Standard & Focused Assessment
A nurse is conducting a general survey of a patient upon admission to the hospital. Which of the following findings would require further assessment and possibly indicate an urgent need for intervention?
A) The patient's skin appears warm and dry
B) The patient is alert and oriented to person, place, and time
C) The patient's respiratory rate is 18 breaths per minute
D) The patient's blood pressure is 140/90 mmHg
Here's a challenging NCLEX-style question related to a general survey:
A nurse is conducting a general survey of a patient upon admission to the hospital. Which of the following findings would require further assessment and possibly indicate an urgent need for intervention?
A) The patient's skin appears warm and dry
B) The patient is alert and oriented to person, place, and time
C) The patient's respiratory rate is 18 breaths per minute
D) The patient's blood pressure is 140/90 mmHg
Correct Answer: D) The patient's blood pressure is 140/90 mmHg
Rationale: While all the options represent components of a general survey, a blood pressure reading of 140/90 mmHg is indicative of hypertension, which may require further assessment and intervention, especially if it is a significant increase from the patient's baseline or if there are accompanying symptoms such as headache, dizziness, or chest pain. Hypertension can increase the risk of cardiovascular complications such as stroke, heart attack, or kidney damage. Therefore, option D is the correct answer as it represents a finding that may require immediate attention and intervention.
A nurse is caring for a patient with active tuberculosis (TB). Which personal protective equipment (PPE) is necessary when providing care for this patient?
a) Surgical mask b) N95 respirator c) Gloves and gown d) Eye protection
b) N95 respirator
Explanation: Tuberculosis is an airborne disease caused by Mycobacterium tuberculosis. To prevent the transmission of TB, healthcare workers should wear an N95 respirator, which provides a higher level of protection against airborne particles compared to a surgical mask. Gloves and gown are also necessary to prevent contact transmission, but the primary concern in this scenario is airborne transmission. Eye protection may be needed if there is a risk of splashes or sprays of respiratory secretions. However, the main emphasis should be on respiratory protection with the use of an N95 respirator.
A 45-year-old patient is admitted to the hospital for a scheduled surgical procedure tomorrow morning. The nurse receives an order from the physician for the patient to be on a clear liquid diet starting tonight. Which of the following options would be appropriate for the nurse to offer the patient on a clear liquid diet?
A) Chicken broth and orange juice
B) Milkshake and gelatin
C) Cream of mushroom soup and apple juice
D) Vegetable soup and lemon-lime soda
A) Chicken broth and orange juice
Rationale: A clear liquid diet consists of liquids that are clear and leave no residue in the gastrointestinal tract. Options like chicken broth and orange juice are appropriate because they meet the criteria of being clear liquids. Milkshakes, cream-based soups, and vegetable soups are not considered clear liquids as they contain particles that may leave residue in the digestive system. Lemon-lime soda may also not be allowed due to the carbonation and sugar content, which can irritate the stomach and interfere with the surgical procedure. Therefore, options B, C, and D are incorrect.
A nurse is conducting a focused assessment of the respiratory system for a patient admitted with pneumonia. Which of the following findings would the nurse prioritize for further assessment and intervention?
A) Respiratory rate of 16 breaths per minute
B) Clear breath sounds bilaterally
C) Productive cough with yellow-green sputum
D) Oxygen saturation of 94% on room air
Correct Answer: C) Productive cough with yellow-green sputum
Rationale: While all the options may be relevant in the assessment of a patient with pneumonia, the presence of a productive cough with yellow-green sputum suggests the possibility of a bacterial infection or progression of pneumonia. This finding may indicate the need for further assessment of sputum characteristics, as well as possible initiation or adjustment of antibiotic therapy. Yellow-green sputum can be indicative of purulent material, suggesting an active infection.
Options A, B, and D represent normal or expected findings in a patient with pneumonia. A respiratory rate of 16 breaths per minute (Option A) falls within the normal range for adults. Clear breath sounds bilaterally (Option B) suggest adequate air movement and ventilation. An oxygen saturation of 94% on room air (Option D) is acceptable for most patients, although supplemental oxygen may be considered if oxygen saturation falls below 90%.
Therefore, option C is the correct answer as it represents a finding that may require further assessment and intervention in a patient with pneumonia.
