Fundamental Nursing Skills And Concepts

MULTIPLE CHOICE 1. The nurse explains to the unlicensed assistive personnel (UAP) that a shearing force is applied to the patient when: a. a lifting sheet is used to move the patient to a stretcher. b. the patient is pulled up in bed without being lifted. c. the patient is seated in a wheelchair without a pressure cushion. d. the patient is left in the supine position. ANS: B When a patient is pulled up in bed without being lifted up first, shearing force is applied on the bony promi...

MULTIPLE CHOICE 1. Fecal matter has contaminated the patients bed sheet. The nurse should: a. place a folded clean, dry sheet or plastic-backed protector over the soiled sheet until it dries and then b. don non-sterile gloves and gown, remove the soiled sheet, replace it with a clean one, and then dispose plastic bag to prevent skin or clothing contact. c. remove the soiled sheet without exposure of skin or clothing to the sheet and rinse it in the patients dilute or remove as much feces ...

MULTIPLE CHOICE 1. The nurse performing tracheotomy care will: a. raise the head of the bed to high Fowlers position. b. remove the inner cannula with the ungloved hand. c. suction tracheotomy before beginning care. d. clean cannula with gauze and replace and lock. ANS: C Proper procedure includes suctioning the tracheotomy before beginning care. DIF: Cognitive Level: Application REF: k 528, Skill 28-7 OBJ: Clinical Practice #3 TOP: Tracheotomy Care KEY: Nursing Process S...

MULTIPLE CHOICE 1. When caring for a patient with acute radiation sickness (ARS) after an accident at an atomic power plant, the nurse should: a. wear a paper gown and boots, gloves, and a mask. b. stay in the room and talk to the patient to alleviate anxiety. c. decrease the amount of time spent in the room. d. wear a chemical mask with a filtered respirator. ANS: A For prolonged periods in caring for a patient with ARS, the nurse should use the barrier protection of gown, boots, a...

MULTIPLE CHOICE 1. The nurse recommends that normal sleep patterns can best be acquired by suggesting to the patient that they: a. smoke cigarettes. b. drink wine. c. take a nap during the day. d. exercise in the mornings. ANS: D Maintaining a regular exercise schedule not too close to bedtime helps a person sleep. DIF: Cognitive Level: Comprehension REF: k 604 OBJ: Theory #8 TOP: Sleep KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: basic ca...

MULTIPLE CHOICE 1. A nurse is assisting in the care of a patient who is receiving pain medication by the epidural route. It is most important to monitor this patient for which adverse drug effects? a. Constipation b. Headache c. Nausea d. Hypoventilation ANS: D Respiratory depression is a potentially dangerous side effect of epidural analgesia, and a patient receiving this type of pain medication requires frequent monitoring of respiratory rate. DIF: Cognitive Level: Comprehensi...

MULTIPLE CHOICE 1. The nursing action that is most beneficial toward creating an atmosphere conducive to eating for a hospitalized patient immobilized in bed is: a. lower the head of bed as tolerated. b. remove the urinal from the over-the-bed table. c. invite the patient to wash hands and face before eating. d. use a deodorizer to remove any unpleasant odor in the room. ANS: B Remove distracting articles such as the urinal and emesis basin. DIF: Cognitive Level: Application R...

MULTIPLE CHOICE 1. The nurse is comparing sitting and standing vital signs for a patient who has been diagnosed with dehydration. The pulse rate has increased by 10 beats/min at 1 minute. The nurse then anticipates the blood pressure to show a(n) _____ mm Hg. a. increase of 5 b. drop of 40 c. drop of 20 d. increase of 10 ANS: C A drop in systolic blood pressure by at least 20 mm Hg accompanied by a pulse rate increase of at least 10 beats/min at 1 minute following position chang...

MULTIPLE CHOICE 1. When obtaining a capillary blood sample for blood glucose, the nurse will select the puncture site to cause the least amount of discomfort, which is: a. the end of the index finger. b. the ball of the third finger. c. at right angles to the fingerprint lines. d. the ball of the thumb. ANS: C Using the right angle to the fingerprint lines places the puncture on the side of the finger rather than on more sensitive areas. DIF: Cognitive Level: Application REF: ...

MULTIPLE CHOICE 1. A patient with visual impairment is identified as at risk for falls related to blindness. An appropriate intervention would be to: a. assist the patient with feeding herself at the end of the meal. b. arrange furnishings in room to provide clear pathways and orient the patient to these. c. take the patients blood pressure before she gets up in the morning. d. report any falls immediately to the charge nurse and the doctor. ANS: B Providing clear pathways directly ...