NUR 3650: One Minute Nurse

Which vaccines should the older adult receive to prevent respiratory complications?

A. Measles, mumps, rubella (MMR) and polio vaccines

B. Varicella and hepatitis B vaccines

C. Influenza and pneumonia vaccines

D. Tetanus, diphtheria, and pertussis (Tdap) vaccine

C. Influenza and pneumonia vaccines

Which makes the older adult more susceptible to respiratory infections such as pneumonia?

A. Decreased cough efficiency

B. Increased ability to clear secretions

C. Increased fluid intake

D. Decreased number of alveoli

A. Decreased cough efficiency

What health promotion strategies support the older adult through musculoskeletal age-related changes? Select all that apply.

A. Calcium and vitamin D supplements

B. Weight-bearing activity

C. High-impact cardiovascular activity

D. Bone density screenings

E. Preventative back braces

A. Calcium and vitamin D supplements

B. Weight-bearing activity

D. Bone density screenings

What is the blood pressure goal for someone over the age of 65?

A. Less than 110/70 mmHg

B. Less than 120/75 mmHg

C. Less than 130/80 mmHg

D. Less than 140/85 mmHg

C. Less than 130/80 mmHg

Which could indicate that an older adult is having difficulty hearing?

A. They provide inappropriate responses to questions.

B. They turn up the television volume during a conversation.

C. They recall a conversation from the previous week.

D. They respond to high-pitched tones quickly.

A. They provide inappropriate responses to questions.

What can lead to impaired mobility in the older adult? Select all that apply.

A. Osteoarthritis

B. Sensory deficit

C. History of stroke

D. Ejection fraction of 58%

E. Walking 2 miles a day

A. Osteoarthritis

B. Sensory deficit

C. History of stroke

Which is not a cause of urinary incontinence in the older adult?

A. Infection

B. Delirium

C. Effects of medication

D. Adequate hydration

D. Adequate hydration

An older adult reports to the clinic stating they have been experiencing intermittent dizziness. They are not currently experiencing dizziness. What is the nurse's best course of action?

A. Obtain a thorough health history.

B. Request a CT scan.

C. Obtain blood work.

D. Encourage range of motion exercises.

A. Obtain a thorough health history.

Which is not a common age-related change in the older adult?

A. Cognitive impairment

B. Impaired mobility

C. Dizziness

D. Increased susceptibility to infection

A. Cognitive impairment

What are interventions that can help prevent falls? Select all that apply.

A. Properly fitted footwear

B. Adequate lighting

C. Frequently rearranging furniture in the home

D. Encouraging polypharmacy

E. Keeping the call light within reach

A. Properly fitted footwear

B. Adequate lighting

E. Keeping the call light within reach

Which nursing intervention can help prevent the development of pressure injuries?

A. Withhold nutrition until prior to discharge.

B. Reposition the patient every 2 hours while in a chair.

C. Add additional sheets underneath the patient while they are in bed.

D. Offload the heels while the patient is in bed.

D. Offload the heels while the patient is in bed.

A patient has a stage 3 pressure injury. Which characterization best describes a stage 3 pressure injury?

A. Nonblanchable area of redness

B. Maroon and purple discoloration

C. Visible bone and tendons

D. Full-thickness skin loss

D. Full-thickness skin loss

Which tool is used for assessing a patient's risk for impaired skin integrity?

A. Braden

B. Glasgow

C. APGAR

D. Injury severity score

A. Braden

Of the following body parts, where is a pressure injury most likely to occur?

A. Sacrum

B. Abdomen

C. Hand

D. Chest

A. Sacrum

Which patient is at the highest risk for developing a pressure injury?

A. 26-year-old post motor vehicle accident ambulating in the hall

B. 48-year-old who is malnourished

C. 51-year-old admitted for routine colonoscopy

D. 74-year-old post cataract surgery

B. 48-year-old who is malnourished

What is the first step of the Clinical Judgment Measurement Model?

