NURS MISC exam 1 questions with answers 2022
update
.
The nurse assesses a patient using the Braden scale. The patient scores a 13. What action is most
important to add to the patient’s care plan?
a. Encourage high-protein meals and snacks
b. Turn the patient every to 2 hours
c. Assess the patient’s skin daily
d. Monitor patient’s prealbumin weekly
ANS: B
A Braden scale score of 13 indicates high risk for developing a pressure ulcer. The most
important intervention is to turn the patient frequently. Good nutrition is important for wound
healing and prevention, but a high-protein snack and monitoring prealbumin do not immediately
impact the patient’s skin condition. Assessing the skin will not prevent an ulcer.
A patient has a purulent, foul-smelling leg wound. What wound care practice is most
appropriate?
a. Leave the wound open to the air.
b. Administer systemic antibiotics.
c. Cleanse the wound with diluted povidone iodine.
d. Prepare the patient for operative débridement.
ANS: C
Antiseptics are not used on healthy granulating tissue. Povidone iodine must be diluted and only
used short term. A moist environment is needed for healing; leaving the wound open to air will
cause too much drying. The patient may eventually need operative débridement. Systemic
antibiotics may or may not be needed.
A patient has a wound that is a shallow crater with surrounding erythema and warmth. What
stage pressure ulcer does the nurse chart?
a. Stage I
b. Stage II
c. Stage III
1
,NURS MISC exam 1 questions with answers 2022
update
d. Stage IV
ANS: B
Stage II is a partial thickness ulcer that looks like an abrasion, blister, or shallow crater. A stage I
pressure ulcer is redness or mottled skin that does not blanch. Stage III ulcers are full thickness
deep craters. Stage IV ulcers may extend into the fascia and may be necrotic.
An older adult patient has an open, draining wound on the lower medial aspect of the right leg.
The skin surrounding the wound is reddish brown with surrounding erythema and edema. Based
on this information, the nurse edits the patient’s care plan to include impaired skin integrity:
a. related to altered venous circulation.
b. peripheral related to arterial insufficiency.
c. related to diabetic neuropathy.
d. open wound related to pressure ulcer.
ANS: A
Venous ulcers are usually on the medial aspect of the lower leg, with flat or shallow craters and
irregular borders, accompanied by varicosities, liposclerosis (brown ruddy color and thickened
skin), and itching. Venous ulcers generate a large amount of exudate and are usually surrounded
by erythema and edema. Arterial insufficiency would produce shiny, taut, hairless skin. There is
no indication the patient is a diabetic. There is no indication the patient has risks for pressure
ulcers
A patient in a nursing home is confused, nonverbal, but pleasant. The nurse notes the patient has
suddenly become agitated and is screaming and scratching at the eyes. While the nurse is
examining the patient, the patient vomits. What action by the nurse is best?
a. Consult the provider about an ophthalmologic exam.
b. Sedate the patient so she won’t injure herself.
c. Place mitts on the patient’s hands to avoid scratches.
d. Give the patient a prn medication for pain.
ANS: A
The patient could be having an episode of acute angle closure glaucoma, manifested by severe
pain, nausea and vomiting, and visual disturbances. Because the patient is nonverbal, the nurse
must assess for pain with behavioral changes. The nurse should contact the provider about
obtaining an ophthalmologic exam to determine if the patient has glaucoma. The other
2
,NURS MISC exam 1 questions with answers 2022
update
interventions will not help determine the cause of the problem. The nurse should attempt to
discover the source of the behavior, not just try to control it.
16. A patient with glaucoma is on timolol (Timoptic). The patient also takes metoprolol (Toprol)
for hypertension. The patient reports to the clinic nurse that the eyedrops “Make me dizzy.”
What assessment by the nurse is most appropriate?
a. Assess the patient’s eyedrop instillation technique.
b. Determine how long the patient has been on the drops.
c. Assess the patient’s gait and balance while walking.
d. Ask the patient if breakfast is eaten prior to applying the eyedrops.
ANS: A
The patient should be using punctal occlusion (closing the lacrimal duct) when instilling these
eyedrops to avoid a cumulative, systemic effect from the combination of both beta-blockers. The
nurse can assess the other factors as well, but this is the most likely cause of the dizziness.
An older patient is being treated for arthritic pain with a nonsteroidal anti-inflammatory drug
(NSAID). Which question best assesses for side effects of this medication class?
“Have you noticed your heart skipping beats since you began taking this
a. drug?”
b. “Did you know you should not to stand up too quickly?”
c. “Are you aware that you should take your pain medication with food?”
“Have you had any episodes of shortness of breath since starting this
d. medicine?”
ANS: C
The most common complaint associated with NSAIDs is indigestion. Indigestion may be
reduced with antacid use or food consumption timed to coincide with analgesic intake.
An older patient admitted to the hospital with symptoms strongly suggestive of tuberculosis (TB)
has a negative Mantoux test. The nurse correctly anticipates that:
3
, NURS MISC exam 1 questions with answers 2022
update
a. the purified protein derivative (PPD) test will be administered.
b. a chest x-ray will be ordered to detect possible infiltration.
c. therapy consisting of a combination of bactericidal drugs will be initiated.
d. the skin test will be repeated to achieve a booster effect.
ANS: D
Tuberculin skin testing in older patients is an unreliable indicator of TB because they are more
likely to have false-negative results because of reduced immune system activity. If skin testing is
used, it is recommended that the standard 5 tuberculin unit (TU) Mantoux test be given and then
repeated to create a booster effect. The PPD is not recommended. The skin test is followed up
with a chest x-ray. Drug therapy should not begin until the patient has a diagnosis.
An older adult patient who has tuberculosis is being treated with the drugs isoniazid 300 mg
daily, rifampin 600 mg daily, and pyrazinamide 1500 mg daily. The nurse stresses the
importance that the patient:
a. wear tinted glasses when out in the sun.
b. minimize contact with children younger than 3 years old.
c. avoid alcohol while on the drug therapy.
d. eat and drink dairy sparingly.
ANS: C
The nurse is caring for a confused patient. Which action by the nurse shows the best
understanding of managing the cascading effects of iatrogenic illnesses in this population cohort?
a. Reorienting the patient to person, place, and time frequently
b. Offering the patient liquids each time there is patient-nurse contact
c. Repositioning the patient every 2 hours
d. Using restraints to ensure patient safety only as a last resort
ANS: D
An older patient has fallen twice in the hospital in the last 2 days. What action by the nurse is
best?
a. Request restraint orders from the provider.
b. Assess the patient for undiagnosed illness.
c. Remind the patient to call for help getting up.
4
update
.
The nurse assesses a patient using the Braden scale. The patient scores a 13. What action is most
important to add to the patient’s care plan?
a. Encourage high-protein meals and snacks
b. Turn the patient every to 2 hours
c. Assess the patient’s skin daily
d. Monitor patient’s prealbumin weekly
ANS: B
A Braden scale score of 13 indicates high risk for developing a pressure ulcer. The most
important intervention is to turn the patient frequently. Good nutrition is important for wound
healing and prevention, but a high-protein snack and monitoring prealbumin do not immediately
impact the patient’s skin condition. Assessing the skin will not prevent an ulcer.
A patient has a purulent, foul-smelling leg wound. What wound care practice is most
appropriate?
a. Leave the wound open to the air.
b. Administer systemic antibiotics.
c. Cleanse the wound with diluted povidone iodine.
d. Prepare the patient for operative débridement.
ANS: C
Antiseptics are not used on healthy granulating tissue. Povidone iodine must be diluted and only
used short term. A moist environment is needed for healing; leaving the wound open to air will
cause too much drying. The patient may eventually need operative débridement. Systemic
antibiotics may or may not be needed.
A patient has a wound that is a shallow crater with surrounding erythema and warmth. What
stage pressure ulcer does the nurse chart?
a. Stage I
b. Stage II
c. Stage III
1
,NURS MISC exam 1 questions with answers 2022
update
d. Stage IV
ANS: B
Stage II is a partial thickness ulcer that looks like an abrasion, blister, or shallow crater. A stage I
pressure ulcer is redness or mottled skin that does not blanch. Stage III ulcers are full thickness
deep craters. Stage IV ulcers may extend into the fascia and may be necrotic.
An older adult patient has an open, draining wound on the lower medial aspect of the right leg.
The skin surrounding the wound is reddish brown with surrounding erythema and edema. Based
on this information, the nurse edits the patient’s care plan to include impaired skin integrity:
a. related to altered venous circulation.
b. peripheral related to arterial insufficiency.
c. related to diabetic neuropathy.
d. open wound related to pressure ulcer.
