Nurs 344 Fundamentals Practice Exam 1 Questions and Answers

Nurs 344 Fundamentals Practice Exam 1 Questions and Answers What instructions will the nurse educate their patient to prevent UTIs? (SATA) A. Take bubble baths B. Wear cotton underwear C. Cleanse the perineum from front to back D. Drink at least 1500 ml of fluid/day E. Urinate as infrequently as possible F. cleanse the genitalia area before intercourse. B. Wear cotton underwear C. Cleanse the perineum from front to back D. Drink at least 1500 ml of fluid/day The nurse is working with a patient who has left-sided weakness. After instruction, the nurse observe the patient ambulate in order to evaluate the use of the cane. Which action indicates that the patient knows how to use the cane properly? A. The patient keeps the cane on the left side. B. Two points of support are kept on the floor at all times C. there is a slight lean to the right when the patient is walking D. after advancing the cane, the patient moves the right leg forward. B. Two points of support are kept on the floor at all times Image: The nurse is working with a patient who has left-sided weakness. After instruction, the nurse observe the patient ambulate in order to evaluate the use of the cane. Which action indicates that the patient knows how to use the cane properly? A. The patient keeps the cane on the left side. B. Two points of support are kept on the floor at all times C. there is a slight lean to the right when the patient is walking D. after advancing the cane, the patient moves the right leg forward. A patient with a fractured left femur has been using crutches for the past 4 weeks/. The physician tells the patient to begin putting a little weight on the left foot when walking. Which of the following gaits should the patient be taught to use? a. two-point b. three-point c. four-point d. swing-through c. four-point Image: A patient with a fractured left femur has been using crutches for the past 4 weeks/. The physician tells the patient to begin putting a little weight on the left foot when walking. Which of the following gaits should the patient be taught to use? a. two-point b. three-point c. four-point d. swing-through Nurses need to implement appropriate body mechanics in order to prevent injury to themselves and their clients. Which principle of body mechanics should the nurse incorporate into client care? 1. Flex the knees and keep the feet wide apart. 2. Assume a position far enough away from the client. 3. Twist the body in the direction of movement. 4. Use the strong back muscles for lifting or moving. 1. Flex the knees and keep the feet wide apart. Image: Nurses need to implement appropriate body mechanics in order to prevent injury to themselves and their clients. Which principle of body mechanics should the nurse incorporate into client care? 1. Flex the knees and keep the feet wide apart. 2. Assume a position far enough away from the client. 3. Twist the body in the direction of movement. 4. Use the strong back muscles for lifting or moving. A patient is admitted to the medical unit following a cerebrovascular accident (stroke). There is evidence of left-sided hemiparesis, and the nurse will be following up on ROM and other exercises performed in PT. The nurse correctly teaches the patient and family members which of the following principles of ROM exercises? a. move the joints quickly b. work from the lower to upper body c. flew the joint to the point of resistance d. provide support above and below joints d. provide support above and below joints The best approach for the nurse to use to assess the presence of deep vein thrombosis in an immobilized patient is to: a. measure the calf and thigh diameters b. attempt to elicit the Homan sign c. palpate the temperature of the feet d. observe for a loss of hair and skin turgor in the lower legs. a. measure the calf and thigh diameters An immobilized client is suspected of having atelectasis. This is assessed by the nurse upon auscultation as: A. Harsh crackles B. Wheezing on inspiration C. Diminished breath sounds D. Bronchovesicular whooshing C. Diminished breath sounds In order to promote respiratory function in the immobilized patient, the nurse should: A. encourage deep breathing and coughing every hour B. use oxygen and nebulizer treatments regularly C. change thhe patient;s position Q 4-8 hours D. suction the patient every hour A. encourage deep breathing and coughing every hour To provide for the psychosocial needs of an immobilized patient, an appropriate statement by the nurse is: a. "the staff will limit your visitors so that you will not be bothered" b. "a roommate can be a real bother. you'd probably rather have a private room." c. "let's discuss the routine to see if there are any changes we can make" d. "I think you should have your hair done and put on some make up" c. "let's discuss the routine to see if there are any changes we can make" Which of the following observations by the nurse indicates the correct use by the patient of a walker without wheels? A. Moving forward with both feet and then advancing the walker B. Moving one foot forward, advancing the walker, and then moving the other foot C. Sliding