A. Evaluate outcomes

B. Prioritize hypotheses

C. Analyze cues

D. Recognize cues

D. Recognize cues

The NCSBN Clinical Judgment Measurement Model was created for what purpose?

A. To measure decision-making skills

B. To measure diagnostic skills

C. To measure fundamental skills

D. To measure ability to read lab values

A. To measure decision-making skills

The NCSBN Clinical Judgment Measurement Model was created for which exam?

A. Traditional NCLEX

B. Next-Generation NCLEX

C. Medical-Surgical Nursing final exam

D. Advanced practice nursing licensing exam

B. Next-Generation NCLEX

Which step of the Clinical Judgment Measurement Model reflects the planning phase of the nursing process?

A. Analyze cues

B. Evaluate outcomes

C. Generate solutions

D. Take action

C. Generate solutions

The NCSBN Clinical Judgment Measurement Model reflects which framework?

A. Maslow's Hierarchy of Needs

B. SBAR

C. The nursing process

D. SOAP

C. The nursing process

In what phase are priorities set?

A. Assessment

B. Diagnosis

C. Plan

D. Implementation

C. Plan

What action is completed during the assessment phase of the nursing process?

A. Choosing interventions

B. Obtaining subjective and objective data

C. Determining the best course of action

D. Assessing if current interventions are working

B. Obtaining subjective and objective data

What is the correct order of the nursing process?

A. Diagnose, assess, plan, implement, evaluate

B. Evaluate, diagnose, implement, assess, plan

C. Assess, diagnose, plan, implement, evaluate

D. Plan, assess, evaluate, diagnose, implement

C. Assess, diagnose, plan, implement, evaluate

What is true about the nursing process?

A. It is always linear.

B. There can be overlap among the stages.

C. There is one nursing process interaction per patient.

D. A finalized plan can be put in place before assessment takes place.

B. There can be overlap among the stages.

In what phase do nurses assist patients in achieving desired outcomes?

A. Assessment

B. Diagnosis

C. Plan

D. Implementation

D. Implementation

In addition to a pain scale, what other information should be included when assessing pain? Select all that apply.

A. What the pain feels like

B. What made the pain start

C. Where the pain is located

D. How long the pain lasts

E. What helps the pain

A. What the pain feels like

B. What made the pain start

C. Where the pain is located

D. How long the pain lasts

E. What helps the pain

A patient is awake, alert, and oriented on a surgical unit. Which pain scale is the preferred pain scale for this patient?

A. Numeric

B. PAINAD

C. FLACC

D. CPOT

A. Numeric

Which is an appropriate nonpharmacologic pain intervention?

A. Applying a cool pack

B. Applying a tourniquet to the area

C. Encouraging sleep

D. Consuming a snack

A. Applying a cool pack

A patient presents with bone pain related to osteomyelitis. What type of pain is this called?

A. Acute

B. Chronic

C. Cutaneous

D. Somatic

D. Somatic

A patient had a below-the-knee amputation 24 hours ago and insists that the toes on the affected side are in pain. What is the nurse's best response?

A. "I think you are hallucinating; there is nothing there to hurt."

B. "You are fine, this is normal."

C. "Phantom pain occurs where the amputated leg should be and is real pain. Let me see when you are due for pain medication."

D. "This is phantom pain, and it goes away in a few hours. It is best to breathe through it and tell yourself it's fine."

C. "Phantom pain occurs where the amputated leg should be and is real pain. Let me see when you are due for pain medication."

What is the goal of clean technique?

A. To keep objects free of microorganisms

B. To provide information on a sterile field

C. To reduce the number and transfer of pathogens

D. To keep the operating room floor clean

C. To reduce the number and transfer of pathogens

Why is it important to know surgical asepsis?

A. To know how to act around a sterile environment

B. To understand how to handle bed linens

C. To know why informed consent is essential

D. To know how to clean a patient for good hygiene

A. To know how to act around a sterile environment

In what area is medical asepsis most likely utilized?

A. The operating room

B. A medical-surgical unit

C. An outpatient psychiatric unit

D. Every area of healthcare

D. Every area of healthcare

In what area would you least expect to see surgical asepsis implemented?

