NS 660 Exam 1 Review Questions with
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correct detailed answers
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A |nurse |administers |an |antihypertensive |medication |to |a |patient |at |the |scheduled |time |of |
0900. |The |nursing |assistive |personnel |(NAP) |then |reports |to |the |nurse |that |the |patient's |blood
|pressure |was |low |when |it |was |taken |at |0830. |The |NAP |states |they |were |busy |and |did |not |
have |a |chance |to |tell |the |nurse |yet. |The |patient |begins |to |complain |of |feeling |dizzy |and |light-
headed. |The |blood |pressure |is |rechecked |and |it |has |dropped |even |lower. |In |which |phase |of |
the |nursing |process |did |the |nurse |first |make |an |error?
Diagnosis
Evaluation
Implementation
Assessment |- |correct |answersAssessment
A |charge |nurse |is |observing |a |newly |licensed |nurse |care |for |a |client |who |reports |pain. |The |
nurse |checked |the |client's |MAR |and |noted |the |last |dose |of |pain |medication |was |6 |hr |ago. |The |
prescription |reads |every |4 |hr |PRN |for |pain. |The |nurse |administered |the |medication |and |
checked |with |the |client |40 |min |later, |when |the |client |reported |improvement. |The |newly |
licensed |nurse |left |out |which |of |the |following |steps |of |the |nursing |process?
Intervention
Evaluation
,Planning
Assessment |- |correct |answersAssessment
A |nursing |assessment |for |a |patient |with |a |spinal |cord |injury |leads |to |several |pertinent |nursing |
diagnoses. |Which |nursing |diagnosis |is |the |highest |priority |for |this |patient?
Risk |for |impaired |skin |integrity
Risk |for |infection
Spiritual |distress
Reflex |urinary |incontinence |- |correct |answersReflex |urinary |incontinence
While |completing |an |admission |database, |the |nurse |is |interviewing |a |patient |who |states |"I |am
|allergic |to |latex." |Which |action |will |the |nurse |take |first?
Immediately |place |patient |in |isolation
Ask |the |patient |to |describe |the |type |of |reaction
Document |latex |allergy |on |medication |administration |record
Process |to |the |termination |phase |of |interview |- |correct |answersAsk |the |patient |to |describe |
type |of |reaction
,A |nurse |is |planning |care |for |a |client |who |is |postoperative. |Which |of |the |following |statements |
about |pain |management |should |the |nurse |consider |when |implementing |client |care? |(Select |all
|that |apply.)
All |clients |will |express |the |feeling |of |pain |both |verbally |and |nonverbally.
Patient-controlled |analgesia |(PCA) |offers |a |constant |level |of |opioids |within |therapeutic |range.
Use |of |analgesics |will |eventually |lead |to |addiction.
Pain |level |and |pain |tolerance |can |be |assessed |using |a |scale |from |0 |to |10.
Each |client's |expression |of |pain |may |be |different |and |individualized. |- |correct |answersPatient-
controlled |analgesia |(PCA) |offers |a |constant |level |of |opioids |within |therapeutic |range.
Pain |level |and |pain |tolerance |can |be |assessed |using |a |scale |from |0 |to |10.
Each |client's |expression |of |pain |may |be |different |and |individualized.
The |nurse |is |caring |for |an |African |American |patient |with |COPD. |The |nurse |knows |that |the |best
|location |to |assess |for |hypoxia |is |the:
Lower |extremities
Abdomen
Earlobes
, Oral |mucosa |- |correct |answersOral |mucosa
What |is |the |most |appropriate |way |to |assess |the |pain |of |a |patient |who |is |oriented |and |has |
recently |had |surgery?
Observe |cardiac |monitor |for |increased |HR
Ask |patient |describe |the |effect |of |pain |on |ability |to |cope
Ask |patient |to |rate |level |of |pain
Assess |patients |body |language |- |correct |answersAsk |patient |to |rate |level |of |pain
An |assistive |personnel |reports |a |client's |vital |signs |as |tympanic |temperature |37.1° |C |(98.8° |F), |
pulse |92/min, |respiratory |rate |18/min, |and |BP |98/58 |mm |Hg. |Which |of |the |following |vital |
signs |should |the |nurse |re-measure?