the walker while shuffing both feet forward D. lifting the walker forward one step, placing it on the ground, and then stepping forward into the walker. D. lifting the walker forward one step, placing it on the ground, and then stepping forward into the walker. In order to reduce the chance of external hip rotation in a patient on prolonged bed rest, the nurse should implement the use of a: a. footboard b. trapeze bar c. bed board d. trochanter roll d. trochanter roll Image: In order to reduce the chance of external hip rotation in a patient on prolonged bed rest, the nurse should implement the use of a: a. footboard b. trapeze bar c. bed board d. trochanter roll An ambulatory diabetic patient states that she is unable to reach her feet to clip her toenails. The patient's toenails are long and thick. What is the next step the nurse should take? a. soak the patient's feet and trim her toenails using clippers b. delegate foot care of this ppatient to the unlicensed assistive personnel c. assess the patient self-care d. ask the primary care provider (PCP) for a referral to a podiatrist d. ask the primary care provider (PCP) for a referral to a podiatrist Which actions by the nurse concerning oral care on an unconscious patient are considered safe? (Select all that apply.) a. performing oral care with the patient in a supine position b. performing oral care with the patient turned to the side c. installing suction equipment at the bbedside d. providing oral care every 2 hours e. using a hard bristle toothbrush Answers: b, c, d Oral care on an unconscious patient is performed with the patient turned to one side so that fluid can drain out of the side of the mouth. Suction equipment is used to remove fluid and secretions during oral care on an unconscious patient. Oral care should be provided at least every 2 hours for patients who are unconscious, receiving nothing by mouth (NPO), intubated, or receiving oxygen by a mask. An unconscious patient may aspirate if oral care is done in the supine position. A hard-bristle brush may damage the oral mucosa. Which nursing diagnosis is a priority for a patient who needs assistance with activities of daily living? a. Self-Care Deficit b. Deficient Knowledge c. Risk for Activity Intolerance d. Readiness for Enhanced Self-Care Answer: aA patient who has an impaired ability to complete bathing, mouth care, toileting, grooming, dressing, and eating without assistance has a Self-Care Deficit. Deficient Knowledge implies that the patient does not have certain information. Risk for Activity Intolerance may be a concern if a patient's level of activity is reduced, but this nursing diagnosis is not related to needing assistance. A diagnosis of Readiness for Enhanced Self-Care means that the patient is ready to perform activities to enhance health. Which statement accurately describes proper technique for performing male perineal care? The nurse a. washes the patient from the back of the perineum toward the penis. b. washes with a circular motion starting with the urinary meatus. c. places the patient in the prone position with supporting pillows. d. places the patient in the dorsal recumbent position. ANS: B During male perineal care the penis is cleansed with soap and water using a circular motion starting at the urinary meatus in order to keep pathogens away from the urinary tract. The shaft of the penis is then cleansed using firm downward strokes. The patient is usually in the supine position with the bed either flat or the head of the bed raised. The nurse has delegated care of a patient's dentures to unlicensed assistive personnel. Which statement by the assistive personnel indicates an understanding of denture care? a. "It is not necessary to use a toothbrush in the patient's mouth since the patient does not have teeth." b. "I will wrap the dentures in a tissue so that they will not get damaged and place them on the bedside table within reach of the patient." c. "I will put on clean gloves and brush the dentures gently with a toothbrush and toothpaste." d. "I will soak the dentures in the sink and then place them in a denture cup labeled with the patient's name." ANS: C Dentures are brushed with a regular toothbrush and toothpaste over a sink that has been padded with a washcloth to prevent breakage if they are accidentally dropped. The patient's mouth should be cleansed with a soft brush or toothette after the dentures are removed and before they are reinserted. Never wrap dentures in a tissue because they may accidently be discarded. Soaking dentures in a sink where nurses and patients wash their hands is contraindicated because pathogens may be present in the sink. A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurse is implementing which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Implementation A. Assessment Rationale: The first step in the nursing process is assessment, the process of collecting data. All subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate and complete data. When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the following before determining whether the BP is normal or represents hypertension? A. Compare this reading against defined