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N125 Exam 1

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N125 Exam 1

Question 1 of 52

1

The nursing assistive personnel (NAP) is working on a medical surgical unit in a hospital and has been providing patient care without performing hand hygiene. Several of the patients on the unit have suffered hospital-associated diarrhea infections (Clostridium difficile). The hospital-associated disease transmission is best described as what?

Select one of the following:

  • natural passive immunity.

  • indirect.

  • natural active immunity.

  • direct.

Explanation

Question 2 of 52

1

When checking for proper blood pressure cuff size, the nurse knows that which guideline is correct?

Select one of the following:

  • The width of the rubber bladder should equal 80% of the arm circumference.

  • The length of the rubber bladder should equal 40% of the arm circumference.

  • The standard cuff size is appropriate for all sizes.

  • The length of the rubber bladder should equal 80% of the arm circumference.

Explanation

Question 3 of 52

1

There was an outbreak of Salmonella infection at a nursing home. Several residents were hospitalized as a result of the infection. What is the best term to describe this infection?

Select one of the following:

  • Community-acquired infection

  • Exogenous infection

  • Asepsis

  • Endogenous infection

Explanation

Question 4 of 52

1

A nurse is assigned to multiple patients on a busy surgical unit. To minimize the onset and spread of infection, the nurse should:

Select one of the following:

  • Insert indwelling catheters to prevent incontinence.

  • Use barriers sparingly to reduce the patient’s sense of isolation.

  • Use sterile technique when performing procedures.

  • Keep mucus membranes dry to prevent maceration.

Explanation

Question 5 of 52

1

A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall.
Which initial action will the nurse take next to revise the plan of care?

Select one of the following:

  • Establish a new plan of care

  • Assess the patient

  • Consult physical therapy

  • Set new priorities for the patient

Explanation

Question 6 of 52

1

The nurse is admitting a patient with a methicillin-resistant Staphylococcus aureus (MRSA) infection located in the patient's pressure ulcer. On what precautions should the nurse place the patient?

Select one of the following:

  • Contact precautions.

  • Protective environment.

  • Airborne precautions

  • Droplet precautions.

Explanation

Question 7 of 52

1

Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)

Select one or more of the following:

  • Document results of goal achievement.

  • Determine whether outcomes or standards are met

  • Ambulate patient 25 feet in the hallway.

  • Administer medications to decrease pain

  • Use self-reflection and correct errors.

  • Set priorities for patient care.

Explanation

Question 8 of 52

1

The student nurse is caring for a postsurgical patient who has developed a health care– acquired wound infection that has become systemic. Which of the following should be the student nurse’s top priority?

Select one of the following:

  • Providing emotional support

  • Taking vital signs

  • Providing personal hygiene

  • Providing patient education

Explanation

Question 9 of 52

1

The nurse is taking the pulse of an adult patient and finds that the patient’s heart rate is 48 beats per minute. What should the nurse document as the finding?

Select one of the following:

  • bradycardia

  • bradypnea

  • normal heart rate

  • tachycardia

Explanation

Question 10 of 52

1

A 36-year-old patient has been admitted to the hospital. The nurse who is admitting him notes that his blood pressure is 164/98. Which of the following should the nurse do next?

Select one of the following:

  • Ask the patient what his blood pressure normally measures for comparison.

  • Do nothing; this is within a normal range for a patient with diabetic ketoacidosis.

  • Tell the patient that they have hypertension and educate them on normal BP values.

  • Immediately call the health care provider and request antihypertensive medication.

Explanation

Question 11 of 52

1

The nurse has had a nasal culture performed and has been found to be MRSA positive. Because the nurse has not been ill from the bacteria, the nurse’s nasal cavity can best be described as a:

Select one of the following:

  • susceptible host.

  • portal of entry.

  • reservoir.

  • mode of transmission.

Explanation

Question 12 of 52

1

Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?

Select one of the following:

  • Reads over the steps and performs a procedure despite lack of clinical competency

  • Establishes goals for a particular patient without assessment

  • Determines whether an intervention is correct and appropriate for the given situation

  • Evaluates the effectiveness of interventions

Explanation

Question 13 of 52

1

A nurse is preparing to collect a blood sample from a patient who is diagnosed with Tuberculosis. What personal protective equipment should the nurse wear prior to entering the patients room?

Select one of the following:

  • Surgical mask and gloves

  • Gloves and gown only

  • N95 or Respirator mask, gloves and gown

  • Surgical mask, gloves and gown

Explanation

Question 14 of 52

1

The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?

Select one of the following:

  • Implementation

  • Assessment

  • Diagnosis

  • Planning

Explanation

Question 15 of 52

1

A 26-year-old man was working on a roof in the hot 105-degree weather. His friend brought him to the hospital after the patient complained of severe muscle cramps and became confused. Which of the following should the admitting nurse do first when assessing the patient?

