Nursing Fundamentals Quiz

For patients with chronic heart failure, dyspnea, orthopnea, and peripheral edema, the primary nursing intervention is administering prescribed diuretics and closely monitoring urine output.

Bounding pulses are a key sign of a Patent Ductus Arteriosus (PDA) in a newborn.

To calculate the correct amoxicillin dose for a 20 kg child, multiply the child's weight by the prescribed dosage, then divide by the frequency.

The most effective method to prevent healthcare-associated infections (HAIs) is strictly adhering to hand hygiene protocols, such as frequent handwashing.

To verify proper placement of a nasogastric (NG) tube, the best method is to auscultate for air insufflation in the stomach. This technique confirms the tube has reached the stomach.

For a patient in the third trimester with painless vaginal bleeding, the priority nursing action is to assess fetal heart rate and maternal vital signs.

If a patient with diabetes mellitus is confused and diaphoretic, the first action should be to check the patient’s blood glucose level.

For a patient arriving with slurred speech and right-sided weakness, the nurse's top priority is to perform a detailed neurological assessment.

During a measles outbreak, the highest priority is to prevent further spread through vaccination. Mass vaccination of susceptible individuals is crucial to stop the outbreak's progression.

Respiratory acidosis is characterized by a low pH (acidic) and an elevated PaCO2 (carbon dioxide).

A low-protein diet is crucial for individuals with liver cirrhosis, as it helps to reduce ammonia levels (a byproduct of protein breakdown) that contribute to hepatic encephalopathy.

The highest priority is to ensure the safety of the patient and others, as command hallucinations can indicate a risk of violence.

The first action should be to assess the patient for adverse effects, as this establishes the immediate consequences of the error.

High potassium levels (hyperkalemia) can be life-threatening. Calcium gluconate is the priority intervention as it antagonizes potassium's effects on the heart, stabilizing the electrical activity.

Early ambulation is crucial for patients with DVT to promote blood flow and prevent complications like pulmonary embolism.

Hypoglycemia is the most common complication of untreated gestational diabetes in newborns due to their inability to manage blood sugar effectively.

Clear fluid drainage from the nose after a head injury is a sign of possible cerebrospinal fluid (CSF) leakage.

A sunken anterior fontanel in a dehydrated child is a serious sign of severe fluid loss.

A patient with COPD who becomes drowsy and lethargic while on oxygen therapy might be experiencing oxygen toxicity. This requires immediate medical attention.

A heart rate of 68 beats per minute (bpm) is within the normal range for adults. It's not a reason to withhold digoxin, a heart medication.

A serum potassium level of 3.2 mEq/L is low and can be dangerous for patients taking digoxin. Digoxin toxicity is more likely when potassium levels are low.

A blood pressure of 140/90 mmHg in a pregnant woman at 32 weeks is a sign of preeclampsia, a serious condition that requires immediate medical attention.

A fever developing 24 hours after surgery is a common sign of a surgical site infection (SSI). This requires prompt medical care.

Overhearing a colleague discussing a patient's diagnosis in a public area is a breach of patient confidentiality. This needs to be reported.

Dysphagia is difficulty swallowing. Aspiration is the inhalation of food or liquid into the lungs, which can be life-threatening. The nurse's priority is to prevent aspiration by monitoring for signs and symptoms.

Warfarin is a blood thinner that prevents blood clots. Vitamin K is a nutrient that helps with blood clotting. A patient on warfarin needs to have consistent vitamin K levels, so avoiding foods rich in vitamin K helps maintain a stable dose.

Late decelerations on fetal heart rate monitoring indicate fetal distress. The nurse's first action should be to position the mother on her side to improve blood flow to the fetus.

Hyperkalemia is a condition where the potassium levels in the blood are too high. Calcium gluconate is used to stabilize cardiac membranes and protect the heart from the harmful effects of high potassium.

Informed consent means the patient understands the risks and benefits of the surgery and has agreed to it. It is the most important nursing action before surgery because it ensures the patient's autonomy and legal protection.

Oxygen saturation measures the percentage of oxygen in the blood. It is a reliable indicator of how well the lungs are delivering oxygen to the body.

A generalized tonic-clonic seizure involves a loss of consciousness followed by muscle rigidity and jerking movements. Positioning the patient on their side will prevent them from choking on saliva or vomit.

Hyponatremia is a low sodium level. Sodium helps regulate fluid balance and nerve function. A low sodium level can cause confusion and weakness.

Amylase and lipase are enzymes produced by the pancreas. High levels indicate inflammation of the pancreas.

Consistent hand hygiene breaks the chain of infection and prevents the spread of germs. It's the single most effective way to reduce HAIs.

Depression is a mental health condition often associated with a loss of energy and interest, leading to a risk of suicide.

Digoxin is a heart medication that can lower potassium levels. Low potassium can increase the risk of digoxin toxicity.

Apnea is a temporary pause in breathing. Periods lasting less than 10 seconds are normal in newborns. However, longer pauses raise concerns about respiratory distress.

Administering naloxone as prescribed is the immediate action when a patient on IV morphine develops shallow respirations and a respiratory rate of 8 breaths per minute. Naloxone is an opioid antagonist that reverses the effects of opioid overdose.

Decreased urine output is the most reliable indicator of dehydration in an infant. Other signs, such as sunken fontanelles or dry mucous membranes, can be present in other conditions.

The most appropriate infection control measure for a patient with active tuberculosis is airborne precautions. This involves placing the patient in a private room with negative air pressure and wearing N95 respirators when caring for the patient.

Nitroglycerin's primary action for a patient with acute coronary syndrome is to reduce myocardial oxygen demand by vasodilation. This reduces the workload on the heart, improving blood flow to the heart muscle.

The priority intervention for a patient with chronic kidney disease and a potassium level of 6.8 mEq/L is to administer sodium polystyrene sulfonate (Kayexalate). This medication binds to potassium in the gut, helping to lower the potassium level.

Contact precautions are the appropriate infection control measure for a patient with Clostridioides difficile (C.diff) infection. This involves using gloves and gown when interacting with the patient and their environment to prevent spreading the bacteria.

The priority nursing action when a loop of the umbilical cord protrudes from the vagina during the second stage of labor is to notify the healthcare provider immediately. This is a medical emergency that can compromise the baby's blood supply.

The nurse's priority action when a patient with major depressive disorder states, "I feel like life is not worth living" is to ask the patient if they have a specific plan to harm themselves. This assess the patient's immediate risk for suicide and guides further action.