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Nursing 121 Midterm Set questions with
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A patient who is hospitalized with C. Diff asks you to explain what he should know about this organism. What is the most appropriate information to include in pt teaching? (select all that apply)
- The organism is usually transmitted through the fecal-oral route
- Hands should always be cleaned with soap and water vs. alcohol based hand sanitizer.
- Everyone coming into the room must be wearing a gown and gloves.
- While pt. is in contact precautions, he cannot leave the room. - ANSWER -1. The organism is usually transmitted through the fecal-oral route
- Hands should always be cleaned with soap and water vs. alcohol based hand sanitizer.
- Everyone coming into the room must be wearing a gown and gloves. The nurse is performing an abdominal assessment on a patient. In which order does she perform the assessment steps? - ANSWER -Inspection, Auscultation, Palpation, Percussion During the assessment a nurse notices a lesion on the arm of the pt. The lesion is irregularly shaped, elevated with edema, and about 3 cm. What type of lesion is this?
- Nodule
- Macule
- Wheal
- Pustule - ANSWER -3. Wheal A toddler is to receive 2.5 mL of an antipyretic by mouth. Which equipment is most appropriate for for medication administration for this child?
- A medication cup
- A teaspoon
Nursing 121 Midterm Set questions with
- A 5-mL syringe
- An oral-dosing syringe - ANSWER -4. An oral-dosing syringe A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription?
- Adding a dose of Heparin sodium
- Holding the next dose of warfarin
- Increasing the next dose of warfarin
- Administering the next dose of warfarin - ANSWER -2. Holding warfarin - normal PT is 11 - 12.5 seconds, therapeutic PT level is 1.5 -2x that. A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?
- 3 mg/dL
- 15 mg/dL
- 29 mg/dL
- 35 mg/dL - ANSWER -2. 15 mg/dL - normal BUN level is 10-20 mg/dL Values of 29 & 35 mg/dL reflect continued dehydration A client is receiving a continuous intravenous infusion of heparin to treat DVT. The client's aPTT is 65 seconds. The nurse anticipates that which action is needed?
- Discontinuing the heparin infusion
- Increasing the rate of the heparin infusion
- Decreasing the rate of the heparin infusion
- Leaving the heparin infusion as it is - ANSWER -4. Leaving the heparin infusion as it is. Normal aPTT is 30-40 seconds. Therapeutic value for DVT treatment is up to 100 seconds, so the pt is within acceptable limits.
Nursing 121 Midterm Set questions with
A client has a history of upper gastrointestinal bleeding and has a platelet count of 300,000 mm3. The nurse should take which action after seeing the test results?
- Report the abnormally low count
- Report the abnormally high count
- Place the client on bleeding precautions
- Place the normal report in the clients medical record - ANSWER -4. Place the normal report Normal values ranges from 150,000 to 400,000 mm3 for platelet count. Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which abnormal laboratory test results should the nurse report? Select all that apply.
- Calcium, 7 mg/dL
- Magnesium, 1 mg/dL
- Phosphorus, 3.6 mg/dL
- Neutrophils, 1000 cells/mm
- Serum creatinine, 1 mg/dL
- White blood cells, 3000 cells/mm3 - ANSWER -1. Calcium - normal range is 8.5 - 10.5 mg/dL
- Magnesium - normal range is 1.5 - 2.
