NR388: Foundations Exam 1 Questions with Answers, Exams of Nursing

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NR388: Foundations Exam 1 Questions with Answers

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1.The nurse assesses a client's pulse to be irregular. How should the nurse count the client's pulse rate? A. Count for one full minute B. Count for 15 seconds and multiply by 4 c. Count for 30 seconds and multiply by 2 D. Count for one minute, pause briefly, count for one minute again and calcu- late the average of the two readings: A. Count for one full minute An irregular pulse requires counting for one full minute in order to accurately obtain the pulse. 2.The nurse has been asked to obtain vital signs for a client who has arrived for an annal physical with his/her primary care provider. The client has no medical problems. What should the nurse do with regards to hand hygiene in this situation? A. The nurse should ask the client to wash his/her hands before checking the vital signs. B. The nurse should use alcohol based hand cleanser before and after check- ing the client's vital signs. C. The nurse should use gloves when checking this client's vital signs. D.The nurse should use soap and water before and after checking the client's vital signs: The nurse has been asked to obtain vital signs for a client who has arrived for an annual physical with his/her primary care provider. The client has no medical problems. What should the nurse do with regard to hand hygiene in this situation? A. The nurse should ask the client to wash his/her hands before checking the vital signs. B.The nurse should use an alcohol-based hand cleaner before and after

2 / 35 checking the client's vital signs. C. The nurse should use gloves when checking this client's vital signs. D.The nurse should use soap and water before and after checking the client's vital signs 3.What should be included any time an assessment is performed (no matter what the scenario, situation or setting)? A. Musculoskeletal B. Neurologic C. HIICARE D. Skin: C. HIICARE 4.Which of the following temperature sites is considered a core temperature? A. Oral B. Axillary C. Temporal D. Tympanic: D. Tympanic Tympanic is considered a core temperature, as is rectal 5.Nurses use Standard Precautions only when caring for clients suspected of having a communicable disease A. True B. False: B. False Standard precautions are used with every client cared for 6.Match the turn with the correct description. Each term can only be used once. A. 1-month-old infant with a heart rate of 88 BPM

3 / 35 B. a 75-year-old female with a systolic BP less than 90 mm Hg

4 / 35 C. Respiratory rate of 32 breaths per minute in an 18-year-old male

1. Bradycardia
2. Tachypnea
3. Hypotension: A. 1-month-old infant with a heart rate of 88 BPM: Bradycardia B. a 75-year-old female with a systolic BP less than 90 mm Hg: Hypotension C. Respiratory rate of 32 breaths per minute in an 18-year-old male: Tachypnea 7.The nurse just obtained vital signs on a patient. Before moving on to the next patient's room, the nurse needs to wash his/her hands. The nurse must determine whether to use hand sanitizer or soap and water. List two situations when the nurse must use soap and water.: When visibly soiled and in the presence of certain germs like C. diff 8.The patient shows no facial expression when discussing a recent visit with the family. The nurse uses which of the following terms when documenting the patients affect? A. Blank B. Depressed C. Narrow D. Flat: D. Flat Flat affect is used to denote an affect in which little or no facial expression is shown. 9.Match the following general survey assessments with the correct descrip- tion: A.The patient is cooperative, pleasant and able to follow instructions.

5 / 35 Appears slightly anxious which is appropriate for the situation B. Steady gait. Movements are smooth and coordinated. No obvious limita- tions to range of motion.

6 / 35 C. The patient is acyanotic. Color and pigmentation are even and consistent with ethnic background. D. The patient sits relaxed and upright on the exam table. Is well- nourished with height and weight proportionate. No obvious deformities noted.