A. The operating room

B. The labor and delivery unit

C. The cardiac catheterization lab

D. A long-term nursing care facility

D. A long-term nursing care facility

What is aseptic technique?

A. All activities to prevent infection or break the chain of infection

B. Strict sterile technique always

C. The proper way to make and maintain a bed

D. A way to safely administer medications to prevent infection

A. All activities to prevent infection or break the chain of infection

What is the proper order for donning personal protective equipment?

A. Gown, mask, goggles, gloves

B. Gloves, gown, goggles, mask

C. Mask, gown, gloves, goggles

D. Goggles, mask, gown, gloves

A. Gown, mask, goggles, gloves

What personal protective equipment (PPE) is required for a patient on contact precautions?

A. N95 mask and eye protection

B. Surgical mask and gown

C. Gown and gloves

D. Face shield and surgical mask

C. Gown and gloves

Which diagnoses warrant airborne precautions?

A. Influenza, rubella, diphtheria

B. Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), extended spectrum beta-lactamase (ESBL)

C. Tuberculosis, measles, disseminated herpes zoster

D. Lung cancer, liver disease, stage IV pressure injuries

C. Tuberculosis, measles, disseminated herpes zoster

For a patient on any type of precautions, when is hand hygiene supposed to be completed?

A. Before entering or exiting the room

B. Only when hands are visibly soiled

C. Before getting report in the morning

D. When wearing sterile gloves

A. Before entering or exiting the room

A patient on droplet precautions needs to leave their room for a computed tomography (CT) scan. How should the nurse address the droplet precautions?

A. The patient should not wear anything additional.

B. The patient must promise not to cough when outside the room.

C. The patient should hold a sheet over their mouth when talking to others outside the room.

D. The patient should don a surgical mask for the duration of time spent outside the room.

D. The patient should don a surgical mask for the duration of time spent outside the room.

Which patient is at the highest risk for falling?

A. A patient in a locked, low bed

B. A patient on a new narcotic prescription

C. A patient wearing nonskid socks

D. A patient whose room is clear of clutter

B. A patient on a new narcotic prescription

What is not true regarding the patient's room and risk of falls?

A. It is best to keep the bed in the lowest position.

B. It is best to keep the wheels locked.

C. It is best to leave a light on at night.

D. It is best to keep personal items out of sight.

D. It is best to keep personal items out of sight.

Where should the patient's call bell be left?

A. Hanging behind the bed

B. On the floor next to the bed

C. With the family member

D. Within reach of the patient

D. Within reach of the patient

What is true regarding restraints and falls?

A. Restraining patients prevents falls.

B. Chemical restraints are most effective for preventing bathroom falls.

C. Restraints increase the risk for falls.

D. Only ankle restraints increase the risk for falls.

C. Restraints increase the risk for falls.

What is the best way to alert other staff that a patient is at risk for falls?

A. By placing a sign on the patient's door and in their chart

B. By making an announcement each shift to the whole floor

C. By putting their name on a list at the nurse's station

D. By documenting in the electronic medical record that the patient is at risk

A. By placing a sign on the patient's door and in their chart

What temperature would be considered a fever in an adult?

A. 97.6°F (36.4°C)

B. 98.6°F (37°C)

C. 99.2°F (37.3°C)

D. 100.2°F (37.9°C)

D. 100.2°F (37.9°C)

Which is a preferred nonpharmacologic method to treat a fever?

A. Hot bath

B. Cooling blankets

C. Heating lamps

D. Turning up the temperature in the room

B. Cooling blankets

Which medication is used to treat the symptoms of a fever?

A. Acetaminophen

B. Diphenhydramine

C. Guaifenesin

D. Amoxicillin

A. Acetaminophen

What is true of older adults and fevers?

A. Older adults spike higher fevers than younger adults.

B. Older adults are less likely to spike a fever, even with a serious infection.

C. Older adults have a higher baseline body temperature than younger adults.

D. Older adults have different fever symptoms than younger adults.

B. Older adults are less likely to spike a fever, even with a serious infection.

A patient has a temperature of 106°F (41°C). What does this mean?

