PCC Exam 1: Nursing Questions and Answers, Exams of Nursing

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What type of authority regulates the practice of nursing? CORRECT ANSWERState nurse practice acts In meeting the safty of needs of the adolescent client, it would be most important for the nurse to focus her teaching on CORRECT ANSWERDrivers education ( most cause of death is because of car accident--- WEAR SEATBELT) How often should restraints be removed? CORRECT ANSWERat least ever two hours What is the protocol when removing restraints? CORRECT ANSWERThe nurse should stay with the patient when the restraint is removed, offer fluids and assistance with toileting, and check for adverse physiological effects from the restraint. What can the nurse delegate to the CNA/UAP regarding restraints? CORRECT ANSWERThe nurse can delegate the checks and releases to a certified nursing assistant (CNA) or UAP. What is the CNA/UAP not allowed to do? CORRECT ANSWERThe UAP cannot teach, educate, or assess the patient. Restraints should only be tied to CORRECT ANSWERA moving part of the bed The 6 factors that contribute to an unsafe patient environment. CORRECT ANSWER1. Age & ability to understand

2. Impaired mobility
3. Communication
4. Pain & discomfort
5. Delayed assistance
6. Equipment Why are the elderly more at risk for falls when they are hospitalized? CORRECT ANSWERThey may be confused for a variety of reasons including unfamiliar surroundings and medications. When they get up, they may not realize that they are attached to tubes and cords, so they may pull them or trip over them. They may not clearly

Answering patients call lights promptly is a safety issue. Defend this statement. CORRECT ANSWERIf a patient does not get assistance in a timely manner, he or she may attempt to get up and walk alone when it is not safe to do so. This leads to falls and injuries that could have been prevented. Discuss the role of nurses in a mass casualty event. CORRECT ANSWERA student nurse's responsibility as a student and as a nurse will be to know and follow his or her facility's disaster plan. A student nurse should expect to be called in to work as an extra if a disaster occurs. It is appropriate for the student nurse to ensure the safety of family first and then assist at his or her place of work. Some facilities have a plan for calling in extra help according to needs, rather than having a barrage of off-duty employees arriving at once. Researchers have found that, because they are more likely than others to move around in bed or try to get out of bed, the individuals who are at highest risk for entrapment are older, frail adults who experience CORRECT ANSWERPain, Confusion, Fecal Impaction, Urinary retention The nurse is caring for a patient who has a history of getting up without assistance, which results in falls. The nurse selects a restraint alternative for this patient. Restraint alternatives include... CORRECT ANSWERLeg Monitors, bed monitors, chair monitors When an order has been obtained to place restraints on a patient, and the restraints are in place, nursing staff is required by the Health Care Financing Administration (HCFA) and the Joint Commission to follow guidelines, which include CORRECT ANSWER1. Offering the patient fluids.

2. Assisting the patient with toileting.
3. Changing the patient's position in bed.
4. Removing the restraint every 2 hours.
5. Assessing the patient's extremities for edema, capillary refill, and sensation. When providing discharge instructions to a patient who has been prescribed home oxygen therapy, the nurse teaches the patient to CORRECT ANSWER3. Avoid smoking near the oxygen source.
6. Avoid wearing wool blankets or sweaters.
7. Use extension tubing to move around the house. When educating a class of nursing students about using good body mechanics and injury prevention, the nursing instructor teaches them to CORRECT ANSWER1. Plan work carefully.
8. Elevate work to a comfortable level.
9. Hold an object close and bend their elbows when carrying something.

A student nurse is out shopping when he or she hears that a mass casualty event (MCE) has occurred in the area. It is his or her responsibility as a student and as a nurse to CORRECT ANSWERA student nurse should expect to be called in to work as an extra if a disaster occurs. It is appropriate for the student nurse to ensure the safety of family first and then assist at his or her place of work. Some facilities have a plan for calling in extra help according to needs, rather than having a barrage of off-duty employees arriving at once. which aspect of restraints can a nurse delecate to a nursing assistant? CORRECT ANSWERthey can remove the restraint to make sure the skin is intact Which one of the following foods should the nurse recommend for an older adult who is constipated? CORRECT ANSWERFRUIT (high fiber) A patient has diareah and decreased skin turger and dark urine, nased on this data which of the following would be the nursing diagnosis? CORRECT ANSWERdeficient fluid volume Which of the following nursing diagnosis are potentially appropriate for a patient with a new ileostomy (diversion for the bowel) CORRECT ANSWERrisk for skin deteriation, disturbed body image Which of the following techniques is appropriate when administering soap suds enema (SEE) CORRECT ANSWERadminister 500-1000 ml of solution ( left side sims because bowel goes down there) The nurse is explaining the mechanism of action for a mineral oil enema. Which of the following explanations is correct? CORRECT ANSWERsoftening of fecal mass COCA CORRECT ANSWERcolor, odor, characteristics, amount (stool, urine, wound discharge, etc.) Fecal Occult Blood Test CORRECT ANSWERFalse positive- wiping too hard, period, hemorrhoids, blue+ positive stool smear on card Chronically constipated- CORRECT ANSWERstretches the colon out Laxative abuse- CORRECT ANSWEReffects your nervous system- your body stops telling your brain that you have to poop

