EAQ 4

The healthcare provider has instructed the nurse to administer 4 mg of morphine sulfate intravenously to a patient. The ampule of morphine contains 1 mL of the solution with a concentration of 10 mg/mL. What volume of the medication should the nurse administer to this patient? Record your answer to one decimal place. ______ mL

0.4 mL The volume required is calculated by the formula: (Dose ordered/dose on hand) x Amount on hand = Amount to administer. (4 mg/10 mg) x 1 mL = Amount to administer = 0.4 mL. Therefore, the patient requires 0.4 mL of morphine to be administered.

The nurse is preparing a medication ordered by the physician. The physician ordered 250 mg of Tylenol to be given to the patient. The medication comes from the pharmacy in dosage strength of 1 gram of Tylenol in 2 mL. How many mL should the nurse administer? Record your answer using one decimal place. _____ mL

0.5 mL By using the formula method: (Dose ordered/Dose on hand) x amount on hand = Amount to administer. (250 mg/1000 mg) x 2 mL = ½ mL = 0.5 mL.

The order is for 20 mg of a medication to a pediatric patient. The ampule of the medication has 40 mg/2 mL of the medication. What is the correct volume to be administered? Record your answer using a whole number. _____ mL

1 mL The amount to be given is half the amount that is provided in the solution. Therefore, the answer is 1 mL. The nurse will calculate the answer using the proportion method. Because the ampule has 40 mg/2 mL, and the nurse has to administer only 20 mg, use the formula 40 mg/2 mL = 20 mg/ x mL, 40 x = 40, x = 1 mL.

The nurse has to administer a subcutaneous injection to a patient. Which precautions should the nurse follow when administering the subcutaneous injection? Select all that apply. 1. Inject medication slowly. 2. Pinch skin with the nondominant hand. 3. Aspirate when administering the injection. 4. Inject the needle slowly at a 45- to 90-degree angle. 5. Insert the needle with bevel up at a 5- to 15-degree angle.

1, 2 Administering a subcutaneous injection for an average-size patient involves pinching the skin with the nondominant hand and injecting the needle quickly and firmly at a 45- to 90-degree angle. The medication has to be injected slowly to minimize pain. The skin is pinched with the nondominant hand, because the dominant hand is used for administering the injection. Piercing a blood vessel during a subcutaneous injection is very rare, so aspiration is not necessary. Injecting the needle should be quick. Inserting the needle with bevel up at a 5- to 15-degree angle is done for intradermal injection.

A patient is prescribed a sublingual nitroglycerin drug. Which instructions should the nurse provide to the patient? Select all that apply. 1. Do not swallow the medication. 2. Place the medication under the tongue. 3. Spit out the drug in case of irritation. 4. Take the medication with water. 5. Place the drug between your tongue and cheeks.

1, 2 When administering medications through the sublingual route, the medication must be placed under the tongue until it fully dissolves. The medication should not be swallowed. Swallowing can make the medication ineffective. The medication should not be spit out to prevent irritation; however, it may be spit out if the desired therapeutic effect is attained. The medication should not be taken with water, because this can alter its effectiveness. Sublingual medication should be administered under the tongue, not between the tongue and cheeks.

The nurse is teaching nursing students about the characteristics of an effective leader. Which statements by the nursing students indicate effective learning? Select all that apply. 1. 'A leader is a role model for the staff.' 2. 'A leader is an effective communicator.' 3. 'A leader is consistent in managing conflict.' 4. 'A leader avoids a participatory approach to decision making.' 5. 'A leader may not be competent in all aspects of delivery of care.'

1, 2, 3 An effective leader has some specialized characteristics. The effective leader is a role model for the staff, an effective communicator, and is consistent in managing conflict. An effective leader takes a participatory approach to decision making, because it is helpful for making the right decisions. It is necessary for a leader to be knowledgeable and competent in all aspects of delivery of care.

The nurse is caring for a patient who is at high risk of aspiration. Which preliminary assessments should the nurse perform to reduce the risk of aspiration while administering oral medications? Select all that apply. 1. Assess the ability to cough. 2. Assess the presence of intact gag reflex. 3. Assess the ability to swallow. 4. Assess the ability to clench teeth. 5. Assess the tongue movement.

1, 2, 3 To prevent aspiration while administering oral medications, the nurse should assess whether the patient is able to cough, has intact gag reflex, and has the ability to swallow. Presence of these reflexes reduces the chances of aspiration. The ability to clench the teeth and move the tongue is not protective against aspiration.

Using Healthy People 2020 as a guide, which action would improve delivery of care to a community? Select all that apply. 1. Community assessment 2. Implementing public health policies 3. Increasing access to care 4. Determining rates of specific illnesses 5. Reducing the number of fast food restaurants in the community

1, 2, 3, 4 Improved delivery of health care occurs through the assessment of health care needs of individuals, families, and communities; development and implementation of public health policies; and improved access to care. For example, assessment includes systematic data collection on the population, monitoring the health status of the population, and accessing available information about the health of the community.

A patient is unable to conduct normal activities due to visual impairment. Which precautions do the family members take to help the patient perform normal activities? Select all that apply. 1. Remove clutter from the floor. 2. Keep all flooring in good repair. 3. Avoid painting the edge of steps. 4. Use low-pile carpeting in the home. 5. Use light fixtures with limited illumination.

1, 2, 4 Patients with visual impairment may not be able to perform normal activities of living within the home. Due to reduced depth perception, the patient has a higher risk of falling. Precautions should be taken by the family members to prevent injury to the patient. Clutter on the floor can increase the risk of falling; therefore, it should be removed. All flooring should be in good repair. Using low-pile carpeting in the home reduces the chance of falling. Painting the edge of the steps helps the patient to easily identify the steps. Light fixtures with wider illumination should be used so that the patient can clearly see the pathway.

Which factors are important during clinical care coordination? Select all that apply. 1. Evaluation 2. Use of resources 3. Interruption control 4. Time management 5. Organizational skills

1, 2, 4, 5 Clinical care coordination is essential to delivering patient care in a timely and effective manner. Clinical care coordination includes factors such as evaluation, use of resources, time management, and organizational skills. It also includes setting priorities and clinical decision making. Interruption control is a principle of time management.

Which normal visual changes are associated with aging? Select all that apply. 1. Reduced visual fields 2. Impaired night vision 3. Reduced glare sensitivity 4. Increased depth perception 5. Reduced color discrimination

1, 2, 5 Some visual changes occur due to aging. Reduced visual fields, impaired night vision, and reduced color discrimination are visual changes associated with aging. Glare sensitivity increases and depth perception declines due to aging.

A registered nurse (RN) is delegating patient care to nursing assistive personnel (NAP). Which tips would help the RN appropriately delegate patient care? Select all that apply. 1. Listen attentively to the NAP. 2. Communicate clearly with the NAP. 3. Let the NAP perform tasks independently. 4. Assign tasks a little higher than the NAP's skills. 5. Assess the knowledge and skills of the NAP.

1, 2, 5 Delegation is the act of transferring responsibility for the performance of an activity or task while retaining accountability for the outcome. There are certain guidelines for appropriate delegation. Listening attentively helps to sort out priorities. Clear communication is helpful to effective delegation, because it prevents miscommunication. Lack of communication may lead to ineffective delegation and omissions of nursing care. Assessment of the knowledge and skills of the NAP helps the RN assign the tasks accordingly. The RN should supervise the task performed by the NAP. The assigned tasks should match the NAP's skills; assigning a higher level task can lead to poor performance.

