1413 Exam 3 Practice Questions from Fundamentals of Nursing

28.9 additional info Proper cleaning and disinfection are processes that occur prior to sterilization, with cleaning always done from dirty to clean to ___ the risk of further infection and contam- ination.

decrease

28.10 T/F Patient-to-patient transmission of infection cannot occur if gloves are routinely used.

false- Although gloves are an additional tool to decrease the spread of infection from patient to patient, touching gloves with unclean hands as you put them on contaminates the gloves so that they are no longer clean.

28.1 additional info Clostridium difficile is transmitted through the _____ and spread through ___The organism develops a hard spore and can live for long periods of time on surfaces, making it very hard to eradicate. As long as patient is continent of stool and first cleans hands and changes gown, a patient with C. difficile may leave the room.

fecal-oral route, contact with contaminated feces or surfaces touched by hands not appropriately cleaned after providing care to a patient infected with C. difficile.

28.9 Which of these statements are true regarding disinfection and cleaning? (Select all that apply.) 1. Proper cleaning requires mechanical removal of all soil from an object or area. 2. General environmental cleaning is an example of medical asepsis. 3. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. 4. Cleaning in a direction from the least to the most contami- nated area helps reduce infections. 5. Disinfecting and sterilizing medical devices and equipment involve the same procedures.

1, 2, 4

13.8 A 45-year-old woman who is obese tells a nurse that she wants to lose weight. Which assessment findings may be contributing factors to the woman's obesity? (Select all that apply.) 1. The woman works in an executive position that is very demanding. 2. The woman says that she has little time to prepare meals at home and eats out at least four nights a week. 3. The woman works out at the corporate gym at 5 am three mornings per week. 4. The woman says that she tries to eat "low-cholesterol" foods to help lose weight.

1, 2

28.1 A patient who has been placed on Contact Precautions for Clos- tridium difficile (C. difficile) asks you to explain what he should know about this organism. What is the most appropriate informa- tion to include in patient teaching? (Select all that apply.) 1. The organism is usually transmitted through the fecal-oral route. 2. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. 3. Everyone coming into the room must be wearing a gown and gloves. 4. While the patient is in Contact Precautions, he cannot leave the room. 5. C. difficile dies quickly once outside the body.

1, 2, 3

28.5 The infection control nurse has asked the staff to work on reduc- ing the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing health care-acquired infections? (Select all that apply.) 1. Teaching correct hand washing to assigned patients 2. Using correct procedures in starting and caring for an intravenous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter 4. Isolating a patient on antibiotics who has been having loose stool for 24 hours 5. decreasing the patents stimuli to reduce nausea

1, 2, 3

36.1 To best assist a patient in the grieving process, which factors are most important for the nurse to assess? (Select all that apply.) 1. Previous experiences with grief and loss 2. Religious affiliation and denomination 3. Ethnic background and cultural practices 4. Current financial status 5. Current medications

1, 2, 3

36.3 The nurse recognizes that which factors influence a person's approach to death? (Select all that apply.) 1. Culture 2. Spirituality 3. Personal beliefs 4. Previous experiences with death 5. Gender 6. Level of education

1, 2, 3, 4

13.4 Chronic illness (e.g., diabetes mellitus, hypertension, rheumatoid arthritis) may affect a person's roles and responsibilities during middle adulthood. When assessing the health-related knowledge base of both the middle-age patient with a chronic illness and his or her family, the assessment should include which of the follow- ing? (Select all that apply.) 1. Medical course of the illness 2. Prognosis for the patient 3. Coping mechanisms of the patient and family 4. Socioeconomic status 5. Need for community and social services.

1, 2, 3, 5

36.5 Which comments to a patient by a new nurse regarding palliative care needs are correct? (Select all that apply.) 1. "Even though you're continuing treatment, palliative care is something we might want to talk about." 2. "Palliative care is appropriate for people with any diagnosis." 3. "Only people who are dying can receive palliative care." 4. "Children are able to receive palliative care." 5. Palliative care is only for people with uncontrolled pain.