Which of the following best describes the rationale behind standard precautions in healthcare settings?
a) Standard precautions are only necessary when dealing with patients who have confirmed infectious diseases. b) Standard precautions are designed to protect healthcare workers from known infectious diseases. c) Standard precautions are a set of infection control practices designed to prevent transmission of infectious agents from recognized and unrecognized sources of infection in healthcare settings. d) Standard precautions are primarily aimed at preventing transmission of bloodborne pathogens only.
c) Standard precautions are a set of infection control practices designed to prevent transmission of infectious agents from recognized and unrecognized sources of infection in healthcare settings.
A nurse is conducting a routine assessment of a postoperative patient. The patient underwent abdominal surgery yesterday. Upon assessment, the nurse notes the following vital signs: temperature 38.5°C (101.3°F), heart rate 110 beats per minute, respiratory rate 24 breaths per minute, and blood pressure 130/80 mmHg. Which of the following actions by the nurse would be appropriate?
A) Document the findings as normal postoperative vital signs
B) Notify the healthcare provider immediately
C) Administer antipyretic medication
D) Reassess the vital signs in 1 hour
Correct Answer: B) Notify the healthcare provider immediately
Rationale: The elevated temperature of 38.5°C (101.3°F) in a postoperative patient, especially following abdominal surgery, may indicate the presence of infection, such as surgical site infection or systemic infection. Infection is a common complication after surgery and requires prompt assessment and intervention to prevent further complications. Therefore, option B is the most appropriate action as it involves notifying the healthcare provider immediately for further evaluation and management of the patient's condition. Options A, C, and D are incorrect because they do not address the potential significance of the elevated temperature and the need for further assessment and intervention.
A nurse is caring for a patient diagnosed with pulmonary tuberculosis (TB) who is also suspected of having influenza. The patient is placed in a negative-pressure isolation room. Which of the following actions by the nurse would be appropriate?
A) Wearing an N95 respirator when entering the patient's room
B) Administering the influenza vaccine to all healthcare personnel
C) Limiting visitor access to the patient's room
D) Utilizing standard precautions only when providing care
Correct Answer: A) Wearing an N95 respirator when entering the patient's room
Rationale: Pulmonary tuberculosis (TB) requires airborne precautions due to the transmission of Mycobacterium tuberculosis through small respiratory droplets that can remain suspended in the air. The negative-pressure isolation room helps prevent the spread of infectious particles to other areas. Additionally, suspected influenza warrants droplet precautions due to its transmission via respiratory droplets.
Option A is appropriate because wearing an N95 respirator is necessary to protect healthcare personnel from inhaling airborne particles of tuberculosis and droplets containing influenza viruses. Option B is a preventive measure but not directly related to the immediate protection of healthcare workers from airborne and droplet pathogens. Option C is a reasonable step to limit the potential spread of both TB and influenza to visitors. Option D is incorrect because standard precautions alone would not provide adequate protection against airborne and droplet pathogens.
Therefore, option A is the correct answer for this question.
A 65-year-old patient is recovering from oral surgery and has been prescribed a mechanical soft diet. Which of the following foods would be appropriate for the nurse to include in the patient's meal plan?
A) Whole grain toast and scrambled eggs
B) Chunky vegetable soup and crackers
C) Grilled chicken breast and steamed broccoli
D) Mashed potatoes and pureed carrots
D) Mashed potatoes and pureed carrots
Rationale: A mechanical soft diet consists of foods that are soft in texture and easy to chew and swallow, making them suitable for individuals with difficulty chewing or swallowing. Options A, B, and C contain foods that may be too challenging for a patient on a mechanical soft diet due to their texture. Whole grain toast, chunky soup, and grilled chicken breast require significant chewing and may pose a risk of choking or discomfort for the patient. However, mashed potatoes and pureed carrots are examples of foods that are soft and can be easily consumed by someone on a mechanical soft diet. Therefore, option D is the correct answer.
A nurse is caring for a patient with impaired gas exchange due to acute respiratory failure. Which of the following assessment findings would the nurse prioritize for immediate intervention?
