PCC Exam Review 2

The nurse performs a focused respiratory assessment at 2:35 in the afternoon. How should the nurse document this in the chart?

• 0235

• 1435

• 16:35

• 02:35 PM

Which of the following documentation entries is the most thorough and appropriate for a patient experiencing pain?

• "Patient appears uncomfortable and states “I’ve never had pain this bad before”. He might be lying but was given something for pain anyway.”

• "Patient has pain. Gave some ordered PRN pain medication.”

• "Patient reports severe pain in the lower back, rated 8/10 on the pain scale, worsens with movement, relieved slightly by rest. Administered 5 mg of morphine at 0900 and reassessed.”​
  

• "Patient complains of pain, called the provider and notified them of this. Morphine given at noon and reassessed."

Which of the following devices administers the least amount of oxygen?

• Non-rebreather mask

• Nasal Cannula

• Face Mask

• Venturi Mask

When comparing and contrasting nebulizers and incentive spirometers, which of the following statements is correct?

• The incentive spirometer takes longer to complete than the nebulizer

• The incentive spirometer can be done using a mouthpiece or a mask.

• One of the key purposes of the incentive spirometer is to assess respiratory improvement.

• A nebulizer would be considered an independent nursing intervention.

Which of the following are nursing interventions to help improve oxygenation and reduce complications in your patients? (Select all that apply)

• Repositioning to High Fowler's

• Using an incentive spirometer

• Teaching about pursed lip breathing

Yankauer suction (see image) is used for which of the following?

• Upper Airway

• Lower Airway

• Oral Cavity

• Ear

Which of the following is/are an appropriate administration site for an IM injection? (select all that apply)

• 
  Scapular muscle

• 
  Ventrogluteal muscle

• 
  Vastus Lateralis

• 
  Dorsogluteal muscle

• Deltoid muscle

A nurse is teaching an adult client how to self-administer ear drops. Which of the following statements indicates an understanding of the teaching?

• 
  I will pull my ear down and back before I insert the drops

• I will chill my ear drops before I use them

• I will lie with the ear I am administering the medication up and lay here for 10 minutes

• I will sit up and be sure to not touch the conjunctiva with the dropper

You are teaching your primarily Spanish-speaking patient about taking nitroglycerin. Which of the following interventions is culturally competent?

• Use a family member who is the decision maker to teach the patient on how to administer the medication

• Show the patient how to use Google translate for the discharge instructions

• 
  Provide information in Spanish through an interpreter and printed materials in Spanish

• Use materials for individuals at a 4th grade reading level

A nurse is conducting patient teaching for a newly diagnosed diabetic patient who states they are anxious and stressed about managing their condition. Which of the following approaches should the nurse take to enhance the effectiveness of the teaching session?

• Provide all the information in one long session to cover everything at once.

• Use medical jargon to ensure the patient understands the technical aspects of their condition.

• Acknowledge their anxiety and break the information into smaller, manageable parts focusing on what they need to know.

• Focus only on the potential complications of diabetes to emphasize the seriousness of the condition.