HA1 Test 1 study questions PDF

Preview

Summary

Exam 1 Study Guide...

Description

Critical Thinking

The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse

a. Completes a comprehensive database.

b. Identifies pertinent nursing diagnoses.

c. Intervenes based on patient goals and priorities of care.

d. Determines whether outcomes have been achieved.

ANS: A

The assessment phase of the nursing process involves data collection to complete a thorough patient database. Identifying nursing diagnoses occurs during the diagnosis phase. The nurse carries out interventions during the implementation phase, and determining whether outcomes have been achieved takes place during the evaluation phase of the nursing process.

Which of the following is a nursing intervention?

a. The patient will ambulate in the hallway twice this shift using crutches correctly.

b. Impaired physical mobility related to inability to bear weight on right leg

c. Provide assistance while the patient walks in the hallway twice this shift with crutches.

d. The patient is unable to bear weight on right lower extremity.

ANS: C

Providing assistance to a patient who is ambulating is a nursing intervention. The statement, “The patient will ambulate in the hallway twice this shift using crutches correctly” is a patient goal. Impaired physical mobility is a nursing diagnosis. The statement that the patient is unable to bear weight and ambulate can be included with assessment data and is a defining characteristic for the diagnosis of Impaired physical mobility.

In which step of the nursing process does the nurse provide nursing care interventions to patients?

a. Assessment

b. Planning

c. Implementation

d. Evaluation

ANS: C

In the five-step nursing process, the implementation phase involves providing direct and indirect nursing care interventions to patients. The nurse gathers data during the assessment phase and mutually sets goals and prioritizes care during the planning phase. During the evaluation phase, the nurse determines the effectiveness of interventions.

Which of the following methods of data collection is utilized to establish a patient’s nursing database?

a. Reviewing the current literature to determine evidence-based nursing actions

b. Orders for diagnostic and laboratory tests

c. Physical examination

d. Anticipated medications to be ordered

ANS: C

A nursing database includes a physical examination. Orders are included in the order section of the patient’s chart. The nurse reviews the current literature in the implementation phase of the nursing process to determine evidence-based actions, and the health care provider is responsible for ordering medications. Medication orders are usually written after the database is completed.

Which of the following are examples of subjective data? (Select all that apply.)

a. Patient describing excitement about discharge

b. Patient’s wound appearance

c. Patient’s expression of fear regarding upcoming surgery

d. Patient pacing the floor while awaiting test results

e. Patient’s temperature

ANS: A, C

Subjective data include patient’s feelings, perceptions, and reported symptoms. Expressing feelings such as excitement or fear is an example of subjective data. Objective data are observations or measurements of a patient’s health status. In this question, the appearance of the wound and the patient’s temperature are objective data. Pacing is an observable patient behavior and is also considered objective data.

Components of a nursing health history include

a. Current treatment orders.

b. Nurse’s concerns.

c. Nurse’s goals for the patient.

d. Patient expectations.

ANS: D

Components of a nursing health history include physical examination findings, patient expectations, environmental history, and diagnostic data. Current treatment orders are located under the Orders section in the patient’s chart and are not a part of the nursing health history. Patient concerns, not nurse’s concerns, are included in the database. Goals that are mutually established, not nurse’s goals, are part of the nursing care plan.

VITALS

Of the following mechanisms of heat loss by the body, identify the mechanism that transfers heat away by using air movement?

a. Radiation

b. Conduction

c. Convection

d. Evaporation

ANS: C

Convection is the transfer of heat away from the body by air movement. Conduction is the transfer of heat from one object to another with direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas.

3. The patient has a temperature of 105.2° F. The nurse is attempting to lower his temperature by

providing tepid sponge baths and placing cool compresses in strategic body locations. The nurse is attempting to lower the patient’s temperature through the use of

a. Radiation.

b. Conduction.

c. Convection.

d. Evaporation.

ANS: B

Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement.

The patient is restless with a temperature of 102.2° F (39° C). One of the first things the nurse should do is

a. Place the patient on oxygen.

b. Restrict fluid intake.

c. Increase patient activity.

d. Increase patient’s metabolic rate.

ANS: A

During a fever, cellular metabolism increases and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Interventions during a fever include oxygen therapy. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for fluid volume deficit. Fluids should not be restricted. Increasing activity would increase the metabolic rate further, which would not be advisable.

The patient requires temperatures to be taken every two hours. Which of the following cannot be delegated to nursing assistive personnel?

a. Selecting appropriate route and device

b. Obtaining temperature measurement at ordered frequency

c. Being aware of the usual values for the patient

d. Assessing changes in body temperature

ANS: D

The nurse is responsible for assessing changes in body temperature. The nurse instructs nursing assistive personnel to select the appropriate route and device to measure temperature, to obtain temperature measurement at ordered frequency, and to be aware of the usual values for the patient.

The patient is being admitted to the emergency department following a motor vehicle accident. His jaw is broken, and he has several broken teeth. He is ashen, and his skin is

cool and diaphoretic. To obtain an accurate temperature, the nurse uses which of the following routes?

a. Oral

b. Axillary

c. Rectal

d. Temporal

ANS: C

The rectal route is argued to be more reliable when oral temperature cannot be obtained. Oral temperatures are not used for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills. Axillary temperature is affected by exposure to the environment, including time to place the thermometer. It also requires a long measurement time. Temporal artery temperature is affected by skin moisture such as diaphoresis or sweating.

While the nurse is assessing the patient’s respirations, it is important for the patient to

a. Be aware of the procedure being done.

b. Not know that respirations are being assessed.

c. Understand that respirations are estimated to save time.

d. Not be touched until the entire process is finished.

ANS: B

Do not let a patient know that respirations are being assessed. A patient who is aware of the assessment can alter the rate and depth of breathing. Respirations are the easiest of all vital signs to assess, but they are often the most haphazardly measured. Do not estimate respirations. Accurate measurement requires observation and palpation of chest wall movement.

The patient’s blood pressure is 140/60. The nurse realizes that this equates to a pulse pressure of

a. 140.

b. 60.

c. 80.

d. 200.

ANS: C

The difference between the systolic pressure and the diastolic pressure is the pulse pressure. For a blood pressure of 140/60, the pulse pressure is 80 (140 – 60 = 80). 140 is the systolic pressure. 60 is the diastolic pressure. 200 is the systolic (140) added to the diastolic (60), but this has no clinical significance.

Of the following values, which value would be considered prehypertension?

a. 98/50 in a 7-year-old child

b. 115/70 in an infant

c. 140/90 in an older adult

d. 120/80 in a middle-aged adult

ANS: D

An adult’s blood pressure tends to rise with advancing age. The optimal blood pressure for a healthy, middle-aged adult is less than 120/80. Values of 120 to 139/80 to 89 mm Hg are considered prehypertension. Blood pressure greater than 140/90 is defined as hypertension. Blood pressure of 98/50 is normal for a child, whereas 115/70 can be normal for an infant.

The incidence of hypertension is greater in which of the following?

a. Non-Hispanic Caucasians

b. African Americans

c. Asian Americans

d. Native Americans

ANS: B

The incidence of hypertension is greater in diabetic patients, older adults, and African Americans.

A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before she assesses the patient’s blood pressure?

a. Neither caffeine nor smoking affects blood pressure.

b. She needs to insist that the patient stop smoking for at least 3 hours.

c. The nurse should have the patient perform mild exercises.

d. Caffeine and smoking can cause false BP elevations.

ANS: D

Smoking immediately increases BP, and this increase lasts up to 15 minutes. Caffeine increases BP for up to 3 hours. Both affect a patient’s blood pressure. The patient should rest at least 5 minutes before BP is measured.

Of the following patients, which one is the best candidate to have his temperature taken orally?

a. A 27-year-old postoperative patient with an elevated temperature

b. A teenage boy who has just returned from outside “for a smoke”

c. An 87-year-old confused male suspected of hypothermia

d. A 20-year-old male with a history of epilepsy

ANS: A

An elevated temperature needs to be evaluated, and there is no contraindication in this patient. Ingestion of hot/cold fluids or foods, smoking, or receiving oxygen by mask/cannula can require delays in taking oral temperature. Oral temperatures are not taken for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills, nor for infants, small children, or confused patients.