Select one of the following:

  • Apply a hyperthermia blanket to lower temperature slowly.

  • Take the patient’s temperature.

  • Place the patient in a tub of iced water.

  • Remove fans to prevent premature chilling.

Explanation

Question 16 of 52

1

Where is the pain located?

Select one of the following:

  • Radiate

  • Provokes

  • Time

  • Quality

  • Severity

Explanation

Question 17 of 52

1

What causes the pain?

Select one of the following:

  • Radiate

  • Provokes

  • Time

  • Quality

  • Severity

Explanation

Question 18 of 52

1

Does it come and go?

Select one of the following:

  • Radiate

  • Provokes

  • Time

  • Quality

  • Severity

Explanation

Question 19 of 52

1

What does the pain feel like?

Select one of the following:

  • Radiate

  • Provokes

  • Time

  • Quality

  • Severity

Explanation

Question 20 of 52

1

What is the rating on a scale of 0 to 10?

Select one of the following:

  • Radiate

  • Provokes

  • Time

  • Quality

  • Severity

Explanation

Question 21 of 52

1

A nursing student is working on a surgical unit in the hospital. Included in the job description is to assist in the cleaning and disinfection of equipment stored on the unit. Which of the following is the best explanation of disinfection?

Select one of the following:

  • Removing organic material

  • Destroying all forms of microbial life

  • Removing inorganic material

  • Eliminating almost all pathogenic organisms

Explanation

Question 22 of 52

1

apical pulse Heartbeat as listened to with the bell or diaphragm of a stethoscope placed on apex of the heart

Select one of the following:

  • True
  • False

Explanation

Question 23 of 52

1

apnea Cessation of airflow through the nose and mouth

Select one of the following:

  • True
  • False

Explanation

Question 24 of 52

1

bradycardia Slower than normal heart rate; heart contracts fewer than 60 times

Select one of the following:

  • True
  • False

Explanation

Question 25 of 52

1

bradypnea Abnormally slow rate of breathing

Select one of the following:

  • True
  • False

Explanation

Question 26 of 52

1

diastolic pressure the blood pressure at the instant of maximum cardiac relaxation

Select one of the following:

  • True
  • False

Explanation

Question 27 of 52

1

A nurse determines that the patient’s condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?

Select one of the following:

  • Implementation

  • Assessment

  • Evaluation

  • Planning

Explanation

Question 28 of 52

1

Nursing is the most trusted profession where professionalism should be shown in all actions. Which of the statements are true to what professionalism means to nurses (select all that apply):

Select one or more of the following:

  • Only respects patients

  • Team player

  • Lifelong learner

  • Does not participate in self-care

  • Respect to self and each other

Explanation

Question 29 of 52

1

In terms of your nursing practice, a general survey has the following characteristics (select all that apply):

Select one or more of the following:

  • Includes subjective parameters

  • Includes objective parameters

  • Proves the registered nurse an overall impression

  • Conveys health state and obvious physical characteristics

Explanation

Question 30 of 52

1

Which of the following statement best reflects objective data?

Select one of the following:

  • Facial features, patient denies drug use, patient's family appears nervous

  • Age, sex, skin color

  • Level of consciousness, patient complains of light headedness, patient reports of burning urination

  • Pain level of 5/10, patient shouting for help

Explanation

Question 31 of 52

1

The best location to assess the pulse during a routine physical assessment is:

Select one of the following:

  • Popliteal

  • Brachial

  • Radial

  • Apical

Explanation

Question 32 of 52

1

You received shift report from the night shift and your first action is to complete an orthostatic blood pressure. Which of the following is the most accurate?

Select one of the following:

  • Reading should be taken 1 minute apart in the following positions: supine, sitting and standing

  • Reading should be taken right after patient wakes up in the morning.

  • Readings should be taken 3 minutes part in the following positions: supine, sitting and standing

  • Reading should be taken standing first to prevent dizziness

Explanation

Question 33 of 52

1

In regards to assessing pain in your assigned patients, which accurately reflects the "PQRST" assessment:

Select one of the following:

  • Pain, Quantity, Region, Sign, Temperature

  • Provokes, Quality, Radiation, Severity, Timing

  • Promotion, Quantity, Radiation, Symptom, Treatment

  • Promote, Quality, Readiness, Sequence, Timing

Explanation

Question 34 of 52

1

hypertension Disorder characterized by an elevated blood pressure persistently exceeding 120/80mm Hg.

Select one of the following:

  • True
  • False

Explanation

Question 35 of 52

1

hypotension
Abnormal lowering of blood pressure that is inadequate for normal perfusion and oxygenation of tissues

Select one of the following:

  • True
  • False

Explanation

Question 36 of 52

1

hypothermia
Abnormal lowering of body temperature below 35 C, or 95 F, usually caused by prolonged exposure to cold

Select one of the following:

  • True
  • False

Explanation

Question 37 of 52

1

orthostatic hypotension Abnormally low blood pressure occurring when a person stands up.

