Misc
The nurse is caring for a 73-year old patient diagnosed with pneumonia. Which data would be of greatest concern to the nurse when completing the nursing assessment of the patient?
A) Alert and oriented to date, time, and place
B) Buccal cyanosis and capillary refill greater than 3 seconds
C) Clear breath sounds and nonproductive cough
D) Hemoglobin concentration of 13 g/dl and leukocyte count 5,300/mm3
Correct Answer B
Explanation:
Buccal cyanosis and capillary refill greater than 3 seconds are indicative of decreased oxygen to the tissues, which requires immediate intervention. Alert and oriented, clear breath sounds, nonproductive cough, hemoglobin concentration of 13 g/dl, and leukocyte count of 5,300/mm3 are normal data.
A 50-year-old widower has arthritis and remains in bed too long because it hurts to get started. Which intervention should the nurse plan?
A) Telling the client to strictly limit the amount of movement of his inflamed joints
B) Teaching the client’s family how to transfer the client into a wheelchair
C) Teaching the client the proper method for massaging inflamed, sore joints
D) Encouraging gentle range-of-motion exercises after administering aspirin and before rising
Correct Answer D
Explanation:
Aspirin raises the pain threshold and, although range-of-motion exercises hurt, mild exercise can relieve pain on rising. Strict limitation of motion only increases the client’s pain. Having others transfer the client into a wheelchair does not increase his feelings of dependency. Massage increases inflammation and should be avoided with this client.
After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the I.V. site reveals that it is warm and erythematous. This usually indicates:
A) Infection
B) Infiltration
C) Phlebitis
D) Bleeding
Correct Answer C
Explanation:
Tenderness, warmth, swelling, and, in some instances, a burning sensation are signs and symptoms of phlebitis. Infection is less likely because no drainage or fever is present. Infiltration would result in swelling and pallor, not erythema, near the insertion site. The patient has no evidence of bleeding
The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. The nurse should anticipate giving how much heparin for each dose?
A) ¼ ml
B) ½ ml
C) ¾ ml
D) 1 ¼ ml
Correct Answer C
Explanation:
The nurse solves the problem as follows: 10,000 units/7,500 units = 1 ml/X 10,000 X = 7,500 X= 7,500/10,000 or ¾ ml
The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process?
A) Assessment
B) Nursing diagnosis
C) Planning
D) Evaluation
Correct Answer B
Explanation:
The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. During the assessment step, the nurse systematically collects data about the patient or family. During the planning step, the nurse develops strategies to resolve or decrease the patient’s problem. During the evaluation step, the nurse determines the effectiveness of the plan of care.
When assessing the lower extremities for arterial function, which intervention should the nurse perform?
A) Assessing the medial malleoli for pitting edema
B) Performing Allen’s test
C) Assessing the Homans’ sign
D) Palpating the pedal pulses
Correct Answer D
Explanation:
Palpating the client’s pedal pulses assists in determining if arterial blood supply to the lower extremities is sufficient. Assessing the medial malleoli for pitting edema is appropriate for assessing venous function of the lower extremity. Allen’s test is used to evaluate arterial blood flow before inserting an arterial line in an upper extremity or obtaining arterial blood gases. Homans’ sign is used to evaluate the possibility of deep vein thrombosis.
When listening to a client’s heart sounds during auscultation, which sounds would most likely be heard using the bell of the stethoscope?
A) S3
B) S1
C) S2
D) High-frequency murmurs
Correct Answer C
These sounds are best heard with the diaphragm of the stethoscope.
Explanation: There are two sides of the stethoscope that the nurse may use with auscultation: the bell and the diaphragm. The bell side is used to hear low-pitched sounds, while the diaphragm is used for high-pitched sounds. The bell is used to assess the S3 and S4 heart sound, as these are low-pitched sounds.
The physician’s order reads “Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal saline solution in 60 minutes.” What is the flow rate if the drop factor is 10 gtt = 1 ml?
A) 25 gtt/minute
B) 37 gtt/minute
C) 50 gtt/minute
D) 60 gtt/minute
Correct Answer A
Explanation:
25 gtt/minute
Volume= 150 ml divided by Time= 60 minute (answer is 2.5 now multiple this by 10 equals 25 gtt)
The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm is true?
A) The bell detects high-pitched sounds best
B) The diaphragm detects high-pitched sounds best
C) The bell detects thrills best
D) The diaphragm detects low-pitched sounds best
Correct Answer B
Explanation:
The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best.
The nurse is revising a client’s care plan. During which step of the nursing process does such revision take place?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
Correct Answer D
Explanation:
During the evaluation step of the nursing process the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions.
A 75- year- old patient has come to the nursing clinic for a comprehensive health assessment. Which statement would be the best way to end the history interview?
A) “What brought you to the clinic today?”
B) “How would you describe your overall health as good?”
C) “Do you understand what is happening?”
D) “Is there anything else you would like to tell me?”
Correct Answer D
Explanation:
By asking the client if there is anything else, the nurse allows the client to end the interview by discussing feelings and concerns. Asking about what brought the client to the clinic is an ambiguous question to which the client may answer “my car” or any similarly disingenuous reply. Asking if the client describes his overall health as good is a leading question that puts words in his mouth. Asking if the client understands what is happening is a yes-or-no question that can elicit little information.
A nurse needs to assess posterior lung sounds in a client. In which position would it be most appropriate to place this client?
A) High Fowler’s
B) Semi-Fowler’s
C) Dorsal recumbent
D) Sims’ position
Correct Answer A
Explanation: To assess the back and listen to posterior lung sounds, the nurse should place the client in the high Fowler's position. In this position, the client is sitting up with the head of the bed at a 90-degree angle. The high Fowler's position is used for performing an assessment that would require the client to sit up, such as the face and head, chest, and back.
