NUR 210 EXAM 1 PREP QUESTIONS
WITH COMPLETE ANSWERS
A nurse will be performing a complete physical examination of a man who has
emphysema with a chronic productive cough, including an assessment of his oral
cavity. Which pieces of personal protective equipment should the nurse wear?
Gloves, gown
Mask, protective eye goggles, gown
Mask, protective eye goggles
Gloves, mask, protective eye goggles, gown - Answer-Gloves, mask, protective eye
goggles, gown
While percussing an adult client during a physical examination, the nurse can expect
to hear flatness over the client's
bone.
lungs.
abdomen.
liver. - Answer-bone.
The nurse is about to leave the floor for her lunch break. Before leaving she must
report using the SBAR model to the nurse who is to care for the patient during her
absence. She tells the nurse, "The patient was admitted 8 hours ago after spending
the night in the ER with abdominal and back pain. He has had numerous tests;
results indicate that he has gallstones. He is scheduled for surgery tomorrow." What
part of the SBAR model does this information represent?
Recommendation
Situation
Background
Assessment - Answer-Background
Explanation:
The model known as SBAR is for improving communication between and among
clinicians. The S stands for situation--why the nurse is communicating; B stands for
background--the circumstances leading up to current situation; A is for
assessement--objective and subjective data pertinent to the situation; and R is for
recommendation--the nurse's suggestions of what needs to be done to manage the
problem. In this case, the nurse gave background information when reporting.
A nurse is caring for a patient who has been admitted to the medical-surgical unit.
After the original admission assessment is done and charted, the nurse documents
only abnormalities found on subsequent assessments. This type of charting is called:
pie charting
narrative charting
batch charting
charting by exception - Answer-charting by exception
A nursing student is working a 7 a.m. to 3 p.m. shift with a preceptor and is caring for
three patients independently. When the preceptor asks if the student has completed
charting all her assessments, the student informs the preceptor that she is going to
, do batch charting. The preceptor informs the student of which of the following about
batch charting?
It helps you remember important information.
It is a useful tool for prioritizing when busy.
It is fine unless you chart on the wrong patient.
It contributes to many potential errors. - Answer-It contributes to many potential
errors.
Explanation:
Batch charting, which is waiting until the end of a shift or until all patients have been
assessed to document, is not recommended. It contributes to many potential errors.
Waiting to chart may also contribute to forgetting important information or charting
assessment data on the wrong patient.
Reference:
A nurse who has been working at the health clinic for 20 years has just taken a
client's blood pressure and found it to be 110/70. When consulting the client's record,
the nurse sees that he has had persistent hypertension for the past 5 years and has
been on antihypertensive medication the whole time. His blood pressure has never
been below 150/90 and was 180/95 at his last visit, 1 year ago. The patient's weight
has remained the same. The nurse realizes that the data need to be validated.
Which method of validation would be most appropriate in this case?
Asking the physician to come in and take the client's blood pressure
Asking the client whether his exercise habits have changed recently
Repeating the measurement with a different sphygmomanometer and stethoscope
Asking the client whether his diet has changed in the past year - Answer-Repeating
the measurement with a different sphygmomanometer and stethoscope
Explanation:
The most appropriate method of validation in this case would be to simply retake the
client's blood pressure with a different sphygmomanometer and stethoscope. Given
the nurse's work experience, it is unlikely that the discrepancy is due to improper
technique, thus having the physician take the client's blood pressure is not
warranted. Given the client's long history of hypertension and that his weight has not
changed, it seems unlikely that the discrepancy could be explained by improved diet
or exercise.
A nurse is working in a health care facility that uses charting by exception. Which of
the following would the nurse expect to document?
Bowel sounds normoactive
Liver palpation normal
No tenderness on palpation
Decreased range of motion in right shoulder - Answer-Decreased range of motion in
right shoulder
A nurse is preparing to assess an adult client's body temperature. At which time of
the day would the nurse expect to obtain the lowest body temperature?