A diabetic patient has been switched from oral antidiabetic drugs to insulin. Which information would help the patient to ensure correct self-administration of insulin? Select all that apply. 1. Insulin is given as a subcutaneous injection. 2. The insulin is absorbed more quickly when injected into the abdomen. 3. The site of injection should be changed monthly. 4. Once a site is chosen for injection, the same site should be used for further injections. 5. The recommended sites of injection include the upper arm, thigh, abdomen, and buttocks.

1, 2, 5 Insulin is given as a subcutaneous injection for slower absorption. The rate of absorption of insulin differs in various sites. The abdomen has the quickest absorption. The recommended sites of insulin injection include the upper arms, anterior and lateral part of the thighs, buttocks, and abdomen. These sites have the appropriate amount of subcutaneous tissue for absorption of insulin. The injection site should not be chosen again for a month. The injection site should be rotated with each injection. Repeated injection at the same site may lead to lipodystrophy.

What improves staff communication in a healthcare team? Select all that apply. 1. Staff meetings 2. Newsletters 3. Standing orders 4. Protocol 5. Minutes of meetings

1, 2, 5 Staff communication is an important component of any healthcare team. It can be improved through staff meetings to discuss major issues. Newsletters are helpful in updating staff members about activities in the unit. Minutes of meetings help update the team members on staff meetings. Standing orders and protocols are issued by healthcare facilities to guide actions in particular situations.

The nurse has to administer a medication via intramuscular (IM) injection. Which are the various sites that can be used for an IM injection? Select all that apply. 1. Deltoid 2. Brachioradialis 3. Vastus lateralis 4. Ventrogluteal 5. Sternocleidomastoid

1, 3, 4 I'm delighted to view the vase. So IM = I'm, del = deltoid, view = ventrogluteal, and vase = vastus lateralis. The three common sites for administering intramuscular (IM) injections are the deltoid, vastus lateralis, and ventrogluteal muscles. The deltoid site is easily accessible and is used for injecting small volumes. The vastus lateralis is a thick and well-developed muscle, located on the anterior lateral aspect of the thigh. The ventrogluteal muscle is the safest site for injection. It is deep and away from major nerves and blood vessels. The brachioradialis is a muscle of the arm and is not used for injecting medications. The sternocleidomastoid is a muscle of the neck and is not a favorable site for administering IM injections.

The nurse on night shift explains a patient's condition to the healthcare provider, who in turn provides the verbal order of medication over the phone. Which accurately describe the roles of nurse and health care provider in executing telephone orders? Select all that apply. 1. The nurse should read back the order. 2. The nurse should not sign the order. 3. The nurse has to enter the order in the computer. 4. The nurse should receive confirmation from the prescriber. 5. The prescriber should countersign within 48 hours.

1, 3, 4 In a hospital setting, whenever a verbal order is given, the nurse should read back the order to the prescriber to confirm it. The order should be entered in the computer. The nurse should receive confirmation of the order from the prescriber for validation. The nurse should enter the time and the prescriber's name and then sign the order, indicating that it was read back. The prescriber should countersign the order within 24 hours, not 48 hours.

The nurse is reviewing a medication order for a patient. What are the components of medication orders? Select all that apply. 1. Dose and frequency 2. Specific nurse in charge 3. Route of administration 4. Generic name of medication 5. Chemical name of medication

1, 3, 4 The components of a medication order include dose and frequency of the medication, route of administration, and generic name of the medication. The dose and frequency are decided based on the patient's weight and the amount of medication required to obtain the therapeutic effect. The route of administration depends on the types of medication and the condition of the patient. The medication can be given via enteral or parenteral route. The generic name of the drug is an important component of the medication order and is used to identify the drug. The chemical name of the medication and the name of the nurse in charge are not components of the medication order.

A nurse manager has been newly appointed. Which activities indicate that the nurse manager has a good understanding of the roles and responsibilities? Select all that apply. 1. The nurse manager conducts routine staff evaluations. 2. The nurse manager provides direct care to the patients. 3. The nurse manager establishes interprofessional committees. 4. The nurse manager monitors professional nursing standards. 5. The nurse manager recommends new equipment for the unit.

1, 3, 4 , 5 The nurse manager has various responsibilities. The nurse manager conducts routine staff evaluations to determine the right staff at the right place. Establishing and supporting staff and interprofessional committees help to ensure quality nursing care. Monitoring professional nursing standards of practice on the unit helps to improve the quality of nursing practice. The nurse manager is also responsible for reviewing and recommending new equipment for the unit. The nurse manager does not provide direct care to the patients.

Which nursing measures are helpful in minimizing medication errors? Select all that apply. 1. Using two patient identifiers 2. Concealing medication errors 3. Ensuring adequate rest for the nurse 4. Properly interpreting illegible prescriptions 5. Preparing medications for one person at a time

1, 3, 5 Using at least two patient identifiers before administering drugs ensures that the medication is given to the right patient. The nurse should get adequate rest, because fatigue increases medication errors. Medication errors are greatly reduced if medications are prepared for one person at a time. Medication errors should be evaluated for their health impact and should be dealt with accordingly; concealing them is ethically unacceptable. Illegible prescriptions should be confirmed rather than interpreted.

The nurse understands that using a PICOT format for clinical questions helps in refining the search for evidence. Which are the best reasons to follow the PICOT format? Select all that apply. 1. It helps to ask a more focused question. 2. It is necessary to follow the sequence of PICOT. 3. It prevents wandering when searching for evidence. 4. It allows the researcher to ask questions that are focused on theory. 5. It helps to identify knowledge gaps within a clinical situation.

1, 3, 5 The PICOT (Patient, Intervention, Comparison, Outcome, Time) format is used when asking a clinical question and looking for related evidence. The PICOT format helps to refine the focus of the question by dividing the question into different components of PICOT. The evidence can be searched through key words of a PICOT question, which helps to refine the search and to identify gaps in the clinical situation in terms of missing evidence. It is not necessary to follow the sequence of PICOT; the components can be used in any order. The PICOT format allows the nurse to ask questions that are focused on intervention, rather than theory.

The nursing student has posed a PICOT clinical question for a research study. The question that has been posed is, 'How do patients with cervical cancer rate their quality of life?' Which PICOT elements does this question contain? Select all that apply. 1. Patient population of interest 2. Intervention of interest 3. Comparison of interest 4. Outcome 5. Time

1, 4 Using the PICOT format helps to ask a focused clinical question. P stands for population of interest, I stands for intervention of interest, C stands for comparison of interest, O stands for outcome, and T stands for time. Patients with cervical cancer represent the population of interest, and rating the quality of life represents the outcome. The question does not contain the other three elements: intervention of interest, comparison of interest, and time.

Which interventions should the nurse perform when administering medications to a patient through a nasogastric tube? Select all that apply. 1. Dissolve the different medications separately. 2. Draw all the medications together in a syringe. 3. Use a pigtail vent after connecting the syringe to the tube. 4. Flush the tube before and after administration of the medication. 5. Contact the health care provider if the patient resists the administration.

1, 4, 5 When administering medication through a nasogastric tube, all the medications should be dissolved separately in suitable solvents. The nasogastric tube should be flushed prior to drug administration and following administration of each drug to prevent blockage. If the nurse encounters resistance while administering the medication, the health care provider should be notified. Each medication should be separately dissolved and administered to prevent mixing of medications. The nurse should not use a pigtail vent after connecting the tube to the syringe, because it can cause air to escape into the digestive tract.

Using the sliding scale for insulin prescribed by the healthcare provider, 2 units of insulin is required for a blood glucose level between 150 and 200 mg/dL. The nurse finds that a patient's blood glucose level is 175 mg/dL. How much insulin should the patient be given? Record your answer using a whole number.

2 units The correction or sliding scale of insulin is based on the patient's blood sugar levels at a given point in time. The prescribed dose of insulin for a blood glucose level of 150 to 200 mg/dL is 2 units; because the patient's level falls in that range, the patient should be given 2 units.

