Final Exam Questions With Step -By -Step Solutions

NUR 311 Final Exam Questions With Step -By -Step Solutions When preparing to measure the height and weight of a newly admitted patient, why would the nurse ask about the patient's ability to stand? - ANSWERTo determine if the patient is steady enough to stand without assistance A nursing assistive personnel (NAP) is preparing to weigh a resident in a skilled nursing facility. The patient is usually weighed in street clothing and socks, with his shoes off. The patient is currently wearing street clothing with shoes and socks. What will the NAP do to ensure that the patient's weight is correctly measured? - ANSWERTake off the patient's shoes, but leave his socks on. Which step must be taken to ensure accurate measurement of a patient's daily weight? - ANSWERAsk the patient to void before he or she is weighed. As the nurse is conducting an admission interview, the patient states, "I've lost 30 pounds over the last 4 months." Which question might the nurse ask to determine if the weight loss was intentional or unintentional? - ANSWER"Have you been following a specific diet?" For which patient would the nurse instruct nursing assistive personnel (NAP) to weigh a patient with a bed scale? - ANSWERPatient who has heart failure and a consequent inability to bear weight After bacteria are cultured from a midstream urine specimen, what is accomplished by sensitivity testing? - ANSWERDetermines which antibiotic agent is most effective in killing the bacteria What is the nurse's priority action if a patient's radial pulse has an irregular rhythm? - ANSWERAssess the patient for a pulse deficit. Inadequate oxygenation to the body will cause the radial pulse to become: - ANSWERTachycardic Which action would best assess the effect of exercise on a patient's radial pulse measurement? - ANSWERMeasuring the patient's radial pulse before and after exercise Which action can the nurse take to keep a patient from consciously controlling his or her breathing during an assessment? - ANSWERAssess respiration after measuring the pulse. On the last assessment of a patient's respiration, her respiratory rate was 10 breaths per minute. What should the nurse do when conducting the next assessment of this patient's respiratory rate? - ANSWERCount breaths for 60 seconds. When measuring a patient's respiratory rate, the nurse will count the number of completed respiratory cycles per minute. What is the definition of a respiratory cycle? - ANSWERThe number of inspirations and expirations per minute. During the assessment of a patient's respiratory rate, when the second hand reaches the 15-second mark, the respiratory count is 8. What should the nurse do at this time? - ANSWERContinue to count the patient's breaths for a full 60 seconds. The nurse plans to assess a patient's respiratory rate; however, the patient has just returned from ambulating to the bathroom. What should the nurse do to minimize the effect of exercise on the patient's respiratory rate? - ANSWEREncourage the patient to rest for 10 minutes before assessing respiration. What can the nurse do to help ensure an accurate result when collecting a midstream urine sample for a patient who is menstruating? - ANSWERMake a note on the lab slip that the patient is menstruating What will the nurse instruct nursing assistive personnel (NAP) to do when measuring a patient's rectal temperature using an electronic thermometer? - ANSWERUse the probe with the red tip. what contraindicates taking a rectal temperature measurement - ANSWERPatient has painful and swollen hemorrhoids. Which nursing action best evaluates the effectiveness of an antipyretic medication in a patient with an oral temperature of 101.6°F? - ANSWERAssess oral temperature 30 minutes after the agent is administered. Which instruction might the nurse give to nursing assistive personal (NAP) that is applicable only to tympanic temperature assessment? - ANSWERGently tug the pinna backward, up, and out before inserting the probe. Which instruction might the nurse give to nursing assistive personnel (NAP) that is applicable only to temporal artery temperature assessment? - ANSWERPlace the sensor flush on the patient's forehead. During the admissions process, the nurse initially assesses the patient's radial pulse primarily for what purpose? - ANSWEREstablishment of a baseline as part of the patient's vital signs What will the nurse instruct nursing assistive personal (NAP) to do when measuring an adult patient's radial pulse? - ANSWERPalpate the patient's inner wrist on the thumb side with the fingertips of your two middle fingers. The nurse is preparing to assess a patient's blood pressure. What would cause the blood pressure reading to be inaccurately high? - ANSWERBlood