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INP 2 Exam 1 Questions And Answers
The nurse is having difficulty reading a medication order. Which is the best action for the nurse to take to prevent a med error? a) Clarify the order with the health care provider who wrote it b) Talk with the pharmacist who knows what is usually ordered c) Ask a nurse who knows the health care provider to read it d) Have a nurse interpret the written medication order a) Clarify the order with the health care provider who wrote it when receiving a telephone order from a physician, which nursing action demonstrates best practice? a) Repeat prescribed orders back to the physician to very accuracy b) document a description of the reason the telephone orders was needed c) Clarify the order with another nurse colleague d) Write physician orders in your best handwriting a) Repeat prescribed orders back to the physician to very accuracy Who takes primary responsibility for the correct transcription of a physicians telephone medication order? a) Nurse administering the medication b) Pharmacist dispensing the medication c) unit clerk transcribing the order d) RN/LPN receiving the order d) RN/LPN receiving the order A physician comes to see his patient and writes orders. Which of the following orders need to be processed first? a) Glucometer test Q.I.D ac meals and at HS b) Nutrition consult: Diabetic 1200 calorie diet. c) ECG, CBC,electrolytes, cardiac enzymes STAT d) Change metformin to 500mg po B.I.D c) ECG, CBC, electrolytes, cardiac enzymes STAT
Performing a physical assessment for an older adult client, the nurse anticipates finding which one of the following normal physiological changes of aging? a) Increased perspiration b) Increased audio pitch discrimination c) Increased salivary secretions d) increased airway resistance d) increased airway resistance *After visiting with a client, the nurse documents the assessment data. Both objective and subjective info have been obtained during the assessment. Which of the following is classified as objective data? a) Pain in the left leg b) Elevated blood pressure reading c) Fear of surgery. d) Discomfort with breathing b) Elevated blood pressure reading The most common angle for an intramuscular injection is: a) 45 degrees b) 60 degrees c) 90 degrees d) 35 degrees c) 90 degrees *Your client feels faint, has difficulty breathing and reports feeling nauseated. What focused assessments does the nurse perform? a) Vital signs, chest and abdominal assessment b) Vital signs and abdominal assessment c) Peripheral vascular assessment, vital signs d) Chest assessment, vital signs, CWMS a) Vital signs, Chest and abdominal assessment What must the practical nurse consider when completing a health assessment of the older adult? a) Vital organs are in different locations due to the expected aging process.
a) Diarrhea b) Coughing c) Cold sores around the mouth d) Stool cultures on all suspected carriers a) Diarrhea *The nurse is considering the correct sequence for putting on the protective equipment which of the following describes the correct sequence? a) Wash hands, put on gown, apply the mask & eye wear, and then apply gloves b) apply mask and eye wear, put on gown, wash hands, and then apply gloves c) wash hands, put on the gown, apply gloves and then put on mask and eye wear d) put on the gown, apply the mask and eye wear, wash ahdns and then apply gloves a) wash hands, put on the gown, apply mask & eye wear The nurse observes the hand washing technique of non-regulated healthcare provider (HCP). Which behavior by the non0regulated HCP requires additional training? a) Washes well lathered hands for 5-10 seconds b) Uses warm running water and soap c) Dries the hands from the fingers to the wrists d) Keeps hands and foramrs below the elbows a) washes well lathered hands for 5-10 seconds The z-track technique is used to give irritating medications via the: a) Subcutaneous route b) Intravenous route c) Intramuscular route d) Intradermal route c) Intramuscular route Which of the following nursing diagnosis is appropriate to use for a pt who is infected with pathogen and is in close contact with people? a) Risk for infection b) Risk for impaired social interaction due to isolation
c) Risk for complications related to infection d) Risk for transmission of infection d) Risk for transmission of infection A client complains of pain and asks the nurse for pain meds. The nurse first assesses vital signs and finds them to be as follows: B/P 134/92; Pulse 90; and respiration 26. which of the following is the nurses most appropriate action? a) Assess with a pain scale and administer medication b) Inquire if the client is anxious c) Check the clients dressing for bleeding d) recheck the clients vital signs in 30 minutes a) assess the pain with a scale and administer medication The nurse frequently must assess a client experiencing pain. When assessing the intensity of pain the nurse should: a) Ask about what precipitates the pain b) Question the client about the location of the pain c) Offer the client a pain scale to provide objective information d) Use open-ended questions to find out the sensation c) Offer the client a pain scale to provide objective information Mrs. Brown, 88 years old, has returned to the long term care unit following hip surgery. She has been encouraged to mobilize following hip surgery, however her hip is painful when she stands and walks and is reluctant to mobilize. The medication order reads: Tylenol #3 (1-2 tablets) po q 4-6 prn for pain. What is the priority nursing action to take before mobilizing her? a) Restrict client to bed rest as she fatigues easily and teach her leg exercises b) Give her half the ordered med dosage due to her advance age c) Best practice advises to assess her degree of pain once mobilizing d) Check MAR and nurses notes for precious administered d) check MAR and nurses notes for previous dose administered. Which of the following is non pharmacological approach that the nurse may implement for clients experience pain, and which focuses on promoting pleasurable meaningful stimuli?