1, 2, 4

36.7 When planning care for a dying patient, which interventions promote the patient's dignity? (Select all that apply.) 1. Providing respect 2. Viewing the patient as a whole 3. Providing symptom management 4. Showing interest 5. Being present 6. Inserting a straight catheter when the patient has difficulty voiding

1, 2, 4, 5

14.5 A nurse sees a 76-year-old woman in the outpatient clinic. She states that she recently started to notice a glare in the lights at home. Her vision is blurred, and she is unable to play cards with her friends, read, or do her needlework. Which of the following nursing interventions are appropriate? (Select all that apply.) 1. Refer her to an ophthalmologist. 2. Suggest large-print books and playing cards. 3. Reassure her that this is part of normal aging. 4. Suggest lower-wattage light bulbs to decrease glare. 5. Assess her home environment for safety.

1, 2, 5

28.4 Which type of personal protective equipment should the nurse wear when caring for a pediatric patient who is placed on Airborne Precautions for confirmed chickenpox/herpes zoster? (Select all that apply.) 1. Disposable gown 2. N95 respirator mask 3. Face shield or goggles 4. Disposable mask 5. Gloves

1, 2, 5

31.3 An older adult states that she cannot see her medication bottles clearly to determine when to take her prescription. What should the nurse do? (Select all that apply.) 1. Provide a dispensing system for each day of the week. 2. Provide larger, easier-to-read labels. 3. Tell the patient what is in each container. 4. Have a family caregiver administer the medication. 5. Use teach-back to ensure that the patient knows what medication to take and when.

1, 2, 5

35.10 The nurse is caring for a 50-year-old woman visiting the outpatient medicine clinic. The patient has had type 1 diabetes since age 13. She has numerous complications from her disease, including reduced vision, heart disease, and severe numbness and tingling of the extremities. Knowing that spirituality helps patients cope with chronic illness, which of the following principles should the nurse apply in practice? (Select all that apply.) 1. Pay attention to the patient's spiritual identity throughout the course of her illness. 2. Select interventions that you know scientifically support spiritual well-being. 3. Listen to the patient's story each visit to the clinic, and offer a compassionate presence. 4. When the patient questions the reason for her long-time suffering, try to provide answers. 5. Consult with a spiritual care adviser, and have the adviser recommend useful interventions.

1, 3

45.10 A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent a central line infection? (Select all that apply.) 1. Change the dressing using sterile technique. 2. Change TPN containers every 48 hours. 3. Change the TPN tubing every 24 hours. 4. Monitor glucose levels to watch and assess for glucose intolerance. 5. Elevate head of the bed 45 degrees to prevent aspiration.

1, 3

31.10 After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection." What should the nurse do next? (Select all that apply.) 1. Assess the injection site. 2. Administer an oral medication for pain. 3. Notify the patient's health care provider of assessment findings. 4. Document assessment findings and related interventions in the patient's medical record. 5. This is a normal finding, so nothing needs to be done. 6. Apply ice to the site for relief of burning pain.

1, 3, 4

13.7 Which are examples of positive health habits that may prevent the development of chronic illness later in life? (Select all that apply.) 1. Routine screening and diagnostic tests 2. Unprotected sexual activity 3. Regular exercise 4. Consistent seat belt use 5. Excess alcohol consumption

1, 3, 4 "Seat belt use saves lives and reduces the extent of injury in motor vehicle accidents" how is this related to chronic illness? chronic pain?

36.10 Which actions by the nurse help grieving families? (Select all that apply.) 1. Encourage involvement in nonthreatening group social activities. 2. Follow up with the family in their home. 3. Remind them that feelings of sadness or pain can return around anniversaries. 4. Encourage survivors to ask for help. 5. Look for overuse of alcohol, sleeping aids, or street drugs.

1, 3, 4, 5

28.7 Put the following steps for removal of protective barriers after leaving an isolation room in order. 1. Remove and dispose of gloves. 2. Perform hand hygiene. 3. Remove eyewear or goggles. 4. Untie top and then bottom mask strings and remove from face. 5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side.

1, 3, 5, 4, 2

14.6 A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are the major concerns for this patient? (Select all that apply.) 1. The loss of his work role 2. The risk of social isolation 3. A determination on whether the wife will need to start working 4. How the wife expects household tasks to be divided in the home in retirement 5. The age the patient chose to retire

1, 4

23.4 Which of the following actions, if performed by a registered nurse, could result in both criminal and administrative law sanc- tions against the nurse? (Select all that apply.) 1. Reviewing the electronic health record of a family member who is a patient in the same hospital on a different unit 2. Refusing to provide health care information to a patient's child 3. Reporting suspected abuse and neglect of children 4. Applying physical restraints without a written order 5. Completing an occurrence report on the unit