A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1 ml. How many milliliters should the nurse administer?
A) 0.5 ml
B) 0.75 ml
C) 1 ml
D) 2 ml
Correct Answer A
Explanation: Practice your dosage calculation and how to covert units (very important)
0.5 ml
The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. how much of the drug should the nurse give?
A) 2 ml
B) 1 ml
C) ½ ml
D) ¼ ml
Correct Answer C
Explanation:
The nurse should give ½ ml of the drug. The dosage is calculated as follows: 250 mg/X=500 mg/1 ml 500x=250 X=1/2 ml
In which step of the nursing process does the nurse analyze data and identify client problems?
A) Assessment
B) Diagnosis
C) Planning outcomes
D) Evaluation
Correct Answer B
Explanation:
In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. In the diagnosis phase, the nurse identifies the client’s health status. In the planning outcomes phase, the nurse formulates goals and outcomes. In the evaluation phase, which occurs after implementing interventions, the nurse gathers data about the client’s responses to nursing care to determine whether client outcomes were met.
For which time period would the nurse notify the health care provider that the client had no bowel sounds?
A) 2 minutes
B) 3 minutes
C) 4 minutes
D) 5 minutes
Correct Answer D
Explanation:
To completely determine that bowel sounds are absent, the nurse must auscultate each of the four quadrants for at least 5 minutes; 2, 3, or 4 minutes is too short a period to arrive at this conclusion.
Which of the following is the nurse’s legal responsibility when applying restraints?
A) Document the patient’s behavior
B) Document the type of restraint used
C) Obtain a written order from the physician except in an emergency, when the patient must be protected from injury to himself or others
D) All of the above
Correct Answer D
Explanation:
When applying restraints, the nurse must document the type of behavior that prompted her to use them, document the type of restraints used, and obtain a physician’s written order for the restraints.
A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first?
A) Call the physician
B) Remedicate the patient
C) Observe the emesis
D) Explain to the patient that she can do nothing to help him
Correct Answer C
Explanation:
After a patient has vomited, the nurse must inspect the emesis to document color, consistency, and amount. In this situation, the patient recently ingested medication, so the nurse needs to check for remnants of the medication to help determine whether the patient retained enough of it to be effective. The nurse must then notify the physician, who will decide whether to repeat the dose or prescribe an antiemetic.
The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of:
A) 15 drop per minute
B) 21 drop per minute
C) 32 drop per minute
D) 125 drops per minute
Correct Answer C
Explanation:
Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of milliliters per minute: 125/60 min = X/1 minute 60X = 125X = 2.1 ml/minute To find the number of drops/minute: 2.1 ml/X gtts = 1 ml/15 gtts X = 32 gtts/minute, or 32 drops/minute
In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client’s health problem?
A) Assessment
B) Diagnosis
C) Planning outcomes
D) Evaluation
Correct Answer D
Explanation:
In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. In the diagnosis phase, the nurse identifies the client’s health status. In the planning outcomes phase, the nurse and client decide on goals they want to achieve. In the intervention planning phase, the nurse identifies specific interventions to help achieve the identified goal. During the implementation phase, the nurse carries out the interventions or delegates them to other health care team members. During the evaluation phase, the nurse judges whether her actions have been successful in treating or preventing the identified client health problem
The nurse is caring for a 46-year-old patient who has had an open reduction and internal fixation of the left hip. One day after the operation, the client is complaining of pain. Which data would cause the nurse to refrain from administering the pain medication and to notify the health care provider instead?
A) Left hip dressing dry and intact
B) Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute
C) Left leg in functional anatomic position
D) Left foot cold to touch; no palpable pedal pulse
Correct Answer D
Explanation:
A left foot cold to touch without palpable pedal pulse represents an abnormal finding on neurovascular assessment of the left leg. The client is most likely experiencing some complication from surgery, which requires immediate medical intervention. The nurse should notify the health care provider of these findings. A dry and intact hip dressing, blood pressure of 114/78 mm Hg, pulse rate of 82 beats per minute, and a left foot in functional anatomic position are all normal assessment findings that do not require medical intervention.
Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing?
A) Have the patient place the specimen in a container and enclose the container in a plastic bag
B) Have the patient expectorate the sputum while the nurse holds the container
C) Have the patient expectorate the sputum into a sterile container
D) Offer the patient an antiseptic mouthwash just before he expectorate the sputum
Correct Answer C
Explanation:
Placing the specimen in a sterile container ensures that it will not become contaminated. The other answers are incorrect because they do not mention sterility and because antiseptic mouthwash could destroy the organism to be cultured (before sputum collection, the patient may use only tap water for nursing the mouth).
A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal?
A) A palpable radial pulse
B) A palpable ulnar pulse
C) Cool, pale fingers
D) Pink nail beds
Correct Answer C
Explanation:
A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings.
The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first?
A) Auscultation
B) Inspection
C) Percussion
D) Palpation
Correct Answer B
Explanation:
Inspection always comes first when performing a physical examination. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation
A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing?
A) Ongoing assessment
B) Comprehensive physical assessment
C) Focused physical assessment
D) Psychosocial assessment
Correct Answer C
Explanation:
The nurse is performing a focused physical assessment, which is done to obtain data about an identified problem, in this case shortness of breath. An ongoing assessment is performed as needed, after the initial data are collected, preferably with each patient contact. A comprehensive physical assessment includes an interview and a complete examination of each body system. A psychosocial assessment examines both psychological and social factors affecting the patient. The nurse conducting a psychosocial assessment would gather information about stressors, lifestyle, emotional health, social influences, coping patterns, communication, and personal responses to health and illness, to name a few aspects.