BP
Temp
Pulse |Rate
Respiratory |Rate |- |correct |answersBP
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correct detailed answers
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A |nurse |administers |an |antihypertensive |medication |to |a |patient |at |the |scheduled |time |of |
0900. |The |nursing |assistive |personnel |(NAP) |then |reports |to |the |nurse |that |the |patient's |blood
|pressure |was |low |when |it |was |taken |at |0830. |The |NAP |states |they |were |busy |and |did |not |
have |a |chance |to |tell |the |nurse |yet. |The |patient |begins |to |complain |of |feeling |dizzy |and |light-
headed. |The |blood |pressure |is |rechecked |and |it |has |dropped |even |lower. |In |which |phase |of |
the |nursing |process |did |the |nurse |first |make |an |error?
Diagnosis
Evaluation
Implementation
Assessment |- |correct |answersAssessment
A |charge |nurse |is |observing |a |newly |licensed |nurse |care |for |a |client |who |reports |pain. |The |
nurse |checked |the |client's |MAR |and |noted |the |last |dose |of |pain |medication |was |6 |hr |ago. |The |
prescription |reads |every |4 |hr |PRN |for |pain. |The |nurse |administered |the |medication |and |
checked |with |the |client |40 |min |later, |when |the |client |reported |improvement. |The |newly |
licensed |nurse |left |out |which |of |the |following |steps |of |the |nursing |process?
Intervention
Evaluation
,Planning
Assessment |- |correct |answersAssessment
A |nursing |assessment |for |a |patient |with |a |spinal |cord |injury |leads |to |several |pertinent |nursing |
diagnoses. |Which |nursing |diagnosis |is |the |highest |priority |for |this |patient?
Risk |for |impaired |skin |integrity
Risk |for |infection
Spiritual |distress
Reflex |urinary |incontinence |- |correct |answersReflex |urinary |incontinence
While |completing |an |admission |database, |the |nurse |is |interviewing |a |patient |who |states |"I |am
|allergic |to |latex." |Which |action |will |the |nurse |take |first?
Immediately |place |patient |in |isolation
Ask |the |patient |to |describe |the |type |of |reaction
Document |latex |allergy |on |medication |administration |record
Process |to |the |termination |phase |of |interview |- |correct |answersAsk |the |patient |to |describe |
type |of |reaction
,A |nurse |is |planning |care |for |a |client |who |is |postoperative. |Which |of |the |following |statements |
about |pain |management |should |the |nurse |consider |when |implementing |client |care? |(Select |all
|that |apply.)
All |clients |will |express |the |feeling |of |pain |both |verbally |and |nonverbally.
Patient-controlled |analgesia |(PCA) |offers |a |constant |level |of |opioids |within |therapeutic |range.
Use |of |analgesics |will |eventually |lead |to |addiction.
Pain |level |and |pain |tolerance |can |be |assessed |using |a |scale |from |0 |to |10.
Each |client's |expression |of |pain |may |be |different |and |individualized. |- |correct |answersPatient-
controlled |analgesia |(PCA) |offers |a |constant |level |of |opioids |within |therapeutic |range.
Pain |level |and |pain |tolerance |can |be |assessed |using |a |scale |from |0 |to |10.
Each |client's |expression |of |pain |may |be |different |and |individualized.
The |nurse |is |caring |for |an |African |American |patient |with |COPD. |The |nurse |knows |that |the |best
|location |to |assess |for |hypoxia |is |the:
Lower |extremities
Abdomen
Earlobes
, Oral |mucosa |- |correct |answersOral |mucosa
What |is |the |most |appropriate |way |to |assess |the |pain |of |a |patient |who |is |oriented |and |has |
recently |had |surgery?
Observe |cardiac |monitor |for |increased |HR
Ask |patient |describe |the |effect |of |pain |on |ability |to |cope
Ask |patient |to |rate |level |of |pain
Assess |patients |body |language |- |correct |answersAsk |patient |to |rate |level |of |pain
An |assistive |personnel |reports |a |client's |vital |signs |as |tympanic |temperature |37.1° |C |(98.8° |F), |
pulse |92/min, |respiratory |rate |18/min, |and |BP |98/58 |mm |Hg. |Which |of |the |following |vital |
signs |should |the |nurse |re-measure?
BP
Temp
Pulse |Rate
Respiratory |Rate |- |correct |answersBP