1, 4

14.10 A 71-year-old patient enters the emergency department after falling down stairs at church. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? (Select all that apply.) 1. Impaired vision 2. Residence design 3. Blood pressure 4. Leg weakness 5. Exercise history

1, 4, 5

23.6 A patient is in skeletal traction and has a plaster cast due to a fractured femur. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to docu- ment this because one of the nurse's other patients experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation? (Select all that apply.) 1. Failure to document a change in assessment data 2. Failure to provide discharge instructions 3. Failure to provide patient education about cast care. 4. Failure to use proper medical equipment ordered for patient monitoring 5. Failure to notify a health care provider about a change in the patient's condition

1, 5

45.2 The nurse is evaluating the recent lab results for a patient. Which labs are the best indicators for malnutrition? (Select all that apply.) 1. Serum total protein 2. Potassium 3. Lipids 4. Albumin 5 Serum BUN

1, 5

14.3 A nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing: 1. Normal aging.2. Delirium.3. Depression.4. Worsening dementia.

2 delirium

36.8 What are the physical circulatory changes that occur as death approaches? 1. Skin irritation 2. Mottling 3. Increased urine output 4. Weakness

2 patients experiencing circulatory changes resulting in mottling. Weakness, skin irritation, and incontinence are some of the physical changes that occur as death nears but are not related to circulatory changes

31.5 A nurse is administering ophthalmic ointment to a patient. Place the following steps in correct order for the administration of the ointment. 1. Clean eye, washing from inner to outer canthus. 2. Assess patient's level of consciousness and ability to follow instructions. 3. Apply thin ribbon of ointment evenly along inner edge of lower eyelid on conjunctiva. 4. Have patient close eye and rub lightly in a circular motion with a cotton ball. 5. Ask patient to look at ceiling, and explain the steps to patient.

2, 1, 5, 3, 4

23.3 A nurse sends a text message to the oncoming nurse to report that a patient refuses to take medication as ordered. What should the oncoming nurse do? (Select all that apply). 1. Add this information to the board hanging at the patient's bedside. 2. Tell the nurse who sent the text that the text is a HIPAA violation. 3. Inform the nursing supervisor. 4. Forward the text to the charge nurse. 5. Thank the nurse for sending the information.

2, 3

28.6 Which of the following actions by the nurse demonstrate the practice of core principles of surgical asepsis? (Select all that apply.) 1. The front and sides of the sterile gown are considered sterile from the waist up. 2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. 4. Only health care personnel within the sterile field must wear personal protective equipment. 5. After cleansing the hands with antiseptic rub, apply clean disposable gloves.

2, 3

35.5 A 44-year-old male patient has just been told that his wife and child were killed in an auto accident while coming to visit him in the hospital. Which of the following statements are assessment findings that support a nursing diagnosis of Spiritual Distress related to loss of family members? (Select all that apply.) 1. "I need to call my sister for support." 2. "I have nothing to live for now." 3. "Why would my God do this to me?" 4. "I need to pray for a miracle." 5. "I want to be more involved in my church."

2, 3

45.1 The nurse is caring for a client with pneumonia, who has severe malnutrition. The nurse should assess the patient for which of the following assessment findings? (Select all that apply.) 1. Heart disease 2. Sepsis 3. Hemorrhage 4. Skin breakdown 5. Diarrhea

2, 3, 4

14.1 A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? (Select all that apply.) 1. The center needs to be clean, and rooms should look like a hospital room. 2. Adequate staffing is available on all shifts. 3. Social activities are available for all residents. 4. The center provides three meals daily with a set menu and serving schedule. 5. Staff encourage family involvement in care planning and assisting with physical care.

2, 3, 5

14.8 A nurse is participating in a health and wellness event at the local community center. A woman approaches and relates that she is worried that her widowed father is becoming more functionally impaired and may need to move in with her. The nurse asks about his ability to complete activities of daily living (ADLs). ADLs include independence with: (Select all that apply.) 1. Driving. 2. Toileting. 3. Bathing. 4. Daily exercise. 5. Eating.

2, 3, 5

35.7 A nurse is preparing to teach an older adult who has chronic arthritis how to practice meditation. Which of the following strat- egies are appropriate? (Select all that apply.) 1. Encourage family members to participate in the exercise. 2. Have patient identify a quiet room in the home that has minimal interruptions. 3. Suggest the use of a quiet fan running in the room. 4. Explain that it is best to meditate about 5 minutes 4 times a day. 5. Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer.

