Fundamentals Exam One

The nurse is trying to establish an effective relationship with a patient in pain. What is the best statement for the nurse to make when beginning the assessment? *"I'll check to see if you can have anything." *"When was your last medication for pain?" *"I believe you are in pain." *"Let me give you a backrub and see if it helps."

"I believe you are in pain." A nursing intervention to establish an effective relationship is to believe the patient. Although the other options are not wrong, they do not help establish an effective relationship.

A nurse is observing isolation precautions by wearing a mask while performing complex patient care. How often should the nurse change masks? *10 to 20 minutes *30 to 40 minutes *5 to 10 minutes *20 to 30 minutes

*20 to 30 minutes The mask should be changed every 20 to 30 minutes

The nurse attempts to avoid a pressure injury for a bedridden patient by turning the patient frequently. What is the most favorable position for the nurse to move this patient into? *Back-lying *Full prone *30-degree lateral *Full lateral

*30-degree lateral It is preferable to use the 30-degree lateral incline position.

The home health nurse is caring for a patient with an implanted pacemaker. What type of pain management would be contraindicated? *A TENS unit *Opioid analgesics *Adjuvant analgesics *Peripheral analgesics

*A TENS unit A TENS unit may interfere with the function of the pacemaker.

A nurse assesses an area of sustained redness on the coccyx area of a resident in long-term care. What is the most likely cause of this pressure area? *Collapse of blood vessels *Collapse of skin tissue *Heat from pressure *Friction from pressure

*Collapse of blood vessels A pressure injury occurs when there is sufficient pressure to collapse the blood vessels.

When preparing a patient for sleep, diming the lights and decreasing the noise levels are examples of nursing interventions. What are these interventions designed to do? *Prepare the patient for sleep. *Decrease environmental stimuli. *Provide for more rest. *Mimic usual sleep patterns.

*Decrease environmental stimuli. Environmental stimuli should be decreased when preparing the patient for sleep.

The nurse is giving a backrub to a patient to relieve pain. What pain theory is the nurse using? *Distraction *Guided imagery *Synergism *Gate control

*Gare control The pressure of a backrub will close the gate, according to the gate control theory of pain.

The nurse is instructing a patient about the most important preventive technique for breaking the chain of infection. What technique is the patient learning about? *Standard Precautions *Medical asepsis *Hand hygiene *Sterilization

*Hand hygiene Hand hygiene is the most important preventive measure for interrupting the infection process.

What should the nurse be diligent in to provide a safe environment for the patient? *Keeping a light on at night to prevent falls *Hand hygiene between patient contacts *Changing the bed linen to diminish microorganisms *Regulating the temperature to avoid drafts

*Hand hygiene between patient contacts One of the most important actions is hand hygiene before caring for another patient.

What is important for the nurse to determine in order to decrease the risk for injury to a patient? *If patient ambulates with assistive device *If patient is left-handed *If patient can read English *If patient can dress independently

*If patient is left-handed Patients requiring an assistive device to ambulate are at an increased risk for injury.

Which are considered phases of the nursing process? (Select all that apply.) *Implementation *Prediction *Diagnosis *Evaluation *Outcome identification *Assessment

*Implementation *Diagnosis *Evaluation *Outcome identification *Assessment

What additional complication does a disease caused by a virus have compared to a disease caused by bacteria? *Returns frequently. *Multiplies rapidly. *Is not killed by antibiotics. *Is unable to be cultured.

*Is not killed by antibiotics. Antibiotics do not alter the course of a disease caused by a virus.

The nurse is assessing pain reported by a Latino male patient. What is important for the nurse take into consideration when observing objective data? *Latino men feel it is unmanly to admit to pain. *Latino men have a cultural bias against use of narcotics. *Latino men are suspicious of female caregivers. *Latino men believe pain is necessary for cure.

*Latino men feel it is unmanly to admit to pain. Many Latino men feel that to admit to being in pain is unmanly.

What are the basic purposes of written patient records? (Select all that apply.) *Temporary record of hospitalization *Permanent record for accountability *Written communication *Teaching *Legal record of care *Research and data collection

*Permanent record for accountability *Written communication *Teaching *Legal record of care *Research and data collection

The nurse is providing hand and foot care to a patient and notices the patient has extremely hard nails. Who is the person best prepared to provide nail care for patients with extremely hard nails? *CNA *Health care provider *RN *Podiatrist

*Podiatrist If the patient's nails are extremely hard, a podiatrist should provide care.

