Fundamentals of nursing exam 1

A client age 50 years reports to a primary care unit with an open wound due to a fall in the bathroom. Which of the following nursing actions represents caring skills? A) The nurse cleans the wound and applies a dressing to it. B) The nurse inspects and examines the wound for swelling. C) The nurse tells the client to use caution while on slippery surfaces. D) The nurse informs the client that the wound is small and will heal easily.

Ans: A

Which clent would be at greatest risk for injury to the skin and mucous membranes? A) Infant 10 days old with no health problems B) adolescent 17 years of age with asthma C) Man 44 years of age with hemorrhoids D) Man 77 years of age with diabetes

Ans: D

The shoulder joint is an example of which type of joint? Ball-and-socket joint Pivot joint Condyloid joint Saddle joint

Ball-and-socket joint

Which is the most appropriate example of the assessment phase of the nursing process? Palpating a mass in the right lower quadrant of the abdomen Evaluating the temperature of a client given medication for a fever Documenting the administration of a medication provided for pain Including a nursing diagnosis of Acute Pain in the client's plan of care

Palpating a mass in the right lower quadrant of the abdomen

When working with a client who has a fractured wrist, the nurse applies what knowledge about the bones in the body? Flat bones are found in the spinal column. The wrist is classified as an irregular bone. Long bones are relatively thin and contribute to shape. Short bones contribute to movement.

Short bones contribute to movement.

The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client? Fowlers' supine Sims' prone

Sims'

When assessing correct body alignment when the client is standing, the nurse would be document which abnormal findings? Select all that apply. The knees are bent. The chest is held upward and forward. The arms are bent at the elbows. The feet are at right angles to the lower legs. The head is held erect.

The knees are bent. The arms are bent at the elbows.

When assessing for proper body alignment of a standing client, which finding is normal? The line of gravity is deviated slightly to the left. The abdominal muscles are held downward and the buttocks upward. The chest is downward and displaced slightly backward. The weight of the body is distributed on the soles and heels.

The weight of the body is distributed on the soles and heels.

A nurse is conducting Weber's test. Which action will the nurse take? a. Place a vibrating tuning fork in the middle of patient's forehead. b. Place a vibrating tuning fork on the patient's mastoid process. c. Compare the number of seconds heard by bone versus air conduction. d. Compare the patient's degree of joint movement to the normal level.

a

What name is given to standardized plans of care? A) Critical pathways B) Computer databases C) Nursing problems D) Care plan templates

a

A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Based on these nonverbal clues, for which condition would the nurse assess? a. Pain b. Anxiety c. Depression d. Fluid volume deficit

a. A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior

A nurse is assessing a patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: a. Clinical judgment b. Clinical reasoning c. Critical thinking d. Blended competencies

a. Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to the result or outcome of critical thinking or clinical reasoning—in this case, the recommendation to meet with a nutritionist.

Which type of mobility aid would be most appropriate for a client who has poor balance? a single-ended cane with a half-circle handle a single-ended cane with a straight handle axillary crutches a cane with four prongs on the end (quad cane

axillary crutches a cane with four prongs on the end (quad cane

A nurse is teaching first aid to counselors of a summer camp for children with asthma. This is an example of what aim of health teaching? a. Promoting health b. Preventing illness c. Restoring health d. Facilitating coping

b. Teaching first aid is a function of the goal to prevent illness. Promoting health involves helping patients to value health and develop specific health practices that promote wellness. Restoring health occurs once a patient is ill, and teaching focuses on developing self-care practices that promote recovery. When facilitating coping, nurses help patients come to terms with whatever lifestyle modification is needed for their recovery or to enable them to cope with permanent health alterations.

A nurse is preparing to perform a complete physical examination on a weak, older-adult patient with bilateral basilar pneumonia. Which position will the nurse use? a. Prone b. Sims' c. Supine d. Lateral recumbent

c

The nurse has completed teaching regarding pediculosis. Which client statement requires further nursing teaching? "Lice can be spread by direct contact." "I will use conditioner so that the lice eggs will slide off my hair." "A pediculicide shampoo is needed to treat this condition." "I will look for eggs on hairs ¼ to ½ in (0.5 to 1.5 cm) from the scalp and skin surfaces."

