NS 660 Exam 1 Review Questions With Factually
Correct Answers
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 Answer - Assessment
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 Answer - Assessment
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 Answer - Reflex 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 Answer - Ask 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
Answer - Patient-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 Answer - Oral 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 Answer - Ask 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 Answer - BP
Correct Answers
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 Answer - Assessment
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 Answer - Assessment
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 Answer - Reflex 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 Answer - Ask 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
Answer - Patient-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 Answer - Oral 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 Answer - Ask 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 Answer - BP