pressure cuff is too loose around the arm What would cause the nurse to delay the assessment of a patient's blood pressure? - ANSWERPatient has just finished having a cigarette The nurse has just measured a patient's blood pressure and is waiting 2 minutes to measure the pressure again. What is the purpose of taking two measurements? - ANSWERMinimize the effect of anxiety The nurse is teaching a patient about ways to reduce blood pressure. What will the nurse include in these instructions? - ANSWEREnsure that your diet has an adequate daily intake of calcium. Where should the nurse measure the blood pressure of a patient recovering from a left-sided mastectomy? - ANSWERUse the right arm to take the blood pressure. The nurse is planning to measure a patient's blood pressure. What does the systolic measurement represent? - ANSWERThe pressure exerted against the arterial wall. You have assigned a new nursing assistive personnel (NAP) to take routine vital signs. You notice that the NAP's last three patients have had unusually low blood pressure that you have had to confirm. What is the most likely reason the NAP is obtaining falsely low blood pressure readings? - ANSWERThe blood pressure cuff is too wide for arm circumference. What should the nurse do if the patient's blood pressure is not within normal limits? - ANSWERThis is the correct response, because the patient must be assessed for possible cardiovascular problems. What would the nurse do to prevent the spread of infection when assessing a patient's blood pressure? - ANSWERClean the stethoscope with alcohol before and after using it. You have assigned a new nursing assistive personnel (NAP) to take routine vital signs. An experienced NAP has been asked to retake a blood pressure that the newly hired NAP has taken three times this week. As the nurse, what action do you take? - ANSWERObserve the NAP as she obtains a blood pressure and pulse on a patient. Which of the following is a risk factor for decreased oxygen saturation level in a patient? - ANSWERChest wall injury What should the nurse teach nursing assistive personnel (NAP) about selecting the appropriate site for measuring a patient's oxygen saturation level? - ANSWER"I've checked her capillary refill, and it's acceptable in both her hands and feet." The nurse measures a patient's oxygen saturation level as being 83%. What would the nurse do first? - ANSWERAsk the patient whether he or she is having trouble breathing. The nurse is preparing to measure the oxygen saturation level of a patient with obesity. Which action would help ensure an adequate measurement? - ANSWERUse a disposable tape-on sensor. A patient is prescribed continuous oxygen saturation monitoring. The nurse would confirm that the alarms have been set to which limits? - ANSWERLow of 85% and high of 100% A nurse is caring for a patient who has just had major abdominal surgery to resect a portion of his colon. What is the most reliable sign that the patient has significant postoperative pain? - ANSWERThe patient rates his pain a 7 on a scale of 0 to 10. What will the nurse instruct nursing assistive personnel (NAP) to do regarding the management of a patient's pain? - ANSWER"Let me know at least 30 minutes before you transport her so I can administer her pain medication. Which observation indicates that a patient's analgesic has been effective in managing pain that she rated a 6 out of 10 on a pain rating scale before the intervention? - ANSWERThe patient rates her current pain as 3 out of 10 on the pain rating scale. A patient with a herniated disk is scheduled for surgery to fuse two vertebrae in her cervical spine. Which activity is most likely to be a palliative factor for this patient? - ANSWERPerforming neck, back, and shoulder exercises prescribed by a physical therapist The nurse notices that his patient has none of the signs and symptoms normally associated with pain, such as diaphoresis, tachycardia, and hypertension. The patient does, however, seem moody and a bit uncooperative. What conclusion does the nurse draw? - ANSWERThe absence of physiological signs and symptoms is associated with chronic pain. The nurse has selected a finger as the puncture site to measure the blood glucose level of a female patient with type 2 diabetes mellitus and peripheral vascular disease (PVD). Although all of the actions listed below are appropriate, which one would be of particular benefit to this patient given her medical history? - ANSWERKeeping the finger in a dependent position during the puncture The nurse would keep the finger in a dependent position to encourage blood flow to the intended puncture site. Blood flow to the extremities is compromised in patients with PVD. For which patient can the nurse delegate to nursing assistive personnel (NAP) the task of routine blood glucose monitoring? - ANSWERPatient with type 2 diabetes who has had a closed reduction of a fracture of the right wrist. This patient's condition would affect his or her ability to self-perform blood glucose testing but would not affect his or her blood glucose level. The skill of blood glucose testing may therefore be delegated to NAP. For which situation would the procedure of glucose testing be interrupted? - ANSWERAn unused lancet is not available.The unavailability of an unused lancet would preclude proceeding with blood glucose testing. A used lancet can never be reused, because of the risk for infection. The nurse must locate an unused lancet for the procedure. A patient with type 2 diabetes mellitus tells the nurse that he has been testing his own blood glucose level six times per day for the past 3 years. What is the most appropriate action for the nurse to take? - ANSWERObserve the patient's testing technique for accuracy. It is useful to evaluate the patient's technique to ensure that he receives accurate results. Which action would the nurse carry out first when performing a blood glucose test on a patient with type 1 diabetes mellitus? - ANSWERAssess the patient's skin for possible puncture sites. The nurse's first action would be to assess possible puncture sites. What is the nurse's primary goal for appropriate, effective pain management when considering the patient's risk for injury? - ANSWERTo maximize pain relief while maintaining the patient's ability to function What is one step the nurse would take if a patient receiving patient-controlled analgesia (PCA) were difficult to arouse? - ANSWERAssess respiration, and then notify the health care provider immediately When a patient is using PCA, which statement is appropriate for the nurse to make to nursing assistive personnel (NAP)? - ANSWER"Tell me if the patient is in too much pain to assist with his bath." Which patient outcome best reflects adequate management for pain originally rated as 8 out of 10 on a pain scale? - ANSWERThe patient rates current pain as 4 out of 10 What will the nurse do when discontinuing PCA? - ANSWEREnsure that the main intravenous line is intact When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to help maintain good skin integrity? - ANSWERAssessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift When caring for a patient who is receiving oxygen by simple face mask, which action ensures that the rate of oxygen being delivered is appropriate? - ANSWERAssessing for proper placement of the mask on the patient's face When caring for a patient for whom oxygen by nonrebreathing mask has been ordered, which action ensures appropriate oxygen delivery? - ANSWERAssessing that the reservoir bag stays inflated When caring for a patient who is receiving supplemental oxygen by face tent, which action ensures that the oxygen is flowing? - ANSWEREnsuring that a mist is always present What would the nurse do when receiving an order to increase the delivery rate of a patient's oxygen per nasal cannula from 1 L/min to 3 L/min? - ANSWERAdjust the float ball on the flow meter to 3 L/min. What would the nurse do first when preparing to begin oxygen therapy for a patient? - ANSWERReview the medical prescription for delivery method and flow rate. When preparing the patient's environment for safe oxygen therapy, which intervention is a priority to minimize the patient's risk for injury? - ANSWERInspect all electrical equipment in the patient's room for the presence of safety-check tags. When a patient is receiving oxygen at home, which instruction to the family would help them understand how to use the oxygen safely? - ANSWERPlace a "No Smoking" sign at the entrance to the house. What would the nurse do first when preparing to educate the patient about safe administration of oxygen therapy at home? - ANSWERAssess the patients emotional readiness and physical ability to provide autonomous care. Which statement by the patient would indicate that he or she understands the safe use of oxygen? - ANSWER"I'll alert the nurse immediately if I have any increased difficulty breathing." Why is it important for the nurse to set the correct flow rate for a patient to whom oxygen is prescribed? - ANSWERTo provide the correct amount of oxygen to the patient What would be the nurse's priority in order to minimize a patient's risk for injury during oxygen therapy? - ANSWERObserving the six rights of medication administration What can the nurse do to evaluate a patient's response to continuous oxygen therapy delivered at 4 L/min by nasal cannula? - ANSWERRegularly measure and trend the patient's pulse oximetry (SpO2) values. What should the nurse do when a patient is ordered