"I will use conditioner so that the lice eggs will slide off my hair."

The nurse is caring for a client with incontinence who has been neglected in supine position at home for more than a week. Which priority nursing diagnosis will the nurse select? risk for disuse syndrome risk for impaired skin integrity impaired physical mobility impaired transfer ability

risk for impaired skin integrity

What nursing organization first legitimized the use of the nursing process? A) National League for Nursing B) American Nurses Association C) International Council of Nursing D) State Board of Nursing

B) American Nurses Association

A nurse working in a long-term care facility uses proper patient care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures? a. Carefully assessing the patient care environment b. Using two nurses to lift a patient who cannot assist c. Wearing a back belt to perform routine duties d. Properly documenting the patient lift

a. Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and movement should be documented but are not the primary focus of interventions related to injury prevention.

A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's BEST response to the neighbor? a. "New mothers need support." b. The lack of a father is difficult." c. "How are you today?" d. "It is a very sad situation."

a. The nurse must maintain confidentiality when providing care. The statement "New mothers need support" is a general statement that all new parents need help. The statement is not judgmental of the family's roles.

Using proper body mechanics, which motions would the nurse make to move an object? a. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. b. The nurse directly lifts an object rather than sliding, rolling, pushing, or pulling it, thus reducing the energy needed to lift the weight against the pull of gravity. c. The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object. d. The nurse uses the muscles of the back to help provide the power needed in strenuous activities.

a. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.

A nursing student is nervous and concerned about working at a clinical facility. Which action would BEST decrease anxiety and ensure success in the student's provision of patient care? a. Determining the established goals of the institution b. Ensuring that verbal and nonverbal communication is congruent c. Engaging in self-talk to plan the day and decrease fear d. Speaking with fellow colleagues about how they feel

c. By engaging in self-talk, or intrapersonal communication, the nursing student can plan her day and enhance her clinical performance to decrease fear and anxiety.

A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a care plan for this patient. Which QSEN competency does this action represent? a. Patient-centered care b. Evidence-based practice c. Quality improvement d. Informatics

c. Quality improvement involves routinely updating nursing policies and procedures. Providing patient-centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making.

A nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure? Add bath oil to the water to prevent dry skin. Allow the patient to lock the door to guarantee privacy. Assist the patient in and out of the tub to prevent falling. Keep the water temperature very warm because older adults chill easily

c. Safe nursing practice requires that the nurse assist a patient with an unsteady gait in and out of the tub. Adding Alpha Keri oil to the bath water is dangerous for this patient because it makes the tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortably warm at 43° to 46°C. Older adults have an increased susceptibility to burns due to diminished sensitivity

A nurse is assisting a patient with dementia with bathing. Which guideline is recommended in this procedure? a. Shift the focus of the interaction to the "process of bathing." b. Wash the face and hair at the beginning of the bath. c. Consider using music to soothe anxiety and agitation. d.Do not perform towel baths or alternate forms of bathing with which the patient is unfamiliar.

c. The nurse should consider the use of music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the "task of bathing" to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. The nurse should wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider other methods for bathing. Showers and tub baths are not the only options in bathing. Towel baths, washing under clothes, and bathing "body sections" one day at a time are other possible options

Once applied, antiembolism stockings should not be removed until the primary care provider writes an order to discontinue them. A) True B) False

false

The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure? lying flat sitting up lying flat with feet raised slightly lying prone

lying flat

The nurse is caring for a female client who is unconscious. The nurse should pay special attention to cleaning which area of the body? the inner and outer canthus of each eye underneath the fingernails and toenails underneath the breasts and in between skin folds the antecubital fossa and popliteal space

underneath the breasts and in between skin folds

When moving a client up in bed, the nurse asks the client to fold the arms across the chest and lift the head with the chin on the chest. What is the rationale for placing the client in this position? A) To prevent hyperextension of the neck B) To prevent pressure on the arms C) To lower the client's center of gravity D) To decrease the effort needed to move the client

Ans: A

Nurses apply critical thinking to clinical reasoning and judgment in their nursing practice every day. Which of the following are characteristics of this practice? Select all that apply. A) It is guided by standards, policies and procedures, ethics codes, and laws. B) It is based on principles of nursing process, problem solving, and the scientific method. C) It carefully identifies the key problems, issues, and risks involved. D) It is driven by the nurse's need to document competent, efficient care. E) It calls for strategies that make the most of human potential.

