Exam 1: Connection Checks and Review Questions

Which nursing action is most reflective of patient centered care? A. Ensuring that all documentation is completed on time B. Providing diagnostic results to the health-care provider C. Encouraging family members to provide direct care D. Including patients in decision-making

D. Including patients in decision-making

Why is IC advantageous for patients and health-care team members? A. The burden of care is removed from the patient to the health-care team. B. The physician has the final say in care decisions. C. Patients with complex needs are evaluated only by the appropriate selected team members. D. Patients become integral members of the health-care team.

D. Patients become integral members of the health-care team.

Mrs. Jones is receiving hospice care in the nursing home. During the assessment, the nurse observes the patient is unconscious and has wet, noisy respirations and cool, mottled extremities. The nurse understands the following action is not indicated: A. Notifying the patient's family B. Requesting an order for an anticholinergic medication C. Notifying the patient's provider D. Performing a sternal rub to assess the patient's response

D. Performing a sternal rub to assess the patient's response

The nurse understands appropriate actions to take after a distressing discussion with a provider over end-of-life issues for a patient include: A. Going home and getting a good night's sleep B. Having a drink after work to calm frazzled nerves C. Arguing with colleagues who disagree D. Soliciting support from and communication with a nurse manager

D. Soliciting support from and communication with a nurse manager

The nurse asks the patient and family members if they have any questions about the patient's diagnosis and plan of care. This is an example of which PC domain? A. Physical aspects of care B. Psychological and emotional aspects of care C. Ethical and legal aspects of care D. Structure and process of care

D. Structure and process of care

Which statement describes the primary difference between the TCM and the Care Transitions Program? A. The Care Transitions Program focuses primarily on hospital-based patients. B. The TCM focuses primarily on elderly patients with chronic diseases. C. The TCM facilitates care across the continuum. D. The Care Transitions Program follows patients for 4 weeks.

D. The Care Transitions Program follows patients for 4 weeks. Rationale: Both programs follow primarily older adults with chronic conditions across the continuum. The transitional care model follows patients for 8 weeks; the care transitions program follows patients for 4 weeks.

The medical-surgical nurse needs to be knowledgeable of which organization that scores patient-centered care via a telephone survey of selected patients after discharge? A. The Joint Commission B. The Beryl Institute C. The Carnegie Institute D. The Hospital Consumer Assessment of Healthcare Providers and Systems

D. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Which ethical principle deals with ensuring truthfulness and commitment? A. Autonomy B. Beneficence C. Justice D. Veracity

D. Veracity Rationale: Veracity is the requirement to tell the truth. It also requires that intentional misleading or deception of the patient to influence decisions is not done. Autonomy examines the individual's personal right to make decisions concerning themselves. Beneficence asks the question of who benefits from the action(s) taken by others. Justice examines who will be vulnerable in any actions taken.

Respiratory System

Fluid loss occurs from the lungs through vaporization, which occurs as a result of inspired air being warmed and humidified by the body.

Regulatory Mechanisms

-Renal System -Endocrine System -Respiratory System -Insensible Losses

Fluid Status of Patient is Evaluated by the following:

-Review of body weight -Osmolality -Blood Urea Nitrogen (BUN) -Creatinine -Urine Specific Gravity

What conditions result in Hypervolemia (FVE)?

-cirrhosis -heart failure stress conditions causing a release of ADH and aldosterone adrenal gland disorders -use of corticosteroids

Assessment of patients for Hypovolemia (FVD) & Hypervolemia (FVE) includes:

-collecting a health history -physical assessment -review of diagnostic result -calculation of I&O

Laboratory tests that are assessed with suspected Hypovolemia (FVD) include:

-electrolytes, specifically Na & K -hemoglobin & hematocrit -serum osmolality -BUN in relationship to Creatinine -urine specific gravity -urine osmolality

Transcellular fluid is only 2% of total body water and consists of fluids located in the:

-gastrointestinal (GI) -respiratory -urinary tracts -glandular, intraocular, and cerebrospinal fluids

Increases in serum osmolality are seen in:

-hyperglycemia -hypernatremia -severe dehydration

Cardiac Manifestations of Hypervolemia (FVE):

-hypertension -tachycardia -elevated central venous pressure -development of S3 heart sounds -jugular vein distention

Specific Gravity

-measurement of dissolved chemicals in urine -reflects the ability of the kidneys to concentrate urine -affected by the number and size of particles (minerals and salts) in urine

Collection of a health history focuses on for Hypovolemia (FVD) & Hypervolemia (FVE) focuses on:

-onset and duration of symptoms -recent illness -medication use/compliance

Management of hypervolemia (FVE) is aimed at:

-prevention -correcting/managing the underlying cause -treating clinical manifestations

Decreases in serum osmolality are seen in:

-renal failure -diuretic use -fluid volume excess

Laboratory tests that are assessed with suspected Hypervolemia (FVE) include:

-serum electrolytes -hematocrit -BUN -serum osmolality -albumin

Manifestations of Hypervolemia (FVE):

-weight gain -ascites -edema -increased urinary output.

Which statement by the nurse indicates understanding of the benefits of multidisciplinary care? (Select all that apply.) A. "I'm glad the social worker can focus on finding a placement for this patient." B. "I don't have time for this teaching; the nutritionist can go over dietary plans." C. "The OT evaluation made it clear there are more ADL issues to resolve before this patient can be discharged." D. "I'm not worried about length of stay. The bean counters can deal with that." E. "Discharge planning is much easier when we talk about it together as a team."

A. "I'm glad the social worker can focus on finding a placement for this patient." C. "The OT evaluation made it clear there are more ADL issues to resolve before this patient can be discharged." E. "Discharge planning is much easier when we talk about it together as a team."

Which statement by the nurse indicates understanding of the benefits of IC care for chronic care patients? (Select all that apply.) A. "Social work can be consulted to assist with long-term counseling." B. "Family members need to be included, with the patient's approval, to assess willingness to assist in the long-term care of the patient." C. "Each member of the ICT participates in patient education and can use teach back as a technique to determine synthesis of the information." D. "The ICT is concerned about developing a solid discharge plan that produces positive outcomes for the patient and prevents readmissions." E. "Direct care nurses are not involved in long-term care planning for chronic care patients."

A. "Social work can be consulted to assist with long-term counseling." B. "Family members need to be included, with the patient's approval, to assess willingness to assist in the long-term care of the patient." C. "Each member of the ICT participates in patient education and can use teach back as a technique to determine synthesis of the information." D. "The ICT is concerned about developing a solid discharge plan that produces positive outcomes for the patient and prevents readmissions."

According to the AMSN's Scope and Standards, registered nurses certified in this practice area are prepared to work in which settings? (Select all that apply.) A. Acute care inpatient settings B. Long-term care facilities C. Childcare agencies D. Mental health clinics E. Intermediate care units

A. Acute care inpatient settings B. Long-term care facilities E. Intermediate care clinics

The ANA Code of Ethics for nurses provides guidelines for which of the areas of nursing practice listed below? (Select all that apply.) A. Advancement of the profession B. Commitment to the patient and family C. Influencing moral values of health-care providers D. Developing legislation to guide nursing practice E. Improving health-care environments

A. Advancement of the profession B. Commitment to the patient and family E. Improving health-care environments

Nursing care priorities at the end of life include which of the following? (Select all that apply.) A. Communication with the patient and family B. Encouraging the family to get rest C. Rationalizing the patient's pain D. Managing pain and other distressing symptoms E. Providing education about the dying process

A. Communication with the patient and family B. Encouraging the family to get rest D. Managing pain and other distressing symptoms E. Providing education about the dying process

Which factors have led to the expansion of medical surgical nursing from traditional acute care facilities to other settings? (Select all that apply.) A. Increases in health-care complexity B. Shortage of registered nurses C. Changes in insurance coverage D. Shortened hospital lengths of stay E. Low salaries for registered nurses in hospitals

A. Increases in health-care complexity C. Changes in insurance coverage D. Shortened hospital lengths of stay

Interprofessional communication is best described by which statements? (Select all that apply.) A. Interprofessional communication is essential in providing comprehensive, safe care. B. Interprofessional communication occurs only in structured patient-centered rounds. C. Interprofessional education is key to effective interprofessional communication. D. Interprofessional communication can occur in a structured format or ad hoc in response to changing patient needs. E. Interprofessional communication occurs primarily between providers and nurses.

A. Interprofessional communication is essential in providing comprehensive, safe care. C. Interprofessional education is key to effective interprofessional communication. D. Interprofessional communication can occur in a structured format or ad hoc in response to changing patient needs.

The nurse is caring for patient who has experienced a CVA. Which ICT members should be involved in this patient's care? (Select all that apply.) A. Occupational therapist B. Physical therapist C. Physician D. Case manager E. Legal counsel

A. Occupational therapist B. Physical therapist C. Physician D. Case manager

In managing care for competent patients, which interventions or activities require the patient's informed consent? (Select all that apply.) A. Participation in a research study B. Change in room/unit C. Invasive diagnostic studies D. Operative procedures E. Discharge time and day

A. Participation in a research study C. Invasive diagnostic procedures D. Operative procedures

The nurse understands that moral distress may result in which of the following? (Select all that apply.) A. Physical exhaustion B. Disagreements among staff C. Anger at family D. Anger at providers E. Poor sleep patterns

A. Physical exhaustion B. Disagreements among staff C. Anger at family D. Anger at providers E. Poor sleep patterns

The nurse recognizes that basing nursing care on evidence is most closely associated with which outcome? A. Quality patient care B. Cost-effective care C. Standardized care D. Higher patient satisfaction

A. Quality Patient Care

The nurse recognizes which attribute as a hallmark of individualistic cultures? A. Self-expression B. Teamwork C. High-context communication D. Expectations of loyalty

A. Self-expression

What is the focus of transitional care programs? (Select all that apply.) A. Supporting the patient after hospital discharge B. Coaching and teaching to enhance patient understanding C. Providing patient-centered discharge instructions D. Ensuring evidence-based medical therapy E. Identifying patients at risk for readmission F. Providing adequate pain control while hospitalized

A. Supporting the patient after hospital discharge B. Coaching and teaching to enhance patient understanding C. Providing patient-centered discharge instructions D. Ensuring evidence-based medical therapy E. Identifying patients at risk for readmission

Palliative care is appropriate in which of the following situations? (Select all that apply.) A. The patient is undergoing cancer treatment. B. The patient is diagnosed with congestive heart failure. C. The patient is dying. D. The patient is dependent on technology. E. The patient is not imminently dying.

A. The patient is undergoing cancer treatment. B. The patient is diagnosed with congestive heart failure. C. The patient is dying. D. The patient is dependent on technology. Rationale: Palliative care is appropriate for patients at the time of initial diagnosis, during the course of active treatment, dependent on technology such as dialysis or artificial ventilation, and for patients who are dying because it focuses on the relief of suffering and promotion of quality of life.

