Basic Nursing Test 2 Study Guide

Card Set Information

Basic Nursing Test 2 Study Guide
2012-09-19 17:50:51
Basic Nursing

Chapters 13-15
Show Answers:

  1. At the community health fair, a nurse is asked by one of the residents about the influenza vaccine. The nurse responds to the resident that the influenza vaccine is recommended for individuals who are:
    a.       health care workers
    b.      traveling to other countries
    c.       younger than 6 years of age
    d.      between 40 and 65 years of age
  2. A nurse is preparing a room for a patient with tuberculosis. The specific aspect for this tier of Standard Precautions that is different that tier 1 is that the care should include:
    a.       a private room with negative air flow
    b.      hand hygiene after gloves are removed
    c.       eye protection if splashing is possible
    d.      disposal of sharps in a puncture-resistant container
  3. A nurse is preparing a teaching plan for patients about the hepatitis B virus. The nurse informs them that this virus may be transmitted by:
    a.       mosquitoes
    b.      droplet nuclei
    c.       blood products
    d.      improperly handled food
  4. A nurse is working on a unit with a number of patients who have infectious diseases. One of the most important methods for reducing the spread of microorganisms is:
    a.       sterilization of equipment
    b.      the use of gloves and gowns
    c.       maintenance of isolation precautions
    d.      hand hygiene before and after patient care
  5. The assignment today for a nurse includes a patient with tuberculosis. In caring for a patient on droplet precautions, the nurse should routinely use:
    a.       regular masks and eyewear
    b.      regular masks, gowns, and gloves
    c.       surgical hand hygiene and gloves
    d.      particulate filtration masks and gowns
  6. A nurse is caring for a patient who has a large abdominal wound that requires a sterile saline soak and dressing. While performing the care, the nurse drops the saline-soaked 4x4 gauze near the wound on the patient's abdomen. The nurse:
    a.       discontinues the procedure
    b.      throws the gauze away and prepares a new 4x4 gauze
    c.       picks up the 4x4 with sterile forceps and places it on the wound
    d.      rinses the 4x4 with saline and places it on the wound using sterile gloves
  7. A nurse is checking the laboratory results of a male patient admitted to the medical unit. The nurse is alerted to the presence of an infectious process based on the finding of:
    a.       iron: 80g/100mL
    b.      neutrophils: 65%
    c.       erythrocyte sedimentation rate (ESR): 13 mm per hour
    d.      white blood cells (WBC): 16,000 mm3
  8. The individual most at risk for a latex allergy is the patient with a history of:
    a.       hypertension
    b.      congenital heart disease
    c.       diabetes mellitus
    d.      cholecystitis
  9. A nurse is working with a patient who has a deep laceration to the right lower extremity. To reduce a possible reservoir of infection, the nurse:
    a.       wears gloves and a mask at all times
    b.      isolates the patient's personal articles
    c.       has the patient cover the mouth and nose when coughing
    d.      changes the dressing to the extremity when it becomes soiled
  10. A nurse implements droplet precautions for the patient with:
    a.       pulmonary tuberculosis
    b.      varicella
    c.       rubella
    d.      herpes
  11. A patient who has had a transplant will require what type of isolation?
    a.       contact
    b.      airborne
    c.       droplet
    d.      protective
  12. For a patient with hepatitis A, the nurse is aware that the disease is transmitted through
    a.       feces
    b.      blood
    c.       skin
    d.      droplet nuclei
  13. A sign that is indicative of a systemic infection resulting from a wound is:
    a.       redness
    b.      drainage
    c.       edema
    d.      fever
  14. There are small open wounds on the hands of the nurse. The nurse's most appropriate action is:
    a.       asking to work at the nurse's station for the day
    b.      using clean, disposable gloves for patient care
    c.       applying antibacterial ointment before patient contact
    d.      providing patient care as usual and washing the hands more frequently
  15. A nurse is aware that older adults are more susceptible to infection as a result of:
    a.       thickening of the dermal and epidermal skin layers
    b.      increased production of T lymphocytes