Ans: A, B, C, E

A nurse interviews a pregnant teenager and documents her answers on the client record. At the same time, the nurse responds to the client's concerns and makes a referral for counseling and maternity care. This scenario is an example of which of the descriptors of the nursing process? A) Systematic B) Dynamic C) Outcome oriented D) Universally applicable

Ans: B Feedback: Although the nursing process is presented as an orderly progression of steps, in reality there is great interaction and overlapping among the five steps. No one step in the nursing process is a one-time phenomenon; each step flows into the next step. In some nursing situations, all five stages occur almost simultaneously.

Which of the following is a correct guideline to follow when providing a bed bath for a client? A) When cleaning the eye, move the washcloth from the outer to the inner aspect of the eye. B) Fold the washcloth like a mitt on your hand so that there are no loose ends. C) Clean the perineal area before cleaning the gluteal area. D) Change the bath water after washing each body part.

Ans: B Feedback: Fold the washcloth like a mitt on your hand so that there are no loose ends. Moving from the inner to the outer aspect of the eye prevents carrying debris toward the nasolacrimal duct. The gluteal area should be cleaned first and the bath water and towels should be changed before cleaning the perineal area. It is not necessary to change the bath water after washing every body part.

A nurse asks a multidisciplinary team to collaborate in developing the most appropriate plan of care to meet the needs of an adolescent with a severe head injury. Which of the blended skills essential to nursing practice is the nurse using? A) Cognitive skills B) Interpersonal skills C) Technical skills D) Ethical/legal skills .

Ans: B Feedback: Interpersonally skilled nurses establish and maintain caring relationships that facilitate the achievement of valued goals, and simultaneously affirm the worth of those in the relationship. They are, among other things, able to work collaboratively with the health care team to reach valued goals

When assisting a client from the bed into a wheelchair, the nurse assesses the client standing up and notices the client is weak and unsteady. What would be the recommended nursing intervention in this situation? A) Allow the client to keep standing for several minutes until balance returns. B) Use the call bell to summon the assistance of another nurse. C) Return the client to the bed. D) Place the client into the wheelchair.

Ans: C

A nurse is placing a client in Fowler's position. What should she teach the family about this position? A) "Use at least two big pillows to support the head." B) "Cross the arms over the client's abdomen." C) "Do not raise the knees with the knee gatch." D) "Keep the hands lower than the rest of the body."

Ans: C Feedback: When positioning the client in Fowler's position, allow the head to rest against the mattress or use only a small pillow. Support the forearms on pillows, with the hand slightly elevated above the forearm. Do not use the knee gatch to raise the knees

A young adult woman has had orthopedic surgery on her right knee. The first time she gets out of bed, she describes weakness, dizziness, and feeling faint. The nurse correctly recognizes that which of the following conditions is likely affecting the client? A) Thrombophlebitis B) Anemia C) Orthostatic hypotension D) Bradycardia

Ans: C Orthostatic hypotension refers to a reduction in blood pressure with position changes from lying to sitting or standing. Blood pooling in the legs increases, thus increasing the postural hypotension. Thrombophlebiits refers to an inflammation of a the veins; it manifests with redness and swelling

A client is admitted to the health care facility with a diagnosis of pediculosis capitis. Which of the following would the nurse expect to find in the client? A) Diffuse scaling of the epidermis B) Itching and flaking of whitish scales C) Premature loss of hair D) Inflammation related to bites along the hairline .

