Download N150A Midterm Review- Week 3 Sherpath Questions Exam With Accurate Answers Rated A+. and more Exams Nursing in PDF only on Docsity!
N150A Midterm Review: Week 3 Sherpath
Questions Exam With Accurate Answers Rated
A+
The nurse uses a U-100 insulin syringe to inject insulin into the anterior and lateral parts of the thigh of the patient. Which nursing intervention would provide consistent absorption of the insulin? A. Slowing the injection rate to 30 seconds B. Rotating the injections within the same body part C. Pinching the injection site while inserting the needle D. Expelling the airbubble in the syringe prior to giving the medication - ANSWER B: Rotating the injections within the same body part Which type of syringe is used to administer a small and precise amount of medication subcutaneously to infants and newborns? A. 5-mL syringe B. 3- mL syringe C. Insulin syringe D. Tuberculin syringe - ANSWER D: Tuberculin syringe Which nursing action reduces the patient's risk of an allergic drug response? A. Checking the patient's name, medication name, and dosage B. Assessing the patient's body build, muscle size, and weight C. Reviewing the medication action, purpose, dose, and route D. Assessing the patient's medical history and medication history - ANSWER D: Assessing the patient's medical history and medication history The nurse is preparing a teaching plan for safe insulin administration. Which intervention included in the plan is appropriate for the patient? SELECT ALL THAT MAY APPLY. A. Teaching the pt to determine the expiration date of the insulin B. Teaching the steps of how to administer an intramuscular injection C. Teaching the pt to avoid refrigeration of the medication D. When necessary, instruct the pt to accept help from a caregiver when rotating injection sites E. Helping the pt determine the insulin required based on the home capillary glucose monitoring results - ANSWER A, D, and E
Which PRIORITY nursing action would the nurse perform when extracting medication from multiple dose vials after reconstitution? A. Checking the vial for leakage B. Placing the vial in the refridgerator C. Monitoring for pt reactions D. Labeling the date and time fo mixing on the vial - ANSWER D: Labeling the date and time fo mixing on the vial Should also label the concentration Which parenteral route of administration uses the Z-track method? A. Intravenous route B. Intradermal route C. Intramuscular route D. Subcutaneous route - ANSWER C: Intramuscular route It is used to seal the medication inside of the muscle tissue to avoid further irritation Which information would the nurse find in the medical administration record? SELECT ALL THAT APPLY. A. Patient's name B. Medication dosage C. Patient's DOB D. Medication expiration date E. Route of administration F. Medication manufacturing date - ANSWER A,B,C, and E Which route of administration is this image depicting? A. Intradermal B. Intraarterial C. Intraosseous D. Intramuscular - ANSWER D: Intramuscular This is an IM injection being administered at the ventrogluteal site Which component can restrict the student nurse's ability to move from a basic level to a complex level of critical thinking? SELECT ALL THAT APPLY. A. Inexperience B. Inflexible atitude C. Weak competency
Creativity involves exploring different approaches if the ongoing interventions are not working for the patient Which guidance would the nurse provide when teaching students about legal guidelines for documentation? SELECT ALL THAT APPLY. A. Record all facts B. Correct all errors promptly C. Chart only for yourself D. Document critical comments about patients E. Use shorthand when necessary to speed your documentation - ANSWER A, B, and C A patient reports not feeling well and has had a productive cough that is worse at night. The patient is observed to cough violently and produces thick, yellow sputum. BP is 150/90 mmHg, HR is 92 bpm, and RR is 22 bpm. Wheezing and rhonchi are heard bilaterally. Pt reports chest pain when coughing that radiates to the arm. Which datum would the nurse document as objective data? SELECT ALL THAT APPLY. A. Chest pain B. BP C. Thick, yellow sputum D. Pain radiating to the arm E. Presence of wheezes and rhonchi - ANSWER B, C, and E A senior nurse is reviewing a nurse's documentation of a patient with pneumonia, "BP is 150/90 mmHg, HR is 92 bpm, and RR is 22 bpm. The patient seems to have difficulty breathing. Sounds are produced when patient exhales. Ascultation reveals rhonchi in the lower lung bases. Copious amounts of phlegm have been produced since this morning." Which statement in the documentation is considered to be poor-quality documentation and informatics? SELECT ALL THAT APPLY. A. Vital signs: BP is 150/90 mmHg, HR is 92 bpm, and RR is 22 bpm B. The patient seems to have difficulty breathing C. Ascultation reveals rhonchi in the lower lung bases D. Sounds are produced when patient exhales E. Copious amounts of phlegm have been produced since this morning - ANSWER B, D, and E These aren't specific enough Which documentation of patient care is appropriate? SELECT ALL THAT APPLY.
