Nursing Concepts 1 - Final Exam Study
Questions With Correct Answers
Question 1: |
A nurse is caring for a client with Clostridium difficile (C. diff). Which infection
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control measures should the nurse implement? (Select all that apply.)
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1. Wash hands with soap and water before and after patient contact.
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2. Use an alcohol-based hand sanitizer after removing gloves.
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3. Wear gloves and a gown when entering the patient's room.
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4. Place the patient in a room with negative airflow.
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5. Use a surgical mask during patient care. - CORRECT ANSWER✔✔-Correct
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Answer: 1, 3
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Rationale: Washing hands with soap and water is essential to remove C. diff
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spores. Gloves and gowns are necessary as it is a contact precaution disease.
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Alcohol-based hand sanitizers are ineffective against C. diff spores. Negative
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airflow and surgical masks are not required for C. diff.
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Question 2: |
Which of the following nursing actions reflect adherence to the ANA Standards of
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Nursing Practice?
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1. Changing a patient's position every 2 hours without a physician's order.
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2. Collaborating with a dietician to create a patient care plan.
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3. Ensuring a colleague has documented an administered medication.
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,4. Adjusting oxygen flow rate from 2 L/min to 4 L/min based on patient needs. -
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CORRECT ANSWER✔✔-Correct Answer: 1
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Rationale: Autonomy, as per ANA standards, allows nurses to perform
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independent interventions like repositioning without a physician's order.
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Adjusting oxygen flow requires a provider's order unless it's an emergency.
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Nurses must document their actions, not rely on others.
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A nurse is providing education to a group about the Braden Scale. Which
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statement indicates understanding?
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1. "A higher Braden Scale score means the patient is at higher risk for pressure
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injuries."
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2. "It assesses the risk of injury due to factors like sensory perception, moisture,
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and activity."
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3. "The scale is used only for patients with existing pressure ulcers."
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4. "A score above 20 indicates a significant risk for pressure injuries." - CORRECT
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ANSWER✔✔-Correct Answer: 2
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Rationale: The Braden Scale evaluates risk factors such as sensory perception,
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moisture, and mobility. Higher scores indicate less risk. It is used preventively, not
| | | | | | | | | | | | |
solely for patients with ulcers.
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Question 4: |
A patient receiving enteral feedings is at risk for aspiration. Which nursing
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interventions are appropriate? (Select all that apply.)
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1. Keep the head of the bed at a minimum of 30 degrees.
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2. Measure gastric residual volume every 12 hours.
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3. Check tube placement before administering feedings.
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,4. Hold feedings if residual volume exceeds 500 mL.
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5. Provide oral suctioning as needed. - CORRECT ANSWER✔✔-Correct Answer: 1,
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3, 4, 5
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Rationale: Keeping the head of the bed elevated, checking tube placement, and
| | | | | | | | | | |
holding feedings when residual volume is high reduce aspiration risks. Gastric
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residual volume should be assessed every 4-6 hours for continuous feedings.
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Which of the following statements about wound care are correct? (Select all that
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apply.)
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1. Stage 1 pressure injuries require transparent dressings or barrier creams.
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2. Hydrocolloid dressings are appropriate for Stage 2 and 3 pressure injuries.
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3. Stage 4 pressure injuries may require gauze soaked in normal saline.
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4. Necrotic wounds are best treated with debridement and enzyme cream.
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5. Stage 3 pressure injuries never require surgical consultation. - CORRECT
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ANSWER✔✔-Correct Answer: 1, 2, 3, 4
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Rationale: Transparent dressings/barrier creams protect Stage 1 injuries.
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Hydrocolloids are suited for Stage 2 and 3 injuries. Deep wounds (Stage 4) often
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need saline-soaked gauze or debridement.
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The nurse is preparing to administer medications to a patient with chronic pain.
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Which considerations are appropriate for opioid administration?
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1. Monitor respiratory rate before administration.
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2. Administer naloxone if respiratory depression occurs.
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3. Anticipate constipation and provide stool softeners.
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4. Wait 10 days before assessing for opioid tolerance.