Ans: D Feedback: The nurse would find inflamed bites along the hairline in the client with pediculosis infestation. Diffuse scaling of the epidermis with itching and flaking of whitish scales is seen in clients who have dandruff. Hair loss is not a manifestation of pediculosis capitis

A nurse technician is assigned to take client vital signs. When making rounds, the nurse notices that one client's vital signs are very different than they were at the beginning of the shift. What is most appropriate for the nurse to do about these findings? Call the health care practitioner for new orders. Assess the client's vital signs again. Document the vital signs in the client's chart. Ask the nurse technician if the vital signs are correct.

Assess the client's vital signs again.

An older adult client with Parkinson's disease is unable to take care of himself. The client frequently soils his bed and is unable to clean himself independently. How should the nurse in this case ensure the client's perineal care? A) Cleanse to remove secretions from less-soiled to more-soiled areas. B) Cleanse using a cotton cloth and warm water. C) Use tissue rolls to clean the client's perineal area. D) Provide the client with a bed pan or a jar to collect the urine.

Ans: A

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which of the following techniques for cleaning the penis is correct? A) Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place. B) Retract the foreskin while washing the penis, allow 10 to 15 minutes for the glans penis to dry; then, replace the foreskin in its original position. C) Avoid retraction of the foreskin because injury and scarring could occur. D) Soak the end of the penis in warm water before cleaning the shaft of the penis.

Ans: A

While being measured for anti-embolism stockings, the client asks the nurse why they are necessary. What would be the nurses's best response? A) They promote venous blood return to the heart. B) They eliminate peripheral edema. C) They provide a nonslip foot surface to help prevent falls. D) They reduce the risk for impaired skin integrity.

Ans: A

While conducting an oral assessment, a nurse notices the client's gums are red and swollen, some teeth are loose, and blood and pus can be expressed when the gums are palpated. What condition do these symptoms indicate? A) Periodontitis B) Plaque C) Halitosis D) Caries

Ans: A

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client? A) Fowler's B) Low-Fowler's C) Protective supine D) Semi-Fowler's

Ans: A Feedback: Fowler's position optimizes cardiac function and respiratory function in addition to being the best position for eating. The client's risk of aspiration would be extreme in a supine position. Low-Fowler's and semi-Fowler's are synonymous, and this position does not aid swallowing as much as a high-Fowler's position.

While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care for this client based upon the understanding that the client has which of the following? A) Paralysis of the legs B) Weakness affecting one-half of the body C) Paralysis affecting one-half of the body D) Paralysis of the legs and arms

Ans: A Feedback: Paraplegia is paralysis of the legs, and quadriplegia is paralysis of the arms and legs. Hemiparesis refers to weakness of one half of the body, and hemiplegia is paralysis of one half of the body.

A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which of the following aspects of the nurse's execution of this order demonstrates technical skill? A) Starting a new, large-gauge intravenous site on the client, and priming the infusion tubing B) Understanding the Rh system that underlies the client's blood type C) Ensuring that informed consent has been obtained and properly filed in the client's chart D) Explaining the process that will be involved in preparing and administering the transfusion

Ans: A Feedback: Performing tasks that require manual dexterity is a manifestation of technical skills. Explaining the transfusion process is largely dependent on interpersonal skills, while understanding the theory behind blood types is indicative of cognitive skills. Informed consent lies within the domain of legal/ethical skills.

The nurse cares for a newly admitted client who will soon need to be taken to the radiology department for a CT scan. The client has a Body Mass Index (BMI) of 52. Which of the following strategies to transport the client is most appropriate? A) Obtain a mechanical lateral transfer device to move the client onto a stretcher. B) Enlist the aid of two other staff members and pull the client across the bed and onto a stretcher. C) Position a friction-reducing sheet under the client before attempting the transfer. D) Transport the client to the radiology department in the hospital bed.

Ans: A Feedback: The combined weight of the bed and client will be difficult to move safely. Additionally, this strategy does not address the need to transfer the client onto, and off of, equipment in the radiology department.

