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FUNDAMENTALS OF NURSING EXAM 1 ELSEVIER QUESTIONS AND
ANSWERS
- EMTALA defines an appropriate transfer as including which of the f preparations?: -Informing the patient of the risks and benefits of the transfer
-Obtaining the patient's written consent for transfer
-Having the transferring hospital provide medical treatment within its capacity
- The Resident Assessment Instrument (RAI) consists of the minimum data set (MDS), Resident Assessment Protocols, and as specified in state operations guidelines.: utilization guidelines
- Patients who fall in the hospital typically are those who:: -muscle weakness
-unsteady gait
-urinary incontinence
-on high-risk medications (e.g., analgesics, antihypertensives).
- Two essential components of successful transfer to a long-term care facility are that are accurately communicated.: medication lists and advance directives
- Which of the following is part of the standard admission procedure?: -Placement of patient in appropriate receiving area. -Explanation of Patients rights and elements of advanced directives.
-Orientation to relevant health care agency policies and procedures and room environment.
-Assessment of patient's health care problems and needs.
-Preliminary testing and screenings Development of a patient-centered plan of care. -Determination of a patient's payment source for health care.
- A UPC committee on an orthopedic nursing unit has chosen an EBP project to compare the use of chlorhexidine against soap and water for cleaning pin sites in patients with external fixation devices. All physicians agreed to the new protocol. The UPC committee planned an inservice for all staff on the two cleansing protocols. Four staff members agreed to assist in monitoring the data collection sheets that were to be completed by all staff. What important step is missing from this EBP project before implementation?: Selection of an outcome measure.
technique?: Challenging Defending Disapproving
- Which statement demonstrates the most effective strategy for teaching an anxious patient?: Use brief statements that also acknowledge current state of feelings.
- Which of the following is an example of a violation in patient confidentiali-ty?: - Leaving a computer screen with patient information in view of a visitor -Opening electronic health records of patients you are not assigned to care for
-Leaving copies of confidential patient information lying in a nonsecluded area on a desk
- Which of the following information entries is included in the patient's health care record?: -Continuing health status -Treatments delivered
-Results of tests
-Patient's response to therapy
- A patient hand-off occurs when:: -the patient transfers to a rehab facility.
-shift change occurs.
-the patient goes ott the unit for a procedure.
-nurse/patient assignments change during a shift.
- Common issues in malpractice caused by inaccurate or incorrect documen-tation include:: - Failing to document the correct time of events.
- Failing to record verbal orders or failing to have them signed.
- Documenting incorrect data.
- Failing to give a report, or giving an incomplete report.
- Which of the following is a classification system that provides standardized language from a nursing diagnosis to describe patient response to health problems?: NANDA-I
- is the classification system that provides standardized language from a nursing diagnosis to describe a patient's response to health problems.
- Place in correct order the following steps in obtaining a blood pressure
- Which of the following techniques is correct when obtaining a patient's blood pressure?: - Ensure that the patient is not crossing his legs.
- Obtain an average of two or more readings separated by at least 2 minutes.
- The following patients require routine vital signs to be obtained by the nursing assistive personnel (NAP). You instruct the NAP to obtain vital signs on which patient first?: 18-year-old teen who has been watching TV with some visitors
- A patient has just returned from a liver biopsy and is ordered to lie on her right side for 1 hour. An IV is in the left basilic vein. What site do you instruct the nursing assistive personnel (NAP) to use to obtain a blood pressure read-ing?: Left Leg
- Which of the following does the nurse document as an abnormal finding during a muscular-neurological assessment?: Patient uses hands to sit down in chair during "get-up-and- go test."
- The nurse is performing a pupil assessment on a patient who is confused and is unable to follow directions. Which component of the pupil examination would most likely be inaccurate?: Accommodation
- The nurse is assessing the respiratory system of a patient with known car- diovascular health issues. Which approach is most appropriate for obtaining accurate data?: When a patient has cardiovascular health issues, the respiratory system may be attected. Elevating the head of the bed relieves respiratory distress and allows for more accurate assessment.
- The patient has an IV infusing in the left arm. The skin looks reddened at the site. Which of the following techniques is most appropriate for the nurse to use to check for warmth at the site?: Applies dorsum of the hand over the site.
- The nurse determines that the patient has an irregular heart rate. Which action by the nurse can help in determining whether a pulse deficit is pre-sent?: Count the apical rate for 60 seconds while another nurse counts the radial pulse at the same time.
- An unconscious elderly patient with poor circulation has to have an arterial blood gas drawn. Which nursing diagnosis would be given priority during and after the procedure?: Risk for Injury
- A nurse in the diabetic clinic is assessing blood glucose levels in patients ranging from infants to the elderly. Which techniques would best ensure that the nurse obtains an adequate amount of blood for testing any of these
forward to lock.
- Raise the footplates.
