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NSG 200 Test 1 Fundamentals: end of chapter questions
Terms in this set (75)
A nurse assesses patients in a physician's office who are experiencing different levels of health and illness. Which statements best define the concepts of health and illness? Select all that apply.
a. Health and illness are the same for all people.
b. Health and illness are individually defined by each person.
c. People with acute illnesses are actually healthy.
d. People with chronic illnesses have poor health beliefs.
e. Health is more than the absence of illness.
f. Illness is the response of a person to a disease.
B, E, F
The student nurse learns that illnesses are classified as either acute or chronic. Which are examples of chronic illnesses? Select all that apply.
a. Diabetes mellitus
b. Bronchial pneumonia
c. Rheumatoid arthritis
d. Cystic fibrosis
e. Fractured hip
f. Otitis media
A, C, D
Despite a national focus on health promotion, nurses working with patients in inner-city clinics continue to see disparities in health care for vulnerable populations. Which patients would be considered vulnerable populations? Select all that apply.
a. A White male diagnosed with HIV
b. An African American teenager who is 6 months pregnant
c. A Hispanic male who has type II diabetes
d. A low-income family living in rural America
e. A middle-class teacher living in a large city
f. A White baby who was born with cerebral palsy
B, C, D, F
A nurse has volunteered to give influenza immunizations at a local clinic. What level of care is the nurse demonstrating?
A nurse's neighbor tells the nurse, "I have a high temperature, feel awful, and I am not going to work." What stage of illness behavior is the neighbor exhibiting?
a. Experiencing symptoms
b. Assuming the sick role
c. Assuming a dependent role
d. Achieving recovery and rehabilitation
Which clinic patient is most likely to have annual breast examinations and mammograms based on the physical human dimension?
a. Jane, whose her best friend had a benign breast lump removed
b. Sarah, who lives in a low-income neighborhood
c. Tricia, who has a family history of breast cancer
d. Nancy, whose family encourages regular physical examinations
Health promotion activities may occur on a primary, secondary, or tertiary level. Which activities are considered tertiary health promotion? Select all that apply.
a. A nurse runs an immunization clinic in the inner city.
b. A nurse teaches a patient with an amputation how to care for the residual limb.
c. A nurse provides range-of-motion exercises for a paralyzed patient.
d. A nurse teaches parents of toddlers how to childproof their homes.
e. A school nurse provides screening for scoliosis for the students.
f. A nurse teaches new parents how to choose and use an infant car seat.
The agent-host-environment model of health and illness is based on what concept?
a. Risk factors
b. Demographic variables
c. Behaviors to promote health
d. Stages of illness
When providing health promotion classes, a nurse uses concepts from models of health. What do both the health-illness continuum and the high-level wellness models demonstrate?
a. Illness as a fixed point in time
b. The importance of family
c. Wellness as a passive state
d. Health as a constantly changing state
A nurse follows accepted guidelines for a healthy lifestyle. How can this promote health in others?
a. By being a role model for healthy behaviors
b. By not requiring sick days from work
c. By never exposing others to any type of illness
d. By spending less money on food
A home health care nurse takes the vital signs of a patient who is receiving supplemental oxygen at home for chronic obstructive pulmonary disease (COPD). This is the nurse's fourth visit to the patient's home. The nurse records the data collected on the patient's chart. What type of assessment has this nurse performed?
b. Ongoing partial assessment
c. Focused assessment
d. Emergency assessment
A nurse caring for patients in a long-term care facility is performing a functional assessment of a new patient. Which questions would the nurse ask? Select all that apply.
a. Are you able to dress yourself?
b. Do you have a history of smoking?
c. What is the problem for which you are seeking care?
d. Do you prepare your own meals?
e. Do you manage your own finances?
f. Whom do you rely on for support?
A, D, E
A nurse is assessing a patient's eyes for extraocular movements. Which action correctly describes a step the nurse would take when performing this test?
a. Ask the patient to sit about 3 feet away facing the nurse.
b. Keep a penlight about 1 foot from the patient's face and move it slowly through the cardinal positions.
c. Move a penlight in a circular motion in front of the patient's eyes.
d. Ask the patient to cover one eye with a hand or index card.
Which actions would the nurse perform when using the technique of palpation during the physical assessment of a patient? Select all that apply.
a. The nurse compares the patient's bilateral body parts for symmetry.
b. The nurse takes a patient's pulse.
c. The nurse touches a patient's skin to test for turgor.
d. The nurse checks a patient's lymph nodes for swelling.
e. The nurse taps a patient's body to check the organs.
f. The nurse uses a stethoscope to listen to a patient's heart sounds.
