NURS 325 Exam 1 Fundamentals, question Answers, Verified Answers

NURS 325 Exam 1 Fundamentals, question Answers, Verified Answers NURS 325 Exam 1-Fundamentals, Exam 1-Fundamentals • Question 1 A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient? d. Upon admission a. When the primary care provider writes the order b. After the congestion is treated c. Right before discharge d. Upon admission Ideally, discharge planning begins at admission. Right before discharge is too late for discharge planning. After the congestion is treated is also too late for discharge planning. Usually the primary care provider writes the order too close to discharge, and nurses do not need an order to begin the teaching that will be needed for discharge. By identifying discharge needs early, nursing and other health care professionals begin planning for discharge to the appropriate level of care, which sometimes includes support services such as home care and equipment needs. • Question 2 The nurse is assessing skin turgor. Which technique will the nurse use? a. Grasp a fold of skin on the back of the hand. b. Press lightly on the fingertips. c. Press lightly on the forearm. d. Grasp a fold of skin on the sternal area. • Question 3 During a routine pediatric history and physical, the parents report that their child was a very small, premature infant that had to stay in the neonatal intensive care unit longer than usual. They state that the infant was yellow when born and developed an infection that required “every antibiotic under the sun” to reach a cure. Which exam is a priority for the nurse to conduct on the child? a. Cardiac b. Respiratory c. Hearing acuity d. Ophthalmic • Question 4 The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with Clostridium difficile in droplet precautions b. A patient with a lung transplant in protective environment precautions c. A patient with tuberculosis in airborne precautions d. A patient with MRSA infection in contact precautions • Question 5 Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage? a. Assess for pain during a bath. a. Assess for pain during a bath. b. Insert an indwelling urinary catheter. c. Turn the patient every 2 hours. d. Limit caloric and protein intake. • Question 6 Which nursing action will most likely increase a patient’s risk for developing a health care–associated infection? a. Uses a sterile bottled solution more than once within a 24-hour period b. Uses a cleaning stroke from the urinary meatus toward the rectum c. Uses a clean technique for inserting a urinary catheter d. Uses surgical aseptic technique to suction an airway • Question 7 A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to follow up? a. The new nurse ends each entry with signature and title. b. The new nurse charts consecutively on every other line. c. The new nurse keeps the password secure. d. The new nurse documents only for self. • Question 8 The patient is being admitted to the emergency department following a motor vehicle accident. The patient’s jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature reading? a. Temporal b. Axillary c. Tympanic d. Oral • Question 9 Which interventions utilized by the nurse will indicate the ability to recognize a localized inflammatory response? a. Vigorous range-of-motion exercises b. Rest, ice, and elevation c. Turn, cough, and deep breathe d. Orient to date, time, and place • Question 10 The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for developing an infection? a. A patient who is recovering from a right total hip surgery b. A patient who has been admitted with dehydration c. A patient who is in observation for chest pain d. A patient who has been admitted for stabilization of heart problems • Question 11 A patient is being discharged home. Which information should the nurse include? a. Community resources b. Acuity level c. Standardized care plan d. Signature for verbal order • Question 12 A patient is pyrexic. Which piece of equipment will the nurse obtain to monitor this condition? a. Blood pressure cuff b. Stethoscope c. Thermometer d. Sphygmomanometer • Question 13 The patient has had a stroke that has affected the ability to speak. The patient becomes extremely frustrated when trying to speak. The patient responds correctly to questions and instructions but cannot form words coherently. Which type of aphasia is the patient experiencing? a. Expressive b. Combination c. Receptive d. Sensory • Question 14 A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area. A nurse is taking a health history. Which question is the priority? a. “Has this condition affected your eating habits in any way?” b. “Are you able to sleep at night?” c. “When was the last time you visited your primary health care provider?” d. “What medications are you currently taking?” • Question 15 A nurse exchanges information with the oncoming nurse about a patient’s care. Which action did the nurse complete? a. An acuity rating b. A referral c. An electronic record entry d. A verbal report • Question 16 After providing care, a nurse charts in the patient’s record. Which entry will the nurse document? a. Drank adequate amounts of water b. Skin pale and cool c. Apparently is asleep with eyes closed d. Appears restless when sitting in the chair • Question 17 A nurse is providing perineal care to a female patient. Which washing technique will the nurse use? a. In a circular motion b. Upward from rectum to pubic area c. From pubic area to rectum d. Back to front • Question 18 The nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency, with peripheral neuropathy and urinary incontinence. On which areas does the nurse focus care? a. Decreased caloric intake and accelerated wound healing b. High risk for impaired venous return and dementia c. High risk for skin infection and low saliva pH level d. Decreased pain sensation and increased risk of skin impairment • Question 19 The patient’s blood pressure is 140/60. Which value will the nurse record for the pulse pressure? a. 80 b. 200 c. 60 d. 140 • Question 20 A nurse is caring for a group of patients. Which patient will the nurse see first? a. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60 b. An 87-year-old male suspected of hypothermia whose temperature is below normal c. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74 d. A 17-year-old male who has just returned from outside “for a smoke” who needs a temperature taken • Question 21 A nurse is assessing a patient’s skin. Which patient is most at risk for impaired skin integrity? a. A patient who is diaphoretic b. A patient with strong pedal pulses c. A patient with adequate skin turgor d. A patient who is afebrile • Question 22 The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease? a. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only. b. Transport the patient safely and quickly when going to the radiology department. c. Wear a gown, gloves, face mask, and goggles for interactions with the patient. d. Place the patient in a room with negative airflow. • Question 23 A nurse is preparing to document a patient who has chest pain. Which information is critical for the nurse to include? a. Sharp pain of 8 on a scale of 1 to 10 b. Had poor results from the pain medication c. The family is a “pain.” d. Pupils equal and reactive to light • Question 24 The nurse is caring for an adult patient in the clinic who has been evacuated and is a victim of flooding. The nurse teaches the patient about rest, exercise, and eating properly and how to utilize deep breathing and visualization. What is the primary rationale for the nurse’s actions related to the teaching? a. Topics taught are standard information taught during health care visits. b. The patient requested this information to teach the extended family members. c. Stress for long periods of time can lead to exhaustion and decreased resistance to infection. d. These techniques will help the patient manage the pain and loss of personal belongings. • Question 25 An older-adult patient is taking aminoglycoside for a severe infection. Which assessment is the priority? a. Ears b. Skin c. Reflexes d. Eyes • Question 26 The nurse is caring for an infant and is obtaining the patient’s vital signs. Which artery will the nurse use to best obtain the infant’s pulse? a. Radial b. Femoral c. Brachial d. Popliteal • Question 27 A patient presents with pneumonia. Which priority intervention should be included in the plan of care for this patient? a. Provide the patient ice chips as requested. b. Assume the patient is in pain and treat accordingly. c. Observe the patient for decreased activity tolerance. d. Maintain the room temperature at 65 F. • Question 28 A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene? a. The student nurse reads the patient’s plan of care. b. The student nurse shares patient information with a friend. c. The student nurse documents medication administered to the patient. d. The student nurse reviews the patient’s medical record. • Question 29 A nurse is caring for a group of patients. Which patient will the nurse see first? a. A young adult with an S3 heart sound b. A young adult with bronchovesicular breath sounds between the scapula posteriorly c. An adult with vesicular lung sounds in the lung periphery d. An adult with an S4 heart sound • Question 30 A nurse is charting. Which information is critical for the nurse to document? a. The family is poor and had to go on welfare. b. The family is demanding and argumentative. c. The patient had a good day with no complaints. d. The patient received a pain medication, Lortab. • Question 31 The female nurse is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient? a. Should be done by the patient b. Should be postponed because it may cause embarrassment c. Should be unnecessary because the patient is uncircumcised d. Should be done by the nurse • Question 32 Which instruction will the nurse provide to the nursing assistive personnel when providing foot care for a patient with diabetes? a. Report sores on the patient’s toes. b. Do not place slippers on the patient’s feet. c. Trim the patient’s toenails daily. d. Check the brachial artery. • Question 33 The nurse is caring for a patient in the hospital. The nurse observes the nursing assistive personnel (NAP) turning off the handle faucet with bare hands. Which professional practice principle supports the need for follow-up with the NAP? a. Allowing the water to run is a waste of resources and money. b. Different scopes of practice allow modification of procedures. c. This is a key step in the procedure for washing hands. d. The nurse is responsible for providing a safe environment for the patient. • Question 34 The nursing assistive personnel (NAP) is taking vital signs and reports that a patient’s blood pressure is abnormally low. What should the nurse do next? a. Instruct the NAP to assess the patient’s other vital signs. b. Ask the NAP retake the blood pressure. c. Disregard the report and have it rechecked at the next scheduled time. d. Retake the blood pressure personally and assess the patient’s condition. • Question 35 Which entry will require follow-up by the nurse manager? 0800 Patient states, “Fell out of bed.” Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, “Did not pass out.” Assisted back to bed. Call bell within reach. Bed monitor on. -------------------Jane More, RN 0810 Notified primary care provider of patient’s status. New orders received. -------------------Jane More, RN 0815 Portable x-ray of L hip taken in room. States, “I feel fine.” -------------------Jane More, RN 0830 Incident report completed and placed on chart. -------------------Jane More, RN a. 0800 b. 0830 c. 0810 d. 0815 • Question 36 The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). The patient’s last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). Which action will the nurse take? a. Be aware that temperatures this high are harmful and affect patient safety. b. Wait 30 minutes and recheck the patient’s temperature. c. Assume that the patient has an infection and order blood cultures. d. Encourage the patient to move around to increase muscular activity. • Question 37 A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement? a. Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order. b. Breathing without difficulty. Sitting up in bed watching TV. Had a good day. c. Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, “felt better.” Finally, patient had no complaints. d. Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours. • Question 38 The nurse is caring for a patient who is immobile. The nurse frequently checks the patient for impaired skin integrity. What is the rationale for the nurse’s action? a. Verbalization of skin care needs is decreased. b. Patients with limited caloric intake develop thicker skin. c. Inadequate blood flow leads to decreased tissue ischemia. d. Pressure reduces circulation to affected tissue. • Question 39 The nurse considers several new female patients to receive additional teaching on the need for more frequent Pap test and gynecological examinations. Which assessment findings reveal the patient at highest risk for cervical cancer and having the greatest need for patient education? a. 15 years old, social smoker, celibate b. 22 years old, smokes 1 pack of cigarettes per day, has multiple sexual partners c. 50 years old, stopped smoking 30 years ago, has history of multiple pregnancies d. 13 years old, nonsmoker, not sexually active • Question 40 The nurse is teaching the patient about flossing and oral hygiene. Which instruction will the nurse include in the teaching session? a. Applying toothpaste to the teeth before flossing is harmful. b. Flossing removes plaque and tartar from the teeth. c. Using waxed floss prevents bleeding. d. Performing flossing at least 3 times a day is beneficial. • Question 41 The health care provider prescription reads “Metoprolol (Lopressor) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic.” The patient’s blood pressure is 92/66. The nurse does not give the medication. Which action should the nurse take? a. Does not inform the health care provider that the medication was held b. Documents only what the blood pressure was. c. Does not tell the patient what the blood pressure is d. Documents that the medication was not given because of low blood pressure • Question 42 After performing foot care, the nurse checks the medical record and discovers that the patient has a foot disorder caused by a virus. Which condition did the nurse most likely observe? a. Plantar warts b. A callus c. Corns d. Athlete’s foot • Question 43 A patient in the emergency department is reporting left lower abdominal pain. Which proper order will the nurse follow to perform the comprehensive abdominal examination? a. Inspection, palpation, auscultation b. Percussion, palpation, auscultation c. Percussion, auscultation, palpation d. Inspection, auscultation, palpation • Question 44 When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding? a. 68 b. 76 c. 138/70 d. 138/62 • Question 45 The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an intravenous (IV) infusion. Which step(s) will the nurse take next? a. Delay washing of the site until the nurse is finished providing care to the patient. b. Do nothing; accidentally getting splashed with blood happens frequently and is part of the job. c. Immediately wash the site with soap and running water, and seek guidance from the manager. d. Obtain an alcohol swab, remove the blood with an alcohol swab, and continue care. • Question 46 The nurse is caring for a patient who has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment? a. Assess surfaces exposed to the edges of the cast for pressure areas. b. Keep the patient’s blood pressure low to prevent overperfusion