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concepts of nursing
week 4
| Question | Answer |
|---|---|
| For which reason is it important that the nurse to review the patient’s chart as part of the preparation for a physical examination? | Enhances rapport between the nurse and patient Reminds the nurse of past health problems and their status Reassures the patient that the nurse is familiar with their history informs the nurse of current health concerns |
| What statement by the patient about hand-washing indicates the patient is in further need of education? | "Washing my hands with antibacterial soap means they are sterile." |
| Which factors should a nurse consider before performing an inspection during a physical exam? | Ample Lighting Time available for exam adequate exposure of anatomical features available assistance |
| What kind of abnormalities can be found with percussion of the abdomen? | Gas Fluid Masses |
| A patient has fallen and suffered a leg injury. A nurse is palpating the leg during the initial examination. The nurse should be attentive to what qualities or reaction? | Crepitation Guarding Rebound Tenderness |
| Following auscultation of the abdomen in a patient reporting pain, which aspects of the bowel sounds will the nurse document? | Frequency Intensity quality Crepitation |
| Which factors should a nurse consider when documenting findings after performing a physical assessment? | Highlight any abnormalities or questionable findings. Review for accuracy and attention to detail. Record education given to the patient or family. Record the assessment in a timely manner. |
| What should a nurse do when an adult with severe developmental disabilities presents to the hospital and has to wait for the healthcare provider | Have the nurse assistant sit with the patient until the provider arrives. |
| A nurse is teaching a class about patient privacy and HIPAA requirements to new staff in a medical clinic. Which statement demonstrates that the content is understood? | Make sure to keep medical charts behind the desk and out of the view of other patients at all times. |
| Upon completion of the physical examination of a patient, which action will the nurse take next? | Allow the patient to ask questions. |
| What is the order of assessment techniques when assessing the abdomen? | Inspection Auscultation Palpation Percussion |
| The nurse is performing a physical assessment on a patient. During inspection, it is imperative that the nurse have _________________and _________ available. | Good lighting and gloves |
| The process of inspection utilizes which senses in order to identify normal and abnormal physical characteristics? | sight smell hearing |
| The patient had been outside in the heat all day and is likely suffering from dehydration. What factor should the nurse make sure to assess when performing palpation? | Skin turgor |
| The nurse must examine an older adult patient with arthritis and dementia. What actions are required for a safe and effective examination for this patient? | Assisting the patient with undressing Supervising the patient at all times Helping the patient change position |
| What does a urine specific gravity greater than 1.03 suggest about the patient’s condition? | Patient is dehydrated, perhaps due to vomiting and diarrhea. Patient is not drinking the recommended amount of fluids. |
| Which medical conditions may be suggested by the presence of blood in a patient’s urine? | Renal trauma Urinary tract infection A bleeding disorder |
| Which urinalysis findings indicate that the patient has a urinary tract infection? | Bacteria Cloudy urine Presence of red blood cells |
| Which urinalysis findings are consistent with a diagnosis of diabetes mellitus? | Presence of glucose Urine with a pH of 9 A protein level of 11 mg/dL |
| Dark yellow to amber | Dehydration |
| Orange | Fever |
| Blue/Green | Pseudomonas UTI |
| Pale yellow | High fluid intake |
| Which conditions are suggested by decreased urobilinogen levels in stool? | Chronic liver disease Biliary obstruction |
| Which condition is suggested by increased urobilinogen levels in stool? | Rapid red blood cell destruction |
| Which laboratory test results support a diagnosis of bile obstruction in a newly admitted patient? | Presence of fecal fat in the patient's stool Urobilinogen level of 40 mg per 24 hours |
| Which conditions are indicated by a discolored stool with an abnormal texture? | Steatorrhea Malabsorption syndrome Pancreatic enzyme deficiency |
| Which samples would be appropriate to use to determine the strain of organism responsible for an epidemic of pneumonia? | Sputum |
| What does it mean for a microorganism to be “resistant” to an antibiotic? | The microorganism continues to grow in the presence of the antibiotic. The microorganism survives in the presence of the antibiotic. |
| What does it mean for a microorganism to be “susceptible” to an antibiotic? | The microorganism is killed by the antibiotic. The microorganism stops growing in the presence of the antibiotic. |
| Which technique is used to obtain tissue samples for the diagnosis of breast cancer? | Needle biopsy |
