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NS 660 Exam 1 Review Questions with Correct Answers
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NS 660 Exam 1 Review Questions with Correct Answers
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NS 660 Exam 1 Review Questions withCorrect Answers
A nurse administers an antihypertensive medication to a patient at the scheduled time
of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the
patient's blood pressure was low when it was taken at 0830. The NAP states they were
busy and did not have a chance to tell the nurse yet. The patient begins to complain of
feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped
even lower. In which phase of the nursing process did the nurse first make an error?
Diagnosis
Evaluation
Implementation
Assessment - Answer-Assessment
A charge nurse is observing a newly licensed nurse care for a client who reports pain.
The nurse checked the client's MAR and noted the last dose of pain medication was 6
hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the
medication and checked with the client 40 min later, when the client reported
improvement. The newly licensed nurse left out which of the following steps of the
nursing process?
Intervention
Evaluation
Planning
Assessment - Answer-Assessment
A nursing assessment for a patient with a spinal cord injury leads to several pertinent
nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?
Risk for impaired skin integrity
Risk for infection
Spiritual distress
Reflex urinary incontinence - Answer-Reflex urinary incontinence
,While completing an admission database, the nurse is interviewing a patient who states
"I am allergic to latex." Which action will the nurse take first?
Immediately place patient in isolation
Ask the patient to describe the type of reaction
Document latex allergy on medication administration record
Process to the termination phase of interview - Answer-Ask the patient to describe type
of reaction
A nurse is planning care for a client who is postoperative. Which of the following
statements about pain management should the nurse consider when implementing
client care? (Select all that apply.)
All clients will express the feeling of pain both verbally and nonverbally.
Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic
range.
Use of analgesics will eventually lead to addiction.
Pain level and pain tolerance can be assessed using a scale from 0 to 10.
Each client's expression of pain may be different and individualized. - Answer-Patient-
controlled analgesia (PCA) offers a constant level of opioids within therapeutic range.
Pain level and pain tolerance can be assessed using a scale from 0 to 10.
Each client's expression of pain may be different and individualized.
The nurse is caring for an African American patient with COPD. The nurse knows that
the best location to assess for hypoxia is the:
Lower extremities
Abdomen
Earlobes
Oral mucosa - Answer-Oral mucosa
What is the most appropriate way to assess the pain of a patient who is oriented and
has recently had surgery?
, Observe cardiac monitor for increased HR
Ask patient describe the effect of pain on ability to cope
Ask patient to rate level of pain
Assess patients body language - Answer-Ask patient to rate level of pain
An assistive personnel reports a client's vital signs as tympanic temperature 37.1° C
(98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the
following vital signs should the nurse re-measure?
BP
Temp
Pulse Rate
Respiratory Rate - Answer-BP
In which order will the nurse use the nursing process steps during the clinical decision-
making process?
1. Evaluating goals
2. Assessing patient needs
3. Planning priorities of care
4. Determining nursing diagnoses
5. Implementing nursing interventions - Answer-Assess, Determine diagnosis, Plan
priorities of care, Implement interventions, Evaluate goals
During a routine physical examination of a 70-year-old patient, a blowing sound is
auscultated over the carotid artery. The nurse notifies the medical provider of the
unexpected physical finding known as:
Clubbing
Bruit
Murmur
Phlebitis - Answer-Bruit
A nurse is caring for a patient with left sided hemiparesis who has developed bronchitis
and has a heart rate of 105, blood pressure of 156/90, and a respiration rate of 30.
Which nursing diagnosis is the priority for this patient?
Impaired gas exchange
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