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Quiz on Basic Nursing Quiz 3, created by mminter002 on 10/11/2014.

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Basic Nursing Quiz 3

Question 1 of 21

1

From what stage of sleep are people typically most difficult to arouse?

Select one of the following:

  • NREM, sleep spindles

  • NREM, delta waves

  • NREM, alpha waves

  • REM

Explanation

Question 2 of 21

1

A patient’s vital signs prior to a blood transfusion were: T = 97.6°F (36.4°C); P = 72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg. Twenty minutes after the transfusion was begun, the patient began complaining of feeling “itchy and hot.” The nurse discovered a rash on the patient’s trunk. Vital signs were: T = 100.8°F (38.2°C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the priority intervention?

Select one of the following:

  • Administer an antihistamine (anti-allergenic) medication.

  • Flush the blood tubing with D5W immediately.

  • Stop the blood transfusion immediately.

  • Prepare for emergency resuscitation

Explanation

Question 3 of 21

1

Chronic stress may lead directly to cardiovascular disease because of the repeated release of which of the following?

Select one of the following:

  • Catecholamines

  • Protease

  • Cortisol

  • Histamines

Explanation

Question 4 of 21

1

You are caring for an adult patient with a tracheostomy who is being mechanically ventilated. His pulse oximetry reading is 85%, heart rate is 113, and respiratory rate is 30. The patient is very restless. His respirations are labored, and you hear gurgling sounds. You auscultate crackles and rhonchi in both lungs. What is the most appropriate action to take?

Select one of the following:

  • Notify the physician of the patient's signs of fluid overload

  • Provide endotracheal suctioning

  • Provide tracheostomy care

  • Call the respiratory therapist to check the ventilator settings

Explanation

Question 5 of 21

1

Patency is the condition of being open, expanded, or unobstructed.

Select one of the following:

  • True
  • False

Explanation

Question 6 of 21

1

A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patient’s pain?

Select one of the following:

  • Acute

  • Neuropathic

  • Chronic

  • Intractable

Explanation

Question 7 of 21

1

A patient who underwent a left above-the-knee amputation complains of pain in his left foot. The nurse should document this finding as what type of pain?

Select one of the following:

  • Phantom

  • Referred

  • Radiating

  • Psychogenic

Explanation

Question 8 of 21

1

The passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration is called which of the following?

Select one of the following:

  • Osmosis

  • Diffusion

  • Hydrostatic pressure

  • Active transport

Explanation

Question 9 of 21

1

When a patient has metabolic acidosis, which body system influences the acid–base imbalance to produce the compensatory changes in the arterial blood gases?

Select one of the following:

  • Respiratory system

  • Renal system

  • Neurological system

  • Vascular system

Explanation

Question 10 of 21

1

What is the rationale for wrapping petroleum gauze around a chest tube insertion site?

Select one of the following:

  • Prevents air from leaking around the site

  • Prevents infection at the insertion site

  • Prevents the tube from becoming dislodged

  • Absorbs drainage from the insertion site

Explanation

Question 11 of 21

1

You are admitting a 54-year-old patient with chronic obstructive pulmonary disease (COPD). The physician prescribes O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient?

Select one of the following:

  • Nasal cannula

  • Venturi mask

  • Non-rebreather mask

  • Partial rebreather mask

Explanation

Question 12 of 21

1

Which pain management task can be safely delegated to nursing assistive personnel?

Select one of the following:

  • Assessing the quality and intensity of the pt's pain

  • Evaluating the effectiveness of pain medication

  • Administering oral dose of acetaminophen

  • Providing a therapeutic back massage

Explanation

Question 13 of 21

1

Which aspect of restraint use can the nurse delegate to the nursing assistive personnel?

Select one of the following:

  • Applying and removing the restraints

  • Assessing the pt's status

  • Evaluating the pt's response to restraints

  • Determining the need for restraint

Explanation

Question 14 of 21

1

A patient who sustained rib fractures in a motor vehicle accident is complaining that his pain medication is ineffective. Inadequate pain control places this patient at risk for which complication?

Select one of the following:

  • Pneumonia

  • Hemothorax

  • Pneumothorax

  • Metabolic alkalosis

Explanation

Question 15 of 21

1

Which process requires energy to maintain the unique composition of extracellular and intracellular compartments?

Select one of the following:

  • Diffusion

  • Active transport

  • Filtration

  • Osmosis

Explanation

Question 16 of 21

1

A patient with a history of falling continually attempts to get out of bed unassisted despite frequent reminders to call for help first. Which action should the nurse take first?

Select one of the following:

  • Encourage a family member to stay with the patient.

  • Administer lorazepam (an antianxiety medication).

  • Keep all four of the patient’s bed side rails up.

Explanation

Question 17 of 21

1

While a patient is receiving hygiene care, her chest tube becomes disconnected from the water-seal chest drainage system (CDU). Which action should the nurse take immediately?

Select one of the following:

  • Set up a new drainage system, and connect it to the chest tube.

  • Have the patient take and hold a deep breath while the nurse reconnects the tube to the CDU.

  • Clamp the chest tube close to the insertion site.

  • Place the disconnected end nearest the patient into a bottle of sterile water.

Explanation

Question 18 of 21

1

Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis?

Select one of the following:

  • Risk for Suffocation (drowning)

  • Risk for Ineffective Airway Clearance (choking)

  • Risk for Poisoning

  • Risk for Falls

Explanation

Question 19 of 21

1

Which electrolyte is the primary regulator of fluid volume?

Select one of the following:

  • K+

  • Na+

  • Calcium

  • Magnesium

Explanation

Question 20 of 21

1

What is typically the most reliable indicator of pain?

Select one of the following:

  • Past medical Hx

  • Description by caregiver(s)

  • Pt's self-report

  • Behavioral cues

Explanation

Question 21 of 21

1

You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patient’s respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern?

Select one of the following:

  • Cheyne-Stokes respirations

  • Biot's breathing

  • Sleep apnea

  • Kussmaul's respirations

Explanation