A. Record pertinent health and drug information B. Use white-out to correct wrong information C. Record medications that are given and any drug reactions D. Document discontinued medications E. Leaving blank spaces in nursing notes F. Sign with initials - ANSWER A, C, and D At the end of shift, the nurse documents a patient's condition, anticipated condition, medications, and nursing interventions fulfilled so that the next nurse can follow the appropriate treatment plan and care for the patient. This describes what type of report? A. Discharge summary B. Incident report C. Hand-off report D. Telephone report - ANSWER Which method is appropriate for the nurse to dispose of printed patient information? A. Rip several times and place in regular trashcan B. Place in patient's paper-based chart C. Place in secure canister marked for shredding D. Burn the documents - ANSWER C: Place in secure canister marked for shredding Which correction is accurate after documentation of a wrong medication? A. Apply correction fluid and document the right medication B. Strike with single line, tag it as an error, put initials, and document the correct medications C. Rewrite the entire document again D. Scratch out the error and document the correct medication - ANSWER B: Strike with single line, tag it as an error, put initials, and document the correct medications The nurse assess a patient on day 3 after surgery and charts a progress note in the SOAP format. Which datum is objective? A. The pt states "Today, I have no pain at the incision site." B. The pt's incision looks clean without purulent drainage or erythema C. The pt's dressing should be changed every day D. The patient should have antibiotics administered for 2 more days - ANSWER B: The pt's incision looks clean without purulent drainage or erythema
E. Assess to see if the red area on the patient's sacrum blanches - ANSWER D and E -Turning the patient on the right side is taking the pressure off of the sacrum and an intervention that the nurse should implement -Assessing to see if the red area on the patient's sacrum blanches is important to implement. If the site blanches, hopefully, the pressure being taken off of the sacrum will allow the site to heal. If the site does not blanche, the patient has a deeper tissue injury than the epidermis A nurse is reviewing personal care procedures with nursing students. The nurse knows they understand the importance of hygiene when they make which statement? A. "Personal care should be delegated to unlicensed personnel." B. "Personal care is the best time to perform a skin assessment." C. "Personal care is not a priority and should be done if the nurse has time." D. "Personal care must be done before any other direct care is performed." - ANSWER B : "Personal care is the best time to perform a skin assessment." The nurse should use personal care as an opportunity to perform a full assessment of the skin and accessory organs, as well as enhance the nurse- patient relationship through communication Why is it important for the nurse to participate in providing a patient's personal care? SELECT ALL THAT APPLY. A. To spend time with the patient B. To perform a more comprehensive assessment C. To assist the nurse assistant D. To help gain the trust of the patient - ANSWER A, B, and D In relation to hygiene, why is it a good practice to clean a patient's mouth? SELECT ALL THAT APPLY. A. Reduces bacteria after eating B. Protects the teeth C. Reduces bacteria after sleeping D. Cleans the mucous membranes E. Assesses the patient's eating abilities - ANSWER A, B, C, and D The nurse is caring for a patient who had a stroke that left him completely paralyzed. The patient is edentulous. How should mouth care be performed on this patient?
