Basic Nursing Quiz 3

From what stage of sleep are people typically most difficult to arouse?

A patient’s vital signs prior to a blood transfusion were: T = 97.6°F (36.4°C); P = 72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg. Twenty minutes after the transfusion was begun, the patient began complaining of feeling “itchy and hot.” The nurse discovered a rash on the patient’s trunk. Vital signs were: T = 100.8°F (38.2°C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the priority intervention?

Chronic stress may lead directly to cardiovascular disease because of the repeated release of which of the following?

You are caring for an adult patient with a tracheostomy who is being mechanically ventilated. His pulse oximetry reading is 85%, heart rate is 113, and respiratory rate is 30. The patient is very restless. His respirations are labored, and you hear gurgling sounds. You auscultate crackles and rhonchi in both lungs. What is the most appropriate action to take?

A patient suddenly develops right lower-quadrant pain, nausea, vomiting, and rebound tenderness. How should the nurse classify this patient’s pain?

A patient who underwent a left above-the-knee amputation complains of pain in his left foot. The nurse should document this finding as what type of pain?

The passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration is called which of the following?

When a patient has metabolic acidosis, which body system influences the acid–base imbalance to produce the compensatory changes in the arterial blood gases?

What is the rationale for wrapping petroleum gauze around a chest tube insertion site?

You are admitting a 54-year-old patient with chronic obstructive pulmonary disease (COPD). The physician prescribes O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient?

Which pain management task can be safely delegated to nursing assistive personnel?

Which aspect of restraint use can the nurse delegate to the nursing assistive personnel?

A patient who sustained rib fractures in a motor vehicle accident is complaining that his pain medication is ineffective. Inadequate pain control places this patient at risk for which complication?

Which process requires energy to maintain the unique composition of extracellular and intracellular compartments?

A patient with a history of falling continually attempts to get out of bed unassisted despite frequent reminders to call for help first. Which action should the nurse take first?

While a patient is receiving hygiene care, her chest tube becomes disconnected from the water-seal chest drainage system (CDU). Which action should the nurse take immediately?

Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis?

Which electrolyte is the primary regulator of fluid volume?

What is typically the most reliable indicator of pain?

You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patient’s respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern?