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Exam 1 - Nursing 1

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Nursing Quiz on Exam 1 - Nursing 1, created by Robinmarie Rivera on 22/01/2017.
Robinmarie Rivera
Quiz by Robinmarie Rivera, updated more than 1 year ago
Robinmarie Rivera
Created by Robinmarie Rivera over 7 years ago
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Resource summary

Question 1

Question
What will the nurse instruct nursing assistive personnel (NAP) to do when measuring an adult patient's radial pulse?
Answer
  • Place the patient in the lateral (side-lying) position before measuring the pulse
  • Apply gloves with each patient before measuring the pulse.
  • Document whether the patient's pulse is bounding or has diminished.
  • Palpate the patient's inner wrist on the thumb side with the fingertips of your two middle fingers.

Question 2

Question
Which action would best assess the effect of exercise on a patient's radial pulse measurement?
Answer
  • Measuring the patient's radial pulse before and after exercise.
  • Assessing the patient's radial pulse 30 minutes after exercise.
  • Comparing the patient's radial and apical pulses after exercise.
  • Comparing the patient's pre-exercise radial and post-exercise apical pulses.

Question 3

Question
During the admissions process, the nurse initially assesses the patient's radial pulse primarily for what purpose?
Answer
  • Assessment of peripheral blood perfusion
  • Establishment of a baseline as part of the patient's vital signs
  • Assessment of the patient's cardiovascular disease risk
  • Determination of oxygen saturation

Question 4

Question
Inadequate oxygenation to the body will cause the radial pulse to become:
Answer
  • Tachycardic
  • Bradycardic
  • Irregular
  • Bounding

Question 5

Question
What is the nurse's priority action if a patient's radial pulse has an irregular rhythm?
Answer
  • Reassess the pulse for 1 full minute.
  • Assess the patient for a pulse deficit.
  • Wait 5 minutes, and then reassess the pulse.
  • Review documentation regarding an irregular rhythm

Question 6

Question
A nursing student is taking care of a patient with possible appendicitis and is curious about the best method of diagnosing this disorder. What does the nursing student have to consider in formulating a question using the PICO format (patient, population, or problem; intervention; comparison intervention; outcomes) to determine evidence-based practice?
Answer
  • Problem: appendicitis; interventions: ultrasound versus CT scan; outcome: diagnosis of appendicitis
  • Problem: pain; interventions: meperidine versus morphine; outcome: pain free
  • Problem: fever; interventions: cooling measures versus antipyretics; outcome: normal temperature
  • Problem: appendicitis; Interventions: complete blood count versus chemistry panel tests; outcome: painless

Question 7

Question
The nurse decides to access a systematic review database to determine evidence-based practice related to the patient’s treatment plan for a diagnosis of otitis media (i.e., ear infection). What database can provide that type of resource?
Answer
  • Cumulative Index of Nursing and Allied Health Literature (CINAHL)
  • Cochrane
  • PubMed
  • MD Consult

Question 8

Question
The nurse researcher provides participants with informed consent so that what ethical principle is upheld?
Answer
  • Respect for persons
  • Beneficence
  • Justice
  • Ethics

Question 9

Question
The nurse feels that the results of a recent literature search and analysis about handwashing should be implemented in the entire hospital system. With whom would the nurse be required to collaborate?
Answer
  • Colleagues caring for patients in her unit
  • Colleagues in the community
  • Administrators at the hospital
  • Others in her department

Question 10

Question
Knowledge gained from research in the 1970s about placing infants on their backs to prevent sudden infant death syndrome was not recommended to parents until the 1990s. This is an example of what barrier to evidence-based practice?
Answer
  • Proliferation of research
  • Implementation delay
  • Information needs not being met
  • Lack of readily available resources

Question 11

Question
6. A patient is on the way to the hospital in an ambulance and is asked to participate in a research protocol for a new treatment for myocardial infarction. What is this an example of? (Select all that apply.)
Answer
  • Standard practice
  • An ethical dilemma
  • A violation of informed consent
  • A patient who is in a vulnerable population category
  • Compliance with important ethical issues of justice and autonomy

Question 12

Question
Patients are participating in a study to identify genetic disorders. What is a potential concern? (Select all that apply.)
Answer
  • Violation of confidentiality if a disorder is revealed
  • Possible adverse consequences related to employment
  • Possible adverse consequences related to reputation
  • Possible adverse consequences to insurability
  • Inability to prevent the progression of genetic disorders

Question 13

Question
Which entity or document specifically addresses the role of the nurse in research? (Select all that apply.)
Answer
  • American Nurses Association standards of practice
  • Institutional review board
  • Hospital Magnet status
  • Joint Commission
  • MD Consult

Question 14

Question
Which of the following factors contributes to the nurse having difficulty keeping up with the latest patient care information? (Select all that apply.)
Answer
  • Implementation delays
  • Proliferation of research
  • Volume of health care literature
  • Hours spent in direct patient care
  • The need to read 3 articles every day of the week

Question 15

Question
After reading various research articles and reviews on a subject, the nurse designs a practice change based on the literature. What stage of evidence-based practice is this?
Answer
  • Maintaining the change
  • Implementing the change
  • Evaluating and critically appraising
  • Synthesizing the evidence and developing a plan

Question 16

Question
The nurse facilitates the use of the intellectual standard of critical thinking of significance by posing which question to determine the patient’s understanding of his or her new diagnosis of type 1 diabetes mellitus on his or her lifestyle?
Answer
  • “What information do I need to provide to teach the patient?”
  • “Do you understand how to administer your insulin?”
  • “What are the signs of low blood glucose?”
  • “How will this diagnosis impact your career?”

Question 17

Question
In providing care to a newly admitted patient, the nurse’s inferences are more accurate if based upon which of the following?
Answer
  • Objective data
  • Assumptions
  • Intuition
  • Experience

Question 18

Question
3. During the postoperative assessment on a patient, the nurse has a “hunch” that the patient has a postoperative complication based upon
Answer
  • intuition
  • interpretation
  • information processing
  • inference

Question 19

Question
In using intuition to address a clinical problem, the expert nurse bases his or her approach upon which of the following?
Answer
  • Judgment
  • Data collection
  • Experiential knowledge
  • Logical deduction

Question 20

Question
A new graduate nurse explains a new approach in the positioning of patients with chronic low back pain. The nurse preceptor responds, “That is not the way we do it here.” The preceptor’s response illustrates which error in critical thinking?
Answer
  • Lack of information
  • Erroneous assumptions
  • Illogical thinking
  • Bias

Question 21

Question
The nurse uses a case study presentation to present an educational offering to the staff on the unit. This strategy improves the staff nurses’ critical thinking through which of the following?
Answer
  • Reviewing the literature
  • Practicing application of knowledge
  • Discussing with colleagues
  • Role playing

Question 22

Question
In preparing to administer medications to a patient, the nurse notes a medication that she has never administered. If the nurse administers the medication without researching the medication, this represents which error in critical thinking?
Answer
  • Lack of information
  • Illogical thinking
  • Close-mindedness
  • Erroneous assumptions

Question 23

Question
The nurse uses critical thinking to interpret data. Which of the following data sources are objective? (Select all that apply.)
Answer
  • Patient interview
  • Laboratory values
  • Body language
  • X-ray results
  • Vital signs
  • Breath sounds

Question 24

Question
In preparing for a certification examination, the nurse chooses to develop a concept map to help understand the content. This strategy is based upon which characteristics of concept maps? (Select all that apply.)
Answer
  • Facilitates note-taking
  • Requires thinking aloud
  • Fosters making correlation between concepts
  • Validates content with an expert
  • Organizes visual data

Question 25

Question
The nurse receives change of shift report on the five assigned patients and reviews prescriptions, treatments, and medications scheduled for the shift. Based on analysis of this information, the nurse chooses which patient to assess first. Which process of critical thinking best describes the nurse’s action?
Answer
  • Problem solving
  • Decision making
  • Judgment
  • Reasoning

Question 26

Question
In approaching a new clinical situation, the nurse uses which question to facilitate precision in critical thinking?
Answer
  • “What do I know about this situation?”
  • “What additional details do I need to gather?”
  • “Does the clinical presentation correlate with the diagnosis?”
  • "Are the treatments appropriate for the diagnosis?”

Question 27

Question
Which question would be most appropriate for the nurse to ask while evaluating the relevance of patient data?
Answer
  • Do these findings make sense?
  • How can this information be verified?
  • What are the most significant factors in the problem?
  • What is the relationship of this information to other data?