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client? A) The client's ability to assist B) The client's body weight C) The client's cognitive status D) The client's age

Ans: A Feedback: The nurse assesses several parameters when choosing whether to use a mechanized assistive device for a client transfer. The most important consideration, however, is the client's ability to safely assist with his or her transfer.

The physician's admitting orders indicate that the client is to be placed in a Fowler's position. Upon positioning this client, how much will the nurse elevate the head of the bed? A) 45 to 60 degrees B) 15 to 20 degrees C) 30 degrees D) 90 degrees

Ans: A In the Fowler's position, the head of the bed is elevated 45 to 60 degrees. Low-Fowler's or semi-Fowler's is positioning of the head of the bed to only 30 degrees. In the high-Fowler's position, the head of the bed is elevated 90 degrees.

Which of the following clients ia at an increased risk for oral problems? Select all that apply. A) Comatose client B) Confused client C) Depressed client D) Client undergoing chemotherapy E) Hypertensive client .

Ans: A, B, C, D Feedback: Clients at increased risk for oral problems include those who are seriously ill, comatose, dehydrated, confused, depressed, or paralyzed. Clients who are mouth breathers, those who can have no oral intake of nutrition or fluids, those with nasogastric tubes or oral airways in place, and those who have had oral surgery are also at increased risk. Variables known to cause oral problems include deficient self-care abilities, poor nutrition or excessive intake of refined sugars, family history of periodontal disease, or ingestion of chemotherapeutic agents that produce oral lesions look jaime i added the feed back like you wanted!

A nurse is assisting in the transfer of a client to a stretcher. The client has casts on both legs. What is the nurse's best choice of transfer equipment for this client who cannot bear weight on either leg? A) Powered-stand assist B) Transfer chair C) Repositioning lift D) Gait belt

Ans: B

A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed? A) Every hour B) Every two hours C) Every four hours D) Every shift

Ans: B

A school nurse is assessing children in the third grade for pediculosis capitis. What assessments should be made? A) The pubic area for growth of hair B) The head for nits on hair shafts C) The nails for evidence of cleanliness D) The body for evidence of abuse

Ans: B

Student nurses are turning a client in bed. In order to move the client to the edge of the bed, which positioning instruction is best to give the client when using the friction-reducing sheet? A) Cross the arms across the chest and keep the legs straight. B) Cross the arms across the chest and cross the legs. C) Keep the arms at the sides and the legs crossed. D) Keep the arms folded loosely at the abdomen and the legs straight.

Ans: B

The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which of the following initial actions by the nurse is appropriate? A) Firmly grasp the client's gait belt. B) Support the client's body against yours and gently slide the client onto the floor. C) Ask the client to lean against the wall while you obtain a wheelchair. D) Apply oxygen and wait several minutes for the weakness to pass. E) Ask the patient, "When was the last time you ate?"

Ans: B

The nurse is preparing to move a patient up in bed with the assistance of another nurse. In what position would the nurse place the patient, if tolerated? A) Reverse Trendelenburg B) Supine C) Sitting D) Semi-Fowler's

Ans: B

Based on an established plan of care, a nurse turns a client every two hours. What part of the nursing process is the nurse using? A) Assessing B) Planning C) Implementing D) Evaluating

Ans: C

The nurse and an assistant are preparing to move a client up in bed. Arrange the following steps in the correct order. 1. Adjust the head of the bed to a flat position. 2. Place a friction-reducing sheet under the client. 3. Ask the client to bend legs and place the chin on the chest. 4. Position the assistant on the side opposite you. 5. Remove all pillows from under the client. 6. Grasp the sheet and move the client on the count of 3. A) 3, 1, 2, 4, 5, 6 B) 1, 2, 4, 3, 5, 6 C) 1, 5, 4, 2, 3, 6 D) 3, 2, 1, 4, 6, 5 E) 1, 3, 2, 4, 5, 6

Ans: C

A nurse is assisting a client to shave his beard. Which of the following statements accurately describes a recommended step in this process? A) Cover the client with a blanket. B) Fill a basin with cool water. C) Apply cream to area to be shaved in a layer about 1/2-inch thick. D) Shave against the direction of hair growth in upward, short strokes .

