Fundamentals Ch 1-40 Updated

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Order: Cyanocobalamin 0.6 mg IM daily Cyanocobalamin Injection USP 1000 mcg/mL For injection How many mL of medication will the patient receive per dose? _____ mL

0.6 mL

When completing the assessment of an immobilized patient, the most likely place for the nurse to assess edema includes which of the following? (Select all that apply.)

1. feet 2. sacrum 3. legs

A group of teenagers are attending a preparation class for babysitters. Which statements by the teenagers indicate a correct understanding of the teaching about safety issues? (Select all that apply.)

1. home fires are a major cause in death and injry 2. keep charged batteries in fire extinguishers 3. toddlers are curious

A patient has just undergone an abdominal aortic aneurysm repair. The patient is pulling at the Foley catheter, nasogastric tube, central line, and abdominal dressing and a wrist restraint is applied after an order is received. Later, the patient reports tingling and numbness in the fingers and hand. Which actions should the nurse take? (Select all that apply.)

1. remove restraint 2. notify health provider 3. stay with pt

Order: Enalaprilat 1.25 mg IV push Enalaprilat injection For IV use only 2.5 mg per 2 mL The agency's safe IV push infusion rate for Enalaprilat is 625 mcg over 5 minutes. How many minutes will it take to safely administer the dose? _____ minutes

10 mins

Order: Potassium chloride solution 9 mL PO daily Potassium chloride Oral solution USP 10% 20 mEq per 15 mL How many mEq of medication will be administered? _____ mEq

12 mEq

A patient recently came to the clinic with complaints of having difficulty sleeping. After the primary health care provider assesses the patient the nurse instructs the patient and partner on how to keep a sleep-wake diary. Entries in the diary often include _____ of sleep-wake activities.

24 hours

Order: 50% Dextrose 15 g IV push STAT 50% Dextrose Injection USP 25 g per 50 mL How many mL of medication will be administered? _____ mL

30mL

A patients vital signs are significantly lower than normal while sleeping. The nurse understands this to be a normal finding when the patient is in what stage of the sleep cycle?

Order: Digoxin 1 mL PO daily Digoxin Oral solution USP 0.25 mg per 5 mL How many mcg of medication will be administered per dose? _____ mcg

50 mcg

(23) Which nursing diagnosis is most appropriate for a toddler who is not walking by the age of 24 months? a. Delayed growth and development related to failure to achieve age-appropriate motor skills b. Impaired walking related to inability to maintain a steady gait along uneven surfaces c. Sedentary lifestyle related to preferred lifestyle that requires minimal physical activity d. Impaired parenting related to unrealistic expectations for age-appropriate motor skills

(34) Which is the highest priority nursing diagnosis for a patient with a spinal cord injury and no pain sensation below the waist? a. Potential for injury related to lack of sensation and protective reflexes b. Disturbed body image related to loss of body function and sensation c. Readiness for enhanced self-care related to desire for increased independence d. Risk for loneliness related to discomfort in social situations due to disability

A patient has a morphine sulfate patient-controlled analgesia (PCA) to control postoperative pain. When the nurse enters the room, the patient complains of pain. The nurse's first response is which of the following? a. Ask the patient to rate the pain on a 0-to-10 scale. b. Check the patency of the patient's intravenous line. c. Call the physician or health care provider immediately. d. Speak to the patient in a calming tone to reduce anxiety

A patient's blood pressure suddenly drops from 132/82 to 104/52. The nurse notes that the patient's skin is pale and the patient appears ready to faint. What is the priority action of the nurse? a. Report the findings to the health care provider immediately. b. Check the patient's apical rate to check for a pulse deficit. c. Elevate the head of the patient's bed to at least 45 degrees. d. Immediately check the patient for orthostatic hypotension.

A young adult is balancing the need to live and work independently with the desire to have a girlfriend for companionship and love. Which developmental stage is the young adult experiencing? a. Intimacy versus isolation b. Obedience and orientation c. Self-control and independence d. Generosity versus self-absorption

How will the nurse administer a nitroglycerin sublingual tablet to the patient? a. Place the tablet under the patient's tongue. b. Place the tablet in the patient's mouth next to the cheek. c. Have the patient swallow the tablet with a sip of water. d. Crush the tablet and dissolve it in a teaspoon of water.

The nurse is assessing a patient with suspicious bruises. Which action is most appropriate to facilitate an accurate account of the patient's injuries? a. Ask the patient's family member to wait outside in the waiting room. b. Ignore the bruises because the patient has provided an explanation. c. Realize that the patient may be abused, but that is a family issue. d. Provide referrals for health counseling once the assessment is complete.

The nurse is caring for a hypotensive patient whose peripheral pulses are very weak. Which grade will the nurse use to document this finding? a. +1 b. +2 c. +3 d. +4

The nurse is caring for a patient who collapsed after working outside on a hot day. The patient is disoriented with hot, dry skin and heart rate of 140 beats/minute. What is the priority action of the nurse? a. Remove the clothes and cover the patient's body with ice-water soaked towels. b. Insert an indwelling urinary catheter to monitor hourly urine output. c. Insert a nasogastric tube to prevent the patient from vomiting. d. Obtain a 12-lead EKG and draw blood to check the patient's electrolyte levels.

The nurse is caring for a patient who feels the urge to urinate but is unable to void. Which is the appropriate action of the nurse? a. Scan the patient's bladder to see how much urine is present. b. Obtain a urine sample for urinalysis, culture, and sensitivity. c. Perform a focused physical assessment of the patient's perineum. d. Help the patient to utilize absorbent undergarments for protection.

The nurse is caring for a patient who has just undergone shoulder replacement surgery. Which is the best option for washing the patient's hair? a. Utilize a no-rinse shampoo cap. b. Use a handheld shower sprayer. c. Have the patient lean back into the sink. d. Have the patient lean over the wash basin.

The nurse is caring for a patient who has perineal skin breakdown after sitting in wet underclothes for many hours. Which term will be used to document the patient's condition in the medical record? a. Maceration b. Dehiscence c. Evisceration d. Debridement

The nurse is caring for a patient who is having a heart attack. The patient tells the nurse that the pain is down his left arm rather than in his chest. What type of pain is the patient experiencing? a. Referred b. Psychogenic c. Peripheral d. Chronic

The nurse is caring for a patient who was just pulled from a freezing lake. The patient's pulse oximetry reads 68% although the patient is not in respiratory distress. What is the correct interpretation of these assessment findings? a. The pulse oximeter will not give an accurate reading until the patient's extremities have warmed to near normal temperature. b. The pulse oximeter adhesive was left on too long and no longer stuck to the patient's finger adequately. c. The pulse oximeter became overheated when it was placed underneath the patient's warming blanket. d. The pulse oximeter displayed a falsely low reading because the patient was receiving supplemental oxygen via nasal cannula.

The nurse is caring for a patient with a highly contagious infection. Which is the appropriate type of blood pressure cuff to use when caring for this patient? a. A disposable vinyl blood pressure cuff b. An electronic vital signs monitor c. A soft cloth blood pressure cuff d. A Doppler ultrasound device

The nurse is caring for a patient with a new, unexpected sigmoid colostomy. The nursing diagnosis knowledge deficit related to colostomy care is included in the patient's care plan. Which is the appropriate outcome for the patient? a. The patient will empty and change the colostomy appliance. b. The patient will resume a sexual relationship with the spouse. c. The patient will verbalize feelings about presence of colostomy. d. The patient will use clothing to effectively conceal the colostomy.

The nurse is caring for a patient with a pulmonary embolism that prevents blood flow to the lower lobe of the right lung. Which breathing process is impaired for this patient? a. Perfusion b. Diffusion c. Respiration d. Ventilation

The nurse is caring for an elderly patient who has just been diagnosed with a bladder infection. The normally alert and appropriate patient thinks that she is going to bake cookies with her mother when she gets home after school this afternoon. Which term best describes the patient's mental status? a. Delirious b. Dejected c. Depressed d. Demented

The nurse is caring for an elderly patient with the nursing diagnosis loneliness related to recent loss of spouse and limited contact with significant others. Which stage of Maslow's hierarchy of needs is addressed with this diagnosis? a. Belonging b. Self-esteem c. Self-actualization d. Safety and security

The nurse is discontinuing the patient's indwelling urinary catheter. The catheter is not easily withdrawn after the balloon is deflated. Which is the appropriate nursing action? a. Reattach the syringe and attempt to withdraw more water from the balloon. b. Ask the patient to bear down as the catheter is withdrawn with gentle pressure. c. Review the patient's chart to see how much water was inserted into the balloon. d. Explain to the patient that removal of the catheter may cause significant discomfort.

The nurse is to administer enoxaparin 40 mg subcutaneously to the patient. Which technique is correct? a. The nurse injects the medication into the soft tissue of the patient's abdomen. b. The nurse aspirates immediately prior to injecting the medication. c. The nurse gently massages the injection site immediately afterward. d. The nurse draws up the medication into a 1-mL syringe with a 32-gauze needle.

The nurse is to administer insulin lispro to the patient using an injection pen. Which is the correct action of the nurse? a. The nurse primes the pen with 2 units of insulin before each injection. b. The nurse always injects into the same spot to minimize discomfort. c. The nurse uses the same pen for multiple patients with a new needle each time. d. The nurse aspirates immediately prior to injecting the medication.

The nurse is unable to hear the blood pressure for a patient who is in septic shock. What is the best option of the nurse? a. Determine the diastolic blood pressure by palpation and notify the health care provider immediately. b. Elevate the head of the patient's bed and obtain the patient's blood pressure with an electronic vital sign machine. c. Assess the patient's blood pressure using a lower extremity and a thigh-sized blood pressure cuff. d. Raise the patient's arm above the level of the heart and apply the stethoscope more firmly against the antecubital fossa.

The nurse notes red, moist patches on the skin under the female patient's breasts. What is the appropriate action of the nurse when caring for this area? a. Gently clean and dry the area and obtain an order for antifungal powder. b. Apply a rich moisturizer cream to the area after washing with soap and water. c. Apply a topical antibiotic cream to the area after rinsing with peroxide and water. d. Wash the area with moisturizing soap and apply a lanolin-based cream to the area.

The nurse notes that the patient has hyperactive bowel sounds in all four quadrants of the abdomen. Which factor from the patient's history will account for this assessment finding? a. The patient has had gastroenteritis for the last 4 days with watery diarrhea. b. The patient takes iron supplements daily to treat chronic anemia.. c. The patient has a paralytic ileus after undergoing abdominal surgery. d. The patient takes ibuprofen 3 times daily for arthritis pain.

The nurse notes that the patient is to receive diprivan to treat the patient's vaginal yeast infection. What is the appropriate action of the nurse? a. Immediately contact the prescriber to clarify the order. b. Check with the pharmacy to confirm that the order was received. c. Ensure that the order appears on the patient's medication sheet. d. Confirm that the dosage is appropriate for the patient's body weight

The nurse observes a postoperative patient trying to take a friend's oxycodone pain pills in addition to the pain medication administered by the nurse. Which is the priority nursing diagnosis for this patient? a. Risk for poisoning b. Situational low self-esteem c. Ineffective impulse control d. Readiness for enhanced comfort

The patient can follow directions but cannot pronounce words to express needs or thoughts. Which term will the nurse use to document this assessment finding? a. Expressive aphasia b. Receptive aphasia c. Primary dysphagia d. Vocal dysphagia

The patient has a history of orthostatic hypotension. What is the priority action of the nurse? a. Assist the patient to sit and stand slowly when getting out of bed. b. Monitor the patient's neurological status carefully for symptoms of a stroke. c. Always take the patient's blood pressure manually using a sphygmomanometer. d. Check the patient's blood pressure on a lower extremity using a thigh-sized cuff.

The patient has a nonblanchable area of redness on the right malleolus. Which pressure injury stage will be recorded in the patient's chart? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

The patient has red, itchy eyes with thick yellow drainage. What will the nurse plan to do as a result of this assessment finding? a. Apply antibiotic eyedrops and use alcohol-based hand sanitizer before and after caring for the patient. b. Assess the patient's visual fields and compare results from each of the patient's eyes. c. Ask the patient about any history of hyperthyroid disease, hypertension, or Addison's disease. d. Instruct the patient not to pluck or wax the eyebrows until the eye infection symptoms have resolved completely.

The patient just sustained a deep laceration that is bleeding profusely. Which stage of healing describes the current state of the patient's wound? a. Hemostasis phase b. Proliferative phase c. Inflammation phase d. Remodeling phase

The patient knocked over the specimen container and spilled some of the urine that had been collected for a 24-hour urine analysis. Which is the appropriate action of the nurse? a. Start the collection over again with a new container. b. Inform the patient that the test will have to be canceled c. Replace the lid on the container and continue the collection. d. Extend the collection period by 2 hours for a replacement void.

The patient's medication is ordered to be administered TID. Which times will be entered into the patient's medication schedule? a. 9:00 a.m., 1:00 p.m., 5:00 p.m. b. Before the patient's meals and at bedtime c. 6:00 a.m., 12:00 noon, 6:00 p.m., 12:00 midnight d. 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m., 10:00 p.m., 2:00 a.m.

The patient's medication order is for transdermal fentanyl. How will the nurse administer this medication? a. Apply the medication patch to a clean, dry intact area of skin. b. Inject the medication into the soft tissue behind the patient's arm. c. Carefully place the medication between the patient's cheek and teeth. d. Have the patient swallow the medication with a small sip of water.

The patient's respirations dropped from 14 breaths/minute to 8 breaths/minute after receiving a large dose of morphine. Which term accurately describes the patient's reaction to the morphine? a. Toxic b. Allergic c. Therapeutic d. Idiosyncratic

The patient's rheumatoid arthritis symptoms were not adequately controlled with methotrexate so adalimumab was prescribed as well. What is the rationale for prescribing both medications? a. To obtain a synergistic effect b. To prevent an anaphylactic reaction c. To reduce medication interactions d. To avoid an iosyncratic reaction

The patient's urinalysis indicates small amounts of protein in the urine. Which diagnosis does the nurse anticipate to see in the patient's electronic health record? a. Diabetes mellitus b. Diabetes insipidus c. Hypothyroid disease d. Hyperparathyroid disease

What is the primary advantage of a hydrogel dressing for wound healing? a. Provide moisture needed for wound healing. b. Act as an absorbent to collect wound drainage. c. Provide negative pressure to promote healing. d. Provide protection from the external environment.

Which assessment charting indicates that the wound is healing by primary intention? a. The 4-inch incision edges are well approximated with intact sutures. b. Ulcerated 3-inch × 1-inch area has thick yellow slough present in the center. c. Incision is 5 inch long × 1 inch deep × 1 inch wide with granulation tissue present. d. Superficial 3-inch × 3-inch abrasion has no active bleeding, drainage or debris.

Which assessment finding explains the patient's tachycardia? a. The patient drinks at least eight cans of diet cola every day. b. The patient takes digoxin 0.125 mg PO daily. c. The patient has a history of untreated hypothyroid disease. d. The patient takes metoprolol 50 mg PO daily.

Which assessment finding indicates to the nurse that the patient is at high risk for developing a pressure injury? a. Serum total protein level of 4.6 g/dL b. Braden Scale score of 22 c. Cetirizine 5 mg PO daily d. Fasting serum glucose level 84 mg/dL

Which assessment finding leads the nurse to clarify the patient's order for morphine sulfate controlled release 60 mg PO every 12 hours? a. The patient cannot swallow pills. b. The patient is allergic to latex and NSAIDs. c. The patient's platelet count is 200,000/mm3. d. The patient does not have an intravenous line.

Which assessment finding leads the nurse to lightly wash the patient's legs rather than using long, firm strokes? a. The patient's platelet count was 40,000/mm3 this morning. b. The patient is taking ciprofloxacin for a bladder infection. c. The patient is taking levothyroxine for hypothyroidism. d. The patient's urinalysis was positive for protein and white blood cells.

Which assessment finding will the nurse expect to note during physical examination of the patient with a history of uncontrolled hyperthyroid disease? a. Exophthalmos b. Strabismus c. Entropion d. Diplopia

Which assessment findings lead the nurse to suspect that the patient has a history of alcohol abuse? a. The patient has prominent tiny blood vessels running across the face. b. The patient's skin is abnormally dry and flaky, especially on the legs. c. The patient's nails have splinter hemorrhages along the nail bed. d. The patient's breath smells faintly of fruity chewing gum.

Which factor in the female patient's history places her at higher risk for the development of breast cancer? a. The patient's first period started at age 10. b. The patient has three children under the age of 12. c. The patient used condoms exclusively for contraception. d. The patient's breasts are tender before each period.

Which is the appropriate nursing action after administering a bisacodyl suppository? a. Make sure that the bedside commode is next to the patient's bed. b. Inform the patient to expect a bowel movement in the morning. c. Check the patient's colon for the presence of a fecal impaction. d. Educate the patient about methods to relieve excess gas formation.

Which is the appropriate nursing action after the patient's fecal occult blood test is positive? a. Educate the patient about colonoscopy preparation. b. Obtain an order for a STAT complete blood count (CBC). c. Check the patient's rectum for the presence of impacted stool. d. Draw blood for type and cross-match testing by the blood bank.

Which is the first intervention of the nurse for changing the dressing to a painful burn? a. Administer pain medication 30 minutes beforehand. b. Gently irrigate the wound using sterile normal saline. c. Loosen the tape gently by pressing the skin away from it. d. Observe the wound bed for presence of granulation tissue.

Which is the highest priority nursing diagnosis for a patient who is frequently incontinent of stool and urine? a. Risk for impaired skin integrity related to exposure to urine and stool b. Powerlessness related to inability to control release of bowel and bladder c. Readiness for enhanced comfort related to expressed desire to smell fresh d. Social isolation related to unpleasant odor from stool and urine

Which is the priority action of the nurse immediately after administration of an intramuscular injection? a. Engage the safety sheath over the needle. b. Ensure that there is no bleeding at the injection site. c. Assess the patient's level of comfort. d. Inform the patient that the injection is complete.

Which is the priority nursing diagnosis for a patient with a continuous epidural infusion of fentanyl and bupivacaine? a. Risk for impaired gas exchange related to respiratory suppression b. Activity intolerance related to generalized weakness and bed rest c. Impaired physical mobility related to presence of epidural catheter d. Delayed surgical recovery related to need for continuous pain management

Which is the priority outcome for the patient with pulmonary embolism and the nursing diagnosis impaired gas exchange related to impaired pulmonary perfusion? a. The patient's pulse oximetry will stay at least 93%. b. The patient's lung sounds will remain clear bilaterally. c. The patient will verbalize understanding of oxygen therapy. d. The patient will walk 50 feet in the hallway without dyspnea.

Which laboratory finding indicates that the body is attempting to compensate for the patient's end-stage chronic obstructive pulmonary disease (COPD)? a. Hemoglobin 22.1 g/dL b. Serum sodium 130 mEq/L c. Serum cholesterol 236 mg/dL d. Serum albumin level 4.8 g/dL

Which laboratory finding indicates that the patient is likely to experience hypoxemia? a. Hematocrit 31% b. Serum creatinine 0.8 mg/dL c. Glycosylated hemoglobin 7% d. White blood cell count 4600/mm3

Which medication does the nurse identify as most likely to cause a patient's constipation? a. Ferrous sulfate 325 mg PO BID b. Cefaclor 500 mg PO TID c. Warfarin 5 mg PO daily d. Prednisone 10 mg PO daily

Which medication may be administered using a 3-mL syringe with a 23- gauze, 1 1 2-inch needle? a. Methotrexate 20 mg subcut b. Lorazepam 2 mg IM c. Lidocaine 2 mg of 2% solution ID d. Enoxaparin 30 mg subcut

Which medication order is written appropriately? a. Morphine 2.5 mg PO b. Methotrexate 15.0 mg PO c. Meropenem 1.0 g IV d. Metformin .5 g PO

Which medication order will provide the most consistent control of the patient's chronic pain? a. Fentanyl transdermal patch 25 mcg b. Hydromorphone 0.5 mg IV c. Fentanyl oral lozenge 200 mcg d. Morphine sulfate liquid 10 mg

Which nursing intervention is appropriate when bathing older adult patients? a. Use warm water, mild skin cleanser, and moisturizing lotion. b. Apply a topical steroid cream to dry skin areas after bathing. c. Assist the patient to take relaxing, long hot showers twice weekly. d. Wash the patient's skin using plain water and dry with a soft towel.

Which of the following patients is most at risk for liver damage after taking acetaminophen regularly for arthritis pain? a. Patient with a history of alcohol abuse and hepatitis C b. Patient with type 2 diabetes and end-stage renal disease c. Patient with prostate enlargement and urinary frequency d. Patient with COPD and a 20 pack-year history of smoking

Which outcome is appropriate for the patient with risk for urinary tract infection related to recent urinary catheterization? a. The patient's urine will remain free from white blood cells and bacteria. b. The patient will take prescribed antibiotics until the urinary symptoms are gone. c. The patient will have serial urine cultures to ensure that the infection is resolved. d. The patient will carefully wipe the perineal area from front to back after voiding.

Which pain medication may be administered to the patient as needed? a. Ketorolac 10 mg IV Q 4 hours prn b. Fentanyl transdermal patch 25 mcg Q 3 days c. Acetaminophen with oxycodone 10 mg/325 mg PO Q 6 hours d. Morphine-extended release 60 mg PO Q 12 hours

Which patient does the nurse identify that would benefit from a nasogastric tube to low intermittent suction? a. A patient who is vomiting due to a complete large bowel obstruction b. A patient with constipation who has not had a bowel movement in 6 days c. A patient with constant diarrhea due to side effects of antibiotic therapy d. A patient with extensive skin irritation due to a leaking colostomy appliance

Which patient does the nurse identify that would benefit from administration of an oil-retention enema? a. A constipated patient with a fecal impaction b. A patient with Clostridium difficile diarrhea c. A patient with a positive fecal occult blood test d. A patient with a serum potassium level of 7.1 mEq/L

Which patient outcome is most important for the patient with the nursing diagnosis bathing/hygiene self-care deficit related to neuromuscular impairment and fatigue? a. The patient's skin will remain intact and free of body odor. b. The patient will report feeling of cleanliness after morning care. c. The patient's privacy and dignity will be maintained during the bath. d. The patient will verbalize understanding of need for bathing assistance.

Which patient would benefit from education about pursed-lip breathing? a. A patient with emphysema after many years of smoking b. A patient with a pneumothorax and a chest tube to suction c. A patient with a tracheostomy following throat cancer surgery d. A patient with respiratory muscle paralysis after spinal cord injury

Which question is best suited for determining the patient's chief complaint? a. "What brings you to the hospital today?" b. "How long have you been having chest pain?" c. "Did your doctor tell you to come to the hospital?" d. "Have you ever experienced this problem before?"

Which respiratory problem is experienced by premature infants due to lack of surfactant in their lungs? a. The alveoli shrivel and are unable to exchange oxygen for carbon dioxide. b. Weakness of the respiratory muscles limits airflow in and out of the lungs. c. Swelling of abdominal organs limits expansion and contraction of the diaphragm. d. Insufficient hemoglobin impairs delivery of oxygen to tissues throughout the body.

Which technique is used to assess fine-motor skills in a middle-school child? a. Observe the child drawing a picture on a piece of paper. b. Watch the child sit on the floor and rise to a standing position. c. Ask the child to walk a straight line in a heel-toe (tandem) gait. d. Ask the child to stand on one leg and hop in place several times.

Which technique will the nurse use to facilitate the history and physical examination of a small child? a. Examine the child's hands and feet before listening to breath sounds. b. Direct assessment questions to the child to avoid unwanted parental influence. c. Gently palpate the child's abdomen before auscultating for bowel sounds. d. Call the parents by their first names to establish a more trusting bond.

Why does the nurse administer lorazepam intramuscularly (IM) to the patient rather than into the subcutaneous tissue? a. The medication will be absorbed and begin to work more quickly when given IM. b. The patient does not have enough body fat to give the medication subcutaneously. c. Intramuscular injections require smaller needles than subcutaneous injections. d. Intramuscular injections are preferred for patients with high risk of bleeding.

Why will the nurse draw a blood culture before giving an antipyretic medication? a. The causative organism is most prevalent during a spike in temperature. b. Elevated temperatures slow metabolic rate and improve blood oxygenation. c. The antipyretic medication will inhibit bacteria growth within the culture tubes. d. Venous distention is greater because of fluid retention from hyperthermia.

The nurse is caring for a patient who suffered a traumatic head injury. The patient's temperature rises to 104.5° F but there is no evidence of infection. Which statement will the nurse make to the patient's family member who verbalizes concern over the patient's fever? a. "The area of the brain that controls body temperature was damaged." b. "The body is compensating for losing too much body heat in the accident." c. "I will contact the physician now to obtain an order for antibiotics." d. "The hospital room must be too warm so I will turn down the thermostat."

A The hypothalamus is the section of the brain that controls body temperature.

When getting a postoperative patient out of bed for the first time, the patient immediately feels light-headed and then faints. What are the appropriate actions of the nurse? (Select all that apply.) a. Have the patient lie down. b. Report findings to the health care provider. c. Instruct the patient not to get out of bed without assistance. d. Have the nursing assistant check the patient's orthostatic blood pressure. e. Take the BP in each arm and use the arm with the lowest systolic reading.

A B C

The nurse is caring for a patient with an elevated blood pressure. Which factors may account for the high measurement? (Select all that apply.) a. The patient's BMI is 42. b. The patient is in acute renal failure. c. The patient is extremely dehydrated. d. The patient refuses to take antihypertensive medications. e. The cuff was not wrapped snugly around the patient's arm.

A B D E

Which assessment finding indicates that the patient is at risk from polypharmacy? (Select all that apply.)? a. The patient takes three different medications to treat hypertension. b. The patient's daughter administers the patient's eyedrops every evening. c. The patient uses four different pharmacies to fill his 16 prescriptions. d. The patient has weekly laboratory tests for warfarin dosing. e. The patient is allergic to strawberries, latex, and penicillin antibiotics.

A C

Which characteristics put the patient at risk for developing orthostatic hypotension? (Select all that apply.) a. Dehydration b. Obesity c. Recent blood loss d. Cigarette smoking e. Prolonged bed rest

A C E

Which site will the nurse use to measure the patient's pulse rate before administering the cardiac medication digoxin? a. Apical b. Radial c. Brachial d. Carotid

A When a patient takes a medication that affects the heart rate, the apical pulse provides a more accurate assessment of heart rate.

The nurse is caring for an unconscious, intubated patient in the intensive care unit. Which methods may be used to check the patient's temperature? (Select all that apply.) a. Axillary b. Rectal c. Oral d. Tympanic e. Pulmonary artery

A B D E

The nurse notes that the patient's temperature varies significantly throughout the day and night. Which are possible reasons for this variation? (Select all that apply.) a. The patient's diagnosis of pneumonia b. The patient's gluten-free, low sodium diet c. The patient's history of hypertension d. The patient's frequent trips outside to smoke e. The patient's allergies to penicillin and shellfish

A D

The nurse hears a distinctive swooshing sound with each heartbeat when auscultating the patient's heart sounds. What is the cause of this assessment finding? a. The mitral valve is leaking and some blood leaks backward with each heartbeat. b. The nurse's stethoscope is not placed firmly enough against the patient's skin. c. The patient's tricuspid valve was replaced with a mechanical prosthetic valve. d. The patient is having short runs of premature supraventricular contractions.

A -- A distinctive swooshing sound with each heartbeat indicates there may be damage to the heart valves, e.g., leakage from the mitral valve.

The nurse is caring for a patient who was pulled unconscious from the pool after a near drowning. Which lung sounds will the nurse expect to hear upon auscultation? a. Moist crackles b. Expiratory wheezes c. Friction rub d. Coarse rhonchi

A -- Fluid in the alveoli causes high-pitched crackles. Wheezes would be expected for a patient with asthma or an allergic reaction.Friction rub is heard with irritation of the pleura. Rhonchi is caused by the presence of thick secretions in the airways

Which characteristics place the patient at high risk for development of hypothermia? (Select all that apply.) a. Lack of funds to pay utility bills b. Lifelong member of Mormon Church c. History of poorly managed schizophrenia d. 25-year history of alcohol abuse e. Occasional incontinence of urine

A C D

Which medications may be administered to reduce the patient's fever without masking signs of infection? (Select all that apply.) a. Acetaminophen b. Prednisone c. Ibuprofen d. Indomethacin e. Ketorolac

A C D E

Which assessment finding is expected for a patient presenting with a middle ear infection? a. The right tympanic membrane is pink and bulging. b. The patient becomes dizzy when sitting upright. c. The pinna is red, swollen, and tender to palpation. d. The eardrum is a translucent pearly gray color.

A The normal eardrum is translucent, shiny, and pearly gray. It is free from tears or breaks. A pink or red bulging membrane indicates inflammation consistent with middle ear infection. Dizziness indicates an inner ear infection. Inflammation of the pinna indicates an external ear infection

(31) Which is the best approach to change nasogastric tube tape that has become crusted with secretions? a. Soften the secretions using a warm moist washcloth. b. Use blunt-edged scissors to loosen the tape from the skin. c. Saturate the tape with a denatured alcohol solution. d. Soak the crusted areas of tape with adhesive remover.

A When patients have nasogastric, feeding, or endotracheal tubes inserted through the nose, change the tape, anchoring the tube at least once a day

The parent of a 13-year-old boy is concerned because the teenager wants to hang out with friends all the time and has stated that he wants to get his ear pierced because all his friends have piercings. What is the best response from the nurse?

"Your son's behavior is normal; he is trying to assert his independence."

* Which of the following is a strategy for creating work environments that enable nurses to demonstrate more caring behaviors? *

Creating a setting that allows flexibility, autonomy, and the ability to discuss care

(17)Which agency determines which training is required for nurses to start intravenous lines for patients? a. The US Food and Drug Administration (FDA) b. The MedWatch program c. Employee Assistance Program (EAP) d. State Nurse Practice Acts

(32) Which term is used to describe a machine that helps to move air in and out of the patient's lungs? a. Aerator b. Diffuser c. Respirator d. Ventilator

(38) The nurse notes a reddened area on the right heel that does not turn lighter in color when pressed with a finger. Which term will the nurse use to describe this area? a. Reactive hyperemia b. Secondary erythema c. Blanchable hyperemia d. Nonblanchable erythema

A patient has an order for a subcutaneous injection of insulin. The nurse will prepare to give this injection into which of the following tissues? a. Into the patient's deltoid b. Into the patient's vastus lateralis c. Into the patient's intravenous line d. Into the fatty tissue of the patient's abdomen

A patient with a Foley catheter needs a urine sample for culture and sensitivity. What is the appropriate action for the nurse to take? a. Disconnect the drainage tube from the catheter. b. Withdraw urine from the closed system drainage bag. c. Empty contents of the drainage bag into the specimen cup. d. Attach a sterile syringe to the catheter port to withdraw urine.

A young child learns how to use scissors and catch a ball. Which term best describes these developments? a. Puberty b. Growth c. Adolescence d. Development

How can the nurse best respect the patient's cultural preferences for hygiene? a. Shave the patient's facial hair every morning after the bath. b. Add scented bath oils to the water before bathing the patient. c. Ensure that a staff member of the same sex bathes the patient. d. Accommodate the patient's wish to wash before morning prayers.

How will the nurse obtain a culture of the patient's wound? a. Obtain a sample from the patient's wound drainage bag. b. Obtain a sample of the drainage around the edge of the wound. c. Obtain a sample of the drainage from the dressing on the wound. d. Gently swab the center of the wound after irrigating with sterile saline.

The patient calls the health care provider's office after obtaining a reading of 170/88 with a home wrist blood pressure monitor. What is the appropriate recommendation of the nurse? a. "Take the blood pressure again now using the other wrist." b. "Take the blood pressure again now with the cuff on your upper arm." c. "Take the blood pressure again tomorrow and call the office with the result." d. "Come to the office today to have your blood pressure checked manually."

The adolescent with a BMI of 18.5 feels overweight after seeing excessively slender actresses on TV and in the movies. Which nursing diagnosis is appropriate for this adolescent? a. Decisional conflict related to how much weight should be lost to look pretty b. Defensive coping related to denial of imbalanced weight to height proportion c. Powerlessness related to perception that weight loss is needed to gain friends d. Disturbed body image related to cultural perception of ideal body proportions

The family requests insertion of a Foley catheter to address the elderly patient's frequent episodes of incontinence. Which is the best action of the nurse? a. Obtain an order for an indwelling urinary catheter. b. Teach family to perform intermittent straight catheterization. c. Utilize disposable absorbent undergarments for the patient. d. Implement a bladder training program to promote continence

The home care nurse is caring for a patient with an indwelling urinary catheter after spinal cord injury. The catheter is patent with clear yellow urine after being in place for 8 weeks. Which is the appropriate action of the nurse? a. Request an order for a urinalysis with culture and sensitivity. b. Irrigate the patient's catheter using 60 mL of sterile normal saline. c. Remove the catheter immediately and notify the health care provider. d. Contact the health care provider for an order to change the catheter.

The mother of a small infant is surprised when the clinic scale indicates a 1-pound weight gain from the scale used that morning at home. What is the appropriate response of the nurse? a. "Babies have significantly different weights throughout the day." b. "Variations occur because of the weight of the baby's clothing." c. "Weight variation of 1 to 2 pounds is common for most scales." d. "Weight measurements can vary with different scales."

The nurse administers a medication to the patient. Which symptoms indicate that the patient is having an allergic reaction rather than a side effect? a. Alopecia and diaphoresis b. Nausea and constipation c. Heartburn and flatulence d. Itchy rash and difficulty breathing

The nurse suspects that the patient is experiencing a drug toxicity rather than a side effect. Which question will the nurse ask to help confirm this suspicion? a. "Are you taking any other medications?" b. "Have you ever taken this medication in the past?" c. "When did you take your last dose of the medication?" d. "Have you been taking extra doses of the medication?"

The patient comes to the hospital with a variety of symptoms. Which symptom will the nurse assess first? a. The patient experiences joint stiffness after sitting still for long periods of time. b. The patient developed an itchy rash after taking the second dose of antibiotics. c. The patient is nauseated and vomited a small amount earlier this morning. d. The patient feels short of breath and has audible expiratory wheezes.

The patient has a deep decubitus ulcer on the heel that is covered in thick necrotic tissue. Which term will the nurse use to describe the ulcer in the patient's medical record? a. Fluctuant b. Indurated c. Macerated d. Unstageable

The patient has cloudy yellow urine with a faint odor of ammonia. Which laboratory test will the nurse expect to note in the patient's admission orders? a. Serum albumin and pre-albumin b. Serum calcium and magnesium levels c. Fasting blood sugar every morning d. Urine sample for culture and sensitivity

The patient takes morphine sulfate controlled release every 12 hours for chronic severe cancer pain. The last dose was 8 hours ago. The patient is presently moaning and states that the pain is very bad. Which is the best action of the nurse? a. Give the next scheduled dose of morphine sulfate controlled release now. b. Wait for the last dose of morphine sulfate controlled release to start taking effect. c. Carefully reposition the patient and reassess the pain in 1 hour. d. Contact the physician for a breakthrough pain medication order.

The patient's sacral pressure injury is open with exposed bone. Which pressure injury stage will be recorded in the patient's chart? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

What will the nurse do with extra clean linens that were left over after the patient's bath? a. Place them back in the linen closet. b. Place them on the patient's bedside table. c. Use them to bathe the patient's roommate. d. Place them in a laundry bag to be laundered.

Which assessment finding explains why the patient developed right-sided heart failure? a. The patient's resting heart rate is usually 55 to 60 beats/minute. b. The patient's resting heart rate is usually 58 to 60 beats/minute. c. The patient has 2+ pitting edema of the legs, feet, and abdomen. d. The patient was diagnosed with cystic fibrosis at 2 years of age.

Which assessment finding indicates why the patient does not have signs of respiratory alkalosis despite a respiratory rate of 30 breaths/minute? a. The patient's hematocrit is 28%. b. The patient's oral temperature is 99.2° F. c. The patient is experiencing a panic attack. d. The patient has a large pulmonary embolism.

