Exam 2 - Elsevier Prep Questions

D (Oxygen saturation: 96%)
(Oxygen therapy increases oxygen saturation. Temperature is not affected by the oxygen. There is no change in heart rate. Administering oxygen should decrease the respiratory rate. The decline in blood pressure is unlikely to be

A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 pounds. Her vital signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8�C (98.2�F)

A (84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%)
(Oxygen saturation is low, indicating a problem with ventilation or diffusion, which is related to the respiratory rate.)

The licensed practice nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first?
A) 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%
B) 54-year-old woman admitted aft

A, B, D, G
(You need to determine the patient's usual temperature to evaluate the degree of temperature elevation. Heart rate and respiratory rate increase with temperature. The presence of diaphoresis may contribute to fluid volume deficit from hyperther

A 56-year-old patient with diabetes admitted for community acquired pneumonia has a temperature of 38.2�C (100.8�F) via the temporal artery. Which additional assessment data are needed in planning interventions for the patient's infection? (Select all tha

B (Right popliteal and right axillae)
(The only extremity that does not have a compromised artery to auscultate is the right lower leg after the sequential device is removed. The tympanic membrane and temporal artery are affected by facial surgery and oxy

A 55-year-old widowed patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fo

C (Baseline vital signs)
(Knowledge of baseline vital signs is needed to prioritize care.)

A patient has been transferred to your unit from the respiratory intensive care unit, where he has been for the past 2 weeks recovering from pneumonia. He is receiving oxygen via 4 L nasal cannula. His respiratory rate is 26 breaths/min, and his oxygen sa

A, B
(Dietary habits may include caffeine fluids and foods that stimulate heart rate. Medication list may include pharmacological agents that increase or decrease heart rate.)

During a patient's routine annual physical, she tells you that she has noted that her heart feels like it's " racing, " usually in the later morning, early afternoon, or just before she goes to bed. Her radial pulse rate is 68 beats/min and regular; her b

D (156/82 mm Hg)
(When you use a blood pressure cuff that is too narrow or short, your patient will most likely have a BP reading that is higher than it really is; you will get a false-high reading.)

You observe a nursing student taking a blood pressure (BP) on a patient. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. The student used a BP cuff that was too narrow for the patient. Which of the following BP readings made by th

C (Nail polish interferes with sensor function.)
(Nail polish reduces light transmission and can alter oxygen saturation measurement.)

As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. Your best re

C (Intermittent fever pattern)

A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7�C (101.6�F) (0400), 36.6�C (97.9�F) (0800), 36.9�C (98.4�F) (1200), 37.6�C (99.6�F) (1600), and 38.3�C (100.9�

C (Assess the patient's apical pulse and evidence of a pulse deficit)
(Your priority is to assess the patient first. The nurse cannot delegate vital signs to an unstable patient. Therefore first you determine if the patient has a pulse deficit. Calling fo

A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a very slow radial pulse of 44. What is your priority intervention?
A) Request that the nursing assistant repeat the pulse check
B) Call for a stat electrocardiogra

C (A patient with a fever of 39.4�C (103�F))
(Patients with a fever have a high heart rate. A healthy athlete has a low heart rate because of conditioning. Hypothermia slows the heart. Beta-blockers reduce heart rate.)

Which of the following patients is most at risk for tachycardia?
A) A healthy professional tennis player
B) A patient admitted with hypothermia
C) A patient with a fever of 39.4�C (103�F)
D) A 90-year-old male taking beta blockers

A, B
(Rib fractures would cause splinting and pain to increase respiratory rate. Pregnancy impedes diaphragmatic excursion, causing shallow, frequent breaths.)

Which of the following patients is at most risk for tachypnea? (Select all that apply.)
A) Patient just admitted with four rib fractures
B) Woman who is 9 months' pregnant
C) Adult who has consumed alcoholic beverages
D) Adolescent awaking from sleep

C (148/82, 148/78, 134/86)
(The definition of hypertension requires two elevated blood pressure measurements in a row. All of the other choices describe prehypertension.)