Ans: C Feedback: Steps in the procedure include: Cover patient's chest with a towel or waterproof pad. Fill bath basin with warm (43ºC to 46ºC [110ºF to 115ºF]) water. Put on gloves. Moisten the area to be shaved with a washcloth. Dispense shaving cream into palm of hand. Apply cream to area to be shaved in a layer about 1/2-inch thick. With one hand, pull the skin taut at the area to be shaved. Using a smooth stroke, begin shaving. If shaving the face, shave with the direction of hair growth in downward, short strokes. If shaving a leg, shave against the hair in upward, short strokes. If shaving an underarm, pull skin taut and use short, upward strokes.

A nurse is caring for a frail older adult client with chronic obstructive pulmonary disease. The client always remains in a sitting position to help him breathe more easily. Based on the understanding that prolonged sitting may put pressure on bony prominences, the nurse frequently assesses which area of this client? A) Back of the skull B) Elbows C) Sacrum D) Heels

Ans: C Feedback: The sacrum bears the greatest pressure during a sitting position. The back of the skull, elbows, and heels bear pressure in a supine position.

A nurse is ambulating a client who catches her foot on the bed frame and begins to fall. Which of the following is an accurate step to prevent or minimize damage from this fall? A) The nurse should place his or her feet close together with one foot in front of the other. B) The nurse should rock his or her pelvis out on the opposite side of the client. C) The nurse should grasp the gait belt and pull the client's body backward away from his or her body. D) The nurse should gently slide the client down his or her body to the floor.

Ans: D

Which of the following interpersonal skills is essential to the practice of nursing? A) Performing technical skills knowledgeably and safely B) Maintaining emotional distance from clients and families C) Keeping personal information among shared clients confidential D) Promoting the dignity and respect of patients as people

Ans: D

The nurse is performing an assessment on a client who presents with a rash on the back that is red and raised. What would be the most appropriate nursing action? Report it to the health care provider. Assess the client's back visually. Document it in the client's chart. Establish a nursing diagnosis of Altered Skin Integrity.

Assess the client's back visually

A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply. a. It promotes the patient's sense of well-being. b. It prevents deterioration of the oral cavity. c. It contributes to decreased incidence of aspiration pneumonia. d. It eliminates the need for flossing. e. It decreases oropharyngeal secretions. f. It helps to compensate for an inadequate diet.

a, b, c. Adequate oral hygiene is essential for promoting the patient's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of aspiration pneumonia and other systemic diseases. Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition.

A nurse is providing range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? Select all that apply. a. Stop performing the exercises. b. Decrease the number of repetitions performed. c. Reevaluate the nursing care plan. d. Move to the patient's other side to perform exercises. e. Encourage the patient to finish the exercises and then rest. f. Assess the patient for other symptoms.

a, c, f. When a patient complains of fatigue during range-of-motion exercises, the nurse should stop the activity, reevaluate the nursing care plan, and assess the patient for further symptoms. The exercises could then be scheduled for times of the day when the patient is feeling more rested, or spaced out at different times of the day.

Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply. a. Compare bilateral parts for symmetry. b. Proceed in a toe-to-head systematic manner. c. Use standard terminology to report and record findings. d. Do not allow data from the nursing history to direct the assessment. e. Document only skin abnormalities on the patient record. f. Perform the appropriate skin assessment when risk factors are identified

a, c, f. When performing a skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to report and record findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, and allow data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings.

