PN 2006 pre lec/quizzes
"cohorting" involves placing patients with similar infections in the same room together.
true or false - ANS - true
\A 79 year old resident in a long term care facility is known to "wander" at night and has fallen in
the past. Which of the following nursing interventions is the most appropriate for this client?
a. The client should be checked frequently during the night
b. An abdominal restraint should be placed on the client during sleeping hours
c. The client should be placed in a room away from the acidity of the nursing station
d. A radio should be left playing at the bedside to assist in reality orientation - ANS - a. The
client should be checked frequently during the night
\A blowing sound osculated over the carotid artery is know as bruit
true or false - ANS - true
\A home care patient receives oxygen by nonbreather (NRB) mask. Which does the nurse
include when teaching the caregiver about the oxygen delivery system?
a. Keep the plastic bag at the end of the mask inflated
b. offer fluids frequently and apply moisturizer to prevent dry skin
c. Remove the elastic head strap to prevent skin breakdown at the ears
d. Adjust the oxygen flow rate whenever the patient feels like the need more oxygen - ANS - a.
Keep the plastic bag at the end of the mask inflated
\A medical diagnosis and a nursing diagnosis are the same thing
true or false - ANS - false
\A nurse preceptor is working with a student nurse. Which behavior by the student nurse
willrequire the nurse preceptor to intervene?
a. The student nurse reviews the patient's medical record.
b. The student nurse reads the patient's plan of care.
c. The student nurse shares patient information with a friend.
d. The student nurse documents medication administered to the patient - ANS - c. The student
nurse shares patient information with a friend.
\A nurse wanting to assess a patients daily weights. Where should the nurse look?
a. Graphic sheet and flow sheet
b. Database
c. Progress notes
d. Medical history and examination - ANS - a. Graphic sheet and flow sheet
,\A patient expresses fear of going home and being alone. Her vital sigma are stable and her
incision is nearly completely healed. What can the nurse infer from the subjective data?
a. The patient can begin retaking all her previous medications
b. The patient can now perform the dressing change herself
c. The patient is apprehensive about discharge
d. The wound is healing as expected and the surgery was a success - ANS - c. The patient is
apprehensive about discharge
\A patient has no bowel sounds in his upper left quadrant. After listening carefully for 10
seconds, you believe that:
a. The patient may have a bowel obstruction
b. You need to listen longer in all quadrants
c. This is a medical emergency
d. The patient may have an ileus - ANS - b. You need to listen longer in all quadrants
\A patient in the emergency department is complaining of left lower abdominal pain. The
comprehensive abdominal examination would include, in proper order, which of the following?
A. Inspection, palpation, auscultation
B. Percussion, inspection, auscultation
C. Inspection, palpation, percussion
D. Inspection, auscultation, palpation - ANS - D. Inspection, auscultation, palpation
\A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while
moving around in bed. What is the nurse'a best action in response to her observations?
a. Ask the patient about the facial grimacing with movement
b. Proceed to the next patients room while making sounds
c. Offer a massage because the patient does not want any more pain medicine.
d. Administer the pain medication ordered for moderate to severe pain - ANS - a. Ask the
patient about the facial grimacing with movement
\A patient who is expecting diarrhea after starting a new tube feed formula may be experiencing
formula intolerance.
true or false - ANS - true
\A patient with a Glasgow coma scale score of 15 would be considered to be in a coma
true or false - ANS - false
\a patient with Glasgow coma scale score 15 would be considered in a coma.
true or false - ANS - false
\A patient with respiratory concerns should be placed in a prone or side-lying position while a
respiratory assessment?
true or false - ANS -
, \A patient's plan of care includes the goal of increasing mobility this shift. As the patient is
ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. What should
the nurse do first when revising the plan of care?
a. Disregard all previous diagnosis and establishing a new plan of care
b. Set new priorities of the patient
c. Ask physical therapy to assist the patient because of the new injuries
d. Reassess the patient - ANS - d. Reassess the patient
\A patient's tube feed has finished running through. Which of the following nursing measures
would be helpful in preventing clogging in the tubing?
a. remove feeding tube from the patient's abdomen
b. flush with 20-30 ml of water after feed
c. ascertain that feeding tube is in correct position by sending the patient for an x-ray
d. leave the patient in left lateral sim's position - ANS - b. flush with 20-30 ml of water after feed
\A pleural friction rub will clear with coughing
true or false - ANS - false
\A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present.
When performing an abdominal assessment, the nurse should
A. Recommend that the patient take more laxatives.
B. Ask the patient about the color of her stools.
C. Avoid sexual references such as possible pregnancy.
D. Assess first the spots that are most tender. - ANS - B. Ask the patient about the color of her
stools.
