A nurse is using SBAR to hand off information to the next nurse. The nurse reports pertinent medical history, previous laboratory tests and treatments, psychosocial issues, allergies, and current code status. Which component of SBAR did the nurse communicate?
R
S
B
A
The nurse is bathing an 80-year-old man and notices his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor?
Increased numbers of sweat and sebaceous glands in the elderly
Increased vascularity of the skin in the elderly
An increased loss of elastin and a decrease in subcutaneous fat in the elderly
An increase in elastin and a decrease in subcutaneous fat in the elderly
The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person’s:
circulatory status.
support systems.
psychological wellness.
socioeconomic status.
During the history, a patient tells the nurse, “it feels like I am spinning around in circles.” The nurse would document this as:
seizure activity.
vertigo.
tinnitus.
syncope.
During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. This suggests?
Test was not performed accurately
Injury to the right eye
Increased intracranial pressure
Normal response after a head injury
Research has shown, the primary reason nurses make medication errors is related to:
The complexity of making accurate drug calculations
The presence of multiple drugs with similar generic and trade names
Heavy client assignments that require massive medication administrations
Events that distract the nurse during the administration process
During the admission interview the client reports to the nurse that she is “a little allergic to penicillin.” Which of the following questions asked by the nurse is most likely to provide the most relevant information regarding the client’s possible allergy to penicillin?
“Can you describe what happens when you take penicillin?”
“What makes you think you are allergic to penicillin?”
“Who told you that you are allergic to penicillin?”
“What do you take for an infection since you are allergic to penicillin?”
A nurse is collecting data on a patient who is being admitted into hospice care. The nurse collects data from both the patient and the family so a clear picture of the patient status is obtained. The nurse is currently involved in which step of the nursing process?
Evaluation
Diagnosing
Implementation
Assessment
A nurse assesses an older adult patient with the skin disorder shown below:
How should the nurse document this finding?
Ecchymoses
Papule
Petechiae
Senile angiomas
A patient states, “I’m burning up, and I have a fever.” The nurse takes the patient’s temperature, observes the skin for flushing, and feels the skin temperature. This is an example of __________ subjective data.
validating
clustering
documenting
reviewing
A nurse is using SBAR when communicating with the primary care provider and suggests a plan of care and requests an order for oxygen. Which component of SBAR did the nurse communicate?
Upon taking a history of a patient, the nurse learns the patient smokes a pack of cigarettes per day. How should the nurse interpret this finding?
This is an example of a health belief.
This is an example of health promotion.
This is an example of a negative health behavior.
This is an example of a basic physiological human need.
A student nurse is responsible for assessing a patient, who is abrupt and requests that the assessment be done later by a Registered nurse. As the student nurse charts the interaction, which statement is the best way to document what happened?
Behavior is inappropriate, requests registered nurse do the assessment
Appears to be in pain as evidenced by grouchy behavior
Patient is grumpy, registered nurse notified
States, “I want a registered nurse to do my assessment”
Which question or comment should the nurse initially use, which would best gather the most information during a health history assessment?
“Tell me about the problems you are having.”
“When did your problem first start?”
“Do you have a family history of this problem?”
“Let us help you.”
When caring for a patient from another culture, what is the best strategy for the nurse to use in communicating with the patient?
Considering the context of the patient’s background
Using a cultural joke to break the ice
Stereotyping the patient within his or her culture
Assuming the patient or the family member speaks English
Which patient is at greatest risk for developing a pressure ulcer?
Middle-aged adult with breast cancer
Teenager with a sprained ankle on crutches
Middle age adult that can turn self in bed
Young adult paraplegic with pneumonia
A patient is admitted to the hospital with a pressure ulcer on the sacrum. The wound is open with exposed bone. The nurse should document this pressure ulcer at what stage?
Stage I
Stage II
Stage III
Stage IV
A 89 year old patient presents in the hospital. Your assessment reveals bleeding gums and loose fitting dentures. What nursing diagnosis would be most appropriate?
Imbalanced Nutrition: more than body requirements
Impaired Circulation
Impaired Swallowing
Imbalanced Nutrition: less than body requirements
You have a patient who weighs 117 pounds and you are planning to administer a medication. Part of the process in nursing is to convert to kilograms.
Convert 117 pounds to ____________ kg Round to the nearest tenths position.
53.2
54.1
24.5
23.5
You are providing care for a patient who is being discharged from the hospital and providing patient education on medication administration. Throughout the hospital stay, you have been administering 15mL of a medication and need to instruct the patient that 15mL is equal to the following home measurement:
1 Tablespoon
2 Teaspoons
1 Ounce
1 Teaspoon
With use of the Braden Scale, it is important to understand concepts of moisture, sensory perception, activity level, and nutrition. You just came on shift and are preparing to care for your patient. You complete the Braden scale and understand the following number would represent a severe risk for skin breakdown?
14
7
18
12
You are completing ADL's with your newly assigned patient and you determine oral care is essential. Which is the best action you could take?
Provide the supplies to your patient and allow patient to complete the task independently
Assess the patient's ability to complete their own oral care.
Ask the patient's family if the patient can complete this by themselves.
Provide thorough oral care by brushing the patient's teeth and providing mouth wash.
