Funds 224 Exam 1

1. PT rates lower left leg 4/10. Nurse begins open ended questions about the pain using
principles of courage, honesty and objectivity. What concept of critical thinking is the
nurse using?
a. Trust seeking
2. Nurse finds PT sitting up in bed crying. Which statement response displays a critical
thinking attitude in this situation
a. You look upset, tell me what’s upsetting you
3. All of the following nursing actions are indicative of the nurse using critical thinking select
all that apply
a. Review the client medical record to verify baseline vital signs
b. Validate BP after UNAP reports low BP
c. What pain relief method has worked in the past
d. Asses the temp who is reporting chills and requesting another blanket
4. A client is having trouble using the water fountain while on crutches. The nurse suggests
the client place the crutches on the wall while using both hands to stabilize themself on
the fountain. Which critical thinking attitude is used
a. Creativity
5. The nurse is preparing the measure temperature. What is the first thing the nurse should
do while preparing to take the temp
a. Assess the equipment being used is working properly
6. What statement is an evaluative process in critical thinking
a. Determining effectiveness in nursing actions and if goals have been met
7. Of the following assessment finding or subjective in nature (find the subjective)
a. A client reports a severe 9/10 pain
b. Client reports feeling feverish
8. The nurse is caring for a client with a nursing dx of: imparied gas exchange related to
immobility as evidenced by crackles in the lungs and 89% o2 on room air. What is an
appropriate goal?
a. PT will have a SPO2 of 95% while on room air by the end of the shift
9. All of the following are modes of transmission ​except
a. Temperature
10. The nurse is caring for PT with an upper respiratory infection who is placed on droplet
precaution. Which statement
a. The patient should be assigned to a private room
11. Which nursing intervention is implemented to reduce a reservoir of infection for a client
a. Changing a soiled dressing
12. The nurse is preparing to remove soiled gloves. What action should the nurse take first?
a. Grabbed the outside of non dominant glove
13. The nurse is reviewing lab values for a client. Client has a low WBC count. What should
the nurse do next?
 a. Notify the provider of the lab value and the concern that client can not adequately
fight potential infections
14. Client needs to be placed in a contact isolation for CDIFF. What items need to be in the
room to break the chain of infection?
a. Isolation cart stocked with gloves and gowns
15. The nurse is admitting a client with DM and shows signs general debilitation and
nutritional impairment. What is an appropriate nursing diagnoses
a. Risk for infection related to nutritional impairment
16. The nurse observes the nursing assistant turning off the faucet with his hands. What is
the next action the nurse should take?
a. Educate the nursing assistant on proper hand hygiene
17. What is the correct order for removing PPE, with a non-breakaway gown while caring for
a client with an infection
a. Remove gloves and discard, and wash hands, then mask, then gown
18. The nurse is caring for a client with a surgical incision. Which action by the nurse best
reduces the client's risk for infection related to a compromised in the body’s first line of
defense against infection
a. Aseptic (sterile) technique when cleaning a dressing
19. The nurse needs to measure the temperature of a client who has a hx of heart disease
and has eaten a bowl of vegetable soup 45 min. Which site should the nurse use?
a. Oral
20. Which statement is correct regarding elevated temperatures
a. Hyperthermia occurs when the body can not reduce heat production
21. When assessing the doris pedis pulse, the nurse determines the pulse is absent.
However, the extremity is warm and pink and blanching 2-3 sec for cap refill. Explain
findings
a. Too much pressure was applied at the pulse site
22. Review the PT temp rating and determine the best action to take:- 8am 98.6- 10am
96.8 - 12pm 100.4
a. Wait an hour and recheck
23. All the following clients are candidate for oral temp except
a. Client eating soup for lunch
24. The client is found to be unresponsive and not breathing. To determine blood circulation,
which pulse to check
a. Carotid
25. The nurse assessing PT respiratory status: clear lung sounds, labored breath RR 22.
Which describes the respirations
a. Hyperpnea
26. Which client is most likely to experience a decrease in the depth of respirations
a. An immobile PT who must remain in supine position
27. A nurse is caring for a client who smokes and drinks caffeine. What is important factor to
understand before obtaining BP
a. Caffeine and smoking can cause BP to elevation
28. UAP is taking VS and reports an abnormal low BP. What should the nurse do
a. The nurse should retake the BP and assess client’s condition
29. The nurse is educating a new grad nurse UAP on BP measurement. How to know
teaching has been effective
a. The UAP states “the last sound I heard is the diastolic and indicates the heart
has relaxed”
30. The nurse is assessing 4 clients for orthostatic HTN, which one has it?
a. 24 year old client 142/84 sitting and 118/68 standing
31. THe nurse is preparing to ambulate a client. What is the ​first ​step the nurse should take
to prevent the client from falling
a. Assess the client for factors for increase the risk of falling
32. Which of the following is best intervention to maintain respiratory system for an
immobilized PT
a. Encourage the PT to take deep breaths and cough every 2hrs
33. The nurse should expect all the physiological effects of exercise on the body system
except
a. Decrease cardiac output
34. Which of following is the best example of a 3 part nursing DX
a. Activity and tolerance related to congestive HF as evidenced by Pt reporting “I
am unable to walk to the bathroom without feeling short of breath, crackles in the
lower lungs and 3+ edema in my lower legs”
35. The nurse is caring for a client who was involved in an accident 2 weeks ago. The client
sustained head injury and is unconscious. Reviewing HX the nurse notes “client was in
optimal health prior to accident” which factor places the client at most risk for pressure
ulcer
a. Immobility
36. Physician orders 100mg of med. Pharm sends 12.5mg/mL. How mL?
37. Pressure ulcers are caused by all of pressure related factors ​except
a. Immobility
38. A nurse is educating a client the effects of immobility and contractures. Which statement
indicated the PT needs further education is necessary
a. A contracture is caused by elongation of the muscle fibers