2, 3, 5

36.2 Which interventions does a nurse implement to help a patient at the end of life maintain autonomy while in a hospital? (Select all that apply.) 1. Use therapeutic techniques when communicating with the patient. 2. Allow the patient to determine timing and scheduling of interventions. 3. Allow patients to have visitors at any time. Provide the patient with a private room close to the nurses' station. 5. Encourage the patient to eat whenever he or she is hungry.

2, 3, 5

31.7 A nurse is administering a metered-dose inhaler (MDI) with a spacer to a patient with chronic obstructive pulmonary disease. Place the steps of the procedure in the correct order. 1. Insert MDI into end of spacer. 2. Perform a respiratory assessment. 3. Remove mouthpiece from MDI and spacer device. 4. Place the spacer mouthpiece into patient's mouth, and instruct patient to close lips around the mouthpiece. 5. Depress medication canister, spraying 1 puff into spacer device. 6. Shake inhaler for 2-5 seconds. 7. Instruct patient to hold breath for 10 seconds. 8. Instruct patient to breathe in slowly through mouth for 3 to 5 seconds.

2, 3, 6, 1, 4, 5, 8, 7

14.9 During a home health visit a nurse talks with a patient and his family caregiver about the patient's medications. The patient has hypertension and renal disease. Which of the following findings place him at risk for an adverse drug event? (Select all that apply.) 1. Taking two medications for hypertension 2. Taking a total of eight different medications during the day 3. Having one physician who reviews all medications 4. Patient's health history of renal disease 5. Involvement of the caregiver in helping with medication administration

2, 4

28.8 A patient is diagnosed with a multidrug-resistant organ- ism (MDRO) in his surgical wound and asks the nurse what this means. What is the nurse's best response? (Select all that apply.) 1. There is more than one organism in the wound that is causing the infection. 2. The antibiotics the patient has received are not strong enough to kill the organism. 3. The patient will need more than one type of antibiotic to kill the organism. 4. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively. 5. There are no longer any antibiotic options available to treat the patient's infection.

2, 4

36.6 A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks whether the patient is dying and now in "hospice." What does the nurse tell the family member about palliative care? (Select all that apply.) 1. Palliative care and hospice are the same thing. 2. Palliative care is for any patient, any time, any disease, in any setting. 3. Palliative care strategies are primarily designed to treat the patient's illness. 4. Palliative care relieves the symptoms of illness and treatment. 5. Palliative care selects home health care services.

2, 4

47.1 Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.) 1. Lift the patient's hips off the bed and slide the bedpan under the patient. 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 3. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient. 4. Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.

2, 5

31.6 The nurse is administering an IV push medication to a patient who has a compatible IV fluid running through intravenous tub- ing. Place the following steps in the appropriate order. 1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration. 2. Select injection port of IV tubing closest to patient. Whenever possible, injection port should accept a needleless syringe. Use IV filter if required by medication reference or agency policy. 3. After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate. 4. Connect syringe to port of IV line. Insert needleless tip or small-gauge needle of syringe containing prepared drug through center of injection port 5. Clean injection port with antiseptic swab. Allow to dry. 6. Occlude IV line by pinching tubing just above injection port. Pull back gently on syringe plunger to aspirate blood return.

2, 5, 4, 6, 1, 3

35.6 A patient has just learned she has been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. The nurse has been caring for her for only 2 hours but has a good relationship with her. What is the most appropriate intervention for support of her spiritual well-being at this time? 1. Make a referral to a professional spiritual care adviser. 2. Sit down and talk with the patient; have her discuss her feelings and listen attentively. 3. Move the patient's Bible from her bedside cabinet drawer to the top of the over-bed table. 4. Ask the patient whether she would like to learn more about the implications of having this type of tumor.

2. Establishing presence contributes to a patient's sense of well-being. It helps to prevent emotional and environmen- tal isolation.

14.7 A nurse is assessing an older adult brought to the emergency depart- ment following a fall and wrist fracture. The patient is very thin and unkempt, has a stage 3 pressure injury on her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son, who accompanied her to the hospital. What is the nurse's next step? 1. Call social services to begin nursing home placement. 2. Ask the son to step out of the room so that she can complete her assessment. 3. Call adult protective services because you suspect elder mistreatment. 4. Assess the patient's cognitive status.