A. This is a medical emergency.

B. This should be treated within 24 hours.

C. The patient will not need intervention.

D. The patient is recovering.

A. This is a medical emergency.

A patient has a sodium level of 124 mEq/L. Which assessment finding is expected?

A. Cardiac arrhythmias

B. Pressured speech

C. Confusion

D. Petechiae

C. Confusion

Which intravenous (IV) solution is expected for a patient with cerebral edema?

A. Normal saline

B. ½ normal saline

C. D5 normal saline

D. 3% saline

D. 3% saline

Upon assessment, a patient has Trousseau and Chvostek signs. Which electrolyte abnormality does this indicate?

A. Hypocalcemia

B. Hypercalcemia

C. Hyperkalemia

D. Hypokalemia

A. Hypocalcemia

A patient is ordered potassium replacement for a potassium level of 3.2 mEq/dL. What is the best way to administer this medication?

A. Crushed and added to applesauce

B. Whole pill by mouth

C. Intravenous push

D. Subcutaneous

B. Whole pill by mouth

What is the difference between crystalloids and colloids?

A. Crystalloids are thicker and more viscous, and colloids are clear fluids. B. Crystalloids are used to correct sodium levels, and colloids are used to correct potassium levels.

C. Crystalloids are clear fluids, and colloids are thicker and more viscous.

D. Crystalloids are used to correct potassium levels, and colloids are used to correct sodium levels.

C. Crystalloids are clear fluids, and colloids are thicker and more viscous.

What is the purpose of Maslow's Hierarchy of Needs?

A. To determine appropriate growth and development

B. To properly diagnose a patient with a disorder

C. To categorize medical diagnoses for insurance purposes

D. To understand relationships among requirements to establish priorities

D. To understand relationships among requirements to establish priorities

What does the base of the hierarchy pyramid, the physiologic needs category, include?

A. Emotional components

B. Love and belonging

C. Food and oxygen

D. Self-esteem

C. Food and oxygen

Where would infection prevention efforts fall on Maslow's Hierarchy of Needs?

A. Physiologic needs

B. Safety and security needs

C. Love and belonging needs

D. Self-actualization needs

B. Safety and security needs

Based on Maslow's Hierarchy of Needs, what is the LOWEST priority nursing intervention?

A. Providing a safe space for personal hygiene

B. Providing a meal

C. Facilitating rest

D. Educating them about the harmful effects of substance use

B. Providing a meal

Which quality would indicate that a person has achieved the self-actualization level in Maslow's Hierarchy of Needs?

A. Ability to be objective

B. Poor self-esteem

C. Judgment of others

D. Discriminatory beliefs

A. Ability to be objective

Which patients need standard precautions?

A. Patients who are immunocompromised

B. All patients at all times

C. Patients who need assistance with hygiene

D. Patients who are visiting outpatient offices

B. All patients at all times

What is a component of proper respiratory hygiene?

A. It is not necessary to cover a cough if no one is within 3 ft of the person coughing.

B. There is no need to cover the nose when coughing.

C. It is best to cough into a tissue and promptly dispose of the tissue.

D. Anyone coughing should wear an N95 mask.

C. It is best to cough into a tissue and promptly dispose of the tissue.

An unlicensed nursing personnel completed vital signs on a patient using an electric machine. What should happen next?

A. They should go to the next patient.

B. They should begin to bathe the patient.

C. They should clean the equipment used to take vital signs.

D. They should notify the RN of their scheduled break.

C. They should clean the equipment used to take vital signs.

Which action is NOT appropriate regarding dirty needles?

A. Use the intended safety lock appropriately.

B. Place them safely in the sharps container.

C. Recap them as part of standard practice.

D. Do not use the same needle twice.

C. Recap them as part of standard practice.

When is hand hygiene NOT appropriate?