The following blood pressures, taken 6 months apart, were recorded from patients screened by the nurse at the assisted living facility. Which patient should be referred to the healthcare provider for hypertension evaluation?
A) 120/80, 118/78, 124/82
B) 1

B, D, E
(An irregular pulse may be the result of a complication of heart disease and requires the assessment of the apical rate. A respiratory rate of 28 is abnormal, yet the oxygen saturation is normal. Both oxygen saturation and respiratory rate would b

A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant tells you his admitting vital signs. Which measurement should you reassess? (Select all th

D (Perform a complete assessment of all pulses.)
(When an LPN reports that one pulse is difficult to obtain, first you need to assess the patient yourself and compare the quality of all pulses.)

A patient returns to your postoperative unit following surgery for right shoulder rotator cuff repair. The licensed practical nurse (LPN) reports that she had difficulty obtaining the patient's heart rate from his right radial pulse. What is your best res

A (Appearance and behavior)
(The nurse inspects appearance and behavior first as part of the nursing assessment. As the patient enters the room, the nurse can observe his or her appearance and behavior, noting any unusual choice of clothing or hygiene or

The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship?
A) Appearance and behavior
B) Measurement of vital signs
C) Observing specific body systems
D

C (Place the back of your hand against the child's forehead and then on the back of the neck.)
(Temperature is best evaluated by palpating the skin with the dorsum or back of the hand. It is best to select two areas to compare to allow you to detect a cha

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?
A) Place the palm of the hand on the child's back.
B) Lightly touch the child's for

B (Pain reported when palpating posterior lower thorax)
(Any areas of tenderness or pain over the posterior thorax could indicate injury such as a broken rib or disturbance of the integumentary system. Further palpation should be avoided until more assess

While assessing the adult patient's lungs, the nurse identifies the following assessment findings. Which finding should be reported to the health care provider?
A) Respiratory rate: 14
B) Pain reported when palpating posterior lower thorax
C) Thorax risin

B (Oral contraceptives and antiinflammatories make the skin more sensitive to the sun.)
(Some medications such as oral contraceptives or antiinflammatory medications may increase the skin's sensitivity to ultraviolet (UV) rays. Skin self-care and self-eva

The nurse is teaching a young female patient to practice good skin health. Which information is important for the nurse to include?
A) Avoid sunbathing between 3 PM and 7 PM.
B) Oral contraceptives and antiinflammatories make the skin more sensitive to th

A, B, D
(Adhesive tape, rubber foley catheters, and rubber-coated plungers should be avoided for patients with latex allergies since they can trigger an allergic or anaphylactic response.)

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.)
A) Applying adhesive tape to anchor a nasogastric tube
B) Inserting a rubber Foley

D (Palpation of a right dorsalis pedis pulse with strength of +1)
(A weak pulse may indicate disruption of arterial flow and should be reported immediately. Mild bruising is normal, but if it increases in size, the femoral artery may be leaking, requiring

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?
A) Pal

C (Retropharyngeal lymph nodes are enlarged and firm.)
(The retropharyngeal nodes are located posteriorly to the throat and are enlarged when an infection is located in the throat or pharynx.)

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?
A) Buccal mucosa is moist and dark pink.
B) Respiratory

A, D
(A normal dorsalis pedis indicates good arterial blood flow to the lower extremities. Chronic loss of arterial flow results in a lack of hair growth and the appearance of shiny tissue. The dorsalis pedis is located along the top of the foot between t

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.)
A) A normal pulse on the top of the foot indicates adequate blood flow to the foot.

C (Supine with the right arm abducted and hand under the head and neck)
(Lying on the back allows breast tissue to relax; raising the arm over the patient's head causes the breast tissue to flatten, and palpation can more accurately locate any nodules or

How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast?
A) Supine with both arms overhead with palms upward
B) Sitting with hands clasped just above the umbilicus
C) Supine with the right arm abd

A (The aorta can be felt using deep palpation in the upper abdomen near the midline.)
(Complete abdominal assessment includes inspection, followed by auscultation, palpation, and percussion - if warranted. Anatomically the aorta is located in the upper ab

The nurse is planning a staff education conference about abdominal assessment. Which point is important for the nurse to include?
A) The aorta can be felt using deep palpation in the upper abdomen near the midline.
B) The patient should be sitting to best

A ("The testes are normally round and feel smooth and rubbery.")
(Men ages 18 to 24 are in the group at most risk for testicular cancer. Teaching should include normal anatomy. A testicular examination should be planned monthly during a shower since the s

The nurse is teaching a patient how to perform a testicular self-examination. Which statement by the nurse is correct?
A) "The testes are normally round and feel smooth and rubbery."
B) "The best time to do a testicular self-examination is before your bat

C (Patient's abduction of right arm was limited to 100 degrees.)
(Abduction of the arm includes raising the arm away from the side and above the shoulder.)

