fundamentals
Health Assessment
Med/Surg
Mental Health
peds/ob
100
A patient's outcome was to have a pain level of 4 out of 10, 30 minutes after receiving medication. 30 minutes later the patient reported a pain level of 3 out of 10. Has the outcome been: a. Met b. Not met c. Partially met d. Not enough information
The answer is met
100
Besides high blood pressure values, what other signs and symptoms may the nurse observe if hypertension is present? A) Unexplained pain and hyperactivity B) Headache, flushing of the face, and nosebleed C) Dizziness, mental confusion, and mottled extremities D) Restlessness and dusky or cyanotic skin that is cool to the touch
What is Headache, flushing of the face, and nosebleed B
100
1. The nurse assesses a client’s surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? a. Red, hard skin b. Serous drainage c. Purulent drainage d. Warm tender skin
What is Serous drainage B
100
1. The nurse visits a client at home. The client states, “I haven’t slept at all the last couple of nights.” Which response by the nurse demonstrates therapeutic communication? a. “I see.” b. “Really?” c. “You’re having trouble sleeping?” d. “Sometimes I have trouble sleeping too.”
What is "You're having trouble sleeping?" C
100
13. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? a. “it connects the pulmonary artery to the aorta.” b. “it is an opening between the right and left atria.” c. “it connects the umbilical vein to the inferior vena cava.” d. “it connects the umbilical artery to the inferior vena cava.”
What is it connects the umbilical vein to the inferior vena cava C
200
Expected outcome should be written following which five step guideline? a. Specific, medications, availability, response, time b. Selective, measurable, availability, reasonable, treatment c. Measurable, achievable, reasonable, time, selective d. Selective, medications, achievable, response, treatment
What is Measurable, achievable, reasonable, time, selective C
200
Which of the following values for vital signs would the nurse address first? A) Heart rate = 72 beats per minute B) Respiration rate = 28 breaths per minute C) Blood pressure = 160/86 D) Oxygen saturation by pulse oximetry = 89% E) Temperature = 37.2° C (99° F), tympanic
What is Oxygen saturation=89% D
200
2. The nurse receives a telephone call from the post anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? a. Assess the patency of the airway. b. Check tubes or drains for patency. c. Check the dressing to assess for bleeding. d. Assess the vital signs to compare with preoperative measurements.
What is assess the patency of the airway A
200
2. A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? a. Using open ended questions and silence b. Sharing personal preference regarding food choices c. Documenting reasons why the client does not want to eat d. Offering opinions about the necessity of adequate nutrition.
What is Using open ended questions and silence A
200
4. The nurse is preparing to care for a 5 year old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child? a. A Radio b. A Sports video c. Large picture book d. Crayons and coloring book
What is crayons and coloring book D
300
Which of the following is a correct expected outcome of a nursing diagnosis? a. Patient will have no crackles in lower lobes b. Patient will feel better c. Patient will ambulate the hall 3 times and back by the end of my shift d. Patient will experience a decrease in pain level
What is Patient will ambulate the hall 3 times and back by the end of my shift C
300
Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 36.1° C (97° F). The client's remaining vital signs are in the normally acceptable range. What should the nurse do next? A) Check the client's temperature history. B) Document the results; temperature is normal. C) Recheck the temperature every 15 minutes until it is normal. D) Get another thermometer; the temperature is obviously an error.
What is Check the client's temperature history A
300
The nurse is assigned to a 40 year old patient diagnosed with chronic pancreatitis/ The nurse anticipates the client's serum amylase level to be which of the following: A. 45 units/L b. 100 units/L c. 300 units/L d. 500 units/L
What is 300 units/L C normal level 25-151 d is too high to be seen in chronic
300
3. What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? a. Ask the client to leave the group for this session only b. Refer the client to another group that includes other manic clients c. Tell the client to stop monopolizing in a firm but compassionate manner d. Thank the client for the input, but inform the client that others now need a chance to contribute.
What is thank the client for the input, but inform the client that others now need a chance to contribute D
300
14. The nurse is preforming an assessment on a client who is at 38 weeks gestation and notes that the fetal heart rate (FHR) is 174 beats per minute. On the basis of this finding, what is the priority nursing action? a. Document the finding b. Check the mother's rate c. Notify the health care provider (HCP) d. Tell the client that the fetal heart rate is normal.
What is notify the healthcare provider C
400
Which of the following is the correctly written first part of the nursing diagnosis? a. Arthritis pain b. Status post hysterectomy c. Dermatitis inflammation d. Impaired skin integrity
What is impaired skin integrity C
400
The client, who has been on bed rest for 2 days, asks to get out of bed to go to the bathroom. He has new orders for "up ad lib." What action should the nurse take? A) Give him some slippers and tell him where the bathroom is located. B) Ask the nursing assistant to assist him to the bathroom. C) Obtain orthostatic blood pressure measurements. D) Tell him it is not a good idea and provide a urinal.
What is obtain orthostatic blood pressure measurements C
400
a nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? metabolic acidosis metabolic alkalosis respiratory acidosis respiratory alkalosis
What is metabolic alkalosis due to loss of gastric fluid
400
4. When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? a. Suppressing feelings of anxiety b. Identifying anxiety-producing situations c. Continuing contact with a crisis counselor d. Eliminating all anxiety from daily situations
What is identifying anxiety-producing situations B
400
5. The nurse is evaluating the developmental level of a 2year old. Which does the nurse expect to observe in this child? a. Uses a fork to eat. b. Uses a cup to drink c. Pours own milk into a cup d. Uses a knife for cutting food
What is uses a cup to drink B
500
The hypothalamus controls body temperature. The anterior hypothalamus controls heat loss, and the posterior hypothalamus controls heat production. What heat conservation mechanisms will the posterior hypothalamus initiate when it senses that the client's body temperature is lower than comfortable? A) Vasodilation and redistribution of blood to surface vessels B) Sweating, vasodilation, and redistribution of blood to surface vessels C) Vasoconstriction, sweating, and reduction of blood flow to extremities D) Vasoconstriction, reduction of blood flow to extremities, and shivering
What is vasoconstriction, reduction of blood flow to extremities, and shivering D
500
The client arrives at the emergency department following burn injury that occurred in the basement at home and inhalation injury is suspected. Which of the following would the nurse anticipate to be prescribed for the client? 100% oxygen via an aerosol mask oxygen via nasal cannula at 15 L/min oxygen via nasal cannula 10L/min 100% oxygen via a tight-fitting, non-rebreather face mask
What is 100% oxygen via a tight-fitting, non-rebreather face mask due to inhalation injury, this is done until carboxyhemoglobin levels fall.
500
5. A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason that this client cannot see, a mental health consult is prescribed. The nurse plans care based on which condition that should be the focus of this consult? a. Psychosis b. Repression c. Conversion disorder d. Dissociative disorder
What is Conversion disorder C
500
23. The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? a. Infection b. Hemorrhage c. Chronic hypertension d. Disseminated intravascular coagulation
What is hemorrhage B
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