A) Respiratory rate of 24 breaths per minute
B) Oxygen saturation of 88% on room air
C) Fine crackles heard on auscultation of lung fields
D) Pink, frothy sputum expectorated during coughing
Correct Answer: D) Pink, frothy sputum expectorated during coughing
Rationale: Pink, frothy sputum is indicative of pulmonary edema, which can severely impair gas exchange and compromise oxygenation. This finding suggests the presence of fluid accumulation in the alveoli, impairing the diffusion of oxygen across the alveolar-capillary membrane. Immediate intervention is necessary to address the underlying cause of pulmonary edema and optimize gas exchange.
Options A, B, and C may also indicate impaired gas exchange, but they are not as critical as pink, frothy sputum, which suggests a more severe and potentially life-threatening condition:
Therefore, option D is the correct answer as it represents the finding that requires immediate intervention to address impaired gas exchange and prevent further deterioration of respiratory function.
Which of the following is the most appropriate action related to hand hygiene for a nurse caring for a patient with Clostridioides difficile (C. difficile) infection?
a) Use hand sanitizer before and after contact with the patient. b) Wash hands with soap and water before and after contact with the patient. c) Use gloves only during direct contact with the patient. d) Skip hand hygiene after removing gloves to avoid irritating the skin.
b) Wash hands with soap and water before and after contact with the patient.
Explanation: C. difficile is a spore-forming bacterium that causes severe diarrhea and is resistant to alcohol-based hand sanitizers. Therefore, the most effective way to prevent its transmission is by washing hands with soap and water. Hand sanitizer does not effectively eliminate C. difficile spores, so it's not suitable for hand hygiene in this situation. Additionally, hand hygiene should always be performed after glove removal to prevent transmission of any potential pathogens from the gloves to the hands.
A nurse is performing a focused assessment on a patient with suspected pneumonia. Which of the following actions by the nurse demonstrates an understanding of the nurse's role in a focused assessment?
A) Conducting a comprehensive head-to-toe physical examination
B) Obtaining a detailed family history of the patient
C) Assessing lung sounds at all auscultation sites
D) Asking the patient about their dietary preferences
Correct Answer: C) Assessing lung sounds at all auscultation sites
Rationale: A focused assessment is a targeted assessment aimed at gathering data related to a specific problem or concern. In the case of suspected pneumonia, assessing lung sounds at all auscultation sites is essential for identifying abnormal breath sounds such as crackles or diminished breath sounds, which are indicative of respiratory pathology.
Option A (Conducting a comprehensive head-to-toe physical examination) involves a broader assessment that may not be necessary or appropriate in a focused assessment setting.
Option B (Obtaining a detailed family history of the patient) is important for a comprehensive assessment but may not be directly relevant to the immediate concern of suspected pneumonia.
Option D (Asking the patient about their dietary preferences) is not relevant to the focused assessment of pneumonia and does not address the patient's respiratory status.
Therefore, option C is the correct answer as it represents an action that aligns with the nurse's role in a focused assessment, specifically focusing on gathering data pertinent to the patient's respiratory condition.
A nurse is preparing to don and doff personal protective equipment (PPE) when caring for a patient with suspected COVID-19. Which of the following sequences represents the correct order for donning and doffing PPE?
A) Donning: Gloves, gown, mask, goggles, doffing: Goggles, gown, mask, gloves
B) Donning: Gown, gloves, mask, goggles, doffing: Gloves, gown, goggles, mask
C) Donning: Mask, goggles, gown, gloves, doffing: Gown, gloves, goggles, mask
D) Donning: Goggles, mask, gown, gloves, doffing: Gloves, gown, mask, goggles
Correct Answer: C) Donning: Mask, goggles, gown, gloves, doffing: Gown, gloves, goggles, mask
Rationale: The correct sequence for donning PPE when caring for a patient with suspected COVID-19 is to first put on a mask, then goggles or a face shield, followed by a gown, and finally gloves. This sequence ensures that the healthcare worker is adequately protected from respiratory droplets and other bodily fluids.
When doffing PPE, the healthcare worker should remove gloves first, followed by the gown, then goggles or face shield, and finally the mask. This sequence minimizes the risk of self-contamination and ensures safe removal of potentially contaminated PPE.
Option C represents the correct sequence for both donning and doffing PPE according to established guidelines for COVID-19 precautions. Therefore, option C is the correct answer for this question.
A nurse is planning meals for a group of postoperative patients on restricted diets. Which of the following foods would be appropriate for a patient on a full liquid diet but not suitable for a patient on a clear liquid diet?