Which bath time assessment of the diabetic patient is most important? a. Presence of fingernail clubbing b. Presence of any petechiae or bruises c. Presence of abdominal rebound tenderness d. Presence of pedal pulses and intact sensation

Which factor contributes to pressure injury formation when patient's body slides downward to the foot of the bed? a. Momentum b. Acceleration c. Applied force d. Shearing force

Which is an example of a primary sexual characteristic? a. Enlarged larynx and deeper voice b. Enlargement of female breast tissue c. Growth of hair on the face and chest d. Development of the penis and testicles

Which is the highest priority nursing diagnosis for a toddler who is at the autonomy versus doubt stage of development? a. Toileting self-care deficit related to readiness for transition from diapers b. Impaired verbal communication related to stage of cognitive development c. Readiness for enhanced sleep related to desire to sleep in a big kids' bed d. Risk for poisoning related to unawareness of environmental risks within reach

Which medication is to be administered immediately to the patient? a. Acetaminophen 325 mg PO prn b. Insulin aspart 12 units subQ AC c. Metronidazole 500 mg PO BID d. Nitroglycerin 0.4 mg sublingual STAT

Which medication may be injected into the deltoid? a. Lorazepam 2 mg in 2-mL saline IM b. Insulin aspart 2 units subcut AC meals c. Lidocaine 2 mg of 2% solution ID d. Cyanocobalamin (vitamin B12) 500 mcg in 0.5 mL IM

Which medication order is written correctly? a. Zolpidem 10 mg PO Q HS prn insomnia b. Vitamin E 1000 IU PO QD with food c. Conjugated estrogens 300 μg daily d. Phenytoin 200 mg PO daily × 4 days

Which nursing diagnosis is appropriate for a patient using CPAP therapy to treat sleep apnea? a. Readiness for enhanced sleep related to desire for restful sleep b. Disturbed body image related to use of CPAP mask for sleeping c. Risk for disuse syndrome related to discomfort from CPAP mask d. Risk for impaired skin integrity related to tight-fitting mask on face

A nurse is caring for a 64-year-old patient who has survived cardiopulmonary resuscitation after a triple coronary artery bypass graft surgery. To help this patient cope with this experience, what is the best thing for the nurse to do? a. Recommend that the patient not discuss the experience with family. b. Assume that the near death experience was a positive experience. c. Explain that people who have not had that experience will not understand. d. Explore what happened with the patient.

D. explore what happened with the patient

The nurse is caring for a patient who states that he does not believe in the existence of God. The nurse realizes that this person: a. is not a spiritual person. b. is an agnostic. c. believes that people bring meaning into the world. d. finds meaning in life through work and relationships.

D. finds meaning in life through work and relationships

A patient has been diagnosed with a terminal disease. Hope may be used effectively with this type of patient. Nurses can support a patient's use of hope because hope provides a: a. system of organized beliefs and worship. b. belief in a higher power, spirit guide, God, or Allah. c. cultural connectedness, structure, and guidance in difficult times. d. motivation to achieve and the resources to use toward that achievement.

D. motivation to achieve and the resources to use toward that achievement

To assess, evaluate, and support a patient's spirituality the best action a nurse should take includes: a. recognizing that spirituality does not enhance therapeutic relationships. b. performing a definitive spiritual assessment once because spirituality does not vary. c. focusing the assessment on religious doctrine and faith. d. remembering that spirituality is very subjective.

D. remembering that spirituality is very subjective

A nurse is caring for an immobile patient. What is the most appropriate nursing intervention to implement?

Encourage the regular use of incentive spirometry while awake.

The patient was hospitalized with pneumonia. He had always been very healthy and was concerned that now his family would have to take care of him. During one conversation the nurse said to him, This gives the ones who love you a chance to show you how much they care for you. The comment that the nurse made best demonstrated which behavior? a. Human respect b. Encouraging manner c. Healing environment d. Affiliation needs

Encouraging manner

The current focus on promoting a culturally competent health care environment is on which of the following? a. The health care providers efforts to become self-aware b. The health care provider learning about other cultures c. Avoiding the systematic provision of care d. Ensuring that cultural competence is integrated into administrative processes

Ensuring that cultural competence is integrated into administrative procesess

The nurse is caring for an older adult patient who has a constant urge to void due to a bladder infection. Which are the appropriate nursing diagnoses for this patient? (Select all that apply.) a. Sleep deprivation related to frequent need to use the toilet during the night b. Risk for falls related to getting up frequently to use the bathroom at night c. Impaired urinary elimination: frequency related to urinary tract inflammation d. Risk for infection related to bacterial invasion of urinary tract e. Risk for urge urinary incontinence related to urinary tract inflammation

A, B, C, E

Which assessment findings indicate that the patient is at risk for developing ventricular fibrillation? (Select all that apply.) a. Serum potassium level 7.6 mEq/L b. Long history of coronary artery disease c. Impaired conduction through the SA node d. Recent incidents of ventricular tachycardia e. Vagal stimulation from removal of fecal impaction

A, B, D

Which characteristics helped promote the development of the patient's tortuous varicose veins (Select all that apply.) a. Smoking 2 packs of cigarettes daily for the last 15 years b. Frequently sitting with the legs crossed c. Taking naproxen sodium daily for arthritis pain d. Standing for long periods of time at work e. Eating a gluten-free, low-sodium diet for the last 10 years

A, B, D

Which interventions are appropriate for the patient with the nursing diagnosis decreased cardiac output related to reduced stroke volume and contractility? (Select all that apply.) a. Frequent lung sound assessment and continuous pulse oximetry. b. Strict intake and output monitoring with daily weights before breakfast. c. Administer oxygen to maintain pulse oximetry levels between 90% and 92%. d. Provide stool softeners and encourage dietary fiber to prevent constipation. e. Encourage the patient to consume additional salt to maintain blood pressure.

A, B, D

On admission a patient is noted to have an alteration in skin integrity on the right heel. The nurse uses the Braden Scale. Which areas will the nurse assess when using this scale? (Select all that apply.) a. Mobility b. Nutrition c. Infection d. Activity e. Friction

A, B, D, E

A postoperative abdominal surgery patient has been admitted to the surgical floor. The nurse is aware that wound healing is delayed due to complications. Which conditions would prevent normal wound healing at the surgical site? (Select all that apply.) a. Dehiscence b. Evisceration c. Debridement d. Hemostasis e. Hemorrhage

A, B, E

Which are expected physical assessments finding for a middle-aged adult? (Select all that apply.) a. Difficulty hearing female voices b. Diminished breath sounds bilaterally c. Gradual loss of senses of taste and smell d. Need for reading glasses to see small print e. Decreased ability to solve practical problems

A, B, E

Which hygiene interventions are appropriate for a patient with the nursing diagnosis ineffective protection related to impaired blood clotting? (Select all that apply.) a. Use an emery board to file the patient's nails. b. Use a soft toothbrush and avoid flossing the teeth. c. Rinse with a chlorhexidine mouthwash after meals. d. Use antibacterial soap for showering each morning. e. Use an electric razor to shave the patient's facial hair.

A, B, E

Which assessment findings show that the patient has a history of chronic arterial insufficiency in the legs? (Select all that apply.) a. The nurse must use a Doppler to find the patient's pedal pulses. b. The patient has calf pain when the knee is flexed and foot pointed downward. c. The patient's legs are cool to the touch and show no hair growth. d. The patient has 3+ pitting pedal edema extending up to the knees. e. The patient has tortuous varicose veins from the hip to the ankle.

A, C

Which outcomes are appropriate for the patient with the nursing diagnosis risk for impaired skin integrity related to immobility and muscle weakness? (Select all that apply.) a. The patient's skin will remain intact without redness or ulceration. b. The nurse will assess the patient's skin daily for any sign of breakdown. c. The patient will verbalize at least two methods to prevent skin breakdown. d. The patient's wounds will be kept clean and will not develop signs of infection. e. The nurse will reposition the patient every 2 hours and pad bony prominences.

A, C

Which positions may be used to perform a rectal examination on the patient? (Select all that apply.) a. Sim's b. Supine c. Lithotomy d. Lateral recumbent e. Dorsal recumbent

A, C

Which possible reasons does the nurse identify that contribute to the patient's black stools? a. Takes ferrous sulfate 325 mg PO BID. b. Hemorrhoids are irritated and bleeding. c. Bleeding from a perforated gastric ulcer. d. Incomplete small bowel obstruction. e. Development of a Clostridium difficile infection.

A, C

Which abilities are required for moral development of the child? (Select all that apply.) a. Accept social responsibility. b. Perform repetitive motion responses. c. Respect the integrity and rights of others. d. Integrate principles of justice and fairness. e. Use symbols and objects for abstract thinking.

A, C, D

Which assessment findings indicate to the nurse that the patient is hypoxic? (Select all that apply.) a. Heart rate is 55 beats/minute and irregular. b. Urine output is 300 mL over the last 8 hours. c. The patient is drowsy and difficult to arouse. d. Hands and feet are pale and cool to the touch. e. Abdomen is soft with bowel sounds × 4 quadrants.

A, C, D

Which assessment findings lead the nurse to conclude that the patient has had chronic obstructive pulmonary disease (COPD) for many years? (Select all that apply.) a. The patient's nails have a clubbed shape. b. The patient has splinter hemorrhages under the nails. c. The patient's chest appears rounded and bulging. d. The patient is short of breath with minimal activity. e. The patient has soft, spongy gums that bleed easily.

A, C, D

The nurse is caring for a patient with diarrhea caused by Clostridium difficile infection. Which are the priority interventions of the nurse? (Select all that apply.) a. Perform hand hygiene with soap and water. b. Increase the patient's dietary intake of fiber. c. Maintain strict contact isolation precautions. d. Accurate calculation of patient's intake and output. e. Liberally apply skin barrier cream to the perineal area. f. Give loperamide 4 mg after each loose stool.

A, C, D, E

Which medications are appropriate for a patient with chronic pain and cannot swallow pills? (Select all that apply.) a. Morphine sulfate liquid b. Crushed extended-release morphine sulfate c. Fentanyl nasal spray d. Acetaminophen suppository e. Fentanyl transdermal patch

A, C, D, E

Which assessment findings lead the nurse to clarify the order for ibuprofen 600 mg PO every 8 hours? (Select all that apply.) a. The patient has a gastrointestinal bleed. b. The patient has allergies to shellfish, strawberries, and iodine. c. The patient takes 30 mg morphine sulfate daily. d. The patient has a history of diabetes and early renal failure. e. The patient has severe joint pain due to aggressive arthritis.

A, D

Which assessment findings indicate to the nurse that the older adult patient has a urinary tract infection? (Select all that apply.) a. Confusion and irritability b. Urinalysis is positive for hyaline casts and ketones. c. Urinalysis is negative for nitrites and white blood cells. d. Reports frequency and burning with urination e. Has had two uncharacteristic episodes of incontinence

A, D, E

Which interventions are appropriate for a patient with the nursing diagnosis impaired oral mucus membranes related to immunosuppression, thrush, and ulceration? (Select all that apply.) a. Rinse the mouth with warm saline solution every few hours. b. Rinse the mouth with half strength hydrogen peroxide twice daily. c. Use cotton swabs soaked in lemon-glycerin solution to clean the oral mucosa. d. Use a tongue scraper to remove the thick coating from the oral mucosa. e. Encourage the patient to have soft foods such as yogurt, ice cream, and pudding.

A, E

The patient becomes acutely short of breath when lying flat in bed. Which term will the nurse use to document this assessment finding? a. Orthopnea b. Atelectasis c. Emphysema d. Stridor

A-- Difficulty breathing while lying flat is termed orthopnea. Atalectasis is collapse of alveolar lung tissue. Emphysema is destruction of the alveoli. Stridor is a crowing sound heard as the patient struggles to breathe through swollen upper airways

Interventions a nurse can use to establish presence with a patient include which of the following? (Select all that apply.) a. Giving attention b. Answering questions c. Listening d. Administering medication e. Speaking with the family

A. giving attention B. answering questions C. listening

An elderly patient is dying, and begins talking to loved ones who have died before him. The nurse feels a sense of inner peace as his patient quietly dies. What is the best term for this feeling of peace? a. Self-transcendence b. Intrapersonal connectedness c. Interpersonal connectedness d. Transpersonal connectedness

A. self-transcendence

When caring for patients, a nurse must understand the difference between religion and spirituality. Religious care helps patients maintain their faithfulness to: a. their belief systems and worship practices. b. a relationship to a higher being or life force. c. a sense of connectedness. d. the awareness of one's inner self.

A. their belief systems and worship practices

A home care nurse is conducting a home assessment. The nurse is looking for the presence of sensory alterations. Factors to assess include if any changes have occurred in which of the following? Select all that apply. a. Activities of ADLs b. Health promotion c. Has person had visitors d. Is person wearing hearing aids and glasses e. Ability to follow a conversation

ALL OF THE ABOVE a. activities of ADLs b. health promotion c. has person had visitors d. is person wearing hearing aids and glasses e. ability to follow a conversation

2.The nurse working on a medical/surgical floor knows that pulmonary embolisms can be a deadly complication after surgery. Which of the following patients is most likely to develop a pulmonary embolism? a. 45-year-old patient after bariatric surgery b. 23-year-old patient with pneumonia c. 13-year-old patient after appendectomy d. 57-year-old patient after cholecystectomy

ANS: A A patient who is obese usually has reduced ventilatory capacity because of the upward pressure against the diaphragm caused by an enlarged abdomen. There is also an increased risk for aspiration during the administration of anesthesia. The recumbent and supine positions required on the operating bed (table) for surgery further limit a patient's ventilation. The increased workload of the heart and atherosclerotic blood vessels often results in compromised cardiovascular function. Because of these physiological changes, patients who are obese often have difficulty resuming normal physical activity after surgery. Hypertension, coronary artery disease, type 2 diabetes mellitus, and heart failure are common in this population. They are also more susceptible to developing embolism, atelectasis, and pneumonia after surgery than patients who are not obese. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1131 OBJ: Identify factors to assess in a patient in postoperative recovery. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

23.A nurse is assisting a patient with right-sided hemiplegia to transfer from the bed to a chair. The most appropriate action for the nurse is to do which of the following? a. Use a transfer belt. b. Grab the patient under the arms while assisting with the transfer. c. Stand on the unaffected side of the patient to ensure less strain on the nurse's back. d. Encourage the patient not to use the hand rests because of their restrictions on movement.

ANS: A A patient with neurological deficits sometimes has paresis (muscle weakness) or paralysis unilaterally or bilaterally, which complicates safe transfer. A flaccid arm sustains injury during transfer if unsupported. As a general rule, use a transfer belt and obtain assistance for mobilization of such patients. Use patient-handling equipment and devices, such as height-adjustable beds, ceiling-mounted lifts, friction-reducing slide sheets, air-assisted devices, and encourage the patient to help as much as possible. Grasping the patient under his or her arms could cause damage to this delicate area and does not allow for a firm hold, as the arms could lift up. A transfer belt is more secure. Always be aware of the patient's motor deficits, ability to aid in transfer, and body weight. As a rule of thumb, GET HELP to transfer a patient. PTS:1DIF:Cognitive Level: Applying (Application) REF:692 | 693 OBJ escribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

* A young Mexican-American woman comes to a clinic for the first time for a gynecological examination. Which nursing behavior applies Swanson's caring process of "knowing" the patient? *

Asking the patient what it means to have a vaginal examination

(16)While auscultating a patient with pneumonia, a nurse hears low-pitched, rumbling coarse sounds during inspiration and expiration. Which term will the nurse use to document this assessment finding? a. Crackles b. Rhonchi c. Wheezes d. Friction rub

(36) Which assessment finding supports the nursing diagnosis overflow urinary incontinence related to urethral obstruction? a. Advanced dementia prevents the patient from indicating need to urinate b. Postvoid residual of 900 mL after incontinence of small amounts of urine c. Leakage of urine around the urostomy appliance leading to skin irritation d. Incontinence of large amounts of urine every time the patient coughs or sneezes

(37) The nurse is caring for a patient who had surgery to remove most of the large intestine. Which finding will the nurse expect to note when assessing the patient? a. Soft formed stools b. Chronic loose stools c. Frequent stool impaction d. Intermittent constipation

An infant born prematurely has irregular breathing patterns and short periods when breathing stops altogether. Which device will be utilized to facilitate respiratory status assessment for this patient after discharge? a. Oxygen flowmeter b. Apnea monitor c. End-tidal CO2 monitor d. Incentive spirometer

The nurse assesses a patient during suctioning. Which finding indicates that the procedure should be stopped immediately? a. Pulse oximetry decreases from 98% to 92%. b. Heart rate decreases from 78 to 40 beats/minute. c. Respiratory rate increases from 16 to 20 breaths/minute. d. Blood pressure increases from 110/70 to 120/80 mm Hg.

The nurse assistant is preparing to take the patient's oral temperature with a red-tipped electronic thermometer probe. What is the priority action of the nurse? a. Remind the nurse assistant to enter the result into the patient's medical record. b. Give the nurse assistant a blue-tipped probe to take the patient's oral temperature. c. Inform the patient that temperatures are most accurate when taken orally. d. Direct the nurse assistant to change the thermometer probe cover daily.

The nurse assists a patient who collapsed in cardiac arrest. Which is the first action of the nurse? a. Determine the patient's cardiac rhythm. b. Administer fast, deep chest compressions. c. Ensure that a patent airway is maintained. d. Ventilate the patient using a barrier device.

The nurse has orders to titrate the patient's oxygen to maintain a pulse oximetry level greater than 94%. The patient's pulse oximetry will not rise above 90% despite use of a nonrebreather mask. Which is the appropriate action of the nurse? a. Insert an oral airway and apply a full face oxygen mask. b. Call respiratory therapy to consider BiPAP support for the patient. c. Remove the nonrebreather mask and replace it with a Venturi mask. d. Place an oxygen nasal cannula underneath the patient's nonrebreather mask.

The nurse hears a blowing sound when auscultating the patient's carotid artery. What is the appropriate action of the nurse? a. Notify the health care provider immediately as the patient may be having a stroke. b. Gently feel over the patient's carotid artery to check for a faint vibration. c. Massage the patient's carotid artery to determine if the blowing sound subsides. d. Palpate the patient's carotid pulse while the patient's neck is hyperextended.

The nurse is caring for a middle-aged adult who verbalizes a desire to start jogging and has a goal to run a half marathon. Which is the most appropriate action of the nurse? a. Tell the patient that exercising during middle age could lead to injury. b. Recommend that the patient have a complete physical examination first. c. Inform the patient that it is unwise to take up new sports during middle age. d. Explain that the disability from normal aging prevents taking up new sports.

The nurse is caring for a patient who continues to have severe pain at the site of a fracture long after it healed. The patient's physicians can find no rationale for the pain. What is the most likely cause of the patient's discomfort? a. The patient is trying to obtain unneeded pain medications. b. The patient has developed a complex regional pain syndrome. c. The patient is in denial that the fracture has healed completely. d. The patient is experiencing referred pain from a fracture elsewhere.

The nurse is caring for a patient who has a dangerously low platelet count. Which assessment finding will the nurse expect to note during physical examination of the patient? a. Bright yellow jaundice in the sclera of the patient's eyes b. Pinpoint red spots on the skin of the patient's torso c. Dry, flaky skin with evidence of frequent scratching d. Thick indurated skin across the patient's back

The nurse is caring for a patient who has just undergone knee-replacement surgery. The patient has incontinent of continuous oozing stool for the last few days. Which is the appropriate action of the nurse? a. Administer loperamide 8 mg PO BID. b. Check the patient's rectum for presence of impacted stool. c. Liberally apply skin barrier cream to prevent perineal irritation. d. Encourage the patient to drink at least 2 L of fluid each day.

The nurse is caring for a patient who has pneumonia and chronic bronchitis. The patient is very congested, coughing up copious amounts of thick green sputum. Which breath sounds will the nurse expect to hear? a. Fine crackles b. Coarse rhonchi c. Diminished bases d. Scattered wheezes

The nurse is caring for a patient who has shallow breaths following abdominal surgery. Which respiratory complication is most likely to occur as a result of the patient's breathing pattern? a. Aspiration b. Atelectasis c. Cor pulmonale d. Pulmonary fibrosis

The nurse is caring for a patient who is very anemic. Which assessment finding will the nurse expect to note in the patient's medical record? a. Irregular breaths with periods of apnea b. Tachypnea with rapid, deep breaths c. Bradypnea with shallow regular breaths d. Eupnea with even, unlabored breaths

The nurse is caring for a patient who relies on laxatives to ensure daily bowel movements. Which is the appropriate nursing diagnosis for this patient? a. Risk for constipation related to irregular bowel elimination patterns b. Perceived constipation related to expectation of daily bowel movements c. Toileting self-care deficit related to inability to set regular defecation regimen d. Powerlessness related to inability to have daily bowel movements without laxatives

The nurse is caring for a patient with a necrotic wound. Which dressing would be the best choice for the nurse to use on this type of wound to help with debridement? a. Transparent film b. Hydrogel dressing c. Dry nonstick gauze d. Hydrocolloid dressing

The nurse is caring for an adult patient with a respiratory rate of 32 breaths/minute. Which term will the nurse use to document this finding in the patient's chart? a. Eupnea b. Tachypnea c. Bradypnea d. Apnea

The nurse is caring for an incontinent male patient with a large sacral pressure injury. Which is the safest intervention that will maintain skin integrity and facilitate healing of the ulcer? a. Obtain a surgical consult for placement of a suprapubic urinary catheter. b. Apply a condom catheter attached to a bedside urinary drainage bag. c. Insert an indwelling urinary catheter attached to a small volume drainage bag. d. Perform intermittent straight catheterization of the patient every 4 to 6 hours

The nurse is concerned that the outside of the stethoscope is becoming dirty and unsightly. Which is the appropriate action of the nurse? a. Obtain a soft cloth cover for the stethoscope tubing. b. Clean the stethoscope tubing throughout each shift with isopropyl alcohol. c. Send the entire stethoscope to central supply for disinfection. d. Clean the stethoscope tubing weekly with a solution of mild dish soap.

The nurse is conducting a health history for a patient who does not speak English. What is the best action of the nurse? a. Communicate with the patient using simple gestures and drawings. b. Arrange for a medical translator to be present during the health history interview. c. Ask an English-speaking family member to translate the nurse's questions. d. Obtain the patient's health history from an English-speaking family member.

The nurse is having difficulty hearing his patient's apical pulse with his stethoscope. Which action will help the nurse hear the heartbeat more clearly? a. Positioning the bell very lightly over the patient's sternum b. Placing the diaphragm firmly against the patient's skin c. Making sure that the earpieces fit loosely in the nurse's ear canals d. Utilizing a stethoscope with the longest possible tubing

The nurse is to administer 3 mL of medication intramuscularly to an adult patient. Which is the appropriate site for the injection? a. Dorsal gluteal b. Vastus lateralis c. Deltoid d. Lateral piriformis

The nurse is to administer the patient's next dose of vancomycin at 9:30 a.m. What time will the nurse draw the patient's blood to check the trough vancomycin level? a. 8:30 a.m. b. 9:00 a.m. c. 10:00 a.m. d. 10:30 a.m.

The nurse notes that the patient has bilateral entropion. What will the nurse plan to do as a result of this assessment finding? a. Instruct the patient to rinse the mouth gently with warm saline solution. b. Clean the patient's eyelids gently and apply antibiotic ointment. c. Place a wedge pillow between the patient's legs to prevent crossing at the hip. d. Elevate the head of the patient's bed and administer supplemental oxygen.

The nurse notes that the patient is utilizing accessory and intercostal muscles to breathe. What is the priority action of the nurse? a. Document this normal assessment finding in the patient's medical record. b. Elevate the head of the bed and listen to the patient's lung sounds. c. Direct the nursing assistant to obtain the patient's temperature and blood pressure. d. Instruct the patient about the importance of smoking cessation.

The nursing staff is caring for a patient who collapsed in cardiac arrest. When will breaths be delivered via the bag-valve mask device? a. After the patient is intubated b. After every 30 chest compressions c. When the patient's lips start to become cyanotic d. When another nurse takes over chest compressions

The patient crushes extended-release pain medication tablets in order to obtain relief immediately. Which term describes the action of this patient? a. Medication dependence b. Medication abuse c. Medication misuse d. Medication underuse

The patient expresses frustration about not being able to function as the family breadwinner any longer due to chronic severe pain. Which psychosocial nursing diagnosis is most appropriate for this patient's concern? a. Risk for loneliness related to need for prescription pain medications b. Interrupted family processes related to changes in assigned roles c. Disturbed sensory perception related to insufficient environmental stimuli d. Moral distress related to time constraints for ethical decision making

The patient has a large red, blistered area on the left hip. Which pressure injury stage will be recorded in the patient's chart? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

The patient is admitted to the cardiac unit. Everyone admitted to the cardiac unit will have an EKG done unless otherwise ordered. This is an example of which type of order? a. prn b. Standing c. One-time d. STAT

The patient reports feeling an urge to urinate even though an indwelling urinary catheter is in place. Which is the priority action of the nurse? a. Measure the patient's urinary output. b. Ensure that the catheter tubing is not kinked. c. Provide perineal care to the patient for comfort. d. Reassure the patient that the sensation is to be expected.

The patient states "I don't take that medication" when the nurse hands the pill to the patient. What is the nurse's best response? a. "It is probably the generic form of the medication you normally take." b. "I will check your chart to see if your medication was changed." c. "The other nurse drew up the medication so I am sure it is correct." d. "I will chart that you refused to take the medication as it is ordered."

The patient's blood pressure is 152/92 but the primary health care provider does not diagnose the patient with hypertension. What is the rationale for this decision? a. The patient's primary health care provider must consult with a cardiologist in order to make a diagnosis of hypertension. b. The patient's blood pressure must remain elevated during several separate assessments in order to make a diagnosis of hypertension. c. The patient's blood pressure must be at least 180/100 during a single assessment in order for a diagnosis of hypertension to be made. d. The patient appeared extremely stressed and the health care provider decided not to inform the patient of the diagnosis at that appointment.

The patient's blood pressure is 180/100. Why does the patient's heart have to work harder due to the high blood pressure? a. Increased preload b. Increased afterload c. Decreased contractility d. Increased stroke volume

The patient's incision is fading to a pale pink following surgery 2 months previously. Which stage of the healing describes the current status of the patient's wound? a. Hemostasis phase b. Remodeling phase c. Proliferative phase d. Inflammation phase

The patient's insurance company refuses to pay for the brand name formulation of a prescribed drug. Which formulation of the drug will the patient receive instead? a. Trade b. Generic c. Chemical d. Proprietary

The patient's urinalysis indicates increased specific gravity of the urine. Which finding does the nurse anticipate will be found upon assessment? a. The patient uses supplemental oxygen due to COPD. b. The patient is thirsty with dry oral mucus membranes. c. The patient has a history of benign prostatic enlargement. d. The patient just completed antibiotics for a bladder infection

The patient's wound has thick creamy yellow drainage present on the dressing. How will the nurse document this finding? a. Serous drainage b. Purulent drainage c. Sanguineous drainage d. Serosanguineous drainage

The rehabilitation nurse is working with a patient to regain bowel continence after a stroke. Which intervention will the nurse include as part of the patient's bowel training program? a. The nurse will administer docusate sodium 100 mg PO BID. b. The nurse will assist the patient to the toilet every morning after breakfast. c. The nurse will check for the presence of a fecal impaction every other day. d. The nurse will apply skin barrier cream to the perineal area after each loose stool.

When will the nurse clamp the patient's chest tube? a. When the patient ambulates in the hallway b. When changing the drainage collection unit c. Before assisting the patient to take a shower d. When disconnecting the chest tube from suction

Which assessment finding by the nurse indicates that the patient's colonoscopy preparation is complete? a. The patient has stopped vomiting. b. The patient's stool is watery clear yellow. c. The patient had a large soft formed stool. d. The patient's abdomen is softly distended.

Which assessment finding explains the cause of the patient's stress urinary incontinence? a. The patient uses a wheelchair and cannot get to the toilet in time to void. b. The patient gave birth to six babies who weighed more than 9 pounds. c. The patient suffered a spinal cord injury and has no sensation below the waist. d. The patient self-catheterizes due to urinary retention from multiple sclerosis.

Which assessment finding indicates that the patient is at risk for developing polypharmacy? a. The patient stores medications in the kitchen cabinet. b. The patient takes four different medications for congestive heart failure. c. The patient requires financial assistance to pay for prescriptions. d. The patient obtains all prescription medications from a mail-order pharmacy.

Which assessment finding indicates that the patient is experiencing hypercapnia during sleep? a. The patient sleeps in the lateral position with at least two pillows. b. The patient wakes up feeling hung over after consuming no alcohol. c. The patient has difficulty falling asleep and wakes up early each morning. d. The patient works the night shift and is unable to sleep well during the day.

Which assessment finding indicates that the sinoatrial node was damaged as a result of the patient's heart attack? a. The patient's jugular vein is distended. b. The patient's heart rate is 34 beats/minute. c. Faint wheezes are heard in the patient's lungs. d. The patient has developed a new heart murmur.

Which assessment finding is expected for a patient with a chest tube for treatment of hemothorax? a. Constant bubbling in the water-seal chamber b. Presence of bloody drainage from the chest tube c. The patient denies having pain at the chest tube site d. Subcutaneous emphysema is present around the chest tube site

Which assessment finding leads the nurse to question an order for an abdominal flat plate test? a. The patient is very claustrophobic. b. The patient is 8 weeks pregnant. c. The patient has a history of renal failure. d. The patient is allergic to iodine and shrimp.

Which assessment question enables the nurse to determine provocative factors of the patient's pain? a. "What does your pain feel like?" b. "Does anything make your pain worse?" c. "Can you show me where the pain is?" d. "Is the pain constant or does it come and go?"

Which intervention is appropriate to prevent the patient from reinfection after recovery from oral thrush? a. The teeth should be flossed after each meal. b. The patient's toothbrush should be replaced. c. Lip balm should be applied to prevent chapping. d. An antiseptic mouthwash should be used twice daily.

Which intervention will most effectively maintain breathing function for a patient with muscle weakness due to amyotrophic lateral sclerosis (ALS)? a. Teaching pursed-lip breathing exercises b. BiPAP (bi-level positive airway pressure) c. Administration of oxygen via nasal cannula d. CPAP (continuous positive airway pressure)

Which is an appropriate goal for a patient's preoperative teaching? a. The nurse will provide written materials about nonpharmacological pain-management techniques. b. The patient will verbalize understanding of the pain-management techniques to be used after surgery. c. The nurse will demonstrate correct use of the patient-controlled anesthesia (PCA) pump. d. The patient will rate current pain of less than 3 out of 10 on the descriptive pain intensity scale.

Which is an example of an adjuvant medication for pain management? a. Naloxone b. Gabapentin c. Morphine sulfate liquid d. Fentanyl transdermal patch

Which is the appropriate method to obtain a urinalysis specimen for culture and sensitivity from an incontinent female patient? a. Obtain a midstream specimen. b. Perform straight catheterization. c. Obtain a double-voided specimen. d. Leave a fresh bedpan under the patient.

Which is the highest priority goal for the young adult patient with the nursing diagnosis risk for suicide related to depression and inability to make friends? a. The patient will express feelings and maintain self-control. b. The patient will not cause any sort of harm or injury to self. c. The patient will develop a therapeutic relationship with the nurse. d. The patient will verbalize less anxiety and fear around other people.

Which is the highest priority nursing diagnosis for the patient admitted with pneumonia? a. Activity intolerance related to increased oxygen demand with exertion b. Ineffective airway clearance related to inability to cough up thick secretions c. Risk for fluid volume deficit related to inadequate intake of fluids with fever d. Imbalanced nutrition related to loss of appetite and increased metabolic demand

Which is the most appropriate goal for an elderly adult with the nursing diagnosis of sedentary lifestyle related to deconditioning and lack of physical exercise? a. The patient will participate in social activities with others. b. The patient will increase walking to at least 5000 steps per day. c. The patient will identify ways to conserve energy and prevent fatigue. d. The patient will develop meaningful relationships with the nursing staff.

Which is the priority nursing intervention for a patient with confusion and the diagnosis impaired dentition related to inability to perform oral care? a. Assess the patient's preferred methods for oral hygiene. b. Brush the patient's teeth twice daily with a soft toothbrush. c. Use foam swab sticks to clean the oral cavity every morning. d. Encourage the patient to chew sugarless gum during the day.

Which medication order will provide the most immediate relief of the patient's acute pain? a. Morphine sulfate 5 mg PO b. Hydromorphone 0.5 mg IV c. Buprenorphine transdermal patch 10 mg d. Oxymorphone 30 mg extended release

Which nursing diagnosis is the highest priority for a patient who just received local anesthesia to the back of the throat for a diagnostic procedure? a. Feeding self-care deficit related to pain and discomfort b. Risk for aspiration related to depressed gag reflex c. Impaired social interaction related to slurred speech d. Impaired oral mucus membrane related to dry mouth

Which of the following drug orders will provide the fastest pain relief for the patient? a. Morphine 30 mg b. Hydromorphone 1 mg IV c. Fentanyl transdermal 25 mcg/hour d. Acetaminophen with oxycodone 10 mg/325 mg

Which patient should have the temperature taken orally rather than using a tympanic thermometer? a. An unconscious, intubated patient b. A patient with bilateral middle ear infections c. A patient with gastroenteritis who is vomiting d. An agitated patient who cannot follow directions

Which patient would benefit from a sitz bath? a. A patient who has not had a bowel movement for the last 4 days b. A patient with painful, swollen hemorrhoids after vaginal childbirth c. A patient with perineal skin breakdown due to continuous oozing of stool d. A patient who is having difficulty adhering the ostomy appliance to the skin

Which patient would benefit from the use of lubricant eye ointment? a. A patient with chronic viral conjunctivitis b. A stroke patient whose right eye does not close fully c. A patient who has extended-wear contact lenses in place d. A patient with an eye infection after swimming in a pond

Which statement is correct about patient tolerance to medications? a. Tolerance only develops when the patients do not take the medication as it is prescribed. b. The patient will continually require higher doses of the drug for the same effect to be achieved. c. The patient will require a stable dose of the medication until the drug is discontinued. d. Tolerance occurs when the liver or kidneys are no longer able to metabolize the drug.

Which technique is best to calm a preschooler's fears before auscultating bowel sounds? a. Reassure the child that listening to bowel sounds will not hurt in the least. b. Allow the child to use the stethoscope to listen to a teddy bear's abdomen. c. Explain how a stethoscope is used to listen to the functioning of the bowel. d. Seat the child in the parent's lap and have the parent hold the child's hands.

Which technique will the nurse use to assess the patient's olfactory nerve? a. Ask to shrug the shoulders and turn the head against the nurse's hand. b. Ask the patient to identify the smell of peppermint oil and orange peel. c. Ask the patient to read the smallest set of letters on a Snellen eye chart. d. Ask the patient to stick out the tongue and move it side to side from midline.

Why does the nurse utilize a head-to-toe approach when performing physical examinations of patients? a. The head-to-toe format excludes unnecessary body systems. b. It is a methodical way to include all body systems. c. It reduces time by allowing examination of only one side. d. It requires that painful procedures be done first.

The nurse is caring for a patient who came to the emergency department with confusion and muscle cramps after working outside on a hot day. What is the priority action of the nurse? a. Place the patient in a tub of iced water. b. Take the patient's temperature and vital signs. c. Remove fans to prevent premature chilling. d. Apply a hyperthermia blanket to lower temperature slowly.

B Assessment includes taking the patient's temperature. The nurse then uses that measurement to guide care of that patient.

The nurse is caring for an adult patient with a temperature of 101.2° F. Which statement will the nurse make to the patient's family member who verbalizes concern over the patient's fever? a. "Fevers this high can cause permanent neurological damage." b. "Fevers under 102° F help the body's immune system fight infections." c. "The fever may cause the patient to have a febrile seizure." d. "I will call the physician now to obtain an order for antibiotics."

B Fever serves as an important defense mechanism.

The nurse notes that the patient's radial pulse is irregular. What is the most appropriate first action of the nurse? a. Document the finding in the patient's medical record. b. Count the patient's apical pulse for 1 full minute. c. Assess the brachial pulse for a pulse deficit. d. Notify the health care provider immediately.

B Irregular peripheral pulses should be compared to the patient's apical pulse to determine if a pulse deficit is present..

Which technique will provide the most accurate measurement of the patient's core temperature? a. Orally b. Rectally c. Axillary d. Forehead

B The core temperature is the temperature of tissues deep w/in the body.

The nurse is caring for an unconscious patient who was just pulled from a freezing lake. What is the priority action of the nurse? a. Have the patient drink hot liquids. b. Wrap the patient in warmed blankets. c. Bathe the patient to promote shivering. d. Remove restrictive items of clothing.

B The priority treatment for hypothermia is to prevent a further decrease in body temperature.

Which of the following orders are for topical medications? (Select all that apply.) a. Methotrexate 20 mg subcutaneously once weekly on Wednesdays b. Latanoprost 0.005% one drop in left eye daily at bedtime c. Acetaminophen 650 mg suppository Q 4 hours prn mild pain d. Ofloxacin otic solution 0.3% instill drops into right ear daily e. Calcitonin nasal spray one spray daily into alternating nostrils

B C D E

Which factors may lead to inaccurate pulse oximetry readings? (Select all that apply.) a. The patient drinks four to six beers every night. b. The patient has thick gel polish on the fingernails. c. The patient was admitted with heatstroke. d. The patient's hemoglobin level is dangerously low. e. The patient has a generalized mild sunburn.