- Neutrophils - normal range 1,500 - 8,000 mm
- WBCs - normal range 5,000- 10,000 mm A nurse is observing a client drawing and mixing up insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has take place? A. The client is able to discuss the appropriate technique B. The client is able to demonstrate appropriate technique C. The client states that he understands
Nursing 121 Midterm Set questions with
D. The client is able to write steps on a piece of paper - ANSWER -B. The client is able to demonstrate appropriate technique A nurse is collecting data from the mother of an infant. The client states that her son is old enough for toilet training. Following an educational session with the nurse, the client now states that she will postpone training until her son is older. Learning has occurred in which domain? A. Cognitive B. Affective C. Psychomotor D. Kinesthetic - ANSWER -B. Affective - because the client's ideas about toilet training have changed A nurse is providing preoperative education for a pt who will undergo a mastectomy. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I don't want my spouse to see my incision." B. "Will you give me pain medicine after the surgery?" C. "Can you tell me about how long the surgery will take?" D. "My roommate listens to everything I say." - ANSWER -C. "Can you tell me about how long the surgery will take?" Asking a concrete question about the surgery indicates readiness. A nurse is preparing an instructional session for an older adult about managing stress incontinence. Which of the following nursing actions should the nurse take first when meeting with the client? A. Encourage the client to participate actively in learning. B. Select instructional materials appropriate for the older adult. C. Identify goals the nurse and client agree are reasonable. D. Determine what the client knows about stress incontinence. - ANSWER -D. Identify what the client knows about stress incontinence. A nurse is evaluating how will a client leaned the information he presented in an instructional session about a heart-healthy diet. The client states that she
Nursing 121 Midterm Set questions with
following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation - ANSWER -A. Assessment A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (select all that apply) A. Respiratory rate is 22/min with even, unlabored respirations. B. The client's partner states, "He said he hurts after walking 10 minutes." C. Pain rating is 3 on a scale of 0-10, D. Skin is pink, warm, and dry. E. The assistive personnel reports the client walked with a limp. - ANSWER -A. Nurse measures = objective D. Nurse observations = objective E. Information on observations of others, such as family and staff = objective A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply) A. Writing a prescription for morphine sulfate, PRN B. Inserting a nasogastric tube to relieve gastric distention. C. Showing a client how to use progressive muscle relaxation. D. Performing a daily bath after the evening meal. E. Re-positioning a client every 2 hours to reduce pressure ulcer risk. - ANSWER -C. D. & E. A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process? A. "I will determine the most important client problems that we should address."
Nursing 121 Midterm Set questions with
B. "I will review the past medical history on the client's medical record to get more information." C. "I will go carry out the new prescriptions from the provider." D. "I will ask the client if their nausea has resolved." - ANSWER -A. "I will determine the most important client problems that we should address." The nurse should determine priority during the planning step of the nursing process. A client is taught the clinical manifestations of inflammation to allow early detection of a complication of a surgical wound. The client states, "I will look at the wound 4 times a day and tell my surgeon if it looks red or swollen." Her statement is an example of: A. Attitudes B. Application C. Analysis D. Evaluation - ANSWER - The nurse recognizes that a variety of teaching methods may be implemented to meet the clients needs. Which teaching method is best applied to a cognitive learning need? A. Computer-assisted instruction B. Demonstration of a procedure C. Modeling of behavior D. Discussion of feelings - ANSWER -A. The nurse has completed client teaching regarding medication administration. Which of the following statements by the client best illustrates compliance? A. "I'm glad to know about my medications. It makes taking them a lot easier." B. "I already knew most of what you told me." C. "I think you should have waited until I was ready to go home. Maybe I would remember better. D. "If I take my medications as prescribed, I'll feel better." - ANSWER -A. compliance is illustrated when the persons recognizes and accepts the need to learn, then follows through
Nursing 121 Midterm Set questions with
