement check. b. Weight gain of 1 pound over the course of a week. c. Active bowel sounds in the four abdominal quadrants. d. Gastric residual aspirate of 350 mL for the second consecutive time B - ANSWER- The home care nurse is seeing the following patients. Which patient is at greatest risk for experiencing inadequate nutrition? a. A 55yr old obese man recently diagnosed with diabetes mellitus. b. A recently widowed 76 yr old woman recovering from a mild stroke. c. A 22 yr old mother with a 3 yr old toddler who had tonsillectomy surgery. d. A 46 yr old man recovering at home following coronary artery bypass surgery. 5 2 1 4 3 6 7 - ANSWER- The nurse is checking feeding tube placement. Place the steps in the proper sequence.
- Draw 5 to 10 mL gastric aspirate into syringe.
- Flush tube with 30 mL air.
- Mix aspirate in syringe and place in medicine cup.
- Observe color of gastric aspirate.
- Perform hand hygiene and put on clean gloves.
- Dip pH strip into gastric aspirate.
- Compare strip with color chart from manufacturer. D - ANSWER- Which statement made by a patient of a 2-month-old infant requires further education? a. I'll continue to use formula for the baby until he is at least 1 year old. b. I'll make sure that I purchase iron-fortified formula. c. I'll start feeding the baby cereal at 4 months. d. I'm going to alternate formula with whole milk starting next month. A C D - ANSWER- The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? (Select 3) a. Avoid grapefruit and grapefruit juice, which impair drug absorption. b. Increase the amount of carbohydrates for energy. c. Take a multivitamin that includes vitamin D for bone health. d. Cheese and eggs are good sources of protein.
B - ANSWER- A patient stats that he does not believe in the existence of God. This patient mostly likely is an: a. Academic b. Atheist c. Agnostic d. Anarchist A - ANSWER- As the nurse cares for a patient in an outpatient clinic, the patient states that he recently lost his position as a volunteer coordinator at a local community center. He expresses that he is angry with his former boss and with God. The nurse knows that the priority at this time is to assess the patient's spirituality in relation to his: a. Vocation b. Life satisfaction c. Fellowship and community d. Connectedness with his family and co-workers A - ANSWER- A patient who is hospitalized with heart failure states that she sees her illness as an opportunity and a challenge. Despite her illness, she is still able to see that life is worth living. This is an example of: a. Hope b. Faith c. Values d. Connectedness B - ANSWER- Which of the following statements made by an older adult whose husband recently died most indicates the need for follow-up by the nurse? a. "I planted a tree at church in my husband's honor." b. "I have been unable to talk with my children lately." c. "My friends think that I need to go to a grief support group." d. "I believe that someday I'll meet my husband in heaven." A E - ANSWER- Which of the following nursing interventions support a healing relationship with a patient? (Select 2): a. Praying with the patient. b. Giving pain medications before a painful procedure. c. Telling a patient that it is time to take a bath before family arrive to visit. d. Making the patient's bed following hospital protocol. e. Helping a patient see positive aspects related to a chronic illness. C - ANSWER- A patient expresses the desire to learn how to meditate. What does the nurse need to do first?
a. Answer the patient's question. b. Help the patient get into a comfortable position. c. Select a teaching environment that is free from distraction. d. Encourage the patient to meditate for 10 to 20 minutes 2 times a day. A B E - ANSWER- An older adult is receiving hospice care. Which nursing interventions help the patient cope with feelings related to death and dying? (Select 3): a. Teaching the patient how to use guided imagery. b. Encouraging the family to visit the patient frequently. c. Taking the patient's vital signs every time the nurse visits. d. Teaching the patient how to manage pain and take pain medications. e. Helping the patient put significant photographs in a scrapbook for the family. C - ANSWER- Which of the following question would best assess a patient's level of connectedness? a. What gives your life meaning? b. Which aspects of your spirituality would you like to discuss right now? c. Who do you consider to be the most important person in t your life at this time? d. How do you feel about the accomplishments you've made in your life so far? D - ANSWER- A nurse is using the BELIEF tool to complete a spiritual assessment on a 12 yr old male who has recently been diagnosed with acute lymphocytic leukemia. Which of the following question would the nurse use to assess the child's involvement in the spiritual community? a. Which church do you attend? b. Which sports do you like to play? c. Are there any foods you cannot eat? d. In which church activities do you participate? A - ANSWER- A nurse is caring for patient who refuses to eat until after the sun sets. Which religion does this patient most likely practice? a. Islam b. Skhism c. Hinduism d. Catholicism C - ANSWER- A Catholic patient with diabetes receives the following items on his meal tray on the Friday before Easter. For which of the foods the nurse offer to substitute? a. Apple sauce b. Cheese and crackers
b. Hopelessness c. Spiritual distress d. Complicated grieving D - ANSWER- A family member asks a home care nurse what he should do if the patient's serious chronic illness worsens even with increased medical interventions. How does the nurse best begin a conversation about the goals of care at the end of life? a. Encourage the family member to think more positively about the patient's new therapy. b. Avoid the discussion because it has to do with medical, not nursing, diagnoses. c. Initiate a discussion about advance directives with the patient, family, and health care team. d. Begin the discussion by asking the patient to identify his or her beliefs about the goals of care while the family member is present. B - ANSWER- Which of the following nursing actions best reflects sensitivity to cultural differences related to end-of-life care? a. Practice honesty with everyone, telling patients about their illness, even if the news is not good. b. Ask family members if they prefer to help with the care of the body after death. c. Provide postmortem care at the time of death to relieve family members of this difficult job. d. Value patient self-determination, understanding that each person makes his or her own decisions. D - ANSWER- A young man is diagnosed with a serious, life-changing illness. His conversation during his first 2 days of hospitalization are abrupt, superficial, and unrelated to his illness. What understanding about communication enhances your therapeutic communication with this patient? a. Younger patients are usually less talkative about their diagnosis. b. All patients benefit by talking about their feelings with another person. c. Avoid discussing illness-related topics with quiet patients. d. Remain alert for signals that the patient wants to discuss his illness. D - ANSWER- A woman experiences the loss of a very early-term pregnancy. Her friends do not mention the loss, and someone suggests to her that she can "always try again." The woman feels confusion over her sadness and stops talking about it with others. What type of grief response is she most likely experiencing? a. Delayed b. Anticipated c. Exaggerated d. Disenfranchised
B - ANSWER- A family member of a recently deceased patient talks casually with the nurse at the time of the patient's death and expresses relief that she will not have to visit at the hospital anymore. What theoretical description of grief best applies to this family member? a. Denial b. Anticipatory grief c. Dysfunctional grief d. Yearning and searching C - ANSWER- A self-care goal you se when caring for dying and grieving patients include: a. Learning not to take losses so seriously. b. Limiting involvement with patients who are grieving. c. Maintaining life balance and reflecting on the meaning of your work. d. Admitting that you are not well suited to care for people who are grieving and asking the charge nurse not to assign you to care for these patients. B - ANSWER- A nurse is providing a postmortem care. Which action is the priority? a. Locating the patient's clothing. b. Providing culturally and religiously sensitive care in body preparation. c. Transporting the body to the morgue as soon as possible to prevent body composition. d. Providing all postmortem care to protect the family of the deceased from having to see the body. C - ANSWER- Which approach to helping grieving people is most consistent with postmodern grief theories? a. Help the patient identify the tasks to be accomplished during his or her grief. b. Encourage people to recognize stages of grieving in anticipation of what is to come. c. Listen carefully to a person's story of how his or her grief experience is unfolding. d. Offer general grief timelines to help the person know when a phase will pass. B - ANSWER- A patient who has a serious, life-limiting chronic illness wants to continue to engage in self-care and live as normally as possible. Which of the following nursing responses reflect a helpful understanding of patient self-care at the end of life? a. "Learning to accept that you can't perform some activities anymore will bring you more acceptance and peace." b. "Which activities are most important to you, and how can you continue to do them." c. "People in your life want to help you with things; allow them to do what they want for you."
be experiencing an allostatic load. As a result, the nurse expects to detect which of the following while assessing the patient? a. Posttraumatic stress disorder b. Rising hormone levels c. Chronic illness d. Return of vital signs to normal A - ANSWER- A patient who is having a difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1C, a measure of blood sugar control over the past 90 days, has increased by saying, "The hemoglobin A1C is wrong. My blood sugar levels have been excellent for the last 6 months." The patient is using the defense mechanism: a. Denial b. Conversion c. Dissociation d. Displacement C - ANSWER- A grandfather in Japan worries about his two young grandsons who disappeared after a tsunami. This is an example of: a. A situational crisis b. A maturational crisis c. An adventitious crisis d. A developmental crisis B - ANSWER- During the assessment interview of an older woman experiencing a developmental crisis, the nurse asks which of the following questions? a. How is this flood affecting your life? b. Since your husband died, what have you been doing in the evening when you feel lonely? c. How is having diabetes affecting your life? d. I know this must be hard for you. Let met ell you what might help. D - ANSWER- The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? a. Loss of autonomy caused by health problems b. Physical appearance, family, friends, and school c. Self-esteem issues, changing family structure d. Search for identity with peer groups and separating from family
