NURS 325|Exam 3-Fundamentals, Spring 2020 (verified,revised solution)

Document Content and Description Below

Exam 3-Fundamentals. • Question 1 1.42 out of 1.42 points A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli’s functio... n will the nurse share with the patient? a. Carries out gas exchange b. Regulates tidal volume c. Stores oxygen d. Produces hemoglobin • Question 2 1.42 out of 1.42 points A home care nurse is inspecting a patient’s house for safety issues. Which findings will cause the nurse to address the safety problems? (Select all that apply.) a. Stairway faintly lit b. Scatter rugs in the kitchen c. Absence of smoke alarms a. Stairway faintly lit b. Scatter rugs in the kitchen c. Absence of smoke alarms d. Level thresholds between bathroom and bedroom e. Bathtub with grab bars f. Low-pile carpeting in the living room • Question 3 1.42 out of 1.42 points The nurse suspects the patient has increased afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition? a. Blood pressure cuff b. Oxygen cannula c. Pulse oximeter d. Yankauer suction tip catheter • Question 4 1.42 out of 1.42 points The nurse enters the patient’s room and notices a small fire in the headlight above the patient’s bed. In which order will the nurse perform the steps, beginning with the first one? 1. Pull the alarm. 2. Remove the patient. 3. Use the fire extinguisher. 4. Close doors and windows. a. 1, 2, 3, 4 b. 2, 1, 4, 3 c. 2, 1, 3, 4 d. 1, 2, 4, 3 • Question 5 1.42 out of 1.42 points The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about employment status and displays a nonjudgmental attitude. What is the rationale for the nurse’s actions? a. Employment status is an internal variable that impacts compliance. b. A person’s compliance is affected by economic status. c. Noncompliant patients thrive on the disapproval of authority figures. d. External variables have little effect on compliance. • Question 6 1.42 out of 1.42 points A patient asks the nurse for a nonmedical approach for excessive worry and work stress. Which therapy should the nurse recommend? c. Meditation a. Ayurvedic herbs b. Acupuncture d. Chiropractic care • Question 7 1.42 out of 1.42 points A nurse is teaching a patient relaxation techniques to decreases stress. Which finding will support the nurse’s evaluation that the therapy is effective? a. Increased blood sugar b. Decreased heart rate c. Dilated pupils d. Elevated blood pressure • Question 8 The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient and spouse refuse to talk about it and refuse to be taught about how to care for it. How will the nurse evaluate this couple’s stage of adjustment? Shock a. Withdrawal b. Rehabilitation c. Shock d. Acceptance • Question 9 1.42 out of 1.42 points The supervising nurse is watching nurses prepare medications. Which action by one of the nurses will the supervising nurse stop immediately? a. Draws up glargine (Lantus) in a syringe by itself b. Rolls insulin vial between hands c. Prepares NPH insulin to be given intravenously (IV) d. Administers a dose of correction insulin • Question 10 1.42 out of 1.42 points Which assessment question should the nurse ask to best understand how visual alterations are affecting the patient’s self-care ability? a. “Are you able to prepare a meal or write a check?” b. “Have you stopped reading books or switched to books on audiotape?” c. “How does your vision impairment make you feel?” d. “What do you do to protect yourself from injury at work?” • Question 11 1.42 out of 1.42 points Which areas should the nurse assess to determine the effects of external variables on a patient’s illness? (Select all that apply.) a. Social support b. Cultural background e. Socioeconomic status a. Social support b. Cultural background c. Patient's perception of the illness d. Patient’s coping skills e. Socioeconomic status • Question 12 Directions: Answer the following questions. Ordered: 1000 mL of 0.9% sodium chloride with 100 units Humulin regular (R) insulin to infuse at 10 units per hr until the blood sugar level is stabilized at 150 mg per dL. At how many mL per hr will you set the infusion device? • Question 13 1.42 out of 1.42 points The nurse administers a central nervous system stimulant to a patient. Which assessment finding indicates to the nurse that an idiosyncratic event is occurring? a. Develops restlessness b. Presents with a pruritic rash c. Falls asleep during daily activities d. Experiences alertness • Question 14 1.42 out of 1.42 points The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient for “detox.” What should the nurse do next? a. Teach the patient that choices will have to change. b. Realize that the patient is ready to change. c. Instruct the patient that relapses will not be tolerated. d. Identify the patient’s stage of change. • Question 15 1.42 out of 1.42 points The nurse prepares a pain injection for a patient but had to check on another patient and asks a new nurse to give the medication. Which action by the new nurse is