\A yankauer suction is a straw- like device, used to suction oral
true or false - ANS - true
\Abnormal gait in a patient, might include, staggering, foot scarping, or high stepping
true or false - ANS - true
\An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimer's
disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is:
1. Confusion
2. Impaired judgment
3. Sensory deficits
4. History of falls - ANS - 4. History of falls
"cohorting" involves placing patients with similar infections in the same room together.
true or false - ANS - true
\A 79 year old resident in a long term care facility is known to "wander" at night and has fallen in
the past. Which of the following nursing interventions is the most appropriate for this client?
a. The client should be checked frequently during the night
b. An abdominal restraint should be placed on the client during sleeping hours
c. The client should be placed in a room away from the acidity of the nursing station
d. A radio should be left playing at the bedside to assist in reality orientation - ANS - a. The
client should be checked frequently during the night
\A blowing sound osculated over the carotid artery is know as bruit
true or false - ANS - true
\A home care patient receives oxygen by nonbreather (NRB) mask. Which does the nurse
include when teaching the caregiver about the oxygen delivery system?
a. Keep the plastic bag at the end of the mask inflated
b. offer fluids frequently and apply moisturizer to prevent dry skin
c. Remove the elastic head strap to prevent skin breakdown at the ears
d. Adjust the oxygen flow rate whenever the patient feels like the need more oxygen - ANS - a.
Keep the plastic bag at the end of the mask inflated
\A medical diagnosis and a nursing diagnosis are the same thing
true or false - ANS - false
\A nurse preceptor is working with a student nurse. Which behavior by the student nurse
willrequire the nurse preceptor to intervene?
a. The student nurse reviews the patient's medical record.
b. The student nurse reads the patient's plan of care.
c. The student nurse shares patient information with a friend.
d. The student nurse documents medication administered to the patient - ANS - c. The student
nurse shares patient information with a friend.
\A nurse wanting to assess a patients daily weights. Where should the nurse look?
a. Graphic sheet and flow sheet
b. Database
c. Progress notes
d. Medical history and examination - ANS - a. Graphic sheet and flow sheet
,\A patient expresses fear of going home and being alone. Her vital sigma are stable and her
incision is nearly completely healed. What can the nurse infer from the subjective data?
a. The patient can begin retaking all her previous medications
b. The patient can now perform the dressing change herself
c. The patient is apprehensive about discharge
d. The wound is healing as expected and the surgery was a success - ANS - c. The patient is
apprehensive about discharge
\A patient has no bowel sounds in his upper left quadrant. After listening carefully for 10
seconds, you believe that:
a. The patient may have a bowel obstruction
b. You need to listen longer in all quadrants
c. This is a medical emergency
d. The patient may have an ileus - ANS - b. You need to listen longer in all quadrants
\A patient in the emergency department is complaining of left lower abdominal pain. The
comprehensive abdominal examination would include, in proper order, which of the following?
A. Inspection, palpation, auscultation
B. Percussion, inspection, auscultation
C. Inspection, palpation, percussion
D. Inspection, auscultation, palpation - ANS - D. Inspection, auscultation, palpation
\A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while
moving around in bed. What is the nurse'a best action in response to her observations?
a. Ask the patient about the facial grimacing with movement
b. Proceed to the next patients room while making sounds
c. Offer a massage because the patient does not want any more pain medicine.
d. Administer the pain medication ordered for moderate to severe pain - ANS - a. Ask the
patient about the facial grimacing with movement
\A patient who is expecting diarrhea after starting a new tube feed formula may be experiencing
formula intolerance.
true or false - ANS - true
\A patient with a Glasgow coma scale score of 15 would be considered to be in a coma
true or false - ANS - false
\a patient with Glasgow coma scale score 15 would be considered in a coma.
true or false - ANS - false
\A patient with respiratory concerns should be placed in a prone or side-lying position while a
respiratory assessment?
true or false - ANS -
, \A patient's plan of care includes the goal of increasing mobility this shift. As the patient is
ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. What should
the nurse do first when revising the plan of care?
a. Disregard all previous diagnosis and establishing a new plan of care
b. Set new priorities of the patient
c. Ask physical therapy to assist the patient because of the new injuries
d. Reassess the patient - ANS - d. Reassess the patient
\A patient's tube feed has finished running through. Which of the following nursing measures
would be helpful in preventing clogging in the tubing?
a. remove feeding tube from the patient's abdomen
b. flush with 20-30 ml of water after feed
c. ascertain that feeding tube is in correct position by sending the patient for an x-ray
d. leave the patient in left lateral sim's position - ANS - b. flush with 20-30 ml of water after feed
\A pleural friction rub will clear with coughing
true or false - ANS - false
\A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present.
When performing an abdominal assessment, the nurse should
A. Recommend that the patient take more laxatives.
B. Ask the patient about the color of her stools.
C. Avoid sexual references such as possible pregnancy.
D. Assess first the spots that are most tender. - ANS - B. Ask the patient about the color of her
stools.
\A yankauer suction is a straw- like device, used to suction oral
true or false - ANS - true
\Abnormal gait in a patient, might include, staggering, foot scarping, or high stepping
true or false - ANS - true
\An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimer's
disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is:
1. Confusion
2. Impaired judgment
3. Sensory deficits
4. History of falls - ANS - 4. History of falls
