Acute Care Exam 2|116 Questions with Verified Answers
The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed
... [Show More] first while the nurse initiates the nurse-patient relationship?
1) Appearance and behavior
2) Measurement of vital signs
3) Observing specific body systems
4) Conducting a detailed health history - CORRECT ANSWER 1) Appearance and behavior Correct
The nurse is teaching a young mother to palpate her 8-year-old child to quickly evaluate if the child has a fever. Which information is important for the nurse to include?
1) Place the palm of the hand on the child's back.
2) Lightly touch the child's forehead with the fingertips.
3) Place the back of your hand against the child's forehead and then on the back of the neck.
4) Use the pads of your fingers and press against the child's neck and over the thorax. - CORRECT ANSWER 3) Place the back of your hand against the child's forehead and then on the back of the neck.
While assessing the adult patient's lungs, the nurse identifies the following assessment findings. Which finding should be reported to the health care provider?
1) Respiratory rate: 14
2) Pain reported when palpating posterior lower thorax
3) Thorax rising and falling symmetrically for right and left lungs
4) Vesicular breath sounds heard with auscultation of peripheral lung fields - CORRECT ANSWER 2) Pain reported when palpating posterior lower thorax
The nurse is teaching a young female patient to practice good skin health. Which information is important for the nurse to include?
1) Avoid sunbathing between 3 PM and 7 PM.
2) Oral contraceptives and antiinflammatories make the skin more sensitive to the sun.
3) Call the health care provider for the presence of a mole on an arm or leg that appears uniformly brown.
4) Wear sunscreen with an SPF of 30 or greater if using a sunlamp or tanning parlor. - CORRECT ANSWER 2) Oral contraceptives and antiinflammatories make the skin more sensitive to the sun.
As a nurse prepares to provide morning care and treatments, it is important to question a patient about a latex allergy before which intervention? (Select all that apply.)
1) Applying adhesive tape to anchor a nasogastric tube
2) Inserting a rubber Foley catheter into the patient's bladder
3) Providing oral hygiene using a standard toothbrush and toothpaste
4) Giving an injection using plastic syringes with rubbercoated plungers
5) Applying a transparent wound dressing - CORRECT ANSWER 1) Applying adhesive tape to anchor a nasogastric tube
2) Inserting a rubber Foley catheter into the patient's bladder
4) Giving an injection using plastic syringes with rubbercoated plungers
The nurse is assessing a patient who returned 3 hours ago from a cardiac catheterization, during which the large catheter was inserted into the patient's femoral artery in the right groin. Which assessment finding would require immediate follow-up?
1) Palpation of a femoral pulse with a heart rate of 76
2) Auscultation of a heart murmur over the left thorax
3) Identification of mild bruising at the catheter insertion site
4) Palpation of a right dorsalis pedis pulse with strength of +1 - CORRECT ANSWER 4) Palpation of a right dorsalis pedis pulse with strength of +1
The patient reports having a sore throat, coughing, and sneezing. While performing a focused assessment, which finding supports the patient's reported symptoms related to upper respiratory infection?
1) Buccal mucosa is moist and dark pink.
2) Respiratory rate is 18, rhythm is even.
3) Retropharyngeal lymph nodes are enlarged and firm.
4) Inspection with a tongue depressor on the posterior tongue causes gagging. - CORRECT ANSWER 3) Retropharyngeal lymph nodes are enlarged and firm.
The nurse is teaching a patient with poor arterial circulation about checking blood flow in the legs. Which information should the nurse include? (Select all that apply.)
1) A normal pulse on the top of the foot indicates adequate blood flow to the foot.
2) To locate the dorsalis pedis pulse, take the fingers and palpate behind the knee
3) When there is poor arterial blood flow, the leg is generally warm to the touch.
4) Loss of hair on the lower leg indicates a long-term problem with arterial blood flow. - CORRECT ANSWER 1) A normal pulse on the top of the foot indicates adequate blood flow to the foot.