Some individuals, regardless of cultural heritage, prefer traditional practitioners over Western allopathic practitioners. What is the most likely explanation for this trend? A. Traditional practitioners are usually known by the individual and are more trusted. B. Most individuals who prefer traditional practitioners cannot afford allopathic practitioners. C. Traditional practitioners specialize in specific health conditions. D. Traditional practitioners stress wellness and health promotion.

A. Traditional practitioners are usually known by the individual and are more trusted

The nurse demonstrates cultural sensitivity through which behavior? A. Using politically correct language B. Having an appreciation of cultural arts and dress C. Knowing aggregate data about a cultural group D. Knowing specific cultural attributes about a group

A. Using politically correct language

Nerves that transmit neurochemical pain impulses from the periphery to the central nervous system are called: A. Afferent nerves B. Efferent nerves C. Connecting nerves D. Vertebral nerves

Answer: A

One of the most common fungal infections is: A. Onychomycosis B. Tinea versicolor C. Tinea cruris D. Tinea captitis

Answer: A

Which statement made by a patient who is currently asymptomatic with an HSV-2 infection indicates the need for more education about the disease? A. "It's okay to have intercourse with my partner as long as we use a barrier method of protection and I take my antiviral medications." B. "It's more likely that I could spread the HSV-2 infection if I have sexual relations when I have open ulcers and pain." C. "When I get pregnant, I will be certain to tell my gynecologist about my HSV-2 infection." D. "I understand that I could still transmit the virus if I don't have symptoms."

Answer: A Rationale: As the nurse counseling the patient in answer A, you must be certain that the patient understands that the likelihood of transmitting the HSV-2 virus is much higher during periods of viral viral shedding, even if she takes her antiviral medications and uses a barrier method of protection. Therefore, you must also be certain that she can recognize the clinical manifestations of viral shedding. Taking the antiviral medications does not cure HSV and does not reduce the risk of transmitting the virus but may decrease the frequency and severity of outbreaks.

The nurse is screening patients for their risk of developing hyperkalemia. The nurse should consider the patient with which disorder at greatest risk? A. End-stage renal disease B. Diabetic mellitus C. Partial thickness burns D. Receiving a loop diuretic

Answer: A Rationale: End-stage renal patients are not able to excrete potassium through the renal system, increasing the risk for developing hyperkalemia.

How should assessment findings of blanched cool skin and leaking fluid at a peripheral infusion site be documented? A. Infiltration B. Infection C. Extravasation D. Phlebitis

Answer: A Rationale: Fluid that has leaked into surrounding tissue will result in cool blanched skin. These are not signs of infection or inflammation. Blisters are seen with extravasation.

During a routine visit, a patient informs the nurse that he has recently started taking an herbal supplement. The nurse sees that the provider has prescribed a new medication for the patient. What should the nurse do to ensure the patient's safety? A. Check with the provider to determine if there are any interactions or incompatibilities between the herbal supplement and the new medication. B. Tell the patient to immediately stop taking the herbal supplement. C. Tell the provider to prescribe a different medication because the patient is taking an herbal supplement. D. Ask the patient how the herbal supplement is working.

Answer: A Rationale: It is essential that we check for interactions or incompatibilities between medications before adding anything new.

The nurse identifies which vein as the most appropriate for placement of a peripheral IVAD to begin infusion therapy? A. Dorsal (hand) B. Femoral (groin) C. Antecubital (midarm) D. Brachial (upper arm)

Answer: A Rationale: It is recommended to start therapy in the most distal available and appropriate vein and move upward with subsequent insertions. Using more distal sites first will preserve sites less distal for future insertions.

The nurse correlates which physiological response to the secretion of natriuretic peptide hormones? A. Increase in urine output B. Increase in blood pressure C. Increase in blood volume D. Increase in serum osmolarity

Answer: A Rationale: Natriuretic peptide hormones are released from specialized cells within the walls of the atrium and ventricles in response to increase blood volume and blood pressure. As a result of the release of ANP and BNP, reabsorption of sodium by the kidney and increase in glomerular filtration rate results in increased urine output that is high in sodium.

When caring for an obese patient, which action represents a skin assessment technique that is unique for this population? A. Thorough inspection of all skin folds for the presence of lesions B. Functional ability to provide adequate self-care C. Gather data about recent skin changes or discomfort D. Personal motivation to lose weight

Answer: A Rationale: Obese patients frequently have increased moisture and friction under skin folds of the breasts, pannus, and back that may lead to full thickness wounds and infection.

During the initial assessment and admission questions, the nurse asks Maria for the time of her last oral intake. The patient replies, "I had dinner last night at 8 p.m., but I took a few sips of water this morning with my vitamins. The nurse's best response is which of the following? A. Explain to the patient that just a sip of water should not be a problem for anesthesia but that the vitamins may be a problem. We will pass that information on to the anesthesiologist. B. Tell the patient that the sip of water is not an issue because it was only a sip. C. Inform the patient that her surgery will not be performed today because the risk is too high for a negative outcome. D. Inform the patient that taking her vitamins before surgery was a good plan.

Answer: A Rationale: Patients are very often told to take certain daily medications with a sip of water early in the morning of surgery. They anesthesiologist will want the patient to have any hypertensive medications or corticosteroids if taken on a routine basis. The anesthesiologist will view the vitamin and non-essential and may wish to give other medications before anesthesia to help the stomach empty. It is imperative to give the anesthesiologist this information.

Which is a common injury that is caused by applying tape to the fragile skin of an elderly patient? A. Skin tear B. Abrasion C. Laceration D. Ulcer

Answer: A Rationale: Skin tears are traumatic wounds usually caused by minor trauma that primarily affects the elderly. Minor trauma in the elderly can include injuries involving wheelchairs (25%), bumping into objects (25%), transfers (18%), falls (12.4%), and tape removal.

What should the nurse teach the patient to expect during and following cryosurgery for the removal of a basal cell carcinoma? A. "You may experience some discomfort during and immediately after the procedure. Local wound care may be required because of minor skin sloughing in the next few days." B. "You will not have any pain with this procedure and need to see your provider only if complications develop." C. "You may experience some discomfort during the procedure, but there is no follow-up care required." D. "You will receive a local anesthetic just prior to the procedure. In the next few days, you may experience burning and itching at the site."

Answer: A Rationale: Teaching the patient what to expect prior to and following a procedure will alleviate anxiety. Cryosurgery causes some minor discomfort during and just following the procedure due to the thawing of the tissues. Skin sloughing and minor local wound care may be required in the following days, but cosmetic results are good.

The preoperative nurse receives her patient posting for the day. There are four 0800 cases in the hospital's OR. Which patient is a priority based on extent of preoperative care needed? A. An 80-year-old male scheduled for a bowel resection with a history of DVTs, chronic hypertension, and smoking B. A 17-year-old female scheduled for exploratory laparoscopy with a history of increased anesthesia recovery time C. A 40-year-old female scheduled for breast augmentation with no risk factors D. A 60-year-old male scheduled for renal biopsy with a history of chronic renal failure

Answer: A Rationale: The 80-year-old male patient with several pre-existing conditions will most likely need more laboratory work and most likely and electrocardiogram (EKG) due to his age. The next patient to prepare for surgery would be the 60-year-old male patient who also has pre-existing conditions.

The nurse assesses for which physiologic response as compensation for metabolic acidosis? A. Increasing the respiratory rate B. Decreasing the respiratory rate C. Increasing urine output D. Decreasing urine output

Answer: A Rationale: The decrease in arterial pH stimulates respirations. The body's attempt to compensate occurs rapidly and may reduce the PaCO2 levels by as much as 10 to 15 mm Hg.

The nurse recommends treatment with transdermal fentanyl for which patient? A. Severe pain due to cancer metastasis to bone B. Postoperative pain after gastric bypass C. Intermittent lower back pain associated with lumbar strain D. Initial treatment for migraine headaches

Answer: A Rationale: Transdermal fentanyl is indicated only for persistent severe pain in patients who are already opioid tolerant. Use in non tolerant patients can cause fatal respiratory depression. The patch should not be used in children under 2 years old, or in anyone under 18 who weighs less than 110 pounds. Also, the patch should not be used for postop pain, intermittent pain, or pain that responds to a less powerful analgesic.

When planning discharge education for a 65-year-old male who is having a hip replacement, it is appropriate for the nurse to consider which of the following? (Select all that apply.) A. The patient's resources at home for completing activities of daily living B. The number of stairs in the patient's home C. Transportation to follow-up appointments D. Preexisting medical conditions E. The number of bathrooms in the home

Answer: A, B, C, and D Rationale: When the nurse begins to make plans for the patient's discharge to home it is imperative to think about if they will have help with activities of daily living. If not, the patient may need to spend more time in the hospital or discharge to a rehabilitation center for a short time. If there are too many steps in the home they patient may require rehabilitation before returning home. Transportation to follow-up appointments will also impact the ability to go home or to a rehabilitation facility. Pre-exisiting medical conditions may indicate that the patient may require visiting nurses to follow not only the surgery but also the existing conditions.

Proper informed consent includes the following: (Select all that apply.) A. Procedure name B. Reason for surgery C. Number of instruments to be used D. Consent to administer blood products E. Alternatives to surgery

Answer: A, B, D, and E Rationale: The allergies of the patient will be documented on the chart not on the informed consent. The number of instruments is not relevant to informed consent. Consent to administer blood products are very often on its own form. The staff in the operating room is not relevant to informed consent.

The nurse assesses for which clinical manifestations in the patient with dehydration? (Select all that apply.) A. Increased urine specific gravity B. Increased serum BUN C. Increased serum osmolality D. Decreased serum osmolarity E. Decreased BUN to creatinine ratio

Answer: A, B, and C Rationale: High specific gravity values indicate concentrated urine and can be seen in patients with decreased renal perfusion, dehydration, or in response to ADH secretion. BUN elevation is seen secondary to dehydration as the retention of waste product accumulates. Increases in serum osmolarity and osmolality are seen in hyperglycemia, hypernatremia, and severe dehydration. Elevation of the BUN to creatinine ratio occurs as a result of decreased renal perfusion in shock states or dehydration.

The nurse recognizes that education for patients receiving infusion therapy should include which information? (Select all that apply.) A. Precautions for preventing infection B. Signs and symptoms to report C. Manufacturer of the IVAD D. Purpose of infusion therapy E. Calculation of infusion rates

Answer: A, B, and D Rationale: Patient teaching about intravenous therapy needs to focus on understanding the rationale for the therapy (fluid replacement, medication administration, etc.), how to care for the site to minimize inflammation, contamination, and occlusion, as well as signs and symptoms to report. Details about the manufacturer and calculation of IV rates is not information that the patient or family need.

