Download PN 2006 PRE MIDTERM EXAM and more Exams Nursing in PDF only on Docsity!
PN 2006 PRE MIDTERM EXAM WITH UPDATED
QUESTIONS AND ANSWERS
The nurse teaches the patient in proper handwashing technique before discharge and ask for a return demonstration, which hand hygiene technique indicates the patient teaching by the nurse is effective? a. The patient turns off the tap and then dries hands b. Soap, water, and friction are used by the patient c. The patient wash his hands with very hot water d. A basin with warm soapy water is used - ANSWERS-b. Soap, water, and friction are used by the patient In which of the following situation should the nurse use surgical asepsis? a. Performing routine urinary catheter care b. Performing oral care c. Wound care dressing d. Performing nasogastric tube care - ANSWERS-c. Wound care dressing Subjective data includes a patient's feelings, perception, and reported symptoms true or false - ANSWERS-true The nurse admits the patient with mild chest pain from emergency department. what should the nurse implement first to gain patient corporation during a physical assessment? a. Explain the procedure and it's purpose b. Perform assessment in stages over the day c. Complete assessment within 3 to 5 minutes
d. Assess painful areas before non-tender areas - ANSWERS-a. Explain the procedure and it's purpose The nurse is performing a neurological assessment which patient behaviour demonstrates a level of consciousness within normal limits a. States name age and date but not location b. is lethargic but responds logically to questions c. respond verbally but words are unintelligible d. responds to questions spontaneously and is alert - ANSWERS-d. responds to questions spontaneously and is alert The nurse assessing with a patients with a cast extending from just below the left knee to the toes. which assessment contain a desirable patient outcome? a. The toes are pink bilaterally b. The cast is warm at the ankle c. Paresthesia is present in the left foot d. The cast is snug at the knee - ANSWERS-a. The toes are pink bilaterally The nurse assesses an adult patient with a cardiopulmonary illness and hears a grating sound over the lower lateral lung during inspiration that does not clear with coughing. What would the nurse most likely document as a result of the assessment findings? a. Crackles b. Wheezes c. A pleural friction rub d. Rhonchi - ANSWERS-c. A pleural friction rub having a misplaced his stethoscope, a nurse borrows a colleagues stethoscope. He next enters to patients room and identified himself,
true or false - ANSWERS-false The nurse considers several new female patients to receive additional teaching on the need for more frequent Pap smears and gynecological examinations. Which of the following patients is at higher risks for cervical cancer and thus having the greatest need for patient education? a. 25 year old, smokes 1/2 pack of cigarettes per day, has multiple sexual partners bc nonsmokers, 13 years old, not sexually active c. 45 year old, stopped smoking 20 years ago, history of hysterectomy d. social smoker, 18 year old, celibate - ANSWERS-a. 25 year old, smokes 1/2 pack of cigarettes per day, has multiple sexual partners to gather information about a patients home and work surroundings, the nurse will need to utilize which method of data collection? a. carefully review lab results b. conduct the physical assessment before collecting subjective information c. perform a through. nursing health history d. prolong the termination phase of the interview - ANSWERS-c. perform a through. nursing health history examples of adventitious breath sounds might include rhonchi and crackles true or false - ANSWERS-true When evaluating a plan of care, the nurse reviews the goals for the patient. Which goal statement is realistic to assign to a patient with a pelvic fracture on bed rest? The patient will increase mobility by A. Ambulating in the hallway two times this shift. B.Turning side to back to side with assistance every 2 hours. C.Using the walker correctly to ambulate to the bathroom as needed.
D.Using a sliding board correctly to transfer to the bedside commode as needed. - ANSWERS-B.Turning side to back to side with assistance every 2 hours a patient with Glasgow coma scale score 15 would be considered in a coma. true or false - ANSWERS-false A patient in the emergency department is complaining of left lower abdominal pain. The comprehensive abdominal examination would include, in proper order, which of the following? A. Inspection, palpation, auscultation B. Percussion, inspection, auscultation C. Inspection, palpation, percussion D. Inspection, auscultation, palpation - ANSWERS-D. Inspection, auscultation, palpation The patient is in isolation in a negative pressure room for active tuberculosis. He coughs and spews large amounts of blood thinks sputum but is too weak to cover his mouth and nose with a tissue. Which is the most important intervention for the nurse to implement for self protection while providing nursing care? a. Cover the patient's mouth and nose snugly with a surgical mask b. Wear an N-95 mask, gloves, face shield, and isolation gown c. Place tissues and a contaminated waste container within reach. d. Use a properly fitted surgical mask and gloves to help with tissues - ANSWERS-b. Wear an N-95 mask, gloves, face shield, and isolation gown A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. When performing an abdominal assessment, the nurse should A. Recommend that the patient take more laxatives. B. Ask the patient about the color of her stools. C. Avoid sexual references such as possible pregnancy.
