Week1
A nurse is caring for a patient who is experiencing severe pain after surgery. The healthcare provider has prescribed a moderate dose of opioids for pain management. The patient requests a higher dose than prescribed, stating that they cannot tolerate the pain. Which of the following actions by the nurse best demonstrates the ethical principle of nonmaleficence?
A) Administer the higher dose of opioids as requested by the patient.
B) Explain the risks of opioid overdose and the importance of adhering to the prescribed dosage.
C) Withhold medication and suggest alternative pain management strategies.
D) Document the patient's request and inform the healthcare provider of the patient's pain level.
B. Explain the risks of opioid overdose and the importance of adhering to the prescribed dosage.
A nurse is conducting a review of systems (ROS) during a health assessment of a new patient. Which of the following statements by the patient should the nurse identify as requiring further assessment?
A) "I have occasional headaches, but they usually go away with rest."
B) "I've been feeling more anxious than usual lately."
C) "I sometimes experience heart palpitations when I exercise."
D) "My vision seems to blur occasionally, especially when I'm tired."
C) "I sometimes experience heart palpitations when I exercise."
A nurse is assessing a patient's vital signs. Which of the following findings should the nurse report immediately?
A) Blood pressure of 150/90 mmHg
B) Heart rate of 120 beats per minute
C) Respiratory rate of 22 breaths per minute
D) Temperature of 99.0°F (37.2°C)
B) Heart rate of 120 beats per minute
A nurse is assessing a patient’s ears during a HEENT examination. Which of the following findings would the nurse consider abnormal?
A) The presence of earwax (cerumen)
B) A pearly gray tympanic membrane
C) Redness and swelling of the external ear canal
D) A clear, non-draining external ear
C) Redness and swelling of the external ear canal
A nurse is explaining the concepts of preload and afterload to a group of nursing students. Which statement accurately describes preload?
A) Preload is the volume- the venous return that builds during diastole.
B) Preload is the resistance the heart must overcome to eject blood.
C) Preload is the volume of blood in the ventricles at the end of systole.
D) Preload is directly affected by systemic vascular resistance.
A) Preload is the volume- the venous return that builds during diastole.
The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse would place the stethoscope over which area?
A. The major bronchi
B. The trachea and larynx
C. The peripheral lung fields
D. The lower posterior thorax
A. The major bronchi
A nurse is conducting a health assessment on a new patient. During the assessment, the patient reports, "I've been feeling very tired and have lost 10 pounds in the last month." The nurse notes that the patient appears pale and has dry skin. Which of the following statements correctly identifies the subjective and objective data presented?
A) Subjective data: Patient’s report of tiredness; Objective data: Patient's pallor and dry skin.
B) Subjective data: Patient's pallor; Objective data: Patient's report of tiredness.
C) Subjective data: Patient's report of weight loss; Objective data: Patient's tiredness.
D) Subjective data: Patient's dry skin; Objective data: Patient's weight loss.
A) Subjective data: Patient’s report of tiredness; Objective data: Patient's pallor and dry skin.
During a health assessment, a nurse is performing a general survey of a patient. Which of the following findings should the nurse document as part of the general survey?
A) The patient's blood pressure is 120/80 mmHg.
B) The patient appears well-nourished and is appropriately dressed for the weather.
C) The patient reports experiencing shortness of breath during exertion.
D) The patient's respiratory rate is 18 breaths per minute.
B) The patient appears well-nourished and is appropriately dressed for the weather.
A nurse is assessing a patient’s skin and notes the presence of multiple lesions. Which of the following findings should prompt the nurse to notify the healthcare provider?
A) Lesions that are raised and red in color
B) Lesions that are flat and brown in color
C) Lesions that are painful to touch
D) Lesions that have a regular border and uniform color
C) Lesions that are painful to touch
A nurse is performing a confrontation exam to assess a patient’s peripheral vision. During the examination, the nurse notes that the patient can only see fingers when they are at the midline and not at the sides. What is the most appropriate nursing action following this finding?
A) Document the finding as a normal variant.
B) Refer the patient for further evaluation by an ophthalmologist.
C) Instruct the patient to perform eye exercises.
D) Reassess the patient's visual acuity with a Snellen chart.
B) Refer the patient for further evaluation by an ophthalmologist.
While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which?
A. Lub-dub sounds
B. Scratchy, leathery heart noise
C. A blowing or swooshing noise
D. Abrupt, high-pitched snapping noise
C. A blowing or swooshing noise
The nurse is assessing a client with chronic obstructive pulmonary disease. With a finger sensor, the nurse measures the client's oxygen saturation with a pulse oximeter machine and obtains a reading of 78% while the client is on oxygen via nasal cannula at 2 L/min. The client is showing no signs of restlessness or dyspnea. What is the first nursing action?
