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Week 3 Sherpath
BSN205
| Question | Answer |
|---|---|
| The cerebral cortex of the brain allows voluntary control of breathing. When a patient sings, to which aspect do the receptors in the medulla react? | Changes in pH High levels of carbon dioxide |
| Which statement describes ventilation? | Movement of oxygen and carbon dioxide in and out of the lungs, or inhaling and exhaling |
| Which value represents an acceptable respiratory rate for a 15-year-old patient? | 15,18 |
| A frail older adult patient who is experiencing shortness of breath is only able to breathe laying on the right side. The patient has a current respiratory rate of 28 breaths per minute (bpm). Which terms describe the signs and symptoms the patient is exh | -Tachypnea -Dyspnea -Orthopnea |
| The student nurse is discussing arterial blood gases (ABGs) with the instructor. Which statement made by the nurse reflects the student needs further education? | Nurses do not draw ABGs. |
| The nurse is assessing the patient’s ventilation status. Which features will the nurse assess? | Chest rise Respiratory rate Lung compliance |
| The nurse is caring for a patient diagnosed with a head and brain injury. Which alterations in breathing pattern could possibly occur? | Hypoventilation Biot’s breathing Cheyne-Stokes respirations |
| During the respiratory assessment, the nurse hears “wheezes.” Which type of sound is the nurse hearing? | Whistling |
| Which percentage reflects a normal value for SvO2? | 70% |
| The nurse obtains an arterial blood gas (ABG) on a patient and the pH is 7.33 and the PaO2 is 103. Which action should the nurse take? | Call the health care provider because these results are abnormal. |
| The nurse is in the emergency department where a patient presents as follows: 65-year-old patient who complains of shortness of breath, is in a tripod position, skin is pale, respiratory rate 42 bpm, blood pressure 152/95 mm Hg, and a history of chronic o | Pale skin color History of COPD High blood pressure |
| The nurse has a patient who was admitted 24 hours ago for asthma exacerbation. The patient is currently on 8 liters high flow oxygen with respiratory treatments every 2 hours. Which statement reflects a realistic goal for this patient? | The patient will demonstrate the ability to complete all activities of daily living with no increase in dyspnea before discharge. |
| Which aspects would the nurse measure to assess respiration and ventilation? | Respiratory rate Respiratory depth Respiratory rhythm |
| A student nurse is learning about altered oxygen saturation levels. Which statement indicates further teaching is needed? | “Nose bleeds are caused by altered oxygenation levels.” |
| Which is an initial nursing action for a patient having shortness of breath? | Assess pulse oximeter for O2 saturation levels. |
| An older adult patient has very poor perfusion in the fingers. Which location should the nurse use to measure oxygen saturation? | Toe nose earlobe |
| A student nurse is taking the temperature of a patient at 6 p.m. and realizes that the temperature is higher than it was only an hour ago. Which statement made by the student nurse indicates effective learning? | “The temperature of most people is lowest around 3 a.m. and highest around 6 p.m.” |
| The nurse is taking care of a patient with a cervical spinal cord injury. The patient is a quadriplegic with a C5 fracture. The patient is sweating profusely and is afebrile with a temperature of 37°C. What does the nurse know about spinal cord injuries a | Disease or trauma to the brain or spinal cord can cause alterations in temperature control. |
| While taking the temperature of a patient the nurse learns that the patient exercised before arriving at the appointment. Which explanation describes why the nurse assumes the temperature reading will not reflect an accurate body temperature? | Body temperature increases with exercise. |
| The nurse would expect a patient to have alterations in temperature control if experiencing which event? | Being admitted to the hospital after experiencing trauma to the neck |
| The novice nurse treats a patient using heat therapy for a back injury. Afterward, the nurse takes the patient’s temperature using the oral method and notices that it is high. Which action made by the novice nurse indicates the need for additional trainin | Should have measured the temperature before providing heat application |
| Match each condition with its proper definition. | Exposure to extreme cold, resulting in low body temperature. - Hypothermia Ice crystals form inside cells, causing permanent tissue damage.- Frostbite Rise in body temperature above normal, caused by -trauma or illness. -Fever High body temperature, |
| A registered nurse is assessing a patient with decreased respirations, cool skin, and decreased muscle coordination. Which action made by the nurse supports the nursing diagnosis of hypothermia? | Takes the patient’s blood pressure, which shows hypotension |