to receive 4 L/min oxygen by nasal cannula? - ANSWEREnsure that humidification is present. What would the nurse monitor frequently to ensure that the prescribed amount of oxygen is being delivered to a patient? - ANSWEROxygen flow meter setting A patient is told the home care nurse will be measuring and recording intake and output (I&O) at home. What will the home care nurse do first? - ANSWERExplain to the patient why I&O has been ordered. What output will the nurse direct nursing assistive personnel (NAP) to measure for a hospitalized patient for whom I&O measurement is prescribed? - ANSWERUrine collection drainage. The nurse may safely delegate the measurement of urine collection drainage to NAP. The nurse is responsible for monitoring nasogastric tube drainage, chest tube drainage, and ileostomy bag drainage. Which statement reflects the nurse's understanding of the importance of accurate urinary output measurement for a patient with acute renal failure? - ANSWER"I will use a collection system with an hourly measurement device added." A patient has consumed three 100-mL cups of ice chips and 4 ounces of ginger ale. What will nursing assistive personnel (NAP) document as this patient's oral intake? - ANSWER270 mL. Three 100-mL cups of ice chips would be 150 mL of fluid, and 4 ounces of ginger ale would be 120 mL of fluid. The intake would be documented as 270 mL A patient is admitted to your unit for dehydration. Which of the following assessments would the nurse identify as a possible sign of fluid imbalance? - ANSWERReduced turgor of the skin. skin remains suspended, peaked, or "tented" for a few seconds, and then slowly returns to place Why might the collection of a sputum specimen be delayed up to 2 hours? - ANSWERThe patient has just finished eating lunch. Which criterion makes it appropriate for the nurse to delegate to nursing assistive personnel (NAP) the skill of collecting a sputum specimen? - ANSWERThe patient can produce the specimen by coughing. What is the role of nursing assistive personnel (NAP) when a sputum specimen is collected by means of nasotracheal suctioning? - ANSWERTransporting the specimen to the lab Which action would help to ensure that the results of a suctioned sputum specimen culture are reliable? - ANSWERRefrigerating the specimen until it can be taken to the lab Which action by the nurse would most effectively reduce the patient's risk for injury when collecting a sputum specimen by means of nasotracheal suctioning? - ANSWERLubricating the catheter with sterile water Virchow's Triad for DVT? - ANSWERvenous stasis, endothelial injury, hypercoagulable state Why might a sequential compression device (SCD) be applied to the legs of an immobile patient? - ANSWERTo help prevent deep vein thrombosis (DVT) While preparing to apply a SCD for a postoperative patient, the nurse realizes that which assessment observation contraindicates the application of the device? - ANSWERHaving dermatitis on the legs The nurse has applied the SCD to a postoperative patient. The most appropriate way for the nurse to confirm proper fit is to do what? - ANSWEREnsure that two fingers will fit between the patient's leg and the device. The nurse is preparing to delegate the application of a SCD to nursing assistive personnel (NAP). Which statement by the NAP requires follow-up by the nurse? - ANSWER"I will measure the patient's legs to determine what size SCD sleeve to use." measuring cannot be delegated When preparing to delegate the application of the SCD to NAP, the nurse must do what first? - ANSWERAssess the patient's lower extremities for signs and symptoms of impaired circulation. When preparing to apply elastic stockings, why does the nurse assess for skin discoloration? - ANSWERTo identify the potential risk for deep vein thrombosis (DVT) Which condition is not associated with venous stasis, part of Virchow's triad? - ANSWERAnxiety Why does the nurse remove the patient's elastic stockings at least once per shift? - ANSWERTo check the skin for irritation or breakdown. Why might the nurse choose not to apply a pair of prescribed elastic stockings to a patient's legs? - ANSWERThe patient's skin is irritated. After determining the proper size stocking and assessing the patient's circulatory status, a nurse delegates the application of elastic stockings to nursing assistive personnel (NAP). The nurse discovers that the NAP has been using moisturizer on the patient's legs before applying the stockings. What is the best action by the nurse? - ANSWERInstruct NAP to use a small amount of cornstarch or powder. A male patient on bed rest is permitted to stand to use the urinal. Which action would the nurse take to ensure his safety before helping him to a standing position? - ANSWERDetermine