Font size
WorksheetsNGS 3100 Exam 1 Review
Total questions: 52
Worksheet time: 52mins
A nurse must make the decision to give a client a full or partial bed bath. Which criterion is most important for the basis of this decision?
Primary health-care provider’s prescription for the client’s activity
Immediate need of the client
Time of client’s last bath
Client preferences
A client is incontinent of urine and stool. For which client response should the nurse be most concerned?
Impaired skin integrity
Altered sexuality
Dehydration
Confusion
A nurse is giving a client a bed bath. Which nursing action is most important?
Lower the 2 side rails on the working side of the bed
Ensure that the bathwater is at least 105-110°F
Fold the washcloth like a mitt on the hand
Raise the bed to the highest position
Which condition identified by the nurse places a client at the highest risk for impaired self-care when toileting?
Amputation of a foot
Early dementia
Fractured hip
Pregnancy
A client just had perineal surgery. Which type of bath should the nurse expect to be prescribed for this client?
Sponge bath
Sitz bath
Tub bath
Bed bath
A nurse must bathe the feet of a client with diabetes. Which should the nurse do before bathing this client’s feet?
File the nails straight across with an emery board
Teach that daily foot care is essential for adequate hygiene
Ensure a provider’s prescription for hygienic foot care is obtained
Assess for additional risk factors that may contribute to localized problems
A nurse is helping a client who has right hemiparesis to get dressed. Which action should the nurse implement?
Put the gown’s right sleeve on first
Keep the client in an open-backed gown
Encourage the client to dress independently
Leave the right sleeve off while adjusting the tie at the neck
A client who has a fever experienced significant diaphoresis during the night. The client states, “I am tired, and I just want to sleep this morning.” Which should the nurse do regarding bathing the client?
Wait until the client feels better
Postpone bathing until the afternoon
Give a bed bath with complete assistance
Consult with the primary health-care provider before providing care
A nurse gives a bedbound client a bed bath. Which is the primary reason why the nurse provides hygiene care to this client?
Support a sense of well-being by increasing self-esteem
Promote circulation by stimulating peripheral nerve endings
Remove excess oil, perspiration, and bacteria by mechanical cleansing
Exercise muscles by contraction and relaxation of muscles when bathing
Which human response, identified by the nurse, best supports the concern that a client has a reduced capacity to provide for activities of daily living?
Presence of joint contractures
Inability to wash body parts
Postoperative lethargy
Visual disorders
When giving a client a bed bath, a nurse washes the client’s extremities from distal to proximal. Which is the rationale for this nursing action?
Decreases the chance of infection
Facilitates removal of dry skin
Stimulates venous return
Minimizes skin tears
A nurse is teaching a client about how many times a day it is necessary to brush the teeth to achieve effective dental hygiene. According to the American Dental Association, how many times a day should the nurse teach the client to brush the teeth?
6
4
3
2
Which nursing intervention most requires the nurse to consider the concept of intimate space?
Providing a bed bath
Obtaining the vital signs
Performing a health history
Ambulating the client down the hall
Which action should be taken when attempting to decrease falls in the hospital setting?
Lower the height of the bed and the bottom two side rails before leaving the room.
Ask patients on first encounter to use the bathroom and every 4 hours thereafter.
Instruct patients to use the call light only if they think they need help getting out of bed.
Encourage patients to not take any prescribed medicine that could cause drowsiness or light headedness.
The nurse demonstrates proper use of a fire extinguisher by taking which action first?
Sweep from side to side
Pull the pin
Squeeze the handles together
Aim and approach the fire
A nurse is assessing a patient in restraints. The nurse observes correct use of restraints by checking which of the following?
Restraint is tied in a secure knot.
Restraint is secured to the bedrail
Restraint allows for 4 fingers width between restraint and patient’s wrist.
Restraint is secured to the bedframe
The nurse implements the necessary safety precautions in an environment for a patient by doing which of the following? (Select all that apply.)
Place bed in lowest position with brakes locked.
Put both upper side rails up while patients are in bed.
Move personal belongings within reach.
Place bedside table between patient and the bathroom to use as a resting area.
Ensure that all patients have bedside commode access.
The nurse is providing discharge instructions on ways to prevent falls at home. Which of the following guidelines are helpful in preventing falls? (Select all that apply.)
Always wear socks when walking to protect your feet when ambulating.
Remove rugs that can slip; use rubber mats instead.
Use your walker or cane even if only moving short distances.
Put frequently used items in easy-to-reach places.