A. Increase the client's oxygen to 4 L/min.
B. Check the finger sensor's position and repeat the test.
C. Notify the client's primary health care provider (PHCP) about the low reading.
D. Check the client's chart to find out what the previous readings have been.
B. Check the finger sensor's position and repeat the test.
A nurse is assessing a patient who has been consistently refusing medication for chronic pain management. During the assessment, the nurse observes that the patient appears to be in significant pain. The nurse decides to address the situation directly by stating, "I’ve noticed you refuse your pain medication even though you seem to be in pain. Can we talk about that?" What is the purpose of this approach?
A) To confront the patient about their behavior.
B) To educate the patient on the importance of medication compliance.
C) To assess the patient's understanding of their pain management plan.
D) To encourage open dialogue about the patient's feelings and concerns.
D) To encourage open dialogue about the patient's feelings and concerns.
During a general survey assessment, a nurse notes that a patient has a slightly hunched posture and appears to be favoring one side of their body while walking. Which of the following interpretations should the nurse consider based on these observations?
A) The patient is likely experiencing acute pain or discomfort.
B) The patient is demonstrating good balance and coordination.
C) The patient is showing signs of good physical fitness.
D) The patient may be experiencing anxiety or nervousness.
A) The patient is likely experiencing acute pain or discomfort.
A nurse is educating a patient diagnosed with purpura about the condition. Which of the following statements by the patient indicates a need for further teaching?
A) "I need to avoid activities that may cause injury or bruising."
B) "I can take aspirin for any pain I have."
C) "I should monitor for any changes in my skin or new bruises."
D) "This condition means I have low platelet levels in my blood."
B) "I can take aspirin for any pain I have."
A nurse assesses a patient’s neck and notes that the lymph nodes are palpable, firm, and tender. Which of the following nursing interventions is most appropriate next?
A) Document the findings and reassure the patient.
B) Initiate a referral to a specialist for further evaluation.
C) Assess for other symptoms such as fever or sore throat.
D) Perform a thorough inspection of the patient’s skin.
C) Assess for other symptoms such as fever or sore throat.
A nurse is caring for a patient with congestive heart failure who reports experiencing episodes of paroxysmal nocturnal dyspnea (PND). Which of the following nursing interventions should the nurse prioritize to alleviate this symptom?
A) Encourage the patient to lie flat to promote relaxation.
B) Administer a diuretic as prescribed to reduce fluid overload.
C) Provide supplemental oxygen during sleep to improve oxygenation.
D) Educate the patient about the importance of avoiding caffeine in the evening.
B) Administer a diuretic as prescribed to reduce fluid overload.
A nurse is assessing a patient who presents with a respiratory rate of 30 breaths per minute and a pattern characterized by deep, rapid breaths followed by periods of apnea. Which of the following terms best describes this breathing pattern?
A) Kussmaul respirations
B) Cheyne-Stokes respirations
C) Biot's respirations
D) Hyperventilation
B) Cheyne-Stokes respirations
A nurse is educating a group of nursing students about bed safety and fall prevention strategies for hospitalized patients. Which of the following measures should be included as effective strategies to prevent falls? (Select all that apply.)
A) Keeping the bed in the lowest position when not in use.
B) Ensuring the call bell is within the patient's reach.
C) Using all four bed rails at all times for all patients.
D) Regularly assessing the patient's fall risk status.
E) Encouraging patients to get out of bed without assistance if they feel capable.
A) Keeping the bed in the lowest position when not in use,
B) Ensuring the call bell is within the patient's reach,
D) Regularly assessing the patient's fall risk status.
A nurse is taking a health history from a new patient at a primary care clinic. Which of the following information should the nurse consider as essential to gather during this assessment? (Select all that apply.)
A) Current medications and dosage
B) Previous surgeries and hospitalizations
C) Patient's religious beliefs
D) Family history of chronic illnesses
E) Patient's preferred activities and hobbies
A) Current medications and dosage,
B) Previous surgeries and hospitalizations,
D) Family history of chronic illnesses
A nurse is assessing a patient’s vital signs. Which of the following findings should the nurse document as abnormal and potentially requiring further evaluation? (Select all that apply.)
A) Blood pressure of 160/95 mmHg
B) Heart rate of 45 beats per minute
C) Respiratory rate of 30 breaths per minute
D) Temperature of 100.2°F
E) Oxygen saturation of 92%
A) Blood pressure of 160/95 mmHg,
B) Heart rate of 45 beats per minute,
C) Respiratory rate of 30 breaths per minute,
E) Oxygen saturation of 92%
A patient presents with a complaint of a sore throat and difficulty swallowing. Upon assessment, the nurse notes redness and swelling of the tonsils. Which of the following additional findings would support a diagnosis of acute tonsillitis? (Select all that apply.)
