The nurse assesses the client's pedal pulses as having a pulse volume of 1 on a scale of 0-3. Based on this assessment finding, it would be important for the nurse to assess the:
C) blood pressure
If the blood pressure was low, then a low pulse volume would be expected.
The nurse assesses the breath sounds on her clients. Which of the following requires immediate attention? A client who has:
C) stridor
Stridor is a sign of respiratory distress. Crackles, rhonchi, and wheezing are potentially serious, but not necessarily a sign of respiratory distress that requires immediate attention
Which of the following client's is experiencing an abnormal change in vital signs? Select all that apply:
a) BP was 132/80 sitting and is 120/60 upon standing
b) Rectal temperature is 97.8F in the morning and 100.4F in the evening
c) Heart rate was 76 before eating and is 60 after eating
d) Respiratory rate was 14 when standing and is 22 after walking
A & C
A BP change greater than 10 mm Hg difference may indicate postural hypotension. Heart rate usually increases slightly after eating rather than decreasing. The temperatures are within normal range for the route. It is normal to have an increased respiratory rate after exercise
Which of the following vital signs is an example of the normal adult heart rate to respiratory rate ratio?
C) 84 heart rate, 20 respiratory rate
The ratio of heart rate to respiratory rate is approx. 4:1
Arrange the steps of the nursing process in the sequence in which they generally occur.
1) Assessment
2) Evaluation
3) Planning outcomes
4) Planning interventions
5) Diagnosis
B) 1, 5, 3, 4, 2
This is the correct order, but keep in mind that steps are not always performed in this order and that steps do overlap
Critical thinking and the nursing process have which of the following in common? Both:
C) are important to use in nursing practice
In which step of the nursing process does the nurse analyze data and identify client problems?
a) Assessment
b) Diagnosis
c) Planning outcomes
d) Evaluation
Diagnosis
In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. In the diagnosis phase, the nurse identifies the client's health status.
A patient who suffered a stroke has difficulty swallowing. Which health care team member should be consulted to assess the patient's risk for aspiration?
C) Speech therapist
Speech and language therapists provide assistance to clients experiencing swallowing and speech disturbances to assess the risk for aspiration and recommend a treatment plan to reduce the risk
The charge nurse on the medical surgical floor assigns vital signs to the UAP and medication administration to the LVN. Which nursing model of care is this flow following?
B) Functional nursing
You are working on a unit that charts on nursing assessment flow sheets. Which statement best reflects your understanding of this form of charting? Nursing flow sheets:
B) Are comprehensive charting documents that contain assessments and nursing actions
Which of the following incidents requires the nurse to complete an occurrence report?
a) Medication administered a half-hour after the scheduled administration time
b) Patient's dentures are lost after transfer
c) Frayed electrical cord discovered on an IV infusion pump
d) Physician's order that does not contain the route of administration
Patient's dentures are lost after transfer
A patient's medication CAN be administered within a half-hour of the administration time without an error in administration; therefore an occurrence report is not necessary. The frayed electrical cord should be taken out of use and reported to the biomedical department. The nurse should seek clarification of the physician's order; an occurrence report is not necessary
A mother who breastfeeds her child passes on which antibody through breast milk?
a) IgA
b) IgE
c) IgG
d) IgM
IgG
The antibody IgG is passed to the child through the mother's breast milk during breastfeeding. IgA, IgE, and IgM are produced by the child's body after exposure to the antigen
A patient with a stage 2 pressure ulcer has MRSA cultured from the wound, and contact precautions are initiated. Which rule must be observed to follow contact precautions?
C) A clean gown and gloves must be worn when contact with the patient is anticipated.
A clean down and gloves must be worm when any contact is anticipated with the patient or with contaminated items in the room. A respirator mask is required only with airborne precautions, not contact precautions. All linen must be double-bagged and clearly marked as contaminated. The patient should be placed in a private room or in a room with a patient with an active infection caused by the same organism and no other infections.
The nurse is teaching a child about firearm safety. The nurse should instruct the child to take which step FIRST is he sees a gun at a friend's house?
A) Tell an adult
The child should be instructed to stop where he is. This allows him to think about the next steps he has memorized. Next he should avoid touching the gun, leave the area, and immediately fo tell an adult
The nurse calculates a body mass index of 18 for a 20 year old patient who comes to the physician's office for a college physical. This patient is considered:
C) Underweight
For adults, BMI should range between 20-25; BMI less than 20 is considered underweight; BMI 25-29.9 is overweight; and BMI greater than 30 is considered obese
The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient has a hip replacement 2 weeks ago. Which position should the nurse AVOID when examining this patient's rectal area?
D) Sims'
Sims' position is typically used to examine the rectal area; however, the position should be avoided if the patient has undergone hip replacement surgery. The patient with a hip replacement can assume supine, dorsal recumbent, or semi-Fowler's positions without causing harm to self
A patient is admitted to the medical surgical floor with dehydration and a urinary tract infection. The nurse introduces herself to the patient and begins her admission assessment. Which goal is most appropriate for this phase of the nurse-patient relationship?
D) Patient will describe how to use the bed and call for the nurse
This is the orientation phase in which the nurse will orient the patient to the hospital room and routines
