NP1 EXAM 4
1. The nurse is caring for a patient who is unable to take oral medications because of
persistent nausea and vomiting. When the nurse decides to call the primary care physician and
ask for a different medication administrationroute, this is a demonstration of what act?
a. Collaboration
b. Delegation
c. Assertiveness
d. Advocacy: D
2. The nurse is assisting a co-worker who is preparing to change a deep wound dressing on
a patient's abdomen. Several of the patient's out-of-townfriends are at the bedside watching a
football game. Which action is most appropriate for the nurse to consider prior to the dressing
change?
a. Ask the friends to leave the room.
b. Pull the curtain around the bed.
c. Allow visitors to stay in the room during the procedure.
d. Ask the patient to turn up the volume on the television.: A
3. The nurse is conducting a presurgical screening interview with a patientat a local surgical
center. When performing a health assessment, the nurse identifies which source should be the
primary source of information?
a. Spouse
b. Medical record
c. Close relative
d. Patient: D
4. A mother of a young child kicks a trashcan in anger and says to the nurse, "You just don't
understand! Why can't the doctor find out what is wrong with my child?" The nurse understands
that this behavior is most likely an exampleof which defense mechanism?
a. Suppression
b. Sublimation
c. Displacement
d. Rationalization: C
5. The nurse is caring for a patient scheduled for a partial mastectomy resulting from
advanced cancer.The patient tells the nurse, "I'm sure when thesurgeon operates on me, he will
not find any cancer in my breast. It looks justfine." The nurse recognizes that the patient is using
which defense mechanismto cope with the medical diagnosis?
a. Suppression
b. Sublimation
c. Displacement
,d. Denial: D
6. The nurse understands that the nurse-patient relationship focuses onwhich areas? (Select
all that apply.)
a. Building trust
b. Demonstrating sympathy
c. Tearing down boundaries
d. Developing a plan of care
e. Applying cultural generalities: A, C, D
7. When administering a bath to a hearing-impaired patient, what actionsshould the nurse
carry out? (Select all that apply.)
a. Speak very loudly into the patient's right ear.
b. Control background noise as much as possible.
c. Turn away when responding to a question.
d. Adjust the lighting in the room.
e. Be wary of consistent affirmative answers.: B, D, E
8. The nursing student is writing a report on the use of nonverbal techniques to encourage
therapeutic communication. Which examples would be included in the report? (Select all that
apply.)
a. Providing a backrub
b. Remaining silent
c. Refraining from distracting body movements
d. Facing the patient
e. Avoiding eye contact: A, B, C, D
9. F& E: Is now
10. The nurse will be caring for a patient who is severely malnourished. Labo- ratory test
results show that the patient's albumin level is critically low. What assessment finding will the
nurse expect to note when assessing the patient?
a. The patient has generalized 3+ pitting edema.
b. The patient is confused and disoriented.
c. The patient's urine is dark and very concentrated.
d. The patient's lung sounds are much diminished.: A
11. The nurse is reviewing the patient's laboratory results. Which result mustbe
communicated to the physician immediately?
a. Serum chloride level 85 mEq/L
b. Serum sodium level 134 mEq/L
c. Serum potassium level 6.8 mEq/L
, d. Serum magnesium level 2.3 mEq/L: C
12. The nurse is caring for a patient who is at risk for fluid overload due to a history of
congestive heart failure. Which intervention will the nurse teach thepatient to perform at home
to monitor fluid balance?
a. "Check to make sure that your urine is a bright yellow color."
b. "Weigh yourself every morning before breakfast."
c. "Count your heart rate every evening before you go to bed."
d. "Drink plain water rather than soda, coffee, or fruit juice.": B
13. The nurse is caring for a patient who is admitted to the hospital with diabetic
ketoacidosis. Which assessment finding indicates an attempt madeby the patient's body to
correct the pH?
a. The patient's respirations are very deep and rapid.
b. The patient's urine is dark and concentrated.
c. The patient's skin is pale, cool, and diaphoretic.
d. The patient is sleepy and difficult to arouse.: A
14. The nurse is caring for a patient who takes furosemide (Lasix) daily to treat congestive heart
failure. The nurse will watch for which electrolyte imbalance that may occur due to this
therapy?
a. Hypocalcemia
b. Hypernatremia
c. Hypokalemia
d. Hyperphosphatemia: C
15. The nurse is caring for a patient who was brought to the ED after overdos- ing on narcotic
pain medication. The patient was found unresponsive with no respirations. Arterial blood gases
were drawn shortly after the patient's arrival to the hospital. Which results will the nurse expect
to see?
a. pH 7.56, PaCO2 32 mm Hg, HCO3 32 mEq/L, PaO2 90 mm Hg
b. pH 7.35, PaCO2 45 mm Hg, HCO3 26 mEq/L, PaO2 70 mm Hg
c. pH 7.45, PaCO2 38 mm Hg, HCO3 28 mEq/L, PaO2 80 mm Hg
d. pH 7.27, PaCO2 58 mm Hg, HCO3 24 mEq/L, PaO2 60 mm Hg: D
16. The nurse is caring for an adult patient with a recent below-the-knee am- putation.
During shift report, the nurse reports that the patient has urinated in the bed multiple times
since the surgery. The nurse knows which defensemechanism best describes this behavior?
