NSE 111 Exam Questions and Answers
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Terms in this set (44)
A home health nurse is ANS: D
performing a home Allowing a car to run in the garage introduces carbon
assessment for safety. monoxide into the environment and decreases the
Which of the following available oxygen for human consumption. Garages
comments by the patient should be opened and not just cracked to allow fresh
would indicate a need for air into the space and allay this concern. Checking the
further education? chimney and
a. "I will schedule an heater, changing the batteries on the detector, and
appointment with a following up on symptoms such as dizziness, nausea,
chimney inspector next and fatigue are all statements that would indicate that
week." the individual has understood the education.
b. "Daylight savings is the
time to change batteries
on the carbon monoxide
detector."
c. "If I feel dizzy when
using the heater, I need to
have it inspected."
d. "When it is cold outside
in the winter, I can warm
my car up in the garage."
,The nurse is caring for an ANS: A
elderly patient admitted Electricity is needed for refrigeration of food, and lack
with nausea, vomiting, and of electricity could have contributed to the nausea,
diarrhea. Upon vomiting, and diarrhea—potential food poisoning. This
completing the health discussion about the patient's electrical needs can be
history, which priority referred to social services. The water supply, the
concern would require increased number of individuals in the home, and not
collaboration with social having a microwave may or may not be concerns but
services to address the do not pertain to the current health care needs of this
patient's health care patient.
needs?
a. The electricity was
turned off 2 days ago.
b. The water comes from
the county water supply.
c. A son and family
recently moved into the
home.
d. The home is not
furnished with a
microwave oven.
The patient has been ANS: A
diagnosed with a The comfort zone for most individuals is the range
respiratory illness and between 65° F and 75° F (18.3° C to 23.9° C). The other
complains of shortness of ranges do not reflect the average person's comfort
breath. The nurse adjusts zone.
the temperature to
facilitate the comfort of
the patient. What is the
usual comfort range for
most patients?
a. 65° F to 75° F
b. 60° F to 75° F
c. 15° C to 17° C
d. 25° C to 28° C
,A homeless adult patient ANS: B
presents to the Hypothermia is defined as a core body temperature
emergency department. of 95° F or below. Homeless individuals are more at
The nurse obtains the risk for hypothermia owing to exposure to the
following vital signs: elements.
temperature 94.8° F, blood
pressure 100/56, apical
pulse 56, respiratory
rate 12. Which of the vital
signs should be addressed
immediately?
a. Respiratory rate
b. Temperature
c. Apical pulse
d. Blood pressure
The nurse is caring for a ANS: D
patient with a urinary After disposing of the urine, the first step in removing
catheter. After the nurse personal protective equipment is removing gloves
empties the collection and disposing of them properly. In this scenario, the
bag and disposes of the next step would be to remove eye protection
urine, the next step is to followed by hand hygiene. Wash hands if the hands
a. Use alcohol-based gel are visibly soiled; otherwise the use of alcohol-based
on hands. gel is indicated for routine decontamination of hands.
b. Wash hands with soap
and water.
c. Remove eye protection
and dispose of in
garbage.
d. Remove gloves and
dispose of in garbage.
, The nurse is preparing a ANS: A
patient for surgery. The The purpose of writing on the surgical site as part of
nurse explains that the the Universal Protocol from the Joint Commission is to
reason for writing in distinguish the correct site on the correct patient and
indelible ink on the match with the correct surgeon for patient safety and
surgical site the word prevention of wrong site surgery. All patients who are
"correct" is to having an invasive procedure should receive labeling
a. Distinguish the correct in many different ways, including the record and
surgical site. patient armbands. Writing in indelible ink may comply
b. Label the correct with the surgeon's preference, but safety is the driving
patient. factor. Although labeling of the site helps to meet
c. Comply with the regulatory standards, this is not the reason to do this
surgeon's preference. activity—the reason is to keep the patient safe.
d. Adhere to the correct
regulatory standard.
The nurse identifies that a ANS: B
patient has received After providing an incorrect medication, assessing
Mylanta (simethicone) and monitoring the patient to determine the effects of
instead of the prescribed the medication is the first step. Notifying the physician
Pepto-Bismol (bismuth and providing treatment would be the best next step.
subsalicylate) for the After the patient has stabilized, completing an
problem of indigestion. incident report would be the last step in the process.
The nurse's next
intervention is to
a. Do nothing, no harm
has occurred.
b. Assess and monitor the
patient.
c. Notify the physician,
treat and document.
d. Complete an incident
report.
Save
Terms in this set (44)
A home health nurse is ANS: D
performing a home Allowing a car to run in the garage introduces carbon
assessment for safety. monoxide into the environment and decreases the
Which of the following available oxygen for human consumption. Garages
comments by the patient should be opened and not just cracked to allow fresh
would indicate a need for air into the space and allay this concern. Checking the
further education? chimney and
a. "I will schedule an heater, changing the batteries on the detector, and
appointment with a following up on symptoms such as dizziness, nausea,
chimney inspector next and fatigue are all statements that would indicate that
week." the individual has understood the education.
b. "Daylight savings is the
time to change batteries
on the carbon monoxide
detector."
c. "If I feel dizzy when
using the heater, I need to
have it inspected."
d. "When it is cold outside
in the winter, I can warm
my car up in the garage."
,The nurse is caring for an ANS: A
elderly patient admitted Electricity is needed for refrigeration of food, and lack
with nausea, vomiting, and of electricity could have contributed to the nausea,
diarrhea. Upon vomiting, and diarrhea—potential food poisoning. This
completing the health discussion about the patient's electrical needs can be
history, which priority referred to social services. The water supply, the
concern would require increased number of individuals in the home, and not
collaboration with social having a microwave may or may not be concerns but
services to address the do not pertain to the current health care needs of this
patient's health care patient.
needs?
a. The electricity was
turned off 2 days ago.
b. The water comes from
the county water supply.
c. A son and family
recently moved into the
home.
d. The home is not
furnished with a
microwave oven.
The patient has been ANS: A
diagnosed with a The comfort zone for most individuals is the range
respiratory illness and between 65° F and 75° F (18.3° C to 23.9° C). The other
complains of shortness of ranges do not reflect the average person's comfort
breath. The nurse adjusts zone.
the temperature to
facilitate the comfort of
the patient. What is the
usual comfort range for
most patients?
a. 65° F to 75° F
b. 60° F to 75° F
c. 15° C to 17° C
d. 25° C to 28° C
,A homeless adult patient ANS: B
presents to the Hypothermia is defined as a core body temperature
emergency department. of 95° F or below. Homeless individuals are more at
The nurse obtains the risk for hypothermia owing to exposure to the
following vital signs: elements.
temperature 94.8° F, blood
pressure 100/56, apical
pulse 56, respiratory
rate 12. Which of the vital
signs should be addressed
immediately?
a. Respiratory rate
b. Temperature
c. Apical pulse
d. Blood pressure
The nurse is caring for a ANS: D
patient with a urinary After disposing of the urine, the first step in removing
catheter. After the nurse personal protective equipment is removing gloves
empties the collection and disposing of them properly. In this scenario, the
bag and disposes of the next step would be to remove eye protection
urine, the next step is to followed by hand hygiene. Wash hands if the hands
a. Use alcohol-based gel are visibly soiled; otherwise the use of alcohol-based
on hands. gel is indicated for routine decontamination of hands.
b. Wash hands with soap
and water.
c. Remove eye protection
and dispose of in
garbage.
d. Remove gloves and
dispose of in garbage.
, The nurse is preparing a ANS: A
patient for surgery. The The purpose of writing on the surgical site as part of
nurse explains that the the Universal Protocol from the Joint Commission is to
reason for writing in distinguish the correct site on the correct patient and
indelible ink on the match with the correct surgeon for patient safety and
surgical site the word prevention of wrong site surgery. All patients who are
"correct" is to having an invasive procedure should receive labeling
a. Distinguish the correct in many different ways, including the record and
surgical site. patient armbands. Writing in indelible ink may comply
b. Label the correct with the surgeon's preference, but safety is the driving
patient. factor. Although labeling of the site helps to meet
c. Comply with the regulatory standards, this is not the reason to do this
surgeon's preference. activity—the reason is to keep the patient safe.
d. Adhere to the correct
regulatory standard.
The nurse identifies that a ANS: B
patient has received After providing an incorrect medication, assessing
Mylanta (simethicone) and monitoring the patient to determine the effects of
instead of the prescribed the medication is the first step. Notifying the physician
Pepto-Bismol (bismuth and providing treatment would be the best next step.
subsalicylate) for the After the patient has stabilized, completing an
problem of indigestion. incident report would be the last step in the process.
The nurse's next
intervention is to
a. Do nothing, no harm
has occurred.
b. Assess and monitor the
patient.
c. Notify the physician,
treat and document.
d. Complete an incident
report.
