Test Bank For Theoretical Basis for Nursing 6thEdition
by Melanie McEwen Evelyn M. Wills Chapter1-
23Complete
.
. A nurse is teaching the staff about alterations in breathing patterns. Which information
will the nurse include in the teaching session? (Select all that apply.)
a. Apnea—no respirations
b. Tachypnea—regular, rapid respirations
c. Kussmaul's—abnormally deep, regular, fast respirations
d. Hyperventilation—labored, increased in depth and rate respirations
e. Cheyne-Stokes—abnormally slow and depressed ventilation respirations
f. Biot's—irregular with alternating periods of apnea and hyperventilation respirations -
ansa. Apnea—no respirations
b. Tachypnea—regular, rapid respirations
c. Kussmaul's—abnormally deep, regular, fast respirations
. The nurse is caring for a patient who needs a protective environment. The nurse has
provided the care needed and is now leaving the room. In which order will the nurse
remove the personal protective equipment, beginning with the first step? 1. Remove
eyewear/face shield and goggles. 2. Perform hand hygiene, leave room, and close door.
3. Remove gloves. 4. Untie gown, allow gown to fall from shoulders, and do not touch
outside of gown; dispose of properly. 5. Remove mask by strings; do not touch outside
of mask. 6. Dispose of all contaminated supplies and equipment in designated
receptacles.
a. 3, 1, 4, 5, 6, 2
b. 1, 4, 5, 3, 6, 2
c. 1, 4, 5, 3, 2, 6
d. 3, 1, 4, 5, 2, 6 - ansd. 3, 1, 4, 5, 2, 6
. The nurse is providing perineal care to an uncircumcised male patient. Which action
will the nurse take?
a. Leave the foreskin alone because there is little chance of infection.
b. Retract the foreskin for cleansing and allow it to return on its own.
c. Retract the foreskin and return it to its natural position when done.
d. Leave the foreskin retracted after cleansing the penis - ansc. Retract the foreskin and
return it to its natural position when done.
A 55-year-old patient is preparing to start an exercise program. The health care provider
wants 60% of maximum target heart rate. Calculate the heart rate that the nurse will add
to the care plan as the target heart rate. Record answer as a whole number.
_________ maximum heart rate - ans99
,A diabetic patient presents to the clinic for a dressing change. The wound is located on
the right foot and has purulent yellow drainage. Which action will the nurse take to
prevent the spread of infection?
a. Position the patient comfortably on the stretcher.
b. Explain the procedure for dressing change to the patient. c. Review the medication
list that the patient brought from home.
d. Don gloves and other appropriate personal protective equipment - ansd. Don gloves
and other appropriate personal protective equipment
A female adult patient presents to the clinic with reports of a white discharge and itching
in the vaginal area. A nurse is taking a health history. Which question is the priority?
a. "When was the last time you visited your primary health care provider?"
b. "Has this condition affected your eating habits in any way?"
c. "What medications are you currently taking?"
d. "Are you able to sleep at night? - ansc. "What medications are you currently taking?"
A nurse delegates a position change to a nursing assistive personnel. The nurse
instructs the assistive personnel (AP) to place the patient in the lateral position. Which
finding by the nurse indicates a correct outcome?
a. Patient is lying on side.
b. Patient is lying on back.
c. Patient is lying semiprone.
d. Patient is lying on abdomen - ansa. Patient is lying on side.
A nurse is assessing a patient who began experiencing severe pain 3 days ago. When
the nurse asks the patient to describe the pain, the patient states, "The pain feels like it
is in my stomach. It is a burning pain, and it spreads out in a circle around the spot
where it hurts the most." Which type of pain does the nurse document the patient is
having at this time?
a. Superficial pain
b. Idiopathic pain
c. Chronic pain
d. Visceral pain - ansd. Visceral pain
A nurse is assessing a patient with activity intolerance for possible orthostatic
hypotension. Which finding will help confirm orthostatic hypotension?
a. Blood pressure sitting 120/64; blood pressure 140/70 standing
b. Blood pressure sitting 126/64; blood pressure 120/58 standing
c. Blood pressure sitting 130/60; blood pressure 110/60 standing
d. Blood pressure sitting 140/60; blood pressure 130/54 standing - ansc. Blood pressure
sitting 130/60; blood pressure 110/60 standing
A nurse is assessing a patient's skin. Which patient is most at risk for impaired skin
integrity?
a. A patient who is afebrile
,b. A patient who is diaphoretic
c. A patient with strong pedal pulses
d. A patient with adequate skin turgor - ansb. A patient who is diaphoretic
A nurse is assessing activity tolerance of a patient. Which areas will the nurse assess?
