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Nur 091 Midterm PDF
Nur 091 Midterm PDF
1. A patient is admitted to the hospital with shortness of breath. As the nurse assesses
this patient, the nurse is using the process of:
a. evaluation.
b. data collection.
c. problem identification.
d. testing a hypothesis.
Feedback
Assessment is the first stage of the nursing process, and is the process of gathering data to
formulate the
nursing diagnosis and care plan.
2. The nursing process organizes your approach to delivering nursing care. To provide
care to your patients, you will need to incorporate nursing process and:
a. decision making.
b. problem solving.
c. interview process.
d. intellectual standards.
Feedback
The interview process is an integral part of patient-centered care, and is continuous throughout
patient
interaction, regardless of the stage of the nursing process.
3. A patient is suffering from shortness of breath. The correct goal statement would be
written as:
c. the patient will not complain of breathing problems within the next 8 hours.
d. the patient will have a respiratory rate of 14 to 18 breaths per minute.
Feedback
The goal for the patient encompasses the SMART acronym. Each goal and outcome should address
only
one behavior, perception, or physiological response. Expected outcomes must also be singular.
Specificity allows you to
decide if there is a need to modify the plan of care.
4. When caring for a patient who has multiple health problems and related medical
diagnoses, nurses can best perform nursing diagnoses and nursing interventions by
developing a:
1/1
a. critical pathway.
b. nursing care plan.
c. concept map.
d. diagnostic label.
Feedback
As noted above, concept maps help the nurse organize nursing interventions for a patient with
multiple
problems.
5. Consultation occurs most often during which phase of the nursing process?
1/1
a. Assessment
b. Diagnosis
c. Planning
d. Evaluation
Feedback
When a nurse is unsure of how to proceed in the planning process, he or she will seek out another
colleague’s knowledge and experience to assist in planning interventions for the patient.
Feedback
Concept mapping helps the busy nurse, with numerous patients, focus on healing patients on an
individual
basis.
a. assess the patient and, if unsure of the finding, ask a faculty member to assess the
patient.
b. review his or her own comfort level and competency with assessment skills.
c. ask another student to perform the assessment.
d. consider whether the diagnosis should be actual, potential, or risk.
Feedback
Data collection is an art that the nurse gets better at with experience, so asking for assistance from a
colleague to help with an unsure finding can ensure that the diagnostic statement is correct.
a. Assessment
b. Diagnosis
c. Planning
d. Evaluating
Feedback
The nurse identifies human responses to actual or potential health problems during the nursing
diagnoses
step of the nursing process. During the assessment step, the nurse collects data. During the
planning step, the nurse
develops strategies to resolve or decrease the patient's problem. During evaluation, the nurse
determines the
effectiveness of the plan of care.
10. The guidelines for writing an appropriate nursing diagnosis include all of the
following except:
Feedback
A nursing diagnosis is a statement about a patient's actual or potential health problem that is within
the
scope of independent nursing intervention. Medical terminology is never part of the nursing
diagnosis.
SESSION 10
2. You are writing a care plan for a newly admitted patient. Which one of these
outcome statements is written correctly?
3. Your patient has met the goals set for improvement of ambulatory status. You
would now:
c. create a new nursing diagnosis that states goals have been met.
d. reassess the patient’s response to care and evaluate the implementation step of the nursing
process.
Feedback
When goals are met, the care plan for that goal is discontinued.
4. Which of the following is an end result that translates into observable patient
behaviors that are measurable and desirable?
a. Unexpected outcome
b. Expected outcome
c. Sensitive outcome
d. Accomplished outcome
Feedback
When a nurse has an expected outcome established, it means that it is measurable. If the patient
does not
meet that outcome, the nurse should reassess and modify the care plan.
5. You have finished with several nursing interventions. To evaluate interventions, you
need to examine the:
a. legal and ethical obligations require health care providers to keep information strictly
confidential.
b. regulations require health care institutions to document evidence of physical and emotional
well-being.
c. reimbursement issues related to patient care and procedures may be of concern.
d. fragmentation of nursing and medical care procedures may be identified.
Feedback
Under HIPAA laws, a patient’s medical information can only be released to team members, unless
express
written consent is given by the patient.
7. A nurse has just admitted a patient with a medical diagnosis of congestive heart
failure. When completing the admission paperwork, the nurse needs to record:
8. A nurse records that the patient stated his abdominal pain is worse now than last
night. This is an example of:
a. PIE documentation.
b. SOAP documentation.
c. narrative charting.
d. charting by exception.
Feedback
Writing subjective data, which includes the information the patient verbalizes, is written in narrative
charting.
9. A patient you are assisting has fallen in the shower. You must complete an incident
report. The purpose of an incident report is to:
Feedback
Any deviation from the norm, such as a patient fall, can be used to improve quality. Incidents are
gathered
and assessed to see if there is a way to prevent it from happening again.