B - ANSWER- A child who has been in a house fire comes to the emergency department with her parents. The child and parents are upset and tearful. During the nurse's first assessment for stress the nurse says: a. "Tell me who I can call to help you." b. "Tell me what bothers you the most about this experience." c. "I'll contact someone who can help get you temporary housing." d. "I'll sit with you until other family members can come help you get settled." C - ANSWER- When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, one of the first assessments includes which of the following? a. The amount of family support. b. A 3-day diet recall c. A thorough physical assessment. d. Threats to safety in her home. C - ANSWER- After a health care provider has informed a patient that he has colon cancer, the nurse enters the room to find the patient gazing out the window in thought. The nurse's first response is which of the following? a. "Don't be sad. People live with cancer every day." b. "Have you thought about how you are going to tell your family?" c. "Would you like for me to sit down with you for a few minutes so you can talk about this?" d. "I know another patient whose colon cancer was cured by surgery." A - ANSWER- A 34-yearl-old man who is anxious, tearful, and tired from caring for his three young children tells you that he feels depressed and doesn't see how he can go on much longer. Your best response would be which of the following? a. "Are you thinking of suicide?" b. "You've been doing a good job raising your children. You can do it." c. "Is there someone who can help you?" d. "You have so much to live for." D - ANSWER- The nurse is evaluating the coping success of a patient experiencing stress from being newly diagnosed with multiple sclerosis and psychomotor impairment. The nurse realizes that the patient is coping successfully when the patient says: a. "I'm going to learn to drive a car so I can be more independent." b. "My sister says she feels better when she goes shopping, so I'll go shopping." c. "I've always felt better when I go for a long walk. I'll do that when I get home." d. "I'm going to attend a support group to learn more about multiple sclerosis."
D - ANSWER- To enhance their cultural awareness, nursing students need to make an in-depth self-examination of their own: a. Motivation and commitment to caring. b. Social, cultural, and biophysical factors. c. Influencing treatment and care for patients. d. Background, recognizing personal biases and prejudices. D - ANSWER- Which of the following is required in the delivery of culturally congruent care? a. Learning about vast cultures. b. Motivation and commitment to caring. c. Influencing treatment and care of patients. d. Acquiring specific knowledge, skills, and attitudes. C - ANSWER- A registered nurse is admitting a patient of French heritage to the hospital. Which question asked by the nurse indicates that the nurse is stereotyping the patient? a. "What are your dietary preferences?" b. "What time do you typically go to bed?" c. "Do you bathe and use deodorant more than one time a week?" d. "Do you have any health issues that we should know about?" A - ANSWER- When action is taken on one's prejudices: a. Discrimination occurs. b. Delivery of culturally congruent care is ensured. c. Effective intercultural communication develops. d. Sufficient comparative knowledge of diverse groups is obtained. C - ANSWER- A nursing student is doing a community health rotation in an inner-city public health department. The student investigates sociodemographic and health data of the people served by the health department, and detects disparities in health outcomes between the rich and poor. This is an example of a(n): a. Illness attributed to natural and biological factors. b. Creation of the student's interpretation and descriptions of the data. c. Influence of socioeconomic factors in morbidity and mortality. d. Combination of naturalistic, religious, and supernatural modalities. D - ANSWER- Culture strongly influences pain expression and need for pain medication. However, cultural pain is: a. Not expressed verbally or physically.
b. Expressed only to others from similar culture. c. Usually more intense than physical pain. d. Suffered by a patient whose valued way of life is disregarded by practitioners. B - ANSWER- Which of the following best represents the dominant values in American society on individual autonomy and self determination? a. Physician orders b. Advance directive c. Durable power of attorney d. Court-appointed guardian A - ANSWER- The nurse at an outpatient clinic asks a patient who is Chinese-American with newly diagnosed hypertension if he is limiting his sodium intake as directed. The patient does not make eye contact with the nurse but nods his head. What should the nurse do next? a. Ask the patient how much salt he is consuming each day. b. Discuss the health implications of sodium and hypertension. c. Remind the patient that many foods such as soy sauce contain "hidden" sodium. d. Suggest some low-sodium dietary alternatives. C - ANSWER- A female Jamaican immigrant has been late to her last two clinic visits, which in turn had to be rescheduled. The best action that the nurse could take to prevent the patient from being late to her next appointment is: a. Give her a copy of the city bus schedule. b. Call her the day before her appointment as a reminder to be on time. c. Explore what has prevented her from being at the clinic in time for her appointment. d. Refer her to a clinic that is closer to her home. C - ANSWER- A nursing student is taking postoperative vital signs in the postanesthesia care unit. She knows that some ethnic groups are more prone to genetic disorders. Which of the following patients is most at risk for developing malignant hypertension? a. Ashkenazi Jew b. Chinese American c. African American d. Filipino A - ANSWER- A community health nurse is making a healthy baby visit to a new mother who recently emigrated to the United States from Ghana. When discussing contraceptives with the new mom, the mother states that she wont have to worry about getting pregnant for the time being. The nurse understands that the mom most likely made this statement because:
