Basic Nursing Test 1 Review
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You are caring for a patient on an inpatient psychiatric unit. He was admitted after a severe anxiety attack. He tells you he feels very out of control and does not know how to deal with these feelings. According to Maslow's hierarchy of needs, with which level of needs are you most concerned?
b. Safety and security
c. Love and belonging
The nurse is working with a 16-year-old in the management of type 1 diabetes. While going through the educational process, the nurse keeps in mind that this adolescent is beginning to assert his independence and allows him to make decisions when possible. Which internal variable is the nurse recognizing.
a. Developmental stage
b. Intellectual background
c. Emotional factors
d. Spiritual factors
Your patient tries to walk for 30 minutes on most days of the week and includes fruits and vegetables with her meals. This is an example of:
a. Illness prevention activities
b. Wellness education
c. Health promotion activities
d. Illness behavior
A patient has decided to eat five fruits and vegetables a day and is exercising at least 3 days a week. What of prevention is this patient practicing?
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. Rehabilitation prevention
A hospital has an influenza immunization program in which all employees are encouraged to get a yearly influenza shot. This is an example of:
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
Your patient realizes he is at risk for type 2 diabetes because his mother and brother have diabetes. Which type of risk factor is this?
c. Physical environment
A 28-year-old male patient travels frequently with his job. He often eats meals high in fat, gets very little exercise, and smokes 1 pack of cigarettes a day. What type of risk factors for heart disease is he experiencing?
c. Physical environment
Your patient smokes 1 to 2 packs of cigarettes per day. He says to you, "I know smoking isn't good for me. I think I am ready to think about quitting." According to the stages of behavior change model, which stage of change is your patient in?
You have been working with a patient on a smoking cessation plan for the past 3 months. At your next visit, the patient states, "Even though I've tried and haven't been able to quit in the past, I want to try again. My thirtieth birthday is in 2 weeks, and this is when I'm going to quit." According to the stages of behavior change model, which stage of change is your patient in now?
A female patient says to her nurse, "Why should I exercise? We're all going to die of something anyway. I'm too busy for exercise" According to the stages of behavior change model, the nurse's best response is:
a. "I want you to start walking 30 minutes a day every day of the week."
b. "It is hard to find time. What things are important to you now? What do you want to make sure you can do 5 years from now? Are there any activities you enjoy doing?"
c. "That's too bad you are so busy. Maybe you'll have more time in the future."
d. "That's fine. Exercise isn't that important anyway."
A nurse uses an institution's policy and procedure manual to confirm how to apply a surgical dressing. The level of critical thinking the nurse is using is:
b. Complex critical thinking
c. Scientific method
d. Basic critical thinking
The nurse enters the room of a patient with diabetes and heart disease. The nurse notes that the patient's color and facial expression suggest something is not right. An assessment of vital signs, the patient's blood glucose level, and a review of the patient's diet intake this morning help the nurse to verify the patient has a low blood glucose level. The nurse's reaction to the patient's color and expression is best described as:
a. Diagnostic reasoning
c. Thinking independently
d. Clinical interference
A patient in hospice care has worsened over the course of the last 4 hours. The nurse knows how close the patient is to his daughter. The daughter has been out of town on an important work assignment. The patient asks the nurse to not call the daughter for fear it would interfere with her work. The nurse decides to call the daughter to notify her of her father's condition. She tells the patient of her action. This is an example of which critical thinking attitude?
d. Risk taking
The nurse cares for a patient receiving tube feedings. The nurse tries to irrigate the tube but is not successful. The nurse checks the medical record to see if other nurses have had difficulty with the tube. The nurse checks the tube and finds no kinking. The nurse's actions are an example of what critical thinking competency?
b. Clinical inference
c. Problem solving
The nurse has a patient with a peripheral IV infusion. Last week the nurse cared for a patient whose IV site developed the complication of phlebitis. The nurse is more prepared to observe for developing problems with this newly assigned patient because of:
The nurse completes his clinical day and discusses his experience with his best friend. The nurse is concerned about an error he made in setting up an IV infusion. He recalls being distracted when the charge nurse asked a question in the medication room. He states, "You know, so much was happening at the time, I should have stopped to answer the question and then double-checked my IV infusion tubing." This is an example of:
a. Risk taking
d. Problem solving
A nurse is about to begin her morning rounds, but before doing so, reads in one patient's chart that a diagnosis of ovarian cancer had just been made. The nurse plans to do her routine physical check of the patient when she first enters the room but then plans to also talk with the patient about her feelings regarding her diagnosis. The nurse's decision to asses her patient's feelings is an example of what critical thinking standard?
A newly oriented nurse has been caring for a patient with a deep pressure ulcer for 2 days. The patient has an order for the application of a negative pressure wound vacuum system. The nurse has not yet had an opportunity to use the wound vacuum system. The nurse approaches the charge nurse and asks for assistance in applying the treatment. This is an example of the critical thinking attitude of:
A patient tells the nurse, "I have had this dull ache in my side now for 4 days; it really hurts when I bend over." The nurse responds, "Uh-huh. Go on." The nurse's response is an example of:
b. A cue
d. Open-ended question
A patient has a pressure ulcer resulting from urine incontinence and sustained pressure over her coccyx. The nursing plan of care includes a goal of "Pressure ulcer will heal in 3 weeks." Which of the following is an evaluative measure for this goal?
a. Turn patient every 90 minutes.
b. Measure the diameter of the ulcer.
c. Measure the color of the patient's urine.
d. Determine patient's report of discomfort during turning.
A nurse has been interviewing a newly assigned patient. The cues from the assessment suggest that the patient has had a problem with breathing. The nurse does not validate the findings by doing a physical examination. This is an example of what type of error?
a. Error in data clustering
b. Error in data collection
c. Error in diagnostic statement
d. Error in interpretation and analysis
Roberta is a nursing student reporting off at the end of her shift to John, an RN. Roberta tells John that her patient has a priority nursing diagnosis of pain. She tells John that the last time the ordered analgesic was given was 2 hours ago. The patient continues to report pain at a level of 4. Roberta also tried repositioning and distraction to reduce the patient's discomfort. Roberta has observed her patient grimace while turning. What expected outcome measure did Roberta report to John?
a. Administration of the analgesic as ordered
b. The use of distraction as a pain-relief measure
c. The reported pain level of 4 on a scale of 0 to 10
d. Observation of the patient grimacing during turning
The nurse prepares to administer care to a patient by first positioning him more comfortable. She inspects his surgical wound and reinforces the dressing with extra tape. The nurse explains the procedure she will use for insertion of a urinary catheter. She prepares the patient and inserts the catheter. Which of the following steps was a dependent nursing intervention?
a. Insertion of the urinary catheter
b. Reinforcement of dressing with tape
c. Instruction about the procedure for insertion of the urinary catheter
d. Positioning the patient for comfort.
A nursing student completes an assessment of a patient who just returned from a diagnostic procedure. The patient's blood pressure is 92/70 mm Hg, and the patient reports feeling dizzy. The student goes to the medical record to learn what the patient's blood pressure and symptoms were before the diagnostic test. The nursing student's review of the medical record for data is an example of:
b. Data analysis
d. Outcome measurement
Mrs. Weber is a 52-year-old patient who is facing reconstructive breast surgery. She has not had surgery in the past and is asking questions of the nurses in the outpatient surgery center. Mrs. Weber tells the nurse she would like to know more about what to expect. The nurse identifies the nursing diagnosis of readiness for enhanced knowledge related to planned surgery. An example of a goal for this diagnosis would be:
a. Provide instruction on routine postoperative monitoring
b. Perform vital sign measurement every hour following surgery
c. Patient identifies reason for vital sign monitoring following surgery
d. By day of surgery, patient understands the routine monitoring protocol following surgery
Which of the following statements are true?
a. Oral reports are more accurate that written reports because they give a more complete picture of the patient's health.
b. The health care provider should avoid reading previous patient assessments to prevent forming preconceived judgments about care.
c. The health care provider should document as soon as possible after providing patient care.
d. The advantage of CBE is that it originates from a nursing model rather than a medical model.
The advantage of focus charting is that:
a. It focuses on tracking patient problems
b. It enables all caregivers to track the patient's condition and progress toward the outcomes of care
c. It uses check marks on a flow sheet
d. It details the use of services and equipment on a spreadsheet
A secondary benefit of thorough documentation is that information gathered from a patient record can be used to:
a. Protect the nurse in legal cases
b. Show that the patient was unpleasant to staff
c. Document the author's assessment of other health care providers
d. Document opinions about the patient's family
When giving a change-of-shift report, you are expected to:
a. Include community resources that the patient can contact
b. Include a step-by-step description of how to perform procedures
c. Provide an organized and concise description of patient status and anticipated needs
d. Review signs and symptoms of complications that should be reported to the health care provider
When you receive telephone orders from a health care provider, you must:
a. Make a photocopy of the order to avoid errors
b. Read back the order to the prescriber
c. Wait until the prescriber signs the order
d. Include why the telephone order was needed
When documenting in the patient's record, which of the following should you avoid writing down?
a. The patient's diagnosis
b. Any patient's previous assessment
c. What the next caregiver will need to know to better care for the patient.
d. Your complaints about the patient.