(Select all that apply.)
a. Skeletal abnormalities
b. Emotional factors
c. Pregnancy status
d. Race
e. Age - ansa. Skeletal abnormalities
b. Emotional factors
c. Pregnancy status
e. Age
A nurse is assessing body alignment. What is the nurse monitoring?
a. The relationship of one body part to another while in different positions
b. The coordinated efforts of the musculoskeletal and nervous systems
c. The force that occurs in a direction to oppose movement d. The inability to move
about freely - ansa. The relationship of one body part to another while in different
positions
A nurse is assessing pressure points in a patient placed in the Sims' position. Which
areas will the nurse observe?
a. Chin, elbow, hips
b. Ileum, clavicle, humerus
c. Shoulder, anterior iliac spine, ankles
d. Occipital region of the head, coccyx, heels - ansb. Ileum, clavicle, humerus
A nurse is assessing results of vital signs for a group of patients. Match the condition to
the assessment findings the nurse is reviewing.
a. Patient's temperature is 113° F (45° C) with hot, dry skin.
b. Patient's blood pressure sitting is 130/60 and 110/40 standing.
c. Patient's pulse is 110 beats/min.
d. Patient's temperature is 93.2° F (34° C).
e. Patient's blood pressure went from 126/76 to 90/50. 1. Hypothermia 2.
Shock/Hypotension 3. Heatstroke 4. Orthostatic hypotension 5. Tachycardia - ans1. D
2. E
3. A
4. B
5. C
A nurse is assessing the body alignment of a standing patient. Which finding will the
nurse report as normal?
a. When observed laterally, the spinal curves align in a reversed "S" pattern.
b. When observed posteriorly, the hips and shoulders form an "S" pattern.
, c. The arms should be crossed over the chest or in the lap. d. The feet should be close
together with toes pointed out. - ansa. When observed laterally, the spinal curves align
in a reversed "S" pattern.
A nurse is assessing the skin of an immobilized patient. What will the nurse do?
a. Assess the skin every 4 hours.
b. Limit the amount of fluid intake.
c. Use a standardized tool such as the Braden Scale.
d. Have special times for inspection so as to not interrupt routine care. - ansc. Use a
standardized tool such as the Braden Scale.
A nurse is assisting the patient to perform isometric exercises. Which action will the
nurse take?
a. Encourage wearing tight shoes.
b. Set the pace for the exercise session.
c. Stop the exercise if pain is experienced.
d. Force muscles or joints to go just beyond resistance. - ansc. Stop the exercise if pain
is experienced.
A nurse is caring for a group of patients. Which patient will the nurse see first to best
manage patient needs?
a. A patient who received morphine and has a pulse of 62 beats/min, respirations 10
breaths/min, and blood pressure 110/60 mm Hg.
b. A patient lying very still in bed who reports no pain but is pale with warm, dry skin.
c. A patient with severe pain who is nauseated and feels like he or she is about to vomit.
d. A patient writhing and moaning from abdominal pain after abdominal surgery. - ansa.
A patient who received morphine and has a pulse of 62 beats/min, respirations 10
breaths/min, and blood pressure 110/60 mm Hg.
A nurse is caring for a group of patients. Which patient will the nurse see first?
a. A 17-year-old male who has just returned from outside "for a smoke" who needs a
temperature taken.
b. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to
100/60.
c. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to
130/74.
d. An 87-year-old male suspected of hypothermia whose temperature is below normal. -
ansb. A 20-year-old male postoperative patient whose blood pressure went from 128/70
to 100/60.
A nurse is caring for a group of patients. Which patient will the nurse see first?
a. A crying infant with P-165 and R-54
b. A sleeping toddler with P-88 and R-23
c. A calm adolescent with P-95 and R-26
d. An exercising adult with P-108 and R-24 - ansc. A calm adolescent with P-95 and R-
26
by Melanie McEwen Evelyn M. Wills Chapter1-
23Complete
.