best? a. Administer the medication just this once. b. Give the medication for any pain score greater than 8. c. Avoid the issue and pretend to not hear the request. d. Do not give the medication. • Question 16 1.42 out of 1.42 points A home health nurse is assessing a family’s home after the birth of an infant. A toddler also lives in the home. Which finding will cause the nurse to follow up? a. Plastic grocery bags are neatly stored under the counter. a. Plastic grocery bags are neatly stored under the counter. b. No bumper pads are in the crib. c. Electric outlets are covered in all rooms. d. Crib slats are 5 cm apart. • Question 17 1.42 out of 1.42 points Upon completion of the assessment, the nurse finds that the patient has quit drinking and has been alcohol free for the past 2 years. Which stage best describes the nurse’s assessment finding? a. Contemplation b. Action c. Maintenance d. Preparation • Question 18 1.62 out of 1.62 points The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using? a. Health promotion model b. Health belief model c. Maslow’s hierarchy of needs d. Holistic health model • Question 19 1.42 out of 1.42 points Which patient does the nurse most closely monitor for an unintended synergistic effect? a. The 35 year old who has ingested meth mixed with several household chemicals b. The 4 year old who has mistakenly taken a half bottle of vitamins c. The 72 year old who is seeing four different specialists d. The 50 year old who is prescribed a second blood pressure medication • Question 20 1.42 out of 1.42 points While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. Which action will the nurse take first? a. Insert a spare tracheostomy with the obturator. b. Press the emergency response button. c. Manually occlude the tracheostomy with sterile gauze. d. Place a face mask delivering 100% oxygen over the nose and mouth. • Question 21 1.42 out of 1.42 points The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate? a. The patient will return to the contemplation or precontemplation phase. b. The patient must pick up the attempt right where the patient left off. c. The patient does not want to and will never quit smoking. d. The patient will need to adopt a new lifestyle for change to be effective. • Question 22 1.42 out of 1.42 points The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient’s application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient’s plan of care? a. Impaired physical mobility b. Risk for falls c. Risk for suffocation d. Deficient knowledge • Question 23 1.42 out of 1.42 points Hours to Administer Rate: D5 1/2NS 1000 mL at 125 mL/hr How many hours are required to administer this fluid at the given rate? • Question 24 1.42 out of 1.42 points Which patient will cause the nurse to question an order for acupuncture? a. A patient with osteoarthritis b. A patient with migraine headaches c. A patient with AIDS d. A patient with low back pain • Question 25 Direct IV Injection (IV Push) Calculate the number of milliliters needed for each intravenous dose for direct IV push. Use either the basic formula, ratio and proportion, fractional equation, or dimensional analysis methods. • Question 26 1.42 out of 1.42 points A Native American patient is asking for a spiritual healer. Which person should the nurse try to contact for the patient? a. Shaman b. Vitalist c. Curanderismo d. Ayurvedic • Question 27 1.42 out of 1.42 points Directions: For the following problems, refer to CHO Intake and Weight Table. Round answers to the nearest whole number. Insulin Units Required Based on CHO Intake and Weight Weight in Pounds Weight in Kg Unit : grams of CHO 100-109 45-49.9 1:16 110-129 50-58.6 1:15 130-139 59-63.2 1:14 140-149 63.6-67.7 1:13 150-159 68.2-72.3 1:12 160-169 72.7-76.8 1:11 170-179 77.3-81.4 1:10 180-189 81.8-85.9 1:9 190-199 86.4-90.5 1:8 200-239 90.9-108.6 1:7 240+ 109.1+ above 1:5 The patient weighs 154 lb and has consumed 35 g CHO. How many units of insulin will be required? • Question 28 1.42 out of 1.42 points A nurse is teaching a community health promotion class and discusses the flu vaccine. Which information will the nurse include in the teaching session? (Select all that apply.) a. The inactivated flu vaccine is given to people over 50. e. It is given yearly. a. The inactivated flu vaccine is given to people over 50. b. The nasal spray is given to people over 50. c. It is given in a series of four doses. d. It is safe for adults with acute febrile illnesses. e. It is given yearly. f. It is safe for children allergic to eggs. • Question 29 1.42 out of 1.42 points A nurse is using the holistic approach to care. Which goal is the priority? a. Join physical care with a vegan diet. b. Integrate spiritual treatments. c. Incorporate the mind-body-spirit connection. d. Use complementary and alternative therapies. • Question 30 1.42 out of 1.42 points A nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority? a. Risk for skin breakdown b. Impaired gas exchange c. Activity intolerance d. Risk