B D

The adult patient's heart rate is 48 beats/minute. Which term will the nurse use when documenting the finding in the patient's medical record? a. Tachycardia b. Bradycardia c. Pulse deficit d. Bradypnea

B Tachycardia is an abornormally elevated heart rate, greater than 100 bpm in adults. Bradycardia is a slow heart rate, less than 60 bpm in adults.

The nurse is caring for a patient with a bacterial infection. After antibiotic treatment is started, the patient develops a generalized itchy rash. What is the most likely reason for the rash? a. Vasodilation to lower the body temperature b. An allergic response to the prescribed medication c. Overloaded temperature release mechanism d. Development of infectious heat exhaustion

B Sometimes a fever results from ahypersensitivity response to a medication, especially when the medication is taken for the first time.

(15)Which vital signs are most important for a patient who is experiencing shortness of breath? a. Temperature, pulse, respirations b. Pulse, respirations, oxygen saturation c. Temperature, pulse, blood pressure d. Respirations, blood pressure, pain

B The priority vital signs for a patient experiencing shortness of breath are pulse, respirations, and oxygen saturation.

The nurse is to administer 250 mg of amoxicillin PO every 6 hours. Amoxicillin for oral suspension USP 125 mg per 5 mL. How many mL of medication will be given to the patient for each dose? a. 5 mL b. 10 mL c. 15 mL d. 20 mL

B -- 250 mg × 5 mL/125 mg = 10 mL

The nurse is to administer 10 mg/kg of acetaminophen to a patient who weighs 70 pounds (32 kg). Acetaminophen elixir 160 mg per 5 mL. How many mL of medication will be given to the patient for each dose? a. 5 mL b. 10 mL c. 15 mL d. 20 mL

B -- 32 kg × 10 mg/kg = 320 mg 320 mg × 5 mL/160 mg = 10 mL

Which technique can the nurse use to facilitate assessment of the thyroid gland? a. Have the patient tip the head back and cough twice. b. Watch the patient's neck when sipping water from a straw. c. Have the patient slowly turn the head from side to side. d. Gently palpate from underneath the jaw to behind the ear.

B Observing the patient's neck during swallowing can help visualize the shape of the thyroid gland.

The nurse is caring for an adolescent with a BMI of 22 and the nursing diagnosis imbalanced nutrition, more than body requirements related to caloric intake greater than metabolic needs. Which nursing interventions will the nurse use to help the adolescent achieve a balanced diet? (Select all that apply.) a. Use sugary treats as a reward for getting good grades in school. b. Encourage the adolescent to gradually increase physical activity. c. Recommend intake of at least 2 to 3 L of water each day. d. Remind the adolescent of how body image affects relationships. e. Encourage the adolescent to eat breakfast every day before school.

B, C, E

A nurse is caring for a patient with a debilitating chronic illness. The patient mentions several times that faith would guide her healing. The nurse knows that faith can best be defined as a: a. system of organized beliefs and worship. b. relationship with a higher power, authority, or spirit. c. source of energy needed to cope with difficult situations. d. multidimensional concept that gives comfort while a person endures hardship.

B. relationship with a higher power, authority, or spirit

A patient refuses to remove a specific spiritual garment for daily bathing. The most appropriate action for the nurse would be to: a. remove the article anyway because the garment hinders daily care delivery. b. respect the patient's wishes and work around it. c. explain to the patient that the garment has no real spiritual value. d. identify the refusal as a sign of spiritual distress.

B. respect the patients wishes and work around it

The long-term care facility nurse is assessing the patients sleep environment for safety. Which finding will cause the nurse to intervene as it is an unsafe situation for the patient?

Bed in high position with side rails up

A patient is to receive insulin aspart and insulin detemir. How will the nurse draw up the insulins for administration? a. Mix the detemir and aspart in the same syringe, drawing up the aspart first. b. Mix the detemir and aspart in the same syringe, drawing up the detemir first. c. Administer the two insulins using different syringes and different sites of the body. d. Roll the bottles between the palms of the hands before drawing up the insulins.

How can the nurse most accurately assess the skin tone for an older adult African American patient with deeply pigmented skin? a. Utilize fluorescent lighting. b. Turn up the heat in the room. c. Utilize natural sunlight. d. Turn down the temperature in the room.

How can the parents best protect their premature infant from developing respiratory syncytial virus (RSV)? a. Immunize the infant against RSV. b. Ensure that the infant's bottles are sterilized. c. Limit the baby's exposure to crowds of people. d. Daily administration of prophylactic antibiotics.

Loud wails erupt whenever the nurse tries to pick up the infant from the mother. Which developmental stage is the infant experiencing? a. Affiliation and love b. Production and care c. Trust versus mistrust d. Autonomy versus doubt

The middle-aged patient is overwhelmed by the stresses of caring for aging parents as well as young children living at home. Which nursing diagnosis is most appropriate for this patient? a. Disturbed body image related to developmental changes associated with middle age b. Deficient diversional activity related to desire to enhance relaxation and contentment c. Caregiver role strain related to amount of attention and care needed by both parents and children d. Readiness for enhanced power related to desire for freedom from family responsibilities

The mother of a healthy toddler reports that the child is eating less than a few months ago but the child has not lost any weight. Which is the most appropriate response of the nurse? a. "You need to make him eat more every day. At this stage, he is growing too fast to not eat." b. "I could show you a growth chart, but each child is different so it doesn't mean much." c. "Toddlers have periods when they aren't growing as fast and they don't need to eat as much." d. "Make him eat with a spoon and don't feed him snacks. He will be hungrier at meal time."

The mother of a school-age child asks the nurse why the child's blood pressure is measured at a routine physical examination appointment. What is the best answer of the nurse? a. "Insurance companies require blood pressure checks of children as well as adults to calculate premium rates." b. "The state health department requires blood pressure checks before immunizations can be administered." c. "Sometimes children develop high blood pressure that can lead to health problems in adulthood." d. "Blood pressure checks are started in childhood so that adults will not be afraid of them later on."

The nurse administers enteric-coated aspirin to the patient. Where will this medication be absorbed into the body? a. In the stomach b. Through the skin c. In the small intestine d. Through the oral mucosa

The nurse applies a warmed blanket to a chilled patient. Which term is used to describe the process by which the blanket increases the patient's temperature? a. Convection b. Radiation c. Conduction d. Emission

The nurse is assessing a patient with shortness of breath. Which is the optimal technique to auscultate the patient's lung sounds? a. Place the binaurals firmly in both ears and utilize the diaphragm of the stethoscope. b. Place the earpieces loosely in both ears and utilize the bell of the stethoscope. c. Place the diaphragm of the stethoscope firmly on the skin of the patient's chest. d. Place the bell of the stethoscope firmly on the skin of the patient's chest.

The nurse is caring for a bedridden patient with long straight hair. Which is the appropriate intervention to prevent the hair from becoming matted? a. Apply no-tangle conditioner to the hair. b. Cut the matted hair. c. Braid the patient's hair into several pigtails. d. Wash the patient's hair daily with baby shampoo.

The nurse is caring for a dehydrated, confused patient whose breath smells like fruity bubble gum. What is the priority action of the nurse based on these assessment findings? a. Check the patient's pulse oximetry. b. Check the patient's oral mucosa for thrush. c. Check the patient's blood sugar. d. Check the patient's sclerae for jaundice.

The nurse is caring for a patient with end-stage chronic obstructive pulmonary disease (COPD). The patient's pulse oximetry reading is 90% on room air. What is the priority action of the nurse? a. Administer 4L/NC oxygen immediately. b. Assist the patient into a recumbent position. c. Determine the patient's normal pulse oximetry values. d. Obtain an order for STAT arterial blood gases (ABGs)

The nurse is inserting an indwelling urinary catheter before the patient has abdominal surgery. Which type of catheter will the nurse utilize for the procedure? a. Straight catheter b. Single-lumen catheter c. Double-lumen catheter d. Triple-lumen catheter

The nurse is performing urinary catheterization for a female patient. The catheter will not advance any further but there is no urine output. What is the appropriate action of the nurse? a. Withdraw the catheter and notify the health care provider immediately. b. Palpate the patient's bladder to assess for fullness, tenderness, or distention. c. Leave the catheter in place and reattempt insertion with a new sterile catheter. d. Utilize the bladder scanner to determine how much urine is in the patient's bladder

The nurse is to administer a clotrimazole troche to the patient. Which instruction will the nurse give to the patient? a. "Your eyesight may be blurry for a short time after I give you the medication." b. "Do not touch or remove the patch after I have applied it to your skin." c. "Keep the tablet in your mouth until it dissolves completely. Do not chew it." d. "Lay on your back so the medication will melt slowly in your vagina."

The nurse is to administer a nephrotoxic medication to the patient. Which assessment finding indicates to the nurse that the patient should receive a reduced dosage of the drug? a. The patient has a 35 pack-year history of cigarette smoking. b. The patient follows a low-carbohydrate, low-protein, high-fat diet. c. The patient has a history of hypertension and diabetic kidney disease. d. The patient is unable to exercise due to severe osteoarthritis in both hips.

The nurse is to administer heparin 5000 units to an adult patient with a BMI of 15.1. Which is the appropriate technique for the injection? a. Pinch the skin tissue and inject at a 90-degree angle. b. Spread the skin tissue and inject at a 45-degree angle. c. Pinch the skin tissue and inject at a 45-degree angle. d. Spread the skin tissue and inject at a 90-degree angle.

The nurse is to take the patient's temperature right after the patient drank a glass of ice water. What is the most appropriate action of the nurse? a. Wait 10 minutes before taking the temperature orally. b. Document that the patient refused the assessment. c. Take the patient's axillary temperature instead. d. Obtain a core temperature measurement instead.

The patient develops constipation after taking the daily iron supplement that was prescribed by the physician. Which term accurately describes the patient's reaction to the supplement? a. Therapeutic effect b. Adverse reaction c. Side effect d. Toxicity

The patient has a large left hip decubitus ulcer with tunneling but no involvement of bone, tendon, or muscle. Which pressure injury stage will be recorded in the patient's chart? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

The patient has been smoking 2 packs of cigarettes for the last 15 years. How will the nurse chart the patient's tobacco use history in pack-years? a. 7.5 pack-years b. 17 pack-years c. 30 pack-years d. 35 pack-years

The patient is brought in after collapsing outside on a very hot day. Which assessment finding will the nurse expect to note during physical examination of the patient? a. Pallor of the patient's extremities b. Cyanosis of the patient's nail beds and lips c. Dry mucus membranes and poor skin turgor d. Lower extremity edema and a generalized itchy rash

The patient's tuberculosis test appears red and flat after the injection 48 hours ago. Which is the appropriate action of the nurse? a. Repeat the tuberculosis test because the results are inconclusive. b. Measure the reddened area in millimeters and document the result. c. Document the results as a negative reaction to the tuberculosis test. d. Contact the state health department about the patient's positive test.

Which action demonstrates Piaget's formal operations period of development? a. Touching everything and putting everything into the mouth to learn about the surroundings b. Learning not to touch a hot radiator cover again after suffering a mild burn the first time c. Taking insulin as prescribed because otherwise dangerous complications of diabetes will develop d. Understanding that a family vacation is in the future and asking daily if vacation will be "today."

Which assessment finding is expected for a patient who may have a lower extremity deep vein thrombosis (DVT)? a. Deep burning pain in the extremity that worsens with walking and exercise b. Weak pedal pulses and an absence of hair on the affected extremity c. Calf pain when the knee is flexed slightly and the foot is pointed downward d. Numbness and tingling of the extremity with hyperreactive reflexes

Which assessment finding is expected for a patient with impaired lung compliance? a. The patient's respirations are very deep and rapid. b. The patient reports sharp left-sided rib and chest pain. c. The patient struggles to take a deep breath and exhale. d. The patient's breathing pattern is irregular with periods of apnea.

Which assessment finding leads the nurse to conclude that digital disimpaction of stool is unsafe for the patient? a. The patient has a large mass of hard, dry stool in the rectum. b. The patient has not had a bowel movement for the last 6 days. c. The patient's pulse is 50 beats/minute due to a history of heart block. d. The patient has taken senna every morning for the last 3 days.

Which assessment finding leads the nurse to include the risk for delayed development nursing diagnosis in the care plan for an infant? a. The baby's father works from home b. The baby has three older sisters at home c. The baby was born at only 30 weeks' gestation d. The baby cannot tolerate formula that contains lactose

Which assessment finding leads the nurse to question the physician's order for irrigation of the patient's ear? a. The patient has some short soft hairs present on the pinna. b. A large amount of cerumen is noted in the patient's ear canal. c. The patient has ear pain with purulent drainage in the ear canal. d. The patient's tympanic membrane is a translucent pearl-gray color.

Which assessment finding needs to be communicated promptly to the patient's health care provider? a. Postvoid residual of 15 mL of urine. b. Leakage of small amounts of urine when coughing. c. Urine output of 160 mL over the last 8 hours. d. Patient's report of an urge to void during palpation of the bladder.

Which assessment finding will the nurse expect to note during physical examination of the patient with a cast on the lower left leg? a. The patient's left foot has a musty, fetid smell b. The patient's left foot has 3+ pitting edema and pallor. c. The temperature of the left foot is the same as the right foot. d. The patient's left foot is cool with thin, shiny skin.

Which instruction will the nurse give to the patient about proper use of patient-controlled analgesia (PCA)? a. "Wait until the pain becomes severe before pushing the PCA button." b. "The PCA will deliver medication through the IV until the pain is all gone." c. "You or a designated family member are the only one who gets to push the PCA button—nobody else may do so." d. "The PCA will give additional pain medication whenever the button is pushed."

Which intervention will facilitate the physical examination of a patient with mobility issues? a. Be sure that the head of the examination table may be elevated for the patient's comfort. b. Tune the radio to the nurse's favorite station as a relaxation intervention for the patient. c. Make sure that the patient has sufficient space and assistance to transfer onto the examination table. d. Instruct the patient on the safest way to transfer onto the examination table.

Which intervention will the nurse use for an abscessed leg wound? a. Warm water sitz baths b. Cold moist compresses c. Warm moist compresses d. Epsom salt solution soaks

Which is an IV bolus order? a. 1 L 0.9% normal saline IV infuse over 4 hours b. Primaxin 750 mg IVPB infuse over 30 minutes Q 12 hours c. Naloxone 300 mcg IV push over 2 minutes STAT d. 0.9% normal saline IV infusion at 125 mL/hour

Which is an example of nociceptive pain? a. Neuropathy due to uncontrolled diabetes b. Phantom pain after amputation of a limb c. Pain from rheumatoid arthritis joint damage d. Chronic nerve pain after shingles infection

Which is the appropriate goal for a nonverbal, confused patient with the nursing diagnosis chronic pain related to widespread tissue damage? a. The patient's pain will be reduced to a minimal level. b. The nurse will assess the patient's pain every 2 hours. c. The patient will not demonstrate moaning or grimacing. d. The patient will use a 0-to-10 pain scale to identify pain levels.

Which is the priority action of the nurse for a patient with ventricular tachycardia? a. Assess the patient for signs of digoxin toxicity. b. Draw serum electrolytes to check for hyperkalemia. c. Start chest compressions if there is no palpable pulse. d. Check the patient's BP and administer sublingual nitroglycerin

Which is the priority nursing assessment for a patient wearing an abdominal binder after abdominal surgery? a. Mental status and orientation b. Hourly fluid intake and output c. Lung sounds and pulse oximetry d. Presence of peripheral pedal pulses

Which nonpharmacological pain-relief technique is appropriate for a confused, nonverbal patient? a. Tai chi b. Biofeedback c. Massage therapy d. Guided imagery

Which pain relieving option should be avoided by a patient with chronic back pain who must continue to work as a truck driver? a. Transcutaneous electrical nerve stimulation (TENS) unit b. Naproxen sodium 200 mg PO every 12 hours c. Tramadol extended release 200 mg PO daily d. Application of hot and cold packs to the lower back area

Which patient would benefit from BiPAP therapy? a. Surgical patient under general anesthesia b. Confused, agitated patient with no gag reflex c. Patient with pulmonary edema due to CHF exacerbation d. Stroke patient who frequently aspirates fluids and saliva

Which test can the nurse use to assess the patient's balance? a. Have the patient reach out to touch the nurse's finger then the patient's nose. b. Have the patient track the nurse's finger as it moves through the field of vision. c. Have the patient stand with feet together, arms out, and eyes closed. d. Have the patient run the heel of the foot along the shin of the other leg.

Which type of sterile dressing will be applied to the chest wall after removal of the patient's chest tube? a. Dry gauze dressing b. Absorbent foam dressing c. Petroleum gauze dressing d. Nonadherent gauze dressing

The nurse delegates vital signs for a patient to the nurse assistant. What is the nurse's responsibility regarding delegation of this task? a. The nurse assistant should not be responsible for obtaining vital signs. b. The nurse assistant should determine if the patient's vital signs are abnormal. c. The nurse should review the patient's vital signs as soon as they are done. d. The nurse is not responsible if the nurse assistant fails to obtain the vital signs.

C A nurse may delegate the measurement of selected vital signs to the CNA.

The nurse is caring for a patient who has just been admitted with a fever of 102.6° F. Which intervention will the nurse perform first for the patient? a. Administer the prescribed antibiotic. b. Administer the prescribed antipyretic. c. Draw blood cultures for laboratory testing. d. Apply a cool washcloth to the patient's forehead.

C Before antibiotic therapy, obtain blood cultures when ordered.

The nurse is caring for a patient whose temperature has dropped from 102.4° F to 99.4° F. The nurse notes that the patient's face is flushed. What is the reason for this assessment finding? a. The patient is exhausted from shivering. b. The patient's infection has spread to the bloodstream. c. Vasodilation is working to lower the body temperature. d. The patient's core temperature has dropped too low.

C Vasodilation is the widening of blood vessels.

The nurse is shown the mercury thermometer which was used to take the patient's temperature before coming to the hospital. What is the appropriate statement of the nurse? a. "Mercury thermometers are more accurate than electronic ones." b. "Hospitals use mercury thermometers for patients with very high fevers" c. "Electronic thermometers are much safer than mercury thermometers" d. "Mercury thermometers can be used to take rectal or oral temperatures"

C The mercury-in-glass thermometers are obsolete in the health care setting because of the environmental hazards of mercury. However, some patients still use mercury-in-glass thermometers at home. Patients should be taught about safer electronic temperature devices.

The nurse is caring for a patient who lost consciousness and collapsed. Which site will be used to determine if the patient has a pulse? a. Apical artery b. Radial artery c. Carotid artery d. Brachial artery

C When a patient's condition suddenly deteriorates, use the carotid site to quickly locate a pulse.

The nurse is to administer acetaminophen to an unconscious patient. Which medication formulations may safely be administered to the patient? (Select all that apply.) a. Acetaminophen tablet b. Acetaminophen elixir c. Acetaminophen IV d. Acetaminophen suppository e. Acetaminophen suspension

C D

The nurse is caring for a patient with the following vital signs: Temperature: 98.9° F Pulse: 94 Respirations: 20 Blood pressure: 144/94 Pulse oximetry: 94% What is the priority action of the nurse? a. Apply a cool washcloth to the patient's forehead. b. Administer oxygen at 2 L/minute via nasal cannula. c. Ask the patient about his usual blood pressure results. d. Document the findings in the patient's medical record.

C The nurse must know the patient's usual range of bital signs in order to make an appropriate judgement.

When is the best time for a male patient to perform a testicular self-assessment? a. Before getting out of bed in the morning b. After having a bowel movement c. After getting out of a hot tub d. Immediately following ejaculation

C -- The best time for the male patient to perform a testicular self-assessment is after getting out of a warm bath or hot tub as the scrotal sac will be relaxed

The patient's pupils are the size of tiny pinpoints. Which factor could lead to this assessment finding? a. The patient has been taking high doses of steroids. b. The patient suffered massive head trauma and is brain dead. c. The patient injected heroin intravenously 1 hour ago. d. The patient has developed acute narrow angle glaucoma.

C Pinpoint pupils are a common sign of opioid intoxication

Which medications are classified as nonsteroidal antiinflammatory medications? (Select all that apply.) a. Tramadol b. Acetaminophen c. Aspirin d. Ibuprofen e. Codeine

C, D

Which interventions are appropriate when providing oral care to an intubated patient receiving mechanical ventilation? (Select all that apply.) a. Floss the gums gently after brushing the teeth each morning. b. Rinse the mouth with a solution of peroxide and baking soda. c. Suction the patient's mouth throughout the cleaning procedure. d. Keep the head of the patient's bed elevated at least 30 degrees. e. Clean the oral mucosa using a chlorhexidine-based mouthwash.

C, D, E

The nurse manager for a busy medical unit in an acute care hospital noticed a trend of complaints regarding the restful environment of the unit in the patient satisfaction reports. At the staff meeting, this issue was discussed with the staff, and they decide that the best thing to do is which of the following?

Cluster nursing activities at night

The nursing assistant informs the nurse that the patient's blood pressure is 220/102 using the electronic monitor. What is the priority action of the nurse? a. Perform a neurological assessment to determine if the patient is stressed, in pain, or having a stroke. b. Inform the patient's health care provider immediately to obtain an order for antihypertensive medication. c. Instruct the nursing assistant to take the patient's blood pressure again and inform the nurse of the results immediately. d. Take the patient's blood pressure manually with a sphygmomanometer and stethoscope.

The nurse is triaging a patient for an annual check-up with the health care provider. When questioned about changes in sleep habits the patient replies, Since my spouse passed away last month, I have not been sleeping well at all. What are the most appropriate interventions for the nurse to make? (Select all that apply.)

Contacting a pastoral care professional. Psychiatric clinical nurse specialist. Clinical psychologist.

* Presence involves a person-to-person encounter that: *

Conveys a closeness and a sense of caring

Which of the following would indicate that the nurse has established a level of mutual problem solving? a. the nurse helps the patient develop questions to ask the health care provider b. the nurse tells the patient what needs to be done to resolve health problems c. the nurse is seen as the authority when it comes to health care issues d. the nurse excludes the family from health discussions to prtect privacy

The nurse helps the patient develop questions to ask the health care provider

* A nurse is caring for an older adult male who is going to an assisted-living facility following discharge. Which of the following descriptions is an example of listening that displays caring? *

The nurse listens to the patient's story while sitting on the side of the bed and summarized an interpretation of the patient's story

A patient has returned from back surgery. The family has brought in the patients continuous positive airway pressure (CPAP) machine. What is the best rationale for allowing the patient to use the CPAP machine at night?

The patient needs ventilator support owing to the increased chance of post-op respiratory complications

A nurse is caring for an elderly patient with a sleeping disorder. When formulating a care plan for this patient it was determined that the goal will be that the patient establishes a healthy sleep pattern. Which of the following is the best example of a measurable outcome to meet this goal?

The patient will have less than two awakenings throughout the night.

A 16-year-old patient is being seen in the emergency department (ED) after being involved in a minor motor vehicle accident. The guardian has voiced that the patient has been spending more time in his or her room, has difficulties getting along with friends, and has declining grades over the past 3 months. The patient seems distant and angry all the time. Which of the following topics is most important for the nurse to discuss with the guardian?

The possibility of substance abuse

* A nurse hears a colleague tell a nursing student that she never touches patients unless she is performing a procedure or doing an assessment. The nurse tells the colleague that from a caring perspective: *

Touch forms a connection between nurse and patient

The student nurse has been studying different cultures in relationship to nursing. She understands that transcultural nursing has been developed as a distinct discipline and can be defined as which of the following. a. Understanding that cultural patterns are generated from predetermined criteria b. Knowing that culturally congruent care is based on health care system values c. Understanding cultural similarities and differences among groups of people d. The realization that illness and disease are the same

Understanding cultural similarities and differences among groups of people

A confused patient was found wandering in the hallways several times during the shift. What is the most appropriate nursing intervention to prevent a fall by this patient?

Using an electronic monitor that sounds an alarm when the patient reaches a near-vertical position

A student nurse is caring for a patient of Mexican descent. In an attempt to become culturally aware, the student should consciously think about which of the following? a. What people of Mexican descent believe b. The relationship between culture and ethnicity c. The fact that the patient belongs to an isolated social group d. Where the person is in the intersections of socially constructed categories

Where the person is in the intersections of socially constructed categories

Which of the following data are most important to assess if a patient is receiving sufficient sleep?

Whether the patient feels rested

(1)Which action by the nurse demonstrates implementation of Florence Nightingale's original theories about nursing care? a. The patient is gently bathed and given fresh linens after giving birth. b. The nurse forms a close therapeutic relationship with the patient. c. The nurse helps the patient conserve energy for healing processes. d. The nurse views the patient as a unique, ever-changing energy field.

(13) A registered nurse works as a case manager on an orthopedic unit. What primary role is fulfilled by the nurse? a. Coordinating care for patients following joint replacement surgery b. Obtaining insurance preauthorization for joint replacement surgeries c. Providing bedside care to patients who have had joint replacement surgery d. Tracking infection rates and outcomes for patients after joint replacement surgery

(14) Which term is used to describe the nares of a patient after a nasal culture is positive for MRSA? a. Reservoir b. Portal of entry c. Susceptible host d. Mode of transmission

(4)Which is an appropriate goal within the scope of Healthy People 2020? a. Uninsured patients will receive the same level of care as patients with private health insurance. b. The patient will be able to transfer to the wheelchair with a gait belt and assistance of one person. c. The patient's family will verbalize reduction of stressors when respite care is provided for the patient. d. Family members are taught how to assist the patient with feeding and other activities of daily living.

(6)Which ethical principle is violated when the patient is not told the truth about the medical diagnosis and therefore is not able to decide on the course of treatment? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

(9)The nurse carefully enters a new patient's medical history and current medication list into the agency's electronic health record (EHR). Which step of the nursing process is being performed by the nurse? a. Assessment b. Implementation c. Evaluation d. Diagnosis

A nurse is caring for a patient who cannot speak clearly. Which technique should the nurse use to enhance conversation with this patient? a. Ask questions that require "yes" or "no" answers. b. Avoid communication aids to prevent embarrassment. c. Speak loudly and slowly to facilitate patient understanding. d. Finish the patient's sentences when the patient is unable to.

A nurse is using SBAR. Which information will the nurse report for the "B"? a. The patient has a fractured right leg with a cast that was applied 2 days ago. b. The patient's toes are cool and pale and the patient reports that the foot feels numb. c. The patient is reporting severe pain 1 hour after pain medication was given. d. The nurse requests that the primary health care provider examines the patient.

A nurse tells a patient with a recent back injury that damage to the nerves is comparable to a water hose that has been pinched off and that time is needed to allow normal nerve transmission. Which technique did the nurse use? a. Analogy b. Discovery c. Role playing d. Demonstration

A registered nurse is caring for a postoperative patient whose systolic blood pressure has dropped 10 points during the shift. The nurse remembers that this was similar to a situation that happened in the past when a patient developed an internal bleed. Which term most accurately describes the thought process of the nurse? a. Reflection b. Curiosity c. Discipline d. Confidence

After a new handwashing protocol is instituted, patients are asked to complete surveys about whether or not providers performed hand hygiene before and aftercare is provided. Which term best describes this action? a. Process measurement b. Peer-reviewed research c. Experimental study d. Outcomes research

At the nursing station, the nurse receives a verbal order from the physician for a routine medication. What is the best action of the nurse? a. Request that the doctor enter the order into the computer. b. Repeat the order to the doctor and enter it into the computer. c. Direct the unit secretary to enter the order into the computer. d. Call the pharmacy to determine that the drug dosage is appropriate.

How will the hospital be reimbursed by Medicare for an elderly patient admitted with pneumonia? a. Based upon the DRG for pneumonia b. Based upon the cost of the patient's care c. Based upon the patient's length of stay d. Based upon the types of therapies required

In a facility with an outbreak of Clostridium difficile, the nurse manager determines that staff members are continuing to use alcohol-based hand sanitizer when caring for patients with Clostridium difficile infection despite the policy which requires hand hygiene using soap and water. Which step of the scientific method was performed by the nurse manager? a. Identification of the problem b. Formation of the hypothesis c. Investigation of the hypothesis d. Evaluation of the intervention

In which case might the patient be ordered by the court to receive treatment? a. The patient has infectious TB and refuses to take the prescribed antibiotics. b. The patient's mother refuses a vaccine for her child because he is allergic to it. c. A Jehovah's Witness refuses a blood transfusion based on religious convictions. d. A patient refuses treatment to slow the advancement of an inoperable brain tumor.

Researchers conduct a study to determine if the use of chlorhexidine mouthwash is more effective than the use of normal saline for oral care to reduce the incidence of ventilator-associated pneumonia. Which action by the researchers makes the study a randomized controlled trial? a. The researchers do not know which patients will be treated with saline and which patients will be treated with chlorhexidine. b. The researchers do not know which treatment will be more effective before the interventions are tested. c. The researchers randomly select nurses at several local health care facilities to implement the mouth-care protocols. d. The researchers do not know which statistical tests will be used to evaluate the effectiveness of the oral care protocols.

The extended care agency administers the flu vaccination to all of the patients who do not have contraindications to the injection. What is the reason that the nurses do not have to obtain orders from each patient's physician for vaccination each year? a. The agency's medical director placed a standing order for patients to receive the flu vaccination yearly unless contraindicated. b. The Centers for Disease Control and Prevention highly recommend yearly flu vaccinations for all individuals over the age of 65. c. The State Licensing Board for extended care facilities requires annual flu vaccinations for all residents and staff. d. The administrator of the agency has the authority to order annual flu vaccinations for all residents and staff.

The nurse asks another nurse for assistance when trying to determine the best way to manage a postoperative patient's pain. Which critical thinking attitude is demonstrated by the nurse? a. Humility b. Confidence c. Risk taking d. Fairness

The nurse becomes frustrated when a patient insists on taking herbal remedies rather than prescribed medications and spends certain hours of each day in prayer. The patient also prefers the care of the spiritualist healer over the attending physician. Which factor may be responsible for the nurse's frustration? a. Cultural differences in health-related practices b. Delay in the patient's psychosocial development c. Impaired ability of the patient to cope with acute illness d. Incorrect organization of health assessment findings

The nurse cuts an unconscious patient's long hair in order to wash and brush it. The patient wakes up and is very upset after seeing the short hair. Which tort did the nurse commit? a. Battery b. Assault c. Slander d. Negligence

The nurse disposes of gauze dressings that are saturated with drainage from a MRSA-positive wound. Which action is appropriate? a. The gauze dressings are placed in a red medical waste disposal bag. b. The gauze dressings are placed in the wall-mounted sharps disposal box. c. The gauze dressings are left in the wastepaper basket in the patient's room. d. The gauze dressings are flushed down the disposal system in the utility room.

The nurse has just completed teaching the patient how to self-administer insulin injections. Which entry in the patient's chart demonstrates that the teaching was successful? a. The patient correctly self-administered his next scheduled dose of insulin. b. The patient denied having any questions or concerns about the procedure. c. Additional written instructions about how to perform the injection was provided. d. The patient identified the steps and equipment used for the injection.

Which action by the nurse demonstrates the concept of nurse autonomy? a. The nurse braids the patient's long hair to prevent tangles. b. The nurse directs the nursing assistant to obtain the patient's weight. c. The nurse counts the patient's pulse before administering digoxin. d. The nurse checks the policy manual before changing the central line dressing.

Which action by the nurse helps to achieve the goals of the Hospital Readmissions Reduction Program? a. The nurse ensures that the patient understands how to take prescribed medications correctly. b. The nurse develops a close therapeutic relationship with the patient and provides privacy when care is provided. c. The nurse uses therapeutic touch to promote relaxation, reduce anxiety, and promote healing. d. The nurse elevates the head of the patient's bed and administers oxygen when the patient feels short of breath.

Which action by the nurse is an example of a workaround? a. In order to save time, the nurse scans medication bar codes after administration to the patient. b. The nurse prioritizes care for patients so that the most urgent patient needs are addressed first. c. The nurse helps the nursing assistant to change the linens after a patient is incontinent of stool and urine. d. The nurse seeks assistance from another nurse when having difficulty advancing the urinary catheter into the bladder.

Which action by the patient reflects a cultural influence on health practices? a. The patient uses seaside purification rituals to ease arthritis pain. b. The patient refuses to take blood pressure medicine due to the side effects. c. The patient has annual mammograms to screen for breast cancer. d. The patient avoids eating red meat due to a family history of heart disease.

Which action indicates the new nurse is fulfilling entry-level competencies? a. Communicating concerns to the patient's physician b. Developing a theoretical framework for practice c. Creating a quality improvement plan for the unit d. Monitoring staff compliance with unit policies

Which action of the nurse demonstrates the concept of the Holistic Health Model? a. The nurse incorporates the patient's religious restrictions, economic status and personal preferences when developing the nutrition plan. b. The nurse has the patient demonstrate how to perform a sterile dressing change after teaching about the procedure. c. The nurse consistently uses a 0-10 objective pain rating scale to achieve consistent pain management for the patient. The nurse assists the patient to sit up slowly when getting out of bed to avoid fainting from orthostatic hypotension

Which action of the nurse demonstrates the use of standard precautions? a. The nurse uses gloves when performing oral care for the patient. b. The nurse puts on a surgical mask before entering the patient's room. c. The patient is placed in a private room with negative-pressure airflow. d. The nurse uses sterile gloves when emptying the patient's urinary catheter bag.

Which action of the nurse is appropriate after leaving the room of the patient with Clostridium difficile? a. Wash hands thoroughly for 20 seconds with antibacterial soap and water. b. Vigorously rub a quarter-sized dollop of hand sanitizer into both hands. c. Perform a sterile scrub procedure using chlorhexidine soap solution. d. Scrub the hands for 2 minutes keeping hands above the level of the elbows.

Which assessment finding is an example of an internal variable that influences the patient's health beliefs? a. The patient's spiritual beliefs prohibit the use of blood transfusions. b. The patient's family is homeless after being evicted from their apartment. c. The patient relies on a pharmacy assistance program to pay for medications. d. The patient and community prefer natural medicines over prescription drugs.

Which assessment findings will the nurse communicate to the physician using the SBAR tool? a. The patient is having difficulty breathing and the pulse oximetry is 75%. b. The patient has not had a bowel movement since surgery eight hours ago. c. The patient's family member initially refused to learn how to perform the dressing changes. d. The patient sent the breakfast tray back to the kitchen because the food was cold.

Which assessment question allows an administrator to determine the level of patient satisfaction after hospitalization? a. "Did the nursing staff treat you with respect and maintain your privacy?" b. "Were you able to keep the follow-up appointment with your physician?" c. "Did you have any difficulty filling your prescriptions after discharge?" d. "Has the occupational therapist come to your home to start therapy yet?"

Which ethical area is challenged when the nurse feels bound to refuse to assist with an abortion procedure? a. Values b. Culture c. Confidentiality d. Social networking

Which form of insurance is appropriate for a single mother who is unable to work and her three children? a. State Medicaid b. Federal Medicare c. Private insurance d. Managed care program

Which health care professional will be of most assistance to help the patient with aphasia following a stroke? a. Speech therapist b. Medical interpreter c. Physical therapist d. Mental health nurse specialist

Which information is included in the Minimum Data Set? a. The patient has a history of gout and macular degeneration. b. The average length of stay for pneumonia is 3 days in the hospital. c. The hospital has a 14% nosocomial urinary tract infection rate. d. Approximately 40% of American adults exercise at least 30 minutes daily.

Which information must be shared during the hand-off report to the oncoming nurse? a. The patient is nauseated and complaining of moderate generalized pain. b. The patient has six children and fourteen grandchildren. c. The patient will drink chicken broth but prefers to have lime gelatin. d. The patient sent back the dinner tray twice because the food was cold.

Which is an appropriate goal for the public health nurse working in the community? a. At least 95% of children in the elementary schools will be up to date on immunizations. b. The family will learn how to transfer the patient to the toilet and assist the patient to dress each morning. c. The patient's white blood cell count will return to normal by the time the antibiotic treatment has been completed. d. Nursing assistants will be allowed to administer routine medications to residents of assisted care facilities.

Which is an example of a Healthy People 2020 goal? a. Women and men will receive equally aggressive care for suspected heart attack. b. The patient will participate in a physical therapy program after suffering a stroke. c. The nurse will identify and address stressors unique to multicultural families. d. The nurse will organize mobile mammograms for female patients in the local area.

Which is an example of a sentinel event? a. The patient suffers a fatal air embolism after a central line is removed incorrectly. b. The nurse identifies a patient's urinary tract infection before symptoms develop. c. The unit's urinary tract infection rate is 5% lower than the national average. d. The pilot study indicates potential effectiveness of a new oral care protocol.

Which is an example of an environmental risk factor? a. The patient's drinking water contains high levels of lead. b. The patient has a strong family history of autoimmune diseases. c. The patient carefully follows a lactose-free, gluten-free diet. d. The patient drinks one glass of red wine every night before bed.

Which is an example of health care disparity? a. The physician treats cardiac patients with insurance more aggressively than noninsured patients. b. The patient takes longer to recover from surgery due to a history of aggressive rheumatoid arthritis. c. The nurse prioritizes care so that additional time is spent with patients who require more intensive interventions. d. The registered nurse is able perform more advanced interventions than the licensed practical nurse.

Which is an example of respite care? a. A patient with dementia attends an adult day care center so that the patient's family can go to work. b. The respiratory therapist comes to the patient's house to ensure that the oxygen equipment is functioning correctly. c. The nurse teaches the patient's spouse how to check blood sugar levels and administer insulin to the patient. d. The patient is seen in an urgent care clinic for stitches and wound care after being bitten by a dog.

Which is an example of suprainfection? a. The patient develops Clostridium difficile diarrhea after taking broad-spectrum antibiotics. b. The immunocompromised patient develops an upper respiratory despite protective isolation precautions. c. The bacteria in the patient's wound are resistant to cephalosporin and penicillin antibiotics. d. The patient's upper respiratory infection progresses to pneumonia with right-sided pleural effusion.

Which is the appropriate action for the nurse manager when a nurse refuses to assist with an abortion due to personal ethical beliefs? a. Assign the nurse to care for other patients. b. Counsel the nurse about professional responsibility. c. Report the nurse's refusal to the State Board of Nursing. d. Inform the nurse that the refusal will lead to termination.

Which is the most appropriate learning goal for new parents who are learning infant CPR? a. The parents will demonstrate infant CPR skills. b. The parents will be able to understand CPR skills. c. The infant will not require further hospitalization. d. The parents will call the hospital if the infant stops breathing.

Which is the most appropriate nursing diagnosis to use for a patient with expressive aphasia following a stroke? a. Impaired verbal communication related to inability to speak and reply b. Readiness for enhanced comfort related to drooling and facial droop c. Deficient diversional activity related to lack of stimuli in hospital room d. Noncompliance related to inability to verbally answer questions

Which mode of transmission is demonstrated when the nurse spreads an infection with the hands after neglecting to perform hand hygiene? a. Direct b. Automatic c. Spontaneous d. Uninterrupted

Which patient assessment finding must be addressed first according to Maslow's hierarchy of needs? a. The patient is cyanotic and feels short of breath. b. The patient refuses to participate in physical therapy. c. The patient verbalizes anxiety about upcoming surgery. d. The patient is unable to reposition in bed without assistance.

Which patient assignment demonstrates the concept of team nursing? a. The RN, the LPN, and the nursing assistant work together to provide all the care needed by eight patients for the shift. b. The RN cares for the same five patients every day during their stay following joint replacement surgery. c. The hospice RN works closely with the patient's daughter to ensure that the patient's dying requests are met. d. The RN coordinates care of the patient with the physician assistant to ensure that the clinical pathway is followed.

Which patient is appropriate for the nursing diagnosis readiness for enhanced knowledge related to the prescribed treatment regimen? a. The patient who asks the nurse how a pill organizer can help to ensure that all medications are taken on time. b. The patient who insists that the blood sugar levels will never stabilize no matter how many medications are taken. c. The patient who believes that influenza was contracted as a result of the flu immunization last year. d. The patient who was just diagnosed with diabetes and has no idea about how to inject insulin.

Which patient is the highest priority for the discharge planner? a. A patient who will require home IV antibiotics for the next 6 weeks b. A patient who will be taking antihypertensive medications after discharge c. A patient who will be discharged after routine tonsillectomy surgery d. A patient who will be returning to a local skilled nursing facility

Which patient scenario allows the physician to perform needed procedures without the need to obtain informed consent first? a. An unconscious patient is brought into the ER after an auto accident. b. The patient speaks only Russian and requires the services of a translator. c. The patient is deaf and communicates through sign language or lip reading. d. The patient is not an American citizen and does not have any health insurance.

Which precautions are appropriate for a patient with a methicillin-resistant Staphylococcus aureus (MRSA) wound infection? a. Contact b. Airborne c. Droplet d. Standard

Which preoperative task may be delegated to the nursing assistant? a. Apply the patient's thromboembolism deterrent (TED) stockings. b. Teach the patient how to perform incentive spirometry exercises. c. Witness the patient's signature on the informed consent document. d. Make sure that the patient swallowed the prescribed preoperative medication.

Which program is appropriate for a nurse who wishes to become an expert in ostomy and wound care? a. Specialty certification b. Master of Science program c. Doctoral degree program d. Continuing education program

Which protective apparel must the nurse wear to start an intravenous line for the patient? a. Gloves only b. Sterile gloves only c. Gloves and a mask d. Gloves and a gown

Which specifics of care will be included in a patient's critical pathway? a. Refer the patient to the outpatient cardiac rehabilitation program. b. Elevate the head of the patient's bed to ease shortness of breath. c. Provide small meals throughout the day and encourage fluid intake. d. Teach the patient how to use relaxation techniques to ease shortness of breath.

Which statement by the nurse is an example of back-channeling? a. "I completely understand. Can you tell me more?" b. "When did you first seek health care for your symptoms?" c. "I am sure the doctor will answer all of your questions shortly." d. "Try not to worry. I'm sure that you will be just fine."

Which statement indicates the patient's perception of susceptibility to illness as described by the Health Belief Model? a. "I am never going to get lung cancer so I refuse to stop smoking." b. "Cancer is no big deal with all of the new treatments available now." c. "I have been smoking for so many years that I will never be able to quit." d. "I cannot afford the nicotine patches so I might as well keep on smoking."

Which technique by the nurse will facilitate communication with an older adult? a. Allow reminiscing. b. Use long sentences. c. Ask several questions in a row. d. Play soft music in the background.

Which type of program is appropriate to educate staff about new fall prevention protocols that are to be implemented on the nursing unit? a. In-service education b. Advanced education c. Continuing education d. Certification education

Which type of research study is most appropriate to determine if premedication with diphenhydramine is more effective than acetaminophen to reduce the incidence of aseptic meningitis after intravenous globulin infusion? a. Randomized trial b. Qualitative study c. Historical review d. Descriptive report

A pediatric nurse is assessing a patient for a routine physical. The nurse identifies that the parents need additional safety teaching when the parents mentions which of the following

a 2 yr old child can safely sit in the front seat

The nurse noted a rise in skin infections on the nursing unit. After a literature review was completed, a new bathing protocol using disposable wash basins and pH balanced skin cleansers was suggested. Which steps of the scientific process were used by the nurse? (Select all that apply.) a. Identify the problem. b. Collect the data. c. Answer the question. d. Evaluate the results. e. Publish findings.

a, b

Which assessment findings indicate to the nurse that the patient's incision has become infected? (Select all that apply.) a. The incision site is red and warm to the touch. b. Thick yellow-green drainage is noted at the site. c. The patient's white blood cell count is 5300/mm3. d. The wound edges are well approximated with sutures. e. The patient received prophylactic antibiotics before surgery.

a, b

Which therapeutic communication techniques should the nurse use while communicating with a small child? (Select all that apply.) a. Sit at the child's eye level. b. Use simple, direct language. c. Use drawings and toys as needed. d. Tell the child exactly what they can do. e. Avoid sudden movements or gestures.

a, b, c, e

Which key elements are included in decentralized decision making? (Select all that apply.) a. Authority b. Autonomy c. Prioritization d. Responsibility e. Accountability

a, b, d, e

Which leadership skills will the nursing student use when caring for patients? (Select all that apply.) a. Priority setting b. Time management c. Case management d. Careful delegation e. Team communication

a, b, d, e

Which findings are included in the nurse's community assessment? (Select all that apply.) a. Approximately 15% of the residents are college graduates. b. The community's water system is free of arsenic and lead. c. The community's mayor has been in office for the last 18 years. d. The community average summer temperature is 78° F. e. The community has paid police officers and volunteer firefighters.

a, b, e

1. Which sources may be found in the Cumulative Index of Nursing and Allied Health Literature (CINAHL) database? (Select all that apply.) a. Literature review about complementary therapies for rheumatoid arthritis b. Randomized trial to study the use of honey to treat decubitus ulcers c. Satirical article about the risk of dihydrogen monoxide exposure to humans d. Blog written by a patient recently diagnosed with myasthenia gravis e. Meta-analysis to analyze coffee intake with risk of developing dementia

a, b, e.

Using the Health Promotion Model while rendering care enables a nurse to do which of the following: (Select all that apply.) a. Help the patient attain better health b. Detect the presence of illness c. Promote health behaviors in a patient d. Assess a family's response to illness e. Stimulate relational transcendence

a, c

Which goals are appropriate for a patient in a restorative care agency? (Select all that apply.) a. The patient will be able to transfer to the wheelchair with one person assist. b. The patient's family will verbalize understanding of the dying process. c. The patient will be able to eat independently using specially molded utensils. d. The patient will be transferred to a trauma hospital within 1 hour of arrival. e. The patient's family will verbalize feeling of relief from strains of caregiving.

a, c

Which patient situations require the completion of an incident report? (Select all that apply.) a. A patient almost receives the wrong medication due to unclear wording on the packaging from the pharmacy. b. A patient repeatedly refuses to eat food from the hospital kitchen because it is always too salty or too cold. c. A visitor trips on an icy sidewalk in the hospital parking lot and suffers a fractured wrist. d. The nurse accidentally enters the wrong vital signs into the patient's medical record and corrects the error shortly afterward. e. The patient dislikes male nursing staff and prefers to have only female nurses providing personal care.

a, c

Which statements are examples of hypotheses? (Select all that apply.) a. Hospitals staffed with primarily bachelor-prepared nurses will have lower mortality rates than hospitals staffed with primarily associates-prepared nurses. b. More than 80% of the patients with catheter-associated urinary tract infections did not have any signs or symptoms of infection. c. Patients who receive ondansetron preoperatively will experience lower rates of nausea and vomiting than patients who do are not premedicated. d. The greatest risk factor for developing ventilator-associated pneumonia was the length of time that the patient was intubated. e. Ultraviolet light disinfection of equipment is a nontoxic, effective method for prevention of Clostridium difficile infection.

a, c

Which actions of the nurse demonstrate the nursing role of educator? (Select all that apply.) a. The nurse teaches the patient's family how to perform sterile dressing changes. b. The nurse includes the patient in clinical decision making whenever possible. c. The nurse provides written teaching materials in the patient's preferred language. d. The nurse speaks about diabetes management at a professional conference. e. The nurse assesses for adequate protein intake for a patient on a vegetarian diet.

a, c, d

Which health care professionals will participate in discharge planning for the patient? (Select all that apply.) a. Registered nurse b. Radiology technician c. Social worker d. Physical therapist e. Laboratory technician

a, c, d

The nurse has received an order to administer warfarin 100 mg PO today to the patient. This amount seems high to the nurse. Which are the appropriate actions of the nurse? (Select all that apply.) a. Clarify the order with the physician. b. Document suspicion about the order. c. Notify the nursing supervisor on duty. d. Administer the medication as ordered. e. Question the pharmacist about the dosage.

a, c, e

Which actions of the nurse demonstrate the nursing role of leader? (Select all that apply.) a. The nurse implements a new skin-care protocol to reduce decubitus ulcers. b. The nurse develops a therapeutic relationship with the patient's family members. c. The nurse ensures that the patient assignments are created fairly for each shift. d. The nurse works to meet the patient's cultural preferences for personal care. e. The nurse clearly communicates expected standards of care for the patients.

a, c, e

Which actions by the nurse are examples of independent nursing interventions for a postoperative patient? (Select all that apply). a. Teaching patients with heart failure how to do accurate daily weights b. Administering intravenous fluids when the patient is unable to eat or drink c. Advancing a patient's diet from clear liquids to solid foods after surgery d. Elevating the head of the patient's bed to facilitate use of the incentive spirometer e. Switching the patient's injected pain medication to oral tablets before discharge

a, d

Which information must be included in the patient's discharge summary? (Select all that apply.) a. The patient is to follow up with the primary care physician in 14 days. b. The patient arrived at the hospital by ambulance with acute shortness of breath. c. Supplemental oxygen was administered to the patient in the emergency room. d. The patient is to have a protime (PT) level drawn daily for the next 7 days. e. The patient is to take the prescribed antibiotic daily even after symptoms subside

a, d, e

Which patients are considered to belong to vulnerable populations? (Select all that apply.) a. An HIV-positive young adult working as a finance expert b. A college graduate living in his parents' basement c. A registered nurse who works at two different clinics d. An unemployed single mother with four small children e. A family that just moved to Florida and speaks no English

a, d, e

The nurse is caring for a patient who climbed out of bed and fell on the floor. What will the nurse do in regard to the incident report? (Select all that apply.) a. Document how the patient was found and a description of the injuries. b. Include recommendations for future fall prevention interventions. c. Note in the patient's chart that an incident report was completed. d. Indicate that the nursing assistant wasn't doing her job correctly. e. Document fall prevention steps that were in place before the patient fell.

a, e

The family is unsure what treatment is appropriate for the comatose patient who is terminally ill. Which steps will the nurse take to help the family process this ethical dilemma? (Select all that apply.) a. Consider all possible treatment options. b. Calculate the odds of the patient's survival. c. Clarify own values and opinions about the issues. d. Provide personal opinions about treatment options. e. Gather all relevant information about the situation.

a,c,e

The patient was involved in a motor vehicle accident. The patient has a fractured right hip and is on bed rest. Because of the prolonged immobility the nurse is concerned about complications such as which of the following? (Select all that apply.)

a. Decreased nutrients/fluids b. Increased disuse osteoporosis d. Decreased lung expansion

A patients daughter died in a ski accident. The patient stated, I cannot believe my daughter has died. According to Wordens tasks of mourning, the patient is experiencing task: a. I. b. II. c. III. d. IV.

a. I

A middle-age patient with a terminal disease is speaking harshly to the nurse every time the call light is answered. The nurse identifies that this patient is experiencing the second stage of Kbler-Ross stages of dying. What is the second stage? a. Anger b. Denial c. Bargaining d. Acceptance e. Depression

a. anger

Bowlbys phases of mourning are founded on which of the following human instincts? a. Attachment b. Numbing c. Searching d. Grief

a. attachment

When a person has difficulty progressing through his or her loss experience, he or she experiences complicated grief. What are the types of complicated grief? (Select all that apply.) a. Chronic b. Delayed c. Exaggerated d. Masked e. Disenfranchised

a. chronic b. delayed c. exaggerated d. masked

A nursing student is concerned with sensory deprivation among the patients in the nursing home during the clinical rotation. Which of the following could be caused by sensory deprivation? Select all that apply. a. Confusion b. Anxiety c. Disorientation d. Panic e. Aggressiveness

a. confusion b.anxiety c.disorientation

The nurse is interviewing a patient who claims to be in the middle of a crisis situation. The nurse should: Select all that apply. a. determine the patients view of the situation. b. be aware that denial is never a coping mechanism for people in crisis. c. point out that the patient is repeating information and ask him to stop. d. assess for the potential for suicide/homicide. e. assess coping mechanisms and support systems.

a. determine the patients view of the situation d. assess for the potential suicide/homicide e. assess coping mechanisms and support systems

A 34-year-old single mother of three had been involved in a secret relationship with her boss, a married man who was 24 years her senior. When her boss suddenly died as the result of a heart attack, the woman had difficulty expressing the extent of her loss. The grief that she was experiencing could best be described as which of the following? a. Disenfranchised b. Complicated c. Normal d. Anticipatory

a. disenfranchised

A patient has been admitted to the hospital with advanced colon cancer and is receiving palliative care at this time. The nurse feels anxious in caring for this patient, but realizes which of the following? a. The patient needs the nurses presence and personal connection. b. Remaining silent would signify a noncaring attitude. c. All people react to loss in the same way. d. Reminiscing only makes a difficult situation worse.

a. the patient needs the nurses presence and personal connection

The patients home has been demolished by a tornado. The patients spouse and child were killed and the spouse is in need of a leg amputation. The nurse realizes that which of the following is true? a. The patient will deal with his losses using usual coping strategies. b. A patients normal coping strategies are always adequate. c. Patients usually seek new strategies to deal with loss. d. At the end of life, people still rely on the usual coping strategies.

a. the patient will deal with his losses using usual coping strategies

* Match the following caring behaviors with their definitions: * a. Knowing b. Being with c. Doing for d. Maintaining belief

a=striving to understand the meaning of an event for another person b=being emotionally there for another person c=Providing for another as he or she would do for themselves d=Sustaining faith in one's capacity to get through a situation

When individuals become ill, there may be a story about the meaning of the illness. When a nurse listens, the patient is: a. able to break the distress of illness. b. unable to express what he actually needed when he was ill. c. usually not able to determine what is at stake because of his illness. d. able keep the nurse from prying into his more personal life.

able to break the distress of illness

A nursing student is volunteering with a local agency to help prepare the community for a potential bioterrorist attack. On which of the following threats would be the nursing student's primary focus?

anthrax

Measurements include height, weight, mid upper-arm circumference, and triceps skinfold measurements

anthropometric

A patient who underwent surgery for a bowel obstruction yesterday has become confused and has made several attempts to climb out of bed. The nurse is considering options to prevent the patient from harm. Which of the following actions could be delegated to assistive nursing personnel working with the nurse?

apply restraints after orders received by nurse

A fire erupts in a hospital waste receptacle in the hallway. What is the nurse's first response?

assist any patients to a safe area

Collapse of alveoli

atelectasis

The patient uses a special telephone connection to allow the cardiologist to assess the patient's pacemaker function while the patient stays at home. Which term is used to describe this type of health care? a. Capitation b. Telemedicine c. Magnet Recognition Program d. Utilization review

The patient verbalized frustration to the nurse about the lengthy recovery time after surgery. The nurse's response was "I understand how you want to be feeling better already." Which communication technique was used by the nurse? a. Sympathy b. Empathy c. Focusing d. Self-disclosure

The patient's daughter requests to see the patient's medical record. What is the nurse's appropriate response? a. "Come with me and we will look at it together." b. "I'm sorry but that information is confidential." c. "Let me ask my supervisor if it is okay." d. "The doctor will have to give permission first."

The patient's family members disagree about which treatment is most appropriate for the terminally ill comatose patient. Which nursing intervention is most appropriate for this situation? a. The nurse will provide statistical information about the patient's odds of survival. b. The nurse will promote effective communication between the family members. c. The nurse will ask the family members to leave medical decisions to the physician. d. The nurse will wait until the patient is able to make the decisions about treatment.

The patient's urine cultures tested positive for Escherichia coli (E. coli) following urinary catheterization. Which term describes this type of infection? a. Protozoan b. Endogenous c. Diagnostic d. Bactericidal

When the nurse takes the patient's hand, the patient quickly pulls it back. How will the nurse interpret this patient's behavior? a. The patient is unable to express feelings. b. The patient is uncomfortable with being touched. c. The patient has impaired social skills with others. d. The patient has difficulty with nonverbal communication.

Where is the best place for the nurse to obtain the latest information about prevention of catheter-associated urinary tract infections? a. Online information b. Peer-reviewed nursing journal c. Latest edition of a nursing textbook d. Most recent edition of a popular magazine

Which action by the nurse best demonstrates independent thinking? a. Removing and carefully cleaning the patient's dentures every night b. Initiating swallow precautions when the patient shows signs of aspiration c. Teaching the diabetic patient how to self-administer insulin injections d. Actively listening to the patient when recording the patient's health history

Which action by the nurse demonstrates appropriate timing for effective communication? a. The nurse sits in a chair next to the patient's bed to maintain eye contact. b. The nurse waits to begin teaching until the patient's nausea has subsided. c. The nurse speaks slowly and loudly for a patient who is hard of hearing. d. The nurse maintains privacy during all conversations with the patient.

Which action by the nurse helps to meet the aesthetic needs of the patient as described by Maslow? a. The nurse uses a drawsheet to carefully reposition the patient in bed. b. The nurse puts a beautiful handmade quilt on the bed for the patient to enjoy. c. The nurse collaborates with the health care team when scheduling care activities. d. The nurse assesses the patient's readiness to learn before beginning teaching.

Which action by the nurse helps to meet the cognitive needs of the patient as described by Maslow? a. Encouraging early ambulation after surgery to prevent formation of blood clots. b. Providing a calm environment when the patient becomes agitated and confused. c. Teaching the patient's family how to perform sterile dressing changes. d. Performing careful perineal care to avoid development of a urinary tract infection.

Which action by the nurse manager facilitates empowerment of the nursing staff? a. The nurse manager sets the policies for the nursing staff to follow. b. The nurse manager works with the staff to set annual goals for the unit. c. The nurse manager advocates for patients when care difficulties develop. d. The nurse manager prioritizes patient care needs when creating assignments.

Which action by the nurse will help to reduce the fears of a hospitalized young child? a. Stand over the bed when talking to the patient. b. Sit in a chair next to the bed when talking to the patient. c. Maintain constant eye contact with the patient at all times. d. Stay within 12 inches of the patient when talking to the patient.

Which action by the patient best represents primary prevention? a. The patient utilizes a cane when walking to prevent falls. b. The patient receives the influenza vaccination every year. c. The patient participates in physical therapy after having a stroke. d. The patient takes prescribed blood pressure medication every morning.

Which action of the nurse addresses Maslow's need for love and belongingness? a. The nurse uses a gait belt and assists the patient to use a walker for ambulation. b. The nurse encourages a widowed patient to join a bereavement support group. c. The nurse plans daily care to allow for rest periods for the patient as needed. d. The nurse reorients the patient to time and place during periods of acute confusion.

Which action of the nurse demonstrates clinical decision making? a. The nurse performs a detailed health history and physical assessment when the patient is admitted to the unit. b. The nurse determines that the patient is at risk for constipation due to use of postoperative narcotic pain medication. c. The nurse applies a hydrocolloid dressing to the patient's decubitus ulcer as ordered by the physician. d. The nurse assesses the patient's oral mucus membranes each morning to check for candida infection or ulceration.

Which action of the nurse demonstrates coordination of care for the patient? a. The nurse creates a warm, therapeutic relationship with the patient by actively listening to what the patient has to say. b. The nurse works with the physical therapist to determine how to best transfer the patient from the bed to the chair. c. The nurse educates the patient about energy conservation techniques to increase activity tolerance. d. The nurse uses clear and objective language when documenting assessment findings in the patient's medical record.

Which action of the nurse will minimize the onset and spread of infection? a. Insert indwelling urinary catheters to prevent incontinence. b. Use aseptic technique when providing mouth care to the patient. c. Keep the patient's mucus membranes dry to prevent maceration. d. Use masks and gowns sparingly to reduce the patient's sense of isolation.

Which assessment finding indicates that the patient is at high risk for infection? a. The patient is allergic to penicillin, iodine. and watermelon. b. The patient has a urinary catheter draining clear yellow urine. c. The patient's white blood cell count is 7500/mm3 this morning. d. The patient follows a kosher diet and refuses to eat pork or shrimp.

Which assessment finding indicates that the patient's body image has been altered due to illness? a. The patient developed a strong dislike for any kind of spicy foods. b. The patient feels uncomfortable wearing a swimsuit after colostomy surgery. c. The patient refuses to take antihypertensive medications due to the side effects. d. The patient drinks six glasses of cranberry juice daily to prevent bladder infections.

Which assessment finding is a modifiable risk factor for disease? a. The patient has a family history of breast cancer. b. The patient smokes two packs of cigarettes every day. c. The patient was born with a congenital heart defect. d. The patient's childhood home contained high levels of radon.

Which behavior best demonstrates active listening by the nurse? a. Keeping arms crossed b. Sitting facing the patient c. Standing facing the patient d. Leaning away from the patient

Which characteristic qualifies the hospital for Magnet Recognition status? a. The hospital is affiliated with a nationally recognized medical school. b. The hospital participates in nursing research and implements the findings. c. The hospital is owned by a religious order that offers daily prayer services. d. The hospital receives federal grant funding for advanced medical research.

Which chart entry documents patient achievement of cognitive learning? a. The patient verbalized decreased desire to commit self-harm. b. The patient described three symptoms of diabetic ketoacidosis. c. The patient demonstrated how to perform active range of motion. d. The patient expressed satisfaction with ability to share feelings with others.

Which chart entry reflects appropriate documentation of patient data? a. The patient voided a moderate amount of urine. b. The patient voided 220 mL of clear yellow urine. c. The patient was incontinent. d. The patient voided an adequate amount of urine for the shift.

Which ethical area is involved when the clinic releases genetic test results to the patient's employer without the patient's consent? a. Veracity b. Bioethics c. Justice d. Beneficence

Which ethical principle is upheld when uninsured patients receive the same level of care as patients with private health insurance? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

Which feature of the hospital enables it to qualify for Magnet Recognition Program? a. The hospital cafeteria is open 24 hours to accommodate staff on every shift. b. The nurses utilize evidence-based practice and flexible staffing plans. c. The hospital radiology technicians have received additional certifications. d. The hospital physicians provide mentoring services for interns and residents.

Which is an appropriate action of the community-based nurse when functioning in the role of case manager? a. The nurse calculates the immunization rate for junior high-school students in the district. b. The nurse arranges for a transportation service to take the patient to physician appointments. c. The nurse uses therapeutic touch to help relieve the patient's chronic low back pain. d. The nurse helps the patient to sit upright and use pursed lip breathing during periods of dyspnea.

Which is an example of a Bundled Payment for Care Improvement? a. The insurance company combines services for several patients into one single payment. b. The hospital is paid a predetermined lump sum for all costs related to the patient's open-heart surgery. c. The hospital is paid an additional bonus if the patient's surgical outcome exceeds national standards. d. The insurance company will withhold all payments for the patient until accreditation is achieved.

Which is an example of a patient-centered medical home team? a. Occupational and physical therapists come to the patient's home to provide rehabilitation services. b. The patient's primary care physician coordinates care with the patient's social worker and respiratory therapist. c. The nurse assesses the patient's home environment for irritants that can worsen the patient's respiratory status. d. A home care company is employed to provide the patient with a nebulizer and supplemental oxygen equipment.

Which is an example of a qualitative research question? a. Will a school hand-hygiene program reduce the frequency of head lice outbreaks? b. What are the experiences of young children diagnosed with type 1 diabetes? c. How does crossing the legs affect the accuracy of blood pressure measurement? d. What is the incidence of side effects after administration of the influenza vaccine?

Which is an example of how a psychosocial variable affects the patient's health beliefs? a. The patient was diagnosed with rheumatoid arthritis as a young child. b. The patient has always been terrified of needles and so never goes to the doctor. c. The patient's neighborhood has few opportunities to buy fresh fruits or vegetables. d. The patient requires three antihypertensive medications to control blood pressure.

Which is an example of normal flora? a. The patient has a tapeworm living in the large intestine. b. The patient's colon contains bacteria to help assist digestion. c. The patient's incision is infected with Staphylococcus bacteria. d. The patient has a viral infection causing nasal congestion and sore throat.

Which is the best tool that the nurse can use to make sense of the patient's multiple medical diagnoses, assessment findings, and medications? a. Plan of care b. Concept map c. Reflective journal d. Intellectual standards

Which is the correct military time entry for a medication that was administered at 8:30 p.m.? a. 0830 b. 140 c. 2030 d. 2230

Which is the expected action of the nurse who is caring for a patient in a hospice agency? a. The nurse teaches the patient how to administer home IV antibiotics through an intravenous line. b. The nurse educates the patient's family about what to expect as the patient progresses through the dying process. c. The nurse reviews the patient's daily laboratory results before preparing to administer the next dose of chemotherapy. d. The nurse teaches the patient about the importance of swallow precautions to avoid the development of aspiration pneumonia.

Which is the highest priority concern for the nurse who is educating the homeless patient about medications, appointments, and therapies for management of diabetes? a. Motivation b. Health literacy c. Developmental stage d. Psychomotor learning

Which is the highest priority problem for a homeless patient without family in December? a. Risk for loneliness b. Risk for hypothermia c. Risk for social isolation d. Risk for compromised human dignity

Which is the priority goal for a patient who is being abused by the spouse? a. The patient's dignity will remain intact. b. The patient will remain free from injury. c. The patient will develop a sense of trust with the nurse. d. The patient will be able to verbalize fears to the nurse.

Which item of protective apparel is removed first when the nurse leaves the room of the patient with Clostridium difficile? a. Gown b. Mask c. Gloves d. Eyewear

Which nursing care order is an example of a standing order? a. Monitor blood glucose level before meals and at bedtime. b. Administer a soapsuds enema if no bowel movement for 3 days. c. Instruct the patient how to self-administer insulin correctly. d. Bathe the patient daily with application of moisturizer to all bony prominences.

Which nursing diagnosis has the highest priority for the patient following a stroke? a. Unilateral neglect related to disturbed perception about left side of body b. Risk for aspiration related to impaired swallowing and absence of gag reflex c. Constipation related to decreased physical activity and medication side effects d. Adult failure to thrive related to apathy and depression about physical disability

Which nursing diagnosis indicates that the patient will have difficulty learning how to perform sterile dressing changes at home? a. Deficient knowledge related to diabetic wound management b. Stress overload related to ongoing emotional abuse and bullying c. Readiness for enhanced knowledge related to diabetes management d. Impaired physical mobility related to need to use a cane for ambulation

Which nursing leadership approach demonstrates decentralized management? a. The nurse manager sets unit policies, conducts annual reviews, and disciplines the staff as needed. b. The staff nurses work with the manager to review care options to prevent surgical site infections. c. The nurse manager conducts regular staff meetings to provide updates about new equipment and agency policies. d. The nurse manager makes rounds on the unit every day to monitor for problems with patient care.

Which organization will discipline the nurse for abandoning patients during an assigned shift? a. The Joint Commission b. The State Board of Nursing c. The State Department of Health d. The National League for Nursing

Which patient will be treated in a Critical Access Hospital (CAH)? a. The cancer patient who requires a bone marrow transplant b. The victim of a serious car accident that occurred in a remote area c. The pregnant patient whose baby will require neonatal intensive care d. The patient who requires minimally invasive heart valve replacement

Which patient's needs must be addressed first by the registered nurse? a. The patient who is waiting for discharge teaching in order to go home b. The patient with chest pain after two doses of sublingual nitroglycerin c. The constipated patient who needs to use the toilet after receiving a laxative d. The patient who is nauseated and vomiting after receiving narcotic pain medication

Which situation gives the patient cause to sue for malpractice due to injury or harm? a. The patient developed an itchy rash after receiving a prescribed antibiotic. b. The patient died after being struck in the head by an oxygen tank during an MRI. c. The patient developed a sore throat after being intubated for emergency surgery. d. The patient developed permanent joint deformity due to severe rheumatoid arthritis.

Which statement exemplifies important patient information in the change-of-shift report? a. The patient sent his dinner tray back to the kitchen twice because the food was cold. b. The patient keeps taking his nasal cannula off and threading it around the side rails of the bed. c. The patient prefers to drink coffee that has cooled to room temperature with two sugars and two creamers. d. The patient took all of the prescribed morning medications with a big glass of apple juice.

Which statement made by the patient indicates readiness for learning about colostomy care? a. "I don't want to look at it and I can't imagine caring for it." b. "The sooner I can take care of it, the sooner I can go home." c. "I never thought I would have to take care of something like this." d. "I hope I can still wear a bathing suit with this thing."

Which teaching approach is demonstrated when the nurse provides guidance while the patient performs the sterile dressing change? a. Telling b. Entrusting c. Reinforcing d. Participating

Which technique should the nurse use when providing information to a patient with a health literacy level of fifth grade? a. Use the passive voice of language. b. Present the most important information first. c. Use medical terminology to explain the concepts. d. Shift from subject to subject until the patient responds.

Which type of reinforcement is used when the nurse gives a sticker to a pediatric patient every time the incentive spirometer is used? a. Social b. Material c. Activity d. Negative

Which actions of the nurse cause a break in the sterile procedure? (Select all that apply.) a. Dropping a sterile instrument onto the sterile field b. Spilling sterile saline solution onto the sterile field c. Reaching over the sterile field to pick up an instrument d. Keeping the top of the table above waist level e. Placing instruments in the center of the sterile field

b, c

Which approaches will the nurse use in order to effectively participate in interprofessional collaboration? (Select all that apply.) a. Utilize a top-down communication strategy. b. Work to maintain a climate of mutual respect. c. Support a team approach to the maintenance of health. d. Use role-specific knowledge to address health care needs. e. Apply relationship-building values and principles of team dynamics.

b, c, d, e

Which are socioeconomic factors that contribute to the health of a community? (Select all that apply.) a. The community covers a total area of 14 square miles. b. Almost 25% of the residents are of Native American descent. c. Nearly 35% of the residents are eligible for free school lunches. d. Approximately half of the residents work in the local automobile factory. e. The community recently built a new hospital and medical office building.

b, c, d, e

Which actions by the nurse violate the American Nurses Association's Social Media Policy? (Select all that apply.) a. The nurse posts a professional profile on LinkedIn. b. The nurse describes a patient's injury on Facebook. c. The nurse posts opinions about co-workers on Twitter. d. The nurse writes a blog about the need for staffing ratios. e. The nurse posts a picture of a patient's wound on Instagram.

b, c, e

Which nursing actions incorporate informatics into nursing practice? (Select all that apply.) a. The nurse uses written materials to teach a patient who is hard of hearing. b. The nurse uses an online database to learn more about the patient's disease. c. The nurse uses a bar-code scanner to prevent medication administration errors. d. The nurse teaches the patient's family how to perform range of motion. e. The nurse checks the electronic record to review the patient's medical history.

b, c, e

The nurse is admitting a 75-year-old patient into the gastrointestinal laboratory for a routine colonoscopy. During the assessment, the nurse learns that the patients spouse died 4 months earlier because of stomach cancer and that the patient has not been sleeping well. Which phase of Bowlbys mourning phases does the nurse suspect? a. The numbing phase b. The yearning/searching phase c. The disorganization phase d. The reorganization phase

b. The yearning/searching phase

A recently widowed mother of two worked with her late husband while he was starting his own business and was managing the accounting paperwork. The family had no life or health insurance. When her husband suddenly died, she was left with a large hospital bill, funeral expenses, unemployment, and no means of support. How are the multiple losses that this woman is experiencing best described? a. Maturational b. Situational c. Actual d. Perceived

b. situational

An older adult patient has been admitted to a busy medical unit. To control environmental stimuli a nurse should do which of the following? a. Leave the hospital room lights on at all times. b. Turn off bedside equipment not in use. c. Leave the window curtains closed at all times. d. Leave the door open so the patient can hear the staff and feel secure.

b. turn off bedside equipment not in use

A registered nurse who works for an orthopedic unit of an acute care hospital makes hourly rounds on his patients. He also closes the door and pulls the curtains around the beds of patients in semiprivate rooms before exposing them for treatments. This is an example of which of the following behaviors? a. Human respect b. Encouraging manner c. Healing environment d. Affiliation needs

Healing environment

* When a nurse helps a patient find the meaning of cancer by supporting his beliefs about life, this is an example of: *

Instilling faith and hope

* Listening is not only "taking in" what a patient says; it also includes: *

Interpreting and understanding what the patient means

A patient asks the nurse to explain how sleep occurs. The nurse explains to the patient that the physiology of sleep is a complex process. However, in simple terms, what is the nurses best response?

Interrelated mechanisms of the brain control wake and sleep cycles

A 2-year-old child in the pediatric unit resists going to sleep. To promote sleep, which is the best action for the nurse to take?

Maintain the childs home bedtime routine

When dealing with cultural awareness, the nurse realizes that the term oppression involves which of the following? a. Maintaining advantages based on social group membership b. Systems that maintain disadvantages aimed purely at individuals c. Intentional discrepancies alone d. Issues at institutional levels independent of individual or cultural factors

Maintaining advantages based on social group membership

The relief of pain and suffering give a patient comfort, dignity, respect, and peace. To enhance the therapeutic environment, what should the nurse do? a. Make the environment as noise free as possible. b. Remove personal items so that the environment is as clinical as possible. c. Focus on removing negative physical stimuli. d. Make the environment a place to soothe mind, body, and spirit.

Make the environment a place to soothe mind, body, and spirit

75-year-old patient in an acute care hospital who underwent surgery for an abdominal aneurysm developed a urinary tract infection 3 days after placement of a Foley catheter. The nurse believes that this is a reportable incident, and which of the following will happen as a result?