. A nurse is teaching the staff about alterations in breathing patterns. Which information
will the nurse include in the teaching session? (Select all that apply.)
a. Apnea—no respirations
b. Tachypnea—regular, rapid respirations
c. Kussmaul's—abnormally deep, regular, fast respirations
d. Hyperventilation—labored, increased in depth and rate respirations
e. Cheyne-Stokes—abnormally slow and depressed ventilation respirations
f. Biot's—irregular with alternating periods of apnea and hyperventilation respirations -
ansa. Apnea—no respirations
b. Tachypnea—regular, rapid respirations
c. Kussmaul's—abnormally deep, regular, fast respirations
. The nurse is caring for a patient who needs a protective environment. The nurse has
provided the care needed and is now leaving the room. In which order will the nurse
remove the personal protective equipment, beginning with the first step? 1. Remove
eyewear/face shield and goggles. 2. Perform hand hygiene, leave room, and close door.
3. Remove gloves. 4. Untie gown, allow gown to fall from shoulders, and do not touch
outside of gown; dispose of properly. 5. Remove mask by strings; do not touch outside
of mask. 6. Dispose of all contaminated supplies and equipment in designated
receptacles.
a. 3, 1, 4, 5, 6, 2
b. 1, 4, 5, 3, 6, 2
c. 1, 4, 5, 3, 2, 6
d. 3, 1, 4, 5, 2, 6 - ansd. 3, 1, 4, 5, 2, 6
. The nurse is providing perineal care to an uncircumcised male patient. Which action
will the nurse take?
a. Leave the foreskin alone because there is little chance of infection.
b. Retract the foreskin for cleansing and allow it to return on its own.
c. Retract the foreskin and return it to its natural position when done.
d. Leave the foreskin retracted after cleansing the penis - ansc. Retract the foreskin and
return it to its natural position when done.
A 55-year-old patient is preparing to start an exercise program. The health care provider
wants 60% of maximum target heart rate. Calculate the heart rate that the nurse will add
to the care plan as the target heart rate. Record answer as a whole number.
_________ maximum heart rate - ans99
,A diabetic patient presents to the clinic for a dressing change. The wound is located on
the right foot and has purulent yellow drainage. Which action will the nurse take to
prevent the spread of infection?
a. Position the patient comfortably on the stretcher.
b. Explain the procedure for dressing change to the patient. c. Review the medication
list that the patient brought from home.
d. Don gloves and other appropriate personal protective equipment - ansd. Don gloves
and other appropriate personal protective equipment
A female adult patient presents to the clinic with reports of a white discharge and itching
in the vaginal area. A nurse is taking a health history. Which question is the priority?
a. "When was the last time you visited your primary health care provider?"
b. "Has this condition affected your eating habits in any way?"
c. "What medications are you currently taking?"
d. "Are you able to sleep at night? - ansc. "What medications are you currently taking?"
A nurse delegates a position change to a nursing assistive personnel. The nurse
instructs the assistive personnel (AP) to place the patient in the lateral position. Which
finding by the nurse indicates a correct outcome?
a. Patient is lying on side.
b. Patient is lying on back.
c. Patient is lying semiprone.
d. Patient is lying on abdomen - ansa. Patient is lying on side.
A nurse is assessing a patient who began experiencing severe pain 3 days ago. When
the nurse asks the patient to describe the pain, the patient states, "The pain feels like it
is in my stomach. It is a burning pain, and it spreads out in a circle around the spot
where it hurts the most." Which type of pain does the nurse document the patient is
having at this time?
a. Superficial pain
b. Idiopathic pain
c. Chronic pain
d. Visceral pain - ansd. Visceral pain
A nurse is assessing a patient with activity intolerance for possible orthostatic
hypotension. Which finding will help confirm orthostatic hypotension?
a. Blood pressure sitting 120/64; blood pressure 140/70 standing
b. Blood pressure sitting 126/64; blood pressure 120/58 standing
c. Blood pressure sitting 130/60; blood pressure 110/60 standing
d. Blood pressure sitting 140/60; blood pressure 130/54 standing - ansc. Blood pressure
sitting 130/60; blood pressure 110/60 standing
A nurse is assessing a patient's skin. Which patient is most at risk for impaired skin
integrity?
a. A patient who is afebrile
,b. A patient who is diaphoretic
c. A patient with strong pedal pulses
d. A patient with adequate skin turgor - ansb. A patient who is diaphoretic
A nurse is assessing activity tolerance of a patient. Which areas will the nurse assess?