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, 5. Withhold opioids if the patient requests pain relief but shows no outward signs
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of discomfort. - CORRECT ANSWER✔✔-Correct Answer: 1, 2, 3
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Rationale: Opioids can cause respiratory depression, requiring naloxone as an
| | | | | | | | |
antidote. Constipation is a predictable side effect. Tolerance may develop sooner
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than 10 days. Pain is subjective, so outward signs are not necessary for
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administration.
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Question 7: |
A patient with pneumonia is experiencing dyspnea. What is the nurse's first
| | | | | | | | | | |
intervention?
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1. Administer prescribed oxygen.
| | |
2. Place the patient in a high-Fowler's position.
| | | | | | |
3. Notify the provider immediately.
| | | |
4. Perform chest physiotherapy. - CORRECT ANSWER✔✔-Correct Answer: 2
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Rationale: Positioning the patient improves lung expansion and is the least
| | | | | | | | | |
invasive initial intervention. Oxygen can follow if needed after assessment.
| | | | | | | | | |
Question 8: |
What teaching should the nurse provide to a patient with a new diagnosis of
| | | | | | | | | | | | |
hypertension? (Select all that apply.)
| | | | |
1. Reduce sodium intake to less than 2g/day.
| | | | | | |
2. Limit physical activity to prevent excessive stress on the heart.
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3. Stop smoking and limit alcohol consumption.
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4. Monitor blood pressure at home regularly.
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Questions With Correct Answers
Question 1: |
A nurse is caring for a client with Clostridium difficile (C. diff). Which infection
| | | | | | | | | | | | |
control measures should the nurse implement? (Select all that apply.)
| | | | | | | | | |
1. Wash hands with soap and water before and after patient contact.
| | | | | | | | | | |
2. Use an alcohol-based hand sanitizer after removing gloves.
| | | | | | | |
3. Wear gloves and a gown when entering the patient's room.
| | | | | | | | | |
4. Place the patient in a room with negative airflow.
| | | | | | | | |
5. Use a surgical mask during patient care. - CORRECT ANSWER✔✔-Correct
| | | | | | | | | |
Answer: 1, 3
| | |
Rationale: Washing hands with soap and water is essential to remove C. diff
| | | | | | | | | | | |
spores. Gloves and gowns are necessary as it is a contact precaution disease.
| | | | | | | | | | | | |
Alcohol-based hand sanitizers are ineffective against C. diff spores. Negative
| | | | | | | | | |
airflow and surgical masks are not required for C. diff.
| | | | | | | | | |
Question 2: |
Which of the following nursing actions reflect adherence to the ANA Standards of
| | | | | | | | | | | |
Nursing Practice?
| |
1. Changing a patient's position every 2 hours without a physician's order.
| | | | | | | | | | |
2. Collaborating with a dietician to create a patient care plan.
| | | | | | | | | |
3. Ensuring a colleague has documented an administered medication.
| | | | | | | |
,4. Adjusting oxygen flow rate from 2 L/min to 4 L/min based on patient needs. -
| | | | | | | | | | | | | | |
CORRECT ANSWER✔✔-Correct Answer: 1
| | | |
Rationale: Autonomy, as per ANA standards, allows nurses to perform
| | | | | | | | |
independent interventions like repositioning without a physician's order.
| | | | | | | |
Adjusting oxygen flow requires a provider's order unless it's an emergency.
| | | | | | | | | | |
Nurses must document their actions, not rely on others.
| | | | | | | | |
A nurse is providing education to a group about the Braden Scale. Which
| | | | | | | | | | | |
statement indicates understanding?
| | |
1. "A higher Braden Scale score means the patient is at higher risk for pressure
| | | | | | | | | | | | | |
injuries."
|
2. "It assesses the risk of injury due to factors like sensory perception, moisture,
| | | | | | | | | | | | |
and activity."
| |
3. "The scale is used only for patients with existing pressure ulcers."
| | | | | | | | | | |
4. "A score above 20 indicates a significant risk for pressure injuries." - CORRECT
| | | | | | | | | | | | |
ANSWER✔✔-Correct Answer: 2
| | |
Rationale: The Braden Scale evaluates risk factors such as sensory perception,
| | | | | | | | | |
moisture, and mobility. Higher scores indicate less risk. It is used preventively, not
| | | | | | | | | | | | |
solely for patients with ulcers.
