SCR 110 exam 1 practice questions and
answers 100% verified
The nurse encourages a patient with a history of heart failure to reduce energy
expenditure by alternating activity and rest. Which nursing process phase is this?
1) Diagnosis
2) Planning
3) Implementation
4) Evaluation - CORRECT ANSWER- 3) Implementation
Teaching a patient about alternating activity and rest is a component of patient
education, which falls into the implementation phase. This is an example of putting an
individualized plan into action. Other components of implementation include assisting
with hygienic care, promoting physical comfort, supporting respiratory and elimination
functions, facilitating ingestion of food/fluids, managing the patient's surroundings,
promoting a therapeutic relationship, and carrying out other therapeutic nursing
activities.
NurseEdu. Fundamentals of Nursing - NCLEX-RN Exam Review: 349 Practice
Questions with Detailed Rationales Explaining Correct & Incorrect Answer Choices .
NEDU LLC. Kindle Edition.
New nurses in orientation are learning about completion of incident reports. Which of
the following incidents would require an incident report be filed?
1) Medication given 30 minutes before scheduled time
2) Patient belongings lost when transferred to their hospital room
3) Frayed electrical cord on an IV pump
4) Medication order missing route of administration - CORRECT ANSWER- 2) Patient
belongings lost when transferred to their hospital room
Any time a patient's belongings are lost an incident report must be filed. This can help
identify people and departments involved, ways to prevent the occurrence in the future,
and even help in locating belongings.
The nurse is preparing to perform a focused assessment of the patient's abdomen.
Which of the following choices is the correct order in which the focused assessment is
performed?
,1) Palpation, Auscultation, Inspection, Percussion
2) Inspection, Palpation, Percussion, Auscultation
3) Percussion, Palpation, Inspection, Auscultation
4) Inspection, Auscultation, Percussion, Palpation
. - CORRECT ANSWER- 4) Inspection, Auscultation, Percussion, Palpation
When performing an abdominal assessment, inspection and auscultation should be
performed prior to percussion and palpation because the last two techniques will alter
bowel sounds. Inspection is looking at the appearance of the abdomen while the patient
is lying supine, with their arms by their side, and head resting on a pillow. (If the neck is
flexed, abdominal muscles may become flexed, and this can alter the appearance
during assessment.).
A patient is admitted to the medical-surgical unit with methicillin-resistant
staphylococcus aureus (MRSA) of a wound. The nurse initiates contact precautions,
which includes use of which of the following?
1) Clean gown and gloves
2) N-95 respirator
3) Biohazard bin placed in the room
4) Negative airflow room - CORRECT ANSWER- 1) Clean gown and gloves
Contact isolation requires all people entering the room to follow standard precautions in
addition to wearing a clean (not sterile) gown and gloves. Other diseases that require
contact precautions include the following: norovirus, rotavirus, and Clostridium difficile.
Additionally, patients with draining wounds, uncontrolled secretions, pressure ulcers,
generalized rash, and ostomy bags/tubes also warrant contact precautions.
A patient in the medical-surgical unit tells the nurse they haven't had a bowel movement
in two days. What is the first intervention the nurse should implement?
1) Review the patient's medical record to determine normal bowel pattern
2) Offer prune juice with every meal
3) Call the healthcare provider to request an order for stool softener 4) increase the
patient's oral fluid intake - CORRECT ANSWER- 1) Review the patient's medical record
to determine normal bowel pattern
BMs daily is considered within normal range. Several factors can influence normal
bowel patterns, including surgery, stress, and opioid medications. The nurse should
, review the medical record to determine the patient's normal bowel patterns prior to
hospitalization.
The nurse is caring for a 72-year-old patient who has a history of a left-sided stroke.
The patient uses a cane while walking. Which is the best way for the nurse to assess
the strength of their lower extremities?
1) Have the patient push with their feet against the nurse's hands
2) Observe the patient walking in the hall
3) Notify the physical therapy department and request an assessment 4) Assist the
patient to the bathroom - CORRECT ANSWER- 4) Assist the patient to the bathroom
Patients who have experienced a stroke often have residual weakness on the affected
side and use assistive devices to help with mobility. Using the cane and assisting the
patient to the bathroom is the best way for the nurse to assess the patient's lower
extremity strength. The nurse can assist the patient to the bathroom, and therefore,
eliminate the risk for a fall.
.
A 64-year-old patient visits the clinic with an open wound on their foot. Which of the
following strategies by the nurse is most appropriate to evaluate the patient's ability to
change their dressing at home?
1) Observe the patient changing their dressing
2) Have the patient write down the steps of the dressing change for reference
3) Write instructions for the patient for reference
4) Observe the patient changing a dressing on a simulated wound model - CORRECT
ANSWER- 1) Observe the patient changing their dressing
Observing the patient changing the dressing will help the nurse evaluate the patient's
ability.
The nurse in the long-term care facility is assessing patients. Which of the following
does the nurse identify as being at highest risk for developing decubitus ulcers? 76-
year-old malnourished patient on bed rest Obese patient who is wheelchair-bound and
quit smoking one year ago Incontinent patient having frequent loose stools, on a high-
protein diet 75-year-old patient with diabetes who is ambulatory
1) 76-year-old malnourished patient on bed rest
2) Obese patient who is wheelchair-bound and quit smoking one year ago
answers 100% verified
The nurse encourages a patient with a history of heart failure to reduce energy
expenditure by alternating activity and rest. Which nursing process phase is this?
1) Diagnosis
2) Planning
3) Implementation
4) Evaluation - CORRECT ANSWER- 3) Implementation
Teaching a patient about alternating activity and rest is a component of patient
education, which falls into the implementation phase. This is an example of putting an
individualized plan into action. Other components of implementation include assisting
with hygienic care, promoting physical comfort, supporting respiratory and elimination
functions, facilitating ingestion of food/fluids, managing the patient's surroundings,
promoting a therapeutic relationship, and carrying out other therapeutic nursing
activities.
NurseEdu. Fundamentals of Nursing - NCLEX-RN Exam Review: 349 Practice
Questions with Detailed Rationales Explaining Correct & Incorrect Answer Choices .
NEDU LLC. Kindle Edition.
New nurses in orientation are learning about completion of incident reports. Which of
the following incidents would require an incident report be filed?
1) Medication given 30 minutes before scheduled time
2) Patient belongings lost when transferred to their hospital room
3) Frayed electrical cord on an IV pump
4) Medication order missing route of administration - CORRECT ANSWER- 2) Patient
belongings lost when transferred to their hospital room
Any time a patient's belongings are lost an incident report must be filed. This can help
identify people and departments involved, ways to prevent the occurrence in the future,
and even help in locating belongings.
The nurse is preparing to perform a focused assessment of the patient's abdomen.
Which of the following choices is the correct order in which the focused assessment is
performed?
,1) Palpation, Auscultation, Inspection, Percussion
2) Inspection, Palpation, Percussion, Auscultation
3) Percussion, Palpation, Inspection, Auscultation
4) Inspection, Auscultation, Percussion, Palpation
. - CORRECT ANSWER- 4) Inspection, Auscultation, Percussion, Palpation
When performing an abdominal assessment, inspection and auscultation should be
performed prior to percussion and palpation because the last two techniques will alter
bowel sounds. Inspection is looking at the appearance of the abdomen while the patient
is lying supine, with their arms by their side, and head resting on a pillow. (If the neck is
flexed, abdominal muscles may become flexed, and this can alter the appearance
during assessment.).
A patient is admitted to the medical-surgical unit with methicillin-resistant
staphylococcus aureus (MRSA) of a wound. The nurse initiates contact precautions,
which includes use of which of the following?
1) Clean gown and gloves
2) N-95 respirator
3) Biohazard bin placed in the room
4) Negative airflow room - CORRECT ANSWER- 1) Clean gown and gloves
Contact isolation requires all people entering the room to follow standard precautions in
addition to wearing a clean (not sterile) gown and gloves. Other diseases that require
contact precautions include the following: norovirus, rotavirus, and Clostridium difficile.
Additionally, patients with draining wounds, uncontrolled secretions, pressure ulcers,
generalized rash, and ostomy bags/tubes also warrant contact precautions.
A patient in the medical-surgical unit tells the nurse they haven't had a bowel movement
in two days. What is the first intervention the nurse should implement?
1) Review the patient's medical record to determine normal bowel pattern
2) Offer prune juice with every meal
3) Call the healthcare provider to request an order for stool softener 4) increase the
patient's oral fluid intake - CORRECT ANSWER- 1) Review the patient's medical record
to determine normal bowel pattern
BMs daily is considered within normal range. Several factors can influence normal
bowel patterns, including surgery, stress, and opioid medications. The nurse should
, review the medical record to determine the patient's normal bowel patterns prior to
hospitalization.
The nurse is caring for a 72-year-old patient who has a history of a left-sided stroke.
The patient uses a cane while walking. Which is the best way for the nurse to assess
the strength of their lower extremities?
1) Have the patient push with their feet against the nurse's hands
2) Observe the patient walking in the hall
3) Notify the physical therapy department and request an assessment 4) Assist the
patient to the bathroom - CORRECT ANSWER- 4) Assist the patient to the bathroom
Patients who have experienced a stroke often have residual weakness on the affected
side and use assistive devices to help with mobility. Using the cane and assisting the
patient to the bathroom is the best way for the nurse to assess the patient's lower
extremity strength. The nurse can assist the patient to the bathroom, and therefore,
eliminate the risk for a fall.
.
A 64-year-old patient visits the clinic with an open wound on their foot. Which of the
following strategies by the nurse is most appropriate to evaluate the patient's ability to
change their dressing at home?
1) Observe the patient changing their dressing
2) Have the patient write down the steps of the dressing change for reference
3) Write instructions for the patient for reference
4) Observe the patient changing a dressing on a simulated wound model - CORRECT
ANSWER- 1) Observe the patient changing their dressing
Observing the patient changing the dressing will help the nurse evaluate the patient's
ability.
The nurse in the long-term care facility is assessing patients. Which of the following
does the nurse identify as being at highest risk for developing decubitus ulcers? 76-
year-old malnourished patient on bed rest Obese patient who is wheelchair-bound and
quit smoking one year ago Incontinent patient having frequent loose stools, on a high-
protein diet 75-year-old patient with diabetes who is ambulatory
1) 76-year-old malnourished patient on bed rest
2) Obese patient who is wheelchair-bound and quit smoking one year ago