Early morning
Early afternoon
Late evening
Late afternoon - Answer-Early morning
Explanation:
WITH COMPLETE ANSWERS
A nurse will be performing a complete physical examination of a man who has
emphysema with a chronic productive cough, including an assessment of his oral
cavity. Which pieces of personal protective equipment should the nurse wear?
Gloves, gown
Mask, protective eye goggles, gown
Mask, protective eye goggles
Gloves, mask, protective eye goggles, gown - Answer-Gloves, mask, protective eye
goggles, gown
While percussing an adult client during a physical examination, the nurse can expect
to hear flatness over the client's
bone.
lungs.
abdomen.
liver. - Answer-bone.
The nurse is about to leave the floor for her lunch break. Before leaving she must
report using the SBAR model to the nurse who is to care for the patient during her
absence. She tells the nurse, "The patient was admitted 8 hours ago after spending
the night in the ER with abdominal and back pain. He has had numerous tests;
results indicate that he has gallstones. He is scheduled for surgery tomorrow." What
part of the SBAR model does this information represent?
Recommendation
Situation
Background
Assessment - Answer-Background
Explanation:
The model known as SBAR is for improving communication between and among
clinicians. The S stands for situation--why the nurse is communicating; B stands for
background--the circumstances leading up to current situation; A is for
assessement--objective and subjective data pertinent to the situation; and R is for
recommendation--the nurse's suggestions of what needs to be done to manage the
problem. In this case, the nurse gave background information when reporting.
A nurse is caring for a patient who has been admitted to the medical-surgical unit.
After the original admission assessment is done and charted, the nurse documents
only abnormalities found on subsequent assessments. This type of charting is called:
pie charting
narrative charting
batch charting
charting by exception - Answer-charting by exception
A nursing student is working a 7 a.m. to 3 p.m. shift with a preceptor and is caring for
three patients independently. When the preceptor asks if the student has completed
charting all her assessments, the student informs the preceptor that she is going to
, do batch charting. The preceptor informs the student of which of the following about
batch charting?
It helps you remember important information.
It is a useful tool for prioritizing when busy.
It is fine unless you chart on the wrong patient.
It contributes to many potential errors. - Answer-It contributes to many potential
errors.
Explanation:
Batch charting, which is waiting until the end of a shift or until all patients have been
assessed to document, is not recommended. It contributes to many potential errors.
Waiting to chart may also contribute to forgetting important information or charting
assessment data on the wrong patient.
Reference:
A nurse who has been working at the health clinic for 20 years has just taken a
client's blood pressure and found it to be 110/70. When consulting the client's record,
the nurse sees that he has had persistent hypertension for the past 5 years and has
been on antihypertensive medication the whole time. His blood pressure has never
been below 150/90 and was 180/95 at his last visit, 1 year ago. The patient's weight
has remained the same. The nurse realizes that the data need to be validated.
Which method of validation would be most appropriate in this case?
Asking the physician to come in and take the client's blood pressure
Asking the client whether his exercise habits have changed recently
Repeating the measurement with a different sphygmomanometer and stethoscope
Asking the client whether his diet has changed in the past year - Answer-Repeating
the measurement with a different sphygmomanometer and stethoscope
Explanation:
The most appropriate method of validation in this case would be to simply retake the
client's blood pressure with a different sphygmomanometer and stethoscope. Given
the nurse's work experience, it is unlikely that the discrepancy is due to improper
technique, thus having the physician take the client's blood pressure is not
warranted. Given the client's long history of hypertension and that his weight has not
changed, it seems unlikely that the discrepancy could be explained by improved diet
or exercise.
A nurse is working in a health care facility that uses charting by exception. Which of
the following would the nurse expect to document?
Bowel sounds normoactive
Liver palpation normal
No tenderness on palpation
Decreased range of motion in right shoulder - Answer-Decreased range of motion in
right shoulder
A nurse is preparing to assess an adult client's body temperature. At which time of
the day would the nurse expect to obtain the lowest body temperature?
Early morning
Early afternoon
Late evening
Late afternoon - Answer-Early morning
Explanation:
