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Week 6 Lab Quiz

Terms in this set (20)

The nurse is using palpation to assess respiratory function. Which action by the nurse requires more education regarding palpation?
a. The nurse asks the client to repeat "ninety-nine" while placing both hands on the chest wall bilaterally.
b. The nurse listens for dull sounds over the chest wall while striking the middle finger of the opposite hand.
c. The nurse places both hands with thumbs touching on the client's back and asked them to take a deep breath.
d. The nurse uses the thumbs of both hands to determine if the trachea is midline.
b. The nurse listens for dull sounds over the chest wall while striking the middle finger of the opposite hand.
The nurse knows that the use of technology is beneficial for sharing patient information with the treatment team quickly. Which of the following is a HIPAA (Health Insurance Portability and Accountability Act) violation related to the use of technology?
a. The emergency room nurse faxes report to the medical unit before transferring a patient to the unit.
b. The nurse contacts a patient's insurance company for pre-approval for surgery with patient consent.
c. The nurse logs in to the computer at the patient's bedside to administer medication with family in the room.
d. The nurse faxes the patient's lab results to the dietary department instead of the primary care provider.
d. The nurse faxes the patient's lab results to the dietary department instead of the primary care provider.
A patient is being admitted to acute care from home. The patient spouse (caregiver) states the patient is only comfortable laying in the left side. What areas are a priority to assess for skin breakdown? (Select all that apply.)
a. Right iliac crest
b. Left ear
c. Sacrum
d. Left knee
e. Right medial thigh
b, d
To palpate lymph nodes, the nurse uses which technique?
a. Compress the nodes between the index fingers of both hands.
b. Use the pads of two or three fingers in a circular motion.
c. Use the back of the hand to feel for temperature differences from the right and left sides.
d. Use all four fingers in a vertical and then side-to-side motion.
b. Use the pads of two or three fingers in a circular motion.
Which statement by the student nurse demonstrates understanding of expected findings during the assessment of the musculoskeletal system?
a. "By comparing the patient's assessment with expected findings for his age group, I can identify any limitations."
b. "By comparing the patient's assessment with expected findings for his gender, I can identify any limitations."
c. "By comparing the patient's assessment with expected findings of his race, I can identify any limitations."
d. "By comparing the patient's left side with his right side, I can identify any limitations."
d. "By comparing the patient's left side with his right side, I can identify any limitations."
The charge nurse is observing a novice nurse administer an intramuscular injection in the deltoid muscle of a well-developed adult. Which observation would cause the charge nurse to intervene?
a. The novice nurse measures three finger widths from the acromion process to mark injection site.
b. The novice nurse asks the patient to remove their arm from their sweatshirt for the injection.
c. The novice nurse asks the patient to relax the arm and cleans the site in a circular motion.
d. The novice nurse has 3 mL of the medication in a 3 mL syringe with a 1 ½ inch needle.
d. The novice nurse has 3 mL of the medication in a 3 mL syringe with a 1 ½ inch needle.
The nurse has an order for acetaminophen rectal suppository for a patient with a fever. What would be a contraindication for this medication order?
a. Patient reports vomiting for 2 days
b. Patient reports allergy to ibuprofen
c. Patient reports bleeding from the bowel
d. Patient reports constipation for 1 week
c. Patient reports bleeding from the bowel
A nurse is observing the unlicensed assistive personnel (UAP) obtain a blood pressure. The patient's arm is lifted above shoulder level. The nurse expects that the blood pressure reading will be:
a. Too high
b. Too low
c. Systolic reading low and diastolic reading high
d. Systolic reading high and diastolic reading low
b. Too low
A novice nurse is preparing to remove a stained dressing from a wound to perform wound irrigation. The charge nurse would question which of the following actions?
a. Placing a biohazard bag on the foot of the bed
b. Preparing syringe with irrigation solution
c. Donning goggles/eye protection
d. Donning sterile gloves
d. Donning sterile gloves
Which assessment finding by the nurse would best determine if the goal of "Demonstrate adequate tissue perfusion" is being met?
a. Symmetrical chest expansion
b. Activity intolerance
c. Brisk capillary refill
d. Regular heart rate of 80 bpm
c. Brisk capillary refill
A new nurse in orientation is approached by a surveyor from the department of health and is asked, "What is the best means to prevent the spread of infection?" What is the best answer for the nurse to provide?
a. "Let me get my preceptor."
b. "Wash your hands before and after any patient care."
c. "Clean all instruments and work surfaces with an approved disinfectant."
d. "Ensure proper disposal of all items contaminated with blood or body fluids."
b. "Wash your hands before and after any patient care."
The nurse suspects a dark-skinned patient is cyanotic. The nurse should assess:
a. The palms of the hands bilaterally
b. The mucus membranes of the mouth
c. Sclera of both eyes
d. Pupil reaction in both eyes
b. The mucus membranes of the mouth
The nurse is discussing strategies with the unlicensed assistive personnel (UAP) for bathing a client with dementia. Which strategies would be appropriate for the client? (Select all that apply.)
a. Be organized
b. Sing or talk to the client
c. Offer choices and follow personal preferences
d. Expect the client to protest, finish quickly
e. Cover the client as much as possible
a, b, c, e
Which of the following actions by the student nurse is a HIPAA (Health Insurance Portability and Accountability Act) violation?
a. The student nurse shares patient history information with peers during instructor led post-conference discussion at the clinical site.
b. The student nurse shares on her social media page that she had the best clinical day watching the delivery of triplets.
c. The student nurse reviews a patient's electronic health record to gather information for writing a care plan for class.
d. The student nurse shares with the clinical staff concerns about the patient verbalizations about wanting to die.
b. The student nurse shares on her social media page that she had the best clinical day watching the delivery of triplets.
Upon auscultation of the heart, the nurse recognizes which as an expected finding for an adult?
a. A low-pitched blowing sound heard over the abdominal aorta.
b. A high-pitched vibration is heard over the base of the heart.
c. The S1 heart sound is louder at the apex of the heart.
d. The S3 heart sound sounds like "Ken-tucky."
c. The S1 heart sound is louder at the apex of the heart.
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