| Which procedure removes fluid from the chest? | Thoracentesis |
| Bone marrow aspiration | Sternum |
| Paracentesis | Peritoneal cavity |
| Thoracentesis | Pleural cavity |
| From which areas of the body could bone marrow samples be collected to assess for blood cancer? | Iliac crest Sternum |
| Which problem can be detected by paracentesis? | Peritonitis |
| When a patient must provide a specimen for diagnostic testing at home, which is the most important factor for the nurse to assess in the patient? | Ability to follow the correct collection technique |
| To whom is the nurse responsible for communicating test results? | Ordering health care provider |
| Which question should the nurse ask a patient who collects a urine specimen at home to ensure result accuracy? | At which temperature the specimen was maintained? How quickly was the specimen transported? |
| Which information should the nurse use to identify a patient prior to collecting a sample for diagnostic testing? | Name Date of birth |
| Which information should the nurse provide to UAP who is performing blood glucose testing on a patient? | Timing of the procedure Need to avoid any extremity |
| When collecting blood from a venipuncture, blood for which test is collected last? | Glucose |
| Which questions should the nurse ask to evaluate the patient’s ability to comply with the prescribed regimen of self-monitoring blood glucose? | "Do you see yourself being able to check your blood glucose at the times prescribed?" "Are you able to buy your own glucometer, strips, and lancets?" "Can you tell me how often you should check your blood glucose?" |
| From which sources can blood be collected for diagnostic testing? | Veins Arteries Capillaries |
| 3-month-old weighing 9 pounds: | Veins too small |
| 86-year-old weighing 120 pounds: | Veins too fragile, risk of bleeding |
| 25-year-old weighing 350 pounds: | Veins difficult to visualize and/or access |
| Which information should UAP collecting a stool sample provide the nurse immediately after collection? | "This stool sample is hemoccult-positive." "The patient said that it hurt when he passed the stool." "The stool sample was clay-colored." |
| Requires all urine to be collected within a specified time period: | Timed |
| Routine urinalysis and drug testing: | Random |
| Needed for culture and sensitivity: | Clean catch |
| Which statement by the nurse is appropriate to UAP who are delegated to obtain a mid-stream clean catch urine specimen? | "Please collect the urine sample immediately." "Use a sterile specimen cup and make sure not to touch the inside of the cup or the cover." |
| Which statement by the nurse is appropriate to UAP who are delegated to obtain a mid-stream clean catch urine specimen? | "Document the date, time, and your action of obtaining the urine specimen in the patient's record." "Please make sure the patient begins to urinate in the toilet, stops, urinates in the specimen cup and then finishes urinating in the toilet." |
| Which patient information should be documented when collecting urine to avoid a false-positive result for hematuria? | Patient is menstruating. |
| Which action should the nurse take if a patient accidently urinates into the stool collection container? | Obtain a new sample. |
| In which aspects of the procedure for collecting a sputum sample should UAP be educated? | Appropriate handling of the specimen Appropriate collection of the specimen Reporting of procedural or physiologic difficulties |
| Place the steps of a throat culture collection in the appropriate order. | Don gloves Depress tongue Run swab over reddened or draining areas Place swab in tube and seal immediately Label container and place in biohazard bag |
| Which measures can the nurse take to avoid stimulating the patient’s gag reflex when obtaining a throat culture? | Swab the patient's throat quickly. Place swab off center. Ask the patient to sit upright and say, "Ahh." |
| Which areas would the nurse swab when obtaining a throat culture? | Tonsils Oropharynx |
| Which techniques can be used to obtain a sputum sample if coughing does not produce sputum? | Suctioning Use of expectorants Chest physiotherapy Use of aerosols or nebulizers |
| Which instructions would the nurse give a patient following a lumbar puncture? | "Drink plenty of fluids." "Lie flat for 4-8 hours." "Notify the nurse if you feel or sense drainage from the puncture site." |
| Paracentesis: | Monitor for signs of shock. |
| Lumbar puncture: | Perform a neurological assessment. |
| Cytoscopy_ | Monitor urine for blood or clots. |
| Arthroscopy_ | Elevate extremity and apply ice_ |
| Which nursing action is a part of all needle aspiration and biopsy procedures? | Provide emotional support. |
| Which instructions would the nurse give a patient who has had a paracentesis? | "Keep track of what you drink and eat." "Notify nurse of any bleeding and abdominal pain." "Keep track of the amount you urinate and possibly vomit." |
| Which procedure is associated with the lowest risk of infection? | Colonoscopy |
Created by:
colby.caswell