A. When in a sterile environment

B. Prior to entering a room

C. Prior to exiting a room

D. When hands are visibly soiled

A. When in a sterile environment

A patient is allergic to penicillins. Which other antibiotics should be avoided due to potential cross-sensitivity?

A. Cephalosporins

B. Aminoglycosides

C. Tetracyclines

D. Fluoroquinolones

A. Cephalosporins

For which type of infection are macrolides indicated?

A. Sexually transmitted infections

B. Respiratory infections

C. Gastrointestinal infections

D. Skin infections

B. Respiratory infections

Which class of antibiotics is associated with tendon rupture?

A. Tetracyclines

B. Cephalosporins

C. Macrolides

D. Fluoroquinolones

D. Fluoroquinolones

Which patient population should not be prescribed tetracyclines?

A. Those with chronic kidney disease

B. Those with a penicillin allergy

C. Children under 8 years old

D. Adults over the age of 65

C. Children under 8 years old

What are the major side effects of aminoglycosides?

A. Hepatotoxicity and CNS changes

B. Ototoxicity and nephrotoxicity

C. Cardiotoxicity and ototoxicity

D. Nephrotoxicity and hepatotoxicity

B. Ototoxicity and nephrotoxicity

A patient with which condition is a candidate for an anticholinergic medication?

A. Myasthenia gravis

B. Glaucoma

C. Chronic obstructive pulmonary disorder (COPD)

D. Severe ulcerative colitis

C. Chronic obstructive pulmonary disorder (COPD)

What are side effects of anticholinergics?

A. Constipation

B. Pupillary dilation

C. Dry mouth

D. Bradycardia

E. Tachypnea

A. Constipation

B. Pupillary dilation

C. Dry mouth

What condition would NOT warrant administration of an anticholinergic?

A. Tachycardia

B. Bladder spasms

C. Extrapyramidal side effects

D. Excessive drooling

A. Tachycardia

Which neurotransmitter is impacted by anticholinergics?

A. Dopamine

B. Serotonin

C. Acetylcholine

D. Norepinephrine

C. Acetylcholine

A patient experiencing excessive oral secretions would most likely be prescribed which medication?

A. Dicyclomine

B. Oxybutynin

C. Glycopyrrolate

D. Ipratropium

C. Glycopyrrolate

Which factor is an absolute contraindication to receiving a thrombolytic?

A. Ischemic stroke

B. Pregnancy

C. Appendectomy 2 years ago

D. Controlled hypertension

B. Pregnancy

Which intervention should be implemented for patients on any medications that increase the risk of bleeding?

A. Utilize basic razors.

B. Encourage intramuscular (IM) injections.

C. Monitor for dark stools.

D. Disregard fall precautions.

C. Monitor for dark stools.

How do anticoagulants work?

A. Thin the blood to prevent clots and stop clots from getting bigger.

B. Prevent platelets from sticking to stents.

C. Dissolve clots.

D. Decrease bleeding times.

A. Thin the blood to prevent clots and stop clots from getting bigger.

A patient is on a heparin infusion. Which lab value is used to titrate this medication?

A. International normalized ratio (INR)

B. Prothrombin time (PT)

C. Activated partial thromboplastin clotting time (aPTT)

D. Hemoglobin

C. Activated partial thromboplastin clotting time (aPTT)

Which medication is an example of an antiplatelet?

A. Atropine

B. Clopidogrel

C. Warfarin

D. Alteplase

B. Clopidogrel

What are common uses for antidepressants? Select all that apply.

A. Toothaches

B. Muscle pain

C. Neuropathy

D. Tachycardia

E. Anxiety

C. Neuropathy

E. Anxiety

A patient is prescribed a monoamine oxidase inhibitor (MAOI). Which foods can the patient include in their diet?

A. Strawberry yogurt and peanuts

B. Salami and parmesan cheese

C. Cottage cheese and bacon

D. Tofu and avocados

C. Cottage cheese and bacon

A nurse is providing patient education related to starting a new antidepressant. Which patient statement indicates effective instruction?