10. Before consulting with a physician about a female patient's need for urinary
catheterization, the nurse considers the fact that the patient has urinary retention and
has been unable to void on her own. The nurse knows that evidence for alternative
measures to promote voiding exists, but none has been effective, and that before
surgery the patient was voiding normally. This scenario is an example of which
implementation skill?
a. Cognitive
b. Interpersonal
c. Psychomotor
d. Consultative
Feedback
Cognitive skills include the critical thinking and decision-making skills described earlier. Always use
good
judgment and sound clinical decision making when performing any intervention.
SESSION 11
1. While caring for a child, you identify that additional safety teaching is needed when
a young and inexperienced mother states that:
2. A newly admitted patient was found wandering the hallways for the past two nights.
The most appropriate nursing interventions to prevent a fall for this patient would
include:
a. a poisoning accident.
b. an equipment-related accident.
c. a procedure-related accident.
a. restraints.
b. poor hygiene.
c. Foley catheter bag.
d. improper positioning.
Feedback
The Foley catheter bag could be both a portal of exit and portal of entry.
5. You are caring for a patient who underwent surgery 48 hours ago. On physical
assessment, you notice that the wound looks red and swollen. The patient’s WBCs are
elevated. You should:
a. start antibiotics.
b. notify the provider.
6. An athletic young woman has just fractured her leg while training for a marathon.
The use of meditation has many physiological properties that will help the young
woman to:
Feedback
Many times, a fracture comes with swelling and muscle contractions to compensate for the injury.
Meditation
may help alleviate any muscle tension this patient is experiencing.
7. You are caring for a patient who has diabetes complicated by kidney disease. You
need to make a detailed assessment when administering medications because this
patient may experience problems with:
a. absorption.
b. biotransformation.
c. distribution.
d. excretion.
Feedback
The kidneys are the main organs for medication excretion. If a patient’s renal function declines, the
kidneys
cannot excrete medications adequately.
a. allergic.
b. idiosyncratic.
c. therapeutic.
d. toxic.
Feedback
Toxic effects often develop after prolonged intake of a medication or when a medication
accumulates in the
blood because of impaired metabolism or excretion. Excess amounts of a medication within the body
sometimes have
lethal effects, depending on its action. For example, toxic levels of morphine, an opioid, cause
severe respiratory
depression and death.
10. If a nurse experiences a problem reading a physician’s medication order, the most
appropriate action will be to:
SESSION 12
1. You are caring for a non–English-speaking male patient. When preparing to assist
him with personal hygiene, you should:
2. A young girl with long hair is experiencing a problem with matting. The most
appropriate action to take would be:
3. The nursing assistant asks you the difference between a wound that heals by
primary or secondary intention. You willreply that a wound heals by primary intention
when the skin edges:
a. are approximated.
a. it has no odor.
b. a culture is negative.
c. the edges reveal the presence of fluid.
d. it shows purulent drainage coming from the incision site.
Feedback
Note the amount, color, odor, and consistency of drainage. The amount of drainage depends on the
type of
wound. Types of drainage include serous, sanguineous, serosanguineous, and purulent. If the
drainage has a pungent or
strong odor, you should suspect an infection.
5. A surgical wound requires a Hydrogel dressing. The primary advantage of this type
of dressing is that it provides:
Feedback
Hydrogel dressings are gauze or sheet dressings impregnated with water or glycerin-based
amorphous gel.
This type of dressing hydrates wounds and absorbs small amounts of exudate. Hydrogel dressings
are for
partial-thickness and full-thickness wounds, deep wounds with some exudate, necrotic wounds,
burns, and
radiation-damaged skin.
b. Full-thickness skin loss; subcutaneous fat may be visible. May include undermining .- III.
Category/stage III
c. Full thickness tissue loss; muscle and bone visible. May include undermining. - IV.
Category/stage IV
d. Partial-thickness skin loss or intact blister with serosanguinous fluid.- II. Category/stage II
7. Which of the following are measures to reduce tissue damage from shear? (Select
all that apply.)
Feedback
Positioning interventions redistribute pressure and shearing force to the skin. Elevating the head of
the bed
to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces.
Consider repositioning
the patient at least every 2 hours if allowed by their overall condition. When repositioning, use
positioning devices to
protect bony prominences. The WOCN guidelines (2010) recommend a 30-degree lateral position,
which should prevent
positioning directly over the bony prominence. To prevent shear and friction injuries, use a transfer
device to lift rather
than drag the patient when changing positions. After repositioning the patient, reassess the skin.
Never massage
reddened areas. Massaging reddened areas increases the breakdown of the capillaries in the
underlying tissues and
leads to the risk of tissue injury and pressure ulcer formation.
a. Necrotic tissue
b. Wound drainage
c. Wound circumference
d. Cleansed wound
Feedback
Never collect a wound culture sample from old drainage. Clean a wound first with normal saline to
remove
skin flora.