The nurse is educating a diabetic patient about how to administer insulin. Which statements pertaining to use of insulin are appropriate? Select all that apply. 1. The insulin vial should be shaken well before drawing the injection. 2. Insulin should not be mixed with any other medication. 3. Insulin detemir should not be mixed with any insulin. 4. Insulin glargine should be mixed only with regular insulin. 5. Rapid-acting insulin mixed with NPH insulin should be given along with meals.

2, 3 Insulin should never be mixed with any other medication, because it can hamper the effectiveness of the insulin. Mixing insulin detemir with any other insulin can make it ineffective. Shaking an insulin vial can form bubbles that can interfere with correct dosage. Insulin glargine should not be mixed with any other insulin. Rapid-acting insulin mixed with NPH insulin must be given 15 minutes before meals for maximum benefit.

The nurse works in a medical unit. Which patients should the nurse consider at a high-priority level for nursing care? Select all that apply. 1. A patient who has a fractured bone in his leg 2. A patient who lost consciousness 3. A patient who has impaired oxygenation 4. A patient whose cardiac output is decreased 5. A patient who has pressure ulcers

2, 3, 4 A high-priority level problem poses an immediate threat to a patient's survival. It is considered an emergency and is a life-threatening condition. If left untreated, it can have fatal consequences. Loss of consciousness, impaired oxygenation and decreased cardiac output are high-priority problems. These conditions may be life-threatening if not treated in a timely manner. A fracture of the leg or presence of pressure ulcers does not pose immediate danger to life. Therefore, these are intermediate-priority problems.

The nurse is reviewing the work of nursing assistive personnel (NAP) and notices that one of them is consistently delivering a dissatisfactory performance. What should the nurse do? Select all that apply. 1. Assign another task. 2. Give constructive and appropriate feedback. 3. Schedule additional training with the educational department. 4. Focus on things that can be changed and give specific detail. 5. Involve other colleagues while giving the feedback to the person so that others do not make the same mistake.

2, 3, 4 When a nursing assistant does not perform the given tasks appropriately, the nurse should give appropriate feedback in a constructive way. The alternate ways to handle the situation and a better way to perform the task should be explained. If there is any deficiency in training and education, additional training sessions should be arranged with educational departments. One issue should be discussed at a time, and specific details should be given. If the performance is not satisfactory, it indicates that either the training is inadequate or the assistant has been assigned too many tasks. Assigning the assistant another task may not solve the issue. The feedback should be provided in private to maintain the assistant's self-esteem. Involving others in the feedback process may embarrass the him or her.

What are the characteristics of an effective team? Select all that apply. 1. Different purposes 2. Effective communication 3. Trust 4. The ability to keep feedback to oneself 5. Effective conflict management

2, 3, 5 A good team is important to effective nursing care. The team should be able to communicate properly and avoid miscommunication. The team members should be able to trust each other. Conflicts may arise among team members; the team should be able to manage them amicably. All the team members should have a common purpose so that their efforts are focused. Providing feedback to each other helps improve patient care.

A 50-year-old woman complains of hair loss. When going through the medical records, the nurse finds that the patient underwent chemotherapy for breast cancer a few years ago. To determine a relationship between hair loss and chemotherapy, the nurse formulates a PICOT question. Which points should the nurse keep in mind when developing a PICOT question? Select all that apply. 1. The sequence of P, I, C, O, and T should be followed. 2. The I in PICOT refers to intervention of interest. 3. PICOT helps to ask an intervention-focused question. 4. The elements P and O can be skipped. 5. PICOT helps to identify knowledge gaps within a given clinical situation.

2, 3, 5 A well-focused question makes it easy to gather evidence. A PICOT question is very useful for evidence-based practice. The I in PICOT refers to intervention of interest. A well-framed PICOT question helps to keep the research question focused on intervention. A well-formed PICOT questions also helps to question the existing routines and identify knowledge gaps within a given clinical situation. The sequence of P, I, C, O, and T is not mandatory in developing the PICOT question. The components I, C, and T may not be suitable to be used in every PICOT question, so they can be skipped accordingly.

A diabetic patient has been switched from oral antidiabetic drugs to insulin. The patient has been prescribed regular insulin and NPH insulin. When teaching the patient about self-administration of insulin, what should the nurse instruct the patient regarding preparation of the insulin? Select all that apply. 1. Shake the insulin vial before preparing. 2. Roll the cloudy insulin vial between the palms of the hands. 3. Prepare the regular insulin first and then draw up the NPH insulin. 4. Presence of bubbles in the syringe does not alter the insulin dose. 5. Administer both insulins 15 minutes before a meal.

2, 3, 5 Rolling cloudy insulin between the palms of the hand helps to resuspend the insulin in the vial. The regular insulin should be prepared first to prevent its contamination by the NPH insulin. The mixed insulin dose should be injected 15 minutes before a meal for its peak action during the mealtime. Bubbles can form if the insulin vial is shaken. The presence of bubbles interferes with the correct dosing of insulin.

Which patients need intravenous therapy? Select all that apply. 1. Patients with edema 2. Patients with dehydration 3. Patients with deep vein thrombosis 4. Patients with electrolyte imbalances 5. Patients who require blood transfusions

2, 4, 5 Patients with dehydration require intravenous therapy to replace the lost fluids. Patients with electrolyte imbalances require intravenous therapy to maintain proper fluid and electrolyte balance in the body. Patients also require intravenous therapy for blood transfusions. Patients with edema should not be given intravenous therapy because it may cause fluid overload. Intravenous therapy is contraindicated for patients with deep vein thrombosis because it may cause blood clots.

A patient with a history of a hearing deficit comes to the medical clinic for a routine checkup. His wife died 2 years ago, and he admits to feeling lonely much of the time. What are some interventions the nurse uses to reduce loneliness? Select all that apply. 1. Reassuring the patient that loneliness is a normal part of aging 2. Providing information about local social groups in the patient's neighborhood 3. Maintaining distance while talking to avoid overstimulating the patient 4. Recommending that the patient consider making living arrangements that will put him closer to family or friends 5. Introducing the idea of bringing a pet into the home

2, 4, 5 Loneliness is not a normal part of aging. Principles for reducing loneliness include providing information about local social groups and recommending alterations in living arrangements if physical isolation occurs. When appropriate, bringing a companion such as a pet into the home can help to reduce loneliness.

Which safety measures should the nurse implement to prevent aspiration when administering oral medications? Select all that apply. 1. Administer all medications at the same time. 2. Time the medications with meals. 3. Encourage the use of straws whenever possible. 4. Choose a different route if the risk of aspiration increases. 5. Recommend self-administration if possible.

2, 4, 5 Timing medications with meals reduces the risk of aspiration, because the medications are consumed with food. If the risk of aspiration increases, the nurse may choose different routes of drug administration. The nurse should encourage the patient to take medications on his or her own if possible. Medications should be administered one after the other, not all at once. The use of straws should be discouraged, because straws affect patient control of volume intake and increase the risk of aspiration.

The registered nurse is teaching a nursing student about preventing errors during medication administration. Which statements if made by the nursing student indicates effective learning? Select all that apply. 1. 'I should document medications before administering.' 2. 'I should ensure that I am well rested when caring for patients.' 3. 'I should use one patient identifier while administering medications.' 4. 'I should read the label once carefully before administering medications.' 5. 'I should use automated medication dispensers (AMDs) to administer medications.'

2, 5 Nurses should be sure they have adequate rest while caring and administering medications to patients. When a nurse 'works around' the technology, medication errors occur. Therefore, the nurse should use automated medication dispensers (AMDs) for medication administration. The nurse should document medications after administration. The nurse should use at least two patient identifiers while administering medications. The label should be read three times before administering the medication.