2. ask the son to step out of the room so that she can complete her assessment

45.9 A nurse sees an assistive personnel (AP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention by the nurse? 1. Fastening tube to the gown with new tape 2. Placing client supine while giving a bath 3. Monitoring the client's weight as ordered 4. Ambulating patient with enteral feedings still infusing

2. placing client supine while giving a bath- this is an aspiration risk!!

23.1 A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits? 1. Family member 2. Surgeon 3. Nurse 4. Nurse manager

2. the person performing the procedure is responsible for informing the patient about the procedure and risk, benefits, and possible complications

35.9 A nurse used spiritual rituals as an intervention in a patient's care. Which of the following questions is most appropriate to evaluate its efficacy? 1. Do you feel the need to forgive your wife over your loss? 2. What can I do to help you feel more at peace? 3. Did either prayer or meditation prove helpful to you? 4. Should we plan on having your family try to visit you more often in the hospital?

3

36.9 When providing postmortem care, which actions are necessary for the nurse to complete? 1. Locating the patient's clothing 2. Calling the funeral home 3. Providing culturally and religiously sensitive care in body preparation 4. Providing postmortem care to protect the family of the deceased from having to view the body

3

13.10 A nurse is completing an assessment on a male patient, age 24. Following the assessment, the nurse notes that his family history is not significant for chronic illnesses, and his physical and lab- oratory findings are within normal limits. Because of these find- ings, nursing interventions are directed toward activities related to: (Select all that apply.) 1. Instructing him to return in 2 years. 2. Instructing him in secondary prevention. 3. Instructing him in health promotion activities. 4. Instructing him about routine screenings. 5. Instructing him about proper vaccinations.

3, 4, 5

35.8 A nursing student is developing a plan of care for a 74-year-old-female patient who has spiritual distress over losing a spouse. As the nurse develops appropriate interventions, which characteristics of older adults should be considered? (Select all that apply.) 1. Older adults do not routinely use complementary medicine to cope with illness. 2. Older adults dislike discussing the afterlife and what might have happened to people who have passed on. 3. Older adults achieve spiritual resilience through frequent expressions of gratitude. 4, Have the patient determine whether her husband left a legacy behind. 5. Offer the patient her choice of rituals or participation in exercise.

3, 4, 5

31.8 A patient is to receive medications through a small-bore nasogastric feeding. Which nursing actions are appropriate? (Select all that apply.) 1. Verifying tube placement after medications are given 2. Mixing all medications together to give all at once 3. Using an enteral tube syringe to administer medications 4. Flushing tube with 30 to 60 mL of water after the last dose of medication 5. Checking for gastric residual before giving the medications 6. Keeping the head of the bed elevated 30 to 60 minutes after the medications are given

3, 4, 5, 6

28.3 A patient is placed on Airborne Precautions for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? 1. Provide a dark, quiet room to calm the patient. 2. Reduce the level of precautions to keep the patient from becoming angry. 3. Explain the reasons for isolation procedures and provide meaningful stimulation. 4. Limit family and other caregiver visits to reduce the risk of spreading the infection.

3. By providing a rationale for the isolation, the patient is able to better understand the safety risks and cooperate with care. Providing reading material or other distractions for the patient will also help with times when alone in the room.

23.8 A home health nurse notices significant bruising on a 2-year-old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take? 1. Document her findings and treat the patient. 2. Instruct the mother on safe handling of a 2-year-old child. 3. Contact a child abuse hotline. 4. Discuss this story with a colleague.

3. nurses are mandated to report suspected child abuse. The assessment findings possible indicate child abuse

13.9 A 34-year-old female executive has a job with frequent deadlines. She notes that when the deadlines appear, she tends to eat high- fat, high-carbohydrate foods. She also explains that she gets fre- quent headaches and stomach pain during these deadlines. After receiving health education from the nurse, the executive decides to try yoga. In this scenario yoga is used as a(n): 1. Outpatient referral. 2. Counseling technique. 3. Health promotion activity. 4. Stress-management technique.

4

23.2 A woman has severe life-threatening injuries, is unresponsive, and is hemorrhaging following a car accident. The health care provider ordered two units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurse's responsibility? 1. Obtain a court order to give the blood. 2. Convince the husband to allow the nurse to give the blood. 3. Call security and have the husband removed from the hospital. 4. Gather more information about the wife's preferences and determine whether the husband is her power of attorney for health care.