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?
A) Patient was not able to flex arm at shoulder.
B) Extension of right arm is limited.
C) Patien

D ("What does this mean: 'A stitch in time saves nine? ' ")
(Abstract reasoning requires cognitive functioning and the ability to identify relationships between concepts.)

The nurse plans to assess the patient's abstract reasoning. Which task should the nurse ask the patient to perform?
A) "Tell me where you are."
B) "What can you tell me about your illness?"
C) "Repeat these numbers back to me: 7...5...8."
D) "What does th

A (VII � Facial)
(The facial nerve innervates the sensory and motor functions of the face above the brow, the cheeks, and the chin and controls face symmetry and smile.)

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?
A) VII � Facial
B) V � Trigeminal
C) XII � Hypoglossal
D

A, C, D
(By assessing for moisture of the mucous membranes and lips, the nurse can quickly evaluate the patient's hydration status. Weighing a patient shows increases of fluid volume from day to day that could result from cardiac problems. This provides u

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.)
A) Inspect the lips and mucous membranes to determine if they are moist.
B

D (Cardiopulmonary disease and lung cancer)
(Effects of nicotine on blood vessels and lung tissue have been proven to increase pathological changes, leading to heart disease and lung cancer.)

A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder:
A) Alcoholism and hypertension
B) Obesity and di

D (Decreased activity tolerance and increased breathlessness)
(Hypoxia occurs because of decreased circulating blood volume, which leads to decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a feeling of shortness of breath.)

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status?
A) Increased breathlessness but increased activity tolerance
B

B (Forms a strong bond with hemoglobin, creating a functional anemia.)
(Carbon monoxide strongly binds to hemoglobin, making it unavailable for oxygen binding and transport.)

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy, not cyanotic, the nurse understands that the patient is at a risk for decreased oxygen-carrying capacity of blood because

A (Fever increases metabolic demands, requiring increased oxygen need.)
(When the body cannot meet the increased oxygenation need, the increased metabolic rate causes breakdown of protein and wasting of respiratory muscles, increasing the work of breathin

A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104�F (40�C). What physiological process explains why the child is at risk for developing dyspnea?
A) Fever increases metabolic demands, requiring increased oxygen need.
B) Bloo

D (Inspiratory crackles in lung bases)
(Decreased effective contraction of left side of heart leads to back up of fluid in the lungs, increasing hydrostatic pressure and causing pulmonary edema, resulting in crackles in lung bases.)

A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds?
A) Sonorous wheezes in the left lower lung
B) Rhonchi midsternum
C) Crackles only in apex of lungs
D) Inspiratory

B (Frequent change of position)
(Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting the effectiveness of gas exchange processes.)

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?
A) Antibiotics
B) Frequent change of positi

C (Decreased independent ability to cough)
(Impaired ability to cough up mucus caused by weakness or very thick secretions indicates a need for suctioning when you know the patient has pneumonia.)

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning?
A) Coughing up thick sputum only occasionally
B) Coughing up thin, watery sputum easily after nebulizati

A (Sharp pleuritic pain that worsens on inspiration)
(When the lung collapses, the thoracic space fills with air on each inspiration, and the atmospheric air irritates the parietal pleura, causing pain.)

A patient was admitted after a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax, which includes which of the following?
A) Sharp pleuritic pain that worsens on inspiration
B) Cra

D ("If I get short of breath, I'll turn up my oxygen level to 6 L/min.")
(Hypoxia is the drive to breathe in a patient with chronic obstructive pulmonary disease who has become used to acidic pH and elevated CO2 levels. Turning up to 6 L/min increases the

A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his statements would indicate a need for further education?
A) "I'll make sure that I rest between activities so I don't get so short of breath."
B) "I

A (Raise the head of the bed to 45 degrees.)
(Raising the head of the bed brings the diaphragm down and allows for better chest expansion, thus improving ventilation.)

The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first?
A) Raise the head of the bed to 45 degrees.
B) Take his oxygen satura

A, B, C
(Pain in the lower calf area indicates vascular, not respiratory, status.)