B. Evaluating C. Diagnosing D. Implementing - ANSWER -A. Assessing Which word best describes the role of the nurse when identifying and meeting the needs of the patient holistically? A. Teacher B. Advocate C. Counselor D. Surrogate - ANSWER -B. Advocate The nurse knows that the appropriateness of a nursing diagnosis is supported by its: A. Defining characteristics B. Planned interventions C. Diagnostic statement D. Related risk factors - ANSWER -A. Defining characteristics Which nursing diagnosis has the highest priority for an obese 68- year-old female who is one day post-op Total Knee Arthroplasty? A. Self-care deficit: Shampoo, R/T limitations in mobility, AMB: Client states, "My hair is so oily. If I could get into the shower, I would wash it." B. Pain, R/T mechanical tissue damage, AMB: Client states pain at incision site in left knee, sharp, throbbing, increases with movement, rated at 9 (1-10 scale), heart rate 110, blood pressure 155/ C. Risk for infection, R/T disruption in skin integrity from surgery, obesity (5' 2", wt. 192 lbs) D. Risk for fall/injury, R/T age (68 yrs), forced bedrest for past 2 days, altered gait, pain, AMB: Client unable to walk unassisted since surgery - ANSWER -B. Pain, R/T mechanical tissue damage, AMB: Client states pain at incision site in left knee, sharp, throbbing, increases with movement, rated at 9 (1-10 scale), heart rate 110, blood pressure 155/
Nursing 121 Midterm Set questions with
Which part of the following nursing diagnosis statement is the validating evidence; "Pain, R/T mechanical tissue damage, AMB: Patient wincing, splinting affected area, states pain is sharp, rating at 9 (1-10 scale), pulse 100." A. Client statement of "pain" B. "Mechanical tissue damage (surgical incision)" C. "Wincing, splinting, patient states pain is sharp, rating @ 9 (1-10 scale), pulse 100." D. "As manifested by:" - ANSWER -C. "Wincing, splinting, patient states pain is sharp, rating @ 9 (1-10 scale), pulse 100." A client comes into the clinic with complaints of "extreme" low back pain after helping to move a heavy object. The client is pale and diaphoretic and walks bent at the waist. Before taking vital signs, the nurse projects that the blood pressure as well as heart rate will be elevated. This is an example of which of the following? A. Fact B. Inference C. Judgement D. Opinion - ANSWER -B. Inference The nurse is performing a dressing change for a client and notices that there is a new area of skin breakdown near the site of the dressing. On closer examination, it appears to be caused from the tape used to secure the dressing. This would be an example of which phase of the nursing process? A. Assessment B. Diagnosis C. Implementation D. Evaluation - ANSWER -A. Assessment A nurse has delegated to a CNA to obtain vital signs for a newly admitted client. The aide reports the following: Temp =99.4 F; Respirations=26/min; pulse=98 bpm; and blood pressure=200/146. To validate the data, the best action by the nurse is: A. Call the physician B. Continue with the physical assessment
Nursing 121 Midterm Set questions with
D. Vaginal secretions - ANSWER -B. Feces The nurse suspects that an older adult client may be experiencing an infection. Older adult clients may react differently to infectious processes, so the nurse is alert to atypical signs and symptoms, such as: A. Hypotension B. Confusion C. Erythema D. Chills - ANSWER -B. Confusion The nurse recognizes the appropriate procedures for sterile asepsis. Of the following, which action is consistent with sterile asepsis? A. Clean forceps may be used to move items on the sterile field B. Sterile fields may be prepared well in advance of the procedure C. The first small amount of sterile solution should be poured and discarded. D. Wrapped sterile packages should be opened starting with the flap closest to the nurse. - ANSWER -C. The first small amount of sterile solution should be poured and discarded. The nurse has redressed a client's wound and now plans to administer a medication to the client. It is important to: A. Remove the gloves and perform hand hygiene before leaving the room. B. Remove gloves and perform hand hygiene before administering the medication. C. Leave the gloves on to administer the medication. D. Leave the medication on the bedside table to avoid having to remove gloves before leaving the client's room. - ANSWER -B. Remove gloves and perform hand hygiene before administering the medication. Before changing a clean dressing of a home care patient, the nurse should first: A. Wash hands with an antibacterial soap B. Remove any nail polish on the fingernails C. Put on a pair of sterile gloves
Nursing 121 Midterm Set questions with
D. Remove any wedding rings or other jewelry - ANSWER -A. Wash hands with an antibacterial soap An adult female patient complains of feeling achy all over and being tired. This stage of infection is called A. Convalescent period B. Full-stage illness C. Prodromal stage D. Incubation period - ANSWER -C. Prodromal stage An 85 year-old patient is hospitalized with pneumonia. The patient has an indwelling urinary catheter and appears malnourished. The nurse caring for the patient determines that the patient's priority nursing diagnosis is: A. Risk for Chronic Infections and Anxiety due to advance age B. Risk for Further Infection related to malnutrition and urinary catheter C. Immobility related to urinary catheter and infection D. Social Isolation related to presence of disease. - ANSWER -B. Risk for Further Infection related to malnutrition and urinary catheter The nurse is aware that it is important to break the chain of infection. An example of a nursing intervention that is implemented to control a portal of exit of infection for a client is: A. Changing soiled dressings B. Administering childhood immunizations C. Covering the mouth and nose when sneezing D. Disposing of soiled gloves in a waste container - ANSWER -C. Covering the mouth and nose when sneezing Utilizing the information from the above question, which of the following is the correct implementation of precautions while caring for a diapered client that is diagnosed with Hepatitis A? A. Keep the door closed at all times
Nursing 121 Midterm Set questions with
- The nurse is assisting a health care provider in the insertion of a central line catheter.