The nurse discovers a reddened area over a patient's hip. What should be the nurse's first intervention? *Apply mild ointment with a cotton-tipped applicator. *Rub gently to increase circulation. *Press the area gently to assess for blanching. *Cover the area with an occlusive dressing.

*Press the area gently to assess for blanching. If the area is a stage 1 decubitus injury, the area will not blanch.

The nurse is assessing a patient's skin for signs of impaired skin integrity. Which finding by the nurse is considered a major manifestation? *Pressure injury *Infection *Laceration *Burn

*Pressure injury A major manifestation of impaired skin integrity is a pressure injury.

What assessment does the nurse recognize as an inflammatory response in a surgical wound on the leg of a patient? *There are raised, red, pruritic welts on the leg. *A foul drainage is coming from the wound. *The affected leg is cooler than the other leg. *Rubor and edema appear around the wound.

*Rubor and edema appear around the wound. Rubor and edema are two of the cardinal signs of an inflammatory response. Foul drainage suggests infection, the affected leg being cooler than the other leg suggests circulatory disorder, and raised, red, pruritic welts on the leg suggest allergy.

Although denying pain, a patient is irritable, responds slowly, and exhibits periods of tachycardia. What should the nurse assess for in this patient? *Sleep deprivation *Constipation *Allergic response *Electrolyte imbalance

*Sleep deprivation With sleep deprivation, patients may experience a variety of physiologic and psychological symptoms.

One reason the nurse focuses on oral hygiene is to maintain a healthy state of the oral cavity. What is another reason to promote oral hygiene? *To improve self-esteem *To assist with periodontitis *To restore tooth destruction *To stimulate appetite

*To stimulate appetite A sense of well-being can stimulate appetite.

A nurse instructs a unlicensed assistive personnel about the proper use of a gait belt and is observing a return demonstration. What action by the unlicensed assistive personnel should cause the nurse to intervene? *Unlicensed assistive personnel is walking to the side of the patient. *Unlicensed assistive personnel is grasping the handles of the gait belt while the patient ambulates. *Unlicensed assistive personnel is securing the gait belt securely around the patient's waist. *Unlicensed assistive personnel is walking on the patient's strong side.

*Unlicensed assistive personnel is walking on the patient's strong side. A gait belt should be securely applied around the patient's waist. It has handles attached for the nurse to grasp while the patient ambulates. The nurse should walk on the patient's weaker side so that assistance may be given if the patient starts to fall.

A patient with a respiratory infection reports that he is not yet on an antibiotic. The nurse explains that the health care provider is waiting on the results of the culture and sensitivity. What does this test determine? *Which antibiotics stop bacterial growth *How fast the bacteria grow *When the bacteria colonize *What media the bacteria requires to grow

*Which antibiotics stop bacterial growth Sensitivity tests are done to determine which antibiotics will stop growth.

The nurse explains that the measurement of radiation exposure is in multiples of Gy. The number of Gy an individual may absorb before becoming ill with radiation syndrome is __.

0.75

The nurse is using a pain scale of 0 to 10 to assess pain in a postoperative patient. What is considered the maximum pain level at which a patient can usually function effectively? *3 *4 *5 *2

4 Most patients do not function effectively if the pain level exceeds 4 on a scale of 10.

What organized approach might the nurse use when performing a complete physical examination? *A head-to-toe assessment *Objective data collection *Maslow's hierarchy of needs *Subjective data collection

A head-to-toe assessment A head-to-toe format provides a systematic approach.

What is the defining term for continuous or intermittent pain that does not serve as a warning of tissue damage? *Chronic *Acute *Unrelieved *Subacute

Chronic Chronic pain can be continuous or intermittent and may not be indicative of tissue damage.

When a nurse protects the information in a patient's record, what ethical responsibility is the nurse fulfilling? *Disclosure *Confidentiality *Privacy *Absolute secrecy

Confidentiality The nurse has an ethical and legal duty to protect information about a patient and preserve confidentiality. Some disclosures are legal and anticipated, and may not be subject to the rules of confidentiality. None of the information in a chart is considered secret.

The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type. This is known as a: *Kardex. *Nursing care plan. *Critical pathway. *Nursing order.