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. How should the nurse proceed? a. Notify the physician to recommend a psychological evaluation. b.Consider cultural differences during this assessment. c.Ask the patient to make eye contact to determine her affect. d.Continue with the interview and document that the patient is depressed - ANSWERS-b. Consider cultural differences during this assessment. small, circumscribed skin lesions filled with serious fluid could be described as vesicle. true or false - ANSWERS-true An example of a report is when a nurse prepares an audiotaped exchanged with another nurse of information about a patient. true or false - ANSWERS-true A nurse wanting to assess a patients daily weights. Where should the nurse look? a. Graphic sheet and flow sheet b. Database c. Progress notes d. Medical history and examination - ANSWERS-a. Graphic sheet and flow sheet A medical diagnosis and a nursing diagnosis are the same thing true or false - ANSWERS-false Which of the following is an example of subjective data?
a. Patients temperature b. Patient's wound appearance c. Patient's expression of feae regarding upcoming surgery d. Patient pacing the floor while awaiting test results - ANSWERS-c. Patient's expression of feae regarding upcoming surgery An oxygen saturation level of 85-95% would be considered normal true or false - ANSWERS-false Wheeezes can be described as high-pitched musical sounds that are heard on inspiration and expirations true or false - ANSWERS-true The nurse is instructing a patient how to breathe during auscultation of the lungs. Intructions by the nurse has been effective if the patient breathes in which manner? a. Takes a deep breath and holds it b. Breathe with the mouth open c. Cough and then takes a deep breath d. Takes rapid shallow breath - ANSWERS-b. Breathe with the mouth open It is normal and does not require intervention should a patient refuse to look at their stoma during care. true or false - ANSWERS-false Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur.
b. Proceed to the next patients room while making sounds c. Offer a massage because the patient does not want any more pain medicine. d. Administer the pain medication ordered for moderate to severe pain - ANSWERS-a. Ask the patient about the facial grimacing with movement In which step of the nursing process does the nurse determine if the patient's condition has improved and whether the patient has met expected outcomes? a. Evaluation b. Implementation c. Planning d. Assessment - ANSWERS-a. Evaluation Discharge planning begins at admission true or false - ANSWERS-true Which of the following is an example of subjective data? a. Patient's tempature b. Patient's wound appearance c. Patient's expression of fear regarding upcoming surgery d. Patient's pacing the floor while awaiting test results - ANSWERS-c. Patient's expression of fear regarding upcoming surgery non blanching erthyema is an indication of a stage 1 pressure ulcer true or false - ANSWERS-true
The nurse completes preparation of the sterile field to change a patient's dressing when the patient's dinner tray arrives. Which action should the nurse take? a. Change the dressing and using clean technique to save time b. Set up the tray aside and proceed with the dressing change c. Use the sterile field on another patient in another room d. Cover the setup with a sterile drape and let the patient eat - ANSWERS-b. Set up the tray aside and proceed with the dressing change The nurse set up a sterile field and notes several tiny holes in the drape of the table that served as the wrap for the pack. What does the nurse do to facilitate completion of the procedure? a. Use a sterile towel to cover the existing holes b. Replaces the entire sterile field and the supplies c. Avoids using any of the sterile items near the holes d. Moves the sterile supplies to a replacement drape - ANSWERS-b. Replaces the entire sterile field and the supplies Items below the waist are considered to be sterile. true or false - ANSWERS-false While setting up a sterile field for a procedure, the nurse knocks a linen-wrapped sterile package to the floor. Which reaction allows the nurse to maintain safe practice? a. Replace the dropped item b. Brush away the visible debris c. Record the procedure as clean d. Inspect the package for tears - ANSWERS-a. Replace the dropped item
a. Carefully review lab results b. Conduct the physical assessment before collecting subjective information c. Perform a through nursing health history d. Prolong the termination phase of the interview - ANSWERS-c. Perform a through nursing health history When cresting care plans the nurse should consider the needs of the family family members as well true or false - ANSWERS-true A patient with respiratory concerns should be placed in a prone or side-lying position while a respiratory assessment? true or false - ANSWERS- While working on a long term care unit, health care aid (HCA) asks the nurse if they could chart the bowel care that the HCA did earlier this morning. Which of the following in true concerning charting? a. As a team leader the nurse should take this opportunity to provide education to the HCA on the importance of charting b. It is acceptable for the nurse to chart in this instance because the HCA is. to regulated c. The nurse is required to report the HCA to the manager as the HCAs conduct is unprofessional d. The nurse should refuse the request and tell the HCA to chart whenever they have time - ANSWERS-a. As a team leader the nurse should take this opportunity to provide education to the HCA on the importance of charting A patient expresses fear of going home and being alone. Her vital sigma are stable and her incision is nearly completely healed. What can the nurse infer from the subjective data? a. The patient can begin retaking all her previous medications