    c.       increased production of digestive juices
    d.      drying of the oral mucosa
  16. A nurse is working on a pediatric unit and assessing the vital signs of an infant admitted for gastroenteritis. The nurse expects that the vital signs are normally the following:
    a.   BP = 90/50, P = 122, R = 46
    b.   BP = 90/60, P = 80, R = 20
    c.   BP = 100/60, P = 140, R = 32
    d.   BP = 110/50, P = 98, R = 40
  17. While working in an extended care facility, a nurse expects the vital signs of anolder adult patient to be:
    a.  BP = 98/70, P = 60, R = 12
    b.  BP = 120/60, P = 110, R = 20
    c.  BP =140/90, P = 74, R = 14
    d.  BP = 150/100, P = 90, R = 25
  18. A student nurse is taking vital signs for her assigned patients on the surgical unit. The student is aware that a patient's body temperature may be reduced after:
    a.  Exercise
    b.  Emotional stress
    c.  Periods of sleep
    d.   Cigarette smoking
  19. While working in an emergency department, a nurse is carefully monitoring the vital signs of the patients who have been admitted. The nurse is alert to the potential for a decrease in a patient's pulse rate as a result of:
    a.  Hemorrhage
    b.  Hypothyroidism
    c.  Respiratory difficulty
    d.  Epinephrine (adrenaline) administration
  20. A patient is being treated for hyperthermia. The nurse anticipates that the patient's response to this condition will be:
    a.  Generalized pallor
    b.  Bradycardia
    c.  Reduced thirst
    d.  Diaphoresis
  21. Several friends have gone on a ski trip and have been exposed to very cold temperatures. One of the individuals appears to be slightly hypothermic. The best initial response by the nurse in the ski lodge is to give this individual:
     a.  Soup
     b.  Coffee
     c.  Cocoa
     d.  Brandy
  22. When checking the temperature of a patient, a nurse notes that he is febrile. An antipyretic medication is ordered. The nurse prepares to administer:
    a.  Digoxin
    b.  Prednisone
    c.  Theophylline
    d.  Acetaminophen
  23. A nurse has been assigned a number of different patients in the long-term care unit. When taking vital signs, the nurse is alert to the greater possibility of tachycardia for the patient with:
    a.  Anemia
    b.  Hypothyroidism
    c.  A temperature of 95⁰ F
    d.  A patient-controlled analgesic (PCA) pump with morphine drip
  24. While reviewing the vital signs taken by the aide this morning, a nurse notes that one of the patients is hypotensive. The nurse will be checking to see if the patient is experiencing:
    a.  Lightheadedness
    b.  A decreased heart rate
    c.  An increased urinary output
    d.  Increased warmth to the skin
  25. Vital sign measurements have been completed on all assigned patients. The nurse will need to immediately report a finding of:
    a.  Pulse pressure of 40 mm Hg
    b.  Apical pulses of 78, 80, 76 beats per minute
    c.  Apical pulse of 82 beats per minute; radial pulse of 70 beats per minute
    d.  BP of 140/80 mm Hg left arm, 136/74 mm Hg right arm
  26. A nurse is preparing to take vital signs for the patients on the acute care unit. A tympanic temperature assessment is indicated for the patient:
    a.  After rectal surgery
    b.  Wearing a hearing aid
    c.  Experiencing otitis media
    d.  After an exercise session
  27. Blood pressure monitoring is being conducted on a cardiac care unit. The nurse is determining whether an automatic blood pressure device is indicated for use. This device is selected for the patient with:
    a.  An irregular heartbeat
    b.  Parkinson disease
    c.  Peripheral vascular disease
    d.  A systolic blood pressure greater than 140 mm/Hg
  28. A 34-year-old patient has gone to a physician's office for an annual physical examination. The nurse is completing the vital signs before the patient is seen by the physician. The nurse alerts the physician to a finding of:
    a.  T: 37.6⁰
    b.  P: 120 beats per minute
    c.  R: 18 breaths per minute
    d.  BP: 116/78 mm Hg
  29. A nurse is assigned to the well-child center that is affiliated with the acute care facility. A mother takes her 1 1/2-year-old son to the center for his immunizations. The nurse assesses the child's pulse rate by checking the:
    a.  Radial artery
    b.  Apical artery
    c.  Popliteal artery
    d.  Femoral artery
  30. A nurse determines that a patient's pulse rate is significantly lower than it has been during the past week. The nurse reassess and finds that the pulse rate is still 46 beats per minute. The nurse should first:
    a.  Document the measurement
    b.  Administer a stimulant medication
    c.  Inform the charge nurse of physician
    d.  Apply 100% oxygen at the maximum flow rate
  31. The most important sign of heat stroke is:
    a.  Hot, dry skin
    b.  Nausea
    c.  Excessive thirst
    d.  Muscle cramping
  32. The most accurate temperature measurement for an adult patient experiencing tachypnea and dyspnea is:
    a.  Oral
    b.  Rectal
    c.  Axillary
    d.  Tympanic
  33. A nurse should insert a rectal thermometer into the adult patient:
    a.  1/4 to 12 inch
    b.  1 to 1 1/2 inches
    c.  1 1/2 to 2 inches
    d.  2 to 2 1/2 inches
  34. A patient is determined to have an intermittent fever. This is supported by which of the following observations?
    a.  A constant body temperature greater than 38⁰ C (100.4⁰ F)
    b.  A fever that spikes and falls but does not return to normal
    c.  Long periods of normal temperatures with febrile episodes
    d.  Spikes in reading mixed with normal temperatures
  35. Which of the following values indicates the correct pulse pressure for a patient with a blood pressure of 170/90? a.  80
    b.  170
    c.  260
    d.  Value not known based on the information given
  36. For a patient who is experiencing a febrile state, the nurse should:
    a.  Ambulate the patient frequently
    b.  Restrict fluid intake
    c.  Keep the patient warm
    d.  Provide oxygen as ordered
  37. A nurse anticipates that bradycardia will be evident if a patient is:
    a.  Exercising
    b.  Hypothermic
    c.  Asthmatic
    d.  Extremely anxious
  38. A nurse anticipates that a patient with hypertension will be receiving:
    a.  Diuretics
    b.  Antipyretics
    c.  Narcotic analgesics
    d.  Anticholinergics
  39. To determine the arterial blood flow to a patient's feet, the nurse should assess the:
    a.  Radial artery
    b.  Brachial artery
    c.  Popliteal artery
    d.  Dorsalis pedis artery
  40. A nurse anticipates an increase in blood pressure for the patient who is:
    a.  Sleeping
    b.  Overweight
    c.  Taking narcotics
    d.  Hemorrhaging
  41. Pre-hypertension is classified as an average of repeated readings of:
    a.  Systolic: 120 to 139 mm Hg: diastolic: 80 to 89 mm Hg
    b.  Systolic: 140 to 159 mm Hg: diastolic: 90 to 99 mm Hg
    c.  Systolic: 160 to 170 mm Hg: diastolic: 90 to 99 mm Hg
    d.  Systolic: greater than 189 mm Hg: diastolic; greater than 100 mm Hg
  42. A nurse is assessing a patient's nail beds. AN expected finding is indicated by:
    a.       softening of the nail bed
    b.      a concave curve to the nail
    c.       brown, linear streaks in the nail bed
    d.      a 160-degree angle between the nail plate and nail
  43. A young adult woman arrives at the family planning center for a physical examination. For this patient with mature breasts, the nurse expects to find that the:
    a.       breast tissue is softer
    b.      nipples project and areolae have receded
    c.       areolae are dark and have increased diameter
    d.      breasts are elongated and nipples are smaller and flatter
  44. A nurse has checked the medical record and found that a patient has anemia. The presence of anemia is accompanied by the nurse's finding of:
    a.       pallor
    b.      erythema
    c.       jaundice
    d.      cyanosis
  45. A patient with asthma has gone to an urgent care center for treatment. On auscultation of the lungs, a nurse hears rhonchi. These sounds are described as:
    a.       dry and grating
    b.      loud, low-pitched, and coarse
    c.       high-pitched, fine, and short
    d.      high-pitched and musical
  46. A patient is admitted to a medical center with a peripheral vascular problem. A nurse is performing the initial assessment of the patient. While assessing the lower extremities, the nurse is alert to venous insufficiency as indicated by:
    a.       marked edema
    b.      thin, shiny skin
    c.       coolness to touch
    d.      dusky red coloration
  47. A nurse is performing a complete neurological assessment on a patient after a cerebrovascular accident (CVA/stroke). To assess cranial nerve III, the nurse:
    a.       uses the Snellen chart
    b.      lightly touches the cornea with a wisp of cotton
    c.       whispers into one ear at a time
    d.      measures pupil reaction to light and accommodation
  48. Student nurses are practicing neurological assessment and determination of cranial nerve functioning. To assess cranial nerve X, the student nurse should ask the patient to:
    a.       say "ah"
    b.      shrug the shoulders
    c.       smile and frown
    d.      stick out the tongue
  49. While completing a physical examination, a nurse assesses and reports that a patient has petechiae. The nurse has found:
    a.       light perspiration on the skin
    b.      moles with regular edges
    c.       thickness on the soles of the feet
    d.      pin-point size, flat red spots
  50. A nurse reviews a chart and sees that a patient who has been admitted to the unit this morning has a hyperthyroid disorder. The nurse anticipates that an examination of the eyes will reveal:
    a.       diplopia
    b.      strabismus
    c.       exophthalmos
    d.      nystagmus
  51. In preparation for an examination of the internal ear, a nurse anticipates that the color of the ear drum should appear:
    a.       white
    b.      yellow
    c.       slightly red
    d.      pearly gray
  52. A patient with a history of smoking and alcohol abuse has gone to a clinic for a physical examination. Based on this history, the nurse is particularly alert during an examination of the oral cavity to the presence of:
    a.       spongy gums
    b.      pink tissue
    c.       thick, white patches
    d.      loose teeth