(Select all that apply.)
a. Skeletal abnormalities
b. Emotional factors
c. Pregnancy status
d. Race
e. Age - ansa. Skeletal abnormalities
b. Emotional factors
c. Pregnancy status
e. Age
A nurse is assessing body alignment. What is the nurse monitoring?
a. The relationship of one body part to another while in different positions
b. The coordinated efforts of the musculoskeletal and nervous systems
c. The force that occurs in a direction to oppose movement d. The inability to move
about freely - ansa. The relationship of one body part to another while in different
positions
A nurse is assessing pressure points in a patient placed in the Sims' position. Which
areas will the nurse observe?
a. Chin, elbow, hips
b. Ileum, clavicle, humerus
c. Shoulder, anterior iliac spine, ankles
d. Occipital region of the head, coccyx, heels - ansb. Ileum, clavicle, humerus
A nurse is assessing results of vital signs for a group of patients. Match the condition to
the assessment findings the nurse is reviewing.
a. Patient's temperature is 113° F (45° C) with hot, dry skin.
b. Patient's blood pressure sitting is 130/60 and 110/40 standing.
c. Patient's pulse is 110 beats/min.
d. Patient's temperature is 93.2° F (34° C).
e. Patient's blood pressure went from 126/76 to 90/50. 1. Hypothermia 2.
Shock/Hypotension 3. Heatstroke 4. Orthostatic hypotension 5. Tachycardia - ans1. D
2. E
3. A
4. B
5. C
A nurse is assessing the body alignment of a standing patient. Which finding will the
nurse report as normal?
a. When observed laterally, the spinal curves align in a reversed "S" pattern.
b. When observed posteriorly, the hips and shoulders form an "S" pattern.
, c. The arms should be crossed over the chest or in the lap. d. The feet should be close
together with toes pointed out. - ansa. When observed laterally, the spinal curves align
in a reversed "S" pattern.
A nurse is assessing the skin of an immobilized patient. What will the nurse do?
a. Assess the skin every 4 hours.
b. Limit the amount of fluid intake.
c. Use a standardized tool such as the Braden Scale.
d. Have special times for inspection so as to not interrupt routine care. - ansc. Use a
standardized tool such as the Braden Scale.
A nurse is assisting the patient to perform isometric exercises. Which action will the
nurse take?
a. Encourage wearing tight shoes.
b. Set the pace for the exercise session.
c. Stop the exercise if pain is experienced.
d. Force muscles or joints to go just beyond resistance. - ansc. Stop the exercise if pain
is experienced.
A nurse is caring for a group of patients. Which patient will the nurse see first to best
manage patient needs?
a. A patient who received morphine and has a pulse of 62 beats/min, respirations 10
breaths/min, and blood pressure 110/60 mm Hg.
b. A patient lying very still in bed who reports no pain but is pale with warm, dry skin.
c. A patient with severe pain who is nauseated and feels like he or she is about to vomit.
d. A patient writhing and moaning from abdominal pain after abdominal surgery. - ansa.
A patient who received morphine and has a pulse of 62 beats/min, respirations 10
breaths/min, and blood pressure 110/60 mm Hg.
A nurse is caring for a group of patients. Which patient will the nurse see first?
a. A 17-year-old male who has just returned from outside "for a smoke" who needs a
temperature taken.
b. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to
100/60.
c. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to
130/74.
d. An 87-year-old male suspected of hypothermia whose temperature is below normal. -
ansb. A 20-year-old male postoperative patient whose blood pressure went from 128/70
to 100/60.
A nurse is caring for a group of patients. Which patient will the nurse see first?
a. A crying infant with P-165 and R-54
b. A sleeping toddler with P-88 and R-23
c. A calm adolescent with P-95 and R-26
d. An exercising adult with P-108 and R-24 - ansc. A calm adolescent with P-95 and R-
26