his risk for orthostatic hypotension The nurse is delegating to nursing assistive personnel (NAP) the task of assisting with a urinal. The nurse specifies to NAP that the urinal is to be used in bed, not in a standing position, for which patient? - ANSWERPatient with complete left-sided paralysis caused by a stroke Why would the nurse assess a patient's abdomen before helping with the use of a urinal? - ANSWERTo assess for bladder distention The nurse is assisting a patient with the placement of a urinal. The patient tells the nurse, "I'll call you when I'm done." What is the nurse's best response? - ANSWER"Fine. Recap the urinal, hang it on your side rail, and use your call light to let me know you're finished." Which action promotes infection control when assisting a patient with a urinal? - ANSWERApplying gloves before emptying and cleaning the patient's urinal The nurse has delegated to nursing assistive personnel (NAP) the skill of assisting with a bedpan for a patient who has had discomfort when walking to the bathroom. Which statement made by the NAP requires the nurse's follow-up? - ANSWER"If I can get someone to help, I'll walk her to the bathroom." The NAP is not qualified to determine whether it is appropriate to ambulate the patient. The nurse has delegated the skill of assisting with a bedpan, and the NAP should carry out that responsibility as instructed A patient with a nasogastric tube, an intravenous infusion line, and an indwelling urinary catheter needs to be placed on the bedpan. Which action would the nurse take first to ensure the patient's safety? - ANSWERObtain help to place the patient on the bedpan. A dependent, confused patient is being given a bedpan. How can the nurse best ensure the patient's safety? - ANSWERRaise the side rails on the bed before leaving the room. The nurse is assisting with a bedpan for a patient who had knee surgery 24 hours ago. What is the best way for the nurse to maximize comfort while the patient uses the bedpan? - ANSWERelevate the head of the bed to between 30 and 60 degrees. After assisting with a bedpan, the nurse notes that the patient's stool is streaked with bright-red blood. What would the nurse do first? - ANSWERAsk if the patient has a history of hemorrhoids. Asking whether the patient has a history of hemorrhoids is the most appropriate initial response, followed by documentation of the observation and notification of the patient's health care provider. Testing with a urine reagent test strip shows that a patient's urine is positive for protein, negative for glucose and blood, and has a pH of 8.2. What will the nurse do in response to these results? - ANSWERNotify the health care provider of the results of the test. Which action is necessary for an accurate chemical reaction when testing urine with a reagent test strip? - ANSWERKeep the test strip horizontal while timing the process. Which statement will the nurse make to nursing assistive personnel (NAP) when delegating urine glucose testing with a reagent strip for a patient with type 2 diabetes? - ANSWER"Don't forget to get a double-voided specimen when you test the patient's urine." What is a double-voided urine specimen? - ANSWERA second urine specimen taken within 40 minutes after the patient voids Which action is performed initially when using a reagent strip to test the urine of a patient with type 1 diabetes for glucose? - ANSWERVerify the patient using two patient identifiers. What is the primary reason the nurse ensures that a patient's indwelling urinary catheter drainage tubing is free of kinks? - ANSWERKinks are associated with the development of urinary tract infection (UTI). The nurse has delegated measurement of a patient's vital signs and catheter care to nursing assistive personnel (NAP). Which observation should the NAP report to the nurse immediately? - ANSWERRedness noted on the external urethral meatus All of the following factors are known to increase the risk of urinary tract infection (UTI) except which one? - ANSWERUse of plain soap instead of an antiseptic cleanser for perineal hygiene While performing catheter care, the nurse moves her hand, allowing the patient's labia to close around the catheter. Why would the nurse repeat this part of the care? - ANSWERThe labia have contaminated the area. What is the most effective way to prevent infection when providing catheter care for a patient? - ANSWERCleanse from the meatus outward. . Which statement might the nurse make to nursing assistive personnel (NAP) assigned to collect a midstream urine specimen from a patient with signs of a urinary tract infection? - ANSWER"Be sure to maintain aseptic technique." Which statement might the nurse make to nursing assistive personnel (NAP) in order to help ensure reliable