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SUNY Canton Nur101 comprehensive lab quiz
quizzes 1-9 without 4
109
Nursing
Undergraduate 1
12/01/2011
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Term
The most important thing a nurse can do to prevent the spread of disease is:
 Definition
Wash their hands
Term
Hands are washed for at least
 Definition
15 Seconds
Term
Hand hygiene is:
 Definition
Any method that removes or destroys microorganisms on hands
Term
The most important way to control MRSA is through:
 Definition
Proper hand hygiene
Term
To turn off the faucets, use
 Definition
A clean paper towel for each faucet
Term
A nurse should not need to wash hands when:
 Definition
none, all of these are times when the nurse should wash their hands
Term
The correct order for putting PPE on is:
 Definition
Gown, mask, goggles, gloves
Term
When washing hands, a nurse should use friction for a minimum of:
 Definition
15 seconds
Term
A mask and goggles should be worn:
 Definition
If contact with splashing or spraying blood or body fluids is likely
Term
All of the following activities require gloves EXCEPT:
 Definition
Care of unbroken skin with no mucous membranes
Term
Hygiene measures promote the following except
 Definition
Bone strength
Term
Hygiene measures do the following except
 Definition
Decrease circulation
Term
Linens are always changed:
 Definition
When wet, damp, soiled, or very wrinkled
Term
You need to brush a person’s teeth. When brushing the person’s teeth, you
 Definition
Position the brush at 45-degree angle to the gums
Term
Cleansing the genital and anal areas is
 Definition
Perineal care
Term
A resident can have a shower
 Definition
As often as the person chooses
Term
A resident is expected to be out of bed all day and is expected to have visitors throughout the day and those visitors will be visiting in the patients room. What kind of bed should be made for the patient?
 Definition
Closed bed
Term
Oral hygiene does the following except
 Definition
Promote the buildup of plaque and tartar
Term
You assist a patient or resident with hygiene needs
 Definition
Whenever necessary
Term
To meet a dementia patients hygiene needs, you need to
 Definition
Follow the person’s plan of care
Term
All of the following may cause an increase in pulse rate EXCEPT:
 Definition
Advanced Age
Term
Of the following, which blood pressure reading would you find most concerning
 Definition
158/98
Term
Of the following which pulse rate would you find the most concerning in a young, otherwise healthy, athlete while at rest:
 Definition
112
Term
The amount of heat in the body that is a balance between the amount of heat produced and the amount lost by the body is
 Definition
Body temperature
Term
What 02 saturation reading would you NOT find concerning?
 Definition
98%
Term
The number of pulses felt in 1 minute is the
 Definition
pulse rate
Term
Both the _____ and _____ pulse are used in taking blood pressure.
 Definition
Radial and brachial
Term
A heart rate less than 60 beats per minute is known as:
 Definition
Bradycardia
Term
The amount of force exerted against the walls of an artery by the blood is BEST referred to as:
 Definition
Blood pressure
Term
Which temperature reading would indicate a febrile patient?
 Definition
101.5
Term
Vital signs include all of the following EXCEPT
 Definition
orientation
Term
The beat of the heart felt at an artery as a wave of blood passes through the artery is the
 Definition
Pulse
Term
Which respiratory rate would be referred to as bradypnea?
 Definition
8
Term
Which of the following is used to measure blood pressure?
 Definition
sphygmomanometer
Term
The heart muscle relaxes during
 Definition
Diastole
Term
An oral thermometer is usually color-coded:
 Definition
Green or blue
Term
The act of inhalation and exhalation is
 Definition
one respiration
Term
The difference between the apical and radial pulse rates is the
 Definition
Pulse deficit
Term
A systolic blood pressure that remains above 140 mm Hg or a diastolic pressure that remains above 90 mm Hg is
 Definition
Hypertension
Term
A client with a new stoma has not had a bowel movement since surgery last week and reports nausea.What is the appropriate nursing action?
 Definition
After assessing the stoma and surrounding skin, notify the surgeon
Term
The nurse assesses a client's abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling "bloated". The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema?
 Definition
Return flow enema
Term
The nurse is caring for a client with an ostomy that has been in place for many years. Which of the following assessment findings can help the nurse determine the type of ostomy the client has? Select all that apply.
 Definition
Drainage consistency - Presence or absence of odor
Term
After having a transverse colostomy constructed for colon cancer, discharge planning for home care would include teaching about the ostomy appliance. Information appropriate for this intervention would include:
 Definition
Instructing the client to report redness, swelling, fever, or pain at the site to the physician for evaluation of infection
Term
The nurse has completed the administration of a cleaning enema for a client being prepared for intestinal surgery. Complete documentation by the nurse of this event includes all but which of the following assessments? (Select all that apply)
 Definition
Type of solution - Relief of flatus and abdominal distention
Term
All of the following are types of enemas EXCEPT:
 Definition
Glucose enema
Term
During an enema, the resident should be in the ______ position:
 Definition
Left Sims
Term
All of the following are true of ostomies EXCEPT:
 Definition
Ostomies are always permanent
Term
While cleaning a patient’s ostomy the patient notices a scant amount of blood on the wash cloth and begins to get upset. How should the nurse respond?
 Definition
Acknowledge the patients fear but reassure them this is a normal finding
Term
Upon assessing your client you notice they have an ileostomy. You would expect to see what characteristics in the drainage?
 Definition
Liquid yellowish drainage
Term
The lack of or absence of breathing is
 Definition
Apnea
Term
Hypoxia means
 Definition
Cells do not have enough 02
Term
Rapid and deep respiration followed by 10 to 30 seconds of apnea is
 Definition
Biot's respiration
Term
Respirations are less than 12 per minute. This is
 Definition
Bradypnea
Term
Respirations gradually increase in rate and depth and then become shallow and slow. Breathing may stop for 10 to 20 seconds. This is
 Definition
Cheyne-Stokes respirations
Term
Difficult, labored, or painful breathing is
 Definition
Dyspnea
Term
Bloody sputum is
 Definition
Hemoptysis
Term
A reduced amount of oxygen in the blood is
 Definition
Hypoxemia
Term
A person can breathe deeply and comfortably only when sitting. This is
 Definition
Orthopnea
Term
Sitting up in bed and leaning over a table to breathe is
 Definition
Orthopneic Position
Term
Listening to lung sounds may otherwise be referred to as:
 Definition
Auscultation of lung sounds
Term
Upon auscultation of lung sounds you hear musical whistling sounds, these are referred to as:
 Definition
wheezes
Term
Upon auscultation of lung sounds you hearing moist course "snoring" sounds, this would be referred to as:
 Definition
Rhonchi
Term
Upon auscultation of lung sounds you hear fine "snapping and popping" noises, almost like the noise you would hear if you rubbed your hair between your fingers near your ear, this would be referred to as:
 Definition
crackles
Term
The best position to listen to a patients lung sounds is:
 Definition
High fowlers
Term
Which would be considered pertinent data when assessing the respiratory systems? (Check all that apply)
 Definition
Skin Color, Lip color - Lung Sounds, Respiratory Rate - Dyspnea, Nasal Flaring - Cough, Color of Sputum - 02 Saturation, Whether or not the patient is receiving 02
Term
The mother of a toddler yells to the nurse, "help! He is choking!" The nurse determines the child's airway is occluded and lifesaving measures are necessary based on which of the following assessment findings?
 Definition
Inability to make any sounds
Term
In a client with long-term emphysema, the nurse might expect to see which condition when inspecting the nails?
 Definition
Clubbing
Term
What signs are indicative of hypoxia (select all that apply)?
 Definition
Flaring of the nostrils - Substernal or intercostals retractions - Rapid pulse - Cyanosis
Term
Difficulty breathing is called:
 Definition
Dyspnea
Term
When assessing any client coming to see a primary care provider, a heart rate assessment is common place. Of the client assessments performed, for which client would most concern the nurse?
 Definition
a 50 year old hypertensive executive with a heart rate of 130
Term
Normal findings when observing and palpating the precordium include:
 Definition
visible pulsation over the mitral area of the chest
Term
Assessment of a client's peripheral vascular system includes all the following except:
 Definition
palpating the apical pulse
Term
Which of the following finding would be of greatest concern to the nurse taking a client's pulse?
 Definition
pulse deficit with an apical rate of 84 beats per minute and a peripheral pulse of 72
Term
The nurse is unable to palpate a client's pulse in an edematous right lower extremity. Which of the following would be the best nursing action at this time?
 Definition
use a Doppler to check for the pedal pulse
Term
Traditional cardiac areas for auscultation of heart sounds include the aortic, pulmonic, tricuspid, and mitral. Which of these is used to assess the apical pulse rate?
 Definition
mitral
Term
Age-related variations the nurse would consider normal when doing a cardiovascular assessment of the older adult client include:
 Definition
decreased peripheral circulation
Term
Identify which of the following statements about newborn cardiac assessment is false.