standards B. Compare the reading with one taken in the opposite arm C. Determine gaps in the vital signs in the client record D. Compare the current measurement with previous ones A. Compare this reading against defined Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an older adult. The nurse compares the client's data against identified standards to determine whether this reading is normal or abnormal. Measuring the BP in the other arm (option 2) and comparing the reading to previous ones (option 4) will give additional client data, but the comparison alone will not determine whether the BP is normal. Gaps in the record (option 3) will not aid in interpreting the current measurement. The nurse who documents on the client's care plan the outcome goal "Anxiety will be relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is engaged in which step of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation B. Planning Rationale: The planning step of the nursing process involves formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problems. Outcome goals are documented on the client's care plan. Assessment data (option 1) is used to help identify a client's human response, and once a plan is established, the interventions are implemented (option 3) and evaluated (option 4). The nurse assigned to care for a postoperative client has asked an unlicensed assistive person (UAP) to help the client ambulate in the hall. Before delegating this task, the nurse must do which of the following? A. Assess the client to be sure ambulation with assistance is an appropriate care measure B. Ask the client if he or she is ready to ambulate C. Ask whether the UAP has time to assist the client D. Ask the charge nurse whether UAPs have ambulated the client during this shift A. Assess the client to be sure ambulation with assistance is an appropriate care measure Rationale: Prior to delegating any client care responsibilities, the nurse must assess the client to assure that the delegation is appropriate to his or her care. Options 2, 3, and 4 would not constitute an assessment of the client's current status. The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? A. Subjective data from a primary source B. Subjective data from a secondary source C. Objective data from a primary source D. Objective data from a secondary source A. Subjective data from a primary source Rationale: The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the last 10 days (and essentially no protein intake). The nurse would formulate which diagnostic statement that would best reflect this problem? A. Risk for malnutrition related to clear liquid diet B. Impaired skin integrity related to no protein intake C. Risk for impaired skin integrity related to malnutrition D. Impaired nutrition related to current illness C. Risk for impaired skin integrity related to malnutrition Rationale: This is a risk diagnosis, and the diagnostic statement has two parts: the human response (impaired skin integrity) and the related/risk factor (malnutrition). Options 1 and 2 do not have related factors that are under the control of the nurse (i.e., type of diet ordered). The diagnosis in option 4 does not specify the type of impairment (greater than or less than body requirements) and is therefore incomplete. It also does not provide direction for development of goals and interventions. Twenty minutes after administering pain medication to the client, the nurse returns to ask if the client's level of pain has decreased. The nurse documents the client's response as part of which phase of the nursing process? A. Diagnosis B. Planning C. Implementation D. Evaluation D. Evaluation Rationale: Evaluating is the process of comparing client responses to the outcome goals to determine whether, or to what degree, goals have been met. Diagnosing identifies health problems, risks, and strengths. Planning is the formulation of client goals and nursing strategies (interventions) required to prevent, reduce, or eliminate the client's health problems. Implementing is carrying out or delegating the nursing interventions. Which of the following outcome goals has the nurse designed correctly for the postoperative client's plan of care? Select all that apply. A. Client will state pain is less than or equal to 3 on zero to ten pain scale B. Client will have no pain C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge E. Client will be medicated every 4 hours by the nurse C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge Rationale: An outcome goal should be SMART: specific, measurable, appropriate, realistic, and timely. Options 3 and 4 are SMART goals. Options 1 and 2 have no timeframe to achieve the goal and are therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect a postoperative client to be pain free. Option 5 is not a client goal. The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult? A. Formulate a nursing diagnosis of impaired gas exchange B. Record in the medical record the distance a client ambulate in the hall C. Write individualized nursing orders in the care plan D. Compare client responses to the desired outcomes for pain relief B. Record in the medical