The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? (Select all that apply.)
A

D ("I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient.")
(Saline has been found to cause more side effects when suctioning and does not increase the amount of secretions removed.)

Which of the following statements made by a student nurse indicates the need for further teaching about suctioning a patient with an endotracheal tube?
A) "Suctioning the patient requires sterile technique."
B) "I'll apply suction while rotating and withd

A (Record the amount and continue to monitor drainage)
(Dark-red drainage after surgery - 50 to 200 mL per hour in first 3 hours - is expected, but be aware of sudden increases greater than 100 mL per hour after the first 3 hours, especially if it becomes

Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform?
A) Record the amount and conti

C (Incentive spirometer)
(An incentive spirometer is used to encourage deep breathing to inflate alveoli and open pores of Kohn. The rest are used to treat atelectasis and increased mucus production.)

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient?
A) Postural drainage
B) Chest percussion
C) Incentive spirometer
D) Suctioning

A (Nasal cannula)
(A nasal cannula delivers precise, high-flow rates of oxygen.)

The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient?
A) Nasal cannula
B) Venturi mask
C) Simple face mask wi

D (Enter only objective and factual information about the patient.)
(Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incor

A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse

B (Gives a newly ordered medication before entering the order in the patient's medical record.)
(Nurses enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur.)

A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse:
A) Uses SBAR (Situati

D (The patient stated that he felt frustrated by the lack of information he received regarding his tests.)
(This is a nonjudgmental statement regarding the nurse's observations about the patient. Documenting that the patient had a defiant attitude or was

As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following i

C (HIPAA provides you with greater control over your personal health care information.)
(HIPAA provides patients with control over who receives and accesses their medical records. It does not allow uncontrolled access to the medical records. HIPAA also do

You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?

B (Indicate that she has the right to read her record.)
(Patients have the right to read their medical records, but the nurse should always know the facility policy regarding personal access to medical records because some require a nurse manager or other

A patient asks for a copy of her medical record. The best response by the nurse is to:
A) State that only her family may read the record.
B) Indicate that she has the right to read her record.
C) Tell her that she is not allowed to read her record.
D) Exp

D (Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.)
(The statement "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular b

Which of the following charting entries is most accurate?
A) Patient walked up and down hallway with assistance, tolerated well.
B) Patient up, out of bed, walked down hallway and back to room, tolerated well.
C) Patient up, walked 50 feet and back down h

B, D, C, A
(B - "The pain increases every time I try to turn on my left side."
D -Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.
C - Acute pain related to tissue injury from s

Match the correct entry with the appropriate SOAP (Subjective�Objective�Assessment�Plan) category.
A. Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device.
B. "The pain increases every time I try to turn

B (Electronic health record.)
(This is an example of an electronic health record. The electronic health record is an electronic record of patient health information generated whenever a patient accesses medical care in any health care delivery setting. In

On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type

A, B, E
(During change of shift report, include essential background information such as the patient's name, age, diagnosis, and allergies. Also include response to treatments such as response to pain-relieving measures. Information about how much the pat

You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.)
A) The patient's name, age, and admitting d

A (Documented medication given by another nursing student.)
(Nurses only document the care they provide; entries in the chart need to be dated, timed, and signed.)

You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student:
A) Documented medication given by another nursing student.
B) Included the date and time of all

A ("CPOE reduces transcription errors.")
(CPOE eliminates the need for someone to transcribe the orders because it allows the provider to enter the order directly.)

A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE?
A) "CPOE reduces transcription errors."
B) "CPOE re

B (You need to use words the patients can understand when writing the directions.)
(Patients need to be able to understand information that you provide to them; ensure that written instructions are provided at a level that matches the patients' reading ab

You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet?
A) The new federal laws require t

C (Clinical decision support system)
(A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user.)

A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed

B (The nurses were charting by exception.)
(Given that the initial assessment indicated that the pulmonary system was within normal limits, the facility is most likely documenting by exception. There is no need for further documentation unless the pulmona

While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress

C (Place in a secure canister marked for shredding)
(Confidential patient information should be shredded. It is generally collected in large secure containers and shredded at scheduled times.)

What is an appropriate way for a nurse to dispose of printed patient information?
A) Rip several times and place in a standard trash can
B) Place in the patient's paper-based chart
C) Place in a secure canister marked for shredding
D) Burn the documents