results of culture and sensitivity testing of a midstream urine specimen? - ANSWER"Please get the specimen to the lab within 20 minutes." What is the most important action the nurse can take to ensure that a midstream urine specimen does not become contaminated? - ANSWEREnsure that the patient's perineum has been cleansed before the specimen is obtained. What is the initial step in preparing to perform a gastric occult blood test for a patient with recurrent vomiting? - ANSWERReview the medications the patient is currently taking. Why might the nurse delegate to nursing assistive personnel (NAP) the skill of performing a gastric occult blood test for a patient who has vomited? - ANSWERThis skill may be delegated if performed on vomited stomach contents. Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) in carrying out a gastric occult blood test for a patient with a low hemoglobin and hematocrit? - ANSWER"The next time the patient vomits, please test it for occult blood." Which statement best illustrates correct interpretation of a positive gastric occult blood test? - ANSWER"If the test sample turns blue, it is positive for blood." Which nursing action addresses the risk for infection related to gastric occult blood testing? - ANSWEREnsuring appropriate hand hygiene before and after testing; most effective way of minimizing the risk for infection The nurse is preparing to logroll a patient in bed. Why are two assistants needed on the side toward which the patient is being turned? - ANSWERTo roll the patient as a unit What is the initial step in preparing a fecal occult blood test? - ANSWERDetermine the patient's ability to help obtain a sample. The nurse has delegated to nursing assistive personnel (NAP) the task of performing fecal occult blood tests on the stool of a patient with a history of positive results. Which instruction is most relevant to performing this test in this particular patient? - ANSWER"Save the stool sample so that I can retest it if it is positive." Which instruction to nursing assistive personnel (NAP) is most relevant to the proper performance of a fecal occult blood test using a Hemoccult slide? - ANSWER"Remember to take samples from two different areas of the specimen." Which statement indicates proper interpretation of the results of a positive fecal occult blood test? - ANSWER"Because it was positive, the patient must be asked when he or she last ate red meat." Which of the following nursing actions addresses the risk for infection related to fecal occult blood testing? - ANSWERWearing clean gloves while testing Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter? - ANSWERSterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination. Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results? - ANSWERHaving someone take the specimen to the lab immediately When preparing to move a patient in bed, what will the nurse do first? - ANSWERAssess the patient's ability to help with moving. When preparing to move a patient in bed with the help of an assistant, which posture will both caregivers use to ensure their own safety? - ANSWERFlex the hips and knees. A patient who weighs 200 lbs. needs to be moved up in bed with the aid of a friction-reducing device. The nurse will prepare for this move by assembling how many caregivers? - ANSWERAt least three In which position will the nurse place the patient to move him or her up in bed? - ANSWERSupine with the head of the bed flat A patient will be moved up in bed with the use of a friction-reducing device. How will the nurse place this device under the patient? - ANSWERRoll the patient from side to side, and place the device under the drawsheet. When positioning a hemiplegic patient in the supported Fowler's position, what is the primary reason a trochanter roll is placed alongside the patient's legs? - ANSWERTo reduce the risk of contracture To which position would the nurse assist the patient who is experiencing difficulty with breathing? - ANSWERFowler's position When repositioning a patient, what can the nurse do to prevent the patient's hips from rolling outward? - ANSWERPlace sandbags along the legs. The nurse is preparing to move a patient with hemiplegia into the prone position. What action should the nurse take when rolling the patient onto her side? - ANSWERPlace a pillow on the abdomen. Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter? - ANSWER"Let me know if the urine contains blood or sediment, or appears cloudy." Which measure may be taken to minimize the staff's risk for infection from a urine specimen? - ANSWERFirmly securing the lid of the urine specimen container When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected? - ANSWERClamping the catheter tubing for 15 minutes before collection