NURS 1871 exam 1 Questions With Complete Solutions
Fundamentals Ch 1: Nursing today
Fundamentals Ch 6: Health and Wellness
Fundamentals Ch 24: Communication
Fundamentals Ch 16: Nursing Assessment
Fundamentals Ch 48: Skin Integrity and Wound Care
Fundamentals Ch 49: Sensory Alterations
Fundamentals Ch 17: Nursing Diagnosis
Fundamentals Ch 18: Planning Nursing Care
Fundamentals Ch 30: Health Assessment
Fundamentals Ch 19: Implementing Nursing Care
Fundamentals Ch 20: Evaluation
Fundamentals Ch 27: Patient Safety ad Quality
Fundamentals Ch 41: Oxygenation
A critical care nurse is using a new research-based intervention
to correctly position her ventilated patients to reduce pneumonia
caused by accumulated respiratory secretions. This is an
example of which Quality and Safety in the Education of Nurses
(QSEN) competency?
1. Patient-centered care
2. Evidence-based practice
,3. Teamwork and collaboration
4. Quality improvement Correct Answer 2
A new nurse is going to help a patient walk down the corridor
and sit in a chair. The patient has an eye patch over the left eye
and poor vision in the right eye. What is the correct order of
steps to help the patient safely walk down the hall and sit in the
chair?
1. Tell patient when you are approaching the chair.
2. Walk at a relaxed pace.
3. Guide patient's hand to nurse's arm, resting just above the
elbow.
4. Position yourself one-half step in front of patient.
5. Position patient's hand on back of chair. Correct Answer 3,
4, 2, 1, 5
A nurse admits a 32-year-old patient for treatment of acute
asthma. The patient has labored breathing, a respiratory rate of
28 per minute, and lung sounds with bilateral wheezing. The
nurse makes the patient comfortable and starts an ordered
intravenous infusion to administer medication that will relax the
patient's airways. The patient tells the nurse after the first
medication infusion, "I feel as if I can breathe better." The nurse
auscultates the patient's lungs and notes decreased wheezing
with a respiratory rate of 22 per minute. Which of the following
is an evaluative measure? (Select all that apply.)
1. Asking patient to breathe deeply during auscultation
2. Counting respirations per minute
3. Asking the patient to describe how his breathing feels
4. Starting the intravenous infusion
5. Auscultating lung sounds Correct Answer 2, 3, 5
,A nurse asks how a patient's condition from a serious infection
changed since yesterday while receiving a hand-off report. The
280nurse leaving the shift reports the patient has two priority
nursing diagnoses—fluid imbalance and fever. The receiving
nurse begins to provide care by measuring the patient's body
temperature, inspecting the condition of the skin, reviewing the
intake and output record, and checking the summary notes
describing the patient's progress since the day before. The nurse
asks a technician to measure intake and output during the shift.
What critical thinking indicators reflect the nurse's ability to
perform evaluation? (Select all that apply.)
1. Checking the summary notes
2. Asking the leaving RN about the patient's condition.
3. Assigning the technician to measure intake and output
4. Comparing current outcomes with those set for the patient's
goals
5. Reflecting on patient's progress Correct Answer 1, 2, 4, 5
A nurse assesses a 78-year-old patient who weighs 108.9 kg
(240 lb) and is partially immobilized because of a stroke. The
nurse turns the patient and finds that the skin over the sacrum is
very red and the patient does not feel sensation in the area. The
patient has had fecal incontinence on and off for the past 2 days.
The nurse identifies the nursing diagnosis of Risk for Impaired
Skin Integrity. Which of the following outcomes is appropriate
for the patient?
1. Patient will be turned every 2 hours within 24 hours.
2. Patient will have normal formed stool within 48 hours.
3. Patient's ability to turn self in bed improves.
, 4. Erythema of skin will be mild to none within 48 hours.
Correct Answer 4
A nurse completes the following steps during her shift of care.
Which are the steps of nursing assessment? (Select all that
apply.)
1. The review of patient data in the medical record
2. Confirming a patient's self-report of abdominal pain by
inspecting the abdomen
3. Reporting results of an ongoing assessment to a nurse
working the next scheduled shift
4. Analyzing a set of signs revealing lower leg weakness and
unsteady gait with a pattern of mobility alteration
5. Conducting an interview of a family caregiver Correct
Answer 1, 2, 4, 5
A nurse conducts an assessment of a 42-year-old woman at a
health clinic. The woman is married and lives in a condo with
her husband. She reports having frequent voiding and pain when
she passes urine. The nurse asks whether she has to go to the
bathroom at night, and the patient responds, "Yes, usually twice
or more." The patient had an episode of diarrhea 1 week ago.
She weighs 300 lb and reports having difficulty cleansing
herself after voiding or passing stool. Which of the following
demonstrate assessment findings that cluster to indicate the
nursing diagnosis Impaired Urination. (Select all that apply.)