ANS: A
Venous ulcers are usually on the medial aspect of the lower leg, with flat or shallow craters and
irregular borders, accompanied by varicosities, liposclerosis (brown ruddy color and thickened
skin), and itching. Venous ulcers generate a large amount of exudate and are usually surrounded
by erythema and edema. Arterial insufficiency would produce shiny, taut, hairless skin. There is
no indication the patient is a diabetic. There is no indication the patient has risks for pressure
ulcers
A patient in a nursing home is confused, nonverbal, but pleasant. The nurse notes the patient has
suddenly become agitated and is screaming and scratching at the eyes. While the nurse is
examining the patient, the patient vomits. What action by the nurse is best?
a. Consult the provider about an ophthalmologic exam.
b. Sedate the patient so she won’t injure herself.
c. Place mitts on the patient’s hands to avoid scratches.
d. Give the patient a prn medication for pain.
ANS: A
The patient could be having an episode of acute angle closure glaucoma, manifested by severe
pain, nausea and vomiting, and visual disturbances. Because the patient is nonverbal, the nurse
must assess for pain with behavioral changes. The nurse should contact the provider about
obtaining an ophthalmologic exam to determine if the patient has glaucoma. The other
2
,NURS MISC exam 1 questions with answers 2022
update
interventions will not help determine the cause of the problem. The nurse should attempt to
discover the source of the behavior, not just try to control it.
16. A patient with glaucoma is on timolol (Timoptic). The patient also takes metoprolol (Toprol)
for hypertension. The patient reports to the clinic nurse that the eyedrops “Make me dizzy.”
What assessment by the nurse is most appropriate?
a. Assess the patient’s eyedrop instillation technique.
b. Determine how long the patient has been on the drops.
c. Assess the patient’s gait and balance while walking.
d. Ask the patient if breakfast is eaten prior to applying the eyedrops.
ANS: A
The patient should be using punctal occlusion (closing the lacrimal duct) when instilling these
eyedrops to avoid a cumulative, systemic effect from the combination of both beta-blockers. The
nurse can assess the other factors as well, but this is the most likely cause of the dizziness.
An older patient is being treated for arthritic pain with a nonsteroidal anti-inflammatory drug
(NSAID). Which question best assesses for side effects of this medication class?
“Have you noticed your heart skipping beats since you began taking this
a. drug?”
b. “Did you know you should not to stand up too quickly?”
c. “Are you aware that you should take your pain medication with food?”
“Have you had any episodes of shortness of breath since starting this
d. medicine?”
ANS: C
The most common complaint associated with NSAIDs is indigestion. Indigestion may be
reduced with antacid use or food consumption timed to coincide with analgesic intake.
An older patient admitted to the hospital with symptoms strongly suggestive of tuberculosis (TB)
has a negative Mantoux test. The nurse correctly anticipates that:
3
, NURS MISC exam 1 questions with answers 2022
update
a. the purified protein derivative (PPD) test will be administered.
b. a chest x-ray will be ordered to detect possible infiltration.
c. therapy consisting of a combination of bactericidal drugs will be initiated.
d. the skin test will be repeated to achieve a booster effect.
ANS: D
Tuberculin skin testing in older patients is an unreliable indicator of TB because they are more
likely to have false-negative results because of reduced immune system activity. If skin testing is
used, it is recommended that the standard 5 tuberculin unit (TU) Mantoux test be given and then
repeated to create a booster effect. The PPD is not recommended. The skin test is followed up
with a chest x-ray. Drug therapy should not begin until the patient has a diagnosis.
An older adult patient who has tuberculosis is being treated with the drugs isoniazid 300 mg
daily, rifampin 600 mg daily, and pyrazinamide 1500 mg daily. The nurse stresses the
importance that the patient:
a. wear tinted glasses when out in the sun.
b. minimize contact with children younger than 3 years old.
c. avoid alcohol while on the drug therapy.
d. eat and drink dairy sparingly.
ANS: C
The nurse is caring for a confused patient. Which action by the nurse shows the best
understanding of managing the cascading effects of iatrogenic illnesses in this population cohort?
a. Reorienting the patient to person, place, and time frequently
b. Offering the patient liquids each time there is patient-nurse contact
c. Repositioning the patient every 2 hours
d. Using restraints to ensure patient safety only as a last resort
ANS: D
An older patient has fallen twice in the hospital in the last 2 days. What action by the nurse is
best?
a. Request restraint orders from the provider.
b. Assess the patient for undiagnosed illness.
c. Remind the patient to call for help getting up.
4