What roles do nurses play in providing quality care to all populations? Select all that apply 1. They partner with political decision makers. 2. They partner with major insurance providers. 3. They practice to the full extent of their education and training. 4. They partner with physicians and other health care providers. 5. They improve data collection for planning and policy making.

3 To have a health care system with quality care for all populations, nurses need to practice to the full extent of their education and training, become full partners with physicians and other health care providers, and improve data collection, which in turn helps workforce planning and policy making. Partnering with political decision makers and major insurance providers is not a nursing role.

Which strategies does the nurse keep in mind when communicating with a hearing-impaired patient? Select all that apply. 1. Speak loudly towards the patient's ear. 2. Avoid sitting at the same level as the patient. 3. Avoid eating or chewing while speaking. 4. Use a normal tone of voice and normal inflections of speech. 5. Use written information to enhance the spoken word.

3, 4, 5 The patient has a hearing impairment, so precaution should be taken while communicating with the patient. Eating or chewing while speaking may lead to misinterpretation of the message by the patient, because the patient tends to read facial expressions and interpret messages. Using a normal tone of voice and inflections of speech help the patient to hear and understand properly. Written information can be used to enhance the spoken word so that the patient can completely understand the message. The nurse should avoid speaking loudly towards the patient's ear, because higher pitched sound often impedes hearing by accentuating vowel sounds and concealing consonants. Sitting at the same level as the patient helps the patient to easily see the communicator, read lip movements, and read facial expressions.

The nurse is teaching a group of student nurses about the three levels of prevention. Which activities are included in the secondary prevention of diseases? Select all that apply. 1. Use of specific immunizations 2. Use of environmental sanitation 3. Individual and mass screening activities 4. Selective examinations to cure and prevent disease process 5. Provision of facilities to limit disability and prevent death

3, 4, 5 The activities of secondary prevention are aimed at early diagnosis, prompt treatment, and disability limitation. The activities include individual and mass screening and selective examination to diagnose diseases in early stages and provide timely treatment. Secondary prevention also includes provision of facilities to limit disabilities and prevent death. Use of specific immunizations and use of environmental sanitation are included in primary prevention.

On a home visit, the nurse finds that a patient has sensory impairment. Which environmental factors can increase the risk of falls for the patient? Select all that apply. 1. A bathroom with a shower 2. Water faucets with red and blue rings indicating hot and cold water 3. Stairways without lamps 4. Lack of handrails 5. Phone cords in the main route of walking

3, 4, 5 The patient with proprioceptive problems or visual impairment will need well-lit stairways to prevent falls. Handrails on the sides of stairways are important for providing support. Phone cords should be placed to the side and not in the main route of walking. A bathroom with a shower and water faucets with red and blue rings indicating hot and cold water are not hazards but are necessary in the home of patients with sensory alterations.

The nurse caring for patients in an inpatient unit asks a clinical question using a PICOT format. What does C stand for in a PICOT question? A. Comparison of interest B. Client who is admitted C. Care provided D. Current diagnosis

A. Comparison of interest There are five elements of a PICOT question. P stands for the patient identified by age, gender, ethnicity, and disease or health problem. I stands for intervention of interest. C stands for comparison of interest. O stands for outcomes, and T stands for time. C does not stand for client, care, or current diagnosis.

Which duties can the shift nurse on the medical-surgical unit delegate to nursing assistive personnel (NAP)? Select all that apply. 1. Perform a pain assessment. 2. Document the completion of a task. 3. Prepare a plan of care. 4. Give a bedpan to a patient. 5. Monitor vital signs of a stable patient.

4, 5 The professional nurse in charge of patient care can decide which activities a nursing assistant performs independently and which activities to perform in partnership. A nursing assistant can be delegated the task of providing bedpans to patients when needed. Although the responsibility of assessment is with the nurse, if the patient is stable, the responsibility of monitoring vital signs can be delegated to the nursing assistant. The nurse is responsible for and should perform the assessment of a patient's ongoing status. For example, the nurse should perform a patient's pain assessment to determine if further intervention is required. The documentation of the completed tasks should be done by the nurse and not delegated to the nursing assistant. Preparing a care plan requires critical thinking skills and should be done by the nurse.

The healthcare provider has instructed the nurse to administer 600 mg of amoxicillin to a pediatric patient. The bottle of the amoxicillin is labeled 400 mg/6 mL. How much of the medication should the nurse administer to this patient? Record your answer using a whole number. _____mL

9 mL The patient requires 600 mg of amoxicillin. The volume of medication (V) appropriate to this amount of amoxicillin is calculated using the proportion method. 400 X V = 600 X 6, which means 400 V = 3600, and V = 3600/400 = 9. Therefore, 9 mL of the medication contains 600 mg of amoxicillin.

Critiquing the evidence is one of the most important steps in the process of implementing evidence-based practice. Which is the most important information required while critiquing evidence? A. Are the findings clinically applicable? B. Can the findings be applied in a different patient group? C. Are the findings applicable to patients of a different ethnicity? D. Do the findings provide better treatment alternatives than conventional therapy?

A. Are the findings clinically applicable? The most important information required while critiquing research is whether the findings of the research are clinically applicable and scientifically relevant. Of lower priority when critiquing the research are questions such as whether the findings of the research are applicable to a different group of patients or to patients belonging to a different ethnicity, and whether the findings of the research provide better treatment alternatives than conventional therapy. Unless the clinical applicability of a research finding is confirmed, it cannot be applied to any patient group.

The nurse takes a medication to a patient, and the patient refuses to take it and tells the nurse to take it away. What is the nurse's next action? A. Ask the patient's reason for refusal. B. Explain that she must take the medication. C. Take the medication away and chart the patient's refusal. D. Tell the patient that her physician knows what is best for her.

A. Ask the patient's reason for refusal. When patients refuse a medication, first ask why they are refusing it.

The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse's next best course of action? A. Ask the prescriber to change the order. B. Crush the pill with a mortar and pestle. C. Hide the capsule in a piece of solid food. D. Open the capsule and sprinkle it over pudding.

A. Ask the prescriber to change the order. Enteric-coated or sustained-release capsules should not be crushed or opened; the nurse should contact the prescriber to change the medication to a form that is liquid or can be crushed. The nurse should not hide the capsule in a piece of solid food, because it could put the patient at risk for choking.

Which informatics technology helps scan the medication before administration? A. Bar-coding technology B. Automated medication dispensers (AMDs) C. Computerized prescription order entry (CPOE) D. Electronic medication administration records (eMARs)

A. Bar-coding technology Bar-coding technology is used to scan medication before administration. Automated medication dispensers (AMDs) and electronic medication administration records (eMARs) are used for medication reconciliation, administration, and documentation. Computerized prescription order entry (CPOE)is used to enter medication orders directly into a networked computer system.

An elderly couple visits the hospital for regular health checkups. The woman, who is 67 years old, has been diagnosed with dementia. She lives with her husband, who is 75 years old. He has hypertension and is on antihypertensive drugs. He is looking for information on health care providers and services to take appropriate care of his wife. What role is the nurse playing when giving information about the community resources to the patient? A. Counselor B. Caregiver C. Educator D. Change agent

A. Counselor A community health nurse may have many roles. As a counselor, the nurse provides information about community resources. As an educator, the nurse conducts health education programs on prenatal care, infant care, cancer screenings and child safety. As a change agent, the nurse identifies and implements new approaches to maintain health. The nurse is not acting as a caregiver in this setting.