Medicare will not reimburse the hospital for this infection.

A new mother has brought in her week-old infant to the health care provider for a 1-week well-baby checkup. She is breastfeeding and has only been sleeping a couple of hours at a time during the night between feedings. She asks the nurse, When can I expect the baby to sleep through the night? What is the nurses best response?

Most children begin to sleep through the night around 3 months.

A primary health care provider prescribes eszopiclone (Lunesta) for a patient. Which classification of drug will the nurse be administering to the patient?

Nonbenzodiazepine, benzodiazepine receptor agonist

When visiting the clinic, a nurse takes the patients sleep history and notes the appearance of a deviated septum. The nurse knows that this structural abnormality predisposes the patient to which condition?

Obstructive sleep apnea

A 67-year-old farmer is at the clinic because he has been sleepy during the day. Which sleep change occurs with age?

Older adults spend more time in falling asleep.

The patient was admitted to the hospital with advanced-stage cancer. As the nurse was admitting her, the patient told her about how her little dog learned a new trick, and could play dead when she said bang-bang. Why did the nurse listen attentively to the patients story? a. She knew it was easy to do and she had nothing else to do at that time. b. It was little more than two people talking back and forth. c. She knew it was probably not going to affect the patient-nurse relationship. d. She knew it was a way to know and respond to what matters to the patient.

She knew it was a way to know and respond to what matter to the patient

.While making night shift rounds, the nursing assistive personnel become concerned when a patient stops breathing from 1 to 2 minutes several times during the shift. The nurse informs the nursing assistive personnel that this condition is known as which of the following?

Sleep apnea

The health care provider is seeing a 16-year-old boy at the local clinic. The guardian is concerned about the patients lack of sleep. The guardian states that the patient goes to school, works at a part-time job until 10 PM, and then stays up doing homework until after midnight. I am worried that he is not getting enough sleep. What is the best response for the health care provider to give the patient and his guardian?

Sleep deprivation can cause a person to get sick or have excessive daytime sleepiness

The nurse encourages a postoperative patient to get adequate amounts of sleep after discharge from the health care facility. When the patient asks why, how should the nurse respond?

Sleep restores biological processes

Nurses care for a variety of patients. What is an activity that best demonstrates the caring role of a nurse? a. staying with a patient and developing a plan of care before surgery b. performing IV insertion with confidence c. assessing the patients entire health history d. inserting a urinary catheter using aseptic technique

Staying with a patient and developing a plan of care before surgery

A nurse is caring for a patient who suffers from a sleep pattern disturbance. To promote adequate sleep, what are the most appropriate nursing interventions? (Select all that apply.)

Straighten and change any soiled bed linens. Synchronize the medication, treatment, and vital signs schedule. Provide personal hygiene before bedtime. Assist the patient to use the toilet before bed.

A researcher tests a new fall prevention protocol on a nursing unit with patients who are at very low risk of falling. Which term describes the problem with this study? a. This type of study is better suited for qualitative research. b. The subjects are at risk of being harmed by participating in the study. c. The study is biased because the subjects are already at low risk of falling. d. The study results will be inaccurate due to placebo effects on the subjects.

After a massive earthquake, the emergency room staff focuses to provide care to the patients who are likely to survive rather than expending maximum effort on a few critically injured patients. Which ethical theory is demonstrated in this situation? a. Deontology b. Feminist ethics c. Utilitarianism d. Ethics of care

After careful research, the nursing staff have implemented a new fall prevention protocol on the unit. Which is the logical next step of the staff? a. Review the available literature. b. Encourage abstract thinking. c. Measure the patient fall rate. d. Execute the theoretical framework.

After the implementation of a new protocol, the nursing unit had a central line site infection rate of 3%. This rate is well below the agency's expected standard of 5%. Which term best describes this evaluation? a. Research bias b. Control group c. Benchmarking d. Descriptive research

Even though immunization injections are momentarily painful to the patient, they are recommended because they will protect the community from infectious diseases. Which ethical system supports this practice? a. Duty ethics b. Deontology c. Utilitarianism d. Situation ethics

The diabetic patient sees the podiatrist regularly to prevent development of ulcers in the feet. Which term best describes this action of the patient? a. Health promotion b. Primary prevention c. Secondary prevention d. Tertiary prevention

The nurse carefully performs a careful physical assessment and health history for the patient, making sure not to miss any body systems. Which attitude for critical thinking is demonstrated by the nurse? a. Integrity b. Planning c. Discipline d. Diagnosis

The nurse educator uses manikins to teach patients how to correctly perform CPR on a victim of cardiac arrest. Which teaching technique is used by the nurse? a. Analogy b. Role play c. Simulation d. Enunciation

The nurse filled out an incident report after a patient fall but makes no mention of the incident report in her notes in the patient's chart. What is the reason for this? a. The incident report includes the nurse's interpretations of what probably led the patient to get out of bed. b. A copy of the incident report is filed in the patient's chart along with the nurse's notes about the fall. c. The incident report is confidential and not intended to be used as evidence in a malpractice suit. d. The nurse does not want to risk a malpractice lawsuit by mentioning the creation of an incident report.

The nurse identified the source of food poisoning as a local restaurant and ensured that no further patrons became ill. Which community health nursing role was demonstrated by these actions? a. Caregiver b. Educator c. Epidemiologist d. Case manager

The nurse implements interventions to address risk for falls after noting that the patient is unsteady when getting out of bed. The nurse is using which skill in this situation? a. Medical diagnosis b. Scientific method c. Diagnostic reasoning d. Data collection

The nurse inappropriately assumed that the patient did not require pain medication due to a history of substance abuse. Which critical thinking concept did the nurse fail to use? a. Criticism b. Maturity c. Analysis d. Organization

Nurses implement therapeutic immobilization for patients to achieve which result?

reduce pain

A patient is confused and has been restrained to prevent injury. Which of the following is a priority as the nurse plans care for the shift?

removing restraint from patient at least every 2 hours

A health care provider orders that a confused and disoriented patient be placed in a full hand restraint because of excessive scratching of skin. The nurse acknowledges which of the following?

restraints must be removed every 2 hours

One of the more common precipitating factors for a patient-inherent accident is a

seizure

A toddler is ready to be discharged home after outpatient surgery. When conducting a home safety assessment the child's guardian states, "I keep the cleaning supplies under the sink for easy access, and how soon can the child resume swimming in the local pond?" Based on this statement, what is the most important safety issue for the nurse to identify?

storage of cleaning supplies in the house

The nurse identifies that one of the IV pumps has been malfunctioning and was placed outside a patient room until it could be repaired. To prevent an equipment-related accident from occurring, which action should the nurse take first?

tag the pump and remove from area

Which patient is most at risk for developing a urinary tract infection

teenage comatose pt on ventilator lying supine

A nursing student is undergoing a community health clinical rotation. One of the patients is a 53-year-old grandmother who has recently assumed custody of her daughter's two young children, ages 3 and 5 years old. Regarding the children's welfare, which of the following is most important for the nursing student to assess on this visit?

the patient's knowledge of safety precautions for young children

The nurse is performing a cultural assessment on a patient. What does the nurse know about cultural assessments? a. They are intrusive and time consuming. b. They are not dependent on a trusting relationship. c. They are rarely plagued by miscommunication. d. They are based in similarities of behavior.

they are intrusive and time consuming

The registered nurse from the home health agency is performing an initial assessment on a 72-year-old patient who was released from a nursing home. The patient had been admitted to the nursing home for therapy after surgery for repair of a fractured left hip. During a survey of the home environment, which finding would cause the nurse to intervene

throwrugs in the bedroom

The nurse is observing a patient's posture while sitting, standing, and assessing gait. What is the rationale for the nurse's assessment?

to determine types of assistance with ambulation

Which patient is most likely to have developmental effects due to prolonged immobility

toddle pt in traction for congenitial skeletal anomaly

The nurse is caring for a patient of a culture different from her own. To provide culturally competent care for this patient, what does the nurse need to do? a. Not be curious about other ways of being in the world b. Understand the forces that influence her own world view c. Recognize that she must not hold any bias toward the patient d. Have no predispositions relative toward the patients culture

understand the forces that influence her own world view

Of the following, who is most at risk for accidental poisoning?

unsupervised 4 yr old playing with moms makeup

Cultural competence is the ongoing process in which a health care professional continuously strives to achieve the ability to work effectively within the cultural context. To do this effectively, what must the nurse do? a. Understand the cultural norms of the patients community. b. See herself or himself as being culturally competent. c. Face the reality that cultural competence can take up to a year to achieve. d. View herself or himself as becoming culturally competent.

view herself or himself as becoming culturally competent

The patient has recently moved into a newly renovated home in the inner city. The patient is being seen in the clinic for complaints of ongoing headaches, nausea, dizziness and fatigue. The symptoms started shortly after moving into the new home. As the nurse gathers information, which of the following questions would be most appropriate to ask the patient

what type of furnace do you have

A young adult patient was involved in a motorcycle accident. The patient was in the intensive care unit of the hospital for 2 months with immobility and was just discharged to a rehabilitation hospital. The patient asks the nurse, "Why am I so weak?" What is the best response from the nurse?

when you're in bed for a while, your boyd begins to break down the protein

A 45-year-old obese patient has been scheduled for cardiac bypass surgery. The nurse who is preparing the patient for surgery asks, Do you have a history of sleep apnea? This is important to know before surgery because patients with sleep apnea:

who receive general anesthesia have a greater risk for airway obstruction

An elderly patient was admitted to the hospital after falling in the nursing home. The patient has a fractured right femur and is awaiting surgery. The surgeon orders bed rest. The patient asks the nurse what this means. What is the nurse's best explanation?

you have to remain in bed

Which patient is at greatest risk for developing a pressure ulcer

young adult paraplegic with pneumonia

The nurse is at the shopping mall when the sales clerk collapses in cardiac arrest. The nurse assists the victim and performs CPR until the paramedics arrive. Which action by the nurse could lead to a malpractice suit even though the state has a Good Samaritan law? a. The nurse went to visit the victim in the hospital the following day. b. The nurse accepted a small gift from the store in appreciation for her help. c. The nurse sent a bill to the victim to request payment for services rendered. d. The nurse provided both chest compressions and rescue breathing for the victim.

The nurse is caring for a patient who has been unable to have a bowel movement for the last 4 days after taking prescribed narcotic pain medication. Which nursing diagnosis is appropriate for this patient? a. Risk for constipation related to irregular defecation habits b. Perceived constipation related to expectation of daily bowel movements c. Constipation related to side effects of pain medication d. Impaired bowel elimination related to abdominal muscle weakness

The nurse is caring for a preoperative patient before hysterectomy surgery. The patient tells the nurse that she plans to have lots of children in the future and is glad that the surgery won't keep her from getting pregnant in the future. Which is the best action of the nurse? a. Continue preparing the patient for the upcoming surgery. b. Contact the operating room and cancel the patient's scheduled surgery. c. Inform the surgeon so the patient can be provided with more information. d. Explain to the patient that the surgery will make her unable to get pregnant.

The nurse is caring for a toddler who will be having surgery. Which will provide the best primary source of information about how to comfort the child after surgery is completed? a. Patient's chart b. Patient c. Parents d. Surgeon

The nurse is entering a note in the patient's medical record using the SOAP format. Which statement belongs in the Assessment section? a. The patient stated "I started feeling short of breath after smelling strong perfume." b. The patient is using accessory muscles and has wheezes in all lung fields. c. Ineffective airway clearance related to exposure to environmental allergen. d. Monitor pulse oximetry and administer nebulized bronchodilators.

The nurse is mandated by the state to complete 25 contact hours of nursing education before the nursing license may be renewed. Which term best describes this requirement? a. In-service education b. Advanced education c. Continuing education d. Certification education

The nurse is working at a hospital whose electronic medical records system uses charting by exception. Which entry would be appropriate to include in the narrative section of the patient's chart? a. The patient voided 400 mL of clear yellow urine during the last 12 hours. b. The patient denies smoking, alcohol intake, or use of illicit substances. c. The patient states that the pain level in his right knee is 7 on a 1-to-10 scale. d. The patient's lung sounds are clear bilaterally with no cyanosis or dyspnea.

The nurse manager rehearses what to say to a nurse who made a serious medication error. Which form of communication is being used by the nurse manager? a. Intonation b. Nonverbal c. Intrapersonal d. Orientation

The nurse often forgets to administer the patient's medication exactly on time, frequently giving it 1 or 2 hours after it is due. Which ethical principle is violated by the nurse? a. Justice b. Judgment c. Responsibility d. Confidentiality

The nurse realizes that the wrong patient's name was written on several important paperwork forms that were already signed by the attending physician. How will the nurse correct this error? a. Black out the error with a thick marker and enter the correct information. b. Use correction tape to write over the incorrect information. c. Draw one line through the error, make the correction and initial it. d. Shred the forms with the incorrect information and write on new ones.

The patient undergoes surgery for a herniated disk and is paralyzed afterward. What must the patient prove to the court in order to win a malpractice lawsuit based on lack of informed consent? a. The patient's paralysis was not due to the surgeon's technique. b. The patient's signature on the consent form was witnessed by his nurse. c. The surgeon performed a laminectomy but the patient consented to a fusion. d. The surgeon performed a surgical procedure that was known to be high risk.

What is the priority action of the nurse immediately after receiving a medication telephone order from a physician? a. Withhold the medication until the physician signs the order. b. Authorize the physician's order with the pharmacy. c. Read back the order to the physician for confirmation. d. Double-check the order with another registered nurse.

Which action by the nurse demonstrates correct hand-hygiene practice? a. Letting hand sanitizer dry for a full minute before applying gloves b. Keeping hands and wrists above the level of the elbows while washing c. Scrubbing hands and nails for at least 15 seconds using plenty of soap d. Making sure that the water is hot before wetting the hands and wrists

Which action by the nurse demonstrates the use of fairness for critical thinking? a. Adherence to the six rights when administering medication to a patient b. Clarification of an unusually high dosage medication with the prescriber c. Effective pain management is provided for all patients regardless of background d. Development of a personalized swallowing precautions protocol for the patient

Which action by the nurse is an example of a legal issue rather than an ethical principle? a. Failing to shut the door completely when bathing the patient b. Providing lower doses of pain medications to patients with red hair c. Working as a registered nurse without a current nursing license d. Deciding not to stop and provide medical care at an accident scene

Which action by the nurse will best allay a young child's fear about auscultation of breath sounds? a. Do nothing because the more fuss that is made about a procedure, the more anxiety it causes the patient. b. Explain to the patient that the stethoscope is used to listen to air going in and out of the lungs. c. Allow the child to listen to sounds with the stethoscope before the nurse uses it for assessment. d. Ask the child's mother to step outside the room because children frequently do better when alone.

Which action communicates to the patient that the nurse wants to leave the patient's room to care for other patients? a. Sitting in a chair next to the patient's bed b. Making sure the door is completely shut for privacy c. Repeatedly checking the clock to see what time it is d. Holding the patient's hand when the patient starts to cry

Which action demonstrates disinfection? a. Washing the hands with warm water and antimicrobial liquid soap b. Cleaning the patient's mouth with a swab soaked in chlorhexidine solution c. Cleaning the stethoscope with isopropyl alcohol after each use with patients d. Using an alcohol-based hand sanitizer after performing physical assessments

Which agency creates standards that require nursing documentation to be accurate, timely, and patient-centered? a. Centers for Disease Control and Prevention b. World Health Organization c. The Joint Commission d. Agency for Healthcare Research and Quality

Which agency would be most appropriate for a patient who requires rehabilitation services for right-sided hemiplegia after a stroke? a. Respite center b. Primary care center c. Restorative care center d. Assisted-living center

Which assessment finding best indicates to the nurse that the teaching about a dressing change was successful? a. The patient understands how to change the dressing using sterile technique. b. The patient verbalizes understanding about how to change the sterile dressing. c. The patient correctly demonstrates the dressing change using sterile technique. d. The patient acknowledges the principles of sterile technique for dressing changes.

Which assessment finding indicates that the family processes were interrupted by the patient's illness? a. The patient must now follow a gluten-free, low-carbohydrate diet. b. The patient must use a walker for ambulation to prevent a fall or injury. c. The patient's spouse had to return to work to maintain the family's income. d. The patient must take three antihypertensive drugs to control high blood pressure

Which type of patient is an appropriate candidate for restorative care services? a. A patient who uses supplemental oxygen for emphysema b. A patient who is actively dying of metastatic cancer c. A patient with right-sided hemiplegia after a recent stroke d. A patient with depression who tried to commit suicide

Which type of study is appropriate to investigate patients' perceptions about quality of life after a diagnosis of liver cancer? a. Quantitative study b. Randomized trial c. Qualitative study d. Case control study

A nurse has been working overtime because of high hospital census and a decreased work force. The nurse is concerned about the danger of work-related burnout or compassion fatigue. To combat this risk, the nurse should: a. increase nursing responsibilities at work. b. take control over new areas at work to reduce stress. c. strengthen relationships outside of the hospital. d. hang out with co-workers when not at work.

c. strengthen relationships outside of the hospital

A nurse is caring for a 3-year-old niece whose mother has recently died of cancer. Because of the childs stage of development, the nurse expects that the child will most likely see the loss of her mother as which of the following? a. An opportunity to re-examine their lives b. A threat to her self-concept c. Temporary d. A challenge to her emerging identity

c. temporary

An older adult patient in a long-term care facility recently had a stroke after experiencing a myocardial infarction. The patient is not speaking or eating. The nurse notices an adverse change in vital signs. When a patient is unable to resist the effects of a stressor, the nurse can identify this stage of the general adaptation system as: a. an alarm reaction. b. the resistance stage. c. the exhaustion stage. d. a fight-or-flight response.

c. the exhaustion stage

The patient has a methicillin-resistant Staphylococcus aureus (MRSA) infection in an abdominal surgical wound. The patient is in a private room, is receiving vancomycin (Vancocin) for the MRSA, and pain is well controlled with a morphine sulfate patient-controlled analgesia (PCA) pump, and is receiving docusate sodium (Colace) to prevent constipation. During the nurses rounds, the patient begins complaining of ringing in the ears. Which is the most likely cause for the patients tinnitus? a. Surgical anesthesia b. Morphine sulfate c. Vancomycin d. Docusate sodium

c. vancomycin

Which of the following bedtime snack(s) helps to promote sleep in a patient?

cereal and milk

The patient is recovering from a cerebrovascular accident (stroke). The patient is having problems with balance and coordination. The patient asks the nurse what part of the brain has been damaged. How should the nurse respond?

cerebellum

A nurse is in the process of admitting an ethnically diverse patient. To plan culturally competent care, what must the nurse do? (Select all that apply.) a. Assume that cultural processes are the same within a social group. b. Conduct a systematic cultural assessment. c. Communicate effectively. d. Negotiate world view differences.

conduct a systematic cultural assessment. communicate effectively. negotiate world view differences.

(10)What is the best method for to The Joint Commission to demonstrate that it is assessing quality patient care? a.Cost of care per patient day b. Number of registered nurses c. Absence of sentinel events d. Documentation audits

(11)The nurse educates the patient about what to expect during insertion of a nasogastric tube. Which term best describes the nurse's communication role? a. Channel b. Receiver c. Message d. Sender

(12) The nurse includes "The patient will demonstrate correct technique for self-injection of insulin" as a goal in the patient's care plan. Which type of learning is addressed by this goal? a. Cognitive b. Affective c. Perceptive d. Psychomotor

(2)Which statement by the patient indicates to the nurse that the patient is in the preparation stage of smoking cessation? a. "I don't ever want to quit smoking." b. "I hope to quit smoking sometime before I die." c. "I am really working hard to stop smoking." d. "I stocked up on nicotine patches and gum."

(3)Which is an example of tertiary care? a. The patient has annual mammograms to screen for breast cancer. b. The patient sees the podiatrist monthly to prevent diabetic foot ulcers. c. The patient is seen at an urgent care clinic to treat a badly sprained wrist. d. The patient is treated in the intensive care unit following a gunshot injury.

(8)The nurse is caring for a patient who is having severe pain despite regular doses of narcotic pain medication. The nurse suspects that the patient may be experiencing neuropathy and obtains an order for gabapentin which relieves the patient's pain. Which term most accurately describes the action of the nurse? a. Intuition b. Reflection c. Perseverance d. Critical thinking

A nurse completes an incident/occurrence report after a patient fell. What is the reason for this report? a. To compare patient fall rates between nursing units in the hospital b. To provide justification for the hospital to fire the nurse c. To prevent the patient from filing a malpractice lawsuit d. To aid in the hospital's quality improvement program

A nurse gives a hand-off report to the oncoming staff nurse. Which type of communication does this illustrate? a. Gossip b. Courtesy c. Validation d. Intrapersonal

After the implementation of a well-researched fall prevention protocol, patients at the agency have a lower incidence of falls than the national average. Which term will the nurse use to describe this finding? a. Sentinel event b. Qualitative research c. Manuscript narrative d. Nursing-sensitive outcome

Before leaving at the end of the shift, the nurse realizes that a set of patient assessments were taken earlier in the day but never charted. What is the appropriate action of the nurse? a. Enter the assessments in the chart the next day before receiving report. b. Do nothing because the other patient assessments were obtained during the shift. c. Direct the nursing assistant to enter the assessments into the patient's chart. d. Enter the assessments into the chart as a late entry with a reason for the delay.

Every time the nurse asks the patient a question for the admission assessment, the patient's husband interrupts and answers the question for her. What is the best action of the nurse? a. Enter the husband's responses into the patient's chart. b. Request that the husband leave the room. c. Complete the admission assessment after the husband has gone home. d. Allow time for the patient to answer each question.

Once a week, staff members from all the disciplines caring for the trauma patients get together to discuss their progress. Which term best describes this patient care action? a. Continuing staff education b. Nursing care delivery model c. Professional shared governance d. Interprofessional communication

Providing assistance to which victim would be covered under the state's Good Samaritan law? a. The unit secretary at the hospital suffers an anaphylactic reaction after eating nuts as a morning snack. b. A patient has a grand mal seizure in the hospital foyer when saying goodbye to his family. c. A patient at the clinic where the nurse is working suffers a cardiac arrest after walking in the door. d. Two people are badly hurt in a car accident on the nurse's way to work in the morning.

The emergency room nurse obtains report from the paramedics as the patient is on the way to the hospital. The nurse is in which phase of the therapeutic relationship? a. Working b. Orientation c. Termination d. Preinteraction

The new nurse keeps a diary to record experiences, patient encounters, and feelings when beginning work in the nursing profession. Which critical thinking action is used by the nurse? a. Professional standards b. Nursing process c. Concept mapping d. Purposeful reflection

The nurse comes up with creative methods to help soothe agitated patients with dementia when the usual approaches fail. Which term best describes the action of the nurse? a. Concept mapping b. Diagnostic reasoning c. Scientific method d. Effective problem solving

The nurse feels strongly that the patient may be suffering from physical abuse. The nurse reports the situation to protective services even though the physician insists that the patient is simply accident-prone. Which component of critical thinking leads the nurse to file the report even though the physician believes it is not needed? a. Fairness b. Creativity c. Discipline d. Confidence

The nurse fills out an incident report after a patient fall but makes no mention of the report in the patient's medical record. What is the reason for this? a. The nurse does not want to risk a malpractice lawsuit by mentioning the creation of an incident report. b. The incident report includes the nurse's interpretations of what probably led the patient to get out of bed. c. A copy of the incident report is filed in the patient's chart along with the nurse's notes about the fall. d. The incident report is confidential and not intended to be used as evidence in a malpractice suit.

The nurse is assessing a patient with chest pain who has just come to the hospital. Which open-ended question will provide the nurse with helpful information about the patient's health status? a. "How long have you been experiencing chest pain?" b. "Do you have a family history of heart disease?" c. "Are you having any difficulty breathing right now?" d. "What does your chest pain feel like?"

The nurse is caring for a nonverbal patient who just had surgery. The nurse notes that the patient moans with position changes, the hands are clenched, and the skin is very sweaty. The nurse decides that the patient is in pain and decides to administer an analgesic. What is the correct term for this nursing action? a. Setting priorities b. Recognizing inconsistencies c. Using empathy d. Making inferences

The nurse is caring for a patient who attempted to get out of bed and fell to the floor, causing a fractured hip. The nursing supervisor asks the nurse to rewrite her entry into the patient's chart to show that the patient's bed was lowered to the floor even though it was not. What is the best action of the nurse? a. Chart that the bed was lowered to reduce liability in case a malpractice lawsuit is filed. b. Ask the nursing assistant to chart that the patient's bed was lowered to the floor before the patient fell. c. Ask the nursing assistant if the patient's bed was lowered to the floor at the time of the fall. d. Remind the nursing supervisor that it is against regulations to alter or falsify the patient's chart.

The nurse is caring for a patient who denies having any pain. The nurse notes that the patient is restless and the patient's hands are tightly clenched. The nurse also heard the patient moaning before walking into the room. What will the nurse take into consideration as the patient assessment is completed? a. Unclear communication techniques b. Unrealistic patient expectations c. Inappropriate empathic response d. Conflicting assessment findings

The nurse is caring for a patient with pneumonia with a congested cough, fever, and wheezing. Which is the priority nursing diagnosis for the patient? a. Risk for infection related to congested cough and wheezing b. Deficient diversional activity related to boredom due to hospitalization c. Risk for imbalanced body temperature related to increased metabolic rate d. Ineffective airway clearance related to inability to clear secretions from airway

The nurse is caring for a patient with sepsis. The nurse includes potential complications: septic shock in the plan of care. Why is this nursing diagnosis considered a collaborative problem? a. The patient must be closely monitored in an intensive care unit. b. The patient has a history of noncompliance with prescribed therapeutic regimens. c. Prevention of septic shock is not a measurable patient outcome. d. Both nursing and physician-prescribed interventions are required.

The nurse maintains a sterile field when inserting a urinary catheter into the patient's bladder. Which term best describes the infection control practice of the nurse? a. Pathogenesis b. Bacteriostasis c. Medical asepsis d. Surgical asepsis

The nurse notes that the nursing assistant did not provide oral care to the patient as directed. Where is the best location for the nurse to address this lapse with the nursing assistant? a. In the patient's room b. At the nurse's station c. In the nursing unit hallway d. In a private conference room

The nurse readily accepts an opportunity to become certified in wound care and ostomy management. Which critical thinking concept is demonstrated by the nurse? a. Maturity b. Analyticity c. Systematicity d. Inquisitiveness

The patient sued the hospital for malpractice after developing a postoperative DVT and PE. The nurse's notes did not state that TED hose and sequential compression devices (SCDs) were applied even though they were ordered. Why did the court rule in favor of the patient in the case? a. DVT and PE can develop even if TED hose and SCDs are applied. b. The patient was informed that DVT and PE are known surgical risks. c. The nurse testified that SCDs and TED hose were applied as ordered. d. The nurse failed to document that TED hose and SCDs were applied as ordered.

What is the primary difference between negligence and malpractice? a. Malpractice is intentional while negligence is unintended. b. Malpractice is a felony while negligence is a misdemeanor. c. Malpractice leads to more serious patient injury than negligence. d. Malpractice is committed by a licensed professional while negligence is not.

When is the nurse covered by the health care agency's malpractice insurance? a. While caring for scouts at summer camp b. When providing first aid at a car accident c. While assisting a fellow passenger on a flight d. While providing care to patients in the agency

Which patient action demonstrates the concept of health promotion? a. The patient receives the influenza vaccination every year. b. The patient participates in cardiac rehabilitation after a heart attack. c. The patient has yearly mammograms to screen for breast cancer. d. The patient follows a macrobiotic, vegetarian diet with organic foods.

Which patient information may be included in the nursing student's assignment that will be turned in to the instructor after the clinical shift has ended? a. Room number b. Date of birth c. Medical record number d. Nursing diagnosis

Which patient is appropriate for an assisted-living agency? a. A patient who requires tube feeding and frequent tracheostomy suctioning after a massive stroke b. A patient with dementia who requires supervision during the day when family members are at work c. A patient with severe depression who has made three suicide attempts in the last 6 months d. A patient who can perform activities of daily living independently but requires assistance with daily medications

Which patient learning goal is measurable? a. The patient will understand the importance of daily iron supplements. b. The patient will be able to learn sufficient information to be discharged. c. The patient will feel comforted by the nurses' presence during anxious periods. d. The patient will verbalize responsibility for obtaining daily weights each morning.

Which sentence is appropriate to write in an incident report for a patient who got out of bed and fell? a. The patient probably urinated on the floor and slipped due to the wet floor. b. The patient's nurse assistant always takes forever to answer patient call lights. c. The patient never follows directions and always causes trouble for the nurses. d. The patient was found lying on the floor with his urinal on the floor next to him.

Which statement by the nurse is an example of an SBAR recommendation? a. "The patient has become increasingly short of breath over the last few hours." b. "The patient has a history of chronic respiratory failure due to emphysema." c. "The patient's pulse oximetry is 84% and crackles are heard over all lung fields." d. "The patient needs oxygen titrated to maintain oximetry between 90% and 92%."

Which statement is true about critical thinking? a. It is the same thing as the nursing process. b. It is moving from writing a plan of care to thinking. c. It is a haphazard method of providing nursing care. d. It is a continuous process characterized by open-mindedness.

Which technique is the best way for the nurse to obtain information from the patient? a. Ask personal questions so as to show interest. b. Use medical vocabulary to appear competent. c. Ask why the patient waited so long to get treatment. d. Use silence while the patient collects his or her thoughts.

Which statements demonstrate that the patient is at the acceptance stage of learning? (Select all that apply.) a. "I do not have to learn how to do the dressing. My wife will do it for me." b. "I feel like such a failure for not consulting a podiatrist earlier about my foot." c. "I'll try to do the exercises you described if you will give me a cookie afterward." d. "I want to learn how to do this myself so I do not have to go to a rehab center." e. "I know that I have to give myself the injections because I could get a blood clot."

d, e

The nurse is caring for a terminally ill patient. In order to provide optimal care, the nurse tries to anticipate patient needs. What does the nurse understand about this patient? a. As patients approach death, they breathe more through their nose. b. Eye blinking may increase as well as tear production. c. Immobility and opioid medications can lead to diarrhea. d. Anxiety in the dying may have a physical cause.

d. anxiety in the dying may have a physical cause

The nurse is assigned a patient who has experienced the alarm reaction and continues to recover. The nurse knows that the primary hormone impacting the stress response in the resistance stage of the general adaptation syndrome is: a. vasopressin. b. adrenaline. c. noradrenaline. d. cortisol.

d. cortisol

A nurse is assigned to care for a dying patient. To deal with this experience and future experiences with dying patients, the nurse should do which of the following? a. Avoid going to funerals of former patients. b. Develop a hard shell against emotional stress to avoid compassion fatigue. c. Understand that people dying is part of the job to get used to. d. Frequently evaluate his or her own emotional well-being.

d. frequently evaluate his or her own emotional well being

A nurse works on an oncology unit and has a lot of stress in her life. Which of the following situational factors would be considered work stress? a. Caring for a family member who has Alzheimers disease b. Being diagnosed with a chronic back injury c. Finding out that a parent has lung cancer d. Having a disagreement with her nurse manager

d. having a disagreement with her nurse manager

A school nurse performs a routine screening on a newly transferred school-age child. This nurse is especially interested in discovering the childs medical history regarding middle ear infections. The nurse knows that chronic ear infections are a major contributing factor to which of the following? a. Respiratory diseases b. Strep throat c. High fevers d. Hearing impairment

d. hearing impairment

Which of the following would not be appropriate for a patient undergoing palliative care? a. Insertion of a peripherally inserted central line b. Chemotherapy c. Radiation treatment d. Knee replacement surgery

d. knee replacement surgery

A nursing student, who maintained a 4.0 GPA since starting nursing school, started working the past semester, is planning a wedding, and has moved into a new home. The student has not been able to maintain the 4.0 GPA this semester, and as a result is feeling like a failure. How is this loss best described? a. Maturational b. Situational c. Actual d. Perceived

d. perceived

The patient, a busy executive who works 80 hours a week, is admitted for angina. The patient is demonstrating physical signs of stress related to the work environment. An appropriate nursing intervention for this patient includes releasing muscle tension every 2 hours. This type of intervention is best known as: a. regular exercise. b. assertiveness training. c. cognitive therapy. d. progressive muscle relaxation.

d. progressive muscle relaxation

The nurse working with a new nursing assistive personnel (NAP), is explaining about the importance of repositioning immobile patients to prevent pressure ulcers. At a minimum, the nurse tells the NAP to reposition patients how often?

every 2 hours

A nurse is working in a health facility that creates a culture of safety. Which behavior will the nurse use in this type of facility?

focus on performance improvement efforts

A young adult was involved in a motor vehicle accident and suffers from brain trauma. The patient has decrease mobility in all joints. The nurse should assess for which common, debilitating contracture?

footdrop

anticoagulant that suppresses clot formation.

heparin

A student nurse is caring for a young adult patient who is immobile with a back injury. On auscultation, the student nurse hears rhonchi in the lower lobes. The student nurse reports this symptom because the patient is developing which complication?

hypostatic pneumonia

pneumonia (inflammation of the lung from stasis or pooling of secretions)

hypostatic pneumonia

A nurse has finished preoperative teaching for a surgical patient. Which statement by the patient indicates teaching was successful about the use of elastic stockings?

i should remove and apply them every 8 hours

A registered nurse works in a small rural health clinic. During a routine well baby visit, a new mother questions the need to have her infant immunized. Which of the following is the best explanation for why it is recommended that her child receive immunizations?

immunization increases resistance to an infectious disease

A patient is recovering from an abdominal aortic bypass graft. To reduce the effects of orthostatic hypotension, what is the most appropriate action for the nurse to take?

increase moving postions slowly

Which assessment finding should the nurse expect to observe on an immobilized patient?

increased serum glucose levels

All hospital employees are concerned about the safety of patients in the hospital, especially regarding the transmission of pathogens. What is the most common means of transmission of pathogens in this environment?

insufficient hand hygience

Disuse, atrophy, and shortening of muscle fibers and surrounding joint tissues cause:

joint contracture

A patient has decrease mobility in all joints. Because of the lack of mobility, the nurse expects the health care provider to order what medication to prevent venous thromboembolisms that will reduce the side effect of hemorrhage?

low-molecular-weight-heparin

An older adult widow reports having problems sleeping at night and states, I miss my spouse. The nurse also recognizes that older patients:

may suffer from emotional stress or depressive mood disorders

A nurse enters a patients room and is very methodical in her assessment skills and in providing a safe environment, but only speaks with the patient when necessary to gather data. This nurse is: a. uncaring and probably always will be. b. most likely a product of a less caring environment. c. probably more caring with other patients. d. a product of a caring environment.

most likely a produce of a less caring environment

While planning care for an immobilized patient, which physiological process will the nurse consider about the patient's musculoskeletal system?

muscle atrophy

A patient in the intensive care unit requires mechanical ventilation, a wound VAC system, patient-controlled analgesia, and an intravenous infusion device. Which safety precaution should the nurse implement in the health care setting?

never operate equipment without previous instruction

Who is responsible for determining need for restraints and assessing pt behavior?

nurse

Patients on prolonged bed rest are at risk for a deep vein thrombosis. Which information indicates the nurse needs more teaching about the factors in Virchow's triad?

on of the factors is atrophy of the muscles

A nurse notes a typical cardiovascular change in an immobilized postoperative patient. Which of the following did the nurse find upon assessment?

orthostatic hypotension

increase in heart rate of more than 15% and a drop of 15 mm Hg or more in systolic blood pressure or a decrease of 10 mm Hg in diastolic blood pressure when the patient rises from a lying or sitting position to a standing position.

orthostatic hypotensionn

A 5-year-old child was admitted to the pediatric unit of the hospital with the diagnosis of fever of unknown origin. Currently the patient's temperature is 105° F. Which of the following is the best way to prevent a patient-inherent accident from occurring?

pad all bed side rails

A student nurse has been asked by the registered nurse with whom the student nurse is working to apply wrist restraints to a patient who is confused and is trying to remove the endotracheal tube. The student nurse knows that it is important to tie the restraints to which part of the bed?

part of the bedframe that moves up and down with the pt

Patient is the primary reason for the accident

patient-inherent accident

Which action should the nurse implement to help prevent thrombus formation in postsurgical patients?

position properly with use to antiembolic stocking

An 85-year-old retired man with arthritis has recently been prescribed a new medication by his health care provider for pain management. The health care provider identifies that the patient is currently taking 13 different medications on a daily basis. The health care provider is concerned about the patient's safety in the home. Which of the following is most important to assess?

potential for falls

A nurse working on the medical unit mistakenly administers the wrong medication to a patient. This type of error would be classified as which of the following?

procedure-related accident

In an outpatient surgery center, the preoperative nurse has the responsibility of starting IVs prior to the patients' surgeries. One of the surgeons who works at the center orders a different type of IV fluid than the rest of the surgeons. Which of the following should the nurse be most concerned about in this situation?

procedure-related accident

caused by health care providers and include medication and fluid administration errors, improper application of external devices, and improper performance of procedures such as dressing changes

procedure-related accident

The nurse is concerned because a 77-year-old patient is weak after abdominal surgery. Which of the following should be done to ensure that one of the preventable conditions identified by the Centers for Medicare and Medicaid does not occur?

provide frequent opportunies to use the restroom

A nurse is caring for a patient in Buck's traction on bed rest for a fracture of the femur. Which action should the nurse take to help preserve skin integrity?

provide meticulous skin care

A college student who is working in northern Alaska during the summer reports that he or she has an increase in difficulty sleeping since moving north. During a pre-employment physical, the patient asks the health care provider what could be causing this. The health care provider suspects the sleep disturbance is most likely because of which factor?