A nurse makes the following documentation in the patient record: "0830 Patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated. Physician notified and analgesic administered as ordered with adequate response. J Cass, RN." The most significant statement about the documentation would that it is:
a. Acceptable because it include assessment, interventions, and evaluation
b. Good because it shows immediate responsiveness to the problem
c. Inadequate because pain is not described on a scale of 0 to 10
d. Unacceptable because it is vague subjective data
Documentation of assessment of a patient recovering from surgery includes the following information: complete bath; level of pain 6 (scale 0 to 10); turning in bed with assist of one; and dressing clean, dry, and intact. The least appropriate information is:
a. Complete bath
b. Level of pain
c. Turning in bed with assistance
d. Status of the dressing
A nurse documents an assessment completed at 5 PM. In military time that this is:
A patient's race, weight, and marital or employment status are examples of:
While administering medications, the nurse realizes that the wrong dose of a medication was given to the patient. The nurse completes an occurrence report and notifies the patient's health care provider. This is an example of nurse exercising:
d. Decision making
During morning rounds the nurse assesses the condition of a patient who had major heart surgery 2 days ago. His vital signs are stable. The nurse finds the incision is clean and healing well. The patient complains of pain in his lower leg where a vein graft for the heart surgery was removed. The IV solution is infusing at 100 mL/hr but only 150 mL remains before the infusion runs out. An order exists for the patient to ambulate twice a day. What action should the nurse do first?
a. Replace the IV bag with a new one.
b. Administer an analgesic for the patient's leg pain.
c. Provide instruction on complications of wound healing.
d. Ambulate the patient 50 feet in the hall.
The nurse checks her patient, a 62-year-old man admitted to the hospital with pneumonia. The patient has been coughing profusely and has required nasotracheal suctioning. He also has an IV infusion of antibiotics. The patient is febrile with a temperature of 101⁰ F (38.3⁰ C). He asks the nurse if he can have a bed bathe because he has been perspiring profusely. The task for the nurse to delegate to the nurse assistant working with her today is:
a. Teaching the use of incentive spirometer
b. Changing the IV dressing
c. Nasotracheal suctioning
d. Administering a bed bath
The nurse has completed morning rounds on her assigned patients and is giving the nursing assistant directions for what he needs to do for the next hour. An example of an appropriate way to communicate directions when delegating nursing care is:
a. "Please go to room 20A and see what the patient needs."
b. "I would like you to take all the vital signs for rooms 12 and 13 and let me know if there are any problems."
c. "Would you start the patient's bath while I check on the IV line in room 14? I will help you with turning her so I can asses her skin and decide on the turning schedule we will need to follow."
d. "I want you to help the patient in room 16B off the bedpan, and while you are at it, get a specimen if he passed any stool. I don't think I can go in his one more time, so I would appreciate your help."
You are caring for a patient who was started on insulin for newly diagnosed diabetes mellitus. You need to teach the patient and family about insulin administration. You recognize that this is classified as what type of priority?
You are an RN providing care to an assigned group of patients. You are responsible for developing the patient care plan, working directly with the patient and family, and interacting with other members of the health care team. What type of nursing care delivery model are you participating in?
a. Total patient care
b. Functional nursing
c. Primary nursing
d. Team nursing
The nurse asks the nursing assistant to walk the patient 100 feet in the hall. The nurse tells the nursing assistant to take the patient's pulse before and after the walk and to notify him what the pulse rates are. The nurse's interaction with the nursing assistant is an example of which of the five rights of delegation?
a. Right supervision
b. Right task
c. Right direction
d. Right circumstances
Which task is appropriate for the RN to delegate to the nursing assistant?
a. Assessing the vital signs on a patient who had a total knee replacement 2 days ago.
b. Explaining to a patient about the colonoscopy that is scheduled for tomorrow morning.
c. Completing the documentation of the patient teaching done on a newly prescribed medication.
d. Administering the contrast medium to a patient who is having an abdominal computed tomography (CT) scan later in the morning.