for infection • Question 31 1.42 out of 1.42 points A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest? a. Omelet with sausage, cheese, and onions b. Whole wheat toast with butter and a side of bacon c. A bowl of cereal with whole milk and a banana d. A cup of nonfat yogurt with granola and a handful of dried apricots Question 32 Which patient will the nurse see first? a. A 56-year-old patient with oxygen with a lighter on the bedside table b. A 1-month-old infant with a pacifier that has no string around the baby’s neck c. A 56-year-old patient with oxygen using an electric razor for grooming d. A 1-month-old infant looking at a shiny, round battery just out of arm’s reach • Question 33 1.42 out of 1.42 points The nurse is administering medications to several patients. Which action should the nurse take? a. Administer an intravenous medication through tubing that is infusing blood. b. Pinch up the deltoid muscle of an adult patient receiving a vaccination. c. Aspirate before administering a subcutaneous injection in the abdomen. d. Advise a patient after a corticosteroid inhaler treatment to rinse mouth with water. • Question 34 1.42 out of 1.42 points The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? (Select all that apply.) a. Note oxygen shut-offs. c. Note evacuation routes. d. Move bedridden patients in their bed. f. Close all doors. a. Note oxygen shut-offs. b. Wait until the fire department arrives to act. c. Note evacuation routes. d. Move bedridden patients in their bed. e. Use type B fire extinguishers for electrical fires. f. Close all doors. • Question 35 1.42 out of 1.42 points Directions: Answer the following questions. The patient’s blood sugar is 180 mg per dL. According to the sliding scale below, how many units of insulin will the patient receive? SLIDING SCALE Blood glucose level 50-79 Treat low BG and retest in 15 minutes 80-99 10 Units 100-149 12 Units 150-199 15 Units 200-249 17 Units 250-299 20 Units 300-349 25 Units 350-above Call Physician • Question 36 1.42 out of 1.42 points A nurse is emphasizing the use of touch to decrease “skin hunger” in caring for patients. Which age group is the nurse primarily describing? a. Older adults b. Middle age c. Children d. Infants • Question 37 1.42 out of 1.42 points Hours to Administer Rate: TPN 1000 mL at 30 mL/hr How many hours are required to administer this fluid at the given rate? • Question 38 1.42 out of 1.42 points A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up? a. “I will schedule an appointment with a chimney inspector next week.” b. “When it is cold outside in the winter, I will use a nonvented furnace.” c. “If I feel dizzy when using the heater, I need to have it inspected.” d. “Every December is the time to change batteries on the carbon monoxide detector.” • Question 39 1.42 out of 1.42 points The supervising nurse is observing several different nurses. Which action will cause the supervising nurse to intervene? a. A nurse calls the health care provider for a patient with nasogastric suction and orders for oral meds. b. A nurse gives an IV medication through a 22-gauge IV needle without blood return. c. A nurse administers a vaccine without aspirating. d. A nurse draws up the NPH insulin first when mixing a short-acting and intermediate-acting insulin. • Question 40 1.42 out of 1.42 points A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately? a. Temperature b. Blood pressure c. Apical pulse d. Respiratory rate • Question 41 1.42 out of 1.42 points A nurse is caring for an older-adult patient who was in a motor vehicle accident because the patient thought the stoplight was green. The patient asks the nurse “Should Istop driving?” Which response by the nurse is most therapeutic? a. “No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is lit up, it means stop, and if the bottom is lit up, it means go.” b. “Yes, you should stop driving. As you age, your cognitive function declines, and becoming confused puts everyone else on the road at risk.” c. “Yes, you should ask family members to drive you around from now on. Your reflex skills have declined so much you can’t avoid an accident.” d. “No, instead you should see your ophthalmologist and get some glasses to help you see better.” • Question 42 1.42 out of 1.42 points Which patient using an inhaler would benefit most from using a spacer? a. A 72 year old with left-sided hemiparesis using a dry powder inhaler b. A 15 year old with a repaired cleft palate who is alert c. A 25 year old with limited coordination of the extremities d. A 50 year old with hearing impairment who uses a hearing aid • Question 43 1.42 out of 1.42 points Directions: For the following problems, refer to CHO Intake and Weight Table. Round answers to the nearest whole number. Insulin Units Required Based on CHO Intake and Weight Weight in Pounds Weight in Kg Unit : grams of CHO 100-109 45-49.9 1:16 110-129 50-58.6 1:15 130-139 59-63.2 1:14 140-149 63.6-67.7 1:13 150-159 68.2-72.3 1:12 160-169 72.7-76.8 1:11 170-179 