A patient has leukemia and is in the terminal stage. The patient has opted for a service that provides palliative care at home. Which service has the patient selected? A. Hospice B. Respite care C. Assisted living D. Adult day care

A. Hospice Hospice is a service in which palliative care is provided to terminally ill patients in their homes. Respite care is a service that provides short-term relief to the family and caregivers of ill patients. Assisted living is an example of a service offered in a long-term care setting. Adult day care is a service that provides care to patients in a facility when their caregivers have other commitments.

Which route of administration involves inserting a needle at a 5- to 15-degree angle from the surface of the skin without puncturing the patient's subcutaneous tissue? A. Intradermal B. Intravenous C. Intramuscular D. Subcutaneous

A. Intradermal Inserting the needle at a 5- to 15-degree angle from the surface of the skin without puncturing subcutaneous tissue indicates the intradermal route of administration. The needle is inserted at an angle of 30 to 45 degrees into the vein when the intravenous route is used. The needle is inserted at the angle of 90 degrees from the skin surface when the intramuscular route is used. One should maintain a 45- or 90-degree angle to administer medication through the subcutaneous route.

The nurse is providing restorative care to a patient following an extended hospitalization for an acute illness. Which option is an appropriate goal for restorative care? A. Patient will be able to walk 200 feet without shortness of breath. B. Wound will heal without signs of infection. C. Patient will express concerns related to return to home. D. Patient will identify strategies to improve sleep habits.

A. Patient will be able to walk 200 feet without shortness of breath. Restorative interventions focus on returning a patient to his or her previous level of functioning or a new level of function limited by his or her illness or disability. The goal of restorative care is to help individuals regain maximal functional status and enhance quality of life by promoting independence.

The nurse is participating at a health fair at the local mall giving influenza vaccines to senior citizens. Which level of prevention is the nurse practicing? A. Primary B. Secondary C. Tertiary D. Quaternary

A. Primary Primary prevention is aimed at health promotion and includes health-education programs, immunizations, and physical and nutritional fitness activities. It can be provided to an individual and includes activities that focus on maintaining or improving the general health of individuals, families, and communities. It also includes specific protection such as immunization for influenza. Secondary prevention is diagnosing and treating an illness and limiting disabilities. Tertiary prevention includes restoration and rehabilitation. Quaternary prevention doesn't exist.

Which option below is an example of the nurse participating in primary care activities? A. Providing prenatal teaching on nutrition to a pregnant woman during the first trimester B. Working with patients in a cardiac rehabilitation program C. Assessing a patient at an emergent care facility D. Providing home wound care to a patient

A. Providing prenatal teaching on nutrition to a pregnant woman during the first trimester Primary care activities are focused on health promotion. Health promotion programs contribute to quality health care by helping patients acquire healthier lifestyles. Health promotion activities keep people healthy through exercise, good nutrition, rest, and the adoption of positive health attitudes.

The nurse has been asked to administer a rectal suppository to a patient. In what position should the nurse place the patient? A. Sims' position B. Prone position C. Lateral position D. Doral recumbent

A. Sims' position For rectal administration of a suppository, the patient should be placed in the Sims' position. Neither the patient nor the nurse would be comfortable if the patient were placed in the prone position, lateral position, or dorsal recumbent position.

While assessing a patient who is on intravenous therapy, the nurse notices infiltration at the intravenous site. Which nursing intervention would best help the patient? A. Stopping the intravenous infusion B. Massaging the intravenous site gently C. Reducing the intravenous infusion rate D. Applying a cool compress to the intravenous site

A. Stopping the intravenous infusion The nurse should stop intravenous therapy immediately if infiltration occurs at the intravenous site. The nurse should remove the catheter and restart the infusion in another site. Massaging the site may cause pain and discomfort. The nurse should not reduce the infusion rate, but should stop the infusion and select a new site for continuation. Applying a cool compress to the site is not an appropriate intervention in this situation.

The nurse observes weight gain, edema, hypertension, and distended neck veins in a patient who is on fluid replacement therapy. What could be the reason behind this condition in the patient? A. The intravenous solution is infusing too fast. B. The level of the fluid bag has been lowered C. The intravenous sites of administration have been rotated. D. The patient was placed in a high Fowler's position.

A. The intravenous solution is infusing too fast. An infusion that is too rapid may cause an excessive infusion of intravenous fluids, which may cause circulatory fluid overload during fluid replacement therapy. Lowering the level of the fluid bag causes a decreased rate of infusion. Rotating the sites of the administration can minimize a patient's pain and discomfort; this action does not cause fluid overload. Placing the patient in high Fowler's position is not responsible for fluid overload.

Before administering an intravenous bolus, the primary health care provider instructs the nurse to flush the intravenous lock with normal saline by pushing slowly on the plunger. What could be the reason behind this instruction? A. To clear the intravenous lock of blood B. To prevent the transmission of infection C. To control the infusion rate of the intravenous bolus D. To determine whether the intravenous needle is positioned in the vein

A. To clear the intravenous lock of blood The nurse should flush the intravenous lock with normal saline by pushing the plunger slowly to clear the lock of blood. Flushing the lock with normal saline does not prevent the transmission of infection nor control the infusion rate of the bolus. The nurse should pull back gently on the syringe plunger and look for blood return to determine whether the needle is properly positioned in the vein.

A patient comes to the local health clinic and states, 'I've noticed how many people are out walking in my neighborhood. Is walking good for you?' Which is the best response to help the patient through the stages of change for exercise? A. 'Walking is okay, but I really think running is better because it burns more calories.' B. 'Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?' C. 'Yes, I want you to begin walking. Walk for 30 minutes every day and eat more fruits and vegetables.' D. 'They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes if you are going to do any good.'

B. 'Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?' The patient's response indicates that the patient is in the contemplative state, possibly intending to make a behavior change within the next 6 months. The nurse's statement reinforces the behavior and provides a specific goal for the patient to begin a walking plan.

Which patient is most likely to experience sensory deprivation? A. A 79-year-old visually impaired resident of a nursing home who enjoys taking part in different hobbies and activities B. A 14-year-old girl isolated in the hospital because of severe immune system suppression C. A hearing-impaired 66-year-old woman who lives in an assisted-living facility D. A 9-year-old boy who is deaf and uses sign language to communicate with his friends, family, and teachers

B. A 14-year-old girl isolated in the hospital because of severe immune system suppression Patients isolated in a private room in a health care setting because of such conditions as severe immune system depression frequently experience sensory deprivation. Such individuals are at risk because of an unfamiliar and unresponsive environment, and they are unable to enjoy normal interactions with visitors.

Which statement is true regarding piggybacks? A. A piggyback is battery-operated. B. A piggyback is connected to a short tubing line. C. A piggyback is commonly known as a saline lock. D. A piggyback contains 10 to 20 mL of fluid.

B. A piggyback is connected to a short tubing line. A piggyback is connected to a short tubing line. A syringe pump is battery-operated and contains a very small amount of fluid. Intermittent venous access is commonly known as a saline lock. A piggyback contains between 25 and 250 mL of fluid.

The nurse is having difficulty reading a physician's order for a medication. The nurse knows that the physician is very busy and does not like to be called. Which is the most appropriate next step for the nurse to take? A. Call a pharmacist to interpret the order. B. Call the physician to have the order clarified. C. Consult the unit manager to help interpret the order. D. Ask the unit secretary to interpret the physician's handwriting.

B. Call the physician to have the order clarified. The nurse must have the right documentation and clarify all orders with the prescriber before administering medications. It is most appropriate to call the physician rather than asking other medical personnel to interpret the order.

The nurse works in a primary health care center. For which service might the nurse be responsible in this health care setup? A. Respite care B. Health screening C. Mental health counseling D. Environmental surveillance

B. Health screening The primary health care center offers services such as health screening, routine physical examinations, diagnostic studies, and management of medical conditions. Respite care, mental health counseling, and environmental surveillance are not provided by primary health care centers. Respite care is provided by certain community agencies. Mental health counseling is provided by mental health care centers. Environmental surveillance is a part of community health in general.