Which activity has the highest priority and should be completed first by a nurse?
a. Collect a culture and sensitivity specimen from the patient's infected foot ulcer.
b. Administer morphine sulfate for the patient's incision pain rated as a 6 on a 0 to 10 scale.
c. Irrigate the patient's nasogastric tube for the complaint of nausea.
d. Provide teaching on insulin administration to the patient on his new diagnosis of diabetes mellitus.
Which activity by the nursing student shows a strategy for effective time management?
a. The student makes two trips to the supply room to gather materials for a dressing change.
b. The student stopped twice while setting up her medications to help another student.
c. The student commented on how unorganized she felt and stated that she would do better next week.
d. After listening to the change-of-shift report, the student revises the schedule she developed last night for the clinical day.
A 68-year-old woman whose husband died last year walks into the wellness clinic of the assisted living facility. She reports that she feels depressed and tired all the time. She provides you with a list of medications, one of which her health care provider altered in the last 3 weeks, atenolol, a beta-adrenergic blocker. Knowing that beta-adrenergic blockers have the potential to cause hypotension and bradycardia, which vital signs can you delegate to the clinics nursing assistant? Select all that apply.
a. Blood pressure
b. Temperature and respiratory rate
c. Oxygen saturation
d. Heart rate
A patient's blood pressure is 102/58 mm Hg in the right arm. On the patient's last visit, the blood pressure was 142/60 mm Hg in the left arm. What is your priority nursing action?
a. Repeat the blood pressure in the right arm.
b. Obtain the blood pressure in the left arm.
c. Allow the patient to relax for 15 minutes.
d. Notify the health care provider.
A 53-year-old man has just returned from the poast-anesthesia care unit (PACU) following a small bowel resection. He has smoked 2 packs per day since he was 18 years old. His admission vital signs obtained by the nursing assistant are heart rat 114 beats per minute, BP 118/72 mm Hg, tympanic temperature 97.8⁰ F, respiratory rate 8 breaths per minute, and SpO2 94% using 3 L of oxygen via nasal cannula. How do you describe his vital signs?
a. Bradycardia with apnea
b. Tachycardia with hypoxia
c. Bradycardia and bradypnea
d. Tachycardia and bradypnea
Thirty minutes after returning from the PACU your patient's pulse oximeter alarms, and you note the SpO2 is 89%. While she was sleeping, the oxygen cannula fell out of her nose. What is your priority nursing action?
a. Reposition the oximeter probe.
b. Reposition the nasal cannula
c. Obtain the patient's respiratory rate while asleep.
d. Shake the patient to see if she wakes.
Poor oxygenation of the blood ordinarily will affect the pulse rate and cause it to become:
You dangle your patient on the side of the bed 6 hours after surgery. The nursing assistant obtains a blood pressure of 92/58 mm Hg while he is sitting. The difference between his postoperative BP of 118/58 mm Hg and the sitting blood pressure is described as:
a. Hypotensive response to surgery
b. Normal response to repositioning
c. Orthostatic hypotension
d. Side effect of fluid shift
You help your patient get out of bed 1 day after surgery for a bowel obstruction. He complains of dizziness and nausea. Your immediate action is to:
a. Assist him to a supine position
b. Assess blood pressure
c. Report findings to the nurse in charge
d. Question the patient about palpitations
Following surgery, your patient's systolic blood pressure drops 25 mm Hg when you are helping him out of bed. What is the likely cause for the change in blood pressure?
a. Pain caused by movement
b. Blood loss during surgery
c. Increase in heart rate as a result of stress
d. Movement too soon after surgery
You have assigned routine vital signs to a new nursing assistant recently hired by your clinical manager. You notice that the nursing assistant's last three patients have had unusually low blood pressures that you have had to reconfirm. What is the most likely reason for the low blood pressures that the nursing assistant is obtaining?
a. BP cuff was too wide for arm circumference.
b. Bladder was inflated and deflated too slowly.
c. Patient's arm was not supported during measurement.
d. BP cuff was not wrapped evenly around arm.
An experienced nursing assistant complains about the vital signs that a newly hired nursing assistant has been asked to retake a BP that the newly hired nursing assistant has taken 3 times this week. As the RN, what action do you take?
a. Do not delegate vital signs to the newly hired nursing assistant.
b. Delegate only temperature and respiratory rate to the newly hired nursing assistant.
c. Report the newly hired nursing assistant to your supervisor.
d. Observe the newly hired nursing assistant as she obtains a blood pressure and pulse on a patient.
What would you like to do?
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