Quiz
N125 Exam 1
Questions in this quiz (52)
1The 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?
- Anatural passive immunity.
- Bindirect.
- Cnatural active immunity.
- Ddirect.
2When checking for proper blood pressure cuff size, the nurse knows that which guideline is correct?
- AThe width of the rubber bladder should equal 80% of the arm circumference.
- BThe length of the rubber bladder should equal 40% of the arm circumference.
- CThe standard cuff size is appropriate for all sizes.
- DThe length of the rubber bladder should equal 80% of the arm circumference.
3There 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?
- ACommunity-acquired infection
- BExogenous infection
- CAsepsis
- DEndogenous infection
4A nurse is assigned to multiple patients on a busy surgical unit. To minimize the onset and spread of infection, the nurse should:
- AInsert indwelling catheters to prevent incontinence.
- BUse barriers sparingly to reduce the patient’s sense of isolation.
- CUse sterile technique when performing procedures.
- DKeep mucus membranes dry to prevent maceration.
5A 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?- AEstablish a new plan of care
- BAssess the patient
- CConsult physical therapy
- DSet new priorities for the patient
6The 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?
- AContact precautions.
- BProtective environment.
- CAirborne precautions
- DDroplet precautions.
7Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)
- ADocument results of goal achievement.
- BDetermine whether outcomes or standards are met
- CAmbulate patient 25 feet in the hallway.
- DAdminister medications to decrease pain
- EUse self-reflection and correct errors.
- FSet priorities for patient care.
8The 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?
- AProviding emotional support
- BTaking vital signs
- CProviding personal hygiene
- DProviding patient education
9The 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?
- Abradycardia
- Bbradypnea
- Cnormal heart rate
- Dtachycardia
10A 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?
- AAsk the patient what his blood pressure normally measures for comparison.
- BDo nothing; this is within a normal range for a patient with diabetic ketoacidosis.
- CTell the patient that they have hypertension and educate them on normal BP values.
- DImmediately call the health care provider and request antihypertensive medication.
11The 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:
- Asusceptible host.
- Bportal of entry.
- Creservoir.
- Dmode of transmission.
12Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?
- AReads over the steps and performs a procedure despite lack of clinical competency
- BEstablishes goals for a particular patient without assessment
- CDetermines whether an intervention is correct and appropriate for the given situation
- DEvaluates the effectiveness of interventions
13A 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?
- ASurgical mask and gloves
- BGloves and gown only
- CN95 or Respirator mask, gloves and gown
- DSurgical mask, gloves and gown
14The 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?
- AImplementation
- BAssessment
- CDiagnosis
- DPlanning
15A 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?
- AApply a hyperthermia blanket to lower temperature slowly.
- BTake the patient’s temperature.
- CPlace the patient in a tub of iced water.
- DRemove fans to prevent premature chilling.
16Where is the pain located?
- ARadiate
- BProvokes
- CTime
- DQuality
- ESeverity
17What causes the pain?
- ARadiate
- BProvokes
- CTime
- DQuality
- ESeverity
18Does it come and go?
- ARadiate
- BProvokes
- CTime
- DQuality
- ESeverity
19What does the pain feel like?
- ARadiate
- BProvokes
- CTime
- DQuality
- ESeverity
20What is the rating on a scale of 0 to 10?
- ARadiate
- BProvokes
- CTime
- DQuality
- ESeverity
21A 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?
- ARemoving organic material
- BDestroying all forms of microbial life
- CRemoving inorganic material
- DEliminating almost all pathogenic organisms
22apical pulse Heartbeat as listened to with the bell or diaphragm of a stethoscope placed on apex of the heart
- ATrue
- BFalse
23apnea Cessation of airflow through the nose and mouth
- ATrue
- BFalse
24bradycardia Slower than normal heart rate; heart contracts fewer than 60 times
- ATrue
- BFalse
25bradypnea Abnormally slow rate of breathing
- ATrue
- BFalse
26diastolic pressure the blood pressure at the instant of maximum cardiac relaxation
- ATrue
- BFalse
27A nurse determines that the patient’s condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?
- AImplementation
- BAssessment
- CEvaluation
- DPlanning
28Nursing 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):
- AOnly respects patients
- BTeam player
- CLifelong learner
- DDoes not participate in self-care
- ERespect to self and each other
29In terms of your nursing practice, a general survey has the following characteristics (select all that apply):
- AIncludes subjective parameters
- BIncludes objective parameters
- CProves the registered nurse an overall impression
- DConveys health state and obvious physical characteristics
30Which of the following statement best reflects objective data?