  53. A patient in a physician's office has an increased anteroposterior diameter of the chest. The nurse should inquire specifically about the patient's history of:
    a.       smoking
    b.      thoracic trauma
    c.       spinal surgery
    d.      exposure to tuberculosis
  54. When auscultating a patient's chest, a nurse hears what appears to be an S3 sound. This is an expected finding if the patient is:
    a.       10 years old
    b.      35 years old
    c.       56 years old
    d.      82 years old
  55. A patient in a medical center has been prescribed bed rest for a prolonged period of time. There is a possibility that the patient may have developed phlebitis. The nurse assess for the presence of this condition by:
    a.       palpating the ankles for pitting edema
    b.      checking the popliteal pulses bilaterally
    c.       inspecting the thighs for clusters of ecchymosis
    d.      checking the appearance and circumference of the lower legs
  56. When teaching a 45-year-old patient in the gynecologist's office about breast cancer, a nurse includes information on recommendations for screening. The patient is informed that a woman her age should have:
    a.       annual mammograms
    b.      biannual CT scans
    c.       physical examinations every 3 years
    d.      breast self-examinations every 3 months
  57. A patient has been experiencing some lightheadedness and loss of balance over the past few weeks. A nurse wants to check the patient's balance while waiting for the patient to over other laboratory tests. The nurse administers the:
    a.       Allen test
    b.      Rinne test
    c.       Weber test
    d.      Romberg test
  58. Screenings are being conducted at the junior high school for scoliosis. A nurse is observing the students for the presence of:
    a.       an S-shaped curvature of the spine
    b.      an exaggerated curvature of the thoracic spine
    c.       an exaggerated curvature of the lumbar spine
    d.      a bulging of the cervical vertebrae and disks
  59. While reviewing a medical record, a nurse notes that a patient has suspected pancreatitis. The nurse assess the patient for:
    a.       positive rebound tenderness
    b.      midline abdominal pulsations
    c.       hyperactive bowel sounds in all quadrants
    d.      bulging of the flanks with dependent distension
  60. An 80-year-old woman is being assessed by a nurse in an extended care facility. The nurse is assessing the genitalia of this patient and suspects that there may be malignancy present. The nurse's suspicion is due to the found of :
    a.       scaly, nodular lesions
    b.      yellow exudates and redness
    c.       small ulcers with serous drainage
    d.      extreme pallor and edema
  61. A screening for osteoporosis is being conducted at an annual health fair. To determine the risk factors for osteoporosis, a nurse is assessing individuals for:
    a.       multiparity
    b.      a heavier than recommended body frame
    c.       an African American background
    d.      a history of dieting and/or alcohol abuse
  62. A patient in rehabilitation facility has experienced a cerebrovascular accident (CVA/stroke) that has left the patient with an expressive aphasia. The nurse anticipates that this patient will:
    a.       be unable to speak or write
    b.      be unable to follow directions
    c.       respond inappropriately to questions
    d.      have difficulty interpreting words and phases
  63. A peripheral pulse that is easily palpable and normal in tension is documented as:
    a.       1+
    b.      2+
    c.       3+
    d.      4+
  64. To assess a patient's visual fields, a nurse should:
    a.       ask the patient to read text
    b.      turn the room light on and off
    c.       move a finger at arm's length toward the patient from an angle
    d.      shine a penlight into the patient's eye at an oblique angle
  65. A nurse exerts downward pressure on the thigh. This assessment is determining the muscle strength of the:
    a.       triceps
    b.      trapezius
    c.       quadriceps
    d.      gastrocnemius
  66. Light palpation involves depressing the part being examined:
    a.       1/2 inch
    b.      1 inch
    c.       1 1/2 inch
    d.      2 inches
  67. A nurse teaches the male patient that he should notify a health care provider if he finds the following during a testicular self-examination:
    a.       small pea-sized lumps on the front of the testicle
    b.      cordlike structures on the top of the testicles
    c.       loose, deeper color scrotal skin with a coarse surface
    d.      smegma under the foreskin
  68. A nurse manager observes a new nurse on the unit performing a patient assessment. The new nurse's assessment should be interrupted if the manager observes the nurse:
    a.       using the pads of the first three fingers to palpate the breast tissue
    b.      auscultating the abdomen continuously for 5 minutes
    c.       palpating both carotid arteries simultaneously
    d.      testing sensory function on random locations with the patient's eyes closed
  69. A nurse assesses a patient's skin and documents that vesicles are present. This observation is based on the nurse finding:
    a.       flat, nonpalpable changes in skin color
    b.      palpable, solid elevations smaller than 1 cm
    c.       irregularly shaped, elevated areas that vary in size
    d.      circumscribed elevations of skin filled with serous fluid
  70. A nurse is assessing a patient's level of consciousness using the Glasgow Coma Scale. The following findings are documented: Eyes open to speech, responses are oriented, localized pain is noted. The score for this patient is:
    a.       15
    b.      13
    c.       11
    d.      9