1. Mobility
2. Mood and affect
3. Skin
4. Posture and position: A. The patient is cooperative, pleasant and able to follow instructions. Appears slightly anxious which is appropriate for the situation: Mood and affect B. Steady gait. Movements are smooth and coordinated. No obvious limitations to range of motion: Mobility C. The patient is acyanotic. Color and pigmentation are even and consistent with ethnic background: Skin D. The patient sits relaxed and upright on the exam table. Is well- nourished with height and weight proportionate. No obvious deformities noted: Posture and position 10.It's Tuesday morning. The nurse is at Duke Hospital on the medical surgical unit caring for post surgical patients. During the morning assessment, the nurse checks the patient's metal status ( Mary Adams). The patient states the following: My name is Mary Adams, and I am at the minute clinic for some medication. It is Wednesday. The nurse documents this as Alert and Oriented x : Alert and Oriented x 1 11.When caring for a patient, the nurse uses the nursing process. Choose the correct steps of the nursing process:

7 / 35 A. Assessment, Diagnosis, Preparation, Implementation, Evaluation

8 / 35 B. Anticipate, Discuss, Prioritise, Investigate, Evaluate C. Articulate, Document, Plan, Integrate, Evaluate D. Assessment, Diagnose, Plan, Implement, Evaluate: D. Assessment, Diagnose, Plan, Implement, Evaluate 12.An elderly patient's grown son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do? A. Individualize the care plan only according to the patient's needs. B. Request that the son leaves at bedtime, so the patient can rest. C. Involve the son in the plan of care as much as possible. D. Suggest that another member of the family stay with the patient: C. Involve the son in the plan of care as much as possible. 13.Before entering the room to begin a health assessment, the nurse must always do the following: A. Check the chart to see what the trends are and what the previous care nurse charted. B. Prepare any needed equipment or supplies and examine one's own biases. C. Ensure that all medication for entire day are available now. D. Ask for help from the other nurses on the unit.: B. Prepare any needed equipment or supplies and examine one's own biases. 14.The student nurse is demonstrating appropriate knowledge regarding BMI when she tells the patient: "Your BMI is 35, which means you are healthy and your weight is good." A. True B. False: B. False 15.A patient was burned on the entire left arm while lighting a charcoal grill. He has an intravenous line in the right arm that was inserted with

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10 / 35 and the provider ordered no other sticks or blood pressures in that arm. Which appropriate action would the nurse take related to vital signs? A. Take and record the blood pressure in the thigh B. Assess the systolic pressure only by palpating the radial artery and take an estimate of the diastolic pressure C. Use a similar size cuff for the blood pressure and apply directly over the IV site. D. Because he is awake and alert, omit taking a BP: A. Take and record the blood pressure in the thigh 16.A patient has been admitted with a kidney infection. Her vital signs indicate hyperthermia, hypotension, tachycardia, and tachypnea. Which set of vital signs belong to this patient? A. T 102.4, BP 110/70, HR 94, R 22 B. T 103, BP 84/60, HR 88, R 20 C. T 101.8, BP 88/66, HR 130, R 24 D. T 100.9, BP 100/74, HR 118, R 18: C. T 101.8, BP 88/66, HR 130, R 24 17.What are the acceptable vital sign ranges for adults? Respirations HR Temp Systolic BP Diastolic BP: Respirations- 12- 20 HR- 60- Temp- 36- 38

11 / 35 Systolic BP- < Diastolic BP- < 18.Hypothermia: body temperature is less than 35C 19.Hyperthermia: Abnormally elevated body temperature 20.Febrile: Fever 21.Bradycardia: a HR less than the expected range or slower than 60/min 22.Tachycardia: HR greater than the expected range or greater than 100/min 23.Bradypnea: Regular breathing pattern with a rate of less than 12/min 24.Eupnea: unlabored or normal breathing 25.Tachypnea: Irregular breathing pattern with rate greater than 20/minute 26.Hypotension: Blood pressure below the expected reference range Systolic less than 90mmHg 27.Hypertension Prehypertension Stage 1 Hypertension Stage 2 Hypertension: Hypertension- elevated blood pressure Prehypertension- 120-139 systolic and 80- diastolic Stage 1 Hypertension- 140-159 systolic and 90-99 diastolic Stage 2 Hypertension- 160 or greater systolic and 100 + diastolic 28.Normotensive: Normal blood pressure Less than 120 and less than 80 29.Pulse deficit: Difference between apical pulse rate and the radial pulse rate 30.The Nursing Process:

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ADPIE:

Assessment Diagnosis Planning Implementation Evaluation

13 / 35 31.What are the 5 levels of consciousness?: 1. alert 2.lethargic 3.obtunded 4.stupor 5.coma 32.BMI Formula: BMI= (weight lbs)/ (height in2) x 703 33.1kg= : 2.2lbs 34.1in=: 2.54cm 35.BMI Ranges: underweight: <18. normal: 18.5- 25 overweight: 25- 30 obese: > 36.What is the brief mental status exam (MSE)?: Assess alertness and orienta- tion A&O to 1.Person- "What's your name?" 2.Place- "Do you know where you are?" 3.Time- "Do you know what month it is?" 4.Situation- "What brought you in here today?" 37.Environment of Care: ISBARR: Identify Situation Background Assessment Recommendation Repeat 38.SOAPS: Suction working Oxygen on wall Ambu bag in place

14 / 35 Position- patient and bed Surfaces- of floor and room 39.What are the 4 assessment techniques utilised throughout the physical assessment: 1. Inspection 2.Palpation 3.Percussion 4.Auscultation 40.When should a nurse perform hand hygiene?: 1) before and after patient care; 2) when visibly soiled; 3) after contact with sources of microorganisms; 4) after invasive procedure; 5) after removing gloves. 41.A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3C (101F), pulse rate of 114/min, and a respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take (select all) A. Obtain culture specimens before initiating antimicrobials B. Restrict the client's oral fluid intake. C. Encourage the client to rest and limit activity. D. Allow the client to shiver to dispel excess heat. E. Assist the client with oral hygiene frequently.: A. CORRECT Obtain culture specimens before initiating antimicrobials B. INCORRECT Restrict the client's oral fluid intake. C. CORRECT Encourage the client to rest and limit activity. D.INCORRECT Allow the client to shiver to dispel excess heat. E. CORRECT Assist the client with oral hygiene frequently. 42.A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. Which of the following instructions is

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16 / 35 for measuring vital signs for this client? A. "Do not measure the clients temperature rectally." B. "Count the client's radial pulse for 30 seconds and multiply it by 2." C. "Do not let the client know you are counting their respirations" D. "Let the client rest for 5 minutes before you measure their BP": A. CORRECT "Do not measure the clients temperature rectally." The greatest risk to a client who has a low platelet count is an injury that results in bleeding. Using a thermometer rectally poses a risk of injury to the rectal mucosa. The low platelet count contraindicates the use of the rectal route for this client 43.A nurse is instructing a group of assistive personnel in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (select all that apply) A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate. D. Count the rate for 30 seconds if it is irregular. E. Count and report any signs the client demonstrates: A. CORRECT Place the client in semi-Fowler's position B. CORRECT Have the client rest an arm across the abdomen. C. CORRECT Observe one full respiratory cycle before counting the rate. D.INCORRECT Count the rate for 30 seconds if it is irregular. E. INCORRECT Count and report any signs the client demonstrates 44.A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure is reading 140/94mmHG, and the client denies

17 / 35 any history of hypertension. Which of the following actions should the nurse take

18 / 35 first? A. Request a prescription for an antihypertensive medication. B. Ask the client if they are having pain. C. Request a prescription for an antianxiety medication. D. Return in 30 min to recheck the client's blood pressure.: B. CORRECT: Ask the client if they are having pain. The first action that should be taken using the nursing process is to assess the client for pain which can cause multiple complication, including elevated BP. Therefore, the priority is to perform a pain assessment. If the client's BP is still elevated after pain interventions, report this finding to the provider. 45.The nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?: 16/minute The pulse deficit is the difference between the apical and radial pulse rates. It reflects the number of ineffective or non perfusing heartbeats that do not transmit pulsations to peripheral pulse points. 84-68= 46.A nurse is caring for a client who states, "I have to check with my partner and see if they think I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? A. Pacing B. Reflecting C. Paraphrasing D. Restating: B. Reflecting Reflecting directs the focus of the conversation back to the client so that they can further explore their own feelings.

