Fundamentals of Nursing Quiz | Practice MCQ #mcq.imBooz

• (A) Apply a vest restraint.
• (B) Move the patient to a quieter room
• (C) Ask another nurse to care for the patient.
• (D) Provide comfort measures.

Check AnswerSolution[D]:- Patients sometimes become agitated because they are uncomfortable or in pain. Providing comfort measures may decrease agitation. If the patient continues to be agitated, the nurse should encourage a family member or friend to sit with the patient. Applying a physical restraint should be kept as a last resort for use only when less restrictive measures fail. The patient should be placed in a room near the nurses’ station so he can be checked frequently if there is no one available to provide one-on-one supervision. A quieter room would probably not help.

• (A) Leave the area.
• (B) Do not touch the gun.
• (C) Stop where he is.
• (D) Tell an adult

Check AnswerSolution[C]:- The child should be instructed to stop where he is. This allows him to think about the next steps he has memorized. Next, he should avoid touching the gun, leave the area, and immediately go tell an adult.

• (A) Orthostatic hypotension
• (B) Appendectomy
• (C) Dizziness
• (D) Orthostatic hypotension and Dizziness

Check AnswerSolution[D]:- Orthostatic hypotension, cognitive impairment, difficulty with walking or balance, weakness, dizziness, and drowsiness from certain medications place the patient at risk for falling. A history of right appendectomy and hyperthyroidism do not place that patient at risk for falling.

• (A) Slow speech
• (B) Monotone
• (C) Slow speech and Monotone
• (D) Formal dress

Check AnswerSolution[C]:- Speaking slowly with a monotone can contribute to reduced attention as the listener can think faster than the speaker is speaking, and the monotone voice has an almost hypnotizing effect. Smiling improves personal interest and connection between the speaker and listener so should not cause a loss of interest. Wearing formal business attire would not directly detract from listeners’ engagement in the speaker’s message unless it was unusual enough to distract listeners; nothing in the situation above indicates that is so.

• (A) “He’s being examined now; he’s awake and talking. We’ll take you to see him soon.”
• (B) “Don’t worry, I’m sure he’ll be fine; we have an excellent trauma team caring for him.”
• (C) “Everything will be okay; please take a seat and I’ll check on him for you.”
• (D) “Your son is strong and has youth on his side; I’m sure he’ll be fine.”

Check AnswerSolution[A]:- By telling the mother that her son is awake and talking and being examined by the doctor, the nurse provides accurate information and helps reduce the mother’s anxiety. Responses such as “Don’t worry, everything will be okay” and “I’m sure he’ll be fine” offer false reassurance and fail to respect the mother’s concern.

• (A) Work-related social support group
• (B) Therapy group
• (C) Task group
• (D) Community committee

Check AnswerSolution[A]:- Therapy groups are designed to help individual members cope with issues, such as the death of a spouse, divorce, or motherhood. Work-related social support groups help members of a profession cope with work-associated stress. Task groups meet to accomplish a specified task. Community-based committees meet to discuss community issues.

• (A) Describe how to operate the bed and call for the nurse.
• (B) Discuss communication patterns and roles within the family.
• (C) Openly express his concerns about the hospitalization.
• (D) State expectations related to discharge.

Check AnswerSolution[A]:- This is the orientation phase of the relationship. The orientation phase begins when the nurse introduces herself to the patient and begins to gather data. In this phase, the nurse and patient are getting to know each other. As part of the orientation phase, the nurse will orient the patient to the hospital room and routines. In the preinteraction phase, the nurse gathers information about the patient before she meets him. Discussion of personal information, particularly if sensitive or complex, is suitable for the working phase of the nurse-patient interaction. The patient expressing feelings and concerns also occurs during the working phase. During the working phase, care is communicated, thoughts and feelings are expressed, and honest verbal and nonverbal communication occurs. Stating expectations related to discharge is most appropriate for the termination phase-the conclusion of the relationship.

• (A) The patient’s shared semiprivate room
• (B) The hallway outside the patient’s room
• (C) An empty corner at the nurse’s station
• (D) A conference room at the end of the hall

Check AnswerSolution[D]:- The best environment in which to discuss sensitive matters is a quiet room where conversation can occur in private, particularly when the space is nonthreatening. The patient might be distracted if conversation takes place in a room where others (e.g., patients and visitors) are present. The hallway outside the patient’s room and the nurses’ station are public areas and should not be used for private conversation.

• (A) Staff meetings
• (B) Positive self-talk
• (C) Shift report
• (D) Wound care committee meeting

Check AnswerSolution[B]:- The nurse engaging in positive self-talk is using intrapersonal communication-conscious internal dialogue. Staff meetings, shift report, and a committee meeting are all examples of group or interpersonal communication.

• (A) Febrile and has a radial pulse of 100 bpm
• (B) A runner who has a radial pulse of 62 bpm
• (C) An infant with no history of cardiac defect
• (D) An elderly adult who is taking antianxiety medication

Check AnswerSolution[C]:- An apical pulse should be taken if the radial pulse is weak and/or irregular, if the rate is <60 or >100, if the patient is on cardiac medications, or when assessing children up to 3 years. It is difficult to palpate a peripheral pulse on infants and young children.

