NURS 220 Quiz #1
The patient has difficulty urinating after surgery, so the nurse is to insert a Foley
catheter. She has not inserted a Foley catheter into a patient before. She reviews the
procedure manual before carrying out the procedure. What level of critical thinking is
she using?
A. Basic critical thinking
B. Complex critical thinking
C. Nursing process
D. Scientific method - answerA. Basic critical thinking
Imbalanced nutrition: less than body requirements related to decreased ability to ingest
food as a result of vomiting is an example of which type of nursing diagnosis?
A. Problem-focused nursing diagnosis
B. Risk nursing diagnosis
C. Wellness nursing diagnosis
D. Health promotion nursing diagnosis - answerA. Problem-focused nursing diagnosis
The nurse writes a goal in measurable terms. An example is:
A. Patient will be pain free.
B. Patient will have less pain.
C. Patient will take pain medication every 4 hours.
D. Patient will report pain acuity less than 4 on a scale of 0 to 10. - answerD. Patient will
report pain acuity less than 4 on a scale of 0 to 10.
As you enter the patient's room, you notice that the patient 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
is the most appropriate documentation of the patient's emotional status?
A. The patient has a defiant attitude and is demanding his test results.
B. The patient appears to be upset with his nurse because he wants his test results
immediately.
C. The patient is demanding and complains frequently about his doctor.
D. The patient stated that he felt frustrated by the lack of information he received
regarding his tests. - answerD. The patient stated that he felt frustrated by the lack of
information he received regarding his tests.
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 hallway with assistance from nurse.
Spouse also accompanied patient during the walk.
D. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88
and regular before exercise, 94 and regular following exercise. - answerD. Patient
walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular
before exercise, 94 and regular following exercise.
Which of the following vital signs recorded for an older adult would be considered
acceptable (i.e., within normal limits)?
A. Temp 96.8° F, P 60, R 18, BP 160/90, O2 sat 93%
B. Temp 97.0° F, P 60, R 16, BP 116/78, O2 sat 95%
C. Temp 98.6° F, P 56, R 20, BP 120/80, O2 sat 91%
D. Temp 98.0° F, P 76, R 22, BP 110/70, O2 sat 88% - answerB. Temp 97.0° F, P 60, R
16, BP 116/78, O2 sat 95%
Which of the following patients would have the most difficulty maintaining
thermoregulation?
A. Young child playing soccer during the summer
B. Middle-aged adult snow skiing
C. Young adult playing golf on a hot day
D. Older adult raking leaves on a cold day - answerD. Older adult raking leaves on a
cold day
Which of the following patients should have an apical pulse taken? A patient who is:
A. Febrile and has a radial pulse of 100 bpm
B. A runner who has a radial pulse of 62 bpm
C. A 55 year old female who has an irregular heart rate
D. An elderly adult who is taking antianxiety medication - answerC. A 55 year old female
who has an irregular heart rate
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), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal
cannula. Which vital sign reflects a positive outcome of the oxygen therapy?
A. Temperature: 37°C (98.6°F)
B. Radial pulse: 112
The patient has difficulty urinating after surgery, so the nurse is to insert a Foley
catheter. She has not inserted a Foley catheter into a patient before. She reviews the
procedure manual before carrying out the procedure. What level of critical thinking is
she using?
A. Basic critical thinking
B. Complex critical thinking
C. Nursing process
D. Scientific method - answerA. Basic critical thinking
Imbalanced nutrition: less than body requirements related to decreased ability to ingest
food as a result of vomiting is an example of which type of nursing diagnosis?
A. Problem-focused nursing diagnosis
B. Risk nursing diagnosis
C. Wellness nursing diagnosis
D. Health promotion nursing diagnosis - answerA. Problem-focused nursing diagnosis
The nurse writes a goal in measurable terms. An example is:
A. Patient will be pain free.
B. Patient will have less pain.
C. Patient will take pain medication every 4 hours.
D. Patient will report pain acuity less than 4 on a scale of 0 to 10. - answerD. Patient will
report pain acuity less than 4 on a scale of 0 to 10.
As you enter the patient's room, you notice that the patient 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
is the most appropriate documentation of the patient's emotional status?
A. The patient has a defiant attitude and is demanding his test results.
B. The patient appears to be upset with his nurse because he wants his test results
immediately.
C. The patient is demanding and complains frequently about his doctor.
D. The patient stated that he felt frustrated by the lack of information he received
regarding his tests. - answerD. The patient stated that he felt frustrated by the lack of
information he received regarding his tests.
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 hallway with assistance from nurse.
Spouse also accompanied patient during the walk.
D. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88
and regular before exercise, 94 and regular following exercise. - answerD. Patient
walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular
before exercise, 94 and regular following exercise.
Which of the following vital signs recorded for an older adult would be considered
acceptable (i.e., within normal limits)?
A. Temp 96.8° F, P 60, R 18, BP 160/90, O2 sat 93%
B. Temp 97.0° F, P 60, R 16, BP 116/78, O2 sat 95%
C. Temp 98.6° F, P 56, R 20, BP 120/80, O2 sat 91%
D. Temp 98.0° F, P 76, R 22, BP 110/70, O2 sat 88% - answerB. Temp 97.0° F, P 60, R
16, BP 116/78, O2 sat 95%
Which of the following patients would have the most difficulty maintaining
thermoregulation?
A. Young child playing soccer during the summer
B. Middle-aged adult snow skiing
C. Young adult playing golf on a hot day
D. Older adult raking leaves on a cold day - answerD. Older adult raking leaves on a
cold day
Which of the following patients should have an apical pulse taken? A patient who is:
A. Febrile and has a radial pulse of 100 bpm
B. A runner who has a radial pulse of 62 bpm
C. A 55 year old female who has an irregular heart rate
D. An elderly adult who is taking antianxiety medication - answerC. A 55 year old female
who has an irregular heart rate
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), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal
cannula. Which vital sign reflects a positive outcome of the oxygen therapy?
A. Temperature: 37°C (98.6°F)
B. Radial pulse: 112