During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? Select all that apply. a. Group decision making b. Group leadership c. Group power d. Group identity e. Group patterns of interaction f. Group cohesiveness

a, d, e, f. Solving problems involves group decision making; ascertaining that the staff completes a task on time and that all members agree the task is important is a characteristic of group identity; group patterns of interaction involve honest communication and member support; and cohesiveness occurs when members generally trust each other, have a high commitment to the group, and a high degree of cooperation. Group leadership occurs when groups use effective styles of leadership to meet goals; with group power, sources of power are recognized and used appropriately to accomplish group outcomes

A nurse is teaching a student nurse how to cleanse the perineal area of both male and female patients. What are accurate guidelines when performing this procedure? Select all that apply. a. For male and female patients, wash the groin area with a small amount of soap and water and rinse. b. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area. c. For male and female patients, always proceed from the most contaminated area to the least contaminated area. d. For male and female patients, use a clean portion of the washcloth for each stroke. e. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. f. In an uncircumcised male patient, do not retract the foreskin (prepuce) while washing the penis

a, d, e. Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis.

A nurse is preparing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply. a. Instruct the patient to avoid sudden position changes that may cause dizziness. b. Recommend that the patient restrict fluid until after exercising is finished. c. Instruct the patient to push a little further beyond fatigue each session. d. Instruct the patient to avoid exercising in very cold or very hot temperatures. e. Encourage the patient to modify exercise if weak or ill. f. Recommend that the patient consume a high-carb, low-protein diet.

a, d. Teaching points for exercising for a patient with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures. The nurse should also instruct the patient to provide for adequate hydration, respect fatigue by not pushing to the point of exhaustion, and avoid exercise if weak or ill. Older adults should consume a high-protein, high-calcium, and vitamin D-enriched diet.

The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply. a. The nurse uses critical thinking skills to plan care for a patient. b. The nurse correctly administers IV saline to a patient who is dehydrated. c. The nurse assists a patient to fill out an informed consent form. d. The nurse learns the correct dosages for patient pain medications. e. The nurse comforts a mother whose baby was born with Down syndrome. f. The nurse uses the proper procedure to catheterize a female patient.

a, d. Using critical thinking and learning medication dosages are cognitive competencies. Performing procedures correctly is a technical skill, helping a patient with an informed consent form is a legal/ethical issue, and comforting a patient is an interpersonal skill.

A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply. a. Wash the skin twice a day with a mild cleanser and warm water. b. Use cosmetics liberally to cover blackheads. c. Use emollients on the area. d. Squeeze blackheads as they appear. e. Keep hair off the face and wash hair daily. f. Avoid sun-tanning booth exposure and use sunscreen.

a, e, f. Washing the skin removes oil and debris, hair should be kept off the face and washed daily to keep oil from the hair off the face, and sunbathing should be avoided when using acne treatments. Liberal use of cosmetics and emollients can clog the pores. Squeezing blackheads is always discouraged because it may lead to infection.

A nurse is counseling a 19-year-old athlete who had his right leg amputated below the knee following a motorcycle accident. During the rehabilitation process, the patient refuses to eat or get up to ambulate on his own. He says to the nurse, "What's the point. My life is over now and I'll never be the football player I dreamed of becoming." What is the nurse counselor's best response to this patient? a. "You're young and have your whole life ahead of you. You should focus on your rehabilitation and make something of your life." b. "I understand how you must feel. I wanted to be a famous singer, but I wasn't born with the talent to be successful at it." c. "You should concentrate on other sports that you could play even with prosthesis." d. "I understand this is difficult for you. Would you like to talk about it now or would you prefer me to make a referral to someone else?

a. A nurse coach establishes a partnership with a patient and, using discovery, facilitates the identification of the patient's personal goals and agenda to lead to change rather than using teaching and education strategies with the nurse as the expert. A nurse coach explores the patient's readiness for coaching, designs the structure of a coaching session, supports the achievement of the patient's desired goals, and with the patient determines how to evaluate the attainment of patient goals.

An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response? a. Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. b. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. c. The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years; it is time to champion intuitive, creative thinking! d. It is simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers.

a. Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care they give; intuitive problem solving comes with years of practice and observation

A nurse is preparing to teach a patient with asthma how to use his inhaler. Which teaching method would be the BEST choice to teach the patient this skill? a. Demonstration b. Lecture c. Discovery d. Panel session

a. Demonstration of techniques, procedures, exercises, and the use of special equipment is an effective patient-teaching strategy for a skill. Lecture can be used to deliver information to a large group of patients but is more effective when the session is interactive; it is rarely used for individual instruction, except in combination with other strategies. Discovery is a good method for teaching problem-solving techniques and independent thinking. Panel discussions can be used to impart factual material but are also effective for sharing experiences and emotions.