A) Beef broth
B) Orange sherbet
C) Chicken broth
D) Grape juice
B) Orange sherbet
Rationale: A full liquid diet includes clear liquids as well as opaque liquids and foods that are liquid at room temperature or liquefy at body temperature. Options A, C, and D are all clear liquids and would be appropriate for both a clear liquid diet and a full liquid diet. However, orange sherbet is a semi-solid food that is not included in a clear liquid diet but is permitted on a full liquid diet. Therefore, option B is the correct answer.
a patient with chronic obstructive pulmonary disease (COPD) who requires supplemental oxygen therapy. The nurse plans to administer oxygen via nasal cannula. Which of the following actions by the nurse would be appropriate?
A) Administering oxygen at 6 liters per minute
B) Placing the nasal cannula in the patient's mouth
C) Applying petroleum jelly to the nasal mucosa before inserting the cannula
D) Checking the patient's oxygen saturation every 4 hours
Correct Answer: A) Administering oxygen at 6 liters per minute
Rationale: When administering oxygen via nasal cannula to a patient with COPD, it's crucial to use a flow rate that provides the prescribed oxygen concentration without causing oxygen toxicity or worsening the patient's condition. Typically, oxygen via nasal cannula is initiated at a flow rate of 1-6 liters per minute, depending on the patient's oxygenation needs.
Option A is the correct answer as it represents an appropriate action by the nurse, ensuring that the patient receives the prescribed oxygen therapy without exceeding safe flow rates.
Option B (Placing the nasal cannula in the patient's mouth) is incorrect and would not deliver oxygen effectively. Nasal cannulas are designed to deliver oxygen through the nostrils, not the mouth.
Option C (Applying petroleum jelly to the nasal mucosa before inserting the cannula) is incorrect and not recommended. Petroleum jelly can interfere with oxygen delivery and increase the risk of nasal irritation or infection.
Option D (Checking the patient's oxygen saturation every 4 hours) is important for ongoing assessment of the patient's response to oxygen therapy, but it does not address the initial administration of oxygen via nasal cannula.
Therefore, option A is the correct answer as it represents the appropriate action for administering oxygen therapy via nasal cannula to a patient with COPD.
A nurse is caring for a patient who is receiving intravenous (IV) medication through a central venous catheter. When should the nurse wear gloves while providing care for this patient?
a) When assessing the patient's vital signs. b) When administering oral medications. c) When changing the IV tubing. d) When speaking with the patient about their treatment plan.
c) When changing the IV tubing.
Explanation: When handling invasive devices like central venous catheters, it is important to wear gloves to prevent the transmission of microorganisms and reduce the risk of infection. Changing the IV tubing involves direct contact with the catheter site and the tubing, which presents a risk of contamination. Wearing gloves during this procedure helps maintain aseptic technique and reduces the risk of introducing pathogens into the patient's bloodstream. While assessing vital signs or administering oral medications, gloves may not be necessary unless there is a possibility of contact with bodily fluids. Speaking with the patient about their treatment plan does not typically require the use of gloves unless there is direct contact with bodily fluids or contaminated surfaces.
What are the unexpected findings for auscultation?
List all three
crackles- pneumonia, coarse: loud bubbly noises fine = high pitched fine
Rhonci - snoring - loud low pitched rumbling coarse sounds
Wheezing - asthma , high-pitched musical sounds heard on inspiration and exhalation
Match the mode of transmission with the corresponding example:
Modes of Transmission:
Examples: A. Influenza virus B. Salmonella food poisoning C. Malaria D. Scabies E. Tuberculosis
Correct Answer: C) 1-B, 2-E, 3-A, 4-C, 5-D
Rationale:
Therefore, option C is the correct answer, as it correctly matches each mode of transmission with the corresponding example.
A nurse is providing dietary education to a patient with dysphagia. Which of the following foods would be appropriate to include in the patient's diet?
A) Crispy bacon and raw carrots
B) Creamy peanut butter and jelly sandwich
C) Pureed chicken and mashed potatoes
D) Popcorn and pretzels
C) Pureed chicken and mashed potatoes
Rationale: Dysphagia is a swallowing disorder that may require modifications to the texture of foods to prevent choking or aspiration. Option C, pureed chicken and mashed potatoes, is suitable for a dysphagia diet as it provides soft, moist foods that are easier to swallow. Options A, B, and D contain foods with textures that may be difficult for a person with dysphagia to swallow safely. Crispy bacon and raw carrots present a choking hazard, a peanut butter and jelly sandwich may be difficult to swallow due to its consistency, and popcorn and pretzels have hard textures that can increase the risk of choking or aspiration. Therefore, option C is the correct answer.
A nurse is providing care to a patient who is immobile due to a spinal cord injury. Which of the following interventions would be the nurse's priority in assisting with hygiene and elimination for this patient?
A) Administering a laxative to promote bowel movements
B) Performing perineal care using antiseptic solution
C) Assisting the patient to use a bedpan for bowel elimination
D) Positioning the patient in a high Fowler's position for urinary catheterization
C) Assisting the patient to use a bedpan for bowel elimination
Rationale: When caring for an immobile patient, promoting regular bowel elimination is essential to prevent constipation and potential complications such as impaction. Assisting the patient to use a bedpan for bowel elimination is the priority intervention among the options provided.
Match the following scenarios with the appropriate application of standard precautions:
Options: a) Wear gloves b) Wear gloves and gown c) Wear gloves and mask d) Wear gloves, gown, mask, and eye protection
Correct answers:
A nurse is caring for a patient admitted with abdominal pain. Initially, the nurse performs a standard assessment followed by a focused assessment. Which of the following statements accurately describes the difference between a standard assessment and a focused assessment?
A) A standard assessment is more detailed and comprehensive compared to a focused assessment.
B) A focused assessment is performed systematically, while a standard assessment is performed haphazardly.
C) A standard assessment gathers data related to a specific problem or concern, while a focused assessment gathers data on all body systems.
D) A focused assessment is typically performed by the healthcare provider, while a standard assessment is performed by the nurse.
A) A standard assessment is more detailed and comprehensive compared to a focused assessment.
Rationale:
Therefore, option A is the correct answer as it accurately describes the difference between a standard assessment and a focused assessment.
Match the characteristics with the corresponding type of asepsis:
Characteristics:
Types of Asepsis: A. Medical Asepsis B. Surgical Asepsis
A) 1-B, 2-A, 3-B, 4-A
B) 1-A, 2-B, 3-A, 4-B
C) 1-B, 2-B, 3-A, 4-B
D) 1-A, 2-A, 3-B, 4-B
Correct Answer: C) 1-B, 2-B, 3-A, 4-B
Rationale:
Therefore, option C is the correct answer as it correctly matches each characteristic with the corresponding type of asepsis.
A nurse is documenting a patient's fluid intake for the past 24 hours. The patient consumed the following beverages: 8 ounces of apple juice, 12 ounces of water, and 6 ounces of tea. Convert the total fluid intake from ounces to milliliters.
A) 710 milliliters
B) 7100 milliliters
C) 532 milliliters
D) 5320 milliliters
Correct Answer: D) 5320 milliliters
Rationale: To convert fluid intake from ounces to milliliters, you can use the conversion factor 1 ounce = 29.5735 milliliters.
Add the converted values together: Total fluid intake = 236.588 milliliters + 354.882 milliliters + 177.441 milliliters = 768.911 milliliters.
Match the risk associated with using a simple face mask with the corresponding preventive measure:
Risks:
Preventive Measures: A. Assess skin integrity regularly and provide padding if necessary B. Ensure proper fit and adjust oxygen flow rate as needed C. Keep the head of the bed elevated during feeding D. Provide emotional support and reassurance to the patient
A) 1-B, 2-D, 3-C, 4-A
B) 1-A, 2-B, 3-C, 4-D
C) 1-C, 2-A, 3-B, 4-D
D) 1-D, 2-C, 3-A, 4-B
Correct Answer: B) 1-A, 2-B, 3-C, 4-D
Rationale:
Therefore, option B is the correct answer as it correctly matches each risk associated with using a simple face mask with the corresponding preventive measure.
Match the following scenarios with the appropriate hand hygiene method: hand washing with soap and water (S&W) or hand sanitizing with alcohol-based hand rub (ABHR).
Options: a) S&W b) ABHR
Scenarios:
Correct answers: