Exam 5 (Ch 21 Test Questions

Question 1

1. Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis?
   1) Risk for Falls
   2) Risk for Ineffective Airway Clearance (choking)
   3) Risk for Poisoning
   4) Risk for Suffocation (drowning)

Answer 1

1

Question 2

2. A 78-year-old patient is being seen in the emergency department. The nurse observes his gait and balance appear to be slightly unsteady. What assessment should the nurse perform next?
   1) Perform the Get Up and Go Test.
   2) Ask the patient if he has fallen in the past year.
   3) Refer the patient for a comprehensive fall evaluation.
   4) Administer the Timed Up and Go Test.

Answer 2

3

Question 3

3. The nurse notes that the electrical cord on an IV infusion pump is cracked. Which action by the nurse is best?
   1) Continue to monitor the pump to see if the crack worsens.
   2) Place the pump back on the utility room shelf.
   3) A small crack poses no danger so continue using the pump.
   4) Clearly label the pump and send it for repair.

Answer 3

4

Question 4

4. A patient with a history of falling continually attempts to get out of bed unassisted despite frequent reminders to call for help first. Which action should the nurse take first?
   1) Apply a cloth vest restraint.
   2) Encourage a family member to stay with the patient.
   3) Administer lorazepam (an antianxiety medication).
   4) Keep the patient’s bed side rails up.

Answer 4

2

Question 5

5. Despite less restrictive interventions, a patient’s behavior escalates, requiring emergency application of restraints. Which of the following must the nurse do in this situation?
   1) Obtain a physician’s order before applying restraints.
   2) Monitor the patient’s status every 4 hours while restrained.
   3) Release the restraints and check circulation every hour.
   4) Continually reevaluate the patient’s need for restraint.

Answer 5

4

Question 6

6. A patient has received a radiation implant. The patient is weak and needs help even to turn in bed. Which action should the nurse take when caring for this patient?
   1) Avoid giving the patient a complete bed bath.
   2) Limit the amount of time spent with the patient.
   3) Allow extra time for the patient to express feelings.
   4) Do not allow anyone to visit the patient.

Answer 6

2

Question 7

7. A child is brought to the emergency department after swallowing liquid cleanser. He is awake and alert and able to swallow. Which action should the nurse take first?
   1) Administer a dose of syrup of ipecac.
   2) Administer activated charcoal immediately.
   3) Give water to the child immediately.
   4) Call the nearest poison control center.

Answer 7

3

Question 8

8. A nurse is teaching a group of mothers about first aid. Should poison come in contact with their child’s clothing and skin, which action should the nurse instruct the mothers to take first?
   1) Remove the contaminated clothing immediately.
   2) Flood the contaminated area with lukewarm water.
   3) Wash the contaminated area with soap and water and rinse.
   4) Call the nearest poison control center immediately.

Answer 8

1

Question 9

9. Which of the following instructions is most important for the nurse to include when teaching a mother of a 3-year-old about protecting her child against accidental poisoning?
   1) Store medications on countertops out of the child’s reach.
   2) Purchase medication in child-resistant containers
   3) Take medications in front of the child, and explain that they are for adults only.
   4) Never leave the child unattended around medications or cleaning solutions.

Answer 9

4

Question 10

10. A patient is brought to the emergency department after inhaling mercury. The nurse should be alert for which acute adverse effects associated with mercury inhalation?
    1) Chest pain, pneumonitis, and inflammation of the mouth
    2) Intestinal obstruction and numbness of the hands
    3) Hypotension, oliguria, and tingling of the feet
    4) Tachycardia, hematuria, and diaphoresis

Answer 10

1

Question 11

11. Which aspect of restraint use can the nurse delegate to the nursing assistive personnel?
    1) Assessing the patient’s status
    2) Determining the need for restraint
    3) Evaluating the patient’s response to restraints
    4) Applying and removing the restraints

Answer 11

4

Question 12

12. The nurse suspects a 3-year-old child who is coughing vigorously has aspirated a small object. Which action should the nurse take first?
    1) Encourage the child to continue coughing.
    2) Deliver upward abdominal thrusts with a fisted hand.
    3) Deliver five rapid back blows between the shoulder blades.
    4) Perform a blind finger sweep of the child’s mouth.

Answer 12

1

Question 13

13. Which is the most commonly reported “incident” in hospitals?
    1) Equipment malfunction
    2) Patient falls
    3) Laboratory specimen errors
    4) Treatment delays

Answer 13

2

Question 14

14. The Joint Commission’s national Speak Up campaign encourages patients to become active and informed participants on the healthcare team. The goal is to:
    1) prevent healthcare errors.
    2) help control the cost of healthcare.
    3) reduce the number of automobile accidents.
    4) provide a forum for people with no health insurance.

Answer 14

1

Question 15

15. A patient in the emergency department is angry, yelling, cursing, and waving his arms when the nurse comes to the treatment cubicle. Which action(s) by the nurse are advisable?
    1) Reassure the patient by entering the room alone.
    2) Ask the patient if he is carrying any weapons.
    3) Stay between the patient and the door; keep the door open.
    4) Make eye contact while stating firmly “I will not tolerate cursing and threats.”

Answer 15

3

Question 16

1. Which point(s) should the nurse include when teaching safety precautions to a mother of a toddler? Select all that apply.
   1) Make sure the child sleeps on his back at night.
   2) Keep the telephone number of the poison control center accessible.
   3) Use a front-facing car seat placed in the back seat of the car.
   4) Keep syrup of ipecac on hand in case of accidental poisoning.

Answer 16

2,3

Question 17

2. During a thermometer exchange program at a local hospital, a person drops a mercury thermometer on the floor. Assume the nurse has been trained in cleanup of such a spill. Select all that are appropriate. How should the nurse intervene?
   1) Using gloves and a paper towel, place the mercury in a plastic bag, and dispose of it.
   2) Notify the hazardous material management team immediately.
   3) Evacuate the area immediately.
   4) After putting on a gown, gloves, and a mask, clean up the mercury.
   5) Wash her hands well after removing the spill.
   6) Ventilate the area well for several days.

Answer 17

1,5,6

Question 18

1. Rank the following leading causes of accidental death in the United States according to their frequency of occurrence. Rank as 1 the one that occurs most frequently; rank as 4 the one that occurs least frequently.

A. Motor vehicle accidents

B. Falls

C. Suffocation

D. Poisonings

Answer 18

A,D,B,C

Question 19

2. When the nurse walks into the patient’s room, she notices fire coming from the patient’s trash can. Rank the following actions in the order they should be performed by the nurse. 1 should be done first; 4 should be last.

A. Activate the fire alarm.

B. Move the patient out of the room.

C. Close all doors and windows.

D. Put out the fire using the proper extinguisher.

Answer 19

B,A,C,D