A. Clean the mouth with a toothbrush and toothpaste B. Clean the mouth with mouth swabs C. Clean the mouth with peroxide mouth rinse D. It is not safe to clean the patient's mouth because of the stroke - ANSWER B: Clean the mouth with mouth swabs The patient's mouth should be cleaned with mouth swabs. Moistening the patient's mouth is important to prevent bacteria from growing and for healthy gums What is the best way to prevent the spread of microorganisms in nursing? A. Educating the staff B. Wearing gloves when going in and out of patient rooms C. Applying lotion after using alcohol-based sanitizers D. Washing the hands before and after each patient - ANSWER D: Washing the hands before and after each patient The nurse is caring for an older adult patient with very fragile skin. The patient has plastic tape on the skin around the IV site. What is the best way to remove the tape without damaging the patient's skin? A. Take the tape corners and quickly pull the tape off the patient's arm B. Take alcohol and put over the tape and quickly pull the tape off of the patient's arm C. Slowly pull the tape off while pushing the skin away from the tape D. Slowly pull the tape off while distracting the patient with the television - ANSWER C: Slowly pull the tape off while pushing the skin away from the tape Slowly pulling the tape off the patient, while pushing the patient's skin away from the tape is the best method to help prevent damaging the skin A patient has a surgical wound with staples. The provider has given an order for the patient to shower with the incision covered, but the patient has refused twice. How can the nurse advise the patient? A. There is no need to bathe B. Bathing has only a small chance of causing infection C. Bathing cleanses microorganisms from the skin and lessens the chance of infection D. Assume that the patient knows about infection prevention - ANSWER C: Bathing cleanses microorganisms from the skin and lessens the chance of infection
Supervising the patient while brushing her teeth, then helping her finish what was missed, is a good compromise. It allows the patient to have her psychological need for independence met, while completing the physical task Why is nail hygiene so important? A. Helps prevent the spread of infection B. Avoids the biting and the chewing of nails C. Prevents biting on cuticles and hangnails D. Prevents cutting the skin on hangnails - ANSWER A: Helps prevent the spread of infection Nails may conceal dirt and microorganisms What should the nurse implement regarding the oral cavity and hygiene? SELECT ALL THAT APPLY. A. Brush the teeth and rinse the mouth with a fluoride, non-drying mouthwash after meals and at bedtime B. Rinse the mouth with water after meals and at bedtime C. Brush the teeth each day after breakfast D. Rinse the mouth with hydrogen peroxide after meals and at bedtime E. Eat a balanced diet and reduce snacks - ANSWER A and E
- The nurse should encourage the patient to eat a balanced diet and to reduce snacks. This helps keep the gums, teeth, and oral cavity healthier What piece of clothing is best to remove when looking for excoriations? A. Adult diaper B. Headband C. Socks D. Pants - ANSWER A: Adult diaper A patient wearing an adult diaper indicates the skin is exposed to stool and urine, which is a major risk factor for excoriation and skin breakdown When discharging a patient with diabetes mellitus, it is important to include which items to buy when educating about the importance of skin integrity? A. Small mirror B. Cuticle clipper C. Open toed shoes D. Slip resistant socks - ANSWER A: Small mirror
A small mirror is most helpful to check the areas of the foot not normally within the line of sight Which patient is most at risk for skin ulcers? A. An older female B. A physical education teacher C. An adolescent D. A frail paraplegic - ANSWER D: A frail paraplegic A frail paraplegic best represents someone with a high risk for spending most of his or her time in bed. This significantly increases the risk for skin breakdown and ulceration Which patient would least likely be at risk for skin ulcers? A. A patient who lies in bed most of the time B. One who needs adult briefs changed frequently C. An inactive patient with poor nutrition habits D. One with Alzheimer's disease - ANSWER D: One with Alzheimer's disease A patient with low mental awareness is at risk for ulcers; however, this option is the least at risk as compared with the other options A patient arrives to urgent care with an excoriation on the torso. How would the nurse note the results of the wound assessment? A. Red and scaly lesions B. Skin is pink and edematous C. White color noted on the skin D. Bluish discoloration - ANSWER A: Red and scaly lesions An excoriation is, by definition, a red and scaly lesion When reviewing a patient's chart, the nurse notes the documentation of a pressure ulcer. What would the nurse expect to find upon assessment? A. Open wound over the sacrum B. Red scaly lesion on buttocks C. Purplish discoloration under the cheek D. An infected surgical wound - ANSWER A: Open wound over the sacrum Pressure ulcers can be open wounds and the sacral area is a particularly high-risk area for pressure ulcer development in bedridden patients