You are assessing the nails of your patient. Which of the following is an abnormal finding which would require additional follow-up?
Pink nail beds
Clubbing
Yellow nails
Capillary Refill time less than 2 seconds
The balance between nutrient intake and nutrient requirements is described as:
Overnutrition
Malnutrition
Undernutrition
Nutritional Status
You obtain which data when screening patients for nutritional status?
Temperature, pulse and respiratory
Serum creatinine levels
Weight and nutritional intake history
Blood pressure and genogram
Assessing a patient's skin turgor is done to assess which clinical finding?
Edema
Scleroderma
Vitiligo
Dehydration
You examine the nail beds of a patient. Which finding indicates a normal angle?
60 degrees
160 degrees
100 degrees
180 degrees
While assessing pressure injuries (PI), you understand the nurse's ability to stage a wound. You view your patient to have full thickness skin loss. Which stage is this?
Unstageable
In regards to medication administration, medication doses have several important responses. It is important to know the peak response, as it related to which of the following
Time at which the medication reaches its highest effective concentration
Time for serum medication concentration to be halved
Minimum blood serum concentration before next scheduled dose
Time it takes for a medication to produce a response
Anisocoria Unequal pupil size
Miosis Constricted and fixed
Mydriasis Dilated and fixed
You are rooming a patient, 3 years old and his mother. Upon your assessment, you identify abnormalities related to the toddlers teeth. You suspect which the following condition and would ask more probing questions.
Dental Caries
Candidiasis
Gingivitis
Baby bottle tooth decay
Using a otoscope, the tympanic membrane is visualized. The normal color of the membrane is:
Creamy white
Pearly Gray
Dependent on the ethnicity of the patient
Deep pink
The common cause of a conductive hearing loss is:
Otitis externa
Acute rheumatic fever
Impacted cerumen
A Cerebral Vascular Accident (CVA)
When assessing the patient, you notice moisture on the skin. This is best described as:
bruising
dehydration
edema
diaphoresis
Alopecia absence of hair
Ecchymosis blue-purple marks
Confluent lesions run together
Pallor paleness
You just admitted a patient to the nursing floor and upon the assessment, you identify lesions that may be caused by trauma or abuse. What of the following aspects is important to know? (select all that apply)
feedback from the parents
patterns of injury
staging of injuries
type of injury
location on the body
Which is the closest telephone call to the correct sequence of SBAR reporting?
Hello, Mrs. Green is status post ACL repair yesterday and requires more morphine. She is a 54-year-old female who is experiencing pain 10-out-of-10. She is on the maximum dose of 4 mg IV every 2 hours. She denies pain relief on her current dose.
Hello, Mrs. Green is a 54-year-old female status post a right ACL repair. Her last dose of morphine was 4 mg IV 2-hours ago. She is complaining of excruciating pain 10-out-of- 10. She needs more pain medication.
Hello, Mrs. Green is a 54-year-old female complaining of pain and needs more pain medication. She got 4 mg of morphine IV 2 hours ago. Her husband came out of the room and is requesting more pain medication for her.
Hello, Mrs. Green has been in pain all night, she is a 54-year-old female status post right ACL repair who has an order for morhphine 2-4 mg IV every 2 hours. She is still experiencing pain 10-out-of-10 with the maximum dose of medication. Can we increase her medication order?
When measuring a patient’s weight, the nurse keeps in mind which of these guidelines?
It does not matter what type of scale is used, as long as the weights are similar from day to day.
The patient may leave on his or her jacket and shoes as long as this is documented next to the weight.
Always weigh the patient with only his or her undergarments on.
Attempt to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.
A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse assess this patient for cyanosis?
Assess the skin color of the earlobes.
Apply pressure to the palms of the hands.
Examine capillary refill time of the nail beds
Check the lips and oral mucous membranes.
The nurse is turning a patient when she notices an area with non-blanchable redness over the patient’s coccyx. The patient complains of pain at the site, and the site feels cooler than the areas immediately around the site. The nurse recognizes that this patient has developed:
a stage II pressure ulcer.
an unstageable pressure ulcer.
deep tissue injury.
a stage I pressure ulcer.
You are assessing a 6 year old patient complaining of pain in their mouth. You visually inspect the area and identify white patches on the tongue and cheeks. You are identifying which of the following:
Chicken Pox
Eczema
Dermatitis
"If I understand you correctly, you are telling me that..." What interview strategy is this an example of?
Summarization
Facilitation
Clarification
Reflection
When assessing the pupillary light reflex, the nurse should use which technique?
Ask the patient to follow the penlight in eight directions and observe for bilateral pupil constriction.
Shine a light across the pupil from the side and observe for direct and consensual pupillary constriction.
Shine a penlight from directly in front of the patient and inspect for pupillary constriction.
Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to about 7 cm from the nose.
A nurse assesses a client who has open lesions. Which action should the nurse take first?
Put on gloves.
Obtain vital signs.
Ask the client about his or her occupation.
Assess the client’s pain.
The nurse is assessing a patient’s eyes for the accommodation response and would expect to see which normal finding?
A consensual light reflex
Conjugate movement of the eyes
Convergence of the axes of the eyes
Dilation of the pupils
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