b. The patient can now perform the dressing change herself c. The patient is apprehensive about discharge d. The wound is healing as expected and the surgery was a success - ANSWERS-c. The patient is apprehensive about discharge A blowing sound osculated over the carotid artery is know as bruit true or false - ANSWERS-true A patient with a Glasgow coma scale score of 15 would be considered to be in a coma true or false - ANSWERS-false Certain medications, like chemotherapeutics or steroids may impede wound healing. true or false - ANSWERS-true When administering a fleet, the patient should be lying on their right side. true or false - ANSWERS-false In preparation for a rectal examination of a non-ambulatory male patient, the patient is informed of the need to be on what position? a. forward sending with flexed hips b. sim's postion c. knee-chest d. Dorsal recumbent - ANSWERS-b. sim's postion
a.Add blue food colouring to the enteral formula b. Run the formula over 12 hours to decrease volume c. verify tube placement before feeding d. lower the head of the bed to a supine position - ANSWERS-c. verify tube placement before feeding When performing an abdominal assessment on a resident, you would carry out: a. Visual inspection of abdomen b. Auscultation of bowel sounds in all four quadrants c. Palpation of abdomen for masses & pain d. All of the above - ANSWERS-d. All of the above Injuries among older adults resulting from falls in the home are due to intrinsic and extrinsic factors. Which one of the following is an example of an extrinsic factor? a. Illness b. Environmental obstacles c. Drug therapy d. Alcohol use - ANSWERS-b. Environmental obstacles When performing a physical musculoskeletal assessment, an LPN would include: a. Palpation of muscle mass b. Inspection of posture c. Observe of gait d. All of the above - ANSWERS-d. All of the above
Which of the following is the most accurate way to determine the correct placement of a newly inserted tube feed? a. Patient description of placement b. X-ray c. ph of aspirated contents d. Surgical report from physcian - ANSWERS-b. X-ray A patient who is expecting diarrhea after starting a new tube feed formula may be experiencing formula intolerance. true or false - ANSWERS-true For the client with receptive aphasia, which of the following nursing interventions is the most effective? a. Using a system of simple gestures and repeated behaviours to communicate b. Providing the client with a letter chart to use to answer complex questions c. Offering the client a notepad to write questions and concerns d. Obtaing a referral for a speech therapist - ANSWERS-a. Using a system of simple gestures and repeated behaviours to communicate The nurse recognizes that changes in elimination occur with the aging process. Which one of the following is an expected change affecting bowel elimination? a. Change in nerve innervation and sensation cause diarrhea b. Mastication processes are less efficient c. Esophageal emptying time is increased d. Absorptive processes are increased in the intestinal mucosa - ANSWERS-b. Mastication processes are less efficient
b. Apply for 40-45 minutes, check every 10,minutes, repeat Q8H c. Apply for 30-40 minutes, check evert 5 minutes, repeat as often as needed d. Apply for 15-20 minutes, check every 5 minutes, evaluate effectiveness 30 minutes after procedure - ANSWERS-d. Apply for 15-20 minutes, check every 5 minutes, evaluate effectiveness 30 minutes after procedure The nurse has completed the admission for a client admitted to the hospital's sub-acute care unit. Of the following nursing diagnosis identified by the nurse's, which one takes the highest priority? a. Adjustment, impaired b. Risk for injury c. Social isolation d. Communication, impaired verbal - ANSWERS-b. Risk for injury When a patient has a seizure it is important to retrain their arms and legs to prevent them hurting themselves true or false - ANSWERS-false An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimer's disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is:
- Confusion
- Impaired judgment
- Sensory deficits
- History of falls - ANSWERS-4. History of falls A 79 year old resident in a long term care facility is known to "wander" at night and has fallen in the past. Which of the following nursing interventions is the most appropriate for this client?
a. The client should be checked frequently during the night b. An abdominal restraint should be placed on the client during sleeping hours c. The client should be placed in a room away from the acidity of the nursing station d. A radio should be left playing at the bedside to assist in reality orientation - ANSWERS-a. The client should be checked frequently during the night Application of cold will cause vasodilation and will therefore help to relive pain true or false - ANSWERS-false While caring for a patient, the nurse determines that he has a rating of 6 on the Glasgow coma scale. The nurse understands that: a. He has received the highest possible score b. His is not in a coma c. He is in a coma d. He has received the lowest possible score - ANSWERS-c. He is in a coma A patient has no bowel sounds in his upper left quadrant. After listening carefully for 10 seconds, you believe that: a. The patient may have a bowel obstruction b. You need to listen longer in all quadrants c. This is a medical emergency d. The patient may have an ileus - ANSWERS-b. You need to listen longer in all quadrants A patient's tube feed has finished running through. Which of the following nursing measures would be helpful in preventing clogging in the tubing?