- Position yourself slightly in front of the patient to guard and protect the patient throughout the transfer.6. Place a transfer belt on the patient and assist the patient to move to the front of the wheelchair.: 1,3,4,5,6,
- Two assistive personnel ask the nurse for assistance to transfer a patient from the bed to a stretcher using the three-person lift technique. What is the most appropriate response from the nurse?: "Please find the slide board for us to use."
- A patient with a proprioceptive disorder is being assessed for his ability to walk from bed to chair. You notice that the patient is bent forward and is leaning toward the right. Which nursing diagnosis would be the primary one on which to base his care?: Risk for injury
- Positioning a hemiplegic patient in Fowler's position will increase the pa- tient's:: ventilatory capacity. cardiac output. ability to swallow.
- The patient is being log-rolled onto his right side. The patient's position
would be correct if what assessment was observed?: A straight line is evident from the shoulder to the hip.
- Place in correct order from first to last step in the following steps for climbing stairs with a railing with crutches (partial weight bearing, one leg).
- Hold handrail with one hand (strong leg next to rail).
- Transfer body weight to crutch.
- Stand in tripod position.
- Bring crutch and weak leg up the stairs at the same time.
- Support weight evenly between handrail and crutch.: 3,2,1,5,
- The nurse teaches a patient ROM exercises for the shoulder. For abduction, how high is the patient taught to raise the arm?: 180
- A child with cerebral palsy can experience difficulty with movement, loss of balance, and lack of muscle control. Which gait does the nurse instruct the parents to use for crutch walking?: Four-Point
- A nurse is conducting a class on fall prevention for staff on the patient care unit. Which statement is appropriate to include in the presentation?: The fall
- A patient is admitted to the emergency department with possible anthrax. What initial action should the nurse anticipate in the care of this person?: The clothes will be cut ott.
- A nurse is attending a class on disaster preparedness. Teaching has been ef-fective if the nurse makes which statement regarding the difference between disaster nursing and general nursing?: "The focus of care is to save the greatest number of lives."
The focus is preservation of as many people as possible by caring first for those who need care and have a good chance of survival, and caring last for those who are critical. This is ditterent from the concepts that pertain to general nursing.
- The nurse in the emergency department receives a call that an individual
has been contaminated by an unknown substance and is 10 minutes away. How should the nurse prepare in anticipation of the patient's arrival?: Get the disaster team dressed in the appropriate PPE.
- A person working with radioactive materials believes she has been con-
taminated. The nurse needs to ask the patient if she is allergic to which substance?: Iodine
- A patient asks the nurse why his mouth is so dry after radiation therapy to his head and neck. What is the most appropriate response from the nurse?: - "Radiation reduces the flow of saliva."
- A patient with chemotherapy-related stomatitis calls the physician's office
to talk with the nurse. What suggestions should the nurse make to help this patient?: Rinse the mouth before and after meals and at bedtime with a saltwater or baking soda solution per protocol, and apply a moisturizing gel to the lips if needed.
- A patient with pulmonary edema had BiPAP started 30 minutes ago. The
nurse should inform the patient that he will undergo which diagnostic test shortly?:
Arterial blood gas
- The nurse is providing discharge instructions to a patient regarding the use of their peak flowmeter. Which statement by the patient indicates the need for further education?: "I should measure my peak flow at various times during the day."
Health care providers usually recommend that patients measure and record their peak expiratory flow rate during the
- The nurse correctly delegates to the nursing assistive personnel (NAP) when she/he delegates the following:: The skill of obtaining an ECG can be delegated to nursing assistive personnel (NAP). The NAP is also instructed to deliver the report to the health care provider and to report any changes in patient conduction. The NAP cannot interpret the ECG.
- The nurse is applying a 12-lead ECG. Put the following steps in the correct order.
- Place patient in supine position.
- Apply chest leads.
- Apply extremity leads.
- Determine the indications for obtaining the ECG.
- Check the ECG machine for messages.
- Press button to obtain 12 lead.: 4, 1, 2, 3, 5, 6
- Which chest tube placement location promotes the removal of air?: Apical (second or third intercostal space)
The location of the chest tube indicates the type of drainage expected. Apical (second or third intercostal space) and anterior chest tube placement promote removal of air. Because air rises, these chest tubes are placed high, allowing evacuation of air from the intrapleural space and lung reexpansion.
- Place in correct order the following steps as performed to reinfuse chest
drainage.: 1. Monitor the patient's vital signs and SpO2 according to the patient's condition and agency policy.
- If ordered, add anticoagulants to the reinfusion through the self-sealing port in the autotransfusion connector.
- Use a new microaggregate filter to reinfuse each autotransfusion bag.
- Access the bag by inverting it and spiking the bag through the spike port with the microaggregate filter and twisting.
- With the bag upside down, gently squeeze the bag to remove the air, and prime the filter with blood.
- Hang the bag on an IV pole, and continue to prime the tubing until all air is gone.
- Which of the following manifestations would be an early sign of silent aspiration?: Respiratory Rate 30
- What is the priority assessment that should be performed before a patient is given food and fluids?: determining orientation
- The nurse is teaching the patient who is taking warfarin about what foods to