1. Age 42
2. Dysuria
3. Difficulty performing perineal hygiene
4. Nocturia
5. Episode of diarrhea Correct Answer 2, 4
Fundamentals Ch 1: Nursing today
Fundamentals Ch 6: Health and Wellness
Fundamentals Ch 24: Communication
Fundamentals Ch 16: Nursing Assessment
Fundamentals Ch 48: Skin Integrity and Wound Care
Fundamentals Ch 49: Sensory Alterations
Fundamentals Ch 17: Nursing Diagnosis
Fundamentals Ch 18: Planning Nursing Care
Fundamentals Ch 30: Health Assessment
Fundamentals Ch 19: Implementing Nursing Care
Fundamentals Ch 20: Evaluation
Fundamentals Ch 27: Patient Safety ad Quality
Fundamentals Ch 41: Oxygenation
A critical care nurse is using a new research-based intervention
to correctly position her ventilated patients to reduce pneumonia
caused by accumulated respiratory secretions. This is an
example of which Quality and Safety in the Education of Nurses
(QSEN) competency?
1. Patient-centered care
2. Evidence-based practice
,3. Teamwork and collaboration
4. Quality improvement Correct Answer 2
A new nurse is going to help a patient walk down the corridor
and sit in a chair. The patient has an eye patch over the left eye
and poor vision in the right eye. What is the correct order of
steps to help the patient safely walk down the hall and sit in the
chair?
1. Tell patient when you are approaching the chair.
2. Walk at a relaxed pace.
3. Guide patient's hand to nurse's arm, resting just above the
elbow.
4. Position yourself one-half step in front of patient.
5. Position patient's hand on back of chair. Correct Answer 3,
4, 2, 1, 5
A nurse admits a 32-year-old patient for treatment of acute
asthma. The patient has labored breathing, a respiratory rate of
28 per minute, and lung sounds with bilateral wheezing. The
nurse makes the patient comfortable and starts an ordered
intravenous infusion to administer medication that will relax the
patient's airways. The patient tells the nurse after the first
medication infusion, "I feel as if I can breathe better." The nurse
auscultates the patient's lungs and notes decreased wheezing
with a respiratory rate of 22 per minute. Which of the following
is an evaluative measure? (Select all that apply.)
1. Asking patient to breathe deeply during auscultation
2. Counting respirations per minute
3. Asking the patient to describe how his breathing feels
4. Starting the intravenous infusion
5. Auscultating lung sounds Correct Answer 2, 3, 5
,A nurse asks how a patient's condition from a serious infection
changed since yesterday while receiving a hand-off report. The
280nurse leaving the shift reports the patient has two priority
nursing diagnoses—fluid imbalance and fever. The receiving
nurse begins to provide care by measuring the patient's body
temperature, inspecting the condition of the skin, reviewing the
intake and output record, and checking the summary notes
describing the patient's progress since the day before. The nurse
asks a technician to measure intake and output during the shift.
What critical thinking indicators reflect the nurse's ability to
perform evaluation? (Select all that apply.)
1. Checking the summary notes
2. Asking the leaving RN about the patient's condition.
3. Assigning the technician to measure intake and output
4. Comparing current outcomes with those set for the patient's
goals
5. Reflecting on patient's progress Correct Answer 1, 2, 4, 5
A nurse assesses a 78-year-old patient who weighs 108.9 kg
(240 lb) and is partially immobilized because of a stroke. The
nurse turns the patient and finds that the skin over the sacrum is
very red and the patient does not feel sensation in the area. The
patient has had fecal incontinence on and off for the past 2 days.
The nurse identifies the nursing diagnosis of Risk for Impaired
Skin Integrity. Which of the following outcomes is appropriate
for the patient?
1. Patient will be turned every 2 hours within 24 hours.
2. Patient will have normal formed stool within 48 hours.
3. Patient's ability to turn self in bed improves.
, 4. Erythema of skin will be mild to none within 48 hours.
Correct Answer 4
A nurse completes the following steps during her shift of care.
Which are the steps of nursing assessment? (Select all that
apply.)
1. The review of patient data in the medical record
2. Confirming a patient's self-report of abdominal pain by
inspecting the abdomen
3. Reporting results of an ongoing assessment to a nurse
working the next scheduled shift
4. Analyzing a set of signs revealing lower leg weakness and
unsteady gait with a pattern of mobility alteration
5. Conducting an interview of a family caregiver Correct
Answer 1, 2, 4, 5
A nurse conducts an assessment of a 42-year-old woman at a
health clinic. The woman is married and lives in a condo with
her husband. She reports having frequent voiding and pain when
she passes urine. The nurse asks whether she has to go to the
bathroom at night, and the patient responds, "Yes, usually twice
or more." The patient had an episode of diarrhea 1 week ago.
She weighs 300 lb and reports having difficulty cleansing
herself after voiding or passing stool. Which of the following
demonstrate assessment findings that cluster to indicate the
nursing diagnosis Impaired Urination. (Select all that apply.)
1. Age 42
2. Dysuria
3. Difficulty performing perineal hygiene
4. Nocturia
5. Episode of diarrhea Correct Answer 2, 4