record the distance a client ambulate in the hall Rationale: The implementation phase of the nursing process involves carrying out or delegating the nursing interventions and recording nursing activities and client responses in the medical records. Option 1 represents diagnosing. Option 3 represents planning. Option 4 represents evaluation. The client reports nausea and constipation. Which of the following would be the priority nursing action? A. Collect a stool sample B. Complete an abnormal assessment C. Administer an anti-nausea medication D. Notify the physician B. Complete an Abdominal assessment Rationale: Assessment involves the systematic collection of data about an individual upon which all subsequent phases of the nursing process are built. In response to a client's complaint, a nurse assesses a specific body system to obtain data that will help the nurse make a nursing diagnosis and plan the client's care. The other options reflect interventions, which are not timely unless there is first a complete assessment. Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the UAP violated? a. Libel b. Slander c. Assault d. Negligence B- Slander Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (Libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below standard of care for a specific professional group An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. What is the most appropriate nursing response? a. "Oh really I will discuss this situation with your son" b. "Let's talk about the ways you can manage your time to prevent this from happening" c. "Do you have any friends that can help you out until you resolve these important issues with your son?" d. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay. D- The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured under a legal obligation. Option 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client. A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? a. Obtain a court order for the surgical procedure b. Ask the EMS team to sign the informed consent c. Transport the victim to the operating room for surgery d. Call the police to identify the client and locate the family. 2. C- In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following hand hygiene methods should the nurse use? a. alcohol-based sanitizer b. soap and water c. iodine solution d. chlorhexidine solution b. soap and water A nurse is admitting a client who has vancomycin-resistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions? a. protective b. contact c. droplet d. airborne b. contact A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take? a. open the first flap on the sterile package away from their body b. place objects on the sterile field at least 1.3cm (0.5in) from the edge c. unwrap both sides of the sterile package at the same time d. set up the sterile field next to a wall in the clients room a. open the first flap on the sterile package away from their body. A nurse is assisting with implementing an infection control bundle for clients at risk for catheter-associated urinary tract infections (CAUTIs). Which of the following interventions should the nurse include in the bundle? a. try to use alternatives before inserting indwelling urinary catheters b. use clean technique for insertion of indwelling urinary catheters c. check client every 2 days to evaluate the need for indwelling catheters d. disconnect the system to obtain urine samples from indwelling urinary catheters a. try to use alternatives before inserting indwelling urinary catheters A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that which of the following types of precautions requires the use of an N95 mask? a. protective isolation b. contact c. droplet d. airborne d. airborne Rationale: Airborne precautions are used to prevent transmission of infections caused by small droplets in the air, such as measles or chickenpox. A nurse who is caring for a client on airborne precautions should don an N95 mask or a high-level respirator when entering the room. A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AIIR). Which of the following information should the nurse include? A.) The door to the AIIR should remain closed. B.) Clients who are on contact precautions require AIIR. C.) An AIIR has at least 4 air exchanges each hr. D.) A mask is not needed to care for clients who are in an AIIR. A.) The door to the AIIR should remain closed. Rationale: The nurse should instruct to keep the door to the AIIR closed at all times to reduce the risk of transmission of the infectious agent. A nurse is caring for a client who has influenza. The client asks how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes? A.) Droplet B.) Indirect contact C.) Airborne D.) Direct contact A.) Droplet Rationale: The nurse should inform the client that influenza is transmitted through large droplets in the air. The client should be placed in a private room, and the nurse should wear a surgical mask when caring for the client A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following bed positions is appropriate for safe care of this client? A. Supine B. Semi-Fowler's C. Semi-prone D. Trendelenburg B. Semi-Fowler's