Nursing Bundle Practice Test

Nursing assistants, and CNAs, can legally measure heights and weights so they can also document it. They do NOT do any assessments or care planning so they do not document these things. Only the nurse can do these things.

An oral temperature is an objective finding. The other answer options are subjective findings.

CNAs are personally accountable and responsible to maintain the safety of all patients. Safety takes priority over esteem, respect, self-determination and justice, although these other needs are also important. Safety is a high priority.

HIPAA protects all communication regarding protected health information of all health care consumers, including patients, residents and clients.

You must immediately report this abnormal physical finding to the nurse. It could be a sign of high blood sugar.

The three words are commonly misused words. Only choice A uses the correct forms in the context of the sentence.

The phrase "with the dog" should be moved to after the word "park." (The man walking to the park with the dog hurried...). The original sentence is unclear who exactly is walking to the park.

By the order of operations, you first carry out multiplication before addition or subtraction.
8 - 12 + 9 = x
-4 + 9 = x
X = 5

To convert Celsius to Fahrenheit, first multiply by 9/5 and then add 32.
32 x 9/5 = 288/5
288/5 = 57.6
57.6 + 32 = 89.6

The nucleus of an atom contains both protons and neutrons. They are the part of the atom that makes the most mass. The protons have mass and a positive charge. The neutrons have no charge but mass.

Nursing care plans are legal documents that contain nursing diagnoses, such as an "Alteration of respiratory function". They also contain patient goals and nursing interventions.

When determining which client to see first while in a long-term care facility, the nurse should decide what tasks are most important that only she can do. If other assistive personnel are present, the nurse can delegate some tasks to continue to meet the needs of the clients. In this scenario, the IV medication is the only task that must be done by the nurse.

Changing a peripherally inserted IV dressing may be necessary due to facility policy or if the site becomes soiled. When performing this procedure, the nurse should remove the old dressing and cleanse the site, allowing it to air dry. The new dressing should be applied and labeled with the date of the change.

A client with carbon monoxide poisoning may present with nausea, vomiting, muscle weakness, or lightheadedness. Untreated, the condition may lead to seizures, coma, or death. Carbon monoxide toxicity is a safety risk because it is a colorless and odorless gas. Many people exposed to carbon monoxide may be unaware of toxic levels that can cause serious illness.

Young adults and teenagers are at greatest risk for sexually transmitted diseases. High bilirubin is a laboratory finding and not an infectious disease. Pre-school and school age children are not at great risk for shingles, the elderly are. Lastly, old age is not associated with malaria. It is associated with shingles.

The patient is addressing the developmental task of generativity. The other developmental tasks for the other age groups are below:
Initiative: Preschool child
Industry: School age child
Ego integrity: Elderly.

There are 30cc per ounce. You will record 240 cc of fluid intake. Italian ice is considered a fluid.

Third degree heart block lacks conduction through the AV node, and is characterized by QRS complexes being conducted at their own rate, with no relation to the p waves. Bradycardia and its effects are the significant symptoms to monitor in patients with this type of conduction system defect. Often, this defect is associated with a causative agent, which must be discovered and removed. Temporary pacemaker use is often necessary, and the patient usually requires permanent pacemaker placement.

The optimal door-to-balloon time for PCI is 90 minutes. PCI is the preferred treatment for most patients with STEMI, as it has a lower risk of bleeding than use of thrombolytic therapy. Further information can also be obtained during the procedure about the extent of the patient's underlying disease. Generally, patients who have PCI are in the hospital for a shorter duration and require less medical support than patients who receive fibrinolytic therapy.

Chronotropic drugs affect heart rate; dromotropic drugs affect conductivity; analgesic medications are not cardiac specific.

Depending on the ICP monitor inserted, the system diagnoses cranial hypertension, allows for drainage of CSF, and allows the medical team to assess the outcome of medical therapies.

The neutrophil is the primary defense against bacterial infection. Normally, neutrophils will constitute about 62% of total white blood cells. In an acute bacterial infection, this number may rise. The neutrophils are released into the blood stream very early in infection. Immature neutrophils (bands) indicate an acute infection.

Pertussis requires droplet precautions. Agents that require airborne precautions are agents that remain infectious over long distances in the air. These include measles, chicken pox (varicella), herpes zoster and tuberculosis. Droplet precautions include pathogens that spread through close respiratory or mucous membrane contact with respiratory secretions. Those include sepsis, scarlet fever, strep, pertussis, parvovirus B19, influenza, pneumonia, diphtheria, epiglottitis, rubella, RSV, mumps, meningitis, mycoplasma and adenovirus. Last type of precaution is contact, which includes any organisms that are spread by direct or indirect contact.

Neuropathic pain responds well to anti-depressants, anticonvulsants and corticosteroids as either primary or adjuvant analgesics. This type of pain is described as sharp, burning and shooting. Examples include spinal nerve compression, invasion of nerves by tumors, post-herpetic neuralgia and post-stroke pain syndromes.

It is not uncommon for patients to have fear that their disease is progressing and either under-report their pain or not want to fully describe it to providers out of concern that it may distract them from their treatment or for another reason. The other three options are false.

Since there can be many causes for terminal agitation, attempting to determine the cause is the most important factor in treating this distressing symptom. Since determining the cause can be difficult, the treatment approach may need to be a trial of various interventions to see what the patient responds best to.