Quiz
N125 Exam 2
Fragen in diesem Quiz (50)
1A 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?
- AR
- BS
- CB
- DA
2The 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?
- AIncreased numbers of sweat and sebaceous glands in the elderly
- BIncreased vascularity of the skin in the elderly
- CAn increased loss of elastin and a decrease in subcutaneous fat in the elderly
- DAn increase in elastin and a decrease in subcutaneous fat in the elderly
3The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person’s:
- Acirculatory status.
- Bsupport systems.
- Cpsychological wellness.
- Dsocioeconomic status.
4During the history, a patient tells the nurse, “it feels like I am spinning around in circles.” The nurse would document this as:
- Aseizure activity.
- Bvertigo.
- Ctinnitus.
- Dsyncope.
5During 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?
- ATest was not performed accurately
- BInjury to the right eye
- CIncreased intracranial pressure
- DNormal response after a head injury
6Research has shown, the primary reason nurses make medication errors is related to:
- AThe complexity of making accurate drug calculations
- BThe presence of multiple drugs with similar generic and trade names
- CHeavy client assignments that require massive medication administrations
- DEvents that distract the nurse during the administration process
7During 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?
- A“Can you describe what happens when you take penicillin?”
- B“What makes you think you are allergic to penicillin?”
- C“Who told you that you are allergic to penicillin?”
- D“What do you take for an infection since you are allergic to penicillin?”
8A 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?
- AEvaluation
- BDiagnosing
- CImplementation
- DAssessment
9A nurse assesses an older adult patient with the skin disorder shown below:
How should the nurse document this finding?
- AEcchymoses
- BPapule
- CPetechiae
- DSenile angiomas
10A 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.
- Avalidating
- Bclustering
- Cdocumenting
- Dreviewing
11A 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?
- AR
- BS
- CA
- DB
12Upon 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?
- AThis is an example of a health belief.
- BThis is an example of health promotion.
- CThis is an example of a negative health behavior.
- DThis is an example of a basic physiological human need.
13A 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?
- ABehavior is inappropriate, requests registered nurse do the assessment
- BAppears to be in pain as evidenced by grouchy behavior
- CPatient is grumpy, registered nurse notified
- DStates, “I want a registered nurse to do my assessment”
14Which question or comment should the nurse initially use, which would best gather the most information during a health history assessment?
- A“Tell me about the problems you are having.”
- B“When did your problem first start?”
- C“Do you have a family history of this problem?”
- D“Let us help you.”
15When caring for a patient from another culture, what is the best strategy for the nurse to use in communicating with the patient?
- AConsidering the context of the patient’s background
- BUsing a cultural joke to break the ice
- CStereotyping the patient within his or her culture
- DAssuming the patient or the family member speaks English
16Which patient is at greatest risk for developing a pressure ulcer?
- AMiddle-aged adult with breast cancer
- BTeenager with a sprained ankle on crutches
- CMiddle age adult that can turn self in bed
- DYoung adult paraplegic with pneumonia
17A 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?
- AStage I
- BStage II
- CStage III
- DStage IV
18A 89 year old patient presents in the hospital. Your assessment reveals bleeding gums and loose fitting dentures. What nursing diagnosis would be most appropriate?
- AImbalanced Nutrition: more than body requirements
- BImpaired Circulation
- CImpaired Swallowing
- DImbalanced Nutrition: less than body requirements
19You 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.- A53.2
- B54.1
- C24.5
- D23.5
20You 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:
- A1 Tablespoon
- B2 Teaspoons
- C1 Ounce
- D1 Teaspoon
21With 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?
- A14
- B7
- C18
- D12
22You are completing ADL's with your newly assigned patient and you determine oral care is essential. Which is the best action you could take?
- AProvide the supplies to your patient and allow patient to complete the task independently
- BAssess the patient's ability to complete their own oral care.
- CAsk the patient's family if the patient can complete this by themselves.
- DProvide thorough oral care by brushing the patient's teeth and providing mouth wash.
23You are assessing the nails of your patient. Which of the following is an abnormal finding which would require additional follow-up?
- APink nail beds
- BClubbing
- CYellow nails
- DCapillary Refill time less than 2 seconds
24The balance between nutrient intake and nutrient requirements is described as:
- AOvernutrition
- BMalnutrition
- CUndernutrition
- DNutritional Status
25You obtain which data when screening patients for nutritional status?
- ATemperature, pulse and respiratory
- BSerum creatinine levels
- CWeight and nutritional intake history
- DBlood pressure and genogram
26Assessing a patient's skin turgor is done to assess which clinical finding?
- AEdema
- BScleroderma
- CVitiligo
- DDehydration
27You examine the nail beds of a patient. Which finding indicates a normal angle?
- A60 degrees
- B160 degrees
- C100 degrees
- D180 degrees
28While 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?
- AUnstageable
- BStage I
- CStage II
- DStage III
29In 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
- ATime at which the medication reaches its highest effective concentration
- BTime for serum medication concentration to be halved
- CMinimum blood serum concentration before next scheduled dose
- DTime it takes for a medication to produce a response
30Anisocoria Unequal pupil size
- ARichtig
- BFalsch
31Miosis Constricted and fixed
- ARichtig
- BFalsch
32Mydriasis Dilated and fixed
- ARichtig
- BFalsch
33You 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.
- ADental Caries
- BCandidiasis
- CGingivitis
- DBaby bottle tooth decay
34Using a otoscope, the tympanic membrane is visualized. The normal color of the membrane is:
- ACreamy white
- BPearly Gray
- CDependent on the ethnicity of the patient
- DDeep pink
35The common cause of a conductive hearing loss is:
- AOtitis externa
- BAcute rheumatic fever
- CImpacted cerumen
- DA Cerebral Vascular Accident (CVA)
36When assessing the patient, you notice moisture on the skin. This is best described as:
- Abruising
- Bdehydration
- Cedema
- Ddiaphoresis
37Alopecia absence of hair
- ARichtig
- BFalsch
38Ecchymosis blue-purple marks
- ARichtig
- BFalsch
39Confluent lesions run together
- ARichtig
- BFalsch
40Pallor paleness
- ARichtig
- BFalsch
41You 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)
- Afeedback from the parents
- Bpatterns of injury
- Cstaging of injuries
- Dtype of injury
- Elocation on the body
42Which is the closest telephone call to the correct sequence of SBAR reporting?
- AHello, 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.
- BHello, 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.
- CHello, 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.
- DHello, 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?
43When measuring a patient’s weight, the nurse keeps in mind which of these guidelines?
- AIt does not matter what type of scale is used, as long as the weights are similar from day to day.
- BThe patient may leave on his or her jacket and shoes as long as this is documented next to the weight.
- CAlways weigh the patient with only his or her undergarments on.
- DAttempt to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.
44A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse assess this patient for cyanosis?
- AAssess the skin color of the earlobes.
- BApply pressure to the palms of the hands.
- CExamine capillary refill time of the nail beds
- DCheck the lips and oral mucous membranes.
45The 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:
- Aa stage II pressure ulcer.
- Ban unstageable pressure ulcer.
- Cdeep tissue injury.
- Da stage I pressure ulcer.
46You 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:
- AChicken Pox
- BEczema
- CDermatitis
- DCandidiasis
47"If I understand you correctly, you are telling me that..." What interview strategy is this an example of?
- ASummarization
- BFacilitation
- CClarification
- DReflection
48When assessing the pupillary light reflex, the nurse should use which technique?
- AAsk the patient to follow the penlight in eight directions and observe for bilateral pupil constriction.
- BShine a light across the pupil from the side and observe for direct and consensual pupillary constriction.
- CShine a penlight from directly in front of the patient and inspect for pupillary constriction.
- DAsk the patient to focus on a distant object. Then ask the patient to follow the penlight to about 7 cm from the nose.
49A nurse assesses a client who has open lesions. Which action should the nurse take first?
- APut on gloves.
- BObtain vital signs.
- CAsk the client about his or her occupation.
- DAssess the client’s pain.
50The nurse is assessing a patient’s eyes for the accommodation response and would expect to see which normal finding?
- AA consensual light reflex
- BConjugate movement of the eyes
- CConvergence of the axes of the eyes
- DDilation of the pupils
Informationen
- Beschreibung
- Nursing Quiz am N125 Exam 2 , erstellt von champagne papii am 28/06/2022.
- Autor
- champagne papii
- Sprache
- English
- Aufrufe
- 353
- Schlagwörter
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