| | | | |
Question 4: |
A patient receiving enteral feedings is at risk for aspiration. Which nursing
| | | | | | | | | | |
interventions are appropriate? (Select all that apply.)
| | | | | | |
1. Keep the head of the bed at a minimum of 30 degrees.
| | | | | | | | | | | |
2. Measure gastric residual volume every 12 hours.
| | | | | | |
3. Check tube placement before administering feedings.
| | | | | |
,4. Hold feedings if residual volume exceeds 500 mL.
| | | | | | | |
5. Provide oral suctioning as needed. - CORRECT ANSWER✔✔-Correct Answer: 1,
| | | | | | | | | |
3, 4, 5
| | |
Rationale: Keeping the head of the bed elevated, checking tube placement, and
| | | | | | | | | | |
holding feedings when residual volume is high reduce aspiration risks. Gastric
| | | | | | | | | | |
residual volume should be assessed every 4-6 hours for continuous feedings.
| | | | | | | | | | |
Which of the following statements about wound care are correct? (Select all that
| | | | | | | | | | | |
apply.)
|
1. Stage 1 pressure injuries require transparent dressings or barrier creams.
| | | | | | | | | |
2. Hydrocolloid dressings are appropriate for Stage 2 and 3 pressure injuries.
| | | | | | | | | | |
3. Stage 4 pressure injuries may require gauze soaked in normal saline.
| | | | | | | | | | |
4. Necrotic wounds are best treated with debridement and enzyme cream.
| | | | | | | | | |
5. Stage 3 pressure injuries never require surgical consultation. - CORRECT
| | | | | | | | | |
ANSWER✔✔-Correct Answer: 1, 2, 3, 4
| | | | | |
Rationale: Transparent dressings/barrier creams protect Stage 1 injuries.
| | | | | | |
Hydrocolloids are suited for Stage 2 and 3 injuries. Deep wounds (Stage 4) often
| | | | | | | | | | | | | |
need saline-soaked gauze or debridement.
| | | | |
The nurse is preparing to administer medications to a patient with chronic pain.
| | | | | | | | | | | |
Which considerations are appropriate for opioid administration?
| | | | | | |
1. Monitor respiratory rate before administration.
| | | | |
2. Administer naloxone if respiratory depression occurs.
| | | | | |
3. Anticipate constipation and provide stool softeners.
| | | | | |
4. Wait 10 days before assessing for opioid tolerance.
| | | | | | | |
, 5. Withhold opioids if the patient requests pain relief but shows no outward signs
| | | | | | | | | | | | |
of discomfort. - CORRECT ANSWER✔✔-Correct Answer: 1, 2, 3
| | | | | | | | |
Rationale: Opioids can cause respiratory depression, requiring naloxone as an
| | | | | | | | |
antidote. Constipation is a predictable side effect. Tolerance may develop sooner
| | | | | | | | | | |
than 10 days. Pain is subjective, so outward signs are not necessary for
| | | | | | | | | | | | |
administration.
|
Question 7: |
A patient with pneumonia is experiencing dyspnea. What is the nurse's first
| | | | | | | | | | |
intervention?
|
1. Administer prescribed oxygen.
| | |
2. Place the patient in a high-Fowler's position.
| | | | | | |
3. Notify the provider immediately.
| | | |
4. Perform chest physiotherapy. - CORRECT ANSWER✔✔-Correct Answer: 2
| | | | | | | |
Rationale: Positioning the patient improves lung expansion and is the least
| | | | | | | | | |
invasive initial intervention. Oxygen can follow if needed after assessment.
| | | | | | | | | |
Question 8: |
What teaching should the nurse provide to a patient with a new diagnosis of
| | | | | | | | | | | | |
hypertension? (Select all that apply.)
| | | | |
1. Reduce sodium intake to less than 2g/day.
| | | | | | |
2. Limit physical activity to prevent excessive stress on the heart.
| | | | | | | | | |
3. Stop smoking and limit alcohol consumption.
| | | | | |
4. Monitor blood pressure at home regularly.
| | | | | |
