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WorksheetsNSG 3100 - Practice Questions - Exam 2
Total questions: 20
Worksheet time: 15mins
The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?
Provide analgesic medications as ordered.
Avoid accidentally removing the drain.
Don sterile gloves.
Gather supplies.
The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?
Continue to monitor the wound.
Document the characteristics of the wound.
Provider will debride the wound.
Drainage from wound will be managed.
The nurse is caring for a patient who is immobile. The nurse wants to decrease the formation of pressure ulcers. Which action will the nurse take first?
Offer frequent fluids.
Turn the patient every 2 hours.
Determine the patient’s risk factors.
Encourage increased quantities of carbohydrates and fats.
The nurse is cleaning a wound. As the nurse performs the procedure, which intervention should be included?
Allow the solution to flow from the most contaminated to the least contaminated.
Scrub vigorously when applying noncytotoxic solution to the skin.
Cleanse in a direction from the least contaminated area to most contaminated.
Utilize clean gauze and clean gloves to cleanse a site.
A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing?
Hemoglobin/Hematocrit
Muscular strength
Sleep
Sensation
The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?
Secondary intention
Tertiary intention
Primary intention
Partial-thickness repair
A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence?
Protrusion of visceral organs through a wound opening
Chronic drainage of fluid through the incision site
Report by patient that something doesn't feel right
Drainage that is odorous and purulent
The nurse is caring for a group of patients. Which patient will the nurse see first?
A patient with tuberculosis in airborne precautions
A patient with MRSA infection in contact precautions
A patient with Clostridium difficile in droplet precautions
A patient with pneumonia in droplet precautions
The nurse is admitting a patient with an infectious disease process. Which question will be most appropriate for a nurse to ask about the patient’s susceptibility to this infectious process?
“Do you have a spouse?”
“Do you have a chronic disease?”
“Do you have any children living in the home?”
“Do you have any religious beliefs that will influence your care?”
The nurse is changing linens for a postoperative patient and feels a prick in the left hand. A contaminated needle is noted in the linens. For which condition is the nurse most at risk?
Diphtheria
Hepatitis B
Methicillin-resistant Staphylococcus aureus
Clostridium difficile
The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change?
Donning clean goggles, gown, and gloves to dress the wound
Donning sterile gown and gloves to remove the wound dressing
Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing
Utilizing clean gloves to remove the dressing and clean supplies for the new dressing
The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for developing an infection?
A patient who is in observation for chest pain
A patient who has been admitted with dehydration
A patient who is recovering from a right total hip surgery
A patient who has been admitted for stabilization of heart problems
The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease?
Place the patient in a room with negative airflow.
Wear a gown, gloves, face mask, and goggles for interactions with the patient.
Transport the patient safely and quickly when going to the radiology department.
Use of dedicated equipment that stays in the room and is used only for that patient.
A nurse assesses a patient’s radial pulse rate to be 110 beats/min and regular. What action by the nurse is best?
Assess the patient for causes of tachycardia.
Take an apical heart rate and compare the two.
Notify the patient’s health care provider.
Document the findings in the patient’s chart.
The nurse is caring for a woman who had a right-sided mastectomy two years ago. What action by the nurse is most appropriate?
No specific action is needed for this situation.
Place a sign above the bed: “Blood pressures in legs only.”
Place a sign above the bed: “No continuous blood pressures on the right arm.”
Place a sign above the bed: “No blood pressures on the right arm.”
Which patient assessment result would require the nurse to assess that patient further?
A 65-year-old man with a respiratory rate of 10
A 50-year-old man with a BP of 112/60 upon awakening in the morning
A 40-year-old woman with a radial pulse of 68
A 12-year-old with a pulse of 92 after ambulating in the hallway
The nurse receives a hand-off report on four patients. Which patient finding should the nurse assess first?
Pulse oximetry 94%
Blood pressure 130/82 mm Hg
Pulse 48 beats/min
Respiratory rate 16 breaths/min
A nurse observes a student taking an adult patient’s tympanic temperature. What action by the student requires the nurse to intervene?
Student pulls the pinna of the patient’s ear down and back.
Student washes hands prior to patient contact.
Student explains the procedure to the patient.
Student pulls the pinna of the patient’s ear up and back.
A nurse performs orthostatic blood pressure readings on a patient with the following results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best?
Reassess the blood pressures in 1 hour.
Reassure the patient that these findings are normal.
Instruct the patient not to get up without help.
Document the findings and continue to monitor.
The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The pulse oximeter does not provide a good reading. What action by the nurse is best?
Move the oximeter probe to another finger.
Remove any fingernail polish present on the fingernail.
Assess the fingers for good circulation.
Document that the reading cannot be obtained.
