Mike's NCLEX Test 3

1.

2 points

The oblique side-lying (lateral) position is helpful because:

the shoulder is rolled to a forward position

all areas of the lung will drain secretions to the bronchus

it takes pressure off of the trochanter and shoulder

the patient does not need to be re-positioned as oftern

2.

2 points

When changing the patient's position, it is most important to:

use only those muscles absolutely necessary

work at the same level or height as the patient

push rather than pull, as your weight helps

stand with feet close together for greater strength

3.

2 points

A principle of body movement for nurses when transferring a patient is:

bend at the waist.

keep feet together.

use smooth, coordinated movements.

fully extend elbows.

4.

2 points

A nurse is performing mouth care on an unconscious patient. The nurse should:

provide full mouth care at least every 8 hours.

provide moist swabbing of the mouth every 4 hours.

provide full mouth care at least every 24 hours.

provide moist swabbing of the mouth every 8 hours.

5.

2 points

Your patient has an area at the left trochanter that is reddened with slightly abraded skin. You would stage this as a _____________ pressure ulcer

stage 3

stage 1

stage 2

unstagable

6.

2 points

A factor in skin problems common to elderly adults is: (Select all that apply)

skin tends to be dry because of increased gland activity

hair becomes thicker and grows more slowly

nails become thin and more brittle

skin is less elastic and more fragile

fewer nutrients are available from the reduced diet

7.

2 points

You have assisted your patient to the prone position. Which intervention is most important?

Count his respirations

Ask if he has any neck discomfort

Place the call bell within reach

Offer him a magaizine

8.

2 points

_________ is the softening of tissue resulting from frequent wetness that increases the chance of trauma or infection.

9.

2 points

Which patient is at greatest risk for developing a pressure ulcer?

a 40-year old paraplegic man who is obese and uses a self propelling wheelchair

a 75-year old woman who is postoperative day 2 for hip replacement surgery

an 80-year old woman with Alzheimer disease, peripheral neuropathy, and urinary incontinence

a 55-year old man who had surgery this afternoon and is difficult to arouse

10.

2 points

Reactive hyperemia occurs when:

blood rushes to a place where there is a decrease in circulation.

pressure on the skin causes the skin to turn white.

pressure on the skin causes the skin to turn red.

blood rushes to a place where there is an increase in circulation.

11.

2 points

Which are main functions of the skin? (Select all that apply.)

Excretion

Metabolism

Protection

Sensation

12.

2 points

When performing passive range-of-motion exercises:

perform each exercise at least 15 to 20 times

support the extremity above and below the joint

help patients who are independently performing these activities

avoid moving the joint to the point of discomfort

13.

2 points

Which statement describes the dorsal recumbent position?

Patients are on their abdomen with knees extended.

Patients are on their back with knees extended and feet plantar-flexed.

Patients are on their back with knees flexed and soles of feet flat on the bed.

Patients are on their abdomen with knees flexed and feet dorsiflexed.

14.

2 points

The primary reason some hospitals prefer a bag bath to a traditional bed bath is:

less mess

time savings

cost savings

infection control

15.

2 points

Which statement describes proper body alignment of a patient?

When supine, support the head with two pillows.

When supine, the vertebral column should be in alignment.

When sitting, the arms should be crossed over the lap.

When sitting, the knees should be flexed at 60 degrees.

16.

2 points

The _______ position is when the patient is lying face down.

17.

2 points

The extremities are washed from distal to proximal because this:

cleanses the skin better than proximal to distal

promotes safety

promotes venous return to the heart

supplies vital skin oils

18.

2 points

The elderly have a greater risk of skin breakdown because they have:

capillary fragility.

decreased circulation.

poor skin turgor.

increased muscle mass.

19.

2 points

Special attention is given to skin over bony prominence's because:

pressure ulcers develop only in these areas

pressure ulcers are more likely to develop in these areas

these areas are often dirtier

the skin here tends to hold moisture

20.

2 points

Which are components of the musculoskeletal system? (Select all that apply.)

Skeletal muscles

Bones

Ligaments

Blood vessels

21.