a) Coughing or sneezing into her hands and then immediately washing hands with alcohol based soap b) Coughing into a tissue or cloth that can be reused to save resources then using alcohol based hand rub immediately c) Coughing or sneezing into a tissue and discarding the tissue into a bio- hazardous waste container d) Coughing into a tissue, disposing the tissue in the garbage followed by washing hands with soap and water d) Coughing into a tissue, disposing the tissue in the garbage followed by washing hands with soap and water The nurse working with clients in pain needs to recognize and avoid misconceptions and myths about pain. With respect to the pain experience, which of the following is correct? a) The client is the best authority on the pain experience b) Chronic pain is mostly psychological in nature c) Regular use of analgesics leads to drug addiction d) The amount of tissue damage is accurately reflect in the degree of pain perceived a)The client is the best authority on the pain experience Upon entering the clients room, the nurse discovers that the client is experiencing acute pain. Which of the following is an expected assessment finding for this client? a) Bradycardia b) Bradypnea c) Diaphoresis d) Decreased muscle tension c) Diaphoresis The nurse needs to document a medication that has just been administered. Which technique should the nurse use to document medication administration? a) Document the medication immediately before administration b) Record the time administered and the nurses name immediately after
administration c) Record medication administration time, route, and dose at the end of the shift d) Delegate recording administration time and nurses; name in the MAR b) Record the time administered and the nurses name immediately after administration A focused assessment is best defined as an assessment that: a) Involves all organ systems of the body b) Is completed on admission to a unit c) Is performed as determined by diagnosis or whenever there is a change in the pts condition d) is performed only on the critically ill pt c) Is performed as determined by diagnosis or whenever there is a change in the pts condition A pt looks at the medication in the cup and tells the nurse that he does not take one of the tablets. Which action should the nurse take next? a) Tell the pt. that the medications are correct b) Recheck the medication and the medication order c) Call the pharmacy to bring the correct medication d) Remove the medication and document the incident b) Recheck the medication and the medication order To maintain principles of medical asepsis when administering subcutaneous medications the nurse should: a) Wash the rubber top of the vial with soap and water b) Cleanse the rubber top of the vial briskly with an alcohol swab c) Wear sterile gloves while injecting the pt. d) Recap the needle after administer the medication b) Cleanse the rubber top of the vial briskly with an alcohol swab The client is to receive heparin by injection. The nurse prepares to inject this medication in the clients: a) Scapula region b) Ventrogluteal site
c) Anterior aspect of the upper thigh d) Acromion process and axilla b) Greateer trochanter, anterior iliac spine, and iliac crest Which of the following is the most effective way in acute care environment to determine the pts identity before administering medications? a) ask the patients name b) Check the name on the chart c) Ask the caregivers d) Check the patients name band d) Check the patients name band *The Patient awakens at 0300hrs requesting pain medication, but the nurse does not administer additional pain medication. What justifies the nurses' decision to withhold the medication? a) The patient had a reaction to asprin 5 years ago b) The nurse wants to help the patient avoid drug addiction c) The patient was sound asleep when the nurse returns with the analgesia d) The patient wants pain medication every 3-4 hours exactly c) The patient was sound asleep when the nurse returns with the analgesia Which of the following needle gauges is the smallest? a) 18 b) 16 c) 21 d) 26 d. 26 *The nurse is administering an intramuscular injection. Upon aspiration, the nurse notices that there is blood in the syringe. Which of the following actions should the nurse take? a) Inject the medication b) Pull the needle back slightly and inject the medication c) Move the skin to the side and inject the medication slowly d) Discontinue the injections and prepare medication again
d. Discontinue the injections and prepare medication again A nurse transfers the pt. from the bed to the chair using a mechanical lift. Which should the nurse do before leaving the pts room to ensure the pt safety? a) Remove the sling from under the pt. b) Document pt response to the transfer c) Secure the call bell within the pt.s reach d) Return the base of the lift to its original position c) Secure the call bell within the pt.s reach A patient has been wandering and is at risk for falling. Which approach by the nurse regarding the use of chemical and physical restraint in the long term care setting needs should be considered initially? a) Use non-prescription restraints first b) Obtain with a telephone prescription c) Implement alternative measures first d) Notify patients family within 24 hours c) Implement alternative measures first Mrs. Thompson tells her nurse that she fell in the shower. According to the guidelines for documentation how should, this information be charted? a) Patient fell in the shower b) Patient states "fell in the shower" c) Patient appears to have fallen in the shower. d) Patient has a bruise on her left leg after falling in the shower b) Patient states "fell in the shower" The Client climbed over the side rails and fell to the floor. An incident report is to be completed. The correct reporting of the incident involves which of the following? a) The nurse witnessing the event completes the report b) Details of the incident are subjectively described c) An explanation of the possible cause for the incident is entered d) Information collected from family members is included in the medical record. a) The nurse witnessing the event completes the report
The nurse writes an incident report on a client who fell. What is the main purpose of this documentation tool? a) Allows the facility a process to avoid future lawsuits b) Assist in quality improvement with future prevention c) Assure a proper plan of care for the client is maintained d) Provide data for maintenance of the medical records b) Assist in the quality improvement with future prevention Quick Priority Assessment (QPA) is performed on patients: a) First 3-5 minutes of your shift b) On awakening prior to breakfast c) At the start of your shift taking 3-5 minutes for each patient d) Done frequently through out your shift taking 3-5 minutes d) Done frequently throughout your shift taking 3-5 minutes