9. What is the correct sequence of steps when performing wound irrigation to a large
open wound? a. Use slow, continuous pressure to irrigate wounds. b. Attach a 19-
gauge angiocatheter to syringe. c. Fill the syringe with irrigation fluid. d. Place a
waterproof bag near bed .e. Position angiocatheter over wound.
A, B, C, D, E
10. For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which
wound-care product helps prevent edema formation, control bleeding, and anesthetize
the body part?
a. Binder
b. Ice bag
c. Elastic bandage
d. Absorptive dressing
Feedback
For a patient who has a muscle sprain, localized hemorrhage, or hematoma, or who has undergone
dental
surgery, an ice bag is ideal to prevent edema formation, control bleeding, and anesthetize the body
part.
11. You notice a respiratory change in your immobilized postoperative patient. The
change you note is most consistent with:
a. atelectasis.
b. hypertension.
c. orthostatic hypotension.
d. coagulation of blood.
Feedback
Atelectasis is the collapse of alveoli.
12. During rounds on the night shift, you note that a patient stops breathing for 1 to 2
minutes several times during the shift. This condition is known as:
a. cataplexy.
b. insomnia.
c. narcolepsy.
d. sleep apnea.
Feedback
Sleep apnea is a disorder characterized by lack of airflow through the nose and mouth for periods of
10
seconds or longer during sleep.
13. A 4-year-old pediatric patient resists going to sleep. To assist this patient, the best
action to take would be:
14. A patient suffers from sleep pattern disturbance. To promote adequate sleep, most
important nursing intervention is:
c. “Antihistamines are effective sleep aids because they do not have many side effects.”
d. “Over-the-counter medications when combined with sleep hygiene measures are a good plan
for sleep.”
Feedback
Confusion is one of the side effects of antihistamine that may increase the risk of falls.
16. The school nurse is teaching health-promoting behaviors that improve sleep to a
group of high school students. Which points should be included in the education?
(Select all that apply.)
Feedback
Sleep routines help you get into sleep better and faster. Coffee contains caffeine that gives you
energy and
stays awake. Cell phones have radiation that could disrupt your sleep, according to research.
17. Which sleep-hygiene actions at bedtime can the nurse delegate to the nursing
assistant? (Select all that apply.)
Feedback
All choices except D and E can be delegated to a nursing assistant. You must avoid giving a cup of
coffee
before bedtime and giving and monitoring the effects of a medication is part of the nurses’ roles and
responsibilities.
18. Which statement made by the parent of a school-age child requires follow-up by
the nurse?
19. The nurse is developing a plan of care for a patient experiencing obstructive sleep
apnea (OSA). Which intervention is appropriate to include on the plan?
20. The effects of immobility on the cardiac system include which of the following?
(Select all that apply.)
A. Thrombus formation
SESSION 13
1. When a smiling and cooperative patient complains of discomfort, nurses caring for
this patient often harbormis conceptions about the patient's pain. Which of the
following is true?
a. adjunctive therapy.
b. non-opioids.
c. NSAIDs.
d. PCA pain management.
Feedback
There are many benefits to PCA use. The patient gains control over pain, and pain relief does not
depend
on nurse availability. Patients also have access to medication when they need it. This decreases
anxiety and leads to
decreased medication use. Small doses of medications are delivered at short intervals, stabilizing
serum drug
concentrations for sustained pain relief.
3. A postoperative patient is using PCA. You will evaluate the effectiveness of the
medication when:
4. A 22-year-old new mother is breastfeeding. You ask her if she is taking the correct
quantities of nutrients. Which statement reflects that she understands the dietary
guidelines?
Feedback
This statement shows that the mother knows the importance of following the recommended dietary
allowances since she is breastfeeding, which is beneficial to the infant.
5. You receive an order to begin enteral tube feedings. The first step is to:
Feedback
Before beginning a tube feeding, you will learn in the skills lab to flush the line with a small amount of
water
to ensure that the tube is clear and patent.
a. bladder.
b. kidney.
c. nephron.
d. ureter.
Feedback
Nephrons, the functional unit of the kidneys, remove waste products from the blood and play a major
role in
the regulation of fluid and electrolyte balance. The normal range of urine production is 1 to 2 L/day.
Nephrons are part of
the kidney where urine is being formed.
7. A health care provider may suspect that a patient is experiencing urinary retention
when the patient has:
Feedback
Urinary retention is the inability to partially or completely empty the bladder. Patients may have no
urine
output over several hours and in some cases experience frequency, urgency, small-volume voiding,
or incontinence of
small volumes of urine.
8. A young girl is having problems urinating postoperatively. You remember that
children may have trouble voiding:
Feedback
Create as much privacy as possible by closing the door and bedside curtain; asking visitors to leave
a room
when a bedside commode, bedpan, or urinal is used; and masking the sounds of voiding with
running water.
9. A newly admitted patient states that he has recently had a change in medications
and reports that stools are now dry and hard to pass. This type of bowel pattern is
consistent with:
a. abnormal defecation.
b. constipation.
c. fecal impaction.
d. fecal incontinence.
Feedback
Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation.
When
intestinal motility slows, the fecal mass becomes exposed over time to the intestinal walls and most
of the fecal water
content is absorbed. Little water is left to soften and lubricate the stool. Constipation is a significant
source of discomfort
and the nurse should assess the need for intervention before the defecation becomes painful or the
stool is impacted.
10. To maintain normal elimination patterns in the hospitalized patient, you should
instruct the patient to defecate 1 hour after meals because:
SESSION 14
1. A patient complains of chest pain. When assessing the pain, you decide that its
origin is cardiac—rather than respiratory or gastrointestinal—when it:
a. tracheal suctioning.
b. oropharyngeal suctioning.
c. nasotracheal suctioning.
d. orotracheal suctioning.
Feedback
Tracheostomy suctioning removes thick mucus and secretions from the trachea and lower airway
that you
are not able to clear by coughing. Suctioning is done when you wake up in the morning and right
before you go to bed in
the evening. Suctioning is also done after any respiratory treatments.
3. When evaluating a post-thoracotomy patient with a chest tube, the best method to
properly maintain the chest tube would be to:
a. strip the chest tube every hour to maintain drainage.
b. place the device below the patient’s chest.
4. A patient is diaphoretic and has an oral temperature of 104° F. These are classic
signs of:
a. ADH deficit.
b. extracellular fluid loss.
c. insensible water loss.
d. sensible water loss.
Feedback
Sensible water loss is a measurable loss of body fluid, e.g., blood, diarrhea, urine, vomit. If sensible
losses
consistently exceed fluid intake, dehydration may result.
Feedback
Antidiuretic hormone, also known as vasopressin is a hormone released by the posterior pituitary. It
is
important mainly for its actions on the kidneys where it increases the reabsorption of water.
Vasopressin is also a powerful
vasoconstrictor.
6. A senior student nurse delegates the task of intake and output to a new nursing
assistant. The student will verify that the nursing assistant understands the task of I&O
when the nursing assistant states,
SESSION 15
1. You are a nurse working in the college student health center. You receive a call that
an athlete has just fallen and has been injured. You know that according to the
general adaptation syndrome, the athlete will be exhibiting:
a. an increased appetite.
b. an increased heart rate.
c. a decrease in perspiration.
d. a decrease in respiratory rate.
Feedback
The alarm reaction stage of GAS refers to the initial symptoms the body experiences when under
stress.
You may be familiar with the “fight-or-flight” response, which is a physiological response to stress.
This natural reaction
prepares you to either flee or protect yourself in dangerous situations. Your heart rate increases,
your adrenal gland
releases cortisol (a stress hormone), and you receive a boost of adrenaline, which increases energy.
This fight-or-flight
response occurs in the alarm reaction stage.
2. A patient comes into the emergency department complaining of chest pain. When
discussing possible reasons why the chest pain has occurred, the nurse learns that
the patient is depressed because of the loss of a job. This type of crisis can be
classified as
a. maturational.
b. situational.
c. sociocultural.
d. posttraumatic.
Feedback
External sources such as a job change, a motor vehicle crash, a death, or severe illness provoke
situational
crises.
3. You are caring for a patient who is depressed because the only child has gone
away to college. The nurse will assess this type of depression as:
a. actual loss.
b. perceived loss.
c. situational loss.
d. maturational loss.
Feedback
When life keeps moving, such as kids growing up and moving away, it is considered maturational
loss.
4. As a first-year nursing student, you are assigned to care for a dying patient. To best
prepare you for this assignment, you will want to:
Feedback
The nurse cannot provide patient-centered nursing if the nurse does not understand his or her own
feelings
about death and dying.
SESSION 16
2. A patient with glaucoma is being discharged from the hospital. When teaching the
patient and family ways to improve home safety, the nurse tells the family to:
3. Which of the following populations have the highest incidence of STI? (Select all
that apply.)
a. Hispanic women age 15 to 24 years
Feedback
Sexual function is an important part of taking a sexual history, as it can indicate other problems the
patient
may be having.
5. When caring for patients, the nurse must understand the difference between
religion and spirituality. Religious care helps individuals:
6. To assess, evaluate, and support a patient’s spirituality, the best action a nurse can
take is to:
Feedback
By understanding the patient’s perceptions and belief system, the nurse is able to provide patient-
centered
care for the patient.