When temperature assessment is required, which of the following cannot be delegated to nursing assistive personnel?

a. Temperature measurement

b. Assessment of changes in body temperature

c. Selection of appropriate route and device

d. Consideration of factors that falsely raise temperature

ANS: B

The skill of temperature measurement can be delegated. The nurse is responsible for assessing changes in body temperature. The nurse instructs nursing assistive personnel to select the appropriate route and device to measure temperature and to consider specific factors that falsely raise or lower temperature.

The nursing assistive person is taking vital signs and reports that a patient’s blood pressure is abnormally low. The nurse should

a. Have the nursing assistive person retake the blood pressure.

b. Ignore the report and have it rechecked at the next scheduled time.

c. Retake the blood pressure herself and assess the patient’s condition.

d. Have the nursing assistive person assess the patient’s other vital signs.

S

ANS: C

The nursing assistive person should report abnormalities to the nurse, who should further assess the patient. The nursing assistive person should not retake the blood pressure or other vital signs because the nurse needs to assess the patient. The report cannot be ignored. Assessment must be done by the nurse.

Of the following sites, which are used for obtaining a core temperature? (Select all that apply.)

a. Oral

b. Rectal

c. Tympanic

d. Axillary

e. Pulmonary artery

ANS: C, E

Intensive care units use the core temperatures of the pulmonary artery, esophagus, and urinary bladder. Because the tympanic membrane shares the same arterial blood supply as the hypothalamus, the tympanic temperature is a core temperature. Oral, rectal, axillary, and skin temperature sites rely on effective blood circulation at the measurement site.

The patient has new-onset restlessness and confusion. His pulse rate is elevated, as is his respiratory rate. His oxygen saturation, however, is 94% according to the portable pulse oximeter. The nurse ignores the oximeter reading and calls the physician to obtain an order for an arterial blood gas (ABG). The nurse does this because many things can cause inaccurate pulse oximetry readings, including which of the following? (Select all that apply.)

a. O2 saturations (SaO2) >70%

b. Carbon monoxide inhalation

c. Nail polish

d. Hypothermia at the assessment site

e. Intravascular dyes

ANS: B, C, D, E

Inaccurate pulse oximetry readings can be caused by outside light sources, carbon monoxide (caused by smoke inhalation or poisoning), patient motion, jaundice, intravascular dyes (methylene blue), nail polish, artificial nails, metal studs, or dark skin. Other factors include peripheral vascular disease (atherosclerosis), hypothermia at the assessment site, pharmacological vasoconstrictors (e.g., epinephrine), low cardiac output, hypotension, peripheral edema, and tight probes.

The nurse is assessing the patient and his family for probable familial causes of the patient’s hypertension. The nurse begins by analyzing the patient’s personal history, as well as family history and current lifestyle situation. Which of the following issues would be considered risk factors? (Select all that apply.)

a. Obesity

b. Cigarette smoking

c. Recent weight loss

d. Heavy alcohol consumption

e. Low blood cholesterol levels

ANS: A, B, D

Obesity, cigarette smoking, heavy alcohol consumption, high blood cholesterol and triglyceride levels, and continued exposure to stress are risk factors linked to hypertension. Weight loss and low blood cholesterol levels are not risk factors for hypertension.

During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is:

a. Xerosis.

b. Pruritus.

c. Alopecia.

d. Seborrhea.

ANS: A

Xerosis is the term used to describe skin that is excessively dry. Pruritus refers to itching, alopecia refers to hair loss, and seborrhea refers to oily skin.

The nurse is examining a patient who tells the nurse, “I sure sweat a lot, especially on my face and feet but it doesn’t have an odor.” The nurse knows that this condition could be related to:

a. Eccrine glands.

b. Apocrine glands.

c. Disorder of the stratum corneum.

d. Disorder of the stratum germinativum.

ANS: A

The eccrine glands are coiled tubules that directly open onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are primarily located in the axillae, anogenital area, nipples, and naval area and mix with bacterial flora to produce the characteristic musky body odor. The patient’s statement is not related to disorders of the stratum corneum or the stratum germinativum.

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is:

a. Highly vascular.

b. Thick and tough.

c. Thin and nonstratified.

d. Replaced every 4 weeks.

ANS: D...