4) Loss of hair on the lower leg indicates a long-term problem with arterial blood flow.
How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast?
1) Supine with both arms overhead with palms upward
2) Sitting with hands clasped just above the umbilicus
3) Supine with the right arm abducted and hand under the head and neck
4) Lying on the right side, adducting the right arm on the side of the body - CORRECT ANSWER 3) Supine with the right arm abducted and hand under the head and neck
The nurse is planning a staff education conference about abdominal assessment. Which point is important for the nurse to include?
1) The aorta can be felt using deep palpation in the upper abdomen near the midline
2) The patient should be sitting to best determine the contour and shape of the abdomen.
3) Always wear gloves when palpating the skin on the patient's abdomen.
4) Avoid palpating the abdomen if the patient reports any discomfort or feelings of fullness. - CORRECT ANSWER 1) The aorta can be felt using deep palpation in the upper abdomen near the midline
The nurse is teaching a patient how to perform a testicular self-examination. Which statement by the nurse is correct?
1) "The testes are normally round and feel smooth and rubbery."
2) "The best time to do a testicular self-examination is before your bath or shower."
3) "Perform a testicular self-examination weekly to detect signs of testicular cancer."
4) "Since you are over 40 years old, you are in the highest risk group for testicular cancer." - CORRECT ANSWER 1) "The testes are normally round and feel smooth and rubbery."
The patient is assessed for range of joint movement. He or she is unable to move the right arm above the shoulder. How should the nurse document this finding?
1) Patient was not able to flex arm at shoulder.
2) Extension of right arm is limited.
3) Patient's abduction of right arm was limited to 100 degrees.
4) Internal rotation of right arm is limited to less than 90 degrees. - CORRECT ANSWER 3) Patient's abduction of right arm was limited to 100 degrees.
ID: 41140170
The nurse plans to assess the patient's abstract reasoning. Which task should the nurse ask the patient to perform?
1) "Tell me where you are."
2) "What can you tell me about your illness?"
3) "Repeat these numbers back to me: 7...5...8."
4) "What does this mean: 'A stitch in time saves nine? ' " - CORRECT ANSWER 4) "What does this mean: 'A stitch in time saves nine? ' "
The nurse teaches a patient about cranial nerves to help explain why the patient's right side of the mouth droops instead of moving up into a smile. What nerve does the nurse explain to the patient?
1) VII — Facial
2) V — Trigeminal
3) XII — Hypoglossal
4) XI— Spinal accessory - CORRECT ANSWER 1) VII — Facial
The nurse is planning to teach the student nurse how to assess the hydration status of an older adult. Which techniques are appropriate for this situation? (Select all that apply.)
1) Inspect the lips and mucous membranes to determine if they are moist.
2) Pinch the skin on the back of the hand to see if the skin tents.
3)Check the patient's pulse and blood pressure.
4) Weigh the patient daily. - CORRECT ANSWER 1) Inspect the lips and mucous membranes to determine if they are moist
3)Check the patient's pulse and blood pressure
4) Weigh the patient daily
The nurse is having difficulty reading a physician's order for a medication. He or she knows that the physician is very busy and does not like to be called. What is the most appropriate next step for the nurse to take?
1) Call a pharmacist to interpret the order
2) Call the physician to have the order clarified
3) Consult the unit manager to help interpret the order
4) Ask the unit secretary to interpret the physician's handwriting - CORRECT ANSWER 2) Call the physician to have the order clarified
The patient has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her?
2 mL
5 mL
16 mL
30 mL - CORRECT ANSWER 30 mL
A nurse is administering eardrops to an 8-year-old patient with an ear infection. How does the nurse pull the patient's ear when administering the medication?
1) Outward
2) Back
3) Upward and back
4) Upward and outward - CORRECT ANSWER 4) Upward and outward
A patient is to receive cephalexin (Kefl ex) 500 mg PO. The pharmacy has sent 250-mg tablets. How many tablets does the nurse administer?
½ tablet
1 tablet
1 ½ tablets
2 tablets - CORRECT ANSWER 2 tablets
A nurse is administering medications to a 4-year-old patient. After he or she explains which medications are being given, the mother states, "I don't remember my child having that medication before." What is the nurse's next action?
1) Give the medications
2) Identify the patient using two patient
3) Withhold the medications and verify the medication orders
4) Provide medication education to the mother to help her better understand her child's medications - CORRECT ANSWER 3) Withhold the medications and verify the medication orders
A patient is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe medication administration for the discharge nurse?
1) Set up the follow-up appointments with the physician for the patient.
2) Ensure that someone will provide housekeeping for the patient at home.
3) Ensure that the home care agency is aware of medication and health teaching needs.
4) Make sure that the patient's family knows how to safely bathe him or her and provide mouth care. - CORRECT ANSWER 3) Ensure that the home care agency is aware of medication and health teaching needs.
A nursing student takes a patient's antibiotic to his room. The patient asks the nursing student what it is and why he should take it. Which information does the nursing student include when replying to the patient?
1) Only the patient's physician can give this information.
2) The student provides the name of the medication and a description of its desired effect.
3) Information about medications is confidential and cannot be shared.
4) He has to speak with his assigned nurse about this. - CORRECT ANSWER 2) The student provides the name of the medication and a description of its desired effect.
The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse's next best course of action?
1) Ask the prescriber to change the order
2) Crush the pill with a mortar and pestle
3) Hide the capsule in a piece of solid food
4) Open the capsule and sprinkle it over pudding - CORRECT ANSWER 1) Ask the prescriber to change the order
The nurse takes a medication to a patient, and the patient tells him or her to take it away because she is not going to take it. What is the nurse's next action?
1) Ask the patient's reason for refusal
2) Explain that she must take the medication
3) Take the medication away and chart the patient's refusal
4) Tell the patient that her physician knows what is best for her - CORRECT ANSWER 1) Ask the patient's reason for refusal
The nurse receives an order to start giving a loop diuretic to a patient to help lower his or her blood pressure. The nurse determines the appropriate route for administering the diuretic according to:
1) Hospital policy.
2) The prescriber's orders.
3) The type of medication ordered.
4) The patient's size and muscle mass. - CORRECT ANSWER 2) The prescriber's orders.
A patient is receiving an intravenous (IV) push medication. If the drug infiltrates into the outer tissues, the nurse:
1) Continues to let the IV run.
2) Applies a warm compress to the infiltrated site.
3) Stops the administration of the medication and follows agency policy.
4) Should not worry about this because vesicant filtration is not a problem. - CORRECT ANSWER 3) Stops the administration of the medication and follows agency policy.
If a patient who is receiving intravenous (IV) fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects:
Sepsis.
Phlebitis.
Infiltration.
Fluid overload. - CORRECT ANSWER Phlebitis.
After seeing a patient, the physician gives a nursing student a verbal order for a new medication. The nursing student first needs to:
1) Follow ISMP guidelines for safe medication abbreviations.
2) Explain to the physician that the order needs to be given to a registered nurse.
3) Write down the order on the patient's order sheet and read it back to the physician.
4) Ensure that the six rights of medication administration are followed when giving the medication. - CORRECT ANSWER 2) Explain to the physician that the order needs to be given to a registered nurse.
A nurse accidentally gives a patient a medication at the wrong time. The nurse's first priority is to:
1) Complete an occurrence report.
2) Notify the health care provider.
3) Inform the charge nurse of the error.
4) Assess the patient for adverse effects. - CORRECT ANSWER 4) Assess the patient for adverse effects.
Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.)
1) Anxiety related to fear of dying
2) Fatigue related to chronic emphysema
3) Need for mouth care related to inflamed mucosa
4) Risk for infection - CORRECT ANSWER 1) Anxiety related to fear of dying
4) Risk for infection
A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in:
1) Data collection.
2) Data clustering.
3) Data interpretation.
4) Making a diagnostic statement. - CORRECT ANSWER 3) Data interpretation.
The nursing diagnosis readiness for enhanced communication is an example of a(n):
1) Risk nursing diagnosis.
2) Actual nursing diagnosis.
3) Health promotion nursing diagnosis
4) Wellness nursing diagnosis. - CORRECT ANSWER 3) Health promotion nursing diagnosis
In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply.)
1) The nurse who listens to lung sounds after a patient reports "difficulty breathing"
2) The nurse who considers conflicting cues in deciding which diagnostic label to choose
3) The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema
4) The nurse who identifies a diagnosis on the basis of a single defining characteristic - CORRECT ANSWER 3) The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema
4) The nurse who identifies a diagnosis on the basis of a single defining characteristic
A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic statement, best described as:
1) Identifying the clinical sign instead of an etiology.
2) Identifying a diagnosis based on prejudicial judgment.
3) Identifying the diagnostic study rather than a problem caused by the diagnostic study.
4) Identifying the medical diagnosis instead of the patient's response to the diagnosis. - CORRECT ANSWER 4) Identifying the medical diagnosis instead of the patient's response to the diagnosis.
Review the following list of nursing diagnoses and identify those stated incorrectly. (Select all that apply.)
1) Acute pain related to lumbar disk repair
2) Sleep deprivation related to difficulty falling asleep
3) Constipation related to inadequate intake of liquids
4) Potential nausea related to nasogastric tube insertion - CORRECT ANSWER 1) Acute pain related to lumbar disk repair
2) Sleep deprivation related to difficulty falling asleep
4) Potential nausea related to nasogastric tube insertion
The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72. Which of the following data form a cluster, showing a relevant pattern? (Select all that apply.)
1) Vital sign results
2) Abdominal distention
3) Age of patient
4) Change in bowel elimination pattern
5) Abdominal pain
6) No past history of hospitalization - CORRECT ANSWER 2) Abdominal distention
4) Change in bowel elimination pattern
5) Abdominal pain
The nurse in a geriatric clinic collects the following information from an 82-year-old patient and her daughter, the family caregiver. The daughter explains that the patient is "always getting lost." The patient sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, "I just don't know what to do because I worry she will fall or hurt herself." The daughter states that, when she took her mother to the store, they became separated, and the mother couldn't find the front entrance. The daughter works part time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern? (Select all that apply.)
1) Daughter's concern of mother's risk for injury
2) Pacing
3) Patient getting lost easily
4) Daughter working part time
5) Getting up frequently - CORRECT ANSWER 2) Pacing
3) Patient getting lost easily
5) Getting up frequently
Which of the following are examples of collaborative problems? (Select all that apply.)
1) Nausea
2) Hemorrhage
3) Wound infection
4) Fear - CORRECT ANSWER 2) Hemorrhage
3) Wound infection
Two nurses are having a discussion at the nurses' station. One nurse is a new graduate who added, "Patient needs improved bowel function related to constipation" to a patient's care plan. The nurse's colleague, the charge nurse says, "I think your diagnosis is possibly worded incorrectly. Let's go over it together." A correctly worded diagnostic statement is:
1) Need for improved bowel function related to change in diet.
2) Patient needs improved bowel function related to alteration in elimination.
3) Constipation related to inadequate fluid intake.
4) Constipation related to hard infrequent stools. - CORRECT ANSWER 3) Constipation related to inadequate fluid intake.
The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics?
1) Risk for aspiration
2) Acute confusion
3) Readiness for enhanced coping
4) Sedentary lifestyle - CORRECT ANSWER 1) Risk for aspiration
A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. The probable cause of these symptoms and findings is:
Cystitis.
Hematuria.