The nurse is teaching skin care guidelines to the caretaker of a 79-year-old incontinent female who has a total Braden score of 14 with a score of 2 in the mobility category. What are appropriate educational priorities? (Select all that apply.) A. Gently cleanse and dry the skin immediately after an incontinence episode. B. Utilize a toileting schedule to minimize episodes of incontinence. C. Aggressively clean the patient's skin after an incontinence episode. D. Assist the patient with repositioning at least every 2 hours. E. Use diapers for stool and urine containment.

Answer: A, B, and D Rationale: This patient has a number of risk factors for developing skin damage. These include: excessive moisture caused by incontinence, immobility and increased fragility of the skin due to advanced age. Choices A, B, and D. are interventions that will help manage these risk factors.

Which properties of the epidermal and dermal layers contribute to wound healing? (Select all that apply.) A. The 30-day maturation time of epidermal keratinocytes B. Eccrine gland sweat production C. Melanocytes in a 1:36 ratio with keratinocytes D. Presence of Langerhans cells, macrophages, and mast cells E. Blood vessels in the dermis and subcutaneous tissue

Answer: A, C, D, and E Rationale: The maturation time of the epidermal keratinocytes and the replication of keratinocytes within the hair follicle impact the rate of wound closure. Langerhans cells, macrophages, and mast cells are part of the skin immune system, which play an important role in orchestrating the healing process. Blood vessels deliver oxygen and nutrients and remove waste products produced by the immune system cells.

When caring for a patient diagnosed with respiratory acidosis, the nurse includes which nursing interventions? (Select all that apply.) A. Monitor the patient's ABGs. B. Have the patient breathe into a paper bag. C. Monitor sedation medication usage. D. Encourage the patient to use slow breathing. E. Administer supplemental oxygen. F. Encourage the patient to use an incentive spirometer.

Answer: A, C, E, and F Rationale: Typically in respiratory acidosis, the patient is in respiratory distress with decreased respirations. Priorities for this patient would include monitor the patient's ABGs, monitor sedation medication usage, and administer supplemental oxygen as needed.

The nurse recognizes which patient may need infusion therapy? (Select all that apply.) A. Patient who sustained trauma presenting to the emergency department B. Patient with osteomyelitis receiving IV antibiotics at home C. High school teacher during an annual health appraisal D. Patient with cancer receiving parenteral chemotherapy E. Patient with multiple sclerosis in remission

Answer: A, C, and D Rationale: A, C, and D all require infusion therapy — he trauma patient for fluid and blood products, chemotherapy administered in an infusion center is given intravenously and postop pain relief is best achieved with IV analgesics. The MS patient in remission would not need IV therapy.

The nurse should report the following findings from a patient's history as an increased risk for DVTs postoperatively. (Select all that apply.) A. History of smoking B. Age C. History of DVTs with previous pregnancy D. Borderline hypertension E. Allergies

Answer: A, C, and D Rationale: History of smoking causes vasoconstriction in a patient, which could be a perfect setting for a deep vein thrombosis (DVT). Decreased vessels size can lead to platelet and red blood cell clumping and leading to DVT. Any time there is a history of the DVT the patient requires prophylaxis before surgery. Hypertension causes injury to vessel walls. The body will place platelets and red blood cells over the injured vessel walls to protect the area. This will be the beginning of a DVT.

If a patient wants to discuss CAM options with a nurse, the nurse should: (Select all that apply.) A. Use an accepting and respectful communication style. B. Automatically refer the patient to a CAM practitioner. C. Ensure that the patient has accurate and reliable educational materials. D. Provide the patient with guidance and assistance in finding a qualified CAM provider. E. Make sure the provider is present for the discussion.

Answer: A, C, and D Rationale: The physician does not need to be present for the discussion and before referring to a practitioner. Gather more information about with the patient needs and understands about CAM.

Which information should be included in the teaching plan for a patient diagnosed with melanoma? (Select all that apply.) A. Teach the ABCD tool for detecting abnormal skin lesions. B. Avoid wearing sun screen. C. Clothing is adequate to protective skin from sun exposure when outdoors. D. Discuss pain management plan for removal of skin lesions. E. Review biopsy or excisional site care instructions.

Answer: A, D, and E Rationale: In a teaching plan regarding treatment and prevention of melanoma, the nurse should emphasize guidelines regarding detection of new sites, pain management, and site care instructions to promote healing.

The nurse recognizes that pressure ulcer development is most probable in which areas in the patient positioned in a supine position? (Select all that apply.) A. Occiput B. Nares C. Behind the knees D. Sacrum E. Heels

Answer: A, D, and E Rationale: The occiput, ears, scapulae, sacrum and coccyx, ischium and buttocks, greater trochanters of the hips, and the heels of the feet are affected when patients are positioned in a supine position. Pressure to the nares is associated with nasogastric tube placement, and pressure to area behind the knees is usually due to pillows or other objects used for positioning.

Interpret the following ABGs and determine the degree of compensation: A. pH: 7.44, PaCO2: 22, HCO3-: 16, PaO2: 42 B. pH: 7.27, PaCO2: 37, HCO3-: 14, PaO2: 90 C. pH: 7.43, PaCO2: 50, HCO3-: 38, PaO2: 80 D. pH: 7.24, PaCO2: 62, HCO3-: 39, PaO2: 74

Answer: A. Completely compensated respiratory alkalosis; B. Uncompensated metabolic acidosis; C. Completely compensated metabolic alkalosis; D. Partially compensated respiratory acidosis

Herpes virus that commonly manifests as blisters on the finger of healthcare workers is called a: A. Canker sore B. Herpetic whitlow C. Secondary HSV infection D. Herpes zoster

Answer: B

The reorganizing of nerve-to-nerve contacts at synapses within the brain and spinal cord in response to illness or injury is called: A. Connectivity B. Plasticity C. Synapticity D. Central pain

Answer: B

This response to acid-base imbalances requires several days to be marginally effective: A. Respiratory compensation B. Renal compensation C. Intracellular buffering system D. Extracellular buffering system

Answer: B

In order to deliver 0.9% sodium chloride at 125mL/hr, the nurse has selected an infusion set with a drop factor of 15 drops/mL. What is the correct drop rate required to deliver this volume? A. 15 drops/min B. 31 drops/ min C. 60 drops/min D. 125 drops/min

Answer: B Rationale: 125ml /60 minutes = 2.1 ml/min x 15 drops/ml =31.25 drops/min (rounds to 31)

Which clinical finding requires additional investigation by the nurse? A. CRT less than 2 seconds B. New-onset petechial rash C. A macule with symmetrical shape, regular border, and uniform color D. Pale or cyanotic nailbed after exposure to cold temperatures

Answer: B Rationale: A new onset petechial rash indicates microvascular dysfunction. The underlying cause for this finding must be immediately identified to minimize risk for uncontrolled bleeding.

The nurse closely monitors the patient receiving morphine and a TCA for which medication interaction? A. Bradycardia B. Urinary retention C. Respiratory depression D. Hyperpyrexia

Answer: B Rationale: Anticholinergic drugs (ex, antihistamines, tricyclic antidepressants, atropine-like drugs) can exacerbate morphine-induced constipation and urinary retention. Hyperpyrexia is associated with the combination of meperidine (a morphine-like drug) with a monoamine oxidase (MAO) inhibitor. Respiratory depression is exacerbated when an opioid is given with another barbiturate.

Which individual is at greatest risk for developing skin cancer? A. A fair-skinned, blue-eyed teenager who works outside in the summers, uses sunscreen with sun protection factor (SPF) 50, and wears long-sleeved dark shirts B. A woman with a medium to dark complexion who applies sunscreen once in the midmorning and afternoon while she is playing tennis C. A 10-year old-child who plays outside in the early morning and late afternoons and uses SPF 30 D. A surfer who wears a wet suit with long sleeves and legs and applies sunscreen to his face periodically throughout the day

Answer: B Rationale: Anyone with any skin tone is at risk for skin cancer due to exposure to UV radiation. The tennis player is applying sunscreen one to two times during the day. Sunscreen should be reapplied at least every 2 hours and more frequently if perspiring. The best ways to decrease damage from UV exposure is to avoid the sun from 10a.m to 4p.m., use long sleeve shirts, wide brimmed hats, and sunglasses.

The nurse monitors for which clinical manifestations of the elderly patient diagnosed with delirium? A. Somnolence and fever B. Abrupt onset of confusion and hallucinations C. Feelings of hopelessness and early morning wakening D. Disorientation and word-finding difficulty

Answer: B Rationale: Delirium has an abrupt onset and changes in perceptions such as hallucinations. Dementia has some disorientation and word finding difficulty. Depression is notable for feelings of hopelessness. Infection can produce somnolence and fever.

The nurse recognizes the prevention of which complication as the primary rationale for initiating Total Parenteral Nutrition at a slow rate? A. Infection B. Hyperglycemia C. Discomfort D. Air embolism

Answer: B Rationale: Due to the high concentrations of dextrose, TPN therapy should be started gradually and the patient's glucose and fluid tolerance evaluated as the infusion rate is gradually increased until the targeted rate is reached.

The nurse realizes which central access device has the least effect on a person's self-image? A. Nontunneled percutaneous catheter B. Implanted chest port C. Tunneled catheter D. Short peripheral catheter

Answer: B Rationale: Implanted ports are under the skin and not easily seen when not accessed. When not accessed they require minimal care and allow patients to swim and bath without special precautions.

The nurse correlates which findings to the pathophysiology of chronic malignant pain? A. Recent trauma B. Rapidly dividing cells C. Direct damage to nerve fibers D. Persistent pain with no known etiology

Answer: B Rationale: In chronic malignant pain, rapidly dividing cells associated with cancer growth invade and distort bone and other tissues causing severe pain. This is the etiology of chronic malignant pain. Recent trauma and direct damage to nerve fibers are characteristic of acute pain.

The nurse is admitting a patient to the unit who is a paraplegic and has a history of healed sacral pressure ulcers, verified by the large scars on the sacrum. What action should the nurse take first? A. Apply moisturizing lotion to the sacrum. B. Apply a dressing such as a silicone foam dressing over the scars. C. Place the patient in a sitting position to keep pressure off the sacrum. D. Help the patient choose the most nutritious foods on the lunch menu.

Answer: B Rationale: In the maturation phase of wound healing, granulation tissue matures into a scar where collagen synthesis and degradation continue for 2 years. The tensile strength of a scar will only become only 80% of normal tissue. Therefore, applying a silicone foam dressing will protect the scars from the effects of shearing.

Which nursing action is the priority in the patient with a serum calcium of 6.0 mg/dL? A. Prepare for placement of a nasogastric tube B. Place an intubation tray at the bedside C. Place an indwelling urinary catheter D. Prepare for emergency dialysis

Answer: B Rationale: In the patient with hypocalcemia, due to the potential of laryngeal stridor, cardiac dysrhythmias and seizures, emergency equipment such as intubation equipment, tracheostomy set, code/emergency cart, and a defibrillator must be readily available. There is no indication for a nasogastric tube, indwelling catheter, or emergency dialysis with hypocalcemia.

The nurse assesses for which clinical manifestations in the patient with hypervolemia? A. Bradycardia B. S3 heart sound C. Postural hypotension D. Decreased skin turgor

Answer: B Rationale: Manifestations of hypervolemia include weight gain, ascites, edema, and increased urinary output. Cardiac manifestations of fluid volume excess include hypertension, tachycardia, elevated central venous pressure, development of S3 heart sound, and jugular vein distension. An extra heart tone, S3, is present due to the large amount of blood volume entering the ventricles during diastole.

A patient is admitted with osteomyelitis and is going to require 3 to 4 weeks of IV antibiotics. Which IVAD is most appropriate for this patient? A. 16-gauge central venous B. 18-gauge over-the-needle IVAD C. 20-gauge midline catheter D. 22-gauge steel-winged device

Answer: B Rationale: Midline catheters are inserted in a peripheral vein in the upper extremities with tips that terminate distal to the shoulder in either the basilica, cephalic or brachial vein. Midlines are appropriate for therapies expected to last between 1 to 4 weeks. Steel-winged devices are indicated only for short term or single-dose therapy because the rigid steel needle is more likely to puncture the vein and lead to fluid or medication leaking out of the vein. Peripheral IVADs cannot stay in place for the full length of required treatment. Central venous lines are more complicated to manage and have higher incidence of complications, such as infection.

The nurse incorporates which content in the teaching plan for the patient receiving Coumadin? A. "It is important to take a stool softener to prevent constipation." B. "Over-the-counter NSAIDs may increase the anticoagulation effect of Coumadin." C. "This medication may cause drowsiness, so please do not take it before driving." D. "You will need to monitor your blood glucose levels while on this medication."

Answer: B Rationale: NSAIDS increase the risk for thrombocytopenia, and low platelet counts can lead to an increased risk of bleeding in patients taking Coumadin. NSAIDS are not associated with constipation, drowsiness, or glucose changes.

If a hemolytic transfusion reaction is suspected, what is the nurse's priority action? A. Slow the transfusion and notify the provider B. Stop the transfusion but maintain the infusion with 0.9% sodium chloride C. Stop the transfusion and change the infusion site D. Send a blood specimen for repeated blood typing

Answer: B Rationale: The infusion needs to be stopped to avoid administration of any further blood product, but the IV needs to be maintained in case immediate venous access is required for emergency medications.

In completing a skin assessment, the nurse correlates erythema, redness, and warmth to which phase of wound healing? A. Hemostasis B. Inflammatory C. Proliferative D. Maturation

Answer: B Rationale: The main function of the inflammatory phase of wound healing is to remove debris within the wound. This phase begins within the first 24 hour after injury and can last up to two weeks for an acute wound. The clinical characteristics of the inflammatory phase include edema, erythema, heat, and pain, and visible necrotic tissue in the wound bed.

An example of an acceptable time-out is: A. Name, medical history, and procedure B. Name, birthday, and procedure including site C. Birthday, Social Security number, and surgeon's name D. Allergies, medical history, and procedure site

Answer: B Rationale: The name, birthdate, and the procedure, including the site are the best response. Allergies, medical history and Social Security number are not found on the patient's ID bracelet.

How does the nurse interpret an arterial pH of 7.47? A. Acidosis B. Alkalosis C. Compensation D. Homeostasis

Answer: B Rationale: The normal pH range is 7.35-7.45. Measurements > 7.45 are considered alkalosis.

Which patient is at greatest risk for pressure ulcer formation? A. A 39-year-old male status post mitral valve replacement with a Braden score of 18, who is NPO for procedure B. A 76-year-old female with an ICD pocket infection, Braden score of 15, incontinent of urine and stool C. A 52-year-old female heart transplant patient in rejection, Braden score of 15, one person assist to stand D. A 67-year-old male status post CABG x 4, Braden of 16, who needs assistance with repositioning when in the chair

Answer: B Rationale: The patient described in B has the most significant risk factors including advanced age, mild-moderate risk for pressure ulcer development based on her Braden score, and excessive moisture caused by incontinence.

A patient is admitted to the emergency department with an attempted aspirin overdose. The nurse notes that the patient is hyperventilating and monitors for which acid-base disorder? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

Answer: B Rationale: The patient's hyperventilation is most likely related to the overdose of salicylate acid. Any time a patient hyperventilates, the patient's carbon dioxide levels (PaCO2) decrease leading to respiratory alkalosis.

The nurse recognizes that the primary indication for the administration of an opioid medication is which outcome? A. To reduce anxiety B. To relieve pain C. To diminish respiratory effort D. To decrease level of consciousness

Answer: B Rationale: The principal indication for morphine is relief of moderate to severe pain. The drug can relieve postoperative pain, chronic pain of cancer, and pain associated with labor and delivery. Morphine may also be administered preoperatively for sedation and reduction of anxiety.

Which statement from a patient being prepared for placement of leads for DBS indicates the need for further teaching? A. "I will be awake during the procedure." B. "This procedure requires me to be sedated during the procedure." C. "The doctor will drill a small hole in my skull." D. "The generator can be programmed without additional surgery."

Answer: B Rationale: The procedure includes a small hole drilled in the skull and placement of leads and an implanted generator. The patient is awake during the procedure so the physician can evaluate the placement of leads and stimulation.

Maria's surgeon has asked that thromboembolic stockings (TEDs) be placed on the patient before surgery as well as sequential compression devices on both legs to the knees. Maria asks the nurse what they will do for her. Which response by the nurse is most appropriate? A. "They work together to make sure that you do not have a decrease in arterial blood flow in your legs during the surgery." B. "They complement each other to prevent blood from backing up in your legs and causing a deep vein thrombosis due to you not moving during the surgery." C. "They prevent deep tissue clotting during the surgery." D. "The two devices do the same thing, but one is better during the surgery and the other is better postoperatively."

Answer: B Rationale: Thromboembolic stockings compress superficial vessels in the legs and force blood to flow through deep vessels, which help prevent deep vein thrombosis. Sequential compression devices push blood through the blood vessels in an upward motion, which helps prevent venous stasis and deep vein thrombosis.

In ayurvedic medicine, unique, well-defined energy patterns are called: A. Qi B. Doshas C. Reflexes D. Life Forces

Answer: B Rationale: Unique, well-defined energy patterns are called doshas in ayurvedic medicine

A patient tells you as you prepare to start his IV line for surgery that he has hard veins to find and that people always miss his veins. The best response by the nurse is which of the following? A. "Do not worry. I am very good at this and very rarely miss." B. "I sense that you are worried about being stuck repeatedly for an IV. I will ask someone to help me if I miss." C. "I can ask someone else to start your IV if you wish." D. "I am going to ask your wife to hold your hand while I start this IV so you will not worry so much."

Answer: B Rationale: We should choose the answer that will help the patient feel comfortable with your abilities to complete this task, but also know that you are able to ask for help as opposed to keep trying. Having the wife hold his hand sounds demeaning and not so helpful. Asking if they wish to have someone else start the IV will decrease their comfort level in your abilities. You never want to boast too much about your abilities and not be able to complete the task.

A patient who has had surgical debridement of a necrotic abdominal wound that will heal by secondary intention will require which treatment? A. Serial surgical debridements followed by skin graft coverage B. Wound dressing changes until the wound closes C. Coverage by myocutaneous flap D. Suturing the wound closed within 7 days

Answer: B Rationale: With secondary intention, the wound is left open and allowed to fill in with granulation tissue. Often, these wounds are packed with gauze and changed daily.

What acid-base imbalance does the nurse suspect on the basis of these results? pH: 7.31 PaCO2: 52 mm Hg HCO3-: 28 mEq/L A. Uncompensated respiratory acidosis B. Partially compensated respiratory acidosis C. Uncompensated metabolic acidosis D. Partially compensated metabolic acidosis

Answer: B Rationale: pH 7.31 (acidosis), PaCO2 52 (acidosis), HCO3 - 28 (alkalosis). When the pH is abnormal and both the PaCO2 and HCO3 - are abnormal, then partial compensation is in process.

Which acid-base imbalance should be suspected with these ABG results? pH: 7.47 PaCO2: 31 mm Hg HCO3-: 24 mEq/L A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

Answer: B Rationale: pH 7.47 (alkalosis), PaCO2 31 (alkalosis), HCO3- 24 (normal). The patient is in a respiratory alkalosis state.

Prioritization Activity: The registered nurse working in the Post-Anesthesia Care Unit (PACU) receives report on the following patients. List in priority the order in which the nurse should complete the initial assessments of these postoperative patients. A. 38-year-old patient received in the PACU 45 minutes ago after undergoing oral-facial reconstructive under general anesthesia after sustaining a direct hit with a baseball. The patient is intubated and on a mechanical ventilator. The patient received 2 mg intravenous morphine upon admission to the PACU. B. 45-year-old patient received in the PACU 5 minutes ago after undergoing a thyroid surgery under general anesthesia. The patient was extubated in the operating room, is receiving 40% oxygen via face mask, and received 6 mg intravenous morphine prior to being transferred to PACU. C. 68-year-old patient received in the PACU 20 minutes ago after undergoing a lumbar laminectomy under general anesthesia. The patient was extubated in the operating room and is receiving 40% oxygen via a face mask. The patient is complaining of severe pain and requesting pain medication, and has an order for intravenous morphine.

Answer: B, A, C Rationale: The priority is the patient who was recently (5 minutes) received from the PACU and received IV morphine prior to transfer. She is at risk to depressed respirations due to the morphine (opioid) administration and the fact that she was recently extubated. Additionally, the surgery was in the neck area, which also places the patient at risk for respiratory compromise. The next patient to be assessed is the patient who underwent the oral surgery; however, because the patient is intubated and ventilated, their respiratory status is more stable than B. Lastly, their last does of opioid was 45 minutes ago. The last patient to be seen is the patient complaining of pain that is expected after this type of surgical procedure.

As the nurse in the emergency department, you are responsible for triaging three new patients. How would you prioritize treatment of the following patients? A. Patient A is a 32-year-old paraplegic male patient who has a stage 4 left ischial pressure ulcer and a stage 4 right trochanteric pressure ulcer. He is currently treated for his pressure ulcers through an outpatient wound clinic affiliated with the hospital and was seen earlier during the same day. He has been experiencing a pain level of 8 out of 10 and does not have a prescription for pain medication. B. Patient B is a 15-year-old female patient who has a 6 cm x 8 cm area of erythema and induration to her right buttocks that started on the morning of admission. She had been swimming the day before and stayed in her wet bathing suit all day. She noticed a very small pruritic rash in the right buttock area the evening before but thought nothing of it. Now she is complaining of pain of 8 out of 10, shaking, and chills. C. Patient C is a 67-year-old female patient being treated with chemotherapy for breast cancer. She had a left mastectomy the month before and was told her chest incision was completely healed prior to starting the chemotherapy. Today she noticed erythema and purulent drainage from the lateral incision line. She has had no symptoms of fever, chills, or sweats and rates her pain as 2 out of 10.

Answer: B, C, A Rationale: Patient B should be seen first. She has clinical manifestations of a NSTI that may require initiation of antibiotic therapy and immediate surgical evaluation for surgical debridement. Delaying treatment could result in more tissue loss or death. Patient C should be seen second. Being on chemotherapy for breast cancer, she is at high risk of infection and sepsis due to her immunocompromised status. Patient A should be seen third. Although he is in significant pain, he is currently being treated through the outpatient wound clinic and is likely not at risk of a life threatening outcome related to his condition. The provider will use judgment as to the appropriate treatment for his pain and his wounds should be evaluated for infection.

A break in the skin that is caused by penetration of a sharp object or high shearing forces that can be superficial or deep is a: A. Skin tear B. Abrasion C. Laceration D. Pressure ulcer

Answer: C

Normal plasma pH levels are: A. 7.00-7.10 B. 7.15-7.25 C. 7.35-7.45 D. 7.45-7.55

Answer: C

Peripheral neurons that selectively respond to pressure, pinprick, and other noxious stimuli are called: A. Interneurons B. Gray cells C. Nociceptors D. Glial cells

Answer: C

The most common type of psoriasis is: A. Guttae B. Erythrodermic C. Plaque D. Pustular

Answer: C

The pH of body fluid is measured in units of: A. Oxygen concentration B. Potassium concentration C. Hydrogen ion concentration D. Carbon dioxide concentration

Answer: C

A 78-year-old woman has had a history of an open stage IV pressure ulcer for 6 months. What is the patient at high risk for developing? A. Hypergranulation tissue B. Necrotic tissue C. Osteomyelitis D. Eschar

Answer: C Rationale: A clinical diagnosis of osteomyelitis is made based on the presence of exposed bone.

The nurse caring for an elderly patient with early signs of dementia incorporates which priority nursing diagnosis into the plan of care? A. Altered nutrition, less than nutritional requirements B. Altered nutrition, greater than nutritional requirements C. Risk for injury D. Activity intolerance

Answer: C Rationale: Although altered nutrition and activity intolerance are possible nursing diagnoses, risk for injury is the priority because of the devastating effects an injury such as one caused by a fall has on the elderly.

A patient is ordered to receive a blood transfusion because of anemia. What is the recommended minimum gauge of the IV catheter to administer blood? A. 16 B. 18 C. 20 D. 22

Answer: C Rationale: An 18 to 20 gauge catheter is recommended for infusion of packed RBCs in the adult population to prevent red blood cell lysis. The 20 gauge is smaller gauge and is acceptable. A 16 gauge is larger and not required for blood administration, and a 22 gauge is too small and would result in cell lysis.

Which of the following patients presents the greatest risk for a negative response to anesthesia? A. A 40-year-old male with high blood pressure B. A 20-year-old female with no prior surgical history C. A 29-year-old female with a history of stage II acute renal failure D. An 85-year-old male who drinks one glass of scotch every night

Answer: C Rationale: Any patient with renal impairment will not be able to excrete anesthesia effectively. Anesthetics are excreted either through the liver or kidneys and impairment of either organ will mean the patient cannot rid the body of anesthesia. The anesthesiologist must reduce the amount of anesthesia used during the surgery.

The nurse is preparing a discharge plan for a 78-year-old woman. Which likely scenario should the nurse anticipate? A. The patient will drive herself home. B. The patient lives in a homeless shelter. C. The patient is a widow and lives alone. D. The patient receives a government pension.

Answer: C Rationale: Census bureau statistics reveal 42% of older women are widows, and of women 75 and older, 49% live alone.

When assessing the patient with cognitive impairment, the nurse should be aware that this is the most common cause of dementia. A. Vascular dementia B. Parkinson's disease C. Alzheimer's disease D. Multi-infarct dementia

Answer: C Rationale: Dementia stems from a variety of pathological conditions. The most common is Alzheimer's dementia.

The nurse has just received a report on assigned patients. Which patient should be assessed first? A. A patient with abdominal pain who has drained 400 mL from her nasogastric tube over 6 hours B. A patient postoperative total hip replacement 2 hours ago with 600-mL urine output C. A patient receiving an IV infusion of 0.9% NS at 125 mL/hr who is now complaining of a cough D. A patient complaining of leg cramps after receiving furosemide (Lasix) for peripheral edema

Answer: C Rationale: Development of a cough in a patient receiving intravenous fluid can indicate the development of fluid volume excess.

A young woman comes to the health clinic of a local college complaining of vaginal burning and pain on urination. Her serologic testing was positive for HSV-1. The woman says, "I can't have herpes because I haven't had intercourse yet." Which statement would be most appropriate in response to this patient? A. HSV-1 causes ulcers on the lips or mouth. There may be a mistake on your blood work. B. You may have times of shedding the virus when you have symptoms similar to what you are experiencing now. C. HSV-1 can cause ulcers on the lips or mouth but can also cause genital lesions on someone partaking in oral sexual activity. Have you had any sexual contact like this? D. When you decide to have sexual intercourse, wearing a condom will reduce the risk of transmitting the virus to your partner.

Answer: C Rationale: HSV-1 was identified as the cause of GH in 71.2% of all subjects.

The nurse monitors for which clinical manifestations in the patient diagnosed with hyponatremia? A. Irregular heart rate, leg cramps, confusion B. Weakness, tachycardia, tingling of the skin C. Headache, nausea, change in level of consciousness D. Bradycardia, hypotension, muscle weakness

Answer: C Rationale: Headache, nausea, and changes in level of consciousness occur secondary to the shift of fluid into the cells of the brain, increasing intracranial pressure.

When the body is in a state of alkalosis, what is the role of the renal buffers? A. ↑ Rate and depth of respirations B. ↓ Rate of respirations C. ↓ Blood HCO3-, ↓ pH D. ↑ Blood HCO3-, ↑ pH

Answer: C Rationale: If the body is in a state of alkalosis, then the kidneys excrete HCO3 - , reabsorb H+, and increase the pH. This results in urine becoming more alkaline, the blood bicarbonate levels drop, and the pH decreases.

The nurse understands that cerebrospinal fluid is considered which type of fluid? A. Intracellular B. Interstitial C. Transcellular D. Plasma

Answer: C Rationale: Intracellular fluid includes all fluid present within the cells, and extracellular fluid is located outside of the cell. Intercellular or interstitial fluid is found between cells and is 25% of total body water. Lymph fluid is considered interstitial fluid. Plasma accounts for 8% of total body water and is located in the intravascular system. Transcelluar fluid is only 2% of total body water and consists of fluids located in the gastrointestinal, respiratory and urinary tract, and glandular, intraocular, and cerebrospinal fluid.

The nurse anticipates which fluid movement when administering an isotonic IV fluid to a patient? A. Causes fluid to move from the cells into the intravascular space B. Causes fluid to move from the intravascular space into the intracellular space C. Causes no or equal movement of fluid into or out of cells D. Causes fluid to move from the intravascular space into the interstitial spaces

Answer: C Rationale: Isotonic solutions have the same or nearly the same osmolarity as plasma and cause no movement of fluid into or out of cells. Isotonic solutions remain in the extracellular compartment in either the intravascular or interstitial compartments. Hypotonic solutions have a lower solution concentration than plasma and cause fluid to move from the intravascular space into both the intracellular and interstitial spaces. Hypertonic solutions have concentrations higher than plasma and cause fluid to move from the cells into the intravascular space.

While assisting family members in finding resources to care for their elderly father, the nurse is aware that this agency can provide assistance with nursing home costs: A. Medicare B. Social Security Administration C. Medicaid D. Department of Health and Human Services

Answer: C Rationale: Medicare is the government health insurance program that covers medical expenses. Medicaid provides for nursing home care or care at an assisted living facility.

Which type of therapy/therapies is focused on the limbic system and the frontal cortex area of the brain? A. Naturopathy B. Massage therapy C. Mind/Body therapies D. Energy healing therapy

Answer: C Rationale: Mind/body therapies focus on the limbic system and the frontal cortex area of the brain

The nurse correlates respiratory depression and decreased gastrointestinal motility to the actions of which opioid receptor? A. Delta B. Kappa C. Mu D. Beta

Answer: C Rationale: Mu receptors, located in the brain, spinal cord, and peripheral sensory neurons, lead to respiratory depression, miosis, euphoria, and reduced gastrointestinal motility. Delta receptors located in the brain and peripheral sensory neurons lead to mild analgesia, antidepressant effects, and respiratory changes based upon dose. Kappa receptors, located in the brain, spinal cord, and peripheral sensory neurons lead to analgesia, sedation, miosis, and dysphoria.

A 78-year-old patient fractured a hip 1 week ago and is now being admitted to a rehabilitation facility for physical therapy because of difficulty ambulating. During the admission skin assessment, the nurse notesan area of non-blanchable erythema on the sacrum. What is the nursing priority at this time? A. Order a redistributing mattress for her bed. B. Consult the nutritionist for a complete nutritional assessment. C. Perform and document the admission skin and risk assessments. D. Apply a hydrocolloid dressing over the area to protect it from further trauma.

Answer: C Rationale: Non-blanchable erythema is considered a stage I PU. Any evidence of pressure on the body of the patient being admitted to a healthcare facility must be documented on the admission skin assessment or the institution could be held responsible for causing it and may not get reimbursed for treating it. The other three answers are important and should be instituted, but the admission skin and risk assessments must be completed at time of admission.

The nurse recognizes the presence of pain, redness, and streak formation at the site of a peripheral IV site as what grade of phlebitis? A. 1 B. 2 C. 3 D. 4

Answer: C Rationale: Phlebitis is graded on a 0 to 4 scale. A score of 0 is given when there are no signs of inflammation. A score of 1 is given when there is erythema at the site with or without pain. A score of 2 is consistent with pain, erythema, and/or edema at the insertion. Pain at the insertion site with erythema, streak formation, and/or a palpable cord are graded with a 3. A score of 4 is characterized by pain, erythema, streak formation, a palpable cord greater than one inch, and/or purulent drainage.

The nurse correlates the use of KOH testing to the definitive diagnosis of which skin disorder? A. Bacterial infections B. Herpes simplex C. Fungal infections D. Psoriasis

Answer: C Rationale: Potassium hydroxide (KOH) microscopy, which has a 76.5% sensitivity and an 81.6% negative predictive value, makes it more sensitive than a fungal culture.

In preparing an in-service about pain management, the nurse includes which finding as the most serious adverse effect of opioids? A. Profound sedation B. Suppressed cardiac automaticity C. Respiratory depression D. Hyperthermia

Answer: C Rationale: Respiratory depression is the most serious adverse effect of the opioids. At equianalgesic doses, all of the pure opioid agonists depress respiration to the same extent. Death following overdose is almost always from respiratory arrest.

The nurse is performing a cardiovascular assessment on an elderly patient. Which physical signs of normal aging can be expected? A. Irregular pulse and diminished lung sounds B. Heart rate of 88 bpm and a heart murmur C. Systolic blood pressure of 150 mm Hg and a fourth heart sound D. Productive cough and hoarseness

Answer: C Rationale: Stiffening of the arterial walls results in increased blood pressure. Heart valve stenosis produces a fourth heart sound.

The nurse in the emergency department is triaging patients. Which patient requires immediate attention? A. A 16-year-old with a laceration that was sutured closed 3 days ago that now has erythema extending 2 cm beyond the suture line. B. A 30-year-old patient with an open sacral pressure ulcer with exposed bone with purulent exudate. C. A 48-year-old patient with an indurated, erythematous area on his thigh who is complaining of 10/10 pain and has had a fever for 24 hours. D. A 60-year-old diabetic patient who has a nail embedded in his foot because he could not feel it in his shoe yesterday.

Answer: C Rationale: The 48 year-old patient with the indurated area of erythema complaining of 10/10 pain and fever for the past 24 hours is displaying clinical manifestations of a CSSTI that would require immediate surgical evaluation for surgical debridement. Delaying treatment could result in more tissue loss or death.

Which parameter of the ABG result correlates to assessment of the base component? A. pH B. PaO2 C. HCO3- D. PaCO2

Answer: C Rationale: The base component of the ABG is determined by the HCO3 -, The hydrogen ion concentration is measured in terms of the pH, and indicates overall acid base level. PaO2 measures the partial pressure of oxygen in arterial blood and is the most important factor determining how oxygen binds to hemoglobin. Carbon dioxide is measured by the PaCO2 levels which indicate the partial pressure of CO2 in the arterial blood. PaCO2 is used to evaluate the respiratory component of acid-base balance.

A mother brings in her 8-year-old child because of a new rash of annular patches, raised borders, and central clearing. What should be done first? A. Obtain a scraping of the rash for KOH microscopy. B. Explain to the mother that this is probably tinea corporis and an antifungal ointment will successfully treat it. C. Obtain a focused history to include medications, activities in which the patient partakes, and any history of skin disorders or fungal rashes. D. Explain to the mother that the rash will subside on its own.

Answer: C Rationale: The diagnosis of tinea infections can be made with a focused history, physical exam, and potassium hydroxide microscopy (KOH). Certainly, obtaining the skin scrapings for KOH microscopy is important to confirm diagnosis but, as with all healthcare visits, obtaining a history should be completed first.

An elderly patient is unusually lethargic and has a temperature of 95.4°F (35.2°C). The nurse suspects: A. A medication side effect B. Urinary retention C. An infection D. Constipation

Answer: C Rationale: The elderly are less likely to have a fever. Most common sign of infection is a change in their behavior such as inattention, confusion, or lethargy.

In a patient with incontinence associated dermatitis caused by frequent, loose stools, the nurse includes which intervention in the plan of care? A. Vigorously scrub skin to remove contaminants. B. Use diapers to contain urine and stool. C. Use invasive containment devices in the presence of diffuse partial thickness wounds. D. Avoid using skin protectants.

Answer: C Rationale: The need for stool containment should be based upon the severity of the incontinence symptoms, the patient's ability for self-care, and the severity of the skin damage. Invasive containment strategies should be considered in the presence of diffuse skin breakdown particularly when a patient has poor mobility.

A patient presents with a new-onset, erythematous rash that contains intact pustules. Subjective symptoms include itching and burning. Which diagnostic evaluation is most helpful in determining the underlying etiology? A. Excisional biopsy B. Skin scraping C. Sterile collection of pustule roof D. Cryosurgery

Answer: C Rationale: The objective appearance and subjective symptoms are consistent with fungal infection. The recommended culturing method for fungal infection is to sterilely remove the roof of an intact pustule so that the tissue can be inspected using a KOH preparation.

The nurse is screening patients for their risk of developing aspiration. The nurse should consider which patient at greatest risk? A. Patient with CHF B. Patient with type 2 diabetes mellitus C. Patient receiving tube feedings D. Patient with COPD

Answer: C Rationale: The patient receiving tube feeding is at increased risk for aspiration caused by improper tube placement and tube feedings going into the lungs.

The nurse recognizes which parameter as the respiratory component of the ABG measurement? A. pH B. HCO3- C. PaCO2 D. H+

Answer: C Rationale: The respiratory components of the ABG measurement are the PaO2 and the PaCO2.

The nurse chooses which pain scale to most effectively assess pain in an older patient with limited vision? A. FACES scale B. Numeric scale C. Verbal scale D. Visual scale

Answer: C Rationale: Verbal rating scales are more effective with older people than the more common numeric rating scales. The Wong-Baker scale is used with children, and the FACES pain scale is used with older adults with expressive aphasia. Numerical rating scales become more difficult to use as patients age, with a higher frequency of incomplete or unscoreable responses. Visual scales are not as effective in older adults often to changes in vision.

The nurse knows that decreased vitamin D absorption predisposes a patient to: A. Skin dryness B. Gastric ulcers C. Osteoporosis D. Venous stasis

Answer: C Rationale: Vitamin D facilitates the GI absorption of calcium which helps maintain bone health.

The nurse understands which is the result of administering hypertonic solutions? A. Cells become hydrated. B. Free water enters the vascular space. C. Fluid shifts from the intracellular space into the intravascular space. D. No shift into the intracellular compartment

Answer: C Rationale: When hypertonic solutions are administered intravenously, fluid move from inside the cells into the vascular space due to the higher osmolarity in the intravascular space.

Protection of underlying organs and tissues represents a key function of the integumentary system. Which statement accurately describes the skin's protective capabilities? A. The epidermis can resist damage when exposed to continuous moisture. B. Melanocytes always provide adequate protection to underlying structures from UV exposure. C. Langerhans cells, located in the epidermis, often provide the initial signal to the immune system that pathogen invasion has occurred. D. Temperature is regulated by blood vessels and sweat glands

Answer: C Rationale: While the skin has many protective features, the presence of Langerhans cells, which are the outermost cells of the immune system, triggers the immune system response to invading pathogens.

A 5-year-old patient will be returning home after surgery for a right inguinal hernia repair. Which of the following is an important teaching need before the child and family leave the hospital? A. The child should be given pain medicine every 4 hours for the first 24 hours. B. There will be no dressing for the family to check because of the laparoscopic surgery. C. Teach the family how to use the facial pain scale to ensure that the child gets pain medication as needed. D. Make sure the child is kept in bed for the first 12 hours to prevent bleeding from the operative site.

Answer: C Rationale: You do not want to give the child pain medication if they do not need it, so you must teach them how to use the facial pain scale to indicate when the child needs pain medication. There is a dressing over the puncture sites in laparoscopic surgery. The child should be as ambulatory and mobile as is tolerated to prevent venous stasis.

The nurse has received a report on assigned patients and receives the following laboratory results. Place the patients in the order they should be seen by the nurse. A. Patient with heart failure receiving furosemide (Lasix) with a serum potassium level of 5.5 mEq/L B. Patient who had a total abdominal hysterectomy with a hemoglobin of 11.8 g/dL and hematocrit of 36.2% C. A postoperative patient receiving D5W with a serum sodium level of 125 mEq/L

Answer: C, A, B Rationale: The patient with a low serum sodium level, normal range 135-145 mEq/L, is at risk for developing neurological symptoms including seizures; a serum potassium level of 5.5 mEq/L is elevated, placing the patient at risk for cardiac dysrhythmias; the hemoglobin and hematocrit are low—female normal ranges 12-16gm/38-46%.

Pressure ulcers can be caused by: A. Pressure over bony prominences B. Shear C. Friction D. A and B

Answer: D

CAM stands for: A. Complementary art modalities B. Comprehensive alternative medicine C. Center for Alternative Manipulation D. Complementary and alternative medicine

Answer: D Rationale: CAM stands for complementary and alternative medicine

The nurse prioritizes the patient with which electrolyte abnormality at greatest risk for ventricular fibrillation? A. Hypochloremia B. Hyponatremia C. Hypocalcemia D. Hypokalemia

Answer: D Rationale: Cardiac symptoms in hypokalemia include the development of palpitations and premature atrial or ventricular complexes. In severe hypokalemia, sudden death can occur as a result of ventricular fibrillation. Hyponatremia is associated with weight loss, tachycardia, and orthostatic hypotension. Patients with hypochloremia may exhibit hypotension, tetany, shallow respirations, and hyperexcitabilty of muscles and nerves. Hypocalcemia is manifested by increased neuromuscular activity resulting in increased deep tendon reflexes and positive Chvostek' s and Trousseau's signs.

A nurse in the intensive care unit is evaluating a critically ill patient who has a flat, erythematous rash surrounded with small satellite lesions between her skin folds, under her breasts, and in her groin. The nurse knows to monitor this patient for clinical manifestations of which disorder? A. Necrotizing fasciitis B. Systemic bacteremia C. Pseudomonas infection D. Systemic candidemia

Answer: D Rationale: Complications of fungal infections, such as a systemic candida infection, occur when they are not treated promptly and are allowed to proliferate, especially in the critically ill and immunocompromised patient.

The nurse questions which intervention in the stable patient with the nursing diagnosis "impaired skin integrity related to draining skin lesions on right lower extremity?" A. Place patient on isolation precautions. B. Obtain a swab specimen from wound bed after cleansing with a non-antiseptic solution. C. Educate patient about wound and skin treatment regimen. D. Administer broad-spectrum antibiotic before obtaining a culture.

Answer: D Rationale: In order to obtain the most accurate result, the culture should be completed before administration of the anti-infective agent or cleansing with an antiseptic solution.

You are preparing a patient for surgery and have asked her to verify her information on her patient identification band. She tells you that the birth date is incorrect on her identification band. The most appropriate action by the nurse at this time is which of the following? A. Cross out the birth date and put the correct one in its place with the nurse's initials. B. Ask the family members to validate the patient's birth date. C. Call the surgeon's office to validate the birth date. D. Ask the admissions office to please send a corrected identification band.

Answer: D Rationale: It is imperative that the patient enters the operating room with all information absolutely correct. The admissions office must send a new identification band.

When speaking to a hearing impaired elderly patient, the nurse remembers to: A. Speak very slowly B. Speak as loudly as possible C. Speak into his or her ear D. Speak in a lower octave

Answer: D Rationale: Lower tones of voice are heard better than high-pitched tones in the elderly

A patient has been admitted to the critical unit with a serum magnesium level of 0.9 mEq/L. The nurse closely monitors the patient for which potential complication of this magnesium level? A. Agitation and restlessness B. Hypotension and bradycardia C. Deep, rapid respirations D. Seizure and ventricular fibrillation

Answer: D Rationale: Patients with low magnesium levels are at risk for seizure and ventricular fibrillation. Agitation and restlessness are seen with hypernatremia. Hypotension and bradycardia are associated with high magnesium levels, and deep, rapid respirations are observed with patients with hypochloremia.

An 18-year-old with psoriatic plaques on the elbows, knees, and legs has been successfully treated with a combination of therapies including phototherapy. Because the patient is an avid soccer player and expects to receive a college scholarship next year, which information is the most important aspect to teach at this time? A. The importance of knowing the clinical manifestations of PsA (soft tissue swelling, limitations of movement) because as many as 30% of those who have psoriasis develop PsA B. The importance of adhering to his medication regimen C. The importance of finding a support group to help cope with stress and anxiety that can develop as a response to treatment and can exacerbate the disease D. The importance of using sunscreen while outside

Answer: D Rationale: Patients with psoriasis are at higher risk of developing non-melanoma skin cancer, especially if they have a history of utilizing phototherapy. Also, teaching the patient to do monthly skin assessments on himself to monitor for new lesions or changes to existing ones.

The nurse recognizes that the incidence of pain is greatest in which patient population? A. Active teenagers B. Unemployed adults regardless of age C. Employed middle-aged and older adults D. Older patients who are institutionalized

Answer: D Rationale: Studies report an increased incidence in all types of persistent pain, generalized musculoskeletal pain, and fibromyalgia in older patients. More than half of older patients report mild to moderate intermittent pain as they age, with the incidence of all types of pain more common in institutionalized elderly

A patient has been diagnosed with an intestinal obstruction. The nurse inserts a nasogastric tube and attaches the tube to low continuous suction. For which acid-base imbalance is the patient at greatest risk? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

Answer: D Rationale: The most common cause of metabolic alkalosis is excessive acid loss from the GI tract, which can occur from vomiting or prolonged NG suctioning.

Which observation in a patient with peripheral vascular disease requires an immediate intervention by the nurse? A. Gradual hair loss on bilateral lower extremities B. Hemosiderin staining on bilateral ankles C. 2+ dorsalis pedis pulses bilaterally D. New-onset pallor, cyanotic or ecchymotic discoloration of distal toe tips

Answer: D Rationale: The skin changes associated with peripheral vascular disease (PVD) often develop over time. New onset discoloration in the form of pallor, cyanosis, or ecchymosis of toe tips represents an acute change such as a blood clot that requires immediate intervention.

In assessing a patient's pain, the nurse asks the patient, "What makes the pain worse?" Which aspect of pain is the nurse determining? A. Onset and duration B. Intensity C. Quality D. Aggravating factors

Answer: D Rationale: This question is assessing factors that make the pain worse, which are considered aggravating factors. For onset and duration of pain ask the patient about the start and length of pain episodes. Intensity is often assessed using a visual scale, or the patient may compare this pain with another pain experience. Quality of pain is assessed by asking the patient to describe in qualitative terms such as sharp, dull, or achy

The patient's ABG results indicate worsening respiratory acidosis. He has rapid, shallow breaths and decreased bilateral breath sounds. Which intervention should be the nurse's first priority? A. Administer an antibiotic for suspected pneumonia B. Administer diuretics for heart failure C. Encourage the patient to breathe into a brown paper bag D. Prepare the patient for intubation and mechanical ventilation

Answer: D Rationale: Treatment for worsening respiratory status should focus on improving ventilation. Therefore, the nurse's first intervention would be to prepare the patient for intubation and mechanical ventilation. Although administering diuretics or antibiotics may also be appropriate, ensuring that the client has a patent airway is the top priority.

Which change in fluid and electrolyte balance is most closely associated with aging? A. Increased sensitivity to smells B. Increased sensitivity to texture in foods C. Decreased manual dexterity D. Decreased olfactory function

Answer: D Rationale: With aging there is a decrease in taste, smell, and thirst which can impact fluid and electrolyte balance because it affects intake of fluids and food. With aging there is a decline in olfactory function due to the decrease in olfactory fibers and receptors. Loss of these fibers and receptors results in a decrease in olfactory function and ability to discriminate smells. Alterations in smell also affect taste impacting oral intake, especially fluids, of older adults.

Which position is best to reduce the risk of skin tears in an immobile, older adult patient? A. In a side-lying position B. Foot of the bed elevated to no greater than 15 degrees C. In a chair with feet on the floor D. Head of the bed elevated no greater than 30 degrees

Answer: D Rationale: With aging, the rete ridges flatten between the dermal-epidermal junction making it more susceptible to tearing injury from external shearing forces. Positioning a patient with the head of bed no greater than 30 degrees minimizes the risk of the patient's body sliding down the bed, increasing the shearing forces and trauma to internal tissues and capillaries.

Mr. Smith's wife is in the terminal stage of chronic obstructive pulmonary disease (COPD). He is very anxious that his wife be comfortable during her last hours. The nurse finds him tearful in the hall outside the room. Which communication should the nurse use first? A. "My aunt had COPD, and she died on a ventilator. Count your blessings that your wife is not on a machine." B. "I can see you're upset, Mr. Smith. Would you like to talk about it? C. "Is your family here?" D. "Do you think your wife would like a visit from pastoral care?"

B. "I can see you're upset, Mr. Smith. Would you like to talk about it?

Which statement alerts the nurse that a patient may not have adequate health literacy? A. "I usually take my medication every morning." B. "My spouse keeps all this information; I will take the form home to complete." C. "I prefer to get my information from the Internet; I can remember it better." D. "I think I understand the information; I will call you if I have additional questions."

B. "My spouse keeps all this information; I will take the form home to complete."

Members of Mr. Smith's family are in the waiting area of the intensive care unit. They have just been told that Mr. Smith has amyotrophic lateral sclerosis, a neurodegenerative disease that is fatal, and are questioning this diagnosis. Later in the day, you meet with the family. What is your best response to the family at this time? A. "Mr. Smith will soon be better. The doctors here are the best." B. "What are your fears at this time?" C. "Families always have a rough time with this information." D. "I will contact pastoral care."

B. "What are your fears at this time?"

What is considered the hospital's span of responsibility for the patient? A. Admission to discharge B. Admission to 30 days post discharge C. Admission to 15 days post discharge D. Admission to full recovery

B. Admission to 30 days post discharge

Mrs. Foster, aged 84, is in the nursing home with dementia, hypertension, and mild renal failure. She has a feeding tube. Mrs. Foster suffers a catastrophic stroke and is taken to the emergency department. The nurse discovers that the patient has an advance directive and does not wish to be put on a ventilator. The nurse brings this to the team's attention during the family meeting to discuss the goals of care. The nurse's behavior is an example of A. Nonmaleficence B. Advocacy C. Veracity D. Beneficence

B. Advocacy

A patient is undergoing chemotherapy for adenocarcinoma. The medications are shrinking the tumors, but the woman has an adverse reaction to the medication during the third treatment and is placed on a mechanical ventilator secondary to respiratory arrest. After numerous unsuccessful attempts to wean the patient off the respirator, the provider tells the patient and family that the woman will be ventilator dependent for the remainder of her life. The woman tells the provider to turn off the machine and allow her to die. Which ethical principle may present a conflict for the nurse? A. Justice B. Autonomy C. Nonmaleficence D. Beneficence

B. Autonomy

What roles does the nurse have in transitional care programs? (Select all that apply.) A. Directing patient care in the inpatient setting B. Coaching the patient after discharge C. Managing chronic conditions after discharge D. Direct patient care in the clinic setting E. Assessing the patient's risk for readmission

B. Coaching the patient after discharge C. Managing chronic conditions after discharge E. Assessing the patient's risk for readmission

The medical-surgical nurse implements SBAR to promote effectiveness in which aspect of quality and safety in patient care? A. Surveillance B. Communication C. Organization D. Cost-effectiveness

B. Communication

A patient living in an extended care facility requests pain medication from the nurse. The nurse is extremely busy, is late giving the 9 p.m. medications, and has only an unlicensed nursing assistant to help. Using the ethical theory of deontology, which action will the nurse take? A. Tell the unlicensed nursing assistant to sit with the man B. Continue to give all of the 9 p.m. medications C. Give the man the ordered pain medication D. Notify the provider of the man's increasing pain

B. Continue to give all of the 9 p.m. medications

Which ethical theory is based upon obeying laws? A. Autonomy B. Deontology C. Rights D. Teleology

B. Deontology

The nurse correlates which example as a hallmark of cultural competence? A. Allowing cultural competence to develop without interference by management B. Developing respect for cultural values C. Trying to Americanize newer immigrants D. Enforcing organizational policies

B. Developing respect for cultural values

The nurse demonstrates cultural awareness by which behavior? A. Using politically correct language B. Having an appreciation of cultural arts and dress C. Knowing aggregate data about a cultural group D. Knowing specific cultural attributes about a group

B. Having an appreciation of cultural arts and dress Rationale: Cultural awareness is demonstrated through behaviors that reflect an appreciation of cultural art and dress. Using politically correct language is cultural sensitivity. Knowing specific cultural attributes about a cultural group is a step in cultural competence. Knowing aggregate data about a cultural group is step in cultural competence.

Which outcome of interprofessional teams is associated with the increased focus on educating health professional students together? A. Decreased hospital costs B. Increased safety and quality C. Decreased length of stay D. Increased patient satisfaction

B. Increased safety and quality

Which is a value of the dominant U.S. culture? A. Dependence B. Individualism C. Hierarchical status D. Formality

B. Individualism

A patient was admitted 15 days ago with an intracranial bleed. The patient was found unresponsive by emergency medical technicians who were called to the home by a family member. After initiation of cardiopulmonary resuscitation, the patient had a heart rate but needed ventilator support and was transported to the hospital and placed on a mechanical ventilator. The cardiac status is unimpaired, but the patient is flaccid, is nonresponsive with an altered electroencephalograph, and has consistently failed weaning from the ventilator. The family is requesting the patient be removed from the ventilator and allowed to die. The provider is reluctant to remove the ventilator, and the family's spiritual minister concurs with the provider. Which option does the nurse have in this situation? A. Encourage the family to change physicians B. Refer the situation to the hospital ethics committee C. Support the provider's decisions, telling the family that the provider is working in the patient's best interest D. Refer the family to social work for counseling

B. Refer the situation to the hospital ethics committee

In distinguishing a stereotype from a generalization, the nurse recognizes a generalization is consistent with which characteristic? A. Endpoint B. Starting point C. Minor variation of stereotype D. Major variation of stereotype

B. Starting Point Rationale: Generalizations can lead to stereotyping, an oversimplified conception, opinion, or belief about some aspect of an individual or group of people. Stereotyping is an endpoint; generalizing is a starting point for assessment.

The initial Nursing Code of Ethics was based upon which work? A. The Bill of Rights B. The Nightingale Pledge C. The Hippocratic Oath D. The International Council of Nurses

B. The Nightingale Pledge

Components of teach back include which of the following? (Select all that apply.) A. Primarily teaching at discharge B. Using simple, plain language C. Asking questions in a nonshaming way D. Asking the patient to repeat back in his or her own words E. Getting additional help if the patient does not understand after the first attempt

B. Using simple, plain language C. Asking questions in a nonshaming way D. Asking the patient to repeat back in his or her own words

Which statement by the nurse about discharge planning indicates understanding about the role of the multidisciplinary team? A. "This patient had a fairly uncomplicated hospital admission. There's no need to involve the team in this discharge plan." B. "Our physical therapist is busy today. I'll take care of the PT evaluation." C. "Let's make sure we are all in agreement about the discharge plans for this patient in multidisciplinary rounds today." D. "We need this bed for an emergency admission. I'm okay with discharging this patient before the OT evaluation."

C. "Let's make sure we are all in agreement about the discharge plans for this patient in multidisciplinary rounds today."

The ethical principle of beneficence involves: A. Assuring that a patient's wishes are honored B. Not doing harm to the patient C. Acting for the good of the patient D. Asking family members about their concerns

C. Acting for the good of the patient

Transitional care models have emerged in an effort to improve what type of care? A. Care in the hospital setting B. Care in the home C. Care across the care continuum D. Care across extended-care settings

C. Care across the care continuum

The primary way a person is socialized into the dominant culture is through socialization described by which term? A. Acculturation B. Assimilation C. Enculturation D. Relativism

C. Enculturation Rationale: Enculturation is the process by which an individual learns the traditional culture and incorporates its practices and values. Acculturation is a process where a person gives up some of his/her cultural practices. Assimilation is when someone takes in the attributes of his/her new culture. Cultural relativism is the belief that the behaviors and practices of people should be judged only from the context of their cultural system.

The goal of implementation of interprofessional care teams is focused primarily on which outcome? A. Decreased costs B. Improved patient safety C. Enhanced patient satisfaction D. Increased patient-centered care

C. Enhanced patient satisfaction

The discharge nurse is providing verbal discharge instructions to Mr. Colin, a 34-year-old Haitian. When the nurse asks him if he understands the instructions, he looks at her with a confused expression. The nurse recognizes that he probably does not understand and therefore should take which action? A. Ask him to repeat the instructions B. Give him written instructions to ensure understanding C. Have him demonstrate the instructions D. Give the instructions to a family member

C. Have him demonstrate the instructions

In addressing an ethical dilemma, which principle guides decision making focused on minimizing harm to the patient? A. Beneficence B. Justice C. Nonmaleficence D. Fidelity

C. Normaleficence

In designing an evidence-based practice guideline for a medical-surgical unit, which source provides the most reliable information? A. Content from a textbook B. Manuscript in a nursing journal C. Results from research studies D. Information from a professional activity

C. Results from research studies

The family of a 3-year-old child has refused a lifesaving blood transfusion for the child on the basis of religious values. The nurse knows that the child will die without the transfusion. According to the principles of ethics, which course of action is most ethical in this situation? A. Notify social work so that legal proceedings can begin to remove the child from the parents for purposes of administering the blood transfusion B. Refer the situation to the interprofessional care committee C. Support the parents in their decision and grief process D. Request that another nurse assume the care of this child and family

C. Support the parents in their decision and grief process

Who publishes the National Patient Safety Goals that focus on improving patient safety through goals that focus on potential problems in the health-care setting? A. The Department of Health and Human Services B. The HCAHPS C. TJC D. The Food and Drug Administration

C. The Joint Commission (TJC)

Hospice care is not appropriate in which of these circumstances? A. The patient decides to forego curative treatment. B. The patient's prognosis is 3 to 6 months. C. The patient is undergoing experimental chemotherapy. D. The patient is receiving palliative chemotherapy.

C. The patient is undergoing experimental chemotherapy Rationale: Hospice care is not appropriate for patients undergoing active curative therapy.

Which phase of care is most critical for medical-surgical patients? A. Acute hospital phase B. Pre-hospital care phase C. Transition phases D. Discharge phase

C. Transition phases

Hypercalcemia

Clinical Manifestations: -abdominal pain, constipation, bone pain, decreased deep tendon reflexes, hypertension, thirst, lethargy, muscle weakness Treatment: IV fluids -Loop diuretics -Bisphosphates

Hypocalcemia

Clinical Manifestations: -anxiety, confusion, fractures, irritability, paresthesias, + Chvostek's/Trousseau sign, tetany, twitching, tremors Treatment: -IV calcium -Oral supplementation (calcium tablets, Tums)

Hyperphosphatemia

Clinical Manifestations: -muscle cramps, paresthesia, weakness, decreased DTRs, ECG changes Treatment: -PhosLo capsules -Oral phosphate-binding drugs -If normal renal function, IV NS and loop diuretics

Hypomagnesmia

Clinical Manifestations: -paresthesias, tetany, twitching, tachycardia, nausea/vomiting, seizures, anorexia, and dysrhythmias such as rapid heart rate and PVCs, ventricular tachycardia, emotional liability, and deep tendon reflexes increased Treatment: -IV replacement -Magnesium 2 g in 100 mL NS or D5W over 1 hour Magnesium tablets -IVP during Code Blue situation

Hypophosphatemia

Clinical Manifestations: -weakness, slurred speech, irritability, confusion, increased bleeding Treatment: Phosphorus supplementation -Neutra-phos powder -KPhos IV replacement

Hypermagnesemia

Clinical Manifestations: ECG changes, widened QRS, hypotension, bradycardia, drowsiness, lethargy, decreased deep tendon reflexes Treatment: Increase fluids

Endocrine System

Control of fluid and electrolyte balances is maintained by the renin-angiotensin-aldosterone system, antidiuretic hormone (ADH), and natriuretic peptides.

What is the first step in correcting Hypovolemia (FVD)?

Identifying the etiology of the fluid volume deficit and implementing appropriate interventions.

Insensible Losses

Insensible water loss occurs through the skin, lungs, and stool. Insensible water loss is NOT controllable and can be significant in the total amount because of the lack of awareness of this fluid loss.

Hyperchloremia

Serum chloride levels greater than 108 mEq/L Clinical Manifestations: -irritability, hypotension, tetany, shallow respirations, and hyperexcitability of muscles and nerves Treatment: -0.45% or 0.9% NS -Correct underlying cause

Hypochloremia

Serum chloride levels less than 96 mEq/L Clinical Manifestations: -deep, rapid respirations, lethargy, tachypnea, decreased cognitive ability, and hypertension Treatment: -0.45% NS -Correct underlying cause

Hyperkalemia

Serum potassium level greater than 5.0 mEq/L Clinical Manifestations: -muscle cramps, paresthesia to weakness, abdominal cramping, ECG changes (abnormal rhythms, widened QRS complex) Treatment: -Kayexalate, 50% dextrose, and IV regular insulin IVP bolus -Sodium bicarbonate 50 mEq IVP -Calcium gluconate -Albuterol nebulization for 1 hour -Loop diuretics

Hypokalemia

Serum potassium level less than 3.5 mEq/L Clinical Manifestations: -weakness, lethargy, hyporeflexia, ECG changes PVCs, nausea/vomiting, constipation Treatment: -Increase dietary intake or supplementation -Slow-K, KCl liquid, powder or tablets -IV replacements (KCL runs, KCL aliquots) Peripheral IV: KCL 10 mEq in 100 mL NS or D5W over 1 hour Central line (PICC, triple-lumen catheter, or portacath): KCL 10 or 20 mEq in 100 mL NS or D5W to infuse over 1 hour ***Never administer as IVP

Hypernatremia

Serum sodium level greater than 145 mEq/L Clinical Manifestations: -disorientation, hallucinations, agitation, restlessness, confusion, seizures, lethargy, tachycardia, dry mucous membranes, skin flushed, agitation, thirst Treatment: -Fluid replacement 1/2 NS or D5W -Treat the underlying cause

Hyponatremia

Serum sodium level less than 135 mEq/L Clinical Manifestations: -headache, lethargy, confusion, convulsions, nausea/vomiting, coma Treatment: -Fluid restriction -In severe neurological symptoms, 3% NS -Oral sodium supplements -Loop diuretics

Renal System

The kidneys are the primary organs in regulating fluid volume and electrolyte balance to maintain homeostasis.

Osmotic Pressure

ability of a solution to draw water across a membrane and is affected by the tonicity of fluids

Diabetes Insipidus (DI) indicates a _______________ in urine osmolality

decrease

Diuretic Use indicates a _______________ in SERUM osmolality

decrease

Fluid Volume Excess indicates a _______________ in SERUM osmolality

decrease

Fluid Volume Excess indicates a _______________ in urine osmolality

decrease

Hyponatremia indicates a _______________ in urine osmolality

decrease

Renal Failure indicates a _______________ in SERUM osmolality

decrease

As urine osmolality ______________, urine becomes more DILUTED and number of particle solutes DECREASES

decreases

Hypovolemia

fluid volume deficit

Hypervolemia

fluid volume excess

Fluid Volume Deficit indicates a _______________ in urine osmolality

increase

Heart Failure indicates a _______________ in urine osmolality

increase

Hyperglycemia indicates a _______________ in SERUM osmolality

increase

Hypernatremia indicates a _______________ in SERUM osmolality

increase

Prerenal Failure indicates a _______________ in urine osmolality

increase

Severe Dehydration indicates a _______________ in SERUM osmolality

increase

As urine osmolality ______________, urine becomes MORE CONCENTRATED and number of particle solutes INCREASES

increases

Creatinine

is the by product of muscle creatinine phosphate metabolism

Diffusion

movement of molecules from an area of HIGHER concentration to an area of lower concentration

Filtration

process by which water and dissolved substances (solutes) cross a membrane as a result of hydrostatic pressure