Question 28

Question
The nurse is assigned to develop a plan of care for a patient with a medical diagnosis that is unknown to the nurse. Guided by critical thinking, which action should the nurse take first?
Answer
  • Ask the patient to describe the chief complaint
  • Request that another nurse be assigned to this patient
  • Review data about the medical diagnosis and routine management
  • Complete a physical assessment of the patient

Question 29

Question
The nurse obtains a lower-than-normal (88% on room air) pulse oximetry reading on a patient. Which actions by the nurse result from accurately employing the critical-thinking skill of analysis in the nursing process? (Select all that apply. )
Answer
  • Assessing the patient for symptoms of hypoxia
  • Providing oxygen according to standing orders
  • Elevating the head of the bed, if not contraindicated
  • Allowing the patient to be alone to rest more comfortably
  • Discussing adaptations needed for daily activities with the patient

Question 30

Question
Which of the following actions reflects inductive reasoning?
Answer
  • Using subjective and objective data to confirm a diagnosis
  • Assessing for specific clinical presentations based on a disease process
  • Correlating elevated blood pressure to pathophysiology
  • Validating an automatic blood pressure cuff reading with a manual measurement

Question 31

Question
The nurse is completing an assessment on a patient with sudden onset of abdominal pain. During the assessment, the nurse considers similar presentations and the underlying pathophysiology related to the patient’s clinical manifestations. Which critical-thinking skill should the nurse use first to determine the cause of the patient’s abdominal pain?
Answer
  • Evaluation
  • Interpretation
  • Reflection
  • Inference

Question 32

Question
The nurse can facilitate critical thinking through the use of which interpersonal skills? (Select all that apply.)
Answer
  • Teamwork
  • Intuition
  • Judgment
  • Conflict management
  • Advocacy
  • Reasoning

Question 33

Question
In providing care to a patient admitted to rule out human immunodeficiency virus (HIV) infection, wearing gloves during which activity may be an indication of bias?
Answer
  • Collecting the patient's medical history
  • Administering IV medications
  • Performing oral care
  • Completing a bed bath

Question 34

Question
During the assessment of a patient admitted for a total hip replacement, the nurse asks the patient to explain prior hospital experiences and, more specifically, any operative experiences. These questions reflect the nurse’s use of which intellectual standard of critical thinking?
Answer
  • Clarity
  • Logic
  • Precision
  • Significance

Question 35

Question
On initial assessment of a patient, the nurse notices an area of redness over the right trochanter that, when pressed lightly, does not blanch. What does this assessment finding indicate to the nurse?
Answer
  • The presence of an infection in the area
  • The presence of a stage I pressure ulcer
  • An allergic reaction to the sheets
  • The need to apply a cold compress to reduce inflammation

Question 36

Question
Four days after abdominal surgery, the patient is getting out of bed and feels something “pop” in his abdominal wound. An increase in amount of drainage from the wound is seen, and further examination shows that the sutured incision is now partially open, with tissue protruding from the wound. What is the nurse’s next action?
Answer
  • Apply Steri-Strips to close the wound edges.
  • Cover the wound with saline-moistened gauze, and notify the physician.
  • Assure the patient that this is common, and document the findings.
  • Apply a binder to pull the wound edges together and provide support to the edges.

Question 37

Question
3. Which features are characteristic of a closed drainage system such as a Jackson-Pratt (JP) drain? (Select all that apply.)
Answer
  • Works by gravity
  • Provides for early discharge
  • Usually is inserted in surgery
  • Reduces the amount of antibiotics required
  • Allows for accurate measurement of wound drainage
  • Allows bacteria to migrate up the drain from the surrounding dressing

Question 38

Question
Which intervention should be initiated by the nurse caring for a patient with urinary or fecal incontinence?
Answer
  • Using a heat lamp to dry the skin
  • Changing the adult brief every 8 hours
  • Cleansing frequently with hot water and a strong soap
  • Using an incontinence cleanser and a moisture barrier ointment

Question 39

Question
Based on knowledge of areas at greatest risk for development of a pressure ulcer in the bedridden patient, the nurse identifies which position to minimize this risk?
Answer
  • 30-degree side-lying
  • Sitting with the head of the bed elevated 75 degrees
  • 90-degree side-lying
  • Lying supine with the bed flat at all times

Question 40

Question
A patient who has suffered a stroke is unable to maintain his position while seated in a chair without sliding down. His physician has ordered him to be up in a chair for part of the day. What does the nurse recognize as the patient’s greatest risk factor for development of pressure ulcers?
Answer
  • Moisture from incontinence
  • Nutritional deficiencies
  • Pressure and shear
  • Aging

Question 41

Question
A patient has a stage III pressure ulcer on the coccyx. Which food will be most beneficial in improving the healing process?
Answer
  • Food high in vitamin D
  • Whole-grain carbohydrates
  • High-calorie, high-protein drink
  • Food high in fat and water content

Question 42

Question
Which technique is used to collect an aerobic culture specimen from a wound?
Answer
  • Collect the specimen immediately after removing the old dressing.
  • Apply sterile gloves, then open the culture tube.
  • Always be sure to culture any necrotic tissue.
  • Irrigate the wound before collecting the culture material.