When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate communication technique? a. Cliché b. Giving advice c. Being judgmental d. Changing the subject

a. Telling a patient that everything is going to be all right is a cliché. This statement gives false assurance and gives the patient the impression that the nurse is not interested in the patient's condition

A nurse uses critical thinking skills to focus on the care plan of an older adult who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply. a. It functions independently of nursing standards, ethics, and state practice acts. b. It is based on the principles of the nursing process, problem solving, and the scientific method. c. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. d. It is not designed to compensate for problems created by human nature, such as medication errors. e. it is constantly re-evaluating, self-correcting, and striving for improvement. f. It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care

b, c, e. Critical thinking applied to clinical reasoning and judgment in nursing practice is guided by standards, policies and procedures, and ethics codes.

A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply. a. Do full-body pushups in bed six to eight times daily. b. Breathe in and out smoothly during quadriceps drills. c. Place the bed in the lowest position or use a footstool for dangling. d. Dangle on the side of the bed for 30 to 60 minutes. e. Allow the nurse to bathe the patient completely to prevent fatigue. f. Perform quadriceps two to three times per hour, four to six times a day.

b, c, f. Breathing in and out smoothly during quadriceps drills maximizes lung inflation. The patient should perform quadriceps two to three times per hour, four to six times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for 30 to 60 minutes is unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling. The nurse should also encourage the patient to be as independent as possible to prepare for return to normal ambulation and ADLs.

A nurse is planning teaching strategies based on the affective domain of learning for patients addicted to alcohol. What are examples of teaching methods and learning activities promoting behaviors in this domain? Select all that apply. a. The nurse prepares a lecture on the harmful long-term effects of alcohol on the body. b. The nurse explores the reasons alcoholics drink and promotes other methods of coping with problems. c. The nurse asks patients for a return demonstration for using relaxation exercises to relieve stress. d. The nurse helps patients to reaffirm their feelings of self-worth and relate this to their addiction problem. e. The nurse uses a pamphlet to discuss the tenants of the Alcoholics Anonymous program to patients. f. The nurse reinforces the mental benefits of gaining self-control over an addiction.

b, d, f. Affective learning includes changes in attitudes, values, and feelings (e.g., the patient expresses renewed self-confidence to be able to give up drinking). Cognitive learning involves the storing and recalling of new knowledge in the brain, such as the learning that occurs during a lecture or by using a pamphlet for teaching. Learning a physical skill involving the integration of mental and muscular activity is called psychomotor learning, which may involve a return demonstration of a skill.

A nurse forms a contractual agreement with a morbidly obese patient to achieve optimal weight goals. Which statement best describes the nature of this agreement? a. "This agreement forms a legal bond between the two of us to achieve your weight goals." b. "This agreement will motivate the two of us to do what is necessary to meet your weight goals." c. "This agreement will help us determine what learning outcomes are necessary to achieve your weight goals." d. "This agreement will limit the scope of the teaching session and make stated weight goals more attainable."

b. A contractual agreement is a pact two people make setting out mutually agreed-on goals. Contracts are usually informal and not legally binding. When teaching a patient, such an agreement can help motivate both the patient and the teacher to do what is necessary to meet the patient's learning outcomes. The agreement notes the responsibilities of both the teacher and the learner, emphasizing the importance of the mutual commitment

A nurse assisting with a patient bed bath observes that an older female adult has dry skin. The patient states that her skin is always "itchy." Which nursing action would be the nurse's best response? a. Bathe the patient more frequently. b. Use an emollient on the dry skin. c. Massage the skin with alcohol. d. Discourage fluid intake.

b. An emollient soothes dry skin, whereas frequent bathing increases dryness, as does alcohol. Discouraging fluid intake leads to dehydration and, subsequently, dry skin

A nurse is scheduling hygiene for patients on the unