N125 Exam 2

A nurse is using SBAR to hand off information to the next nurse. The nurse reports pertinent medical history, previous laboratory tests and treatments, psychosocial issues, allergies, and current code status. Which component of SBAR did the nurse communicate?

The nurse is bathing an 80-year-old man and notices his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor?

The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person’s:

During the history, a patient tells the nurse, “it feels like I am spinning around in circles.” The nurse would document this as:

During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. This suggests?

Research has shown, the primary reason nurses make medication errors is related to:

During the admission interview the client reports to the nurse that she is “a little allergic to penicillin.” Which of the following questions asked by the nurse is most likely to provide the most relevant information regarding the client’s possible allergy to penicillin?

A nurse is collecting data on a patient who is being admitted into hospice care. The nurse collects data from both the patient and the family so a clear picture of the patient status is obtained. The nurse is currently involved in which step of the nursing process?

A patient states, “I’m burning up, and I have a fever.” The nurse takes the patient’s temperature, observes the skin for flushing, and feels the skin temperature. This is an example of __________ subjective data.

A nurse is using SBAR when communicating with the primary care provider and suggests a plan of care and requests an order for oxygen. Which component of SBAR did the nurse communicate?

Upon taking a history of a patient, the nurse learns the patient smokes a pack of cigarettes per day. How should the nurse interpret this finding?

A student nurse is responsible for assessing a patient, who is abrupt and requests that the assessment be done later by a Registered nurse. As the student nurse charts the interaction, which statement is the best way to document what happened?

Which question or comment should the nurse initially use, which would best gather the most information during a health history assessment?

When caring for a patient from another culture, what is the best strategy for the nurse to use in communicating with the patient?

Which patient is at greatest risk for developing a pressure ulcer?

A patient is admitted to the hospital with a pressure ulcer on the sacrum. The wound is open with exposed bone. The nurse should document this pressure ulcer at what stage?

A 89 year old patient presents in the hospital. Your assessment reveals bleeding gums and loose fitting dentures. What nursing diagnosis would be most appropriate?

You have a patient who weighs 117 pounds and you are planning to administer a medication. Part of the process in nursing is to convert to kilograms.

Convert 117 pounds to ____________ kg
Round to the nearest tenths position.

You are providing care for a patient who is being discharged from the hospital and providing patient education on medication administration. Throughout the hospital stay, you have been administering 15mL of a medication and need to instruct the patient that 15mL is equal to the following home measurement:

With use of the Braden Scale, it is important to understand concepts of moisture, sensory perception, activity level, and nutrition. You just came on shift and are preparing to care for your patient. You complete the Braden scale and understand the following number would represent a severe risk for skin breakdown?

You are completing ADL's with your newly assigned patient and you determine oral care is essential. Which is the best action you could take?

You are assessing the nails of your patient. Which of the following is an abnormal finding which would require additional follow-up?

The balance between nutrient intake and nutrient requirements is described as:

You obtain which data when screening patients for nutritional status?

Assessing a patient's skin turgor is done to assess which clinical finding?

You examine the nail beds of a patient. Which finding indicates a normal angle?

While assessing pressure injuries (PI), you understand the nurse's ability to stage a wound. You view your patient to have full thickness skin loss. Which stage is this?

In regards to medication administration, medication doses have several important responses. It is important to know the peak response, as it related to which of the following

You are rooming a patient, 3 years old and his mother. Upon your assessment, you identify abnormalities related to the toddlers teeth. You suspect which the following condition and would ask more probing questions.

Using a otoscope, the tympanic membrane is visualized. The normal color of the membrane is:

The common cause of a conductive hearing loss is:

When assessing the patient, you notice moisture on the skin. This is best described as:

Which is the closest telephone call to the correct sequence of SBAR reporting?

When measuring a patient’s weight, the nurse keeps in mind which of these guidelines?

A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse assess this patient for cyanosis?

The nurse is turning a patient when she notices an area with non-blanchable redness over the patient’s coccyx. The patient complains of pain at the site, and the site feels cooler than the areas immediately around the site. The nurse recognizes that this patient has developed:

You are assessing a 6 year old patient complaining of pain in their mouth. You visually inspect the area and identify white patches on the tongue and cheeks. You are identifying which of the following:

"If I understand you correctly, you are telling me that..." What interview strategy is this an example of?

When assessing the pupillary light reflex, the nurse should use which technique?

A nurse assesses a client who has open lesions. Which action should the nurse take first?

The nurse is assessing a patient’s eyes for the accommodation response and would expect to see which normal finding?