| The nurse is educating a student nurse about appropriate sites to assess temperature. Which statement made by the student nurse indicates the need for further teaching? | “I can get an accurate temperature reading by placing the thermometer to the right of the patient’s axilla.” |
| The nurse is teaching a class on appropriate temperature assessment questions. Which statement made by the student nurse shows that the teaching has been effective? | “I will ask if the patient has been sleeping well.” |
| A student nurse is describing the process of taking a patient’s temperature to the charge nurse. Which statement made by the student nurse indicates teaching has been effective? | “I must determine the patient’s baseline temperature.” |
| Which statement shows the proper relationship between a patient’s condition and temperature site selection? | "Because the patient has a low white blood cell count, she will not receive a rectal temperature measurement." |
| A patient admitted to the hospital has been exposed to below-freezing temperatures while attempting to engage in sports in extreme weather conditions. During assessment, the nurse observes the patient is shivering and learns that the patient was not weari | Hypothermia related to exposure to below-freezing temperature without adequate clothing, as evidenced by a weak pulse and rapid heart rate |
| Which statement made by the nurse shows an understanding of objective and subjective data? | “Subjective data are gathered from the patient.” “Objective data are gathered through observation.” “Subjective data are gathered from the patient’s relatives.” |
| The student nurse discusses goals for thermoregulation with a patient. Which statement made by the patient shows proper understanding of treatment outcomes? | "I will have an oral temperature of 98.4 degrees F. " |
| The nurse assesses a patient who was admitted to the emergency department with a core body temperature of 93.2°F, after being exposed to freezing temperatures for a long period of time. The nurse feels the patient’s skin and documents that it is cool to t | Check the patient's pulse Observe the patient for shivering Measure the patient's blood pressure |
| A patient infected with which pathogen cannot be treated with antibiotics because the infectious agent has a protective envelope? | Virus |
| Which precautions will be implemented for a patient admitted for suspected West Nile virus? | Standard |
| Which patient is considered to be a susceptible host in the chain of infection? | 70-year-old with diabetes learning about insulin therapy |
| Which infections are considered health care–associated infections (HAIs)? | Urinary tract infection related to indwelling catheter Pneumonia related to presence of ventilator Wound infection related to surgical incision |
| Which factor contributed to the development of a health care–acquired respiratory infection in an ambulatory diabetic patient receiving an intravenous antibiotic? | Current comorbidity |
| The nurse recognizes which microorganisms as blood-borne pathogens that can be transmitted by needlesticks? | Hepatitis B virus (HBV) Human immunodeficiency virus (HIV) |
| Prior to discharge, what will the nurse teach patients about prescribed antibiotics to help prevent antimicrobial resistance? | Take all of your medication for the full time prescribed. |
| Antibiotic use in animals contributes to human antimicrobial resistance through which effect? | Creates a reservoir of potentially resistant bacteria. |
| The nurse recognizes which infectious agents as having acquired drug resistance within health care settings? | Methicillin-resistant Staphylococcus aureus (MRSA) Vancomycin-resistant Staphylococcus aureus (VRSA) Vancomycin-resistant enterococci (VRE) Clostridium difficile (C-Diff) |
| The nurse is caring for an older adult patient with heart failure (HF) and atrial fibrillation with rapid ventricular response. The patient’s blood pressure is 88/56 mm Hg with a heart rate of 156 beats per minute. The nurse contacts the health care provi | With an increased heart rate, there is less time available for the heart to contract and fill with blood, leading to decreased cardiac output. |
| The nurse is caring for an 88-year-old patient who is currently in cardiac arrest. A Code Blue has been called and staff is performing cardiopulmonary resuscitation (CPR). When the nurse checks for a pulse, which areas of the body would be most appropriat | Carotid pulse Femoral pulse |
| The nurse is caring for an adult patient, post laparoscopic cholecystectomy 1 day prior. The patient’s heart rate is 132 bpm and temperature is 102°F. The nurse is having a difficult time obtaining a blood pressure reading. Which statements are true of ta | Indicative of anemia Causes a drop in blood pressure Due to hyperthermia |
| The nurse performs assessment on newborn infant patient who weighs 6 lb, 2 oz. The nurse obtains an apical pulse of 60 bpm and notices the infant is not very responsive. Which range reflects the normal pulse rate in a newborn infant? | 80–160 bpm |
| The nurse and health care provider have just reviewed the electrocardiogram (ECG) on an adult patient who has been suffering from fainting spells. The provider suspects that the patient may have an arrhythmia even though the ECG reveals sinus rhythm with | Records the heart’s activity continually for a 24-hour period |
| The postanesthesia care unit (PACU) nurse is caring for a patient who underwent a femoral-popliteal bypass of the right leg. The nurse assesses pedal pulses every half hour and documents that the patient’s pedal pulse in his right foot is 2+ palpable. Whi | The pulse is normal and may be easily palpated. |
| Under which conditions is an apical pulse considered a better alternative to a radial pulse? | If the nurse is unable to accurately palpate a radial pulse When there is need for a more accurate pulse assessment When a patient is on a medication that could affect cardiac function |
| A young mother and an infant were involved in a car crash. As the baby is removed from the car seat, the off-duty nurse notices that the baby appears lifeless. What is the best area of the baby’s body for the off-duty nurse to check for a pulse? | Brachial pulse in the arm |
| The nurse assesses an adult patient who is 3 days postoperative from a femoral-popliteal bypass of the right leg. The nurse assesses the patient’s femoral, posterior tibial, and pedal pulses of both legs. What is the purpose of checking these three pulse | To determine circulatory status of his legs/feet |
| Which patients would most likely require a Doppler to assess pulse? | 62-year-old female with obstructed blood vessels in the feet 56-year-old morbidly obese female with hardening of arteries 26-year-old female with poor circulation in the lower extremities |
| The student nurse is having difficulty palpating the radial pulse on a postoperative adult patient who has a blood pressure of 126/74 mm Hg. Which statement is true about palpating a pulse? | -The radial pulse is best palpated along the thumb side of the inner aspect of the wrist along the radial bone -Too much pressure can obliterate the pulse -Too little pressure can result in inability to feel the pulsations |
| A patient is admitted for heart failure (HF) and atelectasis. The patient has a productive cough and a fever of 102°F, white blood cell (WBC) level is 18.6, hemoglobin is 8.5, and urine output was 400 mL over 8 hours. The patient states they have chills, | -Productive cough -WBC level of 18.6 -Hemoglobin of 8.5 |
| A diabetic patient with peripheral neuropathy in the feet is recovering from a stroke. As the student nurse cares for the patient, the following information is documented. Which item is considered subjective data? | -The patient states, "My feet feel like they are on fire." |
| Which outcomes are appropriate for a patient with Ineffective Peripheral Tissue Perfusion related to decreased cardiac contractility, and who recently suffered a myocardial infarction? | -Blood pressure within normal range for the patient -Warm extremities without pallor -Palpable peripheral pulses |
| Which statement is an example of a measurable, short-term goal related to a patient with lower extremity edema? | -Increased capillary refill of <3 sec and circulation to toes exhibiting pink nail beds within 48 hours of interventions. |
| Nursing diagnoses and realistic goals for an alteration in pulse are selected after carefully reviewing which pieces of information? | -Subjective information -Patient’s knowledge leve -Objective data gathered during the pulse assessment by the nurse -Lab data as well as test results |
| A 56-year-old patient was admitted to the emergency department with sudden chest pain. The patient is stable and the nurse has already inquired about the patient’s current pain factors. Which question related to pain history is most important for the nurs | "Have you ever experienced pain like this before?" |
| A 95-year-old patient was admitted to the hospital with a hip fracture. The patient has a medical history of hypertension and advanced dementia. The patient does not respond appropriately and is disoriented. Which approach is appropriate for assessing the | Closely monitor the patient's vital signs, as well as level of agitation, irritation, and restlessness. |
| The nurse is completing a pain assessment on a 45-year-old patient with a history of rheumatoid arthritis. Which pain response observed by the nurse would indicate the chronic nature of the patient’s pain? | Decrease in blood pressure |
| The nurse is assessing a patient’s pain. In addition to inquiring about pain factors, the nurse should ask which additional questions? | How does your pain affect your ability to get dressed in the morning? Do you do anything to help lessen your pain experience? What medications have you tried taking to relieve your pain? |
| The nurse is educating a patient about the differences between chronic and acute pain. Which statement by the patient indicates further teaching is needed? | "Since my pulse rate is above my normal baseline, I must be experiencing chronic pain." |
| A pediatric patient was admitted to the emergency department (ED) with a broken arm after falling off the jungle gym. Which pain assessment tool would be the most appropriate to use when assessing this patient’s pain? | Wong-Baker Scale |
| A 45-year-old patient complains of upper abdominal pain. Which pain assessment tool would be most appropriate to use when evaluating his condition? | Verbal Descriptor |
| A nurse is performing a physical assessment on a 7-day-old infant who was born premature and admitted to the neonatal intensive care unit (NICU) in respiratory distress. The nurse observes a furrowed brow, with mild intermittent moaning. The infant is ale | Score of 3, mild to moderate pain. |
| A 53-year-old patient is admitted with a chief complaint of abdominal pain. A computed tomography (CT) scan reveals acute pancreatitis. The patient’s blood pressure is 185/98 mm Hg and pulse rate is 143 beats per minute. Which type of pain is the patient | Acute pain |
| A patient who was in a motor vehicle accident presents to the emergency department with a primary complaint of facial pain after the airbag was triggered by the crash. Blood pressure and pulse rate are elevated, and the patient is moaning in pain. The pat | Acute Pain related to long bone fracture as evidenced by pain with movement, reported pain of 10 of 10, and increased blood pressure. |
| A 17-year-old male patient suffered an injury during football practice. He was diagnosed with an ACL tear and was told he will not be able to play for the rest of the football season. The patient is distraught, will not speak to anyone who approaches him, | Ineffective Coping related to severe pain as evidenced by lack of appetite and poor concentration. |
| A 34-year-old patient who suffered a back injury at work 7 years ago has experienced lower back pain ever since. The pain has gotten to the point that the patient is considering applying for disability insurance because the patient is no longer able to pe | Chronic Pain related to back injury as evidenced by inability to work at place of employment. |
| A patient who underwent a cholecystectomy is experiencing severe pain after surgery. The pain has been mostly relieved with PRN (as needed) morphine. The patient is worried about the persistence of this pain, because the patient has never had surgery befo | Anxiety related to fear of increasing pain levels as evidenced by restlessness and increased blood pressure. |
| A patient who was in a car accident 1 month prior is meeting with a pain specialist. The patient indicates that neck pain related to the accident has subsided and expresses a wish to decrease the prescribed dosage of pain medication. Which diagnosis is ap | Readiness for Enhanced Comfort as evidenced by inquiry regarding decreasing dosage of pain medication. |
| A patient with no previous medical history is 6 hours postoperative from abdominal surgery. The patient has been prescribed opioid analgesics for pain. The patient currently rates the pain level at 7 of 10. Which goals and outcomes related to pain are app | Patient will report a pain level of less than 3 of 10 within five postoperative days. Patient will report a pain level of less than 3 of 10 within 45 minutes of receiving pain medication. Patient will meet with a pain specialist to outline a plan for de |
| A patient who had wrist surgery is about to be released from the hospital. The patient has prescriptions for pain medications and is scheduled to begin biweekly outpatient physical therapy sessions. What goal related to pain is most appropriate for the pa | The patient will verbalize understanding of use of prescribed pain medications prior to discharge. |
| The student nurse is learning about vital signs. Which measurements are included in vital sign assessment? | Pulse Blood pressure Respiration rate Oxygen saturation |
| The nurse is teaching a student nurse about vital signs. Which patient response shows teaching has been effective? | “Blood pressure is the measurable pressure of blood within the systemic arteries.” |
| In which patients would pulse oximetry most likely be utilized? | An older adult with hypoxemia A patient with community-acquired pneumonia A teenager having an asthma attack with oxygen saturations of less than 92% in air An adult patient in the outpatient clinic who has a history of chronic obstructive pulmonary di |
| A 21-year-old college football player has been in the hospital 24 hours for observation following a concussion. His blood pressure (BP) has been stable at 118/62 mm Hg, but suddenly he complains of a severe headache and his BP is 170/94 mm Hg. The nurse o | Every 5 minutes |
| The nurse receives a 50-year-old patient back from the endoscopic department. The patient had conscious sedation for an esophageal biopsy. When should the nurse take vital signs? | Monitor vital signs every 15 minutes for one hour than if stable, every hour for 2 hours. This is a typical protocol for post procedure patients to assess their return to a stable status. |
| An 82-year-old patient is 2 days postoperative with right hip replacement. The patient has comorbidities of hypertension, atrial fibrillation, and type 2 diabetes. The patient is scheduled for transfer to a rehab unit later today. Vital signs have been st | Vital signs need to be monitored at the time of morning care and again one hour before transfer to confirm that she maintains her stable status and is suitable for transfer |
| A 35-year-old woman delivered a 9 lb, 7 oz baby boy 24 hours ago via cesarean section. Her vital signs were stable, pulse 74 bpm and temperature 99°F, 4 hours ago. The unlicensed assistive personnel (UAP) reports to the nurse that this patient’s pulse is | Assess the patient. |
| The nurse is ready to give a 60-year-old patient the daily cardiac medication. The certified nursing assistant (CNA) reports that the patient’s vital signs are pulse 42 bpm, blood pressure 148/86 mm Hg, and respirations 20 bpm. What interpretation will th | Withhold the cardiac medication. Recheck the patient’s vital signs. Compare the current vital signs with this patient’s baseline data. |
| A 6-year-old child is carried into the emergency department (ED) by the mother. The child has a history of asthma and is gasping for breath and wheezing. The child’s vital signs are respirations 30 bpm, pulse 120 bpm, SpO292%, and BP 90/50 mm Hg. The nurs | Obtain oxygen saturation measurement. Ask the mother for a medical history including any medications. Call for the appropriate care provider to quickly evaluate. Initiate standing protocols for childhood asthmatic until the appropriate care provider ar |
| The charge nurse in an assisted living community has just arrived for the evening shift. During report, the nurse is told a long-time resident fell in the patient’s room 2 hours ago. The day nurse contacted the primary care provider, who ordered the patie | UAP obtain vital sign assessments of stable patients. The patient is fully conscious and aware of surroundings. The patient has had a continuous drop in blood pressure since the fall. The patient asks to have the UAP provide patient care because the UA |
| The nurse is making the daily assignment on the unit. There is an unlicensed assistive personnel (UAP) available to assist with patient care. Which action is the responsibility of the nurse? | 1) Ensure that the UAP uses the proper technique for measuring vital signs. 2) Ensure that the UAP knows what values need to be reported immediately for each patient. 3) Reassess any abnormal values measured by the UAP. 4) Interpret vital sign data col |
| The nurse working on a busy postoperative floor is making the daily assignment for an experienced unlicensed assistive personnel (UAP) on this unit. Which aspects should the nurse consider regarding delegation? | Nurses may delegate vital sign assessments after determining that a patient is medically stable. Nurses must ensure that the UAP is competent to perform vital sign assessments and knows the values that must be reported immediately. Nurses are responsib |
| The unlicensed assistive personnel (UAP) reports the current vital sign assessment on a patient who is on the third recovery day after a fractured femur: BP 156/92 mm Hg, P 84 beats per minute, R 18 beats per minute, and T 98.8°F. The nurse takes which ac | Verify the vital signs personally. Review the patient’s medical history. Review the patient’s vital sign history. |
| Which actions taken by the nurse when documenting vital signs support the goal of efficient and safe patient care? | Document in a standardized format. Format to easily identify the patient’s vital sign trends. Provide multiple sets of vital signs visible at a time. Communicate with all members of the health care team. |
| Which factors influence the interpretation of vital signs? | patient status Consideration of patient's baseline vital signs Standard range for vital sign values Patient's unique medical condition |
| The nurse recognizes which function as an adaptive immune response? | Triggering lymphocyte production |
| Which type of immunity protects a person from infection after receiving a skin laceration? | Innate immunity |
| Which type of immunity provides long-term, active immunity for an individual who recovered from a viral infection? | Adaptive immunity |
| The nurse understands that the innate immune response involves which components? | 1) fungi 2) low stomach pH 3) skin 4) capillary dilation |
| Introducing the patient’s normal flora into which body area increases the risk for infection? | urinary bladder |
| Which component is part of innate immunity and participates in the inflammatory response? | Leukocytes |
| The nurse recognizes which characteristics of adaptive immunity? | 1) acquired throughout a person's lifetime 2) complex, highly organized system 3) requires exposure to specific antigens 4) generates antigen-specific defenses |
| Which event occurs first when the adaptive immune system is stimulated by an invading antigen? | Decoding of non-self-marker on antigen surface |
| Which type of immunity will a nurse have after receiving the required three immunizations for HBV (hepatitis B)? | Artificially acquired active immunity |
| Reviewing data collected during the assessment assists the nurse with which part of the nursing process? | Planning |
| Which nursing diagnosis takes priority for a patient with an open draining wound, fever, and nausea? | Imbalanced Nutrition |
| Which patient behavior supports the nursing diagnosis of Knowledge Deficit? | Inability to perform incisional care. |
| Which nursing diagnosis will the nurse add to the care plan after noting an open pressure ulcer on the patient’s coccyx during assessment? | Impaired Skin Integrity |
| “Patient will demonstrate correct handling of dirty and clean dressings” is a measurable patient-centered goal for which nursing diagnosis? | Knowledge Deficit |
| Which are measurable data that can be used to support if a patient is meeting infection-related goals? | Hand washing Perspiring Pain Fever |
| Which goal is realistic for a hospitalized patient who has an infection with the nursing diagnosis of Nutrition Imbalance, Less Than Body Requirements? | Patient will eat 75% of meals by the end of 3 days. |
| What should the nurse do when a patient with a wound infection shows no improvement in assessment baseline after a week? | Review interventions to determine need for revision. |
| The nurse must have a written or oral order when implementing which nursing actions? | Administering an oral medication Beginning an intravenous (IV) infusion |
| Which actions will the nurse take for a patient who is experiencing discomfort from an infection? | Assess pain on scale of 1 to 10. Position patient to relieve discomfort. Encourage diversion such as relaxation. |
| What are purposes of hand hygiene? | Prevents the spread of infection Breaks the chain of infection Interrupts organism transmission |
| Which medical asepsis interventions by the nurse protect the patient from infection? | Cleaning patient bedside equipment routinely Disposing of used needles in sharps containers Providing leak-proof receptacles at bedside for tissues Preventing contamination of intravenous sites and ports |
| Which actions are required by the nurse when preparing for a sterile procedure? | Keeping sterile surfaces dry Setting up the sterile field Checking packaging integrity Monitoring activities of others |
| Which action did the nurse recognize as a breach in surgical asepsis that contaminated the sterile field? | Provider reached over sterile field to pick up a towel |
| Equipment being used to enter a sterile body cavity must undergo which procedure? | Sterilization |
| Which step is first in the sequence for donning personal protective equipment (PPE)? | Hand hygiene |
| The nurse will don a fitted N95 respiratory mask when caring for a patient with which infection? | Tuberculosis |
| Which statements best describe the purpose for greeting the patient and explaining the need for personal protective equipment (PPE)? | Eases fear and misunderstanding Creates a professional relationship Builds a trusting relationship |
| It is permissible for the nurse to use alcohol-based hand sanitizer on which occasion? | Nothing can be visibly seen on hands |
| After educating a patient about respiratory etiquette, which behavior indicates the need for additional teaching? | Reusing tissues for a productive cough |
| Which nursing student’s note will the nurse correct? | Standard precautions used during bed bath and mouth care. |
| The nurse will implement contact precautions when learning that a patient is being admitted with which infection? | Hepatitis A |
| By which means are pathogens transmitted through droplets and require infected patients to be placed on protective precautions? | Coughing Sneezing Suctioning Talking |
| A patient with which infection will be admitted to the airborne infection isolation room? | Varicella zoster |
| Which action to reduce the spread of infections is the nursing taking by avoiding going to work when sick? | Personal |
| Communities can help reduce infections among their citizens by engaging in which actions? | Encouraging and facilitating immunization programs |
| The Centers for Disease Control and Prevention (CDC) applies the term quarantine to which group(s)? | People Animals Cargo Buildings |
| Match the precaution with its corresponding description. | Isolation Separates sick and contagious people from others Quarantine Separates people exposed to a contagious disease Protective isolation Separates people with weak immune systems |
| Which rationale supports the restriction on administering aspirin to children under the age of 2 years? | Might cause Reye syndrome. |
| A postoperative patient is febrile. What nonpharmacological steps can the nurse take to lower the patient’s temperature until receiving further orders from the provider? | Apply cool packs. Apply a cooling blanket to the patient Sponge the patient down with cool water. |
| A patient presents with hypothermia after being rescued from drowning in the winter. Which interventions should be employed? | 1. Administering warmed intravenous fluids as ordered by the primary care provider/ 2. Applying several layers of warmed blankets to the patient. 3. Wrapping warm, dry towels around the patients head |
| Which is a goal for a patient who has been assigned the following nursing diagnosis: Activity Intolerance related to immobility, as evidenced by shortness of breath with ambulation and increased pulse rate with activity? | Patient will exhibit respirations, pulse, and heart rate within usual range during exercise activities before discharge. |
| Which nursing action is appropriate for a patient with a decreased cardiac output and a pulse rate of 120 bpm? | 1. Promoting rest 2. Assessing peripheral pulses 3. Elevating the patient’s legs while at rest 4. Administering supplemental oxygen as prescribed |
| A patient presents as follows: able to only speak in short phrases, blood pressure (BP) 152/90 mm Hg, respiratory rate 28 bpm. Which priority intervention should be instituted by the nurse? | Immediate oygenation |
| A patient on a ventilator displays oxygen saturation rates as low as 82%. What interventions can the nurse perform to help alleviate the poor oxygenation? | 1. Suctioning the patient’s airway to free it of any secretions 2. Repositioning the patient and elevating the head of the bed to semi- or high Fowler’s position |
| A patient presents with complaints of chest pain. The patient has a recent history of bronchitis and coughing. The patient is 5’4”, weighs 250 lb, and is a smoker. The patient continues to be short of breath, is afebrile, and reports the cough has subside | 1. Obesity 2. Smoking 3. Chest pain |
| A nurse working in the pulmonary step-down unit realizes that the primary goal for altered respirations in patients is to improve oxygenation. How would evaluation of interventions be measured to assess how successful the interventions have been? | Compare preintervention baseline data with postintervention data. |
| A patient presents with blood pressure of 78/42 mm Hg. Which statement should the nurse understand to interpret the blood pressure reading? | 1. It is considered hypotension. 2. It may lead to shock symptoms, and even death, if not corrected |
| Which statement is accurate about a blood pressure >140/90 mm Hg? | 1. It is considered hypertension. 2. A blood pressure >140/90 mm Hg may lead to a stroke. 3. A blood pressure >140/90 mm Hg may lead to heart disease. |
| A patient is experiencing severe pain due to a kidney stone, with a heart rate of 125 bpm and a blood pressure of 190/86 mm Hg. Which interventions would be appropriate for this patient? | 1. Provide calm, restful surroundings, minimizing environmental activity and noise 2. Assess emotional and psychological factors affecting the patient’s current situation 3. Administer pain medications, as ordered by the provider, for discomfort and eva |
| A patient, postoperative from hip replacement, is receiving two pain tablets by mouth every 6 hours as needed for pain (Norco 5/325 mg). The nurse notes the patient also has a second prescription of IV pain medication to be given every 6 hours as needed f | The nurse gives the two Norco tablets for pain and staggers the ketorolac in between the prn doses of Norco. |
| In the postanesthesia care unit, a patient expresses pain at 9 of 10. The patient receives 2 mg of morphine intravenously. After 20 minutes, the nurse wants to reassess the patient’s pain to evaluate the effectiveness of the morphine. Which action should | Ask the patient to rate the pain on a scale of 1 to 10. |
| Which aspect should be ruled out before utilizing massage therapy as an intervention to combat pain? | Bone fractures |
| The nurse takes the patient’s blood pressure and it is 130/70 mm Hg. Which number reflects the pulse pressure? | 60 mm Hg |
| The nurse takes the patient’s blood pressure (BP) while the patient is lying supine and it is 130/70 mm Hg. The patient sits up to try to go to the bathroom and becomes dizzy. The nurse takes the patient’s BP again and it is 108/60 mm Hg. Which condition | Orthostatic hypotension |
| An older adult patient presents for a yearly physical examination. The female patient is 5’4” and 115 lb. She loves fried foods and occasionally drinks a glass of red wine before going to bed. Her blood pressure is 105/60 mm Hg. The nurse realizes that a | Age |
| The nurse is caring for an older adult patient who experienced a heart attack 1 hour ago. The blood pressure is 110/60 mm Hg and the pulse is 108 beats per minute. The patient is becoming cool, clammy, and confused. The nurse understands that if the patie | Decreased cardiac output |
| The nurse advises the patient to avoid which item in relation to taking an accurate blood pressure reading? | Avoid activity 5 minutes prior to reading. |
| A nurse is teaching a student nurse about blood pressure assessment errors. Which statement by the student shows a need for further education? | "If the cuff is too wide, a false high reading is possible." |
| The nurse is unable to assess an indirect blood pressure in using the patient’s brachial arteries due to bilateral upper extremity injuries. Which alternate artery should the nurse use to assess the patient’s blood pressure? | Popliteal artery |
| The nurse must assess the patient’s indirect blood pressure using the popliteal artery due to bilateral injuries to the upper extremities. Which nursing action is accurate when assessing the indirect blood pressure using this artery? | Inflating the cuff 30 mm Hg above the palpable pulsation of the popliteal artery |
| The nurse is preparing to delegate the task of blood pressure (BP) measurement for several patients on a surgical unit. Which patient condition requires special instructions for the unlicensed assistive personnel (UAP) before delegating this task? | -The patient who had a right-sided mastectomy. -The patient with a cast and pins in the left arm. -The patient with IV fluids running in the left arm. |
| The nurse is caring for a patient with seizures who is not critically ill. Which equipment should the nurse select to measure blood pressure for this patient? | Sphygmomanometer |
| A patient is recovering from hip replacement surgery. The nurse assessed the patient’s blood pressure (BP) lying down, and it registered 126/82 mm Hg. Immediately after sitting, the BP dropped to 96/64 mm Hg. The nurse assessed the BP a third time while t | Risk for Falls related to changes in BP when lying, sitting, and standing reflecting orthostatic hypotension |
| Which goals are appropriate long-term, patient-centered, measurable goals for the nurse to include in the plan of care for a patient with a nursing diagnosis of decreased cardiac output related to decreased myocardial contractility? | -Patient will have strong, palpable peripheral pulses in all extremities within three months of treatment. -Patient will have normal heart sounds of S1 and S2 by the fourth follow-up visit. |
| Which are the appropriate Nursing Outcome Classifications (NOC) to include in the plan of care for a patient with the nursing diagnosis of risk for decreased cardiac output? | -Vital signs status -Circulatory status -Tissue perfusion: Cerebral -Tissue perfusion: Abdominal organs |
| The nurse is providing care for a patient who is displaying symptoms of tissue edema; differences in blood pressure in opposite extremities; skin color changes (pallor); and cool, clammy skin and prolonged capillary refill. Which is the most likely nursin | Ineffective Tissue Perfusion: Peripheral |
| Which are appropriate measurable, short-term goals for a patient with a diagnosis of Ineffective Tissue Perfusion: Peripheral? | -Patient's skin color will return to normal within 48 hours of medication. -Nail beds will return to pinkish color within 3 seconds of nail bed compressions. -Patient will increase behaviors that increase tissue perfusion by the next physician appointme |
| Which patient’s symptoms are consistent with a chronic inflammatory disorder? | 45 year old with pain and swelling of the knees from arthritis |
| Which patient (susceptible host) is at greatest risk for developing an infection? | 70-year-old with diabetes and an indwelling urinary catheter |
| The nurse recognizes that a patient’s surgical incision is no longer inflamed, but infected, by noting which finding? | Greenish drainage |
| The nurse recognizes which manifestation indicates systemic infection and warrants further patient assessment? | Temperature 101.3°F (38.5°C) orally |
| Which are strategies for collecting patient assessment data? | 1. Performing a general assessment 2.Speaking with the patient’s family 3.Performing the physical assessment 4. Obtaining a thorough history |
| Which patient objective findings alert the nurse to the presence of infection or the risk for infection? | 1. Pressure ulcers 2.Enlarged lymph nodes 3. Hyperactive bowel sounds 4. Decreased breath sounds |
| Which blood test specifically indicates the presence of an active inflammatory response rather than infection? | Erythrocyte sedimentation rate (ESR) |
| Which laboratory finding is abnormal and must be reported to the health care provider? | Serum complement 140 hemolytic units |
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Mrsbradley21
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