If a patient who is receiving intravenous (IV) fluids develops tenderness, warmth, erythema, and pain at the site, what would the nurse suspect? A. Sepsis B. Phlebitis C. Infiltration D. Fluid overload

B. Phlebitis Redness, warmth, and tenderness at the intravenous (IV) site are signs of phlebitis.

A nursing student takes a patient's antibiotic to his room. The patient asks the nursing student what it is and why he should take it. How should the nursing student respond to the patient? A. Explain that only the patient's physician can give this information. B. Provide the name of the medication and a description of its desired effect. C. State that information about medications is confidential and cannot be shared. D. Tell the patient he has to speak with his assigned nurse about this.

B. Provide the name of the medication and a description of its desired effect. Patients need to know information about their medications so they can take them correctly and safely. The nursing student can provide the name of the medication and a description of its desired effect. The student should not dismiss the patient's concerns by telling the patient that he should speak with the physician or assigned nurse.

The nurse has been asked to administer a rectal suppository to an adult patient. Where should the nurse place the medication? A. Rectal wall 5 cm into the rectum B. Rectal wall 10 cm into the rectum C. Inner aspect of the anal orifice D. Just prior to the internal anal sphincter

B. Rectal wall 10 cm into the rectum A rectal suppository for an adult should be placed against the rectal wall about 10 cm into the rectum. For children and infants, the suppository should be placed 5 cm deep into the rectum against the rectal wall. The inner aspect of the anal orifice is not the right position for suppository administration. The suppository has to be placed past the internal anal sphincter.

A diabetic patient has been switched from oral antidiabetic drugs to insulin. The nurse teaches the patient about self-administration of insulin. What is the route for insulin injection? A. Intradermal B. Subcutaneous C. Intramuscular D. Intravenous

B. Subcutaneous Insulin is given as a subcutaneous injection for slower absorption. The intradermal route is used for skin tests. The intramuscular route is used for medications that need a faster absorption and are given in a volume that cannot be administered through subcutaneous route. The intravenous route is used for medications that are administered in a large volume.

Which option is an example of the principle of patient-centered care that is focused on continuity and transition? A. The nurse asks the patient which family member should have access to patient information. B. The nurse teaches the patient how to change the wound dressing at home. C. The nurse responds promptly to the patient's request for pain medication. D. The nurse schedules the patient's diagnostic scan following the physical therapy session.

B. The nurse teaches the patient how to change the wound dressing at home. Nursing interventions focused on transition and continuity provide patients with information about medications to take, dietary or treatment plans to follow, and which danger signals to look for after hospitalization or treatment. These interventions also provide patients and families with health care resources after discharge.

The nurse works in a 32-bed, cardiac step-down unit. The nurse delegates some work to a nursing assistant to manage time. Which nursing interventions delegated by the nurse to the nursing assistant are inappropriate? A. 'Could you please help me position the patient as I insert a catheter for this patient?' B. 'Could you please help the patient walk along the hallway, back and forth? I will check with you in 10 minutes.' C. 'Could you please help me to find out the problem with this patient? He is developing severe chest pain.' D. 'Could you please help the respiratory therapist position the patient while he gives chest physiotherapy?

C. 'Could you please help me to find out the problem with this patient? He is developing severe chest pain.' The nurse is responsible for delegating tasks to a nursing assistant based on her assessment and priorities. However, activities that involve assessment; diagnosis, planning, and evaluation are not delegated. These activities require critical thinking and decision-making skills. Evaluating a patient based on the development of new symptoms is beyond the scope of work of a nursing assistant. The nurse should ask a senior nurse for help in such a case. Ambulation of the patient and positioning of the patient are tasks the nursing assistant can help with.

While administering medications, the nurse realizes that she has given the wrong dose of medication to a patient. She completes an incident report and notifies the patient's healthcare provider. What characteristic is the nurse demonstrating? A. Authority B. Responsibility C. Accountability D. Decision making

C. Accountability Accountability means that nurses are answerable for their actions. It means that they accept the commitment to provide excellent patient care and the responsibility for the outcomes of the actions in providing it. Following institutional policy for reporting errors demonstrates the nurse's commitment to safe patient care.

The nurse is caring for a patient who has a skin infection. After applying ointment, the nurse realizes that he applied the wrong ointment by mistake. The nurse informs the healthcare provider. Which element of the decision-making process is indicated by the nurse's action? A. Authority B. Autonomy C. Accountability D. Responsibility

C. Accountability The nurse is showing accountability for the action performed. Accountability means the individual is answerable for his or her actions. Authority refers to the legitimate power to give commands and make final decisions specific to a given position. Autonomy is freedom of choice and responsibility for the choices. Responsibility refers to an individual's duty to perform the activities assigned to him.

The nurse finds morphine sulfate 2 mg IV Q 4 hours prn in the prescription of a newly admitted patient in the hospital. Which action should the nurse perform based on this finding? A. Administer morphine sulfate intravenously (IV) only once at specified time. B. Administer morphine sulfate intravenously (IV) only once within 90 minutes. C. Administer morphine sulfate intravenously (IV) when the patient requires it but not more than every 4 hours. D. Administer morphine sulfate intravenously (IV) only once immediately when the patient's condition changes.

C. Administer morphine sulfate intravenously (IV) when the patient requires it but not more than every 4 hours. The term prn indicates that the medication is prescribed to the patient when it is required, and Q 4 hours means that the medication should not be administered more frequently than every 4 hours. The medication is given only once at a specific interval of time when the nurse finds the term single order or one-time order in the prescription. Medication administration at one time within the period of 90 minutes is considered to be a noworder. Medications are administered immediately, one time, when the nurse finds the term STAT in the prescription.

The nurse has just given a patient a narcotic for pain relief and must now leave the unit. To whom should the nurse delegate the task of evaluating the client's response to the pain medication? A. A unit clerk B. A student nurse C. Another registered nurse (RN) D. A patient care aide

C. Another registered nurse (RN) Assessment and management of pain belongs only to the RN's scope of practice The unit clerk is not responsible for the patient's care. The student nurse may participate in the patient's care but the accountability remains with the RN. The patient care aide is not accountable for the patient's assessment and management of pain.

Which nursing intervention is done to prevent needlestick injuries after intravenous administration? A. Bend the needle before disposal B. Break the needle before disposal C. Avoid recapping the used needles D. Clean the needle with an antiseptic swab before disposal

C. Avoid recapping the used needles The nurse should avoid recapping used needles and should dispose in puncture-proof and leak-proof containers to prevent accidental needlestick injuries. The nurse should not break or bend needles before disposal. The nurse should not clean used needles with an antiseptic swab because they are not used again and should be disposed.

A 72-year-old patient with bilateral hearing loss wears a hearing aid in her left ear. Which approach best facilitates communication with her? A. Speak directly into the patient's left ear. B. Approach the patient from behind and speak frequently. C. Face the patient when speaking; speak slower and in a normal volume. D. Face the patient when speaking; use a louder than normal tone of voice.

C. Face the patient when speaking; speak slower and in a normal volume. To facilitate communication with a hearing-impaired person, face the patient when speaking, speak slower and in a normal tone, talk toward the patient's best or normal ear, and articulate clearly.

The nurse is assisting the patient with coughing and deep-breathing exercises following abdominal surgery. This is which priority nursing need for this patient? A. Low priority B. High priority C. Intermediate priority D. Nonemergency priority

C. Intermediate priority Assisting the patient with coughing and deep breathing is an intermediate priority. Intermediate priorities are not emergency, life-threatening actual or potential needs that the patient and family members are experiencing. Anticipating teaching needs of patients related to a new drug or taking measures to decrease postoperative complications are examples of intermediate priorities.

Which statement is true regarding intermittent venous access? A. Intermittent venous access requires constant monitoring of flow rates. B. Intermittent venous accessreduces the risk of rapid-dose infusion by an intravenous push. C. Intermittent venous access increases patient mobility, safety, and comfort. D. Intermittent venous access allows medications to be given in very small amounts of fluid.

C. Intermittent venous access increases patient mobility, safety, and comfort. Intermittent venous access, also called a saline lock, is an intravenous catheter capped off on the end with a small chamber covered by a rubber diaphragm or a specially designed cap. It increases patient mobility, safety, and comfort. Intermittent venous access does not require constant monitoring of flow rates. Volume-controlled infusions reduce the risk of rapid-dose infusion by an intravenous push. Syringe pumps allow medications to be given in very small amounts of fluid.

A group of nurses on the research council of a local hospital are measuring nursing-sensitive outcomes. Which is a nursing-sensitive outcome that the nurses should consider measuring? A. Incidence of asthma among children of parents who smoke B. Frequency of episodes of low blood sugar in children at a local school C. Number of patients who fall and experience subsequent injury on the evening shift D. Number of sexually active adolescent girls who attend the community-based clinic for birth control

C. Number of patients who fall and experience subsequent injury on the evening shift Nursing-sensitive outcomes are outcomes that are directly related to nursing care. The number of patients who fall and experience injury on the evening shift can be directly correlated to nursing care, and can be measured in accordance to the measures taken by nursing staff. The incidence of asthma among children of parents who smoke, frequency of low blood sugar in children at a local school, and number of sexually active adolescent girls who attend the community clinic for birth control are not directly related to nursing care.

The nurse who works in a newborn nursery asks, 'I wonder if the moms who breastfeed their babies would be able to breastfeed more successfully if we played peaceful music while they were breastfeeding.' In this example of a PICOT question, which represents 'I'? A. Breastfeeding moms B. Infants C. Peaceful music D. The nursery

C. Peaceful music The intervention (I) in this PICOT question is playing peaceful music. Breastfeeding moms, infants, and the nursery are not interventions; however, the mothers and infants are related to the population of interest (P).

The nurse wants to determine the effectiveness of a behavioral therapy intervention in adolescents with conduct disorder. Which type of research should the nurse conduct in order to acquire the most reliable evidence? A. Descriptive study B. Case control study C. Randomized controlled trials D. Controlled trial without randomization

C. Randomized controlled trials Randomized control studies are the most precise form of experimental studies and the gold standard of research. These studies provide the most reliable evidence. A descriptive study, case control study, and controlled trial without randomization are much lower in the hierarchy of evidence.

The nurse is teaching self-administration of insulin to a patient. Which instruction should the nurse include in the teaching? A. Shake the vial before drawing insulin. B. Administer regular insulin intramuscularly. C. Roll the insulin between your palms if the preparation is cloudy. D. Administer insulin after having meals.

C. Roll the insulin between your palms if the preparation is cloudy. Cloudy insulin preparations should be rolled between the palms to resuspend them before drawing into injections. The insulin vial should not be shaken, because shaking can create bubbles that can interfere with correct dosage administration. Regular insulin is given subcutaneously, not intramuscularly. If insulin is taken after meals, it cannot control the rise of blood sugar levels that occurs due to food intake.

Which parameter indicates a high quality of nursing care provided in the care unit? A. The high number of patient falls B. The high number of patients developing pressure ulcers C. The low rate of hospital-acquired infections D. The low rate of patient admissions

C. The low rate of hospital-acquired infections As per the National Database of Nursing Quality Indicators (NDNQI), there are some parameters on which the quality of care offered by nurses can be judged. Some of these parameters are falls, falls with injury, hospital-acquired infections, pressure ulcers, psychiatric patient assault rate, and restraint prevalence. A low rate of hospital-acquired infections indicates that the quality of nursing care is good. A high number of patient falls and high number of patients developing pressure ulcers indicate subpar nursing care. The low rate of patient admissions is not related to the quality of nursing care being provided.

You are the charge nurse on a surgical unit. You are doing staff assignments for the 3:00 PM to 11:00 PM shift. Which patient do you assign to the licensed practical nurse (LPN)? A. The patient who transferred out of intensive care an hour ago B. The patient who requires teaching on new medications before discharge C. The patient who had a vaginal hysterectomy 2 days ago and is being discharged tomorrow D. The patient who is experiencing some bleeding problems following surgery earlier today

C. The patient who had a vaginal hysterectomy 2 days ago and is being discharged tomorrow The patient with the vaginal hysterectomy is stable and requires care that is within the scope of the LPN. The other three patients need a higher level of care requiring assessment, support, and teaching that are the responsibilities of the registered nurse.

The nurse accidently gives a patient a medication at the wrong time. What is the nurse's first priority? A. Complete an occurrence report. B. Notify the healthcare provider. C. Inform the charge nurse of the error. D. Assess the patient for adverse effects.

D. Assess the patient for adverse effects. Patient safety and assessing the patient are priorities when a medication error occurs. The first priority of the nurse is to assess and examine the patient's condition, and notify the healthcare provider of the incident as soon as possible. Once the patient is stable, report the incident to the appropriate person in the agency (e.g., manager or supervisor). The nurse is responsible for preparing and filing an occurrence or incident report as soon as possible after the error occurs.

When unit staffing includes nursing assistive personnel (NAP), which scenario is characteristic? A. The NAP have formal training and are able to function independently. B. The NAP do not have clinical duties on a patient care unit. C. The registered nurse (RN) is accountable for the tasks delegated to the NAP. D. Delegating tasks to the NAP is not in the scope of the RN's practice

C. The registered nurse (RN) is accountable for the tasks delegated to the NAP. Nurses remain accountable for patient outcomes whether or not the specific tasks are performed by nurses or nurse extenders. Accountability implies being responsible and answerable for actions or inactions of the self or others in the context of delegation. The NAP do not function independently but can have clinical duties on a patient care unit. Delegation of tasks is within the scope of the RN's practice.

The nurse is administering medications to a 4-year-old patient. After the nurse explains which medications are being given, the mother states, 'I don't remember my child having that medication before.' Which action should the nurse take next? A. Give the medications. B. Identify the patient using two patient identifiers. C. Withhold the medications and verify the medication orders. D. Provide medication education to the mother to help her better understand her child's medications.

C. Withhold the medications and verify the medication orders. The nurse should not ignore patient or caregiver concerns and should always verify orders whenever a medication is questioned before administering it.

The nurse is conducting discharge teaching for a patient with diminished tactile sensation. Which statements made by the patient would indicate that additional teaching is needed? A. "I am at risk for injury from temperature extremes." B. "I may be able to dress more easily with zippers or pullover sweaters." C. "A home care referral may help me achieve a maximum degree of independence." D. "I have right-sided partial paralysis and reduced sensation, so I should dress the left side of my body first."

D. "I have right-sided partial paralysis and reduced sensation, so I should dress the left side of my body first." If tactile sensation is diminished, the patient can dress more easily with zippers or Velcro® strips, pullover sweaters or blouses, and elasticized waists. Patients with diminished tactile sensation are at risk for injury from temperature extremes and may benefit from a home care referral. If a patient has partial paralysis and reduced sensation, he or she dresses the affected side first.