Increased daylight hours in Northern Alaska

* Which of the following is an example of a nurse caring behavior that families perceive to be important to a patient's well-being? *

Asking permission before performing a procedure of a patient's t

A nurse is giving anticipatory guidance to the mother of a 10-month-old child. The nurse is focusing on providing a safe environment for the child. Which of the following is the best statement regarding childhood safety?

"Injuries are a major cause of death during infancy, especially for children 6 to 12 months old."

17.A nurse is teaching a crutch walking technique that requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times. What is the term for this gait? a. Four-point gait b. Three-point gait c. Two-point gait d. Three-point alternating gait

ANS: A Four-point alternating or four-point gait gives stability to the patient but requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times. The two-point gait requires at least partial weight bearing on each foot. Three-point alternating or three-point gait requires the patient to bear all of the weight on one foot. In a three-point gait, the patient puts weight on both crutches and then on the uninvolved leg, and then repeats the sequence. The affected leg does not touch the ground during the early phase of the three-point gait. Gradually the patient progresses to touchdown and full weight bearing on the affected leg. PTS:1DIF:Cognitive Level: Applying (Application) REF:696 OBJ iscuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

15.A student nurse is caring for 67-year-old patient who is experiencing left-sided weakness caused by a stroke. The student nurse is providing patient teaching regarding the use of a quad-cane for ambulation. Which of the following statements is correct? a. "You should use the cane on the stronger side of the body." b. "Move the stronger leg with the cane." c. "When walking, advance the weaker leg past the cane." d. "Your body weight should be supported by the cane and stronger leg."

ANS: A Make sure the patient keeps the cane on the stronger side of the body. The patient moves the weaker leg to the cane, which divides body weight between the cane and the stronger leg. The patient then advances the stronger leg past the cane so the weaker leg and the body weight is supported by the cane and weaker leg. PTS:1DIF:Cognitive Level: Applying (Application) REF:694 OBJ escribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

4.Which of the following patients is most at risk for hypovolemic shock after emergency surgery? a. 14-year-old adolescent with gastroenteritis b. 59-year-old patient with pneumonia c. 12-year-old patient with H1N1 flu d. 28-year-old patient with a fractured ankle

ANS: A Patients with gastroenteritis have gastrointestinal problems and are at greater risk of complications. Patients with preexisting renal, fluid and electrolyte, gastrointestinal, respiratory, or cardiovascular problems are at greatest risk for operative complications. For example, a patient who is dehydrated from vomiting preoperatively is at greater risk for hypovolemic shock. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1133 OBJ: Identify factors to assess in a patient in postoperative recovery. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

8.A small business owner has noted an increase in back injuries at his company in recent years. During a discussion with an occupational health nurse, knowledge of statistical information regarding this trend throughout the country is exchanged. The occupational health nurse explains that the most common back injury is caused by a strain to which of the following muscle groups? a. Lumbar b. Cervical c. Thoracic d. Trapezius

ANS: A The most common back injury is strain on the lumbar muscle group, which includes the muscles around the lumbar vertebrae. Injury to these areas affects the ability to bend forward, backward, and side to side. This also decreases the ability to rotate the hips and lower back. The cervical response is incorrect because it refers to the neck region of the back. The thoracic response is incorrect because it refers to the rib/chest area of the back which has decreased movement. The trapezius is incorrect because it refers to a muscle in the back over the scapula. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:680 OBJ iscuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

13.The operating room environment is deliberately kept cool. When the nurse assesses the patient in the post anesthesia care unit, the patient is shivering. The nurse needs to understand that shivering may do which of the following? a. Be a side effect of anesthesia. b. Indicate a problem of the hypothalamus. c. Indicate the beginning of the infectious process. d. Be a normal response to stabilize blood pressure.

ANS: A The operating room environment is cool, and the patient's depressed level of body function results in a lowering of metabolism and fall in body temperature. When patients begin to awaken, they often complain of feeling cold and uncomfortable. Shivering is not always a sign of hypothermia, but rather a side effect of certain anesthetic agents. If a patient develops a fever, notify the surgeon immediately. The chances of the shivering being a problem with the hypothalamus, indicating infection (such as fever with sepsis) are very low in this case. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 1154 OBJ: Identify factors to assess in a patient in postoperative recovery. TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

18.The nurse is in charge of caring for five orthopedic patients during ashift. Nursing assistive personnel are available to assist the nurse with care of the patients. Which of the following tasks is most appropriate for the nurse to delegate to the nursing assistive personnel? a. Moving a 45-year-old patient who had a CVA toward the head of the bed b. Transferring an 85-year-old patient for the first time after a total hip replacement c. Providing discharge teaching for a 49-year-old patient who had a stroke d. Preparing a 77-year-old patient for hip replacement surgery

ANS: A The skill of moving and positioning patients in bed can be delegated to nursing assistive personnel. Patients whom you are transferring for the first time after prolonged bed rest, extensive surgery, critical illness, or spinal cord trauma require supervision by professional nurses. Nursing assistive personnel are unable to give preoperative teaching or discharge teaching to a patient. PTS:1DIF:Cognitive Level: Applying (Application) REF:707 OBJ iscuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

1.A 57-year-old patient who is being admitted for an appendectomy. The patient is a 2-pack-a-day smoker, has a history of diabetes, and is 20 pounds overweight. Which of the following potential postoperative complications should be the nurse's highest concern for prevention? a. Atelectasis b. Negative nitrogen balance c. Delayed wound healing d. Hyperthermia

ANS: A There is a significant association between smoking and postoperative pulmonary complications, specifically pneumonia and atelectasis. Chronic smoking increases the amount and thickness of mucous secretions in the lungs. Patients who are obese are more susceptible to developing atelectasis. Hyperthermia is incorrect because general anesthetics inhibit shivering, a protective reflex to maintain body temperature, and anesthetics cause vasodilation, which results in heat loss. Malnourished patients are more likely to have poor tolerance of anesthesia, negative nitrogen balance, delayed postoperative recovery, infection, and delayed wound healing. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1131 OBJ: List factors to include in the preoperative assessment of a surgical patient. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

2.The nurse is providing preoperative teaching for a patient regarding pain control after surgery. Which of the following statements is/are true regarding the use of postoperative analgesia? (Select all that apply.) a. "Analgesics will not provide adequate relief if you wait until the pain becomes excruciating before using them." b. "Pain control will help you recover from surgery quicker." c. "You shouldn't be concerned about becoming addicted to your pain medications immediately after surgery." d. "You will remain pain-free as long as you take your pain medications as prescribed." e. "A PCA pump is commonly used to help patients control their pain." f. "Take pain medication carefully as it will lengthen your recovery period."

ANS: A, B, C, E Analgesics will not provide adequate pain relief if the patient waits until the pain becomes excruciating before using or requesting an analgesic. Even though around-the-clock (ATC) analgesia is more effective, most patients still have analgesics ordered prn (as needed). Pain control is essential for a surgical patient to recover quickly. Encourage the patient to use analgesics as needed and not be fearful of any dependence on pain medications after surgery. Patient-controlled analgesia (PCA) is common and provides patients with control over pain. Explain to a patient how to operate a pump and the importance of administering medication as soon as pain becomes persistent. The patient also needs to know it takes time for a drug to act and that the drug will rarely eliminate all the discomfort. Pain medication will not lengthen the recovery period, it will shorten it. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1146OBJ esign a preoperative teaching plan. TOP:Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

3.Which of the following trouble points are common in the side-lying position? (Select all that apply.) a. Lack of support for the feet b. Lack of protection for pressure points for the ears, shoulders, anterior iliac spine, trochanter, and ankles c. Adduction of the shoulder and hip joints d. Hyperextension of the neck e. Spinal curves out of normal alignment

ANS: A, B, C, E The following are trouble points that are common in the side-lying position: • Lateral flexion of the neck • Spinal curves out of normal alignment • Shoulder and hip joints internally rotated, adducted, or unsupported • Lack of support for the feet • Lack of protection for pressure points at the ear, shoulder, anterior iliac spine, trochanter, and ankles • Excessive lateral flexion of the spine if the patient has large hips and a pillow is not placed superior to the hips at the waist PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:691 OBJ escribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

1.When is it appropriate to ask a surgeon to clarify information for a patient who is undergoing surgery? (Select all that apply.) a. Before the informed consent has been signed b. When a patient is confused about the reason for the procedure c. When a patient understands the risks involved in a procedure d. If there is confusion about the procedure after the informed consent is signed e. After the surgery has been performed

ANS: A, B, D Patients need to sign all consent forms before you administer any preoperative medications that alter the patient's consciousness. The primary responsibility for informing the patient rests with the surgeon and anesthesia care personnel. However, if the patient is confused or uncertain about a procedure, you are ethically obligated to contact the surgeon and/or anesthesia care provider so that further discussion and clarification are provided to meet the patient's needs. The patient always has the right to refuse surgery or treatment even after giving written consent. PTS:1DIF:Cognitive Level: Applying (Application) REF:1142 | 1144OBJ repare a patient for surgery. TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

3.A student nurse has been assigned to a 67-year-old patient who is undergoing thoracic surgery to remove a tumor. As part of the preoperative teaching, the student nurse discusses the importance of coughing. Which of the following statements is true regarding why postoperative coughing is important? (Select all that apply.) a. "Coughing assists in removing retained mucus in the airways." b. "It won't hurt to cough with adequate pain control." c. "You can splint your incision when coughing to minimize pain." d. "Deep breathing and coughing will remove anesthesia gases from your lungs." e. "Deep breathing involves fast, shallow, breaths and then one big breath." f. "Coughing is not encouraged because of the potential or dehiscence at the surgical site."

ANS: A, C, D A patient learns to use the diaphragm during deep breathing to take slow, deep, and relaxed breaths. Eventually a patient's lung volume improves. Deep breathing also helps to clear any anesthetic gases from the airways. To facilitate deep breathing a health care provider often orders an incentive spirometer for a patient. Coughing assists in removing retained mucus in the airways. A deep, productive cough is more beneficial than merely clearing the throat. Teach the patient to splint an abdominal or thoracic incision to minimize pain during coughing. Pain control is essential for effective deep breathing and coughing; educate the patient to ask for pain medications as needed. Deep breathing also helps to clear any anesthetic gases from the airways. The patient needs to anticipate postoperative discomfort and understand the importance of coughing, even when it is painful. Deep breathing is not fast and shallow, it is slow and deep. Coughing and deep breathing are encouraged even if dehiscence is a possibility, teaching them to splint wound. PTS:1DIF:Cognitive Level: Applying (Application) REF:1146 | 1169 OBJ escribe the rationale for nursing interventions designed to prevent postoperative complications.TOP:Nursing Process: Planning MSC:Client Needs: Physiological Integrity

2.The nurse manager is concerned with the safety of the staff as they transfer patients. Facility policy reinforces the principles of appropriate body mechanics, which include which of the following? (Select all that apply.) a. A wide base of support increases stability b. A higher center of gravity increases stability c. Facing the direction of movement prevents abnormal twisting of the spine d. Pivoting requires less work than lifting e. Manually lift the patient in sections f. Dividing balanced activity between arms and the legs

ANS: A, C, D, F Principles of body mechanics include the following: A wide base of support increases stability; a lower center of gravity increases stability; the equilibrium of an object is maintained when the line of gravity passes through its base of support; facing the direction of movement prevents abnormal twisting of the spine; dividing balanced activity between arms and legs reduces the risk for back injury; and leverage, rolling, turning, or pivoting requires less work than lifting. Manual lifting is the last resort, and it is only used when it does not involve lifting most or all of the patient's weight. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:680 | 681 OBJ escribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

1.Which of the following actions are effective in reducing friction when repositioning a patient in bed? (Select all that apply.) a. Lifting rather than pushing b. Pushing the patient up in bed c. Asking the patient to bend his or her knees and lift the hips when moving up in bed d. Asking the patient to lie still as you reposition him or her; even when the patient offers to help e. The use of a draw sheet f. The use of a transfer board

ANS: A, C, E, F You reduce friction by lifting rather than pushing a patient. Lifting has an upward component and decreases the pressure between the patient and the bed or chair. The use of a draw sheet reduces friction because you are able to move the patient more easily along the bed's surface. However, there are several commercially available products to assist in the task of positioning and moving patients in bed such as transfer boards and Maxi Slides. Pushing the patient up in bed is incorrect because pushing increases the friction between the patient and the bed. Asking the patient to lie still is incorrect because a passive or immobilized patient produces greater friction to movement. PTS:1DIF:Cognitive Level: Applying (Application) REF:679 OBJ escribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

6.Which group of muscles is involved with joint stabilization? a. Skeletal muscles b. Antigravity muscles c. Synergistic muscles d. Antagonistic muscles

ANS: B Antigravity muscles are involved with joint stabilization. Skeletal muscles support posture and carry out voluntary movement. Antagonistic muscles bring about movement at the joint. Synergistic muscles contract to accomplish the same movement. When you flex your arm, you increase the strength of the contraction of the biceps brachii by contraction of the synergistic muscle, the brachialis. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:681 OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

5.A 56-year-old nondiabetic patient is undergoing orthopedic surgery. The perioperative nurse is monitoring the blood glucose level. What is the main rationale for monitoring his blood glucose level during surgery? a. She does not want the patient to develop an embolism. b. Research shows a strong relationship between wound infections and hyperglycemia. c. She knows that normal glucose levels promote platelet production. d. She is monitoring to prevent embolism.

ANS: B Evidence has shown that there is a relationship between wound and tissue infection and blood glucose levels. Poor control of blood glucose levels (specifically hyperglycemia) during and after surgery increases the risk for wound infection and patient mortality in certain types of surgery. PT and APTT blood tests are monitored to prevent embolism. Perioperative nurses work with their medical colleagues to maintain normal glucose levels in the postoperative period to reduce the risk for wound and tissue infection. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1133 OBJ: Describe intraoperative factors that affect a patient's postoperative course. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

9.A nurse working in an ambulatory care surgery center is preparing to discharge a postoperative patient. The nurse knows that the convalescence period will occur: a. 1 to 2 hours after surgery. b. at home. c. once the patient has been monitored overnight in the hospital. d. 2 to 4 hours after surgery.

ANS: B For a patient following ambulatory surgery, convalescence will occur at home, the immediate recovery period normally lasts only 1 to 2 hours. For a hospitalized patient the immediate postoperative period often lasts a few hours, with convalescence taking 1 or more days, depending on the extent of surgery and a patient's response. Patient who are admitted to stay overnight at the hospital are not classified as ambulatory care surgery center. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1153 OBJ: Explain the differences in caring for a patient undergoing outpatient surgery versus a patient undergoing inpatient surgery. TOP: Nursing Process: Evaluation MSC:Client Needs: Physiological Integrity

17.A patient asks a nurse to explain the differences between general anesthesia and regional anesthesia. What is the correct response relating to general anesthesia? a. "General anesthesia inhibits peripheral nerve conduction." b. "Under general anesthesia all sensation and consciousness is lost." c. "Under general anesthesia there is a loss of sensation in a specific area of the body." d. "General anesthesia is routinely used for procedures that only require a decreased level of consciousness."

ANS: B General anesthesia is administered during major procedures requiring extensive tissue manipulation or any time analgesia, muscle relaxation, immobility, and control of the autonomic nervous system are required. Regional anesthesia results in loss of sensation in an area of the body by anesthetizing sensory pathways. This type of anesthesia is accomplished by injecting a local anesthetic along the pathway of a nerve from the spinal cord. Administration techniques include peripheral nerve blocks and spinal, epidural, and caudal blocks. A patient requires careful monitoring during and immediately after regional anesthesia for return of sensation and movement distal to the regional anesthesia. PTS:1DIF:Cognitive Level: Applying (Application) REF:1152 OBJ: Differentiate among classifications of surgery and types of anesthesia. TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

9.The nurse is assigned to a 79-year-old patient who has decreased mobility resulting from a stroke. The nurse understands the interventions to prevent skin breakdown for this bedfast patient is to include repositioning of the patient at least every _____ hour(s). a. 1 b. 2 c. 3 d. 4

ANS: B In general, you reposition patients as needed and at least every 2 hours if they are in bed and every 1 hour if they are sitting in a chair. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:689 OBJ: Evaluate the nursing care plan for maintaining body alignment and activity. TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

15.All patients undergoing surgery need to have preoperative preparation. When physically preparing the patient, the most appropriate action for the nurse to take is which of the following? a. Leaving all of the patient's jewelry in place b. Removing the patient's makeup and nail polish c. Providing the patient with sips of water for a dry mouth d. Removing the patient's hearing aid before transport to the operating room

ANS: B Jewelry is removed so it can be safeguarded. In addition, swelling may occur postoperatively. Makeup and nail polish are removed so the patient's skin and mucous membranes can be assessed to determine oxygenation, saturation of blood, and application of a pulse oximeter. Patients are to maintain NPO to prevent postoperative GI complications and to prevent aspiration because the gag reflex is suppressed. Although patients need to remove hearing aids, do not have them do this until immediately before surgery; allowing the patient to wear hearing aids will facilitate communication between the patient and health care providers. PTS:1DIF:Cognitive Level: Applying (Application) REF:114 BJ repare a patient for surgery. TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

11.A patient with a ruptured abdominal aortic aneurysm needs to have major surgery. The nurse explains to the family that major surgery: a. is an excision or removal of a diseased body part. b. involves extensive surgery to reconstruct body parts. c. is not necessary but may prevent additional problems. d. is a surgical exploration that allows the physician or health care provider to confirm a diagnosis.

ANS: B Major surgery involves extensive reconstruction or alteration in body parts; poses great risks to the patient's well-being. Urgent surgery is necessary for the patient's health and will possibly prevent additional problems from developing. Elective surgery is performed on a basis of the patient's choice. It is not always essential, and it is not always necessary for health. Diagnostic surgical exploration allows the physician or health care provider to confirm a diagnosis. PTS:1DIF:Cognitive Level: Applying (Application) REF:1132 OBJ: Differentiate among classifications of surgery and types of anesthesia. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

7.A 44-year-old patient with breast cancer who is scheduled to undergo a right-side mastectomy. Ideally when should preoperative teaching begin? a. As soon as she is diagnosed with breast cancer b. One week before surgery c. The day before surgery d. The day of surgery

ANS: B Preoperative teaching is most useful when started the week before admission and reinforced immediately before surgery. Teaching performed when the patient is less anxious will result in more effective learning. Anxiety and fear are barriers to learning. PTS:1DIF:Cognitive Level: Applying (Application) REF:1144OBJ repare a patient for surgery. TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

4.The patient has been diagnosed with a progressive neuromuscular disease and is having difficulty walking and has decreased awareness of the body's position. What is the term that best describes this phenomenon? a. Balance b. Proprioception c. Posture d. Hemiplegia

ANS: B Proprioception is the awareness of the position of the body and its parts and is dependent on impulses from the inner ear and from receptors in joints and ligaments. The nervous system also regulates posture. Posture is incorrect because it requires coordination of proprioception and balance. Balance is incorrect because it is controlled by the inner ear and the cerebellum. Hemiplegia is incorrect because this term is used to describe paralysis on one side of the body. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:680 OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment MSC:Client Needs: Physiological Integrity

10.The nurse instructs the postoperative patient to perform leg exercises every hour in order to do which of the following? a. Maintain muscle tone. b. Increase venous return. c. Exercise fatigued muscles. d. Assess range of joint motion.

ANS: B The number one priority in a surgical setting is to prevent deep vein thrombosis (DVT) complications. By increasing venous return there is less stasis therefore decreasing the risk of DVT. Early measures directed at preventing venous stasis are aimed at preventing DVT during convalescence. On the surgical nursing unit, begin these interventions as soon as possible. Encourage patients to perform leg exercises at least every hour while awake unless contraindicated by surgery. Maintaining muscle tone, exercising fatigued muscles, and assessing range of joint motion are all reasons to perform leg exercises. PTS:1DIF:Cognitive Level: Applying (Application) REF:1162 OBJ escribe the rationale for nursing interventions designed to prevent postoperative complications.TOP:Nursing Process: Evaluation MSC:Client Needs: Physiological Integrity

1.The nurse working on an orthopedic unit has to assist many of the patients because of limited mobility. The nurse's goal is to maintain a position that most favors function, requires the least muscular work to maintain, and places the least strain on muscles, ligaments, and bones. What is the term that best describes this goal? a. Body alignment b. Posture c. Center of gravity d. Balance

ANS: B The term posture means maintaining optimal body position. It means a position that most favors function, requires the least muscular work to maintain, and places the least strain on muscles, ligaments, and bones. Center of gravity refers to the term that describes how body balance is achieved, over a wide stable base of support. Body alignment refers to the relationship of one body part to another body part along a horizontal or vertical line. Correct alignment reduces strain on musculoskeletal structures, maintains adequate muscle tone, and contributes to balance. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:678 OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment

21.A patient presents to the emergency department with a fractured leg that requires a full leg cast. The nurse needs to teach the patient to ambulate with crutches using which of the following? a. Two-point gait b. Three-point gait c. Four-point gait d. Tripod alternating position

ANS: B Three-point gait requires the patient to bear all of the weight on one foot. In a three-point gait, the patient puts weight on both crutches and then on the uninvolved leg. A two-point gait requires at least partial weight bearing on each foot. A four-point gait gives stability to the patient but requires weight bearing on both legs. The tripod position is the basic crutch stance. PTS:1DIF:Cognitive Level: Applying (Application) REF:696 OBJ: Assess patients for impaired body alignment, exercise, and activity. TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

18.The nurse is conducting preoperative teaching with the patient and family. The nurse teaches the patient the proper use of the incentive spirometer. The nurse knows that the patient understands the need for this intervention when the patient states, "I use this device to: a. help my cough reflex." b. expand my lungs after surgery." c. increase my lung circulation." d. keep me from coughing."

ANS: B To facilitate deep breathing the incentive spirometer encourages forced inspiration to prevent atelectasis. Every preoperative teaching program includes explanation and demonstration of postoperative exercises, which include: diaphragmatic breathing, incentive spirometry, controlled coughing, turning, and leg exercises. Coughing assists in removing retained mucus in the airways. A deep, productive cough is more beneficial than merely clearing the throat. A patient needs to anticipate postoperative discomfort and understand the importance of coughing, even when it is difficult. PTS:1DIF:Cognitive Level: Applying (Application) REF:1146 OBJ escribe the rationale for nursing interventions designed to prevent postoperative complications.TOP:Nursing Process: Evaluation MSC:Client Needs: Physiological Integrity

19.A nurse and another staff member are preparing to reposition a patient in bed. To prevent back strain, these two health care providers must do which of the following? a. Keep their knees stiff to enhance their lifting strength potential. b. Keep the weight of the patient as close to their bodies as possible. c. Loosen their stomach muscles to keep from injuring the pelvic region. d. Twist their upper torsos to enhance the use and strength of their upper extremities.

ANS: B To prevent lifting-related injuries, always follow these steps: 1. Keep weight as close to the body as possible. 2. Bend at the knees. 3. Tighten abdominal muscles, and tuck pelvis. 4. Maintain the trunk erect and knees bent. PTS:1DIF:Cognitive Level: Applying (Application) REF:681 | 708 OBJ escribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

25.The nurse delegates the task of ambulating a patient to the assistive personnel. The nurse ascertains that the assistive personnel understands how to intervene when the patient complains of dizziness when the assistive personnel verbalizes which of the following? a. "I call for help." b. "I gently lower the patient to the floor." c. "I support the patient and walk quickly back to the room." d. "I lean the patient against the wall and wait until the episode passes."

ANS: B When a patient begins to fall, the nurse should assume a wide base of support with one foot in front of the other to support the patient's weight, gently lower the patient to the floor, and protect the patient's head. Assess the patient for injuries at this time and notify the patient's health care provider. Even if the patient is stable, get the assistance of a lift team to help you get the patient off the floor and back in bed or a chair. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:693 OBJ escribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

13.A patient has been hospitalized for 5 days after pancreatic surgery. The nurse is preparing the patient to ambulate for the first time. What is the best action for the nurse to perform to prevent the patient from suffering orthostatic hypotension? a. Have him sit up in bed for a few minutes before standing. b. Have him sit up with his legs dangling over the side of his bed for a few minutes before standing. c. Place him in a high-Fowler's position for a few minutes before standing. d. Place him in a low-Fowler's position for a few minutes before standing.

ANS: B When preparing a patient for ambulation, dangling is an important technique. You assist the patient to a sitting position with the legs dangling off the side of the bed and have the patient rest for 1 to 2 minutes before standing. When the patient has been flat for extended periods, blood pressure drops when the patient stands. Dangling helps to prevent this. Sitting up in bed or placing the patient in high- or low-Fowler's position does not allow for the changes in circulation to occur before ambulation. PTS:1DIF:Cognitive Level: Applying (Application) REF:692 | 693 OBJ escribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment

20.A nurse is caring for a patient who has pneumonia. To facilitate respiration and lung drainage this patient should be placed in what position? a. Sims' b. Prone c. Lateral d. Supine

ANS: B When prone, the patient is in the face-down position. This facilitates respiration and drainage of oral secretions. Place a pillow under the head for comfort and relief from pressure. The Sims' position is used to place the patient in a semiprone position on the right or left side with the opposite arm, thigh, and knee flexed and resting on the bed. In the lateral position, the patient is placed in a side-lying position, supported on the right or left side. This position can compromise chest expansion. In the supine position the patient rests on the back. The risk for aspiration is greater with this position; thus avoid the supine position when the patient is confused, agitated, experiencing a decreased level of consciousness, or at risk for aspiration. PTS:1DIF:Cognitive Level: Applying (Application) REF:691 OBJ iscuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Implementation MSC:Client Needs: Physiological Integrity

2.The nurse is taking care of a 78-year-old comatose patient. The nurse has placed the patient in a supine position. To prevent foot drop, the nurse applies which of the following? a. Pillows to dorsiflex the foot b. Trochanter rolls to the feet c. Foot boots as ordered d. Pillows to elevate the feet

ANS: C Avoid pressure on the back of the legs and heels—pillows elevating the feet or dorsiflexing the foot may cause increased pressure. Use a foot boot to prevent footdrop, maintain proper alignment, and provide freedom of movement for the feet. When a patient is immobile, use pillows, trochanter rolls, and hand rolls or arm splints to increase comfort and reduce injury to the skin or musculoskeletal system. PTS:1DIF:Cognitive Level: Applying (Application) REF:691 OBJ escribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

10.The nurse is assigned to take care of a 56-year-old patient with COPD. The patient does not tolerate a supine position for sleeping. In what position should the nurse place the patient? a. Lateral b. Prone c. Semi-Fowler's d. Sims'

ANS: C In semi-Fowler's position the head of the bed is at a 30-degree angle. Use this position for patients who cannot tolerate a supine position, such as those with cardiac and respiratory problems. Prone position is incorrect because it can compromise lung expansion. Lateral position is incorrect because patients who are obese or older do not tolerate this position for any length of time. Sims' position is incorrect because it is a semi-prone position that can compromise lung expansion. PTS:1DIF:Cognitive Level: Applying (Application) REF:689 | 691 OBJ: Write a nursing care plan for a patient with impaired body alignment and activity. TOP:Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

16.Which of the following statements is appropriate for a nurse to teach a patient regarding the use of crutches? a. "The axillae should support all your body weight." b. "Your elbows should be straight when your hands are on the crutch handgrips." c. "The distance between the crutch pad and axillae should be three to four finger widths." d. "Your elbows should be flexed about 45 degrees when the handgrip position is correct."

ANS: C Make sure you position the handgrips so the axillae do not support all patients' body weight. Pressure on the axillae increases risk to underlying nerves, which sometimes results in partial paralysis of the arm. You determine the correct position of the handgrips with the patient upright, supporting weight by the handgrips with the elbows slightly flexed (20 to 25 degrees). You verify elbow flexion with a goniometer. When you have determined the height and placement of the handgrips, you again verify that the distance between the crutch pad and the patient's axilla is three to four finger widths. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:693-694 OBJ iscuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

6.The perioperative nurse is admitting a patient for an elective surgery. She questions the patient about issues with anesthesia, to assess the patient for malignant hyperthermia. Which of the following is a late sign of malignant hyperthermia? a. High CO2 levels b. Tachycardia c. Elevated temperature d. Tachypnea

ANS: C Malignant hyperthermia is a life-threatening complication. Early signs of malignant hyperthermia include high levels of CO2, tachypnea, and tachycardia. Elevated temperature occurs in the late stages. PTS:1DIF:Cognitive Level: Applying (Application) REF:1135 OBJ: Describe intraoperative factors that affect a patient's postoperative course. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

26.A nurse is caring for a patient with osteogenesis imperfecta. The nurse needs to assess the patient's muscle movement and strength. In doing so, the nurse recalls that osteogenesis imperfecta is characterized by fractures and bone deformities. This condition is known as which of the following? a. A form of osteoporosis b. A form of arthritis c. A congenital defect d. A neurological defect

ANS: C Osteogenesis imperfecta is a congenital defect that affects the bone. Osteoporosis is a well-known and well-publicized disorder of aging in which the density or mass of bone is reduced. Inflammatory and noninflammatory joint diseases and articular disruption all alter joint mobility. Some characteristics of inflammatory joint disease (e.g., arthritis) are inflammation or destruction of the synovial membrane and articular cartilage and systemic signs of inflammation. Damage to any component of the central nervous system that regulates voluntary movement results in impaired body alignment and mobility. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:680 OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment MSC:Client Needs: Physiological Integrity

12.A patient is awaiting surgery. The nurse's best rationale for assessing vital signs is to do which of the following? a. Assess the patient's anxiety level. b. Determine the patient's basal temperature. c. Establish a baseline for vital signs comparisons. d. Assess for any changes that may indicate infection.

ANS: C Preoperative vital signs provide a baseline for intraoperative and postoperative comparison, because anesthetic agents and medications can alter vital signs. Preoperative assessment of vital signs is also important to detect fluid and electrolyte abnormalities. An elevated temperature is cause for concern. If a patient has an underlying infection, elective surgery will often be postponed until the infection is treated or resolved. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1138 OBJ: List factors to include in the preoperative assessment of a surgical patient. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

5.As the result of a brain tumor, a patient is having trouble with balance. The patient's significant other is concerned and asks the nurse how a tumor could affect the patient's balance. The nurse explains that the tumor is growing in the part of the brain that is responsible for balance. The significant other asks, "Which part of the brain controls balance?" The nurse's response would be which of the following? a. Pons b. Cerebrum c. Cerebellum d. Hypothalamus

ANS: C The cerebellum and the inner ear control balance through the nervous system. The major function of the cerebellum is to coordinate all voluntary movement. The pons deals with levels of arousal, consciousness, and sleep. The cerebrum controls thoughts, memory, decision making, and communication. The hypothalamus controls the autonomic functions of the peripheral nervous system. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:680 OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment MSC:Client Needs: Physiological Integrity

16.Intraoperatively, the circulating nurse observes a member of the surgical team breach aseptic technique. As a result of this incident the postoperative patient can be at risk for which of the following? a. Paralytic ileus b. Malignant hyperthermia c. Development of infection d. Alteration in pulmonary hygiene

ANS: C The circulating nurse assists the anesthesia provider with endotracheal intubation, calculating blood loss and urinary output, and administering blood. This nurse monitors sterile technique of surgical team members and a safe OR environment. A nurse also assists the surgeon and scrub nurse by operating nonsterile equipment, providing additional instruments and supplies, maintaining accurate and complete documentation, and tracking sponge, needle, and instrument counts. Paralytic ileus is a loss of function of the intestine, which causes abdominal distention. Anesthetic agents slow gastrointestinal functioning. Malignant hyperthermia results from administration of certain anesthetic agents. Alteration in pulmonary hygiene occurs when the postoperative patient does not cough and deep breathe. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:1150 OBJ: Describe intraoperative factors that affect a patient's postoperative course. TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

11.The nurse is assigned to a 67-year-old comatose patient. To minimize the risk for aspiration, the nurse should avoid placing the patient in what position? a. Semi-Fowler's b. Sims' c. Supine d. Lateral

ANS: C The risk for aspiration is greater in the supine position; thus avoid this position when the patient is confused, agitated, experiencing a decreased level of consciousness, or is at risk for aspiration. Semi-Fowler's is an incorrect answer because that is the position of choice to prevent aspiration. Sims' is incorrect because it is a semi-prone position that would allow the stomach contents to exit the body if the patient experienced emesis. Lateral is incorrect because the patient would be placed on his or her side, which would promote the exit of stomach contents if the patient experiences emesis. PTS:1DIF:Cognitive Level: Applying (Application) REF:691 OBJ escribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC:Client Needs: Reduction of Risk Potential

3.A nurse who works on the orthopedic unit knows that in addition to providing support, bones perform other functions in the body. Besides support, which of the following is an important bone function used during activity and exercise? a. Hematopoiesis b. Protection c. Mineral storage d. Movement

ANS: D Bones perform five functions in the body: support, protection, movement, mineral storage, and hematopoiesis (blood cell formation). Two of these functions—support and movement—are most important during activity and exercise. In support, bones serve as the framework and contribute to the shape, alignment, and positioning of the body parts. In movement, bones with their joints constitute levers for muscle attachment. Hematopoiesis and mineral storage are not involved with bone function during activity and exercise. PTS:1DIF:Cognitive Level: Applying (Application) REF:679 OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment MSC: Client Needs: Safe and Effective Care Environment

27.A nurse is caring for a patient with a broken tibia and fibula. The patient is in a half cast to his knee and is unable to bear weight. The nurse has instructed the patient on how to walk and climb stairs with his injuries. What is the best way to assess the patient's knowledge of how to ascend and descend stairs? a. Incorrectly re-demonstrate the procedure and have the patient point out any errors. b. Have the family member explain the procedure. c. Have the patient explain the procedure. d. Have the patient demonstrate the procedure.