- The patient is in droplet precautions. Which type of PPE are staff required to wear for a pediatric patient who is on airborne precautions for chicken pox/herpes zoster? (select all that apply)
- Disposable gown
- N95 Respirator
- Face shield or goggles
- Surgical gloves
- Mask - ANSWER -1. Disposable gown
- N95 Respirator
- Mask Put the following steps for removal of protective barriers after leaving an isolation room in order: A) Untie top, then bottom mask strings and remove from face. B) Untie waist and neck strings of gown. Allow gown to fall from shoulders and discard. Remove gown, rolling it onto itself without touching the contaminated side. C) Remove gloves. D) Remove eyewear or goggles. E) Perform hand hygiene. - ANSWER -Remove GLOVES, remove GOGGLES, untie waist and neck of GOWN - allowing it to fall contaminated side inward - then MASK & hand hygiene last Which of the following statements is true regarding medical asepsis? (select all that apply)
- Proper cleaning requires mechanical removal of all soil from an object or area.
- General environmental cleaning is an example of medical asepsis.
Nursing 121 Midterm Set questions with
- When cleaning a wound, wipe the edge around the wound first and then clean inward toward the center of the wound.
- Cleaning in a direction from least to most contaminated area helps reduce infections.
- Disinfecting and sterilizing equipment and medical devices involve the same procedures. - ANSWER -1. Proper cleaning requires mechanical removal of all soil from an object or area.
- General environmental cleaning is an example of medical asepsis.
- Cleaning in a direction from least to most contaminated area helps reduce infections. While auscultating an elderly woman's breath sounds, you hear low-pitched "rattling" sounds at the bases of both of her lungs. How would you describe these lung sounds? A. Crackles B. Pleural friction rub C. Rhonchi D. Wheeze - ANSWER -Rhonchi While auscultating the adult patient's lungs, the nurse hears loud, bubbly sounds during inspiration that did not disappear after the pt coughed. Which finding should the nurse document? A. Rhonchi B. Coarse crackles C. Sibilant wheeze D. Pleural friction rub - ANSWER -Coarse crackles Which statement made by the pt. indicates an understanding about teaching related to early detection of colorectal cancer
- I'll make sure to schedule my colonoscopy annually after the age of 60.
- I'll make sure to have a CT colonoscopy every 5 years.
- I'll make sure to have a flexible sigmoidoscopy every year once I turn 55.
Nursing 121 Midterm Set questions with
E) Frequent position changes Which of the following are measures to reduce tissue damage form shear? (Select all that apply)
- Use a transfer device (e.g. board)
- Have head of bed elevated when transferring pt.
- Have head of bed flat when re-positioning pt.
- Raise head of bed 60 degrees when pt is supine
- Raise head of bed 30 degrees when pt is supine - ANSWER -1. Use a transfer device (e.g. board)
- Have head of bed flat when re-positioning pt.
- Raise head of bed 30 degrees when pt is supine A nurse knows that people most at risk for accidental hypothermia are:
- People who are homeless
- People with respiratory conditions
- People with cardiovascular conditions
- The very old
- People with kidney disorders - ANSWER -1. People who are homeless
- People with cardiovascular conditions
- The very old
Nursing 121 Midterm Set questions with