2 points

A nurse assistant (NA) is helping with bathing, dressing, and grooming of patients. The NA knows that a safety razor can be used on which patient?

Patient taking anticoagulants

Patient on chemotherapy

Patient with low platelet count

Patient with pneumonia

22.

2 points

When preparing to move a patient up in the bed who can assist, you would FIRST:

raise the bed to a good working height

ask the patient to grab the upper guard rails

ask the patient to bend the knees and plant the feet on the mattress

pull the bed covers down to the foot of the bed

23.

2 points

Prevention of pressure ulcers is promoted by: (select all that apply)

keeping the heels of the immobile patient off the bed

directly massaging reddened areas

using lift devices such as a trapeze bar to move patients

changing the patients position every 2 hours

24.

2 points

Forgetting to re-position a patient in a wheelchair for more than 1 hour may lead to:

pooling of lung secretions

the beginning of a pressure ulcer

muscle atrophy

skin abrasions from shearing forces

25.

2 points

When providing foot care for the diabetic patient, you must remember to:

cut the cuticles to prevent hangnails

never soak the feet

check for an order before trimming the nails straight across

check for an order before trimming the nails in a curved manner so there are not any sharp points to irritate the skin

26.

2 points

The nurse providing care to a patient with a pressure ulcer should know that initial wound care involves:

intravenous antibiotic therapy.

a surgical flap.

debridement.

amputation.

27.

2 points

Older adults have an increased risk of developing impaired skin integrity resulting from:

increased sebaceous gland activity.

increased subcutaneous fat.

ineffective mucous membrane protection.

decreased skin elasticity.

28.

2 points

Which is the largest organ in the body?

Skin

Liver

Lungs

Colon

29.

2 points

Elevation of the knees above 15 degrees in the supine position is contraindicated in:

pregnant patients.

stroke patients.

elderly patients.

cardiac patients.

30.

2 points

Which is the proper technique when performing a transfer with a lift sheet?

Roll the lift sheet close to the patient's body.

The nurses and/or nursing assistants face the end with feet together.

Remove the pillow from under the patient's head.

Preferably, two people stand on opposite sides of the bed.

31.

2 points

An elderly person may need to be reeducated on how to lift safely because: (select all that apply)

muscles and bones lose strength as one ages

muscle mass is decreased and posture changed

she has forgotten how to lift things

bone density is decreased

32.

2 points

One of the most common injuries for health care workers is:

wrist strain.

lower back strain.

neck strain.

knee strain.

33.

2 points

A stage 3 pressure ulcer is characterized by:

a partial-thickness skin loss involving epidermis and dermis

a reddened area that does not blanch

full thickness skin loss that looks like a deep crater

an area of induration

34.

2 points

A back rub should be offered to every patient because it:

is an expected nursing service

is an active form of exercise

is relaxing and decreases tension

increases medication absorption

35.

2 points

A patient has recently had rectal surgery. Which type of bath would promote healing and relieve discomfort for this patient?

Cleansing bath

Sitz bath

Body soak

Whirlpool bath

36.

2 points

When a patient falls, you document the nurse's notes:

your best guess about what happened

a statement concerning how you believe the hospital was negligent

as little as possible to avoid liability

any patient-stated cause of fall

37.

2 points

When moving the patient up in bed:

place one foot in front of the other

pushing is better than pulling, as your weight helps

lock the knees before moving the patient

use only those muscles absolutely necessary

38.

2 points

A nurse finds a pressure ulcer on a patient's sacrum that resembles a blister. This is most likely:

stage III.

a deep tissue injury.

stage II.

stage I.

39.

2 points

You are dangling your patient in preparation for getting her out of bed. Your plan is to dangle her for 2 minutes, then transfer her to the chair. After 1 minute she complains of nausea and states that she sees "stars." What should you do?

Gently lie her back down

Reassure her that this will pass

Wait 2 more minutes, then check her BP

Get the BP cuff from across the room

40.

2 points

Which changes occur with aging?

Bone mass increases.

Muscle cells are replaced by connective tissue.

Joint motion may decrease.

Elasticity of muscle fibers is increased.