• (A) Young child playing soccer during the summer
• (B) Middle-aged adult snow skiing
• (C) Young adult playing golf on a hot day
• (D) Older adult raking leaves on a cold day

Check AnswerSolution[D]:- Older adults have more difficulty maintaining body heat because of their slower metabolism, loss of subcutaneous fat, and decreased vasomotor control.

• (A) Axillary with an electronic thermometer
• (B) Oral with a glass thermometer
• (C) Rectal with an electronic thermometer
• (D) Tympanic with an infrared thermometer

Check AnswerSolution[C]:- The rectal route is the most accurate for assessing core temperature, especially when it is critical to get an accurate temperature. Therefore, in this situation it is preferred. Temperature is a particularly relevant data point for this client with hypothermia as it indicates the patient’s baseline status and response to treatment. The electronic thermometer is safer than glass and is relatively accurate. Mercury thermometers are no longer used in the hospital setting. The accuracy of tympanic thermometers is debatable.

• (A) 118/68 when standing and 110/72 when lying down
• (B) 140/80, HR 82 bpm when sitting and 136/76, HR 98 bpm when standing
• (C) 126/72 lying down and 133/80 when sitting, and reports shortness of breath
• (D) 146/88 when lying down and 130/78 when standing, and reports feeling dizzy

Check AnswerSolution[D]:- Orthostatic hypotension is a drop of 10 mm Hg or more in blood pressure upon moving to a standing position, with complaints of feeling dizzy and/or faint.

• (A) Pulse deficit
• (B) Blood pressure
• (C) Apical pulse
• (D) Pulse pressure

Check AnswerSolution[B]:- If the leg pulses are weak, the nurse should assess the blood pressure in order to further explore the reason for the low pulse volume. If the blood pressure is low, then a low pulse volume would be expected. The pulse deficit is the difference between the apical and radial pulse. The apical pulse would not be helpful to assess peripheral circulation. The pulse pressure is the difference between the systolic and diastolic pressures.

• (A) Crackles
• (B) Rhonchi
• (C) Stridor
• (D) Wheezes

Check AnswerSolution[C]:- Stridor is a sign of respiratory distress, possibly airway obstruction. Crackles and rhonchi indicate fluid in the lung; wheezes are caused by narrowing of the airway. Crackles, rhonchi, and wheezes indicate respiratory illness and are potentially serious but do not necessarily indicate respiratory distress that requires immediate medical attention.

• (A) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing
• (B) Rectal temperature is 97.9°F in the morning and 99.2°F in the evening
• (C) Heart rate was 76 before eating and is 60 after eating
• (D) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing and Heart rate was 76 before eating and is 60 after eating

Check AnswerSolution[D]:- The BP change is abnormal; a BP change greater than 10 mm Hg may indicate postural hypotension. The change in heart rate is abnormal; heart rate usually increases slightly after eating rather than decreasing. The temperatures are within normal range for the rectal route, and temperature increases throughout the day. It is normal to have an increased respiratory rate after exercise.

• (A) Infection at the catheter insertion site
• (B) Side effect of the epidural analgesic
• (C) Epidural catheter migration
• (D) Spinal cord damage

Check AnswerSolution[C]:- The patient is exhibiting signs of epidural catheter migration, which include nausea, a decrease in blood pressure, and loss of motor function without an identifiable cause. Signs of infection at the catheter site include redness, swelling, and drainage. Loss of motor function is not a typical side effect associated with epidural analgesics. These are common signs of catheter migration, not spinal cord damage.

• (A) Celecoxib (Celebrex)
• (B) Aspirin (Ecotrin)
• (C) Indomethacin (Indocin)
• (D) Celecoxib (Celebrex)

Check AnswerSolution[B]:- Aspirin is a unique NSAID that inhibits platelet aggregation. Low-dose aspirin therapy is commonly administered to decrease the risk of thrombophlebitis, myocardial infarction, and stroke. Ibuprofen, celecoxib, and indomethacin are NSAIDs, but they do not inhibit platelet aggregation.

• (A) Immediately
• (B) In 10 minutes
• (C) In 15 minutes
• (D) In 60 minutes

Check AnswerSolution[D]:- Codeine administered by the oral route reaches peak concentration in 60 minutes; therefore, the nurse should reassess the patient’s pain 60 minutes after administration. The nurse should reassess pain after 10 minutes when administering codeine by the intramuscular or subcutaneous routes. Drugs administered by the intravenous (IV) route are effective almost immediately; however, codeine is not recommended for IV administration.

• (A) Caution the patient to limit the number of times he presses the dosing button.
• (B) Ask another nurse to double-check the setup before patient use.
• (C) Instruct the patient to administer a dose only when experiencing pain.
• (D) Provide clear, simple instructions for dosing if the patient is cognitively impaired.

Check AnswerSolution[B]:- As a safeguard to reduce the risk for dosing errors, the nurse should request another nurse to double-check the setup before patient use. The nurse should reassure the patient that the pump has a lockout feature that prevents him from overdosing even if he continues to push the dose administration button. The nurse should also instruct the patient to administer a dose before potentially painful activities, such as walking. Patient-controlled analgesia is contraindicated for those who are cognitively impaired.