- AFacial features, patient denies drug use, patient's family appears nervous
- BAge, sex, skin color
- CLevel of consciousness, patient complains of light headedness, patient reports of burning urination
- DPain level of 5/10, patient shouting for help
31The best location to assess the pulse during a routine physical assessment is:
- APopliteal
- BBrachial
- CRadial
- DApical
32You 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?
- AReading should be taken 1 minute apart in the following positions: supine, sitting and standing
- BReading should be taken right after patient wakes up in the morning.
- CReadings should be taken 3 minutes part in the following positions: supine, sitting and standing
- DReading should be taken standing first to prevent dizziness
33In regards to assessing pain in your assigned patients, which accurately reflects the "PQRST" assessment:
- APain, Quantity, Region, Sign, Temperature
- BProvokes, Quality, Radiation, Severity, Timing
- CPromotion, Quantity, Radiation, Symptom, Treatment
- DPromote, Quality, Readiness, Sequence, Timing
34hypertension Disorder characterized by an elevated blood pressure persistently exceeding 120/80mm Hg.
- ATrue
- BFalse
35hypotension
Abnormal lowering of blood pressure that is inadequate for normal perfusion and oxygenation of tissues- ATrue
- BFalse
36hypothermia
Abnormal lowering of body temperature below 35 C, or 95 F, usually caused by prolonged exposure to cold- ATrue
- BFalse
37orthostatic hypotension Abnormally low blood pressure occurring when a person stands up.
- ATrue
- BFalse
38systolic pressure The pressure representing ventricular contraction
- ATrue
- BFalse
39tachycardia Rapid regular heart rate ranging between 100 and 150 beats per minute.
- ATrue
- BFalse
40Which of following does not belong when speaking about critical thinking:
- ASpecific knowledge base
- BCompetencies
- CAttitudes
- DExperience
- ELack of knowledge base
41Which of the following vital signs recorded for an older adult would be considered acceptable (i.e., within normal limits)?
- ATemp 96.8° F, P 60, R 18, BP 160/90, O2 sat 93%
- BTemp 97.0° F, P 60, R 16, BP 116/78, O2 sat 95%
- CTemp 98.0° F, P 76, R 22, BP 110/70, O2 sat 88%
- DTemp 98.6° F, P 56, R 20, BP 120/80, O2 sat 91%
42Which of the following situations may affect a patient’s vital signs? Select all that apply.
- AIsolation precautions
- BSeasons
- CMoving from a lying to a standing position
- DTime of day
- EPain rated as a 7 on a 1 to 10 pain scale
43Which nursing diagnosis statement is written correctly?
- AAltered tissue perfusion related to heart failure
- BImpaired tissue integrity related to sacral redness
- CIneffective airway clearance related to weak cough effort.
- DAltered urinary elimination related to reduced urine output.
44Which method of data collection will the nurse use to establish a patient’s database?
- AChecking orders for diagnostic and laboratory tests
- BReviewing the current literature to determine evidence-based nursing actions
- COrdering medications
- DPerforming a physical examination
45The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
- ADetermines whether outcomes have been achieved
- BIntervenes based on priorities of patient care
- CCompletes a comprehensive database
- DIdentifies pertinent nursing diagnoses
46A new nurse writes the following nursing diagnoses on a patient’s care plan. Which nursing diagnosis will alert the charge nurse to intervene immediately?
- AUrinary retention
- BImpaired swallowing
- CHemorrhage
- DWandering
47A nurse is providing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?
- AEvaluation
- BAssessment
- CPlanning
- DImplementation
48Which of the following is true about the force, or strength, of a pulse?
- AIt reflects the blood volume in the arteries during diastole.
- BIt demonstrates elasticity of the vessel wall.
- CIt is usually recorded on a 0- to 2-point scale.
- DIt is a reflection of the heart’s stroke volume.
49A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate?
- A“Nurses use evaluation to determine the effectiveness of nursing care.”
- B“During evaluation, you determine when to downsize staffing on nursing units.”
- C“Evaluation eliminates unnecessary paperwork and care planning.”
- D“An evaluation helps you determine whether all nursing interventions were completed.”
50A 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?
- A“The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts.”
- B“The concept of blood pressure is difficult to understand. The main thing to be concerned about is the top number, or systolic blood pressure.”
- C“The numbers are within normal range and are nothing to worry about.”
- D“The bottom number is the diastolic pressure and reflects the stroke volume of the heart.”
51A 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?
- ALower the head of the bed and return the patient to the supine position.
- BObtain vital signs.
- CAllow the patient to rest for 20 to 30 minutes.
- DNotify the health care provider immediately.
52A 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?
- APatient’s bedding is changed when it becomes damp.
- BPatient understands the need for increased fluid intake.
- CPatient’s skin remains cool and dry throughout hospitalization.
- DPatient has a balanced intake and output.
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- N125 Exam 1
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