4

14.4 Older adults frequently experience a change in sexual activity. Which best explains this change? 1. The need to touch and be touched is decreased. 2. The sexual preferences of older adults are not as diverse. 3. Medication side effects often impact sexual functioning. 4. Frequency and opportunities for sexual activity may decline.

4 (only select medications impact sexual functioning)

47.10 A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Have you taken antibiotics recently? 3. Do you have gluten intolerance? 4. Have you experienced frequent, small liquid stools recently?

4. Frequent or continuous oozing of liquid stools occurs when liquid fecal matter above the impacted stool seeps around the fecal impaction.

45.5 A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request a discontinuation of parenteral nutrition? 1. When 25% of the patient's nutritional needs are met by the tube feedings 2. When bowel sounds return 3. When the central line has been in for 10 days 4. When 75% of the patients nutritional needs are met by the tube feedings

4. When meeting 75% of nutritional needs by enteral feedings or reliable dietary intake, it is usually safe to discontinue PN therapy.

31.9 Place the steps of administering an intradermal injection in the correct order. 1. Inject medication slowly. 2. Note the presence of a bleb. 3. Advance needle through epidermis to 3 mm. 4. Using nondominant hand, stretch skin over site with forefinger. 5. Insert needle at a 5- to 15-degree angle into the skin until resistance is felt. 6. Cleanse the site with antiseptic swab

6, 4, 5, 3, 1, 2

31.4 The nurse must take a verbal order during an emergency on the unit. Which of the following guidelines can be used for taking verbal or telephone orders? (Select all that apply). 1. Only authorized staff may receive and record verbal or telephone orders. The health care agency identifies in writing the staff who are authorized. 2. Clearly identify patient's name, room number, and diagnosis. 3. Read back all orders to health care provider. 4. Use clarification questions to avoid misunderstandings. 5. Write "VO" (verbal order) or "TO" (telephone order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse.

ALL

31.2 The health care provider has written the following orders. Which orders does the nurse need to clarify before administering the medication? Provide rationale for your answers, and rewrite the order so that it follows the ISMP current medication order safety guidelines. Timoptic .25% solution 1 drop OD BID Metoprolol 12.50 mg QD Insulin Glargine 6 u SC twice a day Enalapril 2.5 mg. PO three times a day, hold for systolic blood pressure <100

All need clarified! Timoptic needs a leading zero and OD could be mistaken for AD so it should not be written this way. Metoprolol should not have the trailing zero U in insulin should be written as units Enalapril should have NO period and completely write out HOLD IF BLOOD PRESSURE IF LESS THAN 100

35.1 The nurse is caring for a patient who has just had a near-death experi- ence (NDE) following a cardiac arrest. Which intervention by the nurse best promotes the spiritual well-being of the patient after the NDE? 1. Allowing the patient to discuss the experience 2. Referring the patient to pastoral care 3. Having the patient talk to another patient who had an NDE 4. Offering to pray for the patient

Allowing the patient to discuss the experience

31.1 It is important to take precautions to prevent medication errors. A nurse is administering an oral tablet to a patient. Which of the following steps is the second check for accuracy in determining the patient is receiving the right medication? 1. Logging on to automated dispensing system (ADS) or unlocking medicine drawer or cart. 2. Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR. 3. Selecting correct medication from ADS, unit-dose drawer, or stock supply and comparing name of medication on label with MAR or computer printout. 4. Comparing MAR or computer printout with names of medications on medication labels and patient name at patient's bedside.

Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR.

47.8 What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? 1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks. 2. Initiate bowel or habit training program to promote continence. 3. Help the patient to toilet once every hour. 4. Use sanitary pads in the patient's underwear.

Initiate bowel or habit training program to promote continence

23.5 A nurse received bedside report at the change of shift with the night-shift nurse and the patient. The nursing student assigned to the patient asks to review the patient's medical record. The nurse lists patients' medical diagnoses on the message boards in the patients' rooms. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)? 1. Discussing patient conditions at the bedside at the change of shift 2. Allowing the nursing student to review the assigned patient's chart before providing care during the clinical experience 3. Posting medical information about the patient on a message board in the patient's room 4. Releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared

Posting medical information about the patient on a message board in the patient's room

36.1 additional info ___, ___ and ___ help individuals develop coping and can be a source of support at the end of life.