of tissue. c. Do not allow turning in bed because that may lead to redislocation of the leg. d. Restrict the patient’s dietary intake to reduce the number of times on the bedpan. • Question 47 The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient’s symptoms? a. Red blood cell count of 5.0 million/mm3 b. Hematocrit level of 45% c. Pulse oximetry of 95% d. Hemoglobin level of 8.0 g/100 mL Response Feedback: The concentration of hemoglobin reflects the patient’s capacity to carry oxygen, which if low can lead to shortness of breath and chest discomfort. Normal hemoglobin levels range from 14 to 18 g/100 mL in males and from 12 to 16 g/100 mL in females. Hemoglobin of 8.0 is low and indicates a decreased ability to deliver oxygen to meet bodily needs. All other values in the selection are considered normal. • Question 48 A nurse is providing care to a group of patients. Which situation will require the nurse to obtain a telephone order? c. At 0100, a patient’s blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood. a. At 0800, the nurse and health care provider make rounds, and the primary care provider tells the nurse a diet order. b. As the nurse and health care provider leave a patient’s room, the primary care provider gives the nurse an order. c. At 0100, a patient’s blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood. d. A nurse reads an order correctly as written by the health care provider in the patient’s medical record. • Question 49 The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says “I always bathe in the evening.” Which action by the nurse is best? a. Cancel hygiene for the day and attempt again in the morning. b. Explain the importance of maintaining morning hygiene practices. c. Tell the patient that daily morning baths are the “normal” routine. d. Defer the bath until evening and pass on the information to the next shift. • Question 50 The nurse is caring for a patient with cognitive impairments. Which actions will the nurse take during AM care? (Select all that apply.) a. Administer ordered analgesic 1 hour before bath time. b. Increase the frequency of skin assessment. c. Reduce triggers in the environment. d. Be as quick as possible. e. Keep the room temperature cool. • Question 51 The nurse is assessing the patient and family for probable familial causes of the patient’s hypertension. The nurse begins by analyzing the patient’s personal history, as well as family history and current lifestyle situation. Which findings will the nurse consider to be risk factors? (Select all that apply.) a. Recent weight loss b. Heavy alcohol intake c. Regular exercise sessions d. Obesity e. Cigarette smoking • Question 52 A nurse is describing the purposes of a health care record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all that apply.) a. Nursing process b. Education c. Research d. Communication e. Legal documentation f. Reimbursement • Question 53 Interpret these drug orders. Procrit 40,000 units, SC, weekly _____________________________________________ Case Sensitivity • Question 54 What are the 6 of the 10 rights of medication administration? _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ Correct Answer: Evaluation Method Case Sensitivity Exact Match Exact Match Exact Match Exact Match Exact Match • Question 55 Interpret these drug orders. Prednisone 10 mg, po, tid x 5 days ___________________________________________ Correct Answer: Evaluation Method Case Sensitivity Exact Match • Question 56 List what is missing in the following drug order. Codeine 30 mg, po, PRN for pain ___________________________________________ Evaluation Method Correct Answer Case Sensitivity • Question 57 List what is missing in the following drug orders. TheoDur 200 mg _______________________________________________________ Correct Answer: Evaluation Method Correct Answer Case Sensitivity • Question 58 A nurse is assessing a group of patients. Match the assessment finding the nurse observed to its condition. o Question Correct Match Selected Match Melena Lordosis g. Swayback Venous problems d. Lower extremity swollen and warm with normal pulse Arterial problems a. Lower extremity pale and cool with decreased pulse Koilonychia f. Spoon nails Jugular vein distention e. Neck vein visible when sitting Tinnitus c. Ringing in ears o o • Question 59 Add 8-hour intake: IV: 30 mL/hr, 230 mL in IV medications. PO intake: juice 4 oz, tea 6 oz, water 3 oz, gelatin 4 oz, ginger ale 5 oz, and milk 8 oz. What was the patient’s intake, in mL, (IV and PO) in 8 hours? • Question 60 Convert traditional times to military time. 1. 9:30 am _____________ 2. 10:05 pm _____________ 3. 4:55 pm _____________ Response Feedback: [None Given] • Question 61 Patient intake for lunch included a carton of milk (8 oz), cup of coffee (6 oz), small glass of apple juice (4 oz), and gelatin (4 oz). How many milliliters (mL) did the patient consume for lunch? • Question 62 Order: sulfisoxazole (Gantrisin) 1 g. Drug available: sulfisoxazole (Gantrisin) 250 mg per tablet. How many tablet(s) would you give? _____________________ • Question 63 Add 8-hour intake: IV: 60 mL/hr; 250 mL in IV medications. PO intake: juice 4 oz; water 3 oz; gelatin 2 oz; and broth 4 oz. What was the patient’s intake, in mL, (IV and PO) in 8 hours?