77.3-81.4 1:10 180-189 81.8-85.9 1:9 190-199 86.4-90.5 1:8 200-239 90.9-108.6 1:7 240+ 109.1+ above 1:5 The patient weighs 200 lb. She ate 32 g CHO for breakfast, 30 g CHO for lunch, 32 g CHO for dinner, and 10 g CHO for a bedtime snack. How many total units of insulin did she require for the entire day? • Question 44 1.42 out of 1.42 points The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient’s health care needs? a. The water comes from the county water supply. b. The electricity was turned off 3 days ago. c. A son and family recently moved into the home. d. This home is not furnished with a microwave oven. • Question 45 1.62 out of 1.62 points The nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking. Which health care model is the nurse following? a. Holistic health model b. Health promotion model c. Maslow’s hierarchy of needs d. Health belief model • Question 46 1.42 out of 1.42 points A nurse is teaching about the therapy that is more effective in treating physical ailments than in preventing disease or managing chronic illness. Which therapy is the nurse describing? a. Allopathic b. Complementary c. Mind-body d. Alternative • Question 47 1.42 out of 1.42 points The nurse is teaching about the process of exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process? a. Ventilation b. Diffusion c. Surfactant d. Perfusion • Question 48 1.42 out of 1.42 points Hours to Administer Rate: D51/2NS 1000 mL at 100 mL/hr How many hours are required to administer this fluid at the given rate? • Question 49 1.62 out of 1.62 points A nurse is using Maslow’s hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first? a. Not seeing family members b. Mental health c. Not eating d. Anxiety • Question 50 0 out of 1.42 points The nurse is caring for a patient who is taking gentamicin for an infection. Which assessment is a priority? a. Taste b. Vision c. Smell d. Hearing • Question 51 1.42 out of 1.42 points A nurse is teaching a patient about the use of biofeedback. Which goal should the nurse add to the care plan? a. Holds various postures with breathing b. Controls autonomic physiological functions c. Uses music to calm the mind d. Opens emotional channels • Question 52 1.42 out of 1.42 points A nurse is caring for an older-adult patient on bed rest with potential sensory deprivation. Which action will the nurse take? a. Offer the patient a back rub. b. Place the patient in the room farthest from the nurses’ station. c. Ask the patient “Would you like a newspaper to read?” d. Hang a “Do not disturb” sign on patient’s door. • Question 53 1.42 out of 1.42 points A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. Which level of preventive care is the patient receiving? a. Secondary prevention b. Health promotion c. Primary prevention d. Tertiary prevention • Question 54 1.42 out of 1.42 points The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over the inability to sleep. Which action by the nurse is most appropriate for this patient? a. Keep the door open during the night. b. Administer an opioid medication to help the patient sleep. c. Open the shades at night. d. Provide the patient with earplugs. • Question 55 1.42 out of 1.42 points Directions: Answer the following questions. Ordered: 50 units Humulin R insulin in 250 mL of 0.9% sodium chloride to infuse at 4 units per hr a. How many hours will it take to infuse? b. How many mL per hr will be infused? • Question 56 1.42 out of 1.42 points An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient? a. Positions patient’s buttocks close to the front of wheelchair seat b. Backs wheelchair into elevator, leading with large rear wheels first c. Unlocks wheelchair for easy maneuverability when patient is transferring d. Places locked wheelchair on same side of bed as patient’s weaker side Response Feedback: A correct action when using a wheelchair is to back wheelchair into an elevator, leading with large rear wheels first. A patient’s buttocks should be well back into the seat. A locked wheelchair should be placed on a patient’s strong or unaffected side. Brakes should be securely locked when a patient is transferring. • Question 57 1.42 out of 1.42 points The nurse has placed a yellow armband on a 70-year-old patient. Which observation by the nurse will indicate the patient has an understanding of this action? a. The patient removes the armband to bathe. b. The patient wears the red nonslip footwear. c. The patient who is allergic to penicillin asks the name of a new medicine. d. The patient insists on taking a “water” pill in the evening. • Question 58 1.42 out of 1.42 points A patient is taking an antidepressant medication. The nurse discovers that the patient uses herbs. Which herb will cause the nurse to intervene? a. Saw palmetto b. Garlic c. Chamomile d. Aloe • Question 59 1.42 out of 1.42 points A nurse is attempting to administer an oral medication to a child, but the child refuses to take the medication. A parent is in the room. Which statement by the nurse to the parent