stages of infection CORRECT ANSWERincubation- infection until systom. prodromal- MOST INFECTIONS illness- sign/symptoms decline- pathogens convalescence- repair UTI CORRECT ANSWERconfusion (old people), burning, urgency, infection, dysuria, WBC, hematuria clean catch urine specement CORRECT ANSWERpresents bacteria, pees a little thenput cup under asepsis- CORRECT ANSWERenvironment, hands, CDC guide lines (disinfect, supplies= contaminated) ANA CORRECT ANSWERstandard of nursing, educational materials, works with legislature to promote care/licensure FNA- entry level development National League of nursing CORRECT ANSWER1st to establish a universal standard of eduation, nursing journal, policy in work place NSNA CORRECT ANSWERnursing students in the us, like ANA "immage" STTI CORRECT ANSWERnational honor society, greater scholarship, group- race/gender, clinical:specialty Nightengale CORRECT ANSWERbelieved in INFECTION CONTROL Nurse practice act CORRECT ANSWERregulate nursing practice.- by sates (board of nursing) define practice criteria to be RN enforce

standards of practice CORRECT ANSWERwhat ALL nurses can do competently (ANA) LPN/LVN CORRECT ANSWER1 year under rn, bedside care, no iv push RN CORRECT ANSWERDiploma- 3 years AD- 2 years BSN- more widespread graduate CORRECT ANSWERmasters (independent), doctoral (protessional). DNP- clinical, PHD- research continuing education, keep up with clinical knowledge (inservice) dont count NCLEX- CORRECT ANSWERNational Council Liscensure Examination, basic nursing knowledge to get your license, same nation wide Nursing process CORRECT ANSWERassessment- view client, gather info, patterns, cluster, recording diagnosis- conclusion from increase, statement (nurses can do independently) outcome/PAIN- what we want our patient to accomplish/HOW- GOALS- for implementation and evaluation (intervention- nurse preform) Implementation- Doing, achieving outcome Evaluation- reflection on outcomes clear liquids CORRECT ANSWERsee through (juice, popsicle, jello, tea RISK- inadequate nutrition Full liquid diet CORRECT ANSWERpourable (mmilk, ice cream)--- fractured mouth, safety BMI CORRECT ANSWER18.5- 24.

School- smoking adiolescent- diet osteoperosis, gerd smoking CORRECT ANSWERsnacks insead, rewarding themselves, being accountable A patient reporting itching and tingling arrives at the hospital. The nurse suspects a herpes simplex infection and keeps the patient in an isolation room. What would be the patient's stage of infection? 1 Illness stage 2 Convalescence 3 Prodromal stage 4 Incubation period CORRECT ANSWER The prodromal stage is the interval from onset of nonspecific signs and symptoms to more specific symptoms. During this stage, microorganisms grow and multiply and the patient may be capable of spreading the disease to others. Therefore, the patient may be in an isolation room to reduce the spread of infection. The illness stage is the interval when a patient manifests signs and symptoms that are specific to a type of infection. The convalescence stage is the interval when acute symptoms of an infection disappear. The incubation period is the first stage of the infection process; it is the Interval between the entrance of the pathogen into the body and the appearance of the first symptoms. What major infections are caused by Escherichia coli? Select all that apply. 1 Hepatitis A 2 Pneumonia 3 Gastroenteritis 4

Food poisoning 5 Urinary tract infections CORRECT ANSWER3, 5 Gastroenteritis and urinary tract infections are major infections caused by Escherichia coli. The hepatitis A virus causes Hepatitis A. Pneumonia and food poisoning are major infections caused by Staphylococcus aureus. face tent CORRECT ANSWER8- L/min. 30-35% more humidifying, less accurate than a mask ventury mask CORRECT ANSWERhas a dial, 24%- 50% Useful with chronic lung disease Exhalation ports to keep CO2 buildup to minimum