Pyelonephritis.
Dysuria. - CORRECT ANSWER Cystitis.
A male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not yet voided. Which action would be the most beneficial in assisting the patient to void?
1) Suggest he stand at the bedside
2) Stay with the patient
3) Give him the urinal to use in bed
4) Tell him that, if he doesn't urinate, he will be catheterized - CORRECT ANSWER 1) Suggest he stand at the bedside
Elimination changes that result from inability of the bladder to empty properly may cause which of the following? (Select all that apply.)
1) Incontinence
2) Frequency
3) Urgency
4) Urinary retention
5) Urinary tract infection - CORRECT ANSWER 1) Incontinence
2) Frequency
3) Urgency
4) Urinary retention
5) Urinary tract infection
An older male patient states that he is having problems starting and stopping his stream of urine and he feels the urgency to void. The best way to assist this patient is to:
1) Help him stand to void.
2) Place a condom catheter.
3) Have him practice Credé's method.
4) Initiate Kegel exercises. - CORRECT ANSWER 4) Initiate Kegel exercises.
Since removal of the patient's Foley catheter, the patient has voided 50 to 100 mL every 2 to 3 hours. Which action should the nurse take first?
1) Check for bladder distention
2) Encourage fluid intake
3) Obtain an order to recatheterize the patient
4) Document the amount of each voiding for 24 hours - CORRECT ANSWER 1) Check for bladder distention
To minimize the patient experiencing nocturia, the nurse would teach him or her to:
1) Perform perineal hygiene after urinating.
2) Set up a toileting schedule.
3) Double void.
4) Limit fluids before bedtime. - CORRECT ANSWER 4) Limit fluids before bedtime.
A patient with a Foley catheter carries the collection bag at waist level when ambulating. The nurse tells the patient that he or she is at risk for: (Select all that apply.)
1) Infection.
2) Retention.
3) Stagnant urine.
4) Reflux of urine. - CORRECT ANSWER 1) Infection.
4) Reflux of urine.
The patient is incontinent, and a condom catheter is placed. The nurse should take which action?
1) Secure the condom with adhesive tape
2) Change the condom every 48 hours
3) Assess the patient for skin irritation
4) Use sterile technique for placement - CORRECT ANSWER 3) Assess the patient for skin irritation
The nurse directs the NAP to remove a Foley catheter at 1300. The nurse would check if the patient has voided by:
1400.
1600
1700.
2300. - CORRECT ANSWER 1700.
The postoperative patient has difficulty voiding after surgery and is feeling "uncomfortable" in the lower abdomen. Which action should the nurse implement first?
1) Encourage fluid intake
2) Administer pain medication
3) Catheterize the patient
4) Turn on the bathroom faucet as he tries to void - CORRECT ANSWER 4) Turn on the bathroom faucet as he tries to void
The patient is to have an intravenous pyelogram (IVP). Which of the following apply to this procedure? (Select all that apply.)
1) Note any allergies.
2) Monitor intake and output.
3) Provide for perineal hygiene.
4) Assess vital signs.
5) Encourage fluids after the procedure. - CORRECT ANSWER 1) Note any allergies.
5) Encourage fluids after the procedure.
The nurse assesses that the patient has a full bladder, and the patient states that he or she is having difficulty voiding. The nurse would teach the patient to:
1) Use the double-voiding technique.
2) Perform Kegel exercises.
3) Use Credé's method.
4) Keep a voiding diary. - CORRECT ANSWER 3) Use Credé's method.
The patient states that she "loses urine" every time she laughs or coughs. The nurse teaches the patient measures to regain urinary control. The nurse recognizes the need for further teaching when the patient states:
1) "I will perform my Kegel exercises every day."
2) "I joined weight watchers."
3) "I drink two glasses of wine with dinner."
4) "I have tried urinating every 3 hours." - CORRECT ANSWER 3) "I drink two glasses of wine with dinner." [Show Less]