Question 43

Question
Which patient is at highest risk for impaired wound healing?
Answer
  • A 22-year-old with a pelvic fracture incurred in a motor vehicle accident
  • A 49-year-old with a history of smoking two packs a day who just had abdominal surgery
  • A 72-year-old with diabetes and cardiovascular disease who had surgical repair of a broken hip
  • A 90-year-old with no chronic health conditions with a small blistered burn on the hand

Question 44

Question
Which statement best describes the healing process for a surgical wound that has been closed with the use of sutures?
Answer
  • The edges of the wound are approximated.
  • New tissue fills the sides and base of the wound.
  • The proliferate phase is longer with surgical wounds.
  • Debridement aids in the surgical healing process.

Question 45

Question
What does a Braden Score of 14 indicate to the nurse?
Answer
  • High risk for the development of pressure ulcers
  • Low risk for the development of pressure ulcers
  • The need for a special mattress
  • The presence of a pressure ulcer

Question 46

Question
Which is the most appropriate treatment choice for a wound with a shallow pink wound bed and minimal drainage?
Answer
  • Use of an enzymatic debriding agent
  • A moisture retentive dressing such as a hydrocolloid
  • Gauze moistened with 0.9% normal saline
  • An aginate covered with a foam dressing

Question 47

Question
What does wound irrigation require?
Answer
  • A bulb syringe and 0.9% normal saline
  • Personal protective equipment including goggles
  • Use of an antiseptic solution such as Betadine
  • Twice daily dressing changes

Question 48

Question
What is the most appropriate dressing for a pressure ulcer that is draining a large amount of exudate, extends through the fascia and into the deeper tissues including muscles and bone, and has granulation tissue in the wound bed?
Answer
  • Alginate dressing
  • Damp to dry dressing
  • Hydrocolloidal dressing
  • Gauze dressing reinforced with ABD pads

Question 49

Question
A patient who is on bed rest has a stage I pressure ulcer on the sacrum and is recovering from a pelvic injury sustained in a motor vehicle accident. What is the priority nursing diagnosis for this patient?
Answer
  • Ineffective coping related to pelvic injury
  • Risk for Infection related to open wound site
  • Risk for impaired tissue integrity and pain related to motor vehicle accident
  • Impaired skin Integrity related to pressure, secondary to immobility

Question 50

Question
In planning care on the hospital unit, the nurse prioritizes care for assigned patients with regard to skin integrity. Which patient would be the nurse’s highest priority for skin issues?
Answer
  • A 50-year-old female with diabetes who has an ulcer on her foot
  • An 80-year-old man with incontinence due to clostridium difficile
  • A 22-year-old cocaine addict with a compound fracture of the tibia
  • A 75-year-old female with CHF and a history of breast cancer

Question 51

Question
Which is the most important strategy in the prevention of wound infections?
Answer
  • The use of sterile dressings at all times
  • A high protein diet with vitamin C supplements
  • The use of antibiotics in all patients with wounds
  • Careful and consistent hand hygiene

Question 52

Question
Which is correct concerning the use of pain medication in the care of a patient with a chronic wound such as a pressure ulcer?
Answer
  • It is rarely needed as chronic wounds are not as painful as acute wounds due to nerve damage.
  • It should not be used in the elderly as they are at risk for constipation, a side effect of many pain medications.
  • It should only be considered if the pain score is greater than “5” on a regular basis during dressing changes.
  • It should be incorporated into the overall treatment plan based on the patient’s reported pain level and assessment of the patient.

Question 53

Question
The nurse is planning care for patients on the hospital unit. For which patient will it be most appropriate to use cold therapy?
Answer
  • For any patient who requests a cold compress
  • For a male patient with a stage I pressure ulcer
  • For a female patient with a sprained ankle with edema
  • For stimulating vasodilatation and improved blood flow in an immobile patient

Question 54

Question
Which can be delegated to the unlicensed personnel on the nursing unit? (Select all that apply.)
Answer
  • Morning care including a bath, linen change, and application of a barrier ointment
  • Dressing changes with application of an enzymatic ointment
  • Turning and positioning a patient during dressing changes
  • Assessment of the skin and wounds
  • Obtaining a wound culture
  • Removal of a simple drain
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