Orange slices contain citric acid, which would cause discomfort in a patient with open oral cavity sores The nurse finds a patient to have missing teeth and refusing to wear dentures. Which food items should the nurse advise the patient to eat? SELECT ALL THAT APPLY. A. Steak B. Banana C. Gelatin D. Applesauce E. Apple - ANSWER B, C, and D All of these requires little chewing Which physical trait might a nurse find when treating a patient with gingivitis? SELECT ALL THAT APPLY. A. Red, swollen gums B. Yellow teeth C. Bad breath D. Cracked teeth E. White tongue - ANSWER A, B, C, and D A patient complains of chronic bad breath. What is the best advice to help the patient? A. Stop smoking B. Change to a vegan diet C. Change the patient's brand of floss D. Chew on straws - ANSWER A: Stop smoking Tobacco use is one of the leading factors contributing to halitosis and is the best way to help him eliminate his bad breath Which statement, if made by the patient regarding oral hygiene, would indicate the need for further education? A. "Flossing every day is important." B. "I should avoid hard candy." C. "Brushing after every meal is vital." D. "Changing my toothbrush every year is important." - ANSWER D: "Changing my toothbrush every year is important." A toothbrush should be replaced every three months or more often if the bristles get damaged. After that, it becomes ineffective in plaque removal
Which assessment data would indicate a potential complication associated with the skin of a patient? A. Wrinkling B. Age spots C. Expression lines D. Crusting - ANSWER D: Crusting Crusting is not normal and can be a sign of infection When creating a brochure for parents to help prevent pediculosis, which statement should the nurse include? SELECT ALL THAT APPLY. A. "Assist your child with checking for head lice regularly." B. "Have the child tell you if his head itches." C. "Look for any patches of hair loss." D. "Leave the child to bathe for 20 minutes every day." E. "Leave the child to bathe for 20 minutes every day." - ANSWER A, B, and C A nursing diagnosis of Altered Oral Mucous Membranes related to dental disease will yield which findings upon inspection? SELECT ALL THAT APPLY. A. Missing teeth B. Halitosis C. Sores on the lips D. Dry mouth E. Sinus drainage - ANSWER A, B, and D It would not be sores because sores located inside the mouth are considered to be a part of the oral mucous membranes, but sores on the lips are not part of the mucus membranes and would not be covered under this nursing diagnosis. What contributes to an older adult patient's skin being wrinkled, thin, and dry? A. Increased number of infections B. Decreased elastin C. Decreased varicose veins D. Increase in subcutaneous fat - ANSWER B: Decreased elastin Decreased elastin is a normal finding related to the aging process, and causes an older person's skin to be wrinkled, thin, and dry
B. Halitosis related to poor oral hygiene C. Oily, matted, and tangled hair D. Warm, moist, and intact skin - ANSWER A: Presence of pediculosis Pediculosis, or a lice infestation of the body hair, warrants immediate treatment and a phone call to the healthcare provider for orders. This is not a normal finding and requires treatment before it spreads to other patients and healthcare staff A nurse is reviewing the steps of performing a personal care assessment on a patient requiring bathing assistance. Which step should the nurse perform first? A. Observation of skin, noting dry skin, rashes, sores, and body odor B. Observation of the fingernails and toenails for color, deformities, cracking, and thickness C. Observation of the scalp and hair for signs of poor hygiene, dandruff, or head lice D. Continued observation and palpation of the skin and assessment of the patient's peripheral vascular status - ANSWER C: Observation of the scalp and hair for signs of poor hygiene, dandruff, or head lice What are possible signs of poor hygiene? SELECT ALL THAT APPLY. A. Body odors B. Chipped fingernail polish C. Tangled and matted hair D. Excessively long and dirty toenails E. Noticeably warm skin - ANSWER A, C, and D The nurse is asking a patient hospitalized with acute pancreatitis questions about the patient's self-care capabilities. Which are examples of questions that the nurse may ask to assess the patient's ADLs? SELECT ALL THAT APPLY. A. Do you know where you are? B. How many visitors did you have last week? C. Do you always make it to the bathroom on time? D. How often do you take a bath or shower? E. Can you bathe yourself without help? - ANSWER C, D, and E The nurse is caring for a patient who was involved in a motor vehicle accident (MVA). The patient did not sustain any oral trauma. How should the nurse document the normal assessment of this patient's oral cavity? A. Pink and moist oral cavity without sores