Critical pathway. Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay for patients of a specific case type.

During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a patient problem plan. What does this data represent? *Symptoms *Data clustering *Urinary retention *Signs of fluid overload

Data clustering The nurse organizes data, and those that are related are referred to as clustering

What is the system that classifies patients by age, diagnosis, and surgical procedure, and produces 300 different categories used for predicting the use of hospital resources? *Resource assessment *Quality improvement *Diagnosis-related groups *Quality assurance

Diagnosis-related groups Cost reimbursement rates under government plans are based on diagnosis-related groups (DRGs), which is a system that classifies patients by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources, including length of stay.

The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient? *Every 30 minutes *Every 120 minutes *Every 180 minutes *Every 60 minutes

Every 120 minutes The bedfast patient should have a position change every 2 hours (120 minutes) because skin compromise can occur if there is unrelieved pressure during that amount of time.

What should the nurse do when offering a cup of hot coffee to a frail, older adult patient? *Offer a bib or an apron. *Dilute the coffee with cold water. *Give the patient a straw. *Fill the cup half full.

Fill the cup half full. Filling the cup half full promotes safety and does not change the flavor of the beverage, nor does it demean the patient as would making him or her wear a bib or apron.

What type of assessment is performed continuously throughout nurse-patient contact? *Focused *Body systems *Complete *Subjective

Focused Focused assessments are performed continuously throughout nurse-patient contact based on the nursing care plan.

Patient care emphasis on wellness, rather than illness, begins as a result of: *Increased education concerning causes of illness. *Decentralized care centers. *Increased number of health care givers. *Improved insurance payments.

Increased education concerning causes of illness. The acute awareness of preventive medicine has resulted in today's emphasis on education about issues such as smoking, heart disease, drug and alcohol abuse, weight control, and mental health and wellness promotion activities. This preventive education has resulted in an emphasis on wellness, rather than illness. Improved insurance payments, decentralized care centers, and increased numbers of health care givers did not influence an emphasis on wellness.

Why is documentation especially significant in managed care? *Patients might bring lawsuits if care was not given. *The hospital needs to show that employees care for patients. *Institutions are reimbursed only for patient care that is documented. *Documents may become part of a lawsuit.

Institutions are reimbursed only for patient care that is documented Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the prospective payment system of diagnosis-related groups (DRGs): a system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount.

What does documentation of type of care, time of care, and signature of the person prove? *No litigation can be brought against the person who signed. *Interventions were implemented to meet the patient's needs. *The patient's response to the intervention was positive. *The person who signed the documentation did all the work noted.

Interventions were implemented to meet the patient's needs. Documenting type of care, time of care, and signature of the person results in recording the interventions that are implemented to meet the patient's needs. Many charting entries include health care provider's visits, presence of family, or interventions by other departments. Patient response to some interventions is not always positive.

What are the two primary methods used to collect data? *Written report by patient and family *Interview and physical examination *Review of the chart and the nurse's notes *Review of the health care provider's orders and the Kardex

Interview and physical examination The two primary methods of collecting data are interviewing and physical examination.

What action exemplifies a nurse practicing medical asepsis in performing daily care? *You Answered Using disposable sterile gowns *Keeping bed linens off the floor *Lifting a sterile swab from a sterile field *Washing hands for 5 minutes between patients

Keeping bed linens off the floor Keeping the bed linens off the floor is an example of medical asepsis; all other options are examples of surgical asepsis.

The nurse reassures a patient that most acute pain is intense and of short duration. How long does can acute pain usually last? *More than 1 year *At least 9 months *Less than 6 months *1 week

Less than 6 months Acute pain lasts less than 6 months

The nurse clarifies that the term peripheral analgesics describes the group of drugs also referred to as __.

NSAIDs

The nurse is preparing to bathe a patient. What should the room temperature be set at? *No cooler than 70°F (21.1°C) *No cooler than 68°F (20°C) *75°F or warmer (23.8°C) *No warmer than 67°F (19.4°C)

No cooler than 68°F (20°C) The recommended room temperature is 68° to 74°F (20° to 23.3°C).

What document identifies the roles and responsibilities of the LPN/LVN? *NAPNE Code *Nurse Practice Act *NLN Accreditation Standards *American Nurses' Association Code

Nurse Practice Act The LPN/LVN functions under the Nurse Practice Act. NLN Accreditation Standards, the NAPNE Code, and the American Nurses' Association Code do not identify the roles and responsibilities of the LPN/LVN.

