N125 Exam 1

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The nursing assistive personnel (NAP) is working on a medical surgical unit in a hospital and has been providing patient care without performing hand hygiene. Several of the patients on the unit have suffered hospital-associated diarrhea infections (Clostridium difficile). The hospital-associated disease transmission is best described as what?

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When checking for proper blood pressure cuff size, the nurse knows that which guideline is correct?

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There was an outbreak of Salmonella infection at a nursing home. Several residents were hospitalized as a result of the infection. What is the best term to describe this infection?

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A nurse is assigned to multiple patients on a busy surgical unit. To minimize the onset and spread of infection, the nurse should:

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A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall.
Which initial action will the nurse take next to revise the plan of care?

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The nurse is admitting a patient with a methicillin-resistant Staphylococcus aureus (MRSA) infection located in the patient's pressure ulcer. On what precautions should the nurse place the patient?

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Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)

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The student nurse is caring for a postsurgical patient who has developed a health care– acquired wound infection that has become systemic. Which of the following should be the student nurse’s top priority?

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The nurse is taking the pulse of an adult patient and finds that the patient’s heart rate is 48 beats per minute. What should the nurse document as the finding?

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A 36-year-old patient has been admitted to the hospital. The nurse who is admitting him notes that his blood pressure is 164/98. Which of the following should the nurse do next?

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The nurse has had a nasal culture performed and has been found to be MRSA positive. Because the nurse has not been ill from the bacteria, the nurse’s nasal cavity can best be described as a:

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Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?

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A nurse is preparing to collect a blood sample from a patient who is diagnosed with Tuberculosis. What personal protective equipment should the nurse wear prior to entering the patients room?

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The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?

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A 26-year-old man was working on a roof in the hot 105-degree weather. His friend brought him to the hospital after the patient complained of severe muscle cramps and became confused. Which of the following should the admitting nurse do first when assessing the patient?

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Where is the pain located?

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What causes the pain?

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Does it come and go?

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What does the pain feel like?

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What is the rating on a scale of 0 to 10?

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A nursing student is working on a surgical unit in the hospital. Included in the job description is to assist in the cleaning and disinfection of equipment stored on the unit. Which of the following is the best explanation of disinfection?

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apical pulse Heartbeat as listened to with the bell or diaphragm of a stethoscope placed on apex of the heart

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apnea Cessation of airflow through the nose and mouth

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bradycardia Slower than normal heart rate; heart contracts fewer than 60 times

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bradypnea Abnormally slow rate of breathing

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diastolic pressure the blood pressure at the instant of maximum cardiac relaxation

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A nurse determines that the patient’s condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?

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Nursing is the most trusted profession where professionalism should be shown in all actions. Which of the statements are true to what professionalism means to nurses (select all that apply):

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In terms of your nursing practice, a general survey has the following characteristics (select all that apply):

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Which of the following statement best reflects objective data?

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The best location to assess the pulse during a routine physical assessment is:

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You received shift report from the night shift and your first action is to complete an orthostatic blood pressure. Which of the following is the most accurate?

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In regards to assessing pain in your assigned patients, which accurately reflects the "PQRST" assessment:

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hypertension Disorder characterized by an elevated blood pressure persistently exceeding 120/80mm Hg.

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hypotension
Abnormal lowering of blood pressure that is inadequate for normal perfusion and oxygenation of tissues

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hypothermia
Abnormal lowering of body temperature below 35 C, or 95 F, usually caused by prolonged exposure to cold

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orthostatic hypotension Abnormally low blood pressure occurring when a person stands up.

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systolic pressure The pressure representing ventricular contraction

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tachycardia Rapid regular heart rate ranging between 100 and 150 beats per minute.

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Which of following does not belong when speaking about critical thinking:

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Which of the following vital signs recorded for an older adult would be considered acceptable (i.e., within normal limits)?

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Which of the following situations may affect a patient’s vital signs? Select all that apply.

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Which nursing diagnosis statement is written correctly?

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Which method of data collection will the nurse use to establish a patient’s database?

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The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

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A new nurse writes the following nursing diagnoses on a patient’s care plan. Which nursing diagnosis will alert the charge nurse to intervene immediately?

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A nurse is providing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?

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Which of the following is true about the force, or strength, of a pulse?

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A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate?

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A patient’s blood pressure is 118/82. They ask the nurse to explain “what the numbers mean.” What would be the nurse’s best response?

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A patient is one-day postoperative for major abdominal surgery. When the nurse and the assistive personnel raise the head of the bed to sit the patient on the side of the bed before ambulation, the patient immediately complains of dizziness and nausea. What are your immediate actions?

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A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis (sweating). Which outcome would the nurse recognize as appropriate for this patient?

N125 Exam 1

N125 Exam 1

N125 Exam 1

When checking for proper blood pressure cuff size, the nurse knows that which guideline is correct?

There was an outbreak of Salmonella infection at a nursing home. Several residents were hospitalized as a result of the infection. What is the best term to describe this infection?

A nurse is assigned to multiple patients on a busy surgical unit. To minimize the onset and spread of infection, the nurse should:

A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which initial action will the nurse take next to revise the plan of care?

The nurse is admitting a patient with a methicillin-resistant Staphylococcus aureus (MRSA) infection located in the patient's pressure ulcer. On what precautions should the nurse place the patient?

Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)

The student nurse is caring for a postsurgical patient who has developed a health care– acquired wound infection that has become systemic. Which of the following should be the student nurse’s top priority?

The nurse is taking the pulse of an adult patient and finds that the patient’s heart rate is 48 beats per minute. What should the nurse document as the finding?

A 36-year-old patient has been admitted to the hospital. The nurse who is admitting him notes that his blood pressure is 164/98. Which of the following should the nurse do next?

The nurse has had a nasal culture performed and has been found to be MRSA positive. Because the nurse has not been ill from the bacteria, the nurse’s nasal cavity can best be described as a:

Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?

A nurse is preparing to collect a blood sample from a patient who is diagnosed with Tuberculosis. What personal protective equipment should the nurse wear prior to entering the patients room?

The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?

A 26-year-old man was working on a roof in the hot 105-degree weather. His friend brought him to the hospital after the patient complained of severe muscle cramps and became confused. Which of the following should the admitting nurse do first when assessing the patient?

Where is the pain located?

What causes the pain?

Does it come and go?

What does the pain feel like?

What is the rating on a scale of 0 to 10?

A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall.
Which initial action will the nurse take next to revise the plan of care?

hypotension
Abnormal lowering of blood pressure that is inadequate for normal perfusion and oxygenation of tissues

hypothermia
Abnormal lowering of body temperature below 35 C, or 95 F, usually caused by prolonged exposure to cold