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N125 Exam 1

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N125 Exam 1
champagne papii
Quiz by champagne papii, updated more than 1 year ago
champagne papii
Created by champagne papii almost 2 years ago
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Question 1

Question
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?
Answer
  • natural passive immunity.
  • indirect.
  • natural active immunity.
  • direct.

Question 2

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

Question 3

Question
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?
Answer
  • Community-acquired infection
  • Exogenous infection
  • Asepsis
  • Endogenous infection

Question 4

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

Question 5

Question
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?
Answer
  • Establish a new plan of care
  • Assess the patient
  • Consult physical therapy
  • Set new priorities for the patient

Question 6

Question
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?
Answer
  • Contact precautions.
  • Protective environment.
  • Airborne precautions
  • Droplet precautions.

Question 7

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

Question 8

Question
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?
Answer
  • Providing emotional support
  • Taking vital signs
  • Providing personal hygiene
  • Providing patient education

Question 9

Question
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?
Answer
  • bradycardia
  • bradypnea
  • normal heart rate
  • tachycardia

Question 10

Question
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?
Answer
  • 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.

Question 11

Question
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:
Answer
  • susceptible host.
  • portal of entry.
  • reservoir.
  • mode of transmission.

Question 12

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

Question 13

Question
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?
Answer
  • Surgical mask and gloves
  • Gloves and gown only
  • N95 or Respirator mask, gloves and gown
  • Surgical mask, gloves and gown

Question 14

Question
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?
Answer
  • Implementation
  • Assessment
  • Diagnosis
  • Planning

Question 15

Question
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?
Answer
  • 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.

Question 16

Question
Where is the pain located?
Answer
  • Radiate
  • Provokes
  • Time
  • Quality
  • Severity

Question 17

Question
What causes the pain?
Answer
  • Radiate
  • Provokes
  • Time
  • Quality
  • Severity

Question 18

Question
Does it come and go?
Answer
  • Radiate
  • Provokes
  • Time
  • Quality
  • Severity

Question 19

Question
What does the pain feel like?
Answer
  • Radiate
  • Provokes
  • Time
  • Quality
  • Severity

Question 20

Question
What is the rating on a scale of 0 to 10?
Answer
  • Radiate
  • Provokes
  • Time
  • Quality
  • Severity

Question 21

Question
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?
Answer
  • Removing organic material
  • Destroying all forms of microbial life
  • Removing inorganic material
  • Eliminating almost all pathogenic organisms

Question 22

Question
apical pulse Heartbeat as listened to with the bell or diaphragm of a stethoscope placed on apex of the heart
Answer
  • True
  • False

Question 23

Question
apnea Cessation of airflow through the nose and mouth
Answer
  • True
  • False

Question 24

Question
bradycardia Slower than normal heart rate; heart contracts fewer than 60 times
Answer
  • True
  • False

Question 25

Question
bradypnea Abnormally slow rate of breathing
Answer
  • True
  • False

Question 26

Question
diastolic pressure the blood pressure at the instant of maximum cardiac relaxation
Answer
  • True
  • False

Question 27

Question
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?
Answer
  • Implementation
  • Assessment
  • Evaluation
  • Planning

Question 28

Question
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):
Answer
  • Only respects patients
  • Team player
  • Lifelong learner
  • Does not participate in self-care
  • Respect to self and each other

Question 29

Question
In terms of your nursing practice, a general survey has the following characteristics (select all that apply):
Answer
  • Includes subjective parameters
  • Includes objective parameters
  • Proves the registered nurse an overall impression
  • Conveys health state and obvious physical characteristics

Question 30

Question
Which of the following statement best reflects objective data?
Answer
  • 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

Question 31

Question
The best location to assess the pulse during a routine physical assessment is:
Answer
  • Popliteal
  • Brachial
  • Radial
  • Apical

Question 32

Question
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?
Answer
  • 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

Question 33

Question
In regards to assessing pain in your assigned patients, which accurately reflects the "PQRST" assessment:
Answer
  • Pain, Quantity, Region, Sign, Temperature
  • Provokes, Quality, Radiation, Severity, Timing
  • Promotion, Quantity, Radiation, Symptom, Treatment
  • Promote, Quality, Readiness, Sequence, Timing

Question 34

Question
hypertension Disorder characterized by an elevated blood pressure persistently exceeding 120/80mm Hg.
Answer
  • True
  • False

Question 35

Question
hypotension Abnormal lowering of blood pressure that is inadequate for normal perfusion and oxygenation of tissues
Answer
  • True
  • False

Question 36

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

Question 37

Question
orthostatic hypotension Abnormally low blood pressure occurring when a person stands up.
Answer
  • True
  • False

Question 38

Question
systolic pressure The pressure representing ventricular contraction
Answer
  • True
  • False

Question 39

Question
tachycardia Rapid regular heart rate ranging between 100 and 150 beats per minute.
Answer
  • True
  • False

Question 40

Question
Which of following does not belong when speaking about critical thinking:
Answer
  • Specific knowledge base
  • Competencies
  • Attitudes
  • Experience
  • Lack of knowledge base

Question 41

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

Question 42

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

Question 43

Question
Which nursing diagnosis statement is written correctly?
Answer
  • 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.

Question 44

Question
Which method of data collection will the nurse use to establish a patient’s database?
Answer
  • Checking orders for diagnostic and laboratory tests
  • Reviewing the current literature to determine evidence-based nursing actions
  • Ordering medications
  • Performing a physical examination

Question 45

Question
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?
Answer
  • Determines whether outcomes have been achieved
  • Intervenes based on priorities of patient care
  • Completes a comprehensive database
  • Identifies pertinent nursing diagnoses

Question 46

Question
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?
Answer
  • Urinary retention
  • Impaired swallowing
  • Hemorrhage
  • Wandering

Question 47

Question
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?
Answer
  • Evaluation
  • Assessment
  • Planning
  • Implementation

Question 48

Question
Which of the following is true about the force, or strength, of a pulse?
Answer
  • 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.

Question 49

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

Question 50

Question
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?
Answer
  • “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.”

Question 51

Question
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?
Answer
  • 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.

Question 52

Question
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?
Answer
  • 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.
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