Previous experiences, religious affiliation, and cultural practices

45.3 The nurse is caring for a client with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? 1. Suction her mouth and throat. 2. Turn her on her side. 3. Put on oxygen at 2 L nasal cannula. 4. Stop feeding her.

Stop feeding and THEN place patient on their side. If choking persists, suction airway. Notify HCP. Keep patient NPO until you hear otherwise.

14.3 additional info Hallmark characteristics of delirium are

acute confusion, hallucinations, and agitation. These symptoms are not part of the normal aging process. As dementia worsens, there is a gradual rather than sudden change in memory, usually not accompanied by hallucinations. Depression does not present with acute confusion and agitation.

36.5 additional info Palliative care is available to

all patients regardless of age, diagnosis, and prognosis.

45.1 additional info Patients who are malnourished on admission are at greater risk of life-threatening complications such as

arrhythmia, skin breakdown, sepsis, or hemorrhage during hospitalization.

35.4 A nurse is caring for a patient who is Muslim and has diabetes. Which of the following items does the nurse need to remove from the meal tray when it is delivered to the patient? 1. Small container of vanilla ice cream 2. A dozen red grapes 3. Bacon and eggs 4. Garden salad with ranch dressing

bacon and eggs- islam prohibits the consumption of pork

23.2 additional info Adult patients such as those with specific religious objections are able to refuse treatment for personal religious reasons. Because this patient is unresponsive, it is important for the nurse to

better understand the patient's preferences and know if the woman has a power of attorney for health care before following the hus- band's wishes. However, there needs to be clear directions on who can make the decision.

23.10 You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. Which is the best nurs- ing action to take first? 1. Call the nursing supervisor to discuss the situation. 2. Discuss the problem with a colleague. 3. Leave the nursing unit and go home. 4. Say nothing and begin your work.

call the nursing supervisor to discuss the situation

14.5 additional info A nurse sees a 76-year-old woman in the outpatient clinic. She states that she recently started to notice a glare in the lights at home. Her vision is blurred, and she is unable to play cards with her friends, read, or do her needlework. This woman most likely has

cataracts and should be referred to an ophthalmologist. While common, cataracts are not considered to be part of normal aging. In the meantime, using large-print books or playing cards and reducing home safety hazards would be beneficial. Low- er-wattage light bulbs would not be helpful.

28.5 additional info loose stools are a _____ side effect with antimicrobials.

common

45.6 A client is receiving an enteral feeding at 65 mL/hr. The gastric residual volume in 4 hours was 125 mL. What is the priority nursing intervention? 1. Assess bowel sounds. 2. Raise the head of the bed to at least 45 degrees. 3. Continue the feedings; this is normal gastric residual for this feeding. 4. Hold the feeding until you talk to the primary care provider.

continue the feedings; this is normal gastric residual for this feeding. If its 250 twice or 500 once, we have a problem and feedings should be held

14.2 A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing: 1. Dementia. 2. Depression. 3. Delirium. 4. Anxiety.

depression

36.6 additional info Palliative care and hospice care are ___. Palliative care is available to all patients regardless of age, diagnosis, and prognosis. The focus of palliative care is on management of symptoms.

different

35.1 additional info Patients who have a near death experience (NDE) are often reluctant to speak of the experience. Allowing the patient to

discuss the NDE helps the patient find acceptance of and meaning from the event. It also allows the patient to explore what happened and promotes spiritual well-being.

28.2 A patient is diagnosed with meningitis. Which type of isolation precaution is most appropriate for this patient? 1. Reverse isolation 2. Droplet Precautions 3. Standard Precautions 4. Contact Precautions

droplet precautions

31.3 additional info Larger print and a dispensing system can

ensure safe medication administration in older adults. Medication pamphlets in larger print are also available. The use of teach-back ensures that the patient understands his or her medications and increases safety.

14.1 additional info Adequate staffing, provision of social activities, and active family involvement are _____

essential

35.8 additional info Older-adult patients achieve spiritual resiliency in

expressing gratitude and finding ways to maintain purpose in life. Leaving legacies maintains a connection between the person left behind and the lost loved one. Older adults frequently use complementary medicine, rituals, and exercise to cope with ill- ness and pain. Belief in the afterlife grows with aging.