B, C, D
When inspecting the skin of a patient who has cirrhosis of the liver, the nurse notes that the skin has a yellow tint. What would the nurse document related to this finding?
After inspecting the skin of a patient, the nurse documents the presence of a skin lesion as a palpable solid mass measured at 1 cm. What types of skin lesions might this describe? Select all that apply.
A patient's visual acuity is assessed as 20/40 in both eyes using the Snellen chart. The nurse interprets this finding as:
a. The patient can see twice as well as normal.
b. The patient has double vision.
c. The patient has less than normal vision.
d. The patient has normal vision.
When assessing a patient's breath sounds, the nurse hears a high-pitched continuous sound. What type of breath sound would the nurse document?
A nurse is using the FOUR Coma Scale to assess the neurologic status of a patient following surgery to remove a brain tumor. The nurse rates the patient as M2 for motor response. What condition does this number represent?
a. Localizing to pain
b. Flexion response to pain
c. Extension response to pain
d. No response to pain
A nurse auscultates the thorax and lungs and hears coarse, low-pitched, continuous sounds on expiration. When the patient coughs, the sounds clear up somewhat. The nurse would document these sounds as:
a. Adventitious breath sounds
b. Bronchovesicular breath sounds
c. Vesicular breath sounds
d. Bronchial sounds
A nurse is assessing a patient's eyes for accommodation. What actions would the nurse perform during this test? Select all that apply.
a. Bring a penlight from the side of the patient's face and briefly shine the light on the pupil.
b. Hold a forefinger, a pencil, or other straight object about 10 to 15 cm (4″ to 6″) from the bridge of the patient's nose.
c. Hold a finger about 6″ to 8″ from the bridge of the patient's nose.
d. Darken the room.
e. Ask the patient to look straight ahead.
f. Ask the patient to first look at a close object, then at a distant object, then back to the close object.
A nurse is palpating the breast of a woman during an assessment. Which technique is performed correctly?
a. The nurse starts at the tail of Spence and moves in increasing smaller circles.
b. The nurse uses the palms of the hands to gently compress the breast tissue against the chest wall.
c. The nurse works in a counterclockwise direction and palpates from the periphery toward the areola.
d. The nurse starts at the inner edge of the breast and palpates up and down the breast.
During a physical assessment, a nurse inspects a patient's abdomen. What assessment technique would the nurse perform next?
d. Whichever is more comfortable for the patient
A nurse is assessing the level of consciousness of a patient who sustained a head injury in a motor vehicle accident. The nurse notes that the patient appears drowsy most of the time but makes spontaneous movements. The nurse is able to wake the patient by gently shaking him and calling his name. What level of consciousness would the nurse document?
a. Awake and alert
A nurse is conducting an assessment of a patient's cranial nerves. The nurse asks the patient to raise the eyebrows, smile, and show the teeth to assess which cranial nerve?
A nurse assesses an oral temperature for an adult patient. The patient's temperature is 37.5°C (99.5°F). What term would the nurse use to report this temperature?
A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variations in normal vital signs, which patients would the nurse document as having a normal vital sign? Select all that apply.
a. A 4-month old infant whose temperature is 38.1°C (100.5°F)
b. A 3-year old whose blood pressure is 118/80
c. A 9-year old whose temperature is 39°C (102.2°F)
d. An adolescent whose pulse rate is 70 bpm
e. An adult whose respiratory rate is 20 bpm
f. A 72-year old whose pulse rate is 42 bpm
A, D, E, F
A patient who is febrile may lose body heat through perspiration. The nurse recognizes that this is an example of what mechanism of heat loss?
The rectal temperature, a core temperature, is considered to be one of the most accurate routes. In which cases would taking a rectal temperature be contraindicated? Select all that apply.
a. A newborn who has hypothermia
b. A child who has pneumonia
c. An older patient who is post myocardial infarction (heart attack)
d. A teenager who has leukemia
e. A patient receiving erythropoietin to replace red blood cells
f. An adult patient who is newly diagnosed with pancreatitis
A, C, D, E
While taking an adult patient's pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next?
a. Check the pulse again in 2 hours.
b. Check the blood pressure.
c. Record the information.
d. Report the rate to the primary care provider.
A patient is having dyspnea. What would the nurse do first?
a. Remove pillows from under the head
b. Elevate the head of the bed
c. Elevate the foot of the bed
d. Take the blood pressure
A patient complains of severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments? Select all that apply.
a. An increase in the pulse rate
b. A decrease in body temperature
c. A decrease in blood pressure
d. An increase in respiratory depth
e. An increase in respiratory rate
f. An increase in body temperature
Two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 beats per minute. The nurse would document this difference as which of the following?
a. Pulse deficit
b. Pulse amplitude
c. Ventricular rhythm
d. Heart arrhythmia
A student nurse is learning to assess blood pressure. What does the blood pressure measure?
a. Flow of blood through the circulation
b. Force of blood against arterial walls
c. Force of blood against venous walls
d. Flow of blood through the heart
The nurse instructor is teaching student nurses about the factors that may affect a patient's blood pressure. Which statements accurately describe these factors? Select all that apply.
a. Blood pressure decreases with age.
b. Blood pressure is usually lowest on arising in the morning.
c. Women usually have lower blood pressure than men until menopause.
d. Blood pressure decreases after eating food.
e. Blood pressure tends to be lower in the prone or supine position.
f. Increased blood pressure is more prevalent in African Americans.
B, C, E, F
Prioritization: Place the following descriptions of the phases of Korotkoff sounds in order from Phase I to Phase V.
a. Characterized by muffled or swishing sounds that may temporarily disappear; also known as the auscultatory gap
b. Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery
c. The last sound heard before a period of continuous silence, known as the second diastolic pressure
d. Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; known as the systolic pressure
e. Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; considered to be the first diastolic pressure
D, A, B, E, C
A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient?
a. Follow-up measurements of blood pressure
b. Immediate treatment by a physician
c. No action, because the nurse considers this reading is due to anxiety
d. A change in dietary intake
A nurse is documenting a blood pressure of 120/80 mm Hg. The nurse interprets the 120 to represent:
a. The rhythmic distention of the arterial walls as a result of increased pressure due to surges of blood with ventricular contraction
b. The lowest pressure present on arterial walls while the ventricles relax
c. The highest pressure present on arterial walls while the ventricles contract
d. The difference between the pressure on arterial walls with ventricular contraction and relaxation
It is important to have the appropriate cuff size when taking the blood pressure. What error may result from a cuff that is too large or too small?
a. An incorrect reading
b. Injury to the patient
c. Prolonged pressure on the arm
d. Loss of Korotkoff sounds
A patient has intravenous fluids infusing in the right arm. When taking a blood pressure on this patient, what would the nurse do in this situation?
a. Take the blood pressure in the right arm
b. Take the blood pressure in the left arm
c. Use the smallest possible cuff
d. Report inability to take the blood pressure
Read the following scenario and identify the term for the characteristics of patient data that are numbered below. Place your answers on the lines provided.
The nurse is conducting an initial assessment of a 79-year old female patient admitted to the hospital with a diagnosis of dehydration. The nurse: (1) uses clinical reasoning to identify the need to perform a comprehensive assessment and gather the appropriate patient data, (2) first asks the patient about the most important details leading up to her diagnosis, (3) collects as much information as possible to understand the patient's health problems, (4) collects the patient data in an organized manner, (5) verifies that the data obtained is pertinent to the patient care plan, and (6) records the data according to agency policy.
(5) Factual and accurate
(6) Recorded in a standard manner:
The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed?
d. Quick priority
The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply.
a. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths."
b. "It's hospital policy. I know it must be tiresome, but I will try to make this quick!"
c. "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care."
d. "We want to make sure that your responses to the medical exam are consistent and that all our data are accurate."
e. "We need to check your health status and see what kind of nursing care you may need."
f. "We need to see if you require a referral to a physician or other health care professional.
A, E, F
When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate?
a. Correct the initial assessment form.
b. Redo the initial assessment and document current findings.
c. Conduct and document an emergency assessment.
d. Perform and document a focused assessment of skin integrity.
A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply?
a. "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!"
b. "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care."
c. "No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient."
d. "Don't worry about learning all of the questions to ask. Every agency has its own assessment form you must use."
The nurse collects objective and subjective data when conducting patient assessments. Which patient conditions are examples of subjective data? Select all that apply.
a. A patient tells the nurse that she is feeling nauseous.
b. A patient's ankles are swollen.
c. A patient tells the nurse that she is nervous about her test results.
d. A patient complains of having a rash on her arm that is itchy.
e. A patient rates his pain as a 7 on a scale of 1 to 10.
f. A patient vomits after eating supper.
A, C, D, E
When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. What should the nurse do?
a. Introduce oneself and thank the wife for being present.
b. Introduce oneself and ask the wife if she wants to remain.
c. Introduce oneself and ask the wife to leave.
d. Introduce oneself and ask the patient if he would like the wife to stay.
A nurse is performing an initial comprehensive assessment of an 84-year-old male patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following?
a. Maslow's human needs
b. Gordon's functional health patterns
c. Human response patterns
d. Body system model
The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do?
a. Inform the charge nurse.
b. Inform the surgeon.
c. Validate the finding.
d. Document the finding.
A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response?
a. "You made an inference that she is fine because she has no complaints. How did you validate this?"
b. "She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship."
c. "Sometimes everyone gets lucky. Why don't you try to help another patient?"
d. "Maybe you should reassess the patient. She has to have a problem—why else would she be here?"
During rounds, a charge nurse hears the patient care technician yelling loudly to a patient regarding a transfer from the bed to chair. When entering the room, what is the nurse's best response?
a. "You need to speak to the patient quietly. You are disturbing the patient."
b. "Let me help you with your transfer technique."
c. "When you are finished, be sure to apologize for your rough demeanor."
d. "When your patient is safe and comfortable, meet me at the desk."
A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's best response to the neighbor?
a. "New mothers need support."
b. "The lack of a father is difficult."
c. "How are you today?"
d. "It is a very sad situation."
A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admission interview, the nurse should implement which communication techniques to elicit the most information from the parents?
a. The use of reflective questions
b. The use of closed questions
c. The use of assertive questions
d. The use of clarifying questions
A nurse enters a patient's room and examines the patient's IV fluids and cardiac monitor. The patient states, "Well, I haven't seen you before. Who are you?" What is the nurse's best response?
a. "I'm just the IV therapist checking your IV."
b. "I've been transferred to this division and will be caring for you."
c. "I'm sorry, my name is John Smith and I am your nurse."
d. "My name is John Smith, I am your nurse and I'll be caring for you until 11 p.m."
A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which statement is the most therapeutic?
a. The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill."
b. The nurse places a hand on the patient's arm and states, "You feel so alone."
c. The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day."
d. The nurse holds the patient's hand and asks, "What makes you feel so alone?"
A nurse caring for a patient who is hospitalized following a double mastectomy is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship?
a. Determining the progress made in achieving established goals
b. Clarifying when the patient should take medications
c. Reporting the progress made in teaching to the staff
d. Including all family members in the teaching session
A nursing student is nervous and concerned about the work she is about to do at the clinical facility. To allay anxiety and be successful in her provision of care, it is most important for her to:
a. Determine the established goals of the institution
b. Be sure her verbal and nonverbal communication is congruent
c. Engage in self-talk to plan her day and decrease her fear
d. Speak with her fellow colleagues about how they feel
A nurse in the rehabilitation division states to her head nurse, Mr. Tyler, "I need the day off and you didn't give it to me!" The head nurse replies, "Well, I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of this exchange, what communication by the nurse would have been more effective?
a. "Mr. Tyler, I placed a request to have August 8th off, but I'm working and I have a doctor's appointment."
b. "Mr. Tyler, I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?"
c. "Mr. Tyler, I will need to call in on the 8th of August because I have a doctor's appointment."
d. "Mr. Tyler, since you didn't give me the 8th of August off, will I need to find someone to work for me?"
During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? Select all that apply.
a. Group decision making
b. Group leadership
c. Group power
d. Group identity
e. Group patterns of interaction
f. Group cohesiveness
A, D, E, F
A nurse sees a patient walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. It is important that the nurse assess the patient for:
d. Fluid volume deficit
. A nursing student is preparing to administer morning care to a patient. What is the most important question that the nursing student should ask the patient about personal hygiene?
a. "Would you prefer a bath or a shower?"
b. "May I help you with a bed bath now or later this morning?"
c. "I will be giving you your bath. Do you use soap or shower gel?"
d. "I prefer a shower in the evening. When would you like your bath?"
A nurse is providing instruction to a patient regarding the procedure to change his colostomy bag. During the teaching session, he asks, "What type of foods should I avoid to prevent gas?" The patient's question allows for what type of communication?
a. A closed-ended answer
b. Information clarification
c. The nurse to give advice
d. Assertive behavior
When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate communication technique?
b. Giving advice
c. Being judgmental
d. Changing the subject
A 76-year-old patient states, "I have been experiencing complications of diabetes." The nurse needs to direct the patient to gain more information. What is the most appropriate comment or question to elicit additional information?
a. "Do you take two injections of insulin to decrease the complications?"
b. "Most physicians recommend diet and exercise to regulate blood sugar."
c. "Most complications of diabetes are related to neuropathy."
d. "What specific complications have you experienced?"
During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after she communicates the plan of care. What would be appropriate nurse responses in this situation? Select all that apply.
a. Fill the silence with lighter conversation directed at the patient.
b. Use the time to perform the care that is needed uninterrupted.
c. Discuss the silence with the patient to ascertain its meaning.
d. Allow the patient time to think and explore inner thoughts.
e. Determine if the patient's culture requires pauses between conversation.
f. Arrange for a counselor to help the patient cope with emotional issues.
C, D, E
A nurse is documenting patient data in the medical record of a patient admitted to the hospital with a diagnosis of appendicitis. The physician has ordered 10 mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follows recommended guidelines? Select all that apply.
a. 6/12/15 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN
b. 6/12/15 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN
c. 6/12/15 0945 30 minutes following administration of morphine 10 mg IV patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN
d. 6/12/15 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN
e. 6/12/15 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick, RN
f. 6/12/15 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration.
C, D, F
A nurse is documenting the care given to a 56-year-old patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation?
a. Erase or use correcting fluid to completely delete the error.
b. Draw a single line through the entry and rewrite it above or beside it.
c. Use a permanent marker to block out the mistaken entry and rewrite it.
d. Remove the page with the error and rewrite the data on that page correctly.
A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response?
a. "I'm sorry, but patients are not allowed to copy their medical records."
b. "I can make a copy of your record for you right now."
c. "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules."
d. "I will need to check with our records department to get you a copy."
According to the Health Insurance Portability and Accountability Act of 1996, if a health institution wants to release a patient's health information (PHI) for purposes other than treatment, payment, and routine health care operations, the patient must be asked to sign an authorization. The nurse is aware that there are exceptions to this requirement. In which of the following cases is an authorization form not needed? Select all that apply.
a. News media are preparing a report on the condition of a public figure.
b. Data are needed for the tracking and notification of disease outbreaks.
c. Protected health information is needed by a coroner.
d. Child abuse and neglect are suspected.
e. Protected health information is needed to facilitate organ donation.
f. The sister of a patient with Alzheimer's wants to help provide care.
B, C, D, E
A friend of a nurse calls and asks if she is still working at Memorial Hospital. The nurse replies, "Yes." The friend tells the nurse that his girlfriend's father was just admitted as a patient and he wants the nurse to find out how he is. The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make?
a. "You shouldn't be asking me to do this. I could be
fined or even lose my job for disclosing this
b. "Sorry, but I'm not able to give information about
patients to the public—even when my best friend
or a family member asks."
c. "Because of the Health Insurance Portability and
Accountability Act, you shouldn't be asking for this
information unless the patient has authorized you
to receive it! This could get you in trouble!"
d. "Why do you think Sue isn't talking about her
A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication?
a. Every three hours
b. Every four hours
d. As needed
A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the physician's order sheet. The nurse's best response is:
a. "Thank you for taking care of this!"
b. Get a second nurse to listen to the order, and after
writing the order on the physician order sheet, have
both nurses sign it.
c. "I am sorry, but verbal orders can only be given in
an emergency situation that prevents us from
writing them out. I'll bring the chart and we can do
d. Try calling another resident for the order or wait
until the next shift.
A nurse is looking for trends in a postoperative patient's vital signs. Which documents would the nurse consult first?
a. Admission sheet
b. Admission nursing assessment
c. Activity flow sheet
d. Graphic record
A nurse is using the SOAP format of documentation to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation?
a. A patient problem list
b. Notes describing the patient's condition
c. Overall trends in patient status
d. Planned interventions and patient outcomes
A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a male patient who has been prescribed morphine via a patient-controlled analgesia pump (PCA) for pain related to pancreatic cancer. Place the following nursing statements related to this call in the order in which they should be performed.
a. "I am calling about Mr. Sanchez in Room 202 who is
receiving morphine via a PCA pump for pancreatic
b. "Mr. Sanchez has been difficult to arouse and his
mental status has changed over the past 12 hours
since using the pump."
c. "You want me to discontinue the PCA pump until
you see him tonight at patient rounds."
d. "I am Rosa Clark, an RN working on the second
floor of South Street Hospital."
e. "Mr. Sanchez was admitted two days ago following
a diagnosis of pancreatic cancer."
f. "I think the dosage of morphine in Mr. Sanchez's
PCA pump needs to be lowered."
D, A, E, B, F, C
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