A) Fever of 101°F (38.3°C)
B) Foul breath odor
C) Presence of white exudate on the tonsils
D) Clear nasal discharge
E) Enlarged, tender cervical lymph nodes
A) Fever of 101°F (38.3°C),
B) Foul breath odor,
C) Presence of white exudate on the tonsils,
E) Enlarged, tender cervical lymph nodes
A nurse is prioritizing patients for a cardiac assessment in a busy medical unit. Which of the following patients should the nurse assess first? (Select all that apply.)
A) A patient with chest pain rated 8/10, radiating to the left arm
B) A patient with stable angina who has just completed a stress test
C) A patient with a heart rate of 120 beats per minute and new-onset atrial fibrillation
D) A patient with a history of heart failure who reports increased shortness of breath
E) A patient who is one day post-operative from coronary artery bypass graft (CABG) surgery
A) A patient with chest pain rated 8/10, radiating to the left arm,
C) A patient with a heart rate of 120 beats per minute and new-onset atrial fibrillation,
D) A patient with a history of heart failure who reports increased shortness of breath.
A nurse is assessing a patient with suspected pneumonia. Which of the following findings would the nurse expect to document in the assessment? (Select all that apply.)
A) Increased tactile fremitus over the affected lung area
B) Dullness to percussion over the affected lung area
C) Wheezing on expiration
D) Use of accessory muscles during respiration
E) Decreased breath sounds over the affected lung area
A) Increased tactile fremitus over the affected lung area,
B) Dullness to percussion over the affected lung area,
E) Decreased breath sounds over the affected lung area.
A nurse is reviewing a list of patients scheduled for follow-up assessments in a medical unit. Which of the following patients should the nurse prioritize for immediate follow-up assessment? (Select all that apply.)
A) A patient who was discharged yesterday after a laparoscopic cholecystectomy and reports increasing abdominal pain.
B) A patient with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation of 82% and is on supplemental oxygen.
C) A patient who had a stroke 3 days ago and is showing new signs of right-sided weakness.
D) A patient with diabetes who reports a blood glucose level of 150 mg/dL before breakfast.
E) A patient receiving chemotherapy who has developed a fever of 101°F.
A) A patient who was discharged yesterday after a laparoscopic cholecystectomy and reports increasing abdominal pain,
B) A patient with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation of 82% and is on supplemental oxygen,
C) A patient who had a stroke 3 days ago and is showing new signs of right-sided weakness,
E) A patient receiving chemotherapy who has developed a fever of 101°F.
A nurse is performing a general survey on a patient during a health assessment. Which of the following observations should the nurse document as part of the general survey? (Select all that apply.)
A) The patient's level of consciousness and orientation.
B) The patient’s vital signs, including blood pressure and heart rate.
C) The patient's posture and gait.
D) The presence of any pain or discomfort reported by the patient.
E) The patient's skin color and condition.
A) The patient's level of consciousness and orientation,
C) The patient's posture and gait,
E) The patient's skin color and condition.
A nurse is assessing a patient’s risk for pressure ulcers using the Braden Scale. Which of the following factors are included in the Braden Scale assessment? (Select all that apply.)
A) Sensory perception
B) Mobility
C) Skin moisture
D) Nutritional status
E) History of previous pressure ulcers
A) Sensory perception,
B) Mobility,
C) Skin moisture,
D) Nutritional status
A nurse is assessing a group of patients during a HEENT (Head, Eyes, Ears, Nose, and Throat) clinic. Which of the following patients would the nurse identify as needing priority assessment? (Select all that apply.)
A) A patient with a sudden onset of double vision
B) A patient complaining of a severe sore throat and difficulty swallowing
C) A patient reporting chronic earwax buildup with occasional hearing loss
D) A patient with redness and swelling of the conjunctiva accompanied by purulent discharge
E) A patient experiencing frequent headaches with a recent history of head trauma
A) A patient with a sudden onset of double vision,
B) A patient complaining of a severe sore throat and difficulty swallowing,
D) A patient with redness and swelling of the conjunctiva accompanied by purulent discharge,
E) A patient experiencing frequent headaches with a recent history of head trauma.
A) S3 heart sound upon auscultation
B) Peripheral edema in the lower extremities
C) A pulse rate of 50 beats per minute
D) A bounding pulse
E) Elevated blood pressure readings
A) S3 heart sound upon auscultation,
B) Peripheral edema in the lower extremities
A nurse is assessing a patient with asthma who is experiencing an exacerbation. Which of the following findings should the nurse anticipate during the assessment? (Select all that apply.)
A) Wheezing upon auscultation
B) Increased respiratory rate
C) Use of accessory muscles for breathing
D) Cyanosis of the lips and fingertips
E) Clear lung sounds on auscultation
A) Wheezing upon auscultation,
B) Increased respiratory rate,
C) Use of accessory muscles for breathing,
D) Cyanosis of the lips and fingertips.