ANS: D Ensuring patient safety is an essential role of the professional nurse. To ensure patient safety, communicate clearly with members of the health care team, assess and incorporate the patient's priorities of care and preferences, and use the best evidence when making decisions about your patient's care. Explain the procedure, and describe what you expect of the patient. Demonstration is the most accurate way for the nurse to assess understanding of the skill. PTS:1DIF:Cognitive Level: Applying (Application) REF:697 OBJ iscuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Evaluation MSC: Client Needs: Safe and Effective Care Environment

7.The patient is a 46-year-old woman who is a devout Muslim and who is being evaluated for weight-loss surgery. One aspect of the comprehensive bariatric program is that clients begin an exercise program. The patient is self-conscious about her weight and concerned about maintaining her modesty. Which of the following exercise programs would be the best choice for the nurse to suggest? a. A private trainer at a local fitness center b. An aerobics class at the local YMCA c. The evening yoga class at a local country club d. Walking 30 minutes a day at the mall with a friend

ANS: D Exercise and physical fitness are beneficial to all people. When developing a physical fitness program for culturally diverse populations, consider what motivates individuals to exercise and what activities will be appropriate and enjoyable. Modesty and discretion are highly valued in the Muslim culture. Public aerobics and yoga classes may make the devout Muslim uncomfortable and violate her sense of modesty. Based on her religious and cultural background, the use of a private trainer, an aerobics class at the local YMCA, or yoga classes at the local country club are incorrect choices for this patient. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:681 OBJ: Write a nursing care plan for a patient with impaired body alignment and activity. TOP:Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

12.A 19-year-old patient with cerebral palsy has been admitted to the hospital with pneumonia. The patient has limited voluntary motor control. The student nurse caring for this patient, knows that the easiest intervention to maintain joint mobility would be to perform which of the following exercises? a. Active range-of-motion exercises b. Weight-bearing exercises c. Aerobic exercises d. Passive range-of-motion exercises

ANS: D For the patient who does not have voluntary motor controls, passive range-of-motion exercises are the exercises of choice. Because of limited voluntary motor control, active range of motion exercises, aerobic exercises, and weight-bearing exercises are incorrect responses for this patient. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:692 OBJ iscuss the physiological and pathological influences on body alignment and joint mobility.TOP:Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

14.A patient with a ruptured abdominal aortic aneurysm needs to have major surgery. The family asks the nurse what type of anesthesia the patient will receive. The best response is which of the following? a. Local anesthesia b. Regional anesthesia c. Moderate sedation d. General anesthesia

ANS: D General anesthesia is administered during major procedures requiring extensive tissue manipulation or any time analgesia, muscle relaxation, immobility, and control of the autonomic nervous system are required. Local anesthesia involves loss of sensation at the desired surgical site by inhibiting peripheral nerve conduction. It is used during minor procedures performed in ambulatory surgery. Regional anesthesia results in loss of sensation in an area of the body by anesthetizing sensory pathways. This type of anesthesia is accomplished by injecting a local anesthetic along the pathway of a nerve from the spinal cord. Administration techniques include peripheral nerve blocks and spinal, epidural, and caudal blocks. A patient requires careful monitoring during and immediately after regional anesthesia for return of sensation and movement distal to the regional anesthesia. Intravenous moderate sedation/analgesia or conscious sedation is routinely used for diagnostic or therapeutic procedures (e.g., colonoscopy or certain laparoscopies) that do not require complete anesthesia but simply a decreased level of consciousness. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:1152 OBJ: Differentiate among classifications of surgery and types of anesthesia. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

3.A 45-year-old woman has been admitted for surgery to remove a cancerous abdominal tumor. She has been on chemotherapy and recently radiotherapy to shrink the tumor without success. To best facilitate wound healing, when is the best time for her to undergo surgery? a. During the radiotherapy treatments b. Immediately after the radiotherapy treatments c. 2 to 3 weeks after radiotherapy treatments d. 4 to 6 weeks after radiotherapy treatments

ANS: D Ideally surgery takes place 4 to 6 weeks after the completion of radiation treatments to avoid wound-healing problems. The patient with cancer may have radiotherapy before surgery to reduce the size of a cancerous tumor to remove it surgically. Radiation causes fibrosis and vascular scarring in the radiated area. This causes tissues to become fragile and poorly oxygenated, increasing the risk for wound infection. PTS:1DIF:Cognitive Level: Applying (Application) REF: 1132 OBJ: Identify factors to assess in a patient in postoperative recovery. TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

8.The preoperative nurse who is providing patient teaching to a 49-year-old patient who is scheduled to undergo a right-side inguinal surgery repair. The nurse informs the patient that the American Society of Anesthesiologists recommend that patients undergoing surgery with a general anesthesia fast from meat and fried foods for how many hours before surgery? a. 2 b. 4 c. 6 d. 8

ANS: D The American Society of Anesthesiologists (ASA) provides recommendations on fluid and food intake before procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia. The ASA recommendations include fasting from intake of clear liquids for 2 or more hours, and a light meal of toast and clear liquids for 6 hours. The patient also cannot have any meat or fried foods 8 hours before surgery, unless explicitly specified by the anesthesiologist or surgeon. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:1145OBJ esign a preoperative teaching plan. TOP:Nursing Process: Planning MSC: Client Needs: Safe and Effective Care Environment

24.A patient with arthritis is complaining of sensitivity and warmth in the elbow and wrist joints. To determine the degree of limitation or injury, the nurse can assess which of the following? a. Posture b. Activity tolerance c. Body mechanics d. Range of motion

ANS: D The easiest intervention to maintain or improve joint mobility for patients and one that you are able to coordinate with other activities is the use of range-of-motion exercises. Joints that are not moved periodically develop contractures, a permanent shortening of a muscle followed by the eventual shortening of associated ligaments and tendons. Over time the joint becomes fixed in one position, and the patient loses normal use of the joint. The term posture means maintaining optimal body position. Activity tolerance assesses the patient's ability to become fatigued, lightheaded, dizzy, or short of breath related to activity. Body mechanics require knowledge of proper walking, turning, and lifting and carrying objects in a way to prevent injury. PTS:1DIF:Cognitive Level: Applying (Application) REF:692 OBJ: Assess patients for impaired body alignment, exercise, and activity. TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

22.A nurse is caring for a patient with a neuromuscular condition. The nurse needs to assess the patient's muscle movement and strength. In doing so, the nurse recalls that chemicals that transfer electrical impulses from the nerve across the myoneural junction are called which of the following? a. Isometrics b. Synergistics c. Proprioceptors d. Neurotransmitters

ANS: D Transmission of the impulse from the nervous system to the musculoskeletal system is an electrochemical event that requires a neurotransmitter, a chemical that transfers the electric impulse from the nerve to the muscle. Isometrics is a type of exercise using muscles. Synergistics are opposite effects. Proprioceptors are located in nerve endings. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:679 | 680 OBJ: Describe the role of the skeleton, skeletal muscles, and nervous system in the regulation of movement. TOP: Nursing Process: Assessment MSC:Client Needs: Physiological Integrity

14.A student nurse is assisting a patient who is ambulating with a new walker. Which of the following is appropriate information for student nurse to provide to the patient? a. "The top of the walker should line up with the crease on the inside of your elbows." b. "You should walk behind the walker to maintain balance." c. "You should lean forward over the walker to maintain balance." d. "When walking, you should take a step, move the walker forward, and take another step."

ANS: D When the person relaxes the arms at the side of their body, the top of the walker should line up with the crease on the inside of the wrist. A walker is fitted correctly by having the patient step inside the walker. The person's elbow should bend comfortably, about 30 degrees, while holding onto the grips. When walking, the patient holds the handgrips on the upper bars, takes a step, moves the walker forward, and takes another step. The patient should not lean over the walker or walk behind it; otherwise he or she might lose balance and fall. PTS:1DIF:Cognitive Level: Applying (Application) REF:693 OBJ escribe the interventions for maintaining proper alignment, assisting a patient in moving up in bed, repositioning a patient needing assistance, and transferring a patient from a bed to a chair.TOP:Nursing Process: Implementation MSC: Client Needs: Safe and Effective Care Environment

A nurse has been temporarily assigned to the night shift. A change in this circadian rhythm may cause which of the following? (Select all that apply.)

Anxiety. Decreased appetite. Impaired judgement.

A nurse who works in a neonatal intensive care unit is caring for a critically ill infant with a poor prognosis. She is Christian and feels responsible to care for both the physical and spiritual needs of the infant and his parents. What is the best statement for the nurse to make to the parents of the infant? a. "You should have the child baptized so that its soul will be saved." b. "Would you like me to call the chaplain to christen your child at the bedside?" c. "What can I do to support your spiritual needs?" d. "I have asked my pastor to stop by and talk to you."

C. what can I do to support your spiritual needs?

Madeleine Leininger identifies the concept of care as the essence and unifying domain that sets nursing apart from other health care disciplines. Which of the following is true in her view? a. care and cure are synonymous. b. care is designed to focus only on individuals c. caring acts are independent of patient values d. caring depends on communication

Caring depends on communication

A 57-year-old patient is concerned about the inability to fall/stay asleep at night. This started about 3 months ago. The nurse asks about recent changes in lifestyle and activities of daily living. Which of the following changes is probably most responsible for the change in sleeping pattern?

Changing to a later evening mealtime

During a sleep study test, the patient states, I never dreams anymore. The health care provider tells the patient that everyone dreams, but most people forget about them upon awakening. The health care provider tells the patient that the best way to remember dreams is to do which of the following?

Consciously think about the dreams upon awakening

The nurse applies a cooling blanket to a patient with a dangerously high fever. Which is the most accurate method to monitor the patient's temperature? a. Taping a digital thermometer probe to the skin of the patient's axilla to download the temperature readings directly to the patient's chart b. Checking the patient's oral temperature every 15 minutes while the cooling blanket is in place until the patient is afebrile c. Applying a temperature-sensitive patch to the patient's forehead to monitor the temperature of the patient's skin surface d. Inserting a small rectal thermometer probe for continuous core temperature measurement

The nurse assesses distended neck veins in a patient sitting in a chair to eat. Which is the priority intervention of the nurse? a. Document the observation in the chart. b. Assess the patient's deep tendon reflexes. c. Measure urine specific gravity and volume. d. Check the patient's pulse and blood pressure.

The nurse draws up a medication from a glass ampule before injection. Which technique is correct? a. The nurse wipes the top of the ampule with an isopropyl alcohol swab after removing the metal cap. b. The nurse attaches a new needle to the syringe before administration as the needle was dulled by the rubber stopper. c. The nurse injects air into the ampule before withdrawing the medication in order to avoid creating a vacuum. d. The nurse draws up the medication from the ampule using a filter needle and attaches an injection needle before administration.

The nurse is caring for a diabetic patient who has rough skin on the feet and thick, overgrown toenails. Which is the best intervention of the nurse? a. Liberally apply lotion to the patient's feet, especially between the toes. b. Use a pumice stone to smooth roughened areas of skin on the patient's feet. c. Gently trim the patient's toenails after soaking the feet in warm soapy water. d. Obtain a consultation for a podiatrist to assess the feet and provide nail care.

The nurse is caring for a dying patient in hospice. The patient's respirations are slow and uneven with deep breaths and long periods of apnea. Which term best describes this breathing pattern? a. Rhonchal bradypnea b. Forrest-Shiley breaths c. Kussmaul's respirations d. Cheyne-Stokes breathing

The nurse is caring for a patient a serum potassium level of 7.4 mEq/L. Which is the highest priority nursing diagnosis for this patient? a. Nausea related to side effects from medications b. Ineffective tissue perfusion related to altered mental status c. Fluid volume excess related to increased isotonic fluid retention d. Risk for decreased cardiac output related to altered heart rhythm

The nurse is caring for a patient who collapsed after working outside on a hot day. The patient is disoriented with hot, dry skin and heart rate of 140 beats/minute. Which temperature will the nurse expect the patient to have? a. 99.2° F b. 100.8° F c. 102.2° F d. 104.4° F

The nurse is caring for a patient who develops slurred speech with right-sided facial drooping. The patient is also unable to make a fist with the right hand. What is the priority action of the nurse? a. Place a cool washcloth on the patient's forehead and turn down the lights. b. Obtain an order from the provider for a consultation with a speech therapist. c. Feed the patient by placing the food on the unaffected side of the mouth. d. Immediately obtain vital signs and notify the hospital's acute stroke team.

The nurse is caring for a patient who just underwent knee-replacement surgery. The patient complains of pain at the operative site but it is too soon for the nurse to administer the next dose of pain medication. What is the appropriate action of the nurse? a. Give the next dose of prescribed pain medication early. b. Contact the surgeon immediately to assess the patient's knee. c. Caution the patient about the risk of addiction to pain medications. d. Apply an ice pack to the knee and elevate the patient's knee on pillows.

The nurse is caring for a patient with a colostomy. The nursing diagnosis risk for impaired skin integrity related to leakage of effluent from appliance is included in the patient's care plan. Which is the appropriate intervention of the nurse? a. Apply antifungal cream to the skin before attaching the ostomy appliance. b. Liberally apply a rich skin barrier cream to the skin surrounding the stoma. c. Measure the width and the length of the stoma each week for the first 6 weeks. d. Empty the effluent into the toilet before the ostomy appliance becomes half full.

The nurse is caring for a patient with a puncture wound. How much time must have passed since the patient's last tetanus toxoid vaccination for the patient to require an additional injection before being discharged from the emergency department? a. 1 year b. 3 years c. 5 years d. 10 years

The nurse is caring for a patient with an ileostomy. Which assessment finding is expected when emptying the patient's ostomy appliance? a. Infrequent hard pellets of stool b. Daily soft formed stool c. Frequent unformed stool d. Constant watery liquid stool

The nurse is caring for a patient with painful hemorrhoids. Which is the appropriate recommendation of the nurse to prevent their recurrence? a. Stool softener daily at bedtime b. Low-carbohydrate ketogenic diet c. Periodic bowel cleansing programs d. High-fiber diet with plenty of liquids

The nurse is caring for an elderly patient who has become withdrawn and refuses to eat after being admitted to a long-term nursing facility. Which is the highest priority goal for the patient? a. The patient will participate in social activities with other residents. b. The patient will ask questions about the prescribed care and treatment. c. The patient will develop meaningful relationships with the nursing staff. d. The patient will maintain usual weight and show no signs of dehydration.

The nurse notes that the patient is scratching and has hives 2 hours after receiving a dose of antibiotic medication. The patient soon starts having difficulty breathing and his blood pressure drops. What is the correct analysis of the patient's condition? a. The patient is having a mild reaction that can be treated easily with an antihistamine. b. The patient is experiencing a moderate allergic reaction and should improve shortly. c. These symptoms are probably due to food poisoning because very few patients have true allergic responses. d. The patient is having an anaphylactic reaction and emergency interventions should be started.

Which patient would benefit from soaking in a sitz bath? a. A patient with an abscessed tooth b. A patient with a fractured right arm c. A patient with painful back muscle spasms d. A patient who just had hemorrhoid surgery

Which question will the nurse ask the patient to assess abstract thinking ability? a. "Can you tell me the color of the blanket on your bed?" b. "Can you tell me what you ate for breakfast this morning?" c. "Can you tell me about what it was like to grow up in your neighborhood?" d. "What do I mean when I say that something costs an arm and a leg?"

Which statement by the patient indicates that additional teaching is needed about the application of an elastic bandage to the ankle? a. "I will take the bandage off if my toes start to tingle." b. "I need to make sure the bandage is applied smoothly." c. "I need to watch my toes for swelling and feeling cold." d. "I will to wrap the bandage from my shin toward my toes."

Which teaching will the nurse provide to the patient before having an intravenous pyelogram (IVP)? a. Drink water and do not void so the bladder will be full during the test. b. An urge to void may be felt as the endoscope passes through the urethra. c. The urine may have an orange or pink for a day or two following the test. d. Drink plenty of water afterward to prevent kidney damage from the contrast dye

Which term will the nurse use to document the patient's drooping right eyelid? a. Ectropion b. Esotropia c. Photophobia d. Ptosis

Why is acute pain particularly dangerous for a patient having a heart attack? a. Release of endorphins causes dangerous elevation of blood pressure. b. Release of substance P narrows the airways and leads to hypoxemia. c. Release of prostaglandins lowers the patient's heart rate and blood pressure. d. Stimulation of the sympathetic nervous system will increase cardiac workload.

Which instructions will the nurse give to the patient prior to administering a metered-dose inhaler? (Select all that apply). a. "Inhale deeply and then blow slowly into the inhaler while you press the canister." b. "Open your mouth wide so that the spray will reach the back of your throat." c. "Roll the inhaler gently for a few minutes between your palms before each use." d. "Hold your breath for 5 to 10 seconds immediately after you inhale the medication." e. "Exhale fully

D E

The nurse is caring for a patient with a temperature of 100.3° F. Why will the nurse refrain from administering an antipyretic at this time? a. A temperature of 100.3° F is within the normal range for the patient. b. The patient's shivering will lower the temperature more quickly than an antipyretic. c. Antipyretics should not be administered until the temperature is at over 104° F. d. The patient is diaphoretic after the temperature was 101.3° F 1 hour ago.

D The patient's skin is diaphoretic and the patient's temperature is dropping so no antipyretic medication is needed at this time.

The patient presents with fever for the last few days, sore throat, and enlarged lymph nodes under the jaw. What is the appropriate response of the nurse when the patient asks about the cause of the enlarged lymph nodes? a. "Enlarged lymph nodes are associated with hypertensive heart disease." b. "You probably have a blockage in the thoracic lymph duct." c. "You should probably see an oncologist to rule out lymphedema." d. "They are most likely enlarged as a result of the throat infection."

D Lymph nodes that are large, fixed, inflamed, or tender indicate a problem such as local infection, systemic disease, or neoplasm. Enlarged lymph nodes are not normal. Normally lymph nodes are not easily palpable. An extensive system of lymph nodes collects lymph from the head, ears, nose, cheeks, and lips. The thoracic lymph duct drains lymph from the torso and extremities so a blockage there would not cause enlargement of lymph nodes under the jaw. Lymphedema would be readily apparent with swelling of the affected area. There is no mention of edema and an oncologist is not needed to rule it out. Enlarged lymph nodes are not associated with hypertensive heart disease

Which actions of the nurse demonstrate correct administration of a soapsuds enema? (Select all that apply.) a. The enema is administered while the patient is in the right Sims' position. b. Liquid antibacterial soap is added to the enema bag before administration. c. The tip of the enema tube is lubricated with petroleum jelly before insertion. d. The enema bag is lowered when the patient reports abdominal cramping. e. The nurse removes the patient's fecal impaction before administering the enema.

D, E

A patient who has been diagnosed with terminal liver cancer states that he does not believe in God, but he has had a meaningful life by contributing to the lives of those around him. This person is most likely which of the following? a. Buddhist b. Christian c. Agnostic d. Atheist

D. Atheist

* Helping a surgical patient adapt his learning style to discharge teaching demonstrates which of Swanson's five caring behaviors? *

Doing for

A nurse is working in a health care clinic. She loves her work because of all the different people she meets. She professes to care for all of them and states that she understands them because she realizes which of the following is true? a. Basically all patients are the same b. each person has a unique background. c. caring for people requires very little experience. d. there are standard solutions to most health care problems.

Each person has a unique background

Nurses demonstrate caring behaviors when they do which of the following? Select all that apply. a. Give clear explanations b. Make the patient do everything for himself or herself c. Tell the patient that getting pain medication depends on his or her cooperation d. Share information about the patients responses with other staff members e. Ask permission before doing something to the patient

Give clear explanations Ask permission before doing something to the patient

A 73-year-old patient reports to the nurse about waking up early and not being able to return to sleep. The patient states, I do not go to bed until after the evening news. What is the best advice for the nurse to give this patient to encourage a good nights sleep?

Go to bed earlier

A nurse is admitting a patient to the hospital. The patient admits to a history of sleep problem. Which of the following questions will help the nurse understand the severity of the patients sleep problem?

How long does it take you to fall asleep?

A patient arrives at the ambulatory clinic for a routine physical. The nurse inquires about the patients sleep pattern. The patient has a history of sleep pattern disturbances. The nurse evaluates that the patient is sleeping better when he or she states which of the following?

I don't take melatonin as frequently

A student nurse assigned to a female, observant Muslim patient noticed her discomfort with several of the male health care providers. She wonders if this discomfort is related to the patients religious beliefs. In her preparation for clinical, she learned that Muslims differ in their adherence to tradition, but that modesty is the overarching Islamic ethic pertaining to interaction between the sexes (Rabin, 2010). The student nurse states which of the following to the patient? a. Im going to request that you only have female physicians see you. Does having male nurses bother you as well? b. I know that its hard to get used to, but you just have to get used to it. Thats how it is in America. c. It must be difficult for people like you to adjust to our ways, but there are limitations for all of us. d. I know that for many of our Muslim patients modesty is very important. Is there some way I can make you more comfortable?

I know that for many of our Muslim patients modesty is very important. Is there some way I can make you more comfortable?

A primary health care provider has diagnosed the patient with having a parasomnia. The patient asks the nurse to explain what that means. What is the best explanation?

It is a sleep disorder that produces abnormal sleep movements

The ANA, National League for Nursing, AONE, and American Association of Colleges of Nursing recommend strategies to reverse the current nursing shortage. A number of the strategies have potential for creating work environments that enable nurses to demonstrate more caring behaviors. Which of the following provisions is advocated to create a more desirable work environment? a. Provide nurses with autonomy over their practice. b. Increase the rigor in the work environment structure. c. Increase the availability of technology. d. Stress the cost-effectiveness of health care.

Provide nurses with autonomy over their practice

A female patient has just found a large lump in her breast. The health care provider needs to perform a breast biopsy. The nurse assists the patient into the proper position and offers support during the biopsy. What is the nurse doing? a. Creating a healing environment b. Fulfilling affiliation needs c. Providing a sense of presence d. Demonstrating an encouraging manner

Providing a sense of presence

A patient has been hospitalized with pneumonia. The patient has had some difficulty sleeping while in the hospital. The patient would like to avoid taking medication for sleep because there have been problems with sleeping pills in the past. Which action by the nursing assistant personnel will cause the nurse to intervene?

Providing a warm cup of hot cocoa before bedtime

A registered nurse who worked in an extended care facility could see that a patient was in the process of dying. The lab technician came to draw his blood. The nurse requested that the blood draw be postponed for a while so that the patients wife, who was at his bedside, could spend some quiet time with her husband. This is an example of which caring behavior? a. Providing presence b. Encouraging manner c. Healing environment d. Affiliation needs

Providing presence

A 6-year-old girl is being seen at the clinic for a well-child checkup. The guardian tells the nurse that the child is having difficulty getting to sleep at night and asks for suggestions. What is the nurses best response?

Quiet activities like reading sometimes help to settle down children her age

One of the five caring processes described by Swanson (1991) is knowing the patient. The concept comprises both a nurses understanding of a specific patient and subsequent selection of interventions. To become adept at knowing patients early, what should the nurse do? a. Check on patients at irregular times so they do not get used to a routine. b. Depend on other nurses assessments to evaluate your own. c. Assume that your interventions are effective because they have been ordered. d. Reflect about your patient interactions and evaluations.

Reflect about your patient interactions and evaluations

The nurse is attempting to teach a patient how to perform wound care for when he goes home. Using the "teach back" method the nurse should do which of the following. a. Repeat the instructions until the patient understands. b. Present the information and clarify with closed-ended questions. c. Ask the patient if he understands the instructions. d. Ask if the patient has any questions about the technique.

Repeat the instructions until the patient understands.

The nurse has taught the patient about how to perform sterile dressing changes. Which action by the nurse best assesses whether or not the patient's discharge teaching was effective? a. The nurse watches the patient perform the sterile dressing change and provides feedback as needed. b. The nurse provides additional written instructions as a reminder of how to correctly perform the procedure. c. The nurse includes the patient's spouse when teaching the patient how to perform the sterile procedure. d. The nurse asks the patient and spouse if they have any further questions about how to perform the procedure.

The nurse informs the patient that a code pink is paged overhead when an infant is abducted from the hospital. What is the best description of the use of the term code pink in this situation? a. Denotative meaning b. Perceptual stereotype c. Emotional inflection d. Sender territoriality

The nurse is caring for a patient who will be having surgery shortly. The patient requests that a religious bracelet be worn in the operating room to help ensure a good surgical outcome. Which is the most appropriate action of the nurse? a. Call the operating room staff to determine if the bracelet can stay on during surgery. b. Insist that the patient remove the bracelet and give it to a family member during surgery. c. Notify the patient's surgeon of the patient's refusal to remove the bracelet before having surgery. d. Remove the bracelet from the patient's wrist after sedating medication has been administered.

The nurse is caring for a patient who will have surgery. The nurse witnesses the patient sign the informed consent document, and then the nurse adds her signature as a witness. What does the nurse's signature on the document mean? a. The patient signed the form, not someone else. b. The patient accepts the potential risks of the procedure. c. The patient fully understands the procedure to be performed. d. The patient agrees with the surgeon's planned treatment approach.

The nurse is caring for a patient with the nursing diagnosis constipation related to side effects of medications. Which is an appropriate goal for this patient? a. "The patient will have a soft formed bowel movement by the end of the shift." b. "The nursing assistant will ambulate the patient to the toilet as needed." c. "The patient will not have any nausea, vomiting, or feeling of abdominal fullness." d. "The nurse will palpate for abdominal distention and encourage oral fluid intake."

The nurse is completing the charting after a patient suffered a fall. Which statement is appropriate for the nurse to include in the description of the incident? a. The patient was found on the floor and his urinal was on the floor next to him. b. The patient's nurse assistant always took her time to answer his call lights. c. The patient probably urinated on the floor and slipped on the wet floor. d. The patient is grouchy and inappropriate, always causing trouble for the nurses.

The nurse is frustrated with an agitated patient and tells him "Now stay in that bed or I will make you stay there!" Which tort has the nurse just committed? a. Assault b. Battery c. Incursion d. Onslaught

The nurse is preparing to insert an indwelling urinary catheter into the patient. Where will the nurse check to ensure that the packaging is sterile, intact, and not past the expiration date? a. In the clean utility room immediately after removing the package from the shelf b. At the patient's bedside after verifying the patient's name and birthdate c. At the nurses' station after verifying the physician's order for the procedure d. At the patient's bedside after performing careful perineal care for the patient

The nurse is providing discharge instructions to a patient with memory loss after a head injury. What is the most appropriate action of the nurse? a. Teach the patient and a responsible family member at the same time. b. Teach the patient using simple terminology and a louder tone of voice. c. Teach the patient the most important information first followed by lesser facts. d. Teach the patient immediately before discharge so the patient will remember it.

The nurse is providing discharge instructions to the patient. Which grade level should the instructions be written at as the nurse does not know the patient's educational background? a. Fifth-grade b. Seventh-grade c. Ninth-grade d. Eleventh-grade

The nurse is researching oral care protocols to reduce the incidence of ventilator-associated pneumonia on the unit. Which section allows the nurse to quickly determine if the study is relevant without having to read the entire article? a. Abstract b. Literature review c. Data collection method d. Theoretical framework

The nurse respects the patient's wish not to be intubated even though the patient will most likely die as a result of the decision. Which ethical theory is demonstrated by the action of the nurse? a. Autonomy b. Justice c. Utilitarianism d. Responsibility

The nurse suspects that a patient is being abused by the spouse based on the presence of many unexplained bruises and the nonverbal behavior of the patient. Which critical thinking technique was used by the nurse? a. Intuition b. Humility c. Curiosity d. Fairness

The patient is nauseated and vomiting when the nurse attempts to provide discharge teaching. Which is the most appropriate action of the nurse? a. Administer antinausea medication and provide discharge teaching later. b. Provide written materials to the patient to read when the nausea has subsided. c. Provide discharge teaching to the family members while the patient rests. d. Assist the patient with mouth care and proceed with the discharge teaching.

The patient suffers a large hematoma at the site after arterial blood gases (ABGs) are drawn by the respiratory therapist. Which statement is appropriate to enter in the patient's chart? a. Patient has a painful, raised 2-inch × 2-inch hematoma inside his right wrist after ABGs were drawn there. b. The patient must have moved during the ABG draw because there is a huge bruise inside his wrist. c. The respiratory therapist had a hard time getting the patient's ABGs drawn and caused bruising. d. The respiratory therapist obviously didn't know what he was doing and traumatized the patient's wrist.

The patient was not able to continue along the migraine headache critical pathway after suffering a stroke. Which terminology describes this deviation from the prescribed pathway? a. Negative variance b. Noncompliance with the treatment plan c. Risk-prone health behavior d. Care plan intolerance

The nurse is administering flu vaccines. One of the children who is scheduled to receive the vaccine is afraid of needles and is tearful, and his younger brother is trying to calm him down. The nurse knows that the tearful child has evaluated this event as challenging and therefore is experiencing psychological stress caused by which of the following? a. Primary appraisal b. Coping c. Secondary appraisal d. Dissociation

a. Primary appraisal

The patient has severe injuries. The nurse knows that the general adaptation syndrome (GAS) was viewed as a reaction to stress consisting of: Select all that apply. a. a pattern of alarm. b. deleterious consequences. c. a stage of resistance. d. developmental impairment. e. a state of exhaustion.

a. a pattern of alarm c. a stage of resistance e. a state of exhaustion

Which of the following is true for a patient to receive home hospice care? a. A primary caregiver must be living in the home. b. Caregiver support is available 9 AM to 5 PM daily. c. If the patient goes to the hospital, all prehospital orders are canceled. d. In the hospital, the home hospice care person must provide personal care.

a. a primary caregiver must be living in the home

The nursing student has severe test anxiety. When he receives a test in class, his heart rate increases, he feels more mentally alert, and his pupils dilate. According to the general adaptation theory, the nursing student should identify this response as what stage of the body's reaction to stress? a. Alarm b. Resistance c. Adaptation d. Exhaustion

a. alarm

For a nurse to be effective in assisting patients with problems associated with loss and grief, what should the nurse do? Select all that apply. a. Help people acknowledge the reality of their loss. b. Encourage the use of a support network. c. Reinforce that people all grieve in the same way. d. Assure people that it will take a year to get over the loss, but it will end. e. Provide continuing support even after an extended time.

a. help people acknowledge the reality of their loss b. encourage the use of a support network c. reinforce that people all grieve in the same way e. provide continuing support even after an extended time

A businessman has been diagnosed with multiple sclerosis and has poor prognosis because the disease is progressing very quickly. To help the patient maintain a sense of hope, what should the nurse do? a. Help the patient set realistic goals. b. Assure the patient that he will be well cared for and does not need to do anything. c. Impress on the family the importance of limiting visiting hours to provide rest. d. Withhold negative information about the patients disease processes.

a. help the patient set realistic goals

Health care regulatory agencies, national think tanks, and government agencies expect health care organizations to incorporate cultural competence into policies and practices to ensure effective communication, patient safety and quality, and patient-centered care. Some examples of such organizational policies and practices include which of the following? (Select all that apply.) a. Instituting a requirement for all staff to be trained in cultural competence b. Maintaining the traditional description of family in written policies c. Enforcing strict visitation policies and practices d. Ensuring that persons who are deaf or speak limited English have access to an interpreter e. Embedding health literacy principles in written and verbal communication

a. instituting a requirement for all staff to be trained in cultural competence d. ensuring that persons who are deaf or speak limited English have access to an interpreter e. embedding health literacy principles in written and verbal communication

A nurse is caring for a patient with a terminal illness whose prognosis is grim. The nurse informs the family about hospice care. What should the nurse let them know about hospice care? a. It is designed for people who have less than a 6-month life expectancy. b. It is provided in the hospital setting. c. It helps to hasten the death process to relieve suffering. d. It has predetermined goals that will be explained at the right time.

a. it is designed for people who have less than a 6 month life expectancy.

A nursing student is assisting with ambulation of a blind patient. The patient has hemiplegia of the right side. The best position for the student nurse to assume when ambulating is by standing on the patients _____ side and walking a half step _____ the patient. a. left; ahead b. right; ahead c. left; behind d. right; behind

a. left; ahead

A parent of three children has the oldest child start school this year, and the parent cries as the child is left at kindergarten on the first day. How is the loss that the parent is experiencing best described? a. Maturational b. Situational c. Actual d. Perceived

a. maturational

The patient is on a ventilator and has a heartbeat, but is brain dead. What should the nurse do? a. Provide a private area to discuss organ donation. b. Explain that as long as the heart is beating, the patient is alive. c. Inform the family that the organs will be harvested when he is off the ventilator. d. Stress the importance of leaving the patient on the ventilator to harvest the corneas.

a. provide a private area to discuss organ donation

The nurse is caring for a patient who has just passed away. What should she do? a. Provide postmortem care in a manner consistent with religious or cultural beliefs. b. Place the body in a supine position to prevent disfigurement. c. Ask family to leave the room since they do not know how to provide care. d. Remove all tubes before determining if an autopsy will be done.

a. provide postmortem care in a manner consistent with religious or cultural beliefs

A middle-age patient was admitted to the trauma intensive care unit after a motor vehicle accident. The nurse notes that the patient becomes increasingly agitated when visitors stay for an extended period or after nursing interventions. The nurse identifies this as sensory overload. Which of the following would most likely help the patient? Select all that apply. a. Reducing the number of visitors to her room b. Performing dressing changes with the bath c. Providing a dedicated period of rest time each afternoon d. Requesting that health care providers do rounds when the family is available e. Coordination with other departments for tests and examinations

a. reducing the number of visitors to her room b. performing dressing changes with the bath c. providing a dedicated period of rest time each afternoon e. coordination with other departments for tests and examinations

The school nurse is performing periodic screening on preschool children. She is aware that the most common visual problem in childhood is which of the following? a. Refractive errors b. Strabismus c. Congenital blindness d. Color blindness

a. refractive errors

A 48-year-old nurse is complaining of being continually exhausted because of the workload on her unit. She states that the patients are getting heavier and the halls are getting longer. Sometimes I just dont think I can get through the day. The nurse is dealing with stress caused by: a. situational factors. b. maturational factors. c. sociocultural factors. d. compassion fatigue.

a. situational factors

A patient and family attend a counseling session. The patient has become depressed after a job loss. The nurse leading the counseling session informs the patient and his family that this type of crisis is caused by: a. situational factors. b. maturational factors. c. sociocultural factors. d. compassion fatigue.

a. situational factors

Health disparities are unequal burdens of disease morbidity and mortality rates experienced by racial and ethnic groups that are often exacerbated by which of the following? (Select all that apply.) a. Social status b. Economics c. Environment d. Improved access to health care

a. social status b. economics c. environment

What should the nurse caring for a dying patient understand about the patient? Select all that apply. a. The patient has the right to be in control. b. The patient must be compliant with his medical regimen. c. The patient should expect to be free from pain. d. The patient should be lied to so as to maintain his sense of hope. e. The patient has the right to die in peace and dignity.

a. the patient has the right to be in control c. the patient should expect to be free from pain e. the patient has the right to die in peace and dignity

(7)Which action by the nurse demonstrates the use of evidence-based practice to positively impact the quality and cost of health care? a. The nurse performs decubitus ulcer dressing changes the way they have always been done at the agency. b. The nurse pioneers a new oral care protocol that has been demonstrated to reduce the risk of ventilator-associated pneumonia. c. The nurse enters the physician's orders into the computer system because the physician refuses to learn how to do it. d. The nurse works on a medical-surgical unit for 4 years before becoming certified in critical care nursing.

A nurse is caring for a patient who is visually impaired. Which technique will the nurse use to facilitate communication? a. Touch the patient before speaking. b. Identify self when entering the room. c. Quietly leave the room when finished. d. Keep the room dimly lit for calmness.

A nurse uses personal experience as well as knowledge of body mechanics and medical equipment in order to determine the safest way to transfer the paraplegic patient from the bed to the wheelchair. Which critical thinking concept is demonstrated by the nurse? a. Evaluation b. Explanation c. Development d. Self-regulation

A single mother with three children uses the public health department services in the county to immunize her children. Which level of health care did the mother use? a. Continuing care b. Preventative care c. Secondary acute care d. Restorative care

After a careful literature review, the nurse manager creates a new fall prevention protocol to reduce patient fall rates on the unit. What is the nurse manager's logical next step? a. Discuss the protocol with the patients and families on the unit. b. Present the protocol to the nursing policy and procedure committee. c. Post an entry about the protocol on the agency's social networking page. d. Submit an article about the protocol to be published in the agency newsletter.

After a patient fall, the supervisor asks the nurse to rewrite the entry in the patient's chart to show that the patient's bed was lowered to the floor even though it was not. What is the best action of the nurse? a. Chart that the bed was lowered to reduce liability in case a malpractice lawsuit is filed. b. Remind the supervisor that it is against regulations to alter or falsify the patient's chart. c. Ask the nurse assistant to chart that the patient's bed was lowered to the floor at the time of the fall. d. Rewrite the entry as requested but note that the patient's bed was not lowered to the floor in the incident report.

The experienced trauma nurse determines that the patient may have suffered a cervical spinal cord injury as the patient is unable to feel or move the arms or legs. Which term best describes the nurse's ability to make this conclusion? a. Data collection b. Clinical inference c. Scientific method d. Standardized criteria

The home care nurse suspects that the patient's bedsores are due to neglect from family caregivers. Which is the appropriate action of the nurse? a. Inform the caregivers that their actions are illegal. b. Report it to the proper legal authority immediately. c. Call the agency's security department to handle the problem. d. Prevent the caregivers from being responsible for the patient's care.

The nurse administers the wrong dose of medication and then blames the mistake on a co-worker. Which ethical principle is violated by the nurse? a. Fidelity b. Accountability c. Confidentiality d. Social networking

The nurse attempts to teach the patient about wound care in a loud semiprivate room with many distractions. Which is the appropriate action of the nurse? a. Explain to the patient that all of the information about wound care is in the handout provided. b. Take the patient to a quiet private treatment room to teach the patient about how to perform wound care. c. Ask the distraught roommate to please be considerate of the patient while the nurse is teaching about wound care. d. Arrange for the home-health nurse to provide teaching about wound care after discharge from the hospital.