A. "I will start to feel better in 72 hours."

B. "It is normal to feel even more depressed before starting to feel better."

C. "I may experience side effects such as dry mouth and weight gain."

D. "It is okay to stop taking this medication if I go on vacation."

C. "I may experience side effects such as dry mouth and weight gain."

What are the two main neurotransmitters affected by antidepressants?

A. Dopamine and glutamate

B. Serotonin and norepinephrine

C. Epinephrine and acetylcholine

D. GABA and histamine

B. Serotonin and norepinephrine

Which is a selective serotonin reuptake inhibitor (SSRI)?

A. Venlafaxine

B. Phenelzine

C. Amitriptyline

D. Sertraline

D. Sertraline

A patient is prescribed a beta-blocker. What must be assessed prior to administration of the medication?

A. Heart rate and temperature

B. Blood pressure and respiratory rate

C. Heart rate and blood pressure

D. Respiratory rate and heart rate

C. Heart rate and blood pressure

The provider has given the patient a new prescription for losartan. Which current medication order would cause the nurse to question the new order for losartan?

A. Metoprolol 25 mg PO BID

B. Lisinopril 10 mg PO daily

C. Hydralazine 10 mg PO q 6 hours PRN

D. Amlodipine 10 mg PO daily

B. Lisinopril 10 mg PO daily

A patient is due to receive a dose of verapamil. Their heart rate is 98 beats per minute, and their blood pressure two hours ago was 95/46 mmHg. What is the nurse's best action?

A. Administer the medication as ordered.

B. Administer the PRN labetalol.

C. Obtain current blood pressure.

D. Notify the provider.

C. Obtain current blood pressure.

A patient is prescribed propranolol. Other than hypertension, for what condition might this patient be taking the medication?

A. Migraines

B. Anxiety

C. Seizures

D. Depression

A. Migraines

A patient is prescribed captopril. About what adverse effect should the nurse educate the patient?

A. Cough

B. Angioedema

C. Hypotension

D. Flushing

B. Angioedema

Which intervention is appropriate for a patient on an atypical antipsychotic?

A. Conducting routine electrocardiograms (ECGs)

B. Increasing calorie count

C. Providing warm clothing

D. Instituting a sleep schedule

A. Conducting routine electrocardiograms (ECGs)

For what ailments can antipsychotic medications be prescribed? Select all that apply.

A. Psychosis symptoms

B. Anxiety

C. Stress

D. Alzheimer disease

E. Attention deficit/hyperactivity disorder (ADHD)

A. Psychosis symptoms

B. Anxiety

D. Alzheimer disease

Which medications pose a higher risk of extrapyramidal side effects (EPSs)? Select all that apply.

A. Risperidone

B. Olanzapine

C. Chlorpromazine

D. Haloperidol

E. Quetiapine

C. Chlorpromazine

D. Haloperidol

Which medication would be prescribed to treat extrapyramidal side effects (EPSs)?

A. Metoprolol

B. Benztropine

C. Amoxicillin

D. Tetracycline

B. Benztropine

Antipsychotics affect which neurotransmitter?

A. Acetylcholine

B. Norepinephrine

C. Dopamine

D. Serotonin

C. Dopamine

What is digoxin used to treat?

A. Hypertension

B. Heart failure

C. Hypothyroidism

D. Heart block

B. Heart failure

Which are key findings of digoxin toxicity?

A. Visual halos and nausea

B. Hypertension and constipation

C. Fatigue and bounding pulse

D. Hyperglycemia and diarrhea

A. Visual halos and nausea

How does the nurse assess the heart rate prior to administering digoxin?

A. 30 seconds, radially

B. 30 seconds, apically

C. 60 seconds, radially

D. 60 seconds, apically

D. 60 seconds, apically

How does digoxin work?

A. It opens the coronary arteries.

B. It works on the peripheral vascular system.

C. It improves cardiac contractility.

D. It increases the heart rate.

C. It improves cardiac contractility.

Which medication is the antidote for digoxin?

A. Vitamin K

B. Protamine sulfate

C. Digoxin immune fab

D. Calcium gluconate

C. Digoxin immune fab