13.4 additional info When assessing the patient with a chronic illness, it is important that the nurse know

how much the patient and his family know about how the illness has progressed and the long-term prognosis for the patient. This includes understanding the patient and families' abil- ity and readiness to accept the illness and the outlook for the patient. Understanding the coping mechanisms used by the patient and family will assist the nurse in determining how to proceed to teach and counsel the patient and fam- ily regarding the patient's treatment regimen and whether there is a need and acceptance for community or social ser- vices to assist the patient and family.

13.9 additional info Relaxation techniques, such as ___,___ and ___ help recondition the patient's response to stress. Yoga is an ancient practice of controlling body and mind by which there is a physical and mental harmony. It is frequently used as an effective intervention for stress and stress-related physical symptoms.

imagery, biofeedback and yoga

28.5 additional info: ____ is not typically associated with transmutation of infection

nausea

45.2 additional info When a client is malnourished, he or she is in a state of __ nitrogen balance. Therefore, total protein will indicate the amount of muscle breakdown and protein loss. Albumin is more indicative of inflammation or kidney and liver disease. BUN is also an indicator because urea is the end product of protein metabolism, and when a patient is not getting enough protein, you will see a decreased BUN.

negative,

36.2 additional information Allowing patients to make choices about their care and end-of-life experience provides

opportunities for them to maintain their autonomy.

35.9 additional info Rituals can include

participation in worship, prayer, sac- raments (e.g., baptism, Holy Eucharist), fasting, singing, meditat- ing, scripture reading, and making offerings or sacrifices. When you include the use of rituals in a patient's plan of care, evaluate whether the patient perceived these activities as useful. If not, other interventions will be necessary.

35.10 additional info A person's spiritual well-being can change over time; therefore, it is important to

pay attention to it over the course of his or her illness. Listening is a powerful way to support a patient's spirituality. Evidence-based interventions are preferred, but they must be agreed on by the patient and tailored to his or her per- spectives and not just those of the nurse. Patients are not looking for answers. What is spoken as a spiritual question is most often an expression of spiritual pain. Using spiritual care advisers is a valuable resource but should be selected by the patient, not inde- pendently by the nurse, and any interventions should be mutually agreed on among nurse, patient, and adviser.

45.7 Which action can a nurse delegate to assistive personnel (AP)? 1. Performing glucose monitoring every 6 hours on a patient 2. Teaching the client about the need for enteral feeding 3. Administering enteral feeding bolus after tube placement has been verified 4. Evaluating the client's tolerance of the enteral feeding

performing glucose monitoring every 6 hours on a patient

14.9 additional info The patient is at risk for an adverse drug event (ADE) because of ___ and ___

polypharmacy and his history of renal disease, which affects drug excretion. Taking two medica- tions for hypertension is common. Having one physician review all medications and involving a family caregiver are desirable and are safety factors for preventing ADEs.

14.2 additional info Factors that often lead to depression include

presence of a chronic disease or a recent change or life event (such as loss). Patients are alert but easily distracted in conversation.

14.6 additional info The psychosocial stresses of retirement are usually related to

role changes with a spouse or within the family and to loss of the work role. Often there are new expectations of the retired person. This patient is not likely to become socially isolated because of the size of the family. Whether the wife will have to work is not a major concern at this time, nor is the age of the patient.

14.8 additional info Activities of daily living are

self-care tasks that measure function and are markers for the ability to live independently. Although driving and daily exercise are important to quality of life and health maintenance, they would not necessarily impact a person's ability to live inde- pendently.

14.10 additional info Risk factors for falling include

sensory changes such as visual loss, musculoskeletal conditions affecting mobility (in this case weakness), and decondition- ing (from lack of exercise). The mere presence of a chronic disease is not a risk factor unless it is a condition such as a neurological disorder that alters mobility or cognitive func- tion. The patient's blood pressure is stable, and there is no report of orthostatic hypotension. A one-floor residence should not pose risks.

28.8 additional info An MDRO is a

single organism that is resistant to one or more classes of antibiotics, which makes it harder to treat, but there is treatment available.

28.2 additional info: meningitis, which can be spread when

the patient coughs or sneezes, droplet precautions are most appropriate.

13.10 additional info While young adults generally have a minimum of major health problems, lifestyles such as________put them at risk for health problems. Instructing young adults in health promotion activities can decrease the risk for lifestyle-related health issues in the young adult. Proper vaccinations (e.g., flu vaccines and boosters to routine childhood vaccinations, such as teta- nus) and regular health screenings are also important to maintain health.

tobacco or alcohol abuse, risky sexual activity, obesity, and lack of physical activity