Exam 3- NCLEX style questions

Exam 3- NCLEX style questions 10 studiers today Leave the first rating Students also studied Terms in this set (24) Science MedicineNursing Save

BIOL103-LO1: Study Set

Teacher 62 terms SIASTLTPreview HESI Comprehensive Exit Exam 1 (A...125 terms K_Copeland5Preview Learning System 3.0 NCLEX RN ATI 10 terms ACC848Preview ATI com 198 term yay The nurse is developing a plan of care for a chair-bound patient. To prevent development of pressure ulcers, which intervention(s) must be implemented? (Select all that apply.) 1.Maintain postural alignment.

2.Use pressure-relieving devices.

3.Teach weight shifts every 15 minutes.

4.Use donut-type devices.

5.Shift pressure points every hour.1, 2, 3, and 5 Which physiologic change(s) associated with aging predispose(s) older adults to skin breakdown? (Select all that apply.) 1.Decreased melanocytes 2.Loss of collagen 3.Increased elastic fibers 4.Decreased adipose tissues 5.Reduced sebaceous gland activity 2, 4, and 5 The nurse launching an information campaign to prevent skin tears among the residents in a long-term care facility should include (Select all that apply.) 1.encouraging wearing long sleeves and pants.

2.providing adequate lighting.

3.using germicidal soap every day on extremities.

4.supporting dangling arms and legs with pillows or blankets.

5.removing tape and dressings with extreme caution.1, 2, 4, and 5

The nurse reminds teenagers regarding the importance of protecting their skin from ultraviolet rays by (Select all that apply.) 1.using a sunscreen with a skin protective factor (SPF) of at least 15.

2.applying sunscreen thinly.

3.wearing light, loose-fitting clothing.

4.gauging exposure while in the sun.

5.wearing sunglasses and a hat.

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The patient presents with a rash of unknown origin. Which assessment question(s) would help determine the cause?(Select all that apply.) 1."When did the rash or lesion first appear?" 2."Can you think of any event or different food you ate or substance you were using just before the rash appeared?" 3."Which drugs are you taking? Do you take any over-the- counter preparations?" 4."Have you ever had radiation therapy?" 5."Do you have a history of any skin disorders in your family?" 1, 2, 3, 4, and 5 Which of the following is not a function of the integumentary system?1)Protection 2)Provides color 3)Temperature regulation 4)Excretion and secretion 2 rationale: Providing color is not one of the four functions of the integumentary system. They are protection, sensation, temperature regulation, and excretion and secretion.Justin has a patient in a long-term care facility with a pressure injury. It can be described as full-thickness skin loss that looks like a deep crater and extends to the fascia. Subcutaneous tissue is damaged. Which stage is this injury?1)Stage 1 2)Stage 2 3)Stage 3 4)Stage 4 3 Which of the following is not one of the basic purposes of bathing?1)Cleanses the body 2)Promotes comfort 3)Stimulates conversation 4)Removes waste products 3

Rationale: The basic purposes for bathing are to cleanse the body, promote

comfort, remove waste products, and promote stimulation of circulation to all areas of the body.

Which of the following is true regarding mouth care?1)Mouth care creates halitosis and dental caries.2)An unconscious patient should be provided full mouth care at least every 24 hours.3)When assisting a conscious patient with mouth care, you should raise the head of the bed 15 to 30 degrees.4)Dentures should be kept in a labeled denture container with saline or water when not in the patient's mouth.4

Rationale: Dentures should be properly stored when not in the patient's mouth.

Mouth care prevents halitosis and dental caries. Mouth care should be provided at least every 8 hours for the unconscious patient. You should raise the bed 45 to 90 degrees when assisting in mouth care.Gary is a nurse working in an acute-care facility. His patient is a 20-year-old male who was in an automobile accident. He has blood and glass fragments in his hair, a fractured femur, a mild concussion, and is negative for any other health problems. Which of the following is not an appropriate nursing intervention?1)Shampooing the patient's hair and cutting any glass fragments out of his head and hair 2)Washing his feet and trimming his toenails 3)Asking the patient if he wants you to call any family or friends 4)Allowing the patient time to rest 1 Rationale: You may not cut a patient's hair without informed consent unless it is an emergency. You may trim a patient's toenails if there are no diabetes or bleeding disorders present. It is appropriate to see if the patient wants family or friends called and to give the patient time to rest.In managing dermatitis, the nurse provides which instruction(s)? (Select all that apply.) 1.Avoid the irritant or allergen.

2.Provide adequate skin lubrication.

3.Wash skin frequently with germicidal soaps.

4.Maintain skin moisture.

5.Apply steroid-based preparations.1, 2, 4, and 5 A teenager asks the nurse at the dermatologist's office, "What is acne vulgaris?" Which statement(s) would be true? (Select all that apply.) 1."Accumulations of sebum in occluded sebaceous glands." 2."It is caused by increased androgens and fluctuating premenstrual hormones." 3."Application of heavy creams and heat exposure contribute to the development of acne." 4."Alcohol, caffeine-containing foods, spicy foods, sunlight, and emotional stress cause flare-ups." 5."These lesions are not a sign of uncleanliness." 1, 2, 3, and 5

The nurse who observes evidence of severe itching on the scalp of a school-aged girl with pediculosis should give which important instruction(s)? (Select all that apply.) 1."Machine wash clothes and bedding using the coldest cycle." 2."Share combs and hair brushes." 3."Soak all combs and brushes in very hot water for more than 5 minutes." 4."Seal items that cannot be washed in air-expelled plastic bags for 14 days." 5."Instruct all family members about the infestation and ways to prevent reinfestation." 3, 4, and 5 Which statement(s) regarding human immunodeficiency virus transmission is/are true? (Select all that apply.) 1.Breast milk can harbor the virus.

2.Proper use of personal protective equipment reduces the risk of disease transmission.

3.Needle exchange programs facilitate the spread of the virus.

4.Needle-stick injuries place health professionals at risk.1, 2, and 4 In determining the optimal therapy for a patient infected with the human immunodeficiency virus, the physician considers which factor(s)? (Select all that apply.) 1.Clinical data 2.Compliance with therapy 3.Medication tolerance 4.Insurance coverage 5.Physician's expectations

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Which person is at highest risk for developing a hospital- acquired (nosocomial) infection?1)A visitor 2)An employee 3)An 80-year-old cancer patient 4)A 6-year-old getting ready for discharge from the hospital 3 Rationale: Hospital-acquired (nosocomial) infections are contacted by patients in health care facilities. Elderly patients are at higher risk of infection because of poor nutrition, immobility, chronic illness, and physiologic changes.The most effective way to destroy all types of

microorganisms is to:

1)expose them to moist heat at a high temperature for 16 to 20 minutes.2)expose them to dry heat at a high temperature for 5 minutes.3)wash them thoroughly for 5 minutes.4)wash them thoroughly for 15 minutes under warm soapy water.1

Rationale: The most effective means for destroying viruses and all other

microorganisms is to expose them to moist heat at a temperature of 250° F for 16 to 20 minutes. This is accomplished by using an autoclave.