a. Compensation
b. Denial
c. Rationalization
d. Regression: D
1. The nurse is caring for a patient who is unable to take oral medications because of
persistent nausea and vomiting. When the nurse decides to call the primary care physician and
ask for a different medication administrationroute, this is a demonstration of what act?
a. Collaboration
b. Delegation
c. Assertiveness
d. Advocacy: D
2. The nurse is assisting a co-worker who is preparing to change a deep wound dressing on
a patient's abdomen. Several of the patient's out-of-townfriends are at the bedside watching a
football game. Which action is most appropriate for the nurse to consider prior to the dressing
change?
a. Ask the friends to leave the room.
b. Pull the curtain around the bed.
c. Allow visitors to stay in the room during the procedure.
d. Ask the patient to turn up the volume on the television.: A
3. The nurse is conducting a presurgical screening interview with a patientat a local surgical
center. When performing a health assessment, the nurse identifies which source should be the
primary source of information?
a. Spouse
b. Medical record
c. Close relative
d. Patient: D
4. A mother of a young child kicks a trashcan in anger and says to the nurse, "You just don't
understand! Why can't the doctor find out what is wrong with my child?" The nurse understands
that this behavior is most likely an exampleof which defense mechanism?
a. Suppression
b. Sublimation
c. Displacement
d. Rationalization: C
5. The nurse is caring for a patient scheduled for a partial mastectomy resulting from
advanced cancer.The patient tells the nurse, "I'm sure when thesurgeon operates on me, he will
not find any cancer in my breast. It looks justfine." The nurse recognizes that the patient is using
which defense mechanismto cope with the medical diagnosis?
a. Suppression
b. Sublimation
c. Displacement
,d. Denial: D
6. The nurse understands that the nurse-patient relationship focuses onwhich areas? (Select
all that apply.)
a. Building trust
b. Demonstrating sympathy
c. Tearing down boundaries
d. Developing a plan of care
e. Applying cultural generalities: A, C, D
7. When administering a bath to a hearing-impaired patient, what actionsshould the nurse
carry out? (Select all that apply.)
a. Speak very loudly into the patient's right ear.
b. Control background noise as much as possible.
c. Turn away when responding to a question.
d. Adjust the lighting in the room.
e. Be wary of consistent affirmative answers.: B, D, E
8. The nursing student is writing a report on the use of nonverbal techniques to encourage
therapeutic communication. Which examples would be included in the report? (Select all that
apply.)
a. Providing a backrub
b. Remaining silent
c. Refraining from distracting body movements
d. Facing the patient
e. Avoiding eye contact: A, B, C, D
9. F& E: Is now
10. The nurse will be caring for a patient who is severely malnourished. Labo- ratory test
results show that the patient's albumin level is critically low. What assessment finding will the
nurse expect to note when assessing the patient?
a. The patient has generalized 3+ pitting edema.
b. The patient is confused and disoriented.
c. The patient's urine is dark and very concentrated.
d. The patient's lung sounds are much diminished.: A
11. The nurse is reviewing the patient's laboratory results. Which result mustbe
communicated to the physician immediately?
a. Serum chloride level 85 mEq/L
b. Serum sodium level 134 mEq/L
c. Serum potassium level 6.8 mEq/L
, d. Serum magnesium level 2.3 mEq/L: C
12. The nurse is caring for a patient who is at risk for fluid overload due to a history of
congestive heart failure. Which intervention will the nurse teach thepatient to perform at home
to monitor fluid balance?
a. "Check to make sure that your urine is a bright yellow color."
b. "Weigh yourself every morning before breakfast."
c. "Count your heart rate every evening before you go to bed."
d. "Drink plain water rather than soda, coffee, or fruit juice.": B
13. The nurse is caring for a patient who is admitted to the hospital with diabetic
ketoacidosis. Which assessment finding indicates an attempt madeby the patient's body to
correct the pH?
a. The patient's respirations are very deep and rapid.
b. The patient's urine is dark and concentrated.
c. The patient's skin is pale, cool, and diaphoretic.
d. The patient is sleepy and difficult to arouse.: A
14. The nurse is caring for a patient who takes furosemide (Lasix) daily to treat congestive heart
failure. The nurse will watch for which electrolyte imbalance that may occur due to this
therapy?
a. Hypocalcemia
b. Hypernatremia
c. Hypokalemia
d. Hyperphosphatemia: C
15. The nurse is caring for a patient who was brought to the ED after overdos- ing on narcotic
pain medication. The patient was found unresponsive with no respirations. Arterial blood gases
were drawn shortly after the patient's arrival to the hospital. Which results will the nurse expect
to see?
a. pH 7.56, PaCO2 32 mm Hg, HCO3 32 mEq/L, PaO2 90 mm Hg
b. pH 7.35, PaCO2 45 mm Hg, HCO3 26 mEq/L, PaO2 70 mm Hg
c. pH 7.45, PaCO2 38 mm Hg, HCO3 28 mEq/L, PaO2 80 mm Hg
d. pH 7.27, PaCO2 58 mm Hg, HCO3 24 mEq/L, PaO2 60 mm Hg: D
16. The nurse is caring for an adult patient with a recent below-the-knee am- putation.
During shift report, the nurse reports that the patient has urinated in the bed multiple times
since the surgery. The nurse knows which defensemechanism best describes this behavior?
a. Compensation
b. Denial
c. Rationalization
d. Regression: D