is best? a. “Please hold your child’s arms down, so I can give the full dose.” b. “Since your child loves applesauce, let’s add the medication to it, so your child doesn’t resist.” c. “I will observe if you would like to try to administer the medication.” d. “Let’s turn the lights off and give your child a moment to fall asleep before administering the medication.” • Question 60 1.42 out of 1.42 points The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method? a. A 5-year-old with an asthma attack following severe allergies b. A 24-year-old with a right pneumothorax following a motor vehicle accident c. A 5-year-old with excessive drooling from epiglottitis d. A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation • Question 61 1.42 out of 1.42 points The home health nurse is caring for a patient with tactile and visual deficits. The nurse is concerned about injury related to inability to feel harmful stimuli and teaches the patient safety strategies to maintain independence. Which action by the patient indicates successful learning? a. Places colored stickers on faucet handles to indicate temperature. b. Asks the nurse to test the temperature of the water before entering the bath. c. Uses a heating pad on a low setting to keep warm. d. Replaces all lace-up shoes with Velcro straps for ease. • Question 62 1.42 out of 1.42 points Direct IV Injection (IV Push) Calculate the number of milliliters needed for each intravenous dose for direct IV push. Use either the basic formula, ratio and proportion, fractional equation, or dimensional analysis methods. Atropine sulfate 0.6 mg, IV push Available: 1 mg/10 mL • Question 63 1.42 out of 1.42 points A patient has a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia? a. Carotid artery b. Superior vena cava c. Coronary artery d. Pulmonary artery • Question 64 1.42 out of 1.42 points A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with communication and becomes tearful at times. Which intervention will the nurse include in the patient’s plan of care? a. Place a consult for a home health nurse. b. Make the patient talk as much as possible. c. Obtain an order for antidepressant medications. d. Teach the patient about special assistive devices. • Question 65 1.42 out of 1.42 points The nurse is caring for a patient who is a well-known surgeon at the hospital. The nurse notices the patient becoming more agitated and withdrawn with each group of surgeon visitors. The nurse and patient agree to place a “Do not disturb” sign on the door. A few hours later, the nurse notices a surgeon who is not involved in the patient’s care attempting to enter the room. Which response by the nurse is most appropriate? a. Call for security to remove the surgeon. b. Scold the surgeon for not obeying the sign and respecting the patient’s wishes. c. Firmly explain that the patient does not wish to have visitors at this time. d. Allow the surgeon to enter. • Question 66 1.42 out of 1.42 points A health care provider prescribes aspirin 650 mg every 4 hours PO when febrile. For which patient will this order be appropriate? a. 62 year old with a high fever from an infection b. 21 year old with a sprained ankle c. 7 year old with a bleeding disorder d. 35 year old with a severe headache from hypertension • Question 67 1.42 out of 1.42 points A patient is to receive a proton pump inhibitor through a nasogastric (NG) feeding tube. Which is the most important nursing action to ensure effective absorption? a. Hold feeding for at least 30 minutes after medication administration. b. Thoroughly shake the medication before administering. c. Flush tube with 10 to 15 mL of water, after all medications are administered. d. Position patient in the supine position for 30 minutes to 1 hour. • Question 68 1.42 out of 1.42 points A teen with an anxiety disorder is referred for biofeedback because the parents do not want their child to take anxiolytics. Which statement from the teen indicates successful learning? a. “Biofeedback will direct my energies in an intentional way when stressed.” b. “Biofeedback will help me with my thoughts and physiological responses to stress.” c. “Biofeedback will let me assess and redirect my energy fields.” d. “Biofeedback will allow me to manipulate my stressed out joints.” • Question 69 1.42 out of 1.42 points A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority? a. Blood pressure b. Respirations c. Temperature d. Pulse • Question 70 1.42 out of 1.42 points A nurse is establishing a relationship with the patient who is severely visually impaired and is teaching the patient how to contact the nurse for assistance. Which action will the nurse take? a. Place a raised Braille-like sticker on the call button. b. Instruct the patient to tell a family member to get the attention of the staff. c. Color code the call light system. d. Explain to the patient that a staff person will stop by once an hour to see if the patient needs anything. [Show More]

Last updated: 2 years ago

Preview 1 out of 48 pages