Use handrails when available.
Of the following hospitalized patients, who is most at risk for acquiring a health care–associated infection?
A 60-year-old who smokes two packs of cigarettes per day
A 40-year-old who has an indwelling urinary catheter in place
A 65-year-old who is a vegetarian and slightly underweight
A 60-year-old who has a white blood cell count of 6000
An alert and oriented elderly male patient has been admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). He is unshaven, has unkempt hair, and has a foul body odor. Asking which hygiene-related assessment question is a priority for the nurse?
“Do you have friends or family nearby?”
“Can you raise your arms up to brush your teeth?”
“Do you become short of breath during your shower?”
“Are you able to get in and out of your bed at home?”
Which action by a female patient lets the nurse know the patient has understood perineal care teaching?
The patient washes her perineum with a circular motion beginning at the urinary meatus.
The patient washes her perineum from front to back using a clean washcloth.
The patient washes her perineum from back to front with long, firm strokes.
The patient washes her perineum lightly to prevent tissue damage.
Which actions by the nurse concerning oral care for an unconscious patient are considered safe? (Select all that apply.)
Performing oral care with the patient in a supine position
Performing oral care with the patient turned to the side
Installing suction equipment at the bedside
Providing oral care every 2 hours
Using a hard-bristle toothbrush
Which safety precaution is a priority for the nurse when bathing a patient with peripheral neuropathy?
Keeping the top two side rails up during the bath
Checking the bath water temperature before the bath
Encouraging independence with perineal care during the bath
Facilitating range-of-motion exercises and dangling before the bath
Which nursing diagnosis is a priority for a patient who needs assistance with activities of daily living?
Self-Care Deficit
Lack of Knowledge
Activity Intolerance
Able to Perform Self-Care
The student nurse is preparing for the first clinical day of patient care. Which strategy of critical thinking would be an example of thinking ahead?
Researching evidence-based care strategies
Assessing the patient’s physical status
Identifying and preventing patient risk
Deciding what component of care could be improved
Which educational activities will promote the development of clinical judgment skills in nurses and student nurses? (Select all that apply.)
Unfolding case studies
Clinical assignments
Simulation of clinical scenarios
Answering true/false test questions
Concept mapping
A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first?
Family history of diabetes
Medications the patient is taking
Operations the patient has had in the past
Severity and duration of the nausea and vomiting
An alert, oriented patient is admitted to the hospital with chest pain. From whom should the nurse collect primary data on this patient?
Family member
Physician
Another nurse
Patient
On what premise is a nursing diagnosis identified for a patient? (Select all that apply.)
Recognized cues
Nursing intuition
Clustered data
Medical diagnoses
Which statement is an appropriately written short-term goal?
Patient will walk to the bathroom independently without falling within 2 days after surgery.
Nurse will watch patient demonstrate proper insulin injection technique each morning.
Patient’s spouse will express satisfaction with patient’s progress before discharge.
Patient’s incision will look good each time it is assessed by the nurse.
What should be the primary focus for nursing interventions?
Patient needs
Nurse concerns
Physician priorities
Patient’s family requests
Which nursing action is critical before delegating interventions to another member of the health care team?
Locate all members of the health care team.
Notify the physician of potential complications.
Know the scope of practice and competency of the other team member.
Call a meeting of the health care team to determine the needs of the patient.
A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first?
Consider possible reasons for the patient’s inability to sleep.
Request medication to help the patient sleep.
Tell the patient that sleep will come with relaxation.
Notify the physician that the patient is restless and anxious.
What action should the nurse take regarding a patient’s plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery?
Consult the surgeon to see whether the clinical pathway is being followed.
Discontinue the plan of care because the patient has met the established goal.
Monitor patient urine output to evaluate the need for the current plan of care.
Notify the patient that the goal has been attained and no further intervention is needed.
Which factors should be taken into consideration by the nurse before and during a patient interview? (Select all that apply.)
Distance between the chairs in which the nurse and patient are sitting
Traditional treatments typically used by the patient to treat disease
Physical condition of the patient
Music preference of the patient
Gender preference for primary care providers (PCPs)
Which entry in a patient’s electronic health record best indicates the need for a nurse to gather secondary rather than primary subjective data?
Complaining of chest pain
Apical pulse 110
Comatose
Difficulty swallowing
Which nursing goal is written correctly for a patient with the nursing diagnosis of Risk for Infection after abdominal surgery?
Nurse will encourage use of sterile technique during each dressing change.