Select one of the following:

  • True
  • False

Explanation

Question 38 of 52

1

systolic pressure The pressure representing ventricular contraction

Select one of the following:

  • True
  • False

Explanation

Question 39 of 52

1

tachycardia Rapid regular heart rate ranging between 100 and 150 beats per minute.

Select one of the following:

  • True
  • False

Explanation

Question 40 of 52

1

Which of following does not belong when speaking about critical thinking:

Select one of the following:

  • Specific knowledge base

  • Competencies

  • Attitudes

  • Experience

  • Lack of knowledge base

Explanation

Question 41 of 52

1

Which of the following vital signs recorded for an older adult would be considered acceptable (i.e., within normal limits)?

Select one of the following:

  • Temp 96.8° F, P 60, R 18, BP 160/90, O2 sat 93%

  • Temp 97.0° F, P 60, R 16, BP 116/78, O2 sat 95%

  • Temp 98.0° F, P 76, R 22, BP 110/70, O2 sat 88%

  • Temp 98.6° F, P 56, R 20, BP 120/80, O2 sat 91%

Explanation

Question 42 of 52

1

Which of the following situations may affect a patient’s vital signs? Select all that apply.

Select one or more of the following:

  • Isolation precautions

  • Seasons

  • Moving from a lying to a standing position

  • Time of day

  • Pain rated as a 7 on a 1 to 10 pain scale

Explanation

Question 43 of 52

1

Which nursing diagnosis statement is written correctly?

Select one of the following:

  • Altered tissue perfusion related to heart failure

  • Impaired tissue integrity related to sacral redness

  • Ineffective airway clearance related to weak cough effort.

  • Altered urinary elimination related to reduced urine output.

Explanation

Question 44 of 52

1

Which method of data collection will the nurse use to establish a patient’s database?

Select one of the following:

  • Checking orders for diagnostic and laboratory tests

  • Reviewing the current literature to determine evidence-based nursing actions

  • Ordering medications

  • Performing a physical examination

Explanation

Question 45 of 52

1

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

Select one of the following:

  • Determines whether outcomes have been achieved

  • Intervenes based on priorities of patient care

  • Completes a comprehensive database

  • Identifies pertinent nursing diagnoses

Explanation

Question 46 of 52

1

A new nurse writes the following nursing diagnoses on a patient’s care plan. Which nursing diagnosis will alert the charge nurse to intervene immediately?

Select one of the following:

  • Urinary retention

  • Impaired swallowing

  • Hemorrhage

  • Wandering

Explanation

Question 47 of 52

1

A nurse is providing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?

Select one of the following:

  • Evaluation

  • Assessment

  • Planning

  • Implementation

Explanation

Question 48 of 52

1

Which of the following is true about the force, or strength, of a pulse?

Select one of the following:

  • It reflects the blood volume in the arteries during diastole.

  • It demonstrates elasticity of the vessel wall.

  • It is usually recorded on a 0- to 2-point scale.

  • It is a reflection of the heart’s stroke volume.

Explanation

Question 49 of 52

1

A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate?

Select one of the following:

  • “Nurses use evaluation to determine the effectiveness of nursing care.”

  • “During evaluation, you determine when to downsize staffing on nursing units.”

  • “Evaluation eliminates unnecessary paperwork and care planning.”

  • “An evaluation helps you determine whether all nursing interventions were completed.”

Explanation

Question 50 of 52

1

A patient’s blood pressure is 118/82. They ask the nurse to explain “what the numbers mean.” What would be the nurse’s best response?

Select one of the following:

  • “The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts.”

  • “The concept of blood pressure is difficult to understand. The main thing to be concerned about is the top number, or systolic blood pressure.”

  • “The numbers are within normal range and are nothing to worry about.”

  • “The bottom number is the diastolic pressure and reflects the stroke volume of the heart.”

Explanation

Question 51 of 52

1

A patient is one-day postoperative for major abdominal surgery. When the nurse and the assistive personnel raise the head of the bed to sit the patient on the side of the bed before ambulation, the patient immediately complains of dizziness and nausea. What are your immediate actions?

Select one of the following:

  • Lower the head of the bed and return the patient to the supine position.

  • Obtain vital signs.

  • Allow the patient to rest for 20 to 30 minutes.

  • Notify the health care provider immediately.

Explanation

Question 52 of 52

1

A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis (sweating). Which outcome would the nurse recognize as appropriate for this patient?

Select one of the following:

  • Patient’s bedding is changed when it becomes damp.

  • Patient understands the need for increased fluid intake.

  • Patient’s skin remains cool and dry throughout hospitalization.

  • Patient has a balanced intake and output.

Explanation

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