A patient is to receive cephalexin 500 mg PO. The pharmacy has sent 250-mg tablets. How many tablets should the nurse administer? A. 1/2 tablet B. 1 tablet C. 1 1/2 tablets D. 2 tablets

D. 2 tablets Using dimensional analysis: Tablets = 1 tablet/250 mg × 500 mg = 500/250 = 2 tablets.

The patient has an order for 2 tablespoons of magnesium hydroxide. How much medication does the nurse give him or her? A. 2 mL B. 5 mL C. 16 mL D. 30 mL

D. 30 mL 1 tablespoon = 15 mL; 2 tablespoons = 30 mL.

The registered nurse (RN) checks on a patient who was admitted to the hospital with pneumonia. The patient is coughing profusely and requires nasotracheal suctioning. Orders include an intravenous (IV) infusion of antibiotics. The patient is febrile and asks the RN if he can have a bath because he has been perspiring profusely. Which task is appropriate to delegate to the nursing assistant? A. Assessing vital signs B. Changing IV dressing C. Nasotracheal suctioning D. Administering a bed bath

D. Administering a bed bath The bed bath is a skill and task within the knowledge level and tasks appropriate for a nursing assistant. The other tasks are the responsibility of the RN. Assessment, dressing change, and suctioning require assessment and skill that are within the scope of practice of the RN.

A nurse is about to withdraw medication from an ampule. Which nursing action reduces the patient's risk for an allergic drug response? A. Checking the patient's name, medication name, and dosage B. Assessing the patient's body build, muscle size, and weight C. Reviewing the medication action, purpose, dose, and route D. Assessing the patient's medical history and medication history

D. Assessing the patient's medical history and medication history The nurse should assess the patient's medical history, medication history, and history of allergies to reduce the risk of an allergic drug response. The nurse should check the patient's name, medication name, and dosage to ensure that the patient receives the correct medication. Assessing the patient's body build, muscle size, and weight helps to determine the type and size ofthe syringe and needles for injection. The nurse should review all pertinent information regarding medication action, dose, purpose, and route of administration to administer the medication properly and to monitor the patient's response.

Which task is appropriate for a registered nurse (RN) to delegate to the nursing assistant? A. Explaining to the patient the preoperative preparation before the surgery in the morning B. Administering the ordered antibiotic to the patient before surgery C. Obtaining the patient's signature on the surgical informed consent D. Assisting the patient to the bathroom before leaving for the operating room

D. Assisting the patient to the bathroom before leaving for the operating room Assisting the patient to the bathroom is a skill and task within the knowledge level and tasks appropriate for a nursing assistant. The other tasks are the responsibility of the RN. The RN is responsible for patient teaching, medication administration, and surgical consents.

The nurse is providing care to a patient who is experiencing major abdominal trauma following a car accident. The patient is losing blood quickly and needs a blood transfusion. The nurse finds out that the patient is a Jehovah's Witness and cannot have blood transfusions because of religious beliefs. The nurse notifies the patient's health care provider and receives an order to give the patient an alternative to blood products. Of what is this an example? A. A quality improvement study B. A change in practice based on evidence C. A time when calling the hospital's ethics committee is essential D. Consideration of patient preferences and values while providing care

D. Consideration of patient preferences and values while providing care This example illustrates a situation in which the health care providers take the patient's values and beliefs into consideration while providing care. This is not an example of a quality improvement study or change in practice based on evidence. Although ethics is a critical consideration in this instance if the patient's life is in danger and the patient refuses treatment, the provider orders an alternative to blood products, which in itself is not an ethical dilemma.

During discharge teaching, the nurse gives the patient prescriptions to have filled at the local pharmacy. Which section of the medication prescription should the nurse check before giving the patient the prescription for a controlled substance? A. Signature B. Inscription C. Superscription D. Drug Enforcement Agency (DEA) number

D. Drug Enforcement Agency (DEA) number When the primary health care provider prescribes a controlled substance to the patient, the prescriber's Drug Enforcement Agency (DEA) number must be on the prescription. The primary health care provider who wishes to prescribe controlled substances must register with the Federal Drug Enforcement Agency. Therefore, the nurse should check for DEA number section in the prescription before administering the medication. The signature section of the prescription contains information about label instructions, such as directions to the patient. The inscription section of the prescription contains the drug name, strength, and dose. The superscription section of the prescription contains the patient's name, address, age, and the date given.

Which task could a staff nurse delegate to a certified nursing assistant? A. Making rounds with a healthcare provider B. Evaluating a patient's response to pain C. Assessing a patient's central venous line site D. Feeding a stroke patient who has minimal dysphagia

D. Feeding a stroke patient who has minimal dysphagia The majority of state boards have addressed the issue of delegation and have developed rules that offer specific guidelines regarding who can do what tasks. The scope of practice for the providers at each level of care usually includes a description of the tasks that may be performed at that level. Feeding a stroke patient who has minimal dysphagia can be delegated to a certified nursing assistant. Making rounds with a healthcare provider, evaluating a patient's response to pain, and assessing a patient's central venous line require knowledge and expertise. These activities should be carried out by a registered nurse.

As the nurse, you need to complete all of the steps below. Which task do you complete first? A. Administer the oral pain medication to the patient who had surgery 3 days ago. B. Make a referral to the home care nurse for a patient who is being discharged in 2 days. C. Complete wound care for a patient with a wound drain that has had an increased amount of drainage since the last shift. D. Notify the healthcare provider of the decreased level of consciousness in the patient who had surgery 2 days ago.

D. Notify the healthcare provider of the decreased level of consciousness in the patient who had surgery 2 days ago. A decreased level of consciousness is a high priority. A high priority is an immediate threat to a patient's survival or safety such as a physiological episode of obstructed airway, loss of consciousness, or a psychological episode of an anxiety attack. Wound care for the patient with increased wound drainage would be the next priority, but it is not as critical as a change in consciousness. The other options are intermediate- or low-priority activities because they do not pose an immediate threat.

When communicating with a patient who has expressive aphasia, what is the highestpriority for the nurse? A. Asking open-ended questions B. Understanding that the patient will be uncooperative C. Coaching the patient to respond D. Offering pictures or a communication board so the patient can point

D. Offering pictures or a communication board so the patient can point Patients who have expressive aphasia understand questions but have difficulty expressing an answer. To promote interaction with the patient, offer pictures or a communication board so the patient can point to key words or images. Listen to the patient and wait for him or her to communicate. Use simple, short questions and facial gestures to give additional cues.

Which health promotion intervention is important to teach parents and children to prevent hearing impairment? A. Avoid activities in which there may be crowds. B. Delay childhood immunizations until hearing can be verified. C. Prophylactically administer antibiotics to reduce the incidence of infections. D. Take precautions when involved in activities associated with high-intensity noises.

D. Take precautions when involved in activities associated with high-intensity noises. Good sensory function begins with prevention. Nurses need to routinely assess children for noise exposure and reinforce the use of protective devices to minimize hearing loss. There is no need to delay immunizations, prophylactically administer antibiotics, or avoid crowds, because these measures will not prevent or cause hearing impairment.

Which statement about medication preparation and administration is correct? A. Medications should be prepared in unmarked containers. B. The nurse cannot delegate medication preparation to another nurse. C. The nurse should not reveal the disposal of narcotic drugs to other health care personnel. D. The nurse who administers medication to the patient is responsible for any errors related to it.

D. The nurse who administers medication to the patient is responsible for any errors related to it. The nurse who administers the medication to a patient is responsible for any errors related to it. Therefore, the nurses should administer medications with caution. Medications should not be prepared in unmarked containers. The nurse can delegate medication preparation to another nurse. If a patient refuses narcotics, proper agency procedure should be followed by having someone else witness the disposed medication.

The nurse is administering eardrops to an 8-year-old patient with an ear infection. How does the nurse pull the patient's ear when administering the medication? A. Outward B. Back C. Upward and back D. Upward and outward

D. Upward and outward Eardrops are administered with the ear positioned upward and outward for patients greater than 3 years of age.