The nurse becomes very skilled at feeding patients with dysphagia after working on a rehabilitation unit for many years. Which component of critical thinking allows the nurse to function at this high level of practice? a. Integrity b. Experience c. Risk taking d. Responsibility

The nurse completes the assessment for a patient who has just been admitted to the hospital. The nurse carefully documents the patient's current drug list and asks about the use of any herbal supplements or over-the-counter medications. Which phase of the interview does this occur in? a. Orientation b. Working c. Reasoning d. Termination

The nurse educates the patient about what to expect during suctioning of the tracheostomy tube. Which term best describes the patient's communication role? a. Channel b. Receiver c. Message d. Sender

The nurse feels that an assigned duty is outside the scope of nursing practice. Which document is the best source to answer the nurse's concern? a. ANA Code of Ethics b. State Nurse Practice Act c. QSEN Initiative Act d. Nurse's Bill of Rights

The nurse has just completed an assessment for a patient. Which data will the nurse categorize as objective? a. The patient felt less short of breath after receiving a nebulizer treatment. b. The patient's lung sounds are diminished bilaterally with expiratory wheezes. c. The patient worries that the insurance company will not pay the hospital bill. d. The patient wonders if supplemental oxygen at home would be beneficial.

The nurse is accused of stealing narcotic pain medications from patients. Which type of crime may the nurse be charged with? a. Tort b. Felony c. Malpractice d. Misdemeanor

The nurse is caring for a patient who came to the hospital with acute shortness of breath. What is the priority action of the nurse as the assessment process is started? a. Pull the curtain around the bed and ensure patient privacy. b. Listen to the patient's lung sounds and check the pulse oximetry level. c. Tell the patient that the physician will be in shortly to start treatment. d. Reassure the patient that the shortness of breath will be relieved shortly.

The patient requests that her chart be destroyed as soon as she is discharged. What is the best response of the nurse? a. "The hospital can give you the chart after you are discharged." b. "Your chart will be kept secure and confidential." c. "The information must be reported to the health department first." d. "Your chart can be shredded if you give consent."

The nurse is caring for a patient who had a stroke because of lack of understanding about how to take the prescribed blood pressure medication. Which is the priority nursing diagnosis for this patient? a. Noncompliance related to patient's refusal to follow the prescribed treatment regimen b. Ineffective therapeutic regimen management related to lack of understanding about prescribed medications c. Ineffective health maintenance related to lack of expressed interest in taking prescribed medications correctly d. Readiness for enhanced decision making related to desire to choose the course of action that best meets health needs

The nurse is caring for a patient who has a do-not-resuscitate order from the physician in the chart. The patient stops breathing and his skin turns blue. What is the best action of the nurse to avoid a lawsuit for malpractice or wrongful death? a. Call the Rapid Response Team in case the patient's wife changes her mind. b. Stay with the patient and offer support to the family members in the room. c. Verify that the do-not-resuscitate order is signed by the physician and valid. d. Review the nursing policy and procedure manual for resuscitation guidelines.

The nurse is caring for a patient who has just arrived at the hospital with chest pain. Which is the most important question for the nurse to ask the patient? a. "Did your family doctor tell you to come to the hospital?" b. "When did your chest pain begin?" c. "Do you have a family history of heart disease?" d. "Did someone come to the hospital with you?"

The nurse is caring for a patient with the nursing diagnosis ineffective airway clearance related to narrowed airways and thick sputum. Which is an appropriate goal for this patient? a. "The patient will be resting comfortably by the morning." b. "The patient's airway will remain clear throughout the night." c. "The patient will not experience any feelings of shortness of breath or anxiety." d. "The patient's respiratory rate and pulse will remain within normal limits."

The nurse is caring for a patient with the nursing diagnosis risk for latex allergy response related to multiple food allergies. Which is the priority intervention of the nurse? a. Recommend that the patient wear a medical alert bracelet at home. b. Ensure that a medical plan is in place if an allergic response occurs. c. Lightly powder inside of the gloves before putting them on the hands. d. Provide written information about latex allergy prevention to the patient.

The nurse is caring for a trauma patient who has just arrived to the emergency room. The nurse listens to the patient's lung sounds, palpates the patient's peripheral pulses, and obtains vital signs. What is the best description of the nurse's actions? a. Establishing priorities for outcomes b. Performing a physical examination c. Demonstrating diagnostic reasoning d. Setting time frames for interventions

The nurse is caring for an unconscious patient. The nurse repositions the patient at least every 2 hours and ensures that all of the patient's bony prominences are padded. What is the rationale for these actions? a. The nurse is following the standing orders listed in the patient's medical record. b. The nurse realizes the potential for bedsores and acts to prevent their development. c. The nurse identifies the patient care areas in which additional assistance is required. d. Nursing regulations do not allow these care tasks to be delegated to unlicensed personnel.

The nurse is conducting an admission assessment for a patient who was brought to the hospital after having a seizure. Which question will the nurse ask to quickly focus on the patient's symptoms? a. "Have you been to this hospital before?" b. "How long did the seizure last?" c. "Are you currently seeing a neurologist?" d. "You don't abuse drugs, do you?"

The nurse is directed to take an unsafe patient assignment. What is the most appropriate first action of the nurse? a. Contact the State Board of Nursing. b. Contact the nursing supervisor on duty. c. Contact the hospital administrator on call. d. Refuse to accept the assignment and leave.

The nurse is researching the use of music therapy for patients with dementia and finds that many research articles have been published about the topic. Which single source will provide the best evidence for the nurse? a. The opinion of an expert committee b. Meta-analysis of randomized control trials c. One well-designed randomized control trial d. Systematic review of qualitative nursing studies

The nurse manager will use evidence-based practice to address a recent increase in catheter-associated urinary tract infections on the unit. Which type of trigger did the nurse manager use? a. Literature-focused b. Problem-focused c. Knowledge-focused d. Expectations-focused

The nurse observed a postoperative patient trying to take her friend's narcotic pain pills in addition to the pain medication administered by the nurse. Which nursing diagnosis is the highest priority for this patient? a. Health-seeking behaviors b. Risk-prone health behavior c. Readiness for enhanced comfort d. Situational low self-esteem

The patient developed a large hematoma where the laboratory technician drew blood earlier in the shift. Which statement is appropriate to enter in the patient's chart? a. The laboratory technician did not know what he was doing and traumatized the patient's arm. b. The patient has a painful raised 2-inch × 2-inch hematoma on the outer left arm after venipuncture. c. The laboratory technician must have had a hard time getting the blood sample drawn as the patient's arm is now bruised. d. The patient must have moved during the blood draw because there is a huge bruise on his left arm.

The patient has a goal of maintaining urinary output of at least 30 mL/hour as part of the nursing care plan. However the patient's urinary output for the shift was only 20 mL/hour. What is the appropriate action of the nurse? a. Contact the physician to obtain an order for diuretics to increase urinary output. b. Reassess the patient to determine why the urinary output was less than 30 mL/hour. c. Change the goal to: patient will maintain urinary output of at least 20 mL/hour. d. Inform the patient that the urinary output goal for the shift was not met.

The patient reports using history of ibuprofen for arthritis pain after telling the nurse about a severe allergy to NSAID medications. The nurse asks the patient to further explain the allergy and use of ibuprofen. Which action is demonstrated by the nurse? a. Focusing b. Clarifying c. Summarizing d. Sharing observations

The nurse enters the patient's room to begin teaching the patient about wound care management. The nurse notes that the patient is nauseated due to medication side effects. What are the priority actions of the nurse? (Select all that apply). a. Begin teaching the patient about wound care management, taking care to avoid using terms that the patient might find upsetting. b. Provide measures to relieve the patient's nausea and return to teach about wound care when the patient is feeling better. c. Document in the patient's chart that teaching about wound care management was not done because the patient refused to learn. d. Check the patient's order list to determine if antiemetic medication has been prescribed for the patient. e. Apply a cold cloth to the patient's forehead and maintain a quiet, odor-free environment for the patient.

b, d, e

Which action of the nurse demonstrates patient-centered care? (Select all that apply.) a. The nurse elevates the head of the bed when the patient becomes short of breath. b. The nurse and patient work together to determine the patient's health goals. c. The nurse checks the patient's name and birthdate before giving medications. d. The nurse maintains privacy when conversing with the patient and providing care. e. The nurse respects the patient's choice to refuse transfusion of blood products.

b, d, e

The nurse is caring for a patient with terminal lung cancer. The patient is in a great deal of pain and is anxious. The nurse contacts the health care provider to request pain medication for the patient and is given an order for morphine, but the family of the patient refuses to let the patient have it based on religious grounds. This is most likely because the patient and family are members of which of the following faiths? a. Jewish b. Hindu c. Catholic d. Christian

b. Hindu

A patient who was injured in a motor vehicle accident is taken via ambulance to the emergency department. The nurse performing the physical assessment knows that, according to the general adaptation syndrome, the patient should be expected to exhibit: a. increased blood flow to the intestines. b. increased heart rate. c. decreased blood pressure. d. decreased blood glucose levels.

b. Increased heart rate

Immobilized patients often become depressed. A nurse can best combat this effect of immobilization by doing which of the following? (Select all that apply.)

b. Involving the patient in planning time for care and activities d. Encouraging the patient to comb hair, wear make-up, and/or use cologne if appropriate e. Having the patient in a room with another patient who is interactive.

The charge nurse on the evening shift of a busy medical unit in an acute care hospital received a call from a physicians office that they are admitting a patient who is dying of lung cancer. She is told that the patients family is out of town and is not expected to make it to the hospital before the patient expires. What is the best room for the nurse to place this patient? a. A private room near the nurses station b. A semi private room halfway down the hall with another terminally ill patient c. A private room at the end of the hall d. A semiprivate room with instructions for staff to enter only when necessary

b. a semi private room halfway down the hall with another terminally ill patient.

An older adult patient residing at an adult assisted living facility complains of hearing and visual disturbances. A nurse must be alert to the effects of sensory deprivation that are associated with which of the following? a. Stable affect b. Altered perception c. Improved task completion d. Decreased need for social interaction

b. altered perception

A patient has been suffering from liver cancer for more than a year. The family has requested hospice services. The family members are taking turns staying with the patient. They have been reminiscing with the patient about her life and are now saying their good-byes. The type of grief that this family is experiencing is best described as which of the following? a. Normal b. Anticipatory c. Complicated d. Disenfranchised

b. anticipatory

A patient complains of pain. The nursing order calls for pain medication via injection. The patient is afraid of needles. The nurse can assist the patient through this stressful incident by encouraging the patient to think of a relaxing situation. The nurses actions can be identified as: a. restorative care. b. cognitive therapy. c. assertiveness training. d. progressive muscle relaxation.

b. cognitive therapy

A patient telephones a crisis intervention hotline. The nurse assigned to this center assesses that the patient is experiencing a crisis. What is the most appropriate action for the nurse to take? a. Take control of the situation and tell the patient what needs to be done. b. Define the problem at hand and ensure that the patient is safe. c. Ask the patient how he would like to handle the crisis and follow through. d. Ask the patient to list all of his problems and prioritize which to deal with first.

b. define the problem at hand and ensure that the patient is safe

The student nurse was late for clinical rounds because she had to change the tire on her car. She is in the process of preparing pain medication for her patient when her nursing instructor asks her to identify the drug classification of the medication that she is preparing. The student nurse is very frustrated, becomes tearful, and states, I cant seem to crush this tablet correctly. This reaction to the instructor is most likely a result of what ego-defense mechanism? a. Compensation b. Displacement c. Denial d. Dissociation

b. displacement

The nurse is talking to a patient who was involved in a motor vehicle accident. The patient asks the nurse why there was no sensation of pain at the time of the accident. The best explanation would be: a. Vasopressin was released to decrease pain sensation. b. Endorphins are released during a time of stress to reduce pain. c. Alcohol reduces the perception of stress when injury occurs. d. You probably have chronic high levels of cortisol to help with chronic pain.

b. endorphins are released during a time of stress to reduce pain

A patient with poor vision is ready to be discharged. The nurse is educating the patient and family regarding ways to improve vision. The nurse teaches the patient and family to avoid reading materials with shiny surfaces. The rationale for this intervention is which of the following? a. Glare causes headaches. b. Glare will reduce visual acuity. c. Shiny surfaces reflect damaging rays. d. Too much light is damaging to the eyes.

b. glare will reduce visual acuity

A home care nurse visits a new patient. The family asks how the home can be made safer. The nurses best advice includes which of the following? a. Using throw rugs to prevent tripping b. Installing extra incandescent lighting c. Painting the floor black and white to add perception d. Installing handrails painted the same color as the walls

b. installing extra incandescent lighting

A 64-year-old house painter who is seeing his health care provider for his annual checkup. When the nurse asks the patient if they have any health concerns, the patient states, I dont think my vision is as good as it used to be, things look more yellow than they used to. The nurse knows that this is a visual change in older adults caused by which of the following? a. Iris yellows b. Lens yellows c. Retina is hypersensitive d. Need for less light to see than when they were in young adulthood

b. lens yellows

The spouse of a homebound elderly patient voices a concern to the visiting nurse, Im having a hard time getting the patient to eat a balanced diet. All the patient wants to eat are sweets. What is the best explanation the nurse can give to the spouse? a. Maybe she has a sweet tooth. b. Older adults seem to be able to taste sweet foods best. c. I wouldn't worry about it as long as she is eating something. d. She is probably getting all the nutrients that she needs.

b. older adults seem to be able to taste sweet foods best.

A family member is accompanying the elderly patient to their follow-up appointment after a recent hospitalization for gastrointestinal problems. The nurse interrupts a discussion between the family member and the patient regarding rancid food in the patients refrigerator. The family member looks at the nurse and states, She was trying to eat spoiled food for lunch, it spelled terrible, and she still wanted to eat it. What is the most likely physiological reason that the patient not realizes that the food is spoiled? a. She has xerostomia. b. She has a diminished sense of smell. c. She has a diminished sense of taste. d. She has a limited vision.

b. she has a diminished sense of taste

A woman is attending a nurse-facilitated grief support group. The womans son was killed in Iraq 18 months earlier. She confides that while at the gravesite yesterday, she broke down and the feelings of hurt were as deep as the day she found out about the death. She states, I will never get over this feeling of intense grief. The nurse discovers that yesterday would have been her sons 21st birthday. What is the nurses best response? a. That kind of reaction is very rare after so long a time. It would be best to avoid the cemetery on dates that might trigger this type of reaction. b. What happened to you yesterday is understandable and common in people who have lost loved ones. c. I find that hard to believe. We all grieve basically the same way, and I know that I would not react that way after such a long time. d. The fact that you reacted so strongly is concerning to me. This could be the beginning of some bigger issues.

b. what happened to you yesterday is understandable and common in people who have lost loved ones

(5)Which description of the state Nurse Practice Act is correct? a. It is a judicial decision. b. It is a federal senate bill. c. It is a statute enacted by state legislature. d. It is a law enacted by the federal government.

A new central line care protocol to prevent site infection is instituted after it has been shown to be significantly more effective than previous approaches. Which term best describes this action? a. Inductive reasoning b. Qualitative research c. Evidence-based practice d. Process measurement

A nurse enters a patient's room and sees the patient grimacing with each movement. When the nurse asks how the patient is feeling, the patient states "I feel fine." Which finding will the nurse classify as nonverbal communication? a. The patient states "I feel fine." b. The nurse asks how the patient is feeling. c. The patient grimaces with each movement. d. The nurse is present at the patient's bedside.

A nurse is collecting data during the assessment of a patient. During the assessment, the nurse collects both subjective and objective data. Which information should the nurse consider as subjective data? a. The patient's catheter drained 400 mL of urine during the last 8 hours. b. The patient's incision is clean, dry, and intact with staples. c. The patient reports having sharp, burning pain with urination. d. The patient refused breakfast after vomiting 200 mL green emesis.

A nurse is delegating care of patients to the certified nursing assistant (CNA) and a licensed practical nurse (LPN). Which task assignment indicates that the nurse needs additional education about delegation? a. The LPN is assigned to change a sterile dressing. b. The CNA is assigned to provide skin care. c. The CNA is assigned to insert an indwelling urinary catheter. d. The LPN is assigned to administer a soapsuds enema.

A nurse must give feedback to a nursing assistant that did not take vital signs. How will the nurse give feedback? a. "Did you miss the class about how to take vital signs?" b. "I refuse to work with you again if you cannot do your job." c. "The patient's vital signs were not taken. What happened?" d. "I cannot trust you to complete tasks that you are assigned."

A nurse wants to follow nursing standards of care. Which document should the nurse follow? a. National League for Nursing manuscript b. World Health Organization guiding principles c. Health care agency's written procedure manual d. US Department of Health and Human Services guidelines

A patient with a rare neurological disease is misdiagnosed by the physician and told that the symptoms are psychosomatic. The patient's sense of self is shattered after being told "You are a waste of a hospital bed." Which ethical theory is violated in this situation? a. Liberty b. Fidelity c. Ethics of care d. Confidentiality

Which type of health care agency is appropriate for a patient who sustained a back injury while at work? a. Respite care center b. Skilled nursing facility c. Occupational health clinic d. Outpatient surgical center

Which behavior demonstrates basic critical thinking expected of beginning nursing students? a. Creating a personalized bowel elimination program for a patient with constipation due to narcotic pain medications b. Elevating the patient's leg and applying ice packs when the patient's postoperative pain is not relieved with prescribed pain medications c. Asking the instructor for assistance when having difficulty inserting the urinary catheter into the male patient's bladder d. Advocating for delay in the patient's discharge when the nurse suspects that a serious surgical complication has developed

Which ethical principle is upheld when the nurse refuses to administer a placebo pill to the patient? a. Justice b. Culture c. Veracity d. Competency

Which ethical principle is violated when the nurse promises to administer pain medication to the patient every 2 hours throughout the shift and then fails to do so? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

Which information must be obtained from the patient upon admission to the hospital? a. Patient's religious preference b. Health insurance authorization c. Presence of an advanced directive d. Primary physician telephone number

Which is an appropriate goal for the diagnosis risk for infection related to aspiration of fluids into the airway? a. The patient will respond positively to IV antibiotic therapy. b. The nurse will elevate the head of the patient's bed at mealtimes. c. The patient will remain afebrile with clear lung sounds bilaterally. d. The nurse will have suction equipment available when feeding the patient.

Which is an example of a PICO question? a. How does the agency's monthly catheter-associated urinary tract infection rate compare with the national average? b. Which types of topical antibiotic irrigation solutions may be used to reduce healing time for stage 4 decubitus pressure injuries? c. Does oral care with chlorhexidine solution more effectively reduce the incidence of ventilator-associated pneumonia in intubated patients than saline solution? d. Which emotions are commonly felt by patients upon learning that they were diagnosed with a terminal illness?

Which is an example of a tertiary health care provider? a. An outpatient rehabilitation center b. A nurse-managed urgent care clinic c. A university-based research hospital d. A community center offering adult day care services

Which is an example of an incidence rate? a. The patient was able to ambulate 50 feet in 10 minutes. b. 65% of the hospital's registered nurses are bachelor-prepared. c. The hospital has a 12% ventilator-associated pneumonia rate. d. The patient's hemoglobin rate is 50% lower than the previous day.

Which is the best strategy for the nurse to use when communicating with a patient from different culture? a. Using a cultural joke to break the ice b. Stereotyping the patient within his or her culture c. Considering the context of the patient's background d. Assuming the patient or the family member speaks English

Which is the first action of the nurse when starting care for the patient at the beginning of the shift? a. Administer prescribed medications. b. Conduct the patient's health history. c. Perform a focused patient assessment. d. Create the nursing care plan for the patient.

Which is the primary purpose of a patient's medical record? a. To invoice the nursing services for hospital reimbursement b. To protect the patient in case of a malpractice suit c. To facilitate professional communication and safe health care d. To contribute to a worldwide databank for trends in health care

Which nursing care concept is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient? a. Delegation b. Empowerment c. Accountability d. Responsibility

Which patient's need constitutes the highest priority for the nurse? a. The patient who is waiting for discharge teaching in order to go home b. The constipated patient who has not had a bowel movement in 3 days c. The patient with sudden onset of slurred speech and right-sided weakness d. The patient who requires linen changes after being incontinent of urine and stool

Which problem is the highest priority for a family who has just moved to the United States and does not speak any English? a. Risk for acute confusion b. Disturbed energy field balance c. Impaired verbal communication d. Readiness for enhanced decision making

Which professional nursing organization ensures that nursing programs adequately prepare students to enter the nursing profession? a. Federal Nurses Association (FNA) b. International Council of Nurses (ICN) c. National League for Nursing (NLN) d. National Student Nurses Association (NSNA)

Which question is the most appropriate for the nurse to use to start the health history assessment? a. "Does your family doctor know that you are here?" b. "Did you drive yourself to the hospital?" c. "What brings you to the hospital today?" d. "Did you give your insurance card to the receptionist?"

Which situation will enable a nurse to use restraints? a. To punish a patient b. To ensure staff convenience c. To ensure the patient's safety d. To retaliate against poor behavior

Which statement by the nurse accurately reflects a benefit of installing a new electronic medical record system? a. "I am thankful that I won't have to keep changing my passwords all the time." b. "I'll be able to see my son's medical record using my password and user ID." c. "I won't have to worry about reading the doctor's messy handwriting anymore." d. "It will take me so much less time than writing everything out on paper."

Which statement by the nurse will help the patient progress to the preparation stage for smoking cessation? a. "You will die of emphysema or lung cancer if you do not stop smoking." b. "Research has shown that smoking causes emphysema and lung cancer." c. "The physician will give you nicotine patches to help you start to quit smoking." d. "You need to avoid people who smoke so you will not be tempted to start again."

Which term is used to describe the body's protection against whooping cough after receiving the pertussis vaccination? a. Natural passive immunity b. Natural active immunity c. Acquired active immunity d. Acquired passive immunity

While at the grocery store, the nurse witnesses another shopper collapse near the checkout. The nurse performs CPR and the patient survives after being treated at the hospital. The patient later attempts to sue the nurse for malpractice because several ribs were broken as a result of chest compressions. Why will the patient's lawsuit be thrown out of court? a. The patient should not have been at the grocery store with a history of heart disease. b. The patient needed to disclose her history of heart disease to the nurse before she collapsed. c. The patient's rib fractures occurred as a result of properly performed CPR by the nurse. d. The nurse's personal liability insurance company decided to settle rather than face a jury.

A nurse prepares to teach the patient about strategies to minimize feelings of powerlessness. Which techniques will the nurse implement that are the best for this type of learning? (Select all that apply.) a. Lecture b. Practice c. Discussion d. Role play e. Return demonstration

c, d

What is wrong with this picture of a nurse administering eyedrops to a patient? (Select all that apply.) a. The tip of the eyedropper should touch the inner canthus. b. The nurse should be applying pressure to the nasolacrimal duct. c. The medication will land in the center of the patient's cornea. d. The nurse should have gloves on when administering eyedrops. e. The patient's eye should be closed during administration of eyedrops.

c, d

Which communication methods will the community nurse use when interacting with recent immigrants who do not speak English? (Select all that apply.) a. The nurse will obtain the assistance of a speech pathologist. b. The nurse will speak in a louder tone of voice than usual. c. The nurse will be sensitive to nonverbal communication cues. d. The nurse will identify the preferred language for each family member. e. The nurse will utilize an interpreter when explaining health care procedures.

c, d, e

The nurse is caring for a patient who climbed out of bed and fell to the floor. What will the nurse do in regard to the incident report? (Select all that apply.) a. Include a recommendation for fall prevention interventions. b. Note in the patient's chart that an incident report was completed. c. Document how the patient was found and a description of the injuries. d. Indicate that the nursing assistant wasn't paying attention to the patient. e. Document fall prevention steps that were in place before the patient fell.

c, e

Which actions by the nurse are examples of dependent nursing interventions for a postoperative patient? (Select all that apply). a. Calculating the patient's fluid intake and output at the end of every shift b. Encouraging fluid and fiber intake to prevent constipation from pain medications c. Administering a mild stool softener daily to prevent constipation d. Assessing the patient's abdomen for distention, bowel sounds, and passage of flatus e. Reinserting of the patient's urinary catheter for retention of greater than 500 mL of urine

c, e

Which nursing diagnosis is the highest priority for a patient with pneumonia? a. Activity intolerance related to fatigue and shortness of breath b. Knowledge deficit related to pneumonia risk factors c. Pruritus related to side effects of prescribed medications d. Impaired gas exchange related to alveolar inflammation and infection

A patient has been hospitalized for 5 days and has had no visitors. The nurse observes the patient to be bored, restless, and anxious. The nurse identifies this behavior as which of the following? a. Sensory deficits b. Sensory overload c. Sensory deprivation d. Changes in attitudes

c. Sensory deprivation

A businessman who had been employed at one company since graduating from college was recently downsized at work and is unemployed. He was always very proud of this job and is grieving the loss. What type of loss is this? a. Maturational b. Situational c. Actual d. Perceived

c. actual

An older extended care resident was dying. The family came to visit, but one of the great-granddaughters had difficulty accepting the impending death. What is the best thing that the nurse can do to help her feel more comfortable? a. Telling her that she probably should not visit if it upsets her so much. b. Tell her to avoid talking about the past and focus on the present. c. Ask her if she would like to brush the residents hair. d. Ask the family to leave at the end of visiting hours so that they can rest.

c. ask her if she would like to brush the residents hair

The nurse has recently been promoted to a new management position in her hospital. She is concerned about her new responsibilities and has found that she is having difficulty sleeping at night. This is an example of what ego-defense mechanism? a. Compensation b. Denial c. Conversion d. Displacement

c. conversion

The nurse works in a small clinic with two other nurses and a nurse practitioner. Recently the nurse has been staying at work longer than usual. His neighbor, a patient at the clinic, asks one of the other employees at the clinic how the nurse is coping since his wife left him. The nurse had not shared this information with his co-workers. The nurse may be coping with his loss with which of the following? a. Compensation b. Conversion c. Denial d. Dissociation

c. denial

The parent of a child who drowned in a neighbors pool that was not secured, would most likely file a wrongful death lawsuit against the neighbor during which of Bowlbys phases of mourning? a. Numbing b. Yearning and searching c. Disorganization and despair d. Reorganization

c. disorganization and despair

A 45-year-old widow, who is being seen in a mental health clinic for clinical depression and alcohol dependency, lost her husband and her son in a boating accident 10 months earlier, and has become increasingly despondent and withdrawn. She verbalizes that she feels overwhelmed by her loss. Her daughter urged her mother to seek help. Which type of complicated grief best explains Eleanors behavior? a. Chronic b. Delayed c. Exaggerated d. Masked

c. exaggerated

A new nurse is looking for a staff nurse position. She had several instances during clinical rotations in nursing school in which she was late because she studied until the early hours of the morning. According to her circadian rhythm she would be best suited for which of the following positions? a. Full-time 8-hour day/evening rotation b. Part-time 12-hour day/night rotation position c. Full-time 12-hour night position d. Full-time 8-hour day position

c. full-time 12 hour night position

A young widower who lost his wife in Afghanistan has worked through the first task of Wordens mourning theory. He asks you if he will ever feel able to move forward with his life. According to Wordens theory, what is your best response? a. You will never love anyone as much as your wife. b. Nobody will ever be able to take your wifes place. c. It takes time to adjust to this type of loss, typically at least a year. d. Some people are able to move forward faster by suppressing the pain.

c. it takes time to adjust to this type of loss, typically at least a year

A nurse is caring for a patient who has become depressed because her children have gone away to college. The nurse assesses this type of depression as what type of loss? a. Actual b. Perceived c. Maturational d. Situational

c. maturational

A 63-year-old welder who has gone to the clinic for an annual checkup. The patient shares a concern regarding difficulty hearing conversations at the coffee shop in the mornings. After looking in his ears to determine if there is a build-up of cerumen, the nurse tells the patient that the hearing loss may be associated with his occupation or it may be associated with aging. The nurse is aware that hearing loss associated with the aging process is known as which of the following? a. Tinnitus b. Mnires disease c. Presbycusis d. Presbyopia

c. presbycusis

A nurse who grew up in Korea has been in the United States for the past 4 years. The nurse is especially sensitive about the differences in how mourning is different between the native culture and that of Western society. The nurse should use which model of mourning to help understand an action-oriented process of grieving? a. Bowlbys Four Phases b. Wordens Four Tasks c. Randos R Process d. Kbler-Ross Five Stages

c. randos r process

A patient suffering from lung cancer experiences nausea and vomiting. When rendering palliative care, the nurse knows that this type of care: a. is only done in intensive care units. b. is for the elderly. c. requires an interdisciplinary team. d. utilizes standard medical treatments to provide care.

c. requires an interdisciplinary team

A 16-year-old mother and her newborn come into the clinic for a routine checkup. The mother is concerned that her baby could be deaf because her uncle lost his hearing at a young age. The nurse hits a buzzer and the baby turns toward the sound. The nurse assures the mother that the baby can hear because the baby: a. was discharged from the hospital without any known problems. b. is producing ear wax. c. responds to loud noises. d. is too long young to determine any type of hearing loss.

c. responds to loud noises.

A nurse is caring for a patient who signs and lip reads. When communicating, the most appropriate nursing action is to do which of the following? a. Rely on family members to interpret. b. Speak louder and more distinctly than normal. c. Sit facing the patient when speaking. d. Repeat the entire conversation if it is not understood the first time.

c. sit facing the patient when speaking

Which action by the nurse best demonstrates the concept of right supervision? a. The nurse ensures that the scale is accurate before directing the nursing assistant to obtain the patient's weight. b. The nurse directs the nursing assistant to ambulate the patient at least 20 feet in the hallway using the gait belt before lunch. c. The nurse checks if the hospital policy allows the licensed practical nurse to perform venipuncture before delegating the task. d. The nurse confirms that the patient's urine output is entered into the medical record by the nursing assistant by the end of the shift.

Which action by the nurse minimizes the risk of unauthorized use of computer passwords for the electronic medical record system? a. Using the same password for home and health care agency computers b. Writing each new computer password on the back of the name badge c. Periodically reusing previous computer passwords to prevent forgetting them d. Using passwords of at least eight characters with at least one number and symbol

Which approach will be most successful for the nurse to teach a preschooler about tube feeding through a gastrostomy tube? a. Offer opportunities to discuss tube feeding options and answer questions. b. Hold the child while smiling and speaking softly to convey a sense of trust. c. Collaborate with the child to develop an individualized tube feeding schedule. d. Use simple terms and show the child a gastrostomy tube inserted into a teddy bear.

Which chart entry represents appropriate documentation about the patient's pain assessment? a. The patient appears not to be in any pain. b. The patient is sleeping comfortably. c. The patient always complains about being in pain. d. The patient rated the pain at 2 on a 0-to-10 scale.

Which entry in the patient's chart will justify home nursing care reimbursement from Medicare, Medicaid, and private insurance companies? a. The patient's wound is improving slightly each day. b. The patient was receptive to the smoking cessation information. c. The patient's family appreciated the nurse's caring demeanor. d. The patient's wound was 6 cm × 4 cm and is now 4 cm × 2 cm.

Which ethical principle is upheld when the registered nurse provides medical assistance to victims of an accident? a. Veracity b. Fidelity c. Autonomy d. Beneficence

Which ethical principle is upheld when the surgeon refuses to operate on the patient because potential benefit is minimal compared to the pain that the patient will endure? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

Which ethical principle is violated when the nurse is overhead talking about the patient's prognosis in the elevator? a. Judgment b. Advocacy c. Accountability d. Confidentiality

Which example demonstrates a breach of confidentiality and a violation of the Health Insurance Portability and Accountability Act (HIPAA) of 1996? a. Giving a report to the oncoming nurse in a conference room b. Discussing a patient's diagnosis with the patient's health care provider c. Providing patient information to the nursing assistant caring for the patient d. Sharing a patient's diagnosis and prognosis with other nurses in the cafeteria

Which is a responsibility of the Centers for Medicare and Medicaid (CMS)? a. Create teaching materials to educate health care professionals. b. Research evidenced-based practices to improve health care for patients. c. Accredit and certify hospitals in order to ensure safe health care for patients. d. Manage health insurance coverage for elderly, disabled, and low-income patients.

Which is a semicritical item that requires disinfection? a. Nail file b. Safety pin c. Emesis basin d. Laryngoscope

Which is an example of a diagnosis-related group (DRG)? a. Patients recovering from orthopedic surgery are placed on the same nursing unit. b. Specialty hospitals are utilized to treat patients with life-threatening illnesses. c. The speech therapist is consulted to see every patient admitted with dysphagia. d. Hospitals will be paid $4500 to care for patients with uncomplicated pneumonia

Which is an example of an acute illness? a. Type 2 diabetes b. Multiple sclerosis c. Alcohol addiction d. Bacterial meningitis

Which is an example of capitation in health care? a. The patient's rheumatologist is reimbursed for services provided at each consultation appointment with the patient. b. The discharge planner arranges for a home respiratory care company to deliver home oxygen supplies before the patient leaves the hospital. c. The patient's care is managed by a nurse practitioner rather than an attending physician. d. The patient's primary care physician is paid a flat monthly fee no matter how many appointments are scheduled with the patient.

Which is the best method to begin teaching the adult patient how to self-administer tube feeding through a new gastrostomy tube? a. Analogies b. Detachment c. Role play d. Demonstration

Which is the first action of the nurse when teaching the patient how to perform colostomy care? a. Determine the patient's educational background and learning abilities. b. Identify a responsible family member to reinforce colostomy care teaching. c. Have the patient watch a video that demonstrates how to perform colostomy care. d. Assess the patient's level of comfort with looking at and caring for the colostomy.

Which is the highest priority nursing intervention for a patient with the nursing diagnosis risk for suicide related to recent suicide attempt and desire to die? a. Assist the patient to identify sources of support in the community. b. Assess the patient's readiness to sign a pledge to do no self-harm. c. Question the patient's family members about previous suicide attempts. d. Remove dangerous items such as scissors from the patient's environment.

Which laboratory result indicates to the nurse that antibiotic therapy is effectively treating the patient's infection? a. The patient's urinalysis tested positive for nitrites and leukocytes. b. The patient's wound culture showed a positive result for Candida albicans. c. The patient's white blood cell count has increased from 12,000 to 25,000/mm3. d. The patient's erythrocyte sedimentation rate (ESR) dropped from 56 to 33 mm/hour.

Which nursing diagnosis is the highest priority for a patient with multiple sclerosis? a. Chronic sorrow related to loss of independence b. Disturbed sensory perception related to nerve cell damage c. Risk for powerlessness related to impaired fine- and gross-motor skills d. Risk for falls related to impaired mobility and sensation

An elderly patient with diabetes is seeing the health care provider for complaints of visual changes. The patient explains to the nurse that visual changes include distortion that makes the edges of objects appear wavy. The nurse knows that this is an early sign of which of the following? a. Cataracts b. Glaucoma c. Diabetic retinopathy d. Age-related macular degeneration

d. age-related macular degeneration

The nurse is caring for a patient of the Chinese community who is dying. The nurse needs to understand the Chinese communitys beliefs regarding death, but it is most important to keep in mind which of the following? a. Most survivors in Chinese society wail loudly to communicate their loss. b. People in the Chinese culture believe that talking about death is healthy. c. Chinese people are strong believers in reincarnation. d. Regardless of cultural or religious beliefs, people respond to death in their own unique way.

d. regardless of the cultural or religious beliefs, people respond to death in their own unique way.

A 4-year-old boy has been admitted to the hospital with pneumonia. He has been in the hospital for 3 days and has suddenly started to become incontinent of urine. The nurse knows that this is most likely a result of what ego-defense mechanism? a. Compensation b. Conversion c. Denial d. Regression

d. regression

A widow, whose spouse died 3 years ago, has recently started dating and is thinking about going back to school to complete a degree she had started at an earlier age. Which of Bowlbys phases of mourning best describes this behavior? a. Numbing b. Yearning and searching c. Disorganization and despair d. Reorganization

d. reorganization

The student nurse is assisting an elderly patient to get ready for bed. The patient states, Please make sure you clean my hearing aids. The student nurse knows it is important to keep in mind which of the following when cleaning a hearing aid? a. Keep the battery in the machine when turned off. b. Store the hearing aid on the overnight table for easy access at night. c. Clean the hearing aid with hot water. d. Use a soft dry cloth to wipe the hearing aid.

d. use a soft dry cloth to wipe the hearing aid

An elderly nursing home resident fell 2 weeks ago and has been on bed rest. The patient has become increasingly fatigued during activities of daily living (ADLs). The family is concerned about the patient's declining condition. The best explanation that the nurse can give the family is that the patient's fatigue is caused by which of the following?

decreased muscle endurance due to immobility

A female 36-year-old bank executive was recently promoted to vice president. She and her husband have two school-age children. The patient is being seen at the clinic and reports severe abdominal pain with diarrhea. During the assessment, the patient explains to the health care worker that she and her family will be moving to another state because of her promotion. Her children are upset about leaving their friends. The health care worker recognizes that which of the following information is a priority for patient teaching

discuss how high level of stress can cause illness

increased urine excretion

diuresis

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