B. Red and dry oral cavity without sores C. Pink and dry oral cavity without sores D. Cyanotic and moist oral cavity without sores - ANSWER A: Pink and moist oral cavity without sores An immobile patient is running a fever. The nurse suspects the patient has a decubitus ulcer. The nurse observes the patient's skin for signs of infection, which may include what symptoms? SELECT ALL THAT APPLY. A. Redness B. Freckles C. Scars D. Swelling E. Drainage - ANSWER A, D, and E An older adult patient with arthritis has difficulty using his hands to button clothing, holding an eating utensil or toothbrush, and turning a door lock. In regards to this patient's discharge from the hospital to home, it is the nurse's responsibility to: A. Notify the healthcare provider B. Overlook the deficit C. Assist the patient with community referrals D. Tell the family to place the patient in a nursing home - ANSWER C: Assist the patient with community referrals The nurse's role is to educate the patient about arthritis, and to educate the patient regarding the importance of performing ADLs independently, or with minimal assistance, as much as possible. If the patient is still struggling to perform ADLs, it is the nurse's role to implement resources to assist the patient. If a patient is unable to care for basic needs, the nurse assists the patient during hospitalization and consults with the provider to facilitate referral of the patient to appropriate community resources for assistance after discharge Based on the answers given during an initial health history, the nurse suspects that the patient has a fungal infection in his toenails. What physical exam findings would confirm this suspicion? A. Presence of pediculosis B. Red and swollen nail beds C. Thickening of the nail D. Missing toenails - ANSWER C: Thickening of the nail
The nurse is assessing a teenager's oral cavity as part of the admission assessment. Which finding, if observed during the assessment, should the nurse refer the patient to the dentist for further care? A. Dry mouth B. Halitosis C. Cyanotic gums D. Broken teeth - ANSWER D: Broken teeth Broken teeth are not treated by a general healthcare provider. The patient should be referred to a dental specialist A nurse is initiating a care plan for a newly admitted hospitalized patient who is unable to perform basic ADLs independently. What intervention should be listed in the care plan? A. Daily bed bath and assistance with hygiene, and as needed B. Patient's family to hire personal caregiver to assist with hygiene needs C. Educate family about how to perform a bed bath and oral hygiene measures D. Physical therapy to work on ambulation to the bathroom for toileting - ANSWER A: Daily bed bath and assistance with hygiene, and as needed The nurse should assist a patient with hygiene measures and bathing while hospitalized, and ensure that the patient has enough support and assistance when discharged A nurse is caring for a patient with a severe infection of the gums. What is one possible nursing diagnosis based on the patient's "at risk" status? A. Risk for self-care deficit B. Risk for altered nutrition C. Risk for infection D. Risk for ineffective tissue perfusion - ANSWER B: Risk for altered nutrition The patient is at Risk for Altered Nutrition due to the likelihood of pain with eating or chewing. The nurse should consider a dietary consult, or switching the patient's diet to a soft or pureed diet What are the three parts of the nursing diagnosis? SELECT ALL THAT APPLY. A. Diagnostic label B. Related factors C. Defining characteristics D. Diagnostic statement E. Evidence statement - ANSWER A, B, and E
Which outcome is desirable for a pediatric patient being treated for head lice? A. Child's hair will be cleansed with medicated shampoo daily B. Bed linens will be washed in hot soapy water once weekly C. Child refrains from sharing personal items with school classmates D. Mother will find no evidence of lice in child's hair within one week - ANSWER C: Child refrains from sharing personal items with school classmates This is a desired outcome, meaning the goal of teaching the child not to share personal items is being met. The child is refraining from sharing personal items at school. Which factors should the nurse consider when developing an individualized care plan for a patient's hygienic and self-care needs? SELECT ALL THAT APPLY. A. Present capabilities B. Supportive resources C. Available lift equipment D. Family involvement E. Personal care supplies - ANSWER A, B, D, and E Which activity does the nurse perform when planning for a patient's hygiene and personal care? SELECT ALL THAT APPLY. A. Prioritizes patient's hygiene-related nursing diagnoses B. Sets realistic personal care goals with the patient C. Assesses patient's hygiene and self-care abilities D. Measures achievement of patient's hygiene outcomes E. Assesses the patient's home environment - ANSWER A and B Which hygiene and personal care nursing diagnosis is correctly stated? A. Ineffective Health Maintenance related to impaired ability to understand due to brain injury, as evidenced by poor hygiene and unkempt appearance B. Readiness for Discharge related to eagerness to return home as evidenced by increased independence at hospital C. Readiness for Enhanced Care related to ability to bathe without assistance D. Body Image Deficit as evidenced by strong body odors and decayed teeth
- ANSWER A: Ineffective Health Maintenance related to impaired ability to understand due to brain injury, as evidenced by poor hygiene and unkempt appearance
