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Fundamentals Study Guide

Terms in this set (132)

What phrase best describes health?
A) individually defined by each person
B) experienced by each person in exactly the same way
C) the opposite of illness
D) the absence of disease
A
A 4-year-old child has leukemia but is now in remission. What does it mean to be in remission when one has a chronic illness?
A) The chronic disease has been cured.
B) Nothing further can be done in terms of treatment.
C) Severe symptoms of the chronic illness have reappeared. D) The disease is present, but symptoms are not experienced.
D
What is the nurses primary role in promoting health?
A) educating others about health promotion activities
B) avoiding smoking or drinking in public
C) being a role model for health promotion
D) implementing stress reduction activities
C
According to Maslows basic human needs hierarchy, which needs are the most basic?
A) physiologic
B) safety and security
C) love and belonging
D) self-esteem
A
An 80-year-old woman states, I have successfully raised my family and had a good life. This statement illustrates meeting which basic human need?
A) safety and security
B) love and belonging
C) self-esteem
D) self-actualization
D
A 2-year-old boy arrives at the emergency department of a local hospital with difficulty breathing from an asthmatic attack. Which of the following would be the priority nursing intervention?
A) giving him his favorite stuffed animal to hold
B) assessing respirations and administering oxygen
C) raising the side rails and restraining his arms
D) asking his mother what are his favorite foods
B
What action by a nurse will help a patient meet self-esteem needs? A) verbally negate the patients negative self-perceptions
B) freely give compliments to increase positive self-regard
C) independently establish goals to improve self-esteem
D) respect the patients values and belief systems
D
Mrs. Dunn has cared for her husband with Alzheimers disease for 2 years. She comes to a local health center because she is feeling worn out and stressed. What might be an appropriate nursing diagnosis for Mrs. Dunn?
A) Dysfunctional Family Processes B) Health-Seeking Behaviors
C) Risk for Caregiver Burden
D) Risk for Anxiety
C
An older adult woman of Chinese ancestry refuses to eat at the nursing home, stating, Im just not hungry. What factors should the staff assess for this problem?
A) The woman does not like to eat with other residents of the home. B) The woman is using this as a means of going home.
C) The food served may not be culturally appropriate.
D) The food served may violate religious beliefs
C
Which of the following group of terms best describes the nursing process?
A) nursing goals, medical terminology, linear
B) nurse-centered, single focus, blended skills
C) patient-centered, systematic, outcomes-oriented
D) family-centered, single point in time, intuitive
C
Legally speaking, how would the nurse ensure that care was not negligent?
A) verbally reporting assessments to the patients physician
B) keeping private notes about the care given to each assigned patient
C) documenting the nursing actions in the patients record
D) tape recording complete information for each oncoming shift
C
Mrs. James comes to her healthcare providers office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do?
A) initial assessment
B) focused assessment
C) emergency assessment
D) time-lapsed assessment
B
Of the following data, what type would be collected during a physical assessment?
A) color, moisture, and temperature of the skin
B) type, amount, and duration of pain
C) foods eaten that cause nausea
D) specific allergies resulting in itching
A
Which of the following are examples of common factors that may influence assessment priorities? Select all that apply.
A) a patients diet and exercise program
B) a patients standing in the community
C) a patients ability to pay for services
D) a patients developmental stage
E) a patients need for nursing
A, D, E
A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, I have been so constipated lately. How should the nurse respond?
A) Do you have a family history of chest problems?
B) Why dont you use a laxative every night?
C) Do you take anything to help your constipation?
D) Everyone who ages has bowel problems.
C
In which of the following cases should a progress note be written? Select all that apply.
A) for any nursepatient interaction
B) when admitting a patient
C) when receiving a patient postoperatively
D) when assisting a patient with ADLs
E) when a procedure is performed
F) when a patient sends back an untouched dinner tray
B, C, E
Which of the following are physical changes that occur in middle adulthood? Select all that apply.
A) Body fat is redistributed.
B) The skin is more elastic.
C) Cardiac output begins to increase.
D) Muscle mass gradually decreases.
E) There is a loss of calcium from bones.
F) Hormone production increases.
A, D, E
The daughter of an older adult calls the nurse practitioner to report that her mother is becoming very confused after dark. What is this type of confusion named?
A) night-time confusion
B) sundowning syndrome
C) Alzheimers disease
D) cognitive dysfunction
B
During a health assessment, a 49-year-old woman tells the nurse that she is just so tired and has been having mood swings and hot flashes. Based on this information, the nurse would conduct a more thorough history and assessment of what body system?
A) reproductive
B) cardiovascular
C) respiratory
D) cranial nerves
A
While caring for an elderly man, the nurse observes that his skin is dry and wrinkled, his hair is gray, and he needs glasses to read. Based on these observations, what would the nurse conclude?
A) These are normal physiologic changes of aging.
B) The observations are not typically found in older adults.
C) These are abnormal observations and must be reported.
D) Extra teaching will be necessary to prevent complications.
A
Which of the following most accurately defines an infection?
A) an illness resulting from living in an unclean environment
B) the result of lack of knowledge about food preparation
C) a disease resulting from pathogens in or on the body
D) an acute or chronic illness resulting from traumatic injury
C
A patient who has had abdominal surgery develops an infection in the wound while still hospitalized. Which of the following agents is most likely the cause of the infection?
A) virus
B) bacteria
C) fungi
D) spores
B
Which of the following questions asked by the nurse when taking a patients health history would collect data about infection control?
A) Tell me what you eat in each 24-hour period.
B) Do you sleep well and wake up feeling healthy?
C) What were the causes of death for your family members?
D) When did you complete your immunizations?
D
A college-aged student has influenza. At what stage of the infection is the student most infectious?
A) incubation period
B) prodromal stage
C) full stage of illness
D) convalescent period
B
A nurse has seen several patients at a community health center. Which of the patients would be most at risk for developing an infection?
A) an older adult with several chronic illnesses
B) an infant who has just received first immunizations
C) an adolescent who had a basketball physical
D) a middle-aged adult with joint pain and stiffness
A
A nurse is teaching adolescents how to prevent infections. What statement by one of the adolescents indicates that more teaching is needed?
A) I will wash my hands before and after going to the bathroom.
B) I dont wear a condom when I have sex, but I know my partners. C) I always eat fruits and vegetables, and I sleep 8 hours a night.
D) When I have an infection, I rest and take my medications.
B
The following procedures have been ordered and implemented for a hospitalized patient. Which procedure carries the greatest risk for a nosocomial infection?
A) enema
B) intramuscular injections
C) heat lamp
D) urinary catheterization
D
Which of the following is an average normal temperature in Centigrade for a healthy adult?
A) oral: 37.0C
B) rectal: 36.5C
C) axillary: 37.5C
D) tympanic: 34.4C
A
The arterial blood gases for a patient in shock demonstrate increased carbon dioxide and decreased oxygen. What type of respirations would the nurse expect to assess based on these findings?
A) absent and infrequent
B) shallow and slow
C) rapid and deep
D) noisy and difficult
C
A nurse is assessing a patient who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would be likely?
A) bradycardia
B) tachycardia
C) dysrhythmia
D) bigeminal
B
A middle-aged, overweight adult man has had hypertension for 15 years. What pathologic event is he most at risk for?
A) stroke
B) anemia
C) cancer
D) infection
A
A nurse is caring for a patient who is ambulating for the first time after surgery. Upon standing, the patient complains of dizziness and faintness. The patients blood pressure is 90/50. What is the name for this condition?
A) orthostatic hypotension
B) orthostatic hypertension
C) ambulatory bradycardia
D) ambulatory tachycardia
A
A nurse is preparing to examine the breasts of a patient. In what position should the nurse place the patient?
A) prone
B) standing
C) dorsal recumbent
D) lithotomy
C
Which of the following positions should not be used to assess the abdomen?
A) supine
B) dorsal recumbent
C) kneechest
D) Sims
B
Which of the following can a nurse assess by palpation?
A) heart sounds, lung sounds, blood pressure
B) temperature, turgor, moisture
C) vision, hearing, cranial nerves
D) tissue density, gait, reflexes
B
A nurse is conducting a physical examination and is percussing the gastric area of a patient. What percussion tone is normally heard in this area?
A) flat
B) dull
C) resonant
D) tympany
D
When auscultating a patients abdomen, a nurse notes gurgling sounds. What characteristic of sound would the nurse document?
A) resonance
B) turgor
C) quality
D) texture
C
When inspecting the skin of a patient, the nurse notes a bluish tinge to the skin. What condition would the nurse document?
A) jaundice
B) cyanosis
C) erythema
D) pallor
B
The nurse palpating the skin of a patient documents a firm 1.5 cm mass on the lower right leg. What type of skin lesion does this describe?
A) macule
B) wheal
C) vesicle
D) nodule
D
A nurse assesses a patients eyes by testing the cardinal fields of vision for coordination and alignment. What eye characteristic is being assessed by this process?
A) visual acuity
B) extraocular movements
C) peripheral vision
D) existence of cataracts
B
While conducting a physical examination of the thorax, a nurse notes and documents breath sounds as moderate blowing sounds with equal inspiration and expiration. What type of breath sounds are these?
A) bronchial
B) bronchovesicular
C) vesicular
D) adventitious
B
When assessing the abdomen, which assessment technique is used last?
A) inspection
B) auscultation
C) percussion
D) palpation
D
Which of the following people is at greater risk for accidental injury?
A) an infant just learning to crawl
B) an older adult who walks 2 miles a day
C) an athlete who exercises on a regular basis
D) a worker who operates industrial machines
D
A physician has ordered peak and trough levels of a medication. When would the nurse schedule the trough level specimen?
A) before administering the first dose
B) immediately after the first dose C) 30 minutes before the next dose
D) 24 hours after the last dose
C
A nurse is converting the dosage of a medication to a different unit in the metric system. The medication label specifies the drug as being 0.5 g per tablet. The order is for 500 mg. How many tablets will the nurse give?
A) 1
B) 2
C) 5
D) 10
A
A physician orders Cipro 500 mg, PO q12h for a patient with bronchial pneumonia. The nurse has Cipro 250 mg on hand. How many tablets would the nurse dispense?
A) 1/2 tablet
B) 1 tablet
C) 2 tablets
D) 2 1/2 tablets
C
A nurse is administering a liquid medication to an infant. Where will the nurse place the medication to prevent aspiration?
A) between the gum and the cheek
B) in front of the teeth and gums
C) on the front of the tongue
D) under the tongue
A
What would a nurse instruct a patient to do after administration of a sublingual medication?
A) Take a big drink of water and swallow the pill.
B) Try not to swallow while the pill dissolves.
C) Swallow frequently to get the best benefit.
D) Chew the pill so it will dissolve faster.
B
A nurse is teaching a patient about regional anesthesia. Which of the following statements is accurate about this type of anesthesia?
A) You will be asleep and wont be aware of the procedure.
B) You will be asleep but may feel some pain during the procedure. C) You will be awake but will not be aware of the procedure.
D) You will be awake and will not have sensation of the procedure.
D
Which of the following patients are at an increased risk for oral problems? Select all that apply.
A) a comatose patient
B) a confused patient
C) a depressed patient
D) a patient undergoing chemotherapy
E) a hypertensive patient
F) an obese patient
A, B, C, D
A nurse is developing a plan of care for an older adult who is malnourished and on bed rest. Which of the following interventions would be included to prevent skin alterations?
A) turn and reposition every 2 hours
B) limit fluids to 500 mL every 24 hours
C) do not use lotions or creams on skin
D) assess vital signs every 4 hours
A
Which of the following are functions of the skin? Select all that apply.
A) protection
B) temperature regulation
C) psychosocial, sensation
D) vitamin C production
E) immunological
F) lipid reduction
A, B, C, E
Which of the following patients would be considered at risk for skin alterations? Select all that apply.
A) a teenager with multiple body piercings
B) a homosexual in a monogamous relationship
C) a patient receiving radiation therapy
D) a patient undergoing cardiac monitoring
E) a patient with diabetes mellitus
F) a patient with a respiratory disorder
A, C ,E
Which of the following statements accurately describes a developmental consideration when assessing skin integrity of patients?
A) In children younger than 2 years, the skin is thicker and stronger than it is in adults.
B) An infants skin and mucous membranes are injured easily and are subject to infection.
C) A childs skin becomes increasingly at risk for injury and infection.
D) In the older adult, circulation and collagen formation are increased.
B
A nurse assessing the skin of patients knows that the following are health states that may predispose patients to skin alterations. Select all that apply.
A) obesity
B) excessive perspiration
C) cataracts
D) hypertension
E) low BMI
F) Jaundice
A, B, E, F
What are the two major processes involved in the inflammatory phase of wound healing?
A) bleeding is stimulated, epithelial cells are deposited
B) granulation tissue is formed, collagen is deposited
C) collagen is remodeled, avascular scar forms
D) blood clotting is initiated, WBCs move into the wound
D
A nurse is caring for a patient who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time?
A) Administer pain medications on a p.r.n. and regular basis.
B) Assist in moving to prevent strain on the suture line.
C) Tell the patient that a mild fever is a normal response.
D) If a scar forms over a joint, it may limit movement.
B
A nurse is teaching a postoperative patient about essential nutrition for healing. What statement by the patient would indicate a need for more information?
A) I will drink a lot of orange juice and drink milk too.
B) I will take the zinc supplement the doctor recommended.
C) I will restrict my diet to fats and carbohydrates.
D) I will drink 8 to 10 glasses of water every day.
C
A nurse is assessing a patient with a stage IV pressure ulcer. What assessment of the ulcer would be expected?
A) full-thickness skin loss
B) skin pallor
C) blister formation
D) eschar formation
A
Which of the following is a recommended guideline nurses follow when using an electric heating pad on a patient?
A) Secure the heating pad to the patients clothing with safety pins.
B) Place a heavy towel or blanket over the heating pad to maximize heat effects.
C) Use a heating pad with a selector switch that can be turned up by the patient if needed.
D) Place a heating pad anteriorly or laterally to, not under, the body part.
D
A nurse working the night shift assesses a patients vital signs at 4 a.m. (0340). What would be the expected findings, based on knowledge of NREM sleep?
A) decreased TPR and BP
B) increased TPR and BP
C) no change from daytime readings
D) highly individualized, cannot predict
A
A nurse is discussing sleep problems with a patient. What type of foods would she recommend to promote sleep?
A) one cup of hot chocolate
B) three glasses of red wine
C) a high-protein snack
D) a carbohydrate snack
D
Which of the following medications is least likely to affect sleep quality?
A) diuretic
B) steroid
C) antidepressant
D) Ambien
D
Which of the following patients would be classified as having chronic pain?
A) a patient with rheumatoid arthritis
B) a patient with pneumonia
C) a patient with controlled hypertension
D) a patient with the flu
A
A nurse is assessing the vital signs of a patient who is moaning with pain. What would be the expected findings?
A) decreased pulse and respirations
B) increased pulse and blood pressure
C) increased temperature
D) no change from usual results
B
Which of the following is the drug of choice to treat chronic pain in the home?
A) oral morphine
B) intravenous morphine
C) NSAIDs
D) antidepressants
A
A nurse researching a diet for a patient with diabetes includes foods that supply energy to the body. Which of the following are classes of nutrients that supply this energy? Select all that apply.
A) vitamins
B) proteins
C) fats
D) minerals
E) carbohydrates
F) water
B, C, E
A hospitalized patient has been NPO with only intravenous fluid intake for a prolonged period. What assessments might indicate protein-calorie malnutrition?
A) fever, joint pain, dehydration
B) poor wound healing, apathy, edema
C) sleep disturbances, anger, increased output
D) weight gain, visual deficits, erythema of skin
B
At what percent of weight over ideal weight is a person considered obese?
A) 20%
B) 40%
C) 60%
D) 100%
A
At what period of life do nutrient needs stabilize?
A) infancy
B) adolescence
C) pregnancy
D) adulthood
D
A healthy, active 72-year-old woman asks a nurse if it is safe to take dietary supplements and, if so, what should be taken? What would the nurse tell her?
A) Yes, take calcium, vitamin D, and vitamin B12.
B) Yes, take iron, folic acid, and iodine.
C) No, instead increase intake of carbohydrates.
D) No, increase fat intake for fat-soluble vitamins.
A
A patient has been prescribed a clear liquid diet. What food or fluids will be served?
A) milk, frozen dessert, egg substitutes
B) high-calorie, high-protein supplements
C) hot cereals, ice cream, chocolate milk
D) Jell-O, carbonated beverages, apple juice
D
A nurse has assessed the residual amount before beginning a nasogastric tube feeding and has found 100 mL. What will the nurse do next?
A) Nothing; this amount is within normal limits.
B) Report the finding to the physician.
C) Omit the feeding and document the reason.
D) Rinse the tube and repeat the assessment.
A
Which laboratory test is the best indicator of a patient in need of TPN?
A) hemoglobin
B) hematocrit
C) serum albumin
D) creatinine
C
What is the route of administration for TPN?
A) oral
B) subcutaneous
C) intramuscular
D) intravenous
D
A nurse is preparing to catheterize a female patient. What will the nurse consider when comparing the anatomy of the female urethra with that of the male urethra?
A) has different innervation
B) no connection with bladder
C) shorter in length
D) longer in length
C
Which of the following describes the term micturition?
A) emptying the bladder
B) catheterizing the bladder
C) collecting a urine specimen
D) experiencing total incontinence
A
A nurse is assessing the urine output of a patient with Parkinsons disease who is on levodopa. Which of the following is a common finding for a patient on this medication?
A) The urine may be brown or black.
B) The urine may be blood tinged.
C) The urine may be green or blue-green.
D) The urine may be orange or orange-red.
A
A patient tells the nurse, Every time I sneeze, I wet my pants. What is this type of involuntary escape of urine called?
A) urinary incontinence
B) urinary incompetence
C) normal micturition
D) uncontrolled voiding
A
During a health history interview, a male patient tells the nurse that he does not feel that he completely empties his bladder when he voids. He has been diagnosed with an enlarged prostate. What is the name of this symptom?
A) urinary incontinence
B) urinary retention
C) involuntary voiding
D) urinary frequency
B
An older woman who is a resident of a long-term care facility has to get up and void several times during the night. This can be the result of what physiologic change with normal aging?
A) diminished kidney ability to concentrate urine
B) increased bladder muscle tone causing urinary frequency
C) increased bladder contractility causing urinary stasis
D) decreased intake of fluids during daytime hours
A
A nurse is conducting a health history interview for an office patient who is having problems with urinary control. What would be an appropriate interview question to collect further data?
A) Why dont you go to the bathroom more?
B) How have you handled this problem?
C) What does your wife think about this problem?
D) What makes you think you have a problem?
B
A nurse is teaching a patient about the amount of water to drink each day. What is the recommended daily fluid intake for adults?A) 1 to 2 (4-oz) glasses per day
B) 5 to 6 (6-oz) glasses per day
C) 8 to 10 (8-oz) glasses per day D) 16 to 20 (12-oz) glasses per day
C
A nurse is carrying out an order to remove an indwelling catheter. What is the first step of this skill? A) Deflate the balloon by aspirating the fluid.
B) Ask the patient to take several deep breaths.
C) Tell the patient burning may initially occur.
D) Wash hands and put on gloves.
D
A nurse has catheterized a patient to obtain urine to measure postvoid residual (PVR) amount. The nurse obtains 40 mL of urine. What should the nurse do next?
A) Report this abnormal finding to the physician.
B) Perform another catheterization to verify the amount.
C) Document this normal finding for postvoid residual.
D) Palpate the abdomen for a distended bladder.
C
A patient complains of having to void frequently, burning on urination, and odorous urine. Based on these assessment findings, the nurse would suspect the patient has which of the following conditions?
A) stress incontinence
B) urge incontinence
C) urinary tract infection
D) lower colon infection
C
A patient is taking diuretics. What should the nurse teach the patient about his urine?
A) Urinary output will be decreased.
B) Urinary output will be increased.
C) Urine will be a pale yellow color.
D) Urine may be brown or black.
C
The student nurse studying bowel elimination learns that the following statements accurately describe the process of peristalsis. Select all that apply.
A) The sympathetic nervous system stimulates movement.
B) The autonomic nervous system innervates the muscles of the colon.
C) Peristalsis occurs every 3 to 12 minutes.
D) Mass peristaltic sweeps occur one to four times each 24-hour period in most people.
E) Mass peristalsis often occurs after food has been ingested.
F) One-third to one-half of ingested food waste is normally excreted in the stool within 48 hours.
B, C, D, E
Based on knowledge of the physiology of the gastrointestinal tract, what type of stools would the nurse assess in a patient with an illness that causes the stool to pass through the large intestine quickly?
A) hard, formed
B) black, tarry
C) soft, watery
D) dry, odorous
C
The following foods are a part of a patients daily diet: high-fiber cereals, fruits, vegetables, 2,500 mL of fluids. What would the nurse tell the patient to change?
A) decrease high-fiber foods
B) decrease amount of fluids
C) omit fruits if eating vegetables D) nothing; this is a good diet
D
A young woman comes to the Emergency Department with severe abdominal cramping and frequent bloody stools. Food poisoning is suspected. What diagnostic test would be used to confirm this diagnosis?
A) routine urinalysis
B) chest x-ray
C) stool sample
D) sputum sample
C
A patient with terminal cancer is taking high doses of a narcotic for pain. The nurse will teach the patient or family about what common side effect of opioids?
A) inability to change positions
B) problems with communication C) diarrhea
D) constipation
D
A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented?
A) Auscultated abdomen for bowel sounds, bowel not functioning.
B) All four abdominal quadrants auscultated. Inaudible bowel sounds.
C) Bowel sounds auscultated. Patient has no bowel sounds.
D) Patient may have bowel sounds, but they cant be heard.
B
A nurse is conducting an abdominal assessment. What is the rationale for palpating the abdomen last when conducting an abdominal assessment?
A) it is the most painful assessment method
B) it is the most embarrassing assessment method
C) to allow time for the examiners hands to warm
D) it disturbs normal peristalsis and bowel motility
D
A patient is on bedrest, and an enema has been ordered. In what position should the nurse position the patient?
A) Fowlers
B) Sims
C) Prone
D) Sitting
B
A nurse is caring for a patient with a colostomy. What type of stools would she expect to find in the colostomy bag?
A) liquid
B) watery
C) formed
D) none
C
A nurse is documenting the appearance of feces from a patient with a permanent ileostomy. Which of the following would she document?
A) Ileostomy bag half filled with liquid feces.
B) Ileostomy bag half filled with hard, formed feces.
C) Colostomy bag intact without feces.
D) Colostomy bag filled with flatus and feces.
A
A nurse is assessing the stoma of a patient with an ostomy. What would the nurse assess in a normal, healthy stoma?
A) pallor
B) purple-blue
C) irritation and bleeding
D) dark red and moist
...
In what age group would a nurse expect to assess the most rapid respiratory rate?
A) older adults
B) middle adults
C) adolescents
D) infants
D
A 90-year-old woman has been in an automobile crash and sustained four fractured ribs on the left side of her thorax. Based on her age and the injury, what complication is she at risk for?
A) pneumonia
B) altered thought processes
C) urinary incontinence
D) viral influenza
A
A nurse is percussing the thorax of a patient with chronic emphysema. What percussion sound would most likely be assessed?
A) resonance
B) hyperresonance
C) flat
D) tympany
B
An emergency room nurse is auscultating the chest of a child who is having an asthmatic attack. Auscultation reveals the presence of wheezes. During what part of respirations do wheezes occur?
A) inspiration and expiration
B) only on inspiration
C) only on expiration
D) when coughing
A
A patient is experiencing hypoxia. Which of the following nursing diagnoses would be appropriate? A) Anxiety
B) Nausea
C) Pain
D) Hypothermia
A
A nurse is caring for a patient who suddenly begins to have respiratory difficulty. In what position would the nurse place the patient to facilitate respirations?
A) supine
B) prone
C) high Fowlers
D) dorsal recumbent
C
A nurse is teaching a preoperative patient how to effectively deep breathe. Which of the following would be included?
A) Make each breath deep enough to move the bottom ribs. B) Breathe through the mouth when you inhale and exhale.
C) Breathe in through the mouth and out through the nose.
D) Practice deep breathing at least once each week.
A
A nurse is teaching a home care patient how to do pursed-lip breathing. What is the therapeutic effect of this procedure?
A) using upper chest muscles more effectively
B) replacing the use of incentive spirometry
C) reducing the need for p.r.n. pain medications
D) prolonging expiration to reduce airway resistance
D
A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them?
A) It is inserted into the space between the lining of the lungs and the ribs.
B) I dont exactly know, but I will make sure the doctor comes to explain.
C) It is inserted directly into the lung itself, connecting to a lung airway.
D) It is inserted into the peritoneal space and drains into the lungs.
A
What is the action of codeine when used to treat a cough?
A) antisuppressant
B) suppressant
C) antihistamine
D) expectorant
B
What can a nurse ask a patient to do before suctioning to prevent hypoxemia?
A) Sit in an upright position and cough.
B) Breathe normally for at least 5 minutes.
C) Lie flat in bed and practice relaxation.
D) Take several deep breaths.
D
A patient has had a tracheostomy and the nurse is prepared to conduct tracheostomy care. What part of the tracheostomy tube is removed for cleaning?
A) obturator
B) outer cannula
C) inner cannula
D) cuff
C
The student nurse studying fluid and electrolyte balance learns that which of the following is a function of water? Select all that apply.
A) provide a medium for transporting wastes to cells and nutrients from cells
B) provide a medium for transporting substances throughout the body
C) facilitate cellular metabolism and proper cellular chemical functioning
D) act as a buffer for electrolytes and nonelectrolytes
E) help maintain normal body temperature
F) facilitate digestion and promote elimination
B, C, E, F
Which body fluid is the fluid within the cells, constituting about 70% of the total body water?
A) extracellular fluid (ECF)
B) intracellular fluid (ICF)
C) intravascular fluid
D) interstitial fluid
B
What is the average adult fluid intake and loss in each 24 hours? A) 500 to 1,000 mL
B) 1,000 to 1,500 mL
C) 1,500 to 2,000 mL
D) 1,500 to 3500 mL
D
A nurse monitoring the intake and output of fluids for a patient with severe diarrhea knows that normally how many mL of body fluids is lost via the gastrointestinal tract?
A) 300 mL
B) 1,000 mL
C) 1,300 mL
D) 2,600 mL
A
Which of the following descriptions best summarizes fluid homeostasis?
A) Almost every body organ and system helps maintain homeostasis.
B) The cardiovascular and renal systems primarily maintain homeostasis.
C) Homeostasis is maintained through intra- and extracellular exchange.
D) Homeostasis is maintained by the arterioles, capillaries, and venules
A
A nurse reads the laboratory report for a patient and notes that the patient has hyponatremia. What physical assessment would be made?
A) Observe skin color and texture. B) Auscultate bowel sounds.
C) Percuss lung density.
D) Palpate skin of sternum.
D
A patient has metabolic (nonrespiratory) acidosis. What type of respirations would be assessed?
A) periods of apnea
B) decreased depth and rate
C) increased depth and rate
D) alternating fast and slow
C
Which of the following questions about fluid balance would be appropriate when conducting a health history for a patient?
A) Describe your usual urination habits.
B) Describe your problems with constipation
C) How did you feel when your calcium was low?
D) Do you eat fruits and vegetables each day?
A
A nurse measures a patients 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?
A) Compare the patients intake with the normal range of adult fluid intake.
B) Report the exact milliliter of intake to the physicians office nurse.
C) Compare the total intake and output of fluids for the 24 hours.
D) Ensure that the information is included in the verbal end-of-shift report.
C
A nurse reads a complete blood count report for a patient who has been admitted to the hospital with fluid overload from late-stage kidney disease. What abnormal result would the nurse expect to find?
A) increased white blood cells
B) increased platelets
C) decreased hematocrit
D) increased hematocrit
C
A patient has a decreased potassium level. What high-potassium foods would the nurse teach the patient to eat?
A) lunch meat, salted nuts, whole milk
B) buttermilk, hard candy, spinach
C) carbonated beverages, beer, olives
D) oranges, bananas, broccoli
D
A specially trained nurse has inserted a PICC line. What would be done next?
A) Start administration of prescribed fluids.
B) Explain the procedure to the patient and family.
C) Place the patient on restricted oral fluids.
D) Send the patient to the radiology department.
D
A woman has had a breast removed to treat cancer. What type of loss will she most likely experience?
A) actual loss
B) perceived loss
C) maturational loss
D) anticipatory loss
A
Which of the following is an example of a perceived loss?A) A patient mourns the loss of his amputated leg.
B) A patient grieves for the loss of his wife to cancer.
C) An older patient grieves for the loss of his independence.
D) A patient grieves for the loss of his job.
C
A man is diagnosed with terminal kidney failure. His wife demonstrates loss and grief behaviors. What type of loss is the wife experiencing?
A) maturational loss
B) anticipatory loss
C) dysfunctional grieving
D) bereavement
B
A patient asks a nurse to explain a living will. What is the nurses best answer?
A) It specifies who will inherit the patients estate.
B) It determines an individuals quality of life.
C) It lists specific instructions for healthcare provisions.
D) It identifies a trusted person to make healthcare decisions.
C
A dying patient states in writing ahead of time what her choices would be for healthcare should certain circumstances develop. What is the term for this document?
A) living will
B) advance directives
C) durable power of attorney
D) comfort measures only
B
Which of the following are considered external male genitalia? Select all that apply.
A) testes
B) scrotum
C) epididymis
D) prostate gland
E) penis
F) seminal vesicles
A, B, E
Which of the following are considered internal female genitalia? Select all that apply.
A) mons pubis
B) labia majora
C) ovaries
D) uterus
E) fallopian tubes
F) clitoris
C, D, E
A young woman has been diagnosed with human papilloma virus (HPV). As a result, she will be at increased risk for which of the following?
A) infertility
B) genital warts
C) vaginal bleeding
D) cervical cancer
D
What term is used to describe painful intercourse?
A) dyspareunia
B) dysmenorrhea
C) impotence
D) vulvodynia
A
A nurse is teaching a female patient about breast self-examination (BSE). At what time of the month would the nurse recommend BSE?
A) any day of the month is satisfactory
B) once a month right after the menstrual period
C) once a month right before the menstrual period
D) on Friday evening or Saturday morning each week
B
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