19 / 35 47.Which of the following actions should the nurse take when demonstrating an empathic presence to a client? Select all that apply A. Use an open posture B. Write down what the client says to avoid forgetting details C. Establish and maintain eye contact. D. Nod in agreement with the client throughout the conversation. E. Sit facing the client.: A. CORRECT: Use an open posture B. INCORRECT: Write down what the client says to avoid forgetting details C. CORRECT: Establish and maintain eye contact. D.INCORRECT Nod in agreement with the client throughout the conversation. E. CORRECT: Sit facing the client. 48.A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (Select all that apply) A. "You will do great! You just have to get used to it." B. "Why are you worried about going home?" C. "Your daily routines will be different when you get home." D. "Tell me about the support system you'll have after you leave the hospital." E. "It sounds like you are not sure how having a colostomy will affect swim- ming.": A. INCORRECT: "You will do great! You just have to get used to it."

20 / 35 B. INCORRECT: "Why are you worried about going home?" C. CORRECT: "Your daily routines will be different when you get home."

21 / 35 D.CORRECT: "Tell me about the support system you'll have after you leave the hospital." E. CORRECT: "It sounds like you are not sure how having a colostomy will affect swimming." 49.Which of the following strategies should a nurse use to establish a helping relationship with a client? A. Make sure the communication is equally distributed between the nurse's and client's desires. B. Encourage the client to communicate their thoughts and feelings. C. Give the nurse-client communication no tome limits. D. Allow communication to occur spontaneously throughout the nurse- client relationship: B. Encourage the client to communicate their thoughts and feelings. Therapeutic communication facilitates a helping relationship that maximizes the client's ability to express their thoughts and feelings openly. 50.A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? A. Touch the child's arm B. Sit at eye level with the child. C. Stand facing the child. D. Stand with a relaxed posture.: B. Sit at eye level with the child. Be at the same eye level as the child to facilitate communication. 51.A nurse provides an introduction to a client as the first step of a compre- hensive physical exam. Which of the following strategies should the nurse use with this client? Select all that apply

22 / 35 A. Address the client with the appropriate title and their last name.

23 / 35 B. Use a mix of open and close-ended questions. C. Reduce environmental noise. D. Have the client complete a printed history form. E. Perform the general survey before the examination.: A. INCORRECT: Ad- dress the client with the appropriate title and their last name. B. CORRECT: Use a mix of open and close ended questions. C. CORRECT: Reduce environmental noise. D.INCORRECT: Have the client complete a printed history form. E. CORRECT: Perform the general survey before the examination. 52.A nurse in a provider's office is documenting findings following an ex- amination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (Select all that apply.) A. Posture B. Skin lesions C. Speech D. Allergies E. Immunization status: A. CORRECT: Posture B. CORRECT: Skin lesions C. CORRECT: Speech D.INCORRECT: Allergies (this is part of the health history, not a general survey) E. INCORRECT: Immunization status (this is part of the health history,

24 / 35 not a general survey)

25 / 35 53.A nurse is collecting data for a client's comprehensive physical examina- tion. After inspecting the client's abdomen, which of the following skills of the physical examination process should the nurse perform next? A. Olfaction B. Auscultation C. Palpation D. Percussion: A. Olfaction B. CORRECT: Auscultation; because palpation and percussion can alter the fre- quency and intensity of bowel sounds, auscultate the abdomen next and before using those two techniques. C. Palpation D. Percussion 54.A nurse is preparing to perform a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? Select all that apply A. Expect the session to be shorter than for a younger client. B. Plan to allow plenty of time for position changes. C. Make sure the client has any essential sensory aids in place. D. Tell the client to take their time answering questions. E. Invite the client to use the bathroom before beginning the exam.: A. INCOR- RECT: Expect the session to be shorter than for a younger client. B. CORRECT: Plan to allow plenty of time for position changes. C. CORRECT: Make sure the client has any essential sensory aids in place.