Patient’s white blood count will remain within normal range throughout hospitalization.
Patient’s visitors will be instructed in proper handwashing before direct interaction with patient.
Patient will understand the importance of cleaning around the incision with a clean cloth during bathing.
Which intervention would be most important for the nurse to include in a patient’s care plan if the patient is unable to complete activities of daily living without becoming fatigued?
Instruct the patient to shower and shave simultaneously.
Discourage the patient from bathing while hospitalized.
Encourage the patient to rest between bathing activities.
Ask the patient’s spouse to assist with all bathing.
What should be taken into consideration by the nurse when deciding on interventions to include in a patient’s plan of care? (Select all that apply.)
Patient’s treatment preferences
Cultural and ethnic influences
Nurse’s professional expertise
Current evidence-based research
Convenience to the nursing staff
Which notation is most appropriate for the nurse to include in a patient’s chart regarding evaluation of the goal “Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)”?
Goal not met; patient states he is tired.
Goal not met; patient ambulated three times in room.
Goal met; patient ambulated three times in the hallway.
Goal met; patient ambulated three times in the hallway without SOB.
The nurse is preparing to assist the patient to walk to the bathroom after medicating the patient with a narcotic for pain management. What possible adverse effect should the nurse be immediately aware?
Constipation
Depression
Dizziness
Pain relief
The nurse correctly selects which intervention to avoid causing shear or friction when moving a patient in bed?
Using an airflow bed
Using a slide board
Using a trochanter roll
Using a gel mattress
The nurse is preparing to reposition the patient in bed. What is the first step in this process?
Position the patient’s arms across his/her chest.
Lower the side rails.
Grasp the draw sheet.
Raise the bed to a working height.
The nurse has delegated to the UAP to assist a patient with ambulating in the hallway with a cane. Which statement by the UAP indicates a need for further education?
“I should report any complaints of soreness to the nurse.”
“I should watch for indications that the patient has difficulties using the cane.”
“I should let the nurse or PT know if the cane doesn’t seem to fit correctly.”
“I should teach the patient how to walk with the cane.”
The nurse knows which items are included in the documentation for a patient on fall precautions? (Select all that apply.)
History of any falls
Falls risk assessment scores
Patient and family education
Use of assist devices
Any fall or reported fall
The nurse is correctly demonstrating the use of a transfer belt when engaging in which actions? (Select all that apply.)
The belt is placed around the patient’s hips.
The belt is secure, leaving only enough room for the nurse to grasp the belt.
The nurse stands on the weaker side.
The nurse holds the belt on the side of the patient.
The nurse stands behind the patient while ambulating.
The nurse is correctly assisting the patient in using a cane when the patient demonstrates which activities? (Select all that apply.)
The top of the cane is level with the patient’s bent elbow.
The patient holds the cane on his/her weaker side.
The patient moves the cane forward first.
The patient’s arm is comfortably bent when walking.
The patient moves the strong leg forward first.
The nurse is providing discharge education for the patient who is going home with a walker. Which statements by the patient indicate a good level of understanding of safety in the home? (Select all that apply.)
“I need to remove the throw rugs.”
“I should make sure I only take a tub bath.”
“I cannot use the stairs.”
“I need to place a nonskid mat in front of the kitchen sink.”
“I wish I had two ways of leaving the house.”
The nurse is implementing generalized falls precautions for patients who are at risk for falls. Which intervention indicates a lack of understanding of these precautions?
The bed is placed in the low position.
The patient is wearing socks.
The patient’s cell phone is by the bedside.
The patient’s call light is within reach.
The nurse identifies which goal to be appropriate for the patient who is postoperative day one from abdominal surgery and on bed rest with the nursing diagnosis of Impaired skin integrity?
Patient will ambulate twice a day.
Patient will eat 50% of meals.
Patient will have no further skin breakdown.
Patient will interact with others.
The nurse recognizes which goal to be appropriate for the patient who is postoperative day one from a hip fracture with the nursing diagnosis Impaired mobility?
Patient will interact with others.
Patient will ambulate to the bathroom with assistance.
Patient will have no skin breakdown.
Patient will have a physical therapy consult.
The nurse is educating the family of a patient on falls risk precautions. Which statement by the family indicates a need for further education?
“I should keep the wheelchair locked unless using it to move Mom.”
“I should leave the bathroom light on as she does at her home.”
“I should leave her slippers by the wheelchair.”
“I should keep her cell phone close to her bed.”