The relationships among nursing, patients, health, and the environment are the basis for? *Care plans. *Evaluation of patient care. *Health care provider's orders. *Nursing models

Nursing models. Nursing models are theories based on the relationship between nursing, patients, health, and environment. Care plans, health care provider's orders, and evaluation of patient care are not based on the relationships among nursing, patients, health, and environment.

According to Maslow's hierarchy of needs, what is an individual's most basic need? *Self Actualization *Esteem *Safety and Security *Physiologic *Love/belongingness

Physiologic Abraham Maslow believed that an individual's behavior is formed by the individual's attempts to meet essential human needs, which he identified as physiologic, safety and security, love and belongingness, and esteem and self-actualization.

What is the documentation format that uses the acronym SOAPE? *Crisis *Focused *Problem-oriented *Traditional

Problem-oriented The problem-oriented medical record uses the acronym SOAPE to format and for focus charting on a list of patient problems.

What subjective data does the nurse record following a head-to-toe examination? *Rash on back *White blood cell count of 19,000 *Prolonged nausea *Blood pressure of 190/100

Prolonged Nausea Another term for subjective data is symptoms, which cannot be observed or measured. This data must come from the patient.

Human responses to health conditions and life processes that may develop in a vulnerable individual, family, or community are known as a(n) __ patient problem.

Risk

What can result from the nurse consistently performing hand hygiene and using sterile supplies when caring for patients in the hospital setting? *Nursing care needed is reduced *Sense of self-worth is improved *Hospital stay is shortened *Risk of infection is reduced

Risk of infection is reduced Hand hygiene is the most important measure for interrupting the infectious process.

What are the universal guidelines that define appropriate measures for all nursing interventions? *Advocacy *Scope of practice *Prudent practice *Standard of care

Standard of care Standards of care define actions that are permitted or prohibited in most nursing interventions. These standards are accepted as legal guidelines for appropriateness of performance. The laws that formally define and limit the scope of nursing practice are called nurse practice acts. An advocate is one who defends or pleads a cause or issue on behalf of another. Prudent is a term that refers to careful and/or wise practice.

What is true about nurse practice acts? *The nurse must know the nurse practice act within his or her state. *Only some states have adopted a nurse practice act. *They informally define the scope of nursing practice. *They provide for unlimited scope of nursing practice.

The nurse must know the nurse practice act within his or her state. The laws formally defining and limiting the scope of nursing practice are called nurse practice acts. All state, provincial, and territorial legislatures in the United States and Canada have adopted nurse practice acts, although the specifics they contain often vary. It is the nurse's responsibility to know the nurse practice act that is in effect for her geographic region.

What must the nurse realize when assessing physical and social environmental factors affecting health and illness? *They cause illness. *They can be separated. *They cause patients to react similarly. *They affect one another.

They affect one another. Physical and social factors affect each other, cannot be separated, and cause each patient to react in a unique manner. They do not necessarily cause illness or cause patients to react similarly, and they cannot be separated.

What is the primary purpose of nursing interventions? *To clarify nursing principles *To provide direction for all caregivers *You Answered To support health care provider's orders *To provide broad, general statements

To provide direction for all caregivers Nursing orders are necessary to provide instructions for all caregivers.

What important safety precaution should the home health nurse teach parents in order to prevent burns to small children? *Turn hot water on first when filling the bathtub. *Keep side rails up on the crib. *Never leave them unattended. *Turn pot handles on stoves away from reach.

Turn pot handles on stoves away from reach. To protect infants and children from burns, turn the pot handles on stoves away from the child's reach.

The nurse is assisting a patient to clarify values by encouraging the expression of feelings and thoughts related to the situation. What is the most appropriate action for the nurse? *Compare values with those of the patient. *Make a judgment. *Withhold an opinion. *Give advice.

Withhold an opinion. The nurse can assist the patient in values clarification without giving an opinion.

The nurse has strong moral convictions that abortions are wrong. When assigned to assist with an abortion, what is the most appropriate action for the nurse to take? *Transfer to another floor. *Leave work. *Ask for another assignment. *Protest to the supervisor.

Ask for another assignment The nurse should not abandon the patient, but ask for another assignment.