 Definition
The nurse can assess the cardiac rate best using the radial pulse site
Term
To assess the apical heart sounds the nurse should do all the following except:
 Definition
auscultate the apical pulse over the 3-4 intercostal space
Term
A client with chest pain and shortness of breath has arrived in the emergency department. The nurse is about to perform a physical assessment on this person. Data to be obtained in the nursing history of relevance to heart disease include:
 Definition
history including diabetes and smoking
Term
The nurse assesses the clients level of consciousness and finds she can only be aroused by vigorous and continuous stimulation. The nurse documents the level of consciousness as what?
 Definition
Stuporous
Term
Which of the following clients is most at risk for a cardiovascular accident (CVA)?
 Definition
65 year old male who has high blood pressure and smokes
Term
A client has a 5 on the Glasgow Coma Scale. When assessing this client, the nurse would expect what level of consciousness?
 Definition
comatose
Term
What evidence most likely tells the nurse a client had a negative Romberg test?
 Definition
maintains an upright posture and foot stance
Term
As part of the examination, the nurse will be assessing the client’s balance. The test that should be administered is the:
 Definition
Romberg test
Term
Measurement of the client’s ability to differentiate between sharp and dull sensations over the forehead tests which cranial nerve?
 Definition
Trigeminal
Term
Part of the neurological examination is evaluating the response of the cranial nerves. To test cranial nerve VIII, the nurse should:
 Definition
Assess the client’s ability to hear the spoken word
Term
When assessing cognitive function, the nurse should evaluate the client's:
 Definition
Orientation to time, place, person, and ability to recall recent and past events.
Term
When testing the client to determine if tremors are present, the nurse should assess for:
 Definition
Shaking
Term
The nurse observes a client who has a lack of coordination, clumsy movements, and an unbalanced gait. What is this called?
 Definition
Ataxia
Term
The nurse is preparing a client for an abdominal examination. Which of the following should be performed before the examination?
 Definition
Ask the client to urinate
Term
The nurse is performing a lung assessment on a client with suspected pneumonia. Which of the following assessments should the nurse report to the physician immediately?
 Definition
Asymmetric chest expansion
Term
The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. The nurse would document this as which of the following?
 Definition
Jaundice
Term
The Glasgow Coma Scale is used for assessing level of consciousness. It tests in which of the following areas? (Select all that apply.)
 Definition
Eye response - Verbal response - Motor response
Term
A nurse is to begin an abdominal exam on a client. Which of the following reflects the appropriate order for the examination?
 Definition
Inspection, auscultation, light palpation
Term
During a physical health assessment conducted in a semi-darkened room, the nurse shines the light from a small pen light in the eyes of the client. The pupil constricts or tightens. The nurse understands this reaction is a(n):
 Definition
Direct response to light
Term
The nurse is assessing peripheral pulses on a client with suspected peripheral vascular disease. Which of the following should the nurse report to the physician immediately?
 Definition
Thready pulses
Term
The nurse is performing a musculoskeletal assessment on a client admitted with a possible stroke. When testing for muscle grip strength, the nurse should ask the client to:
 Definition
Grasp the nurse's index and middle fingers while the nurse tries to pull the fingers out.
Term
How would the nurse assess an African - American client for cyanosis?
 Definition
Look for a bluish tinge in the nail beds, lips, and buccal mucosa that does not blanch when pressure is applied.
Term
What are the methods used for physical examination? (Select all that apply)
 Definition
Inspection – Percussion – Auscultation - Palpation
Term
After auscultating the abdomen, the nurse should report which of the following to the primary care provider?
 Definition
Absence of bowel sounds for 5 minutes
Term
A client's wound is draining thick white to yellow material. The nurse correctly documents the drainage as:
 Definition
Purulent
Term
While caring for a 90 year old immobile client the nurse turns him and notes a reddened area over the coccyx with intact skin but
the area does not blanch with gentle pressure. The nurse documents this as what stage of pressure ulcer?
 Definition
I
Term
The nurse is caring for a client in the clinic who was involved in a motorcycle crash and slid across the pavement while wearing
shorts. The legs have multiple scrape wounds with dirt embedded under the epidermis. The nurse documents these wounds as:
 Definition
Abrasions
Term
Which exam technique is being used when the nurse touches the client's abdomen to examine the size of the liver?
 Definition
Palpation
Term
All of the following are pressure points on the human body EXCEPT:
 Definition
Soles of the feet
Term
Guidelines for preventing pressure sores include all of the following EXCEPT:
 Definition
Massage white, red, or purple areas on skin often
Term
The first signs of skin breakdown include all of the following EXCEPT:
 Definition
Pressure sores
Term
All of the following are risk factors for pressure sores EXCEPT:
 Definition
Obesity
Term
All of the following are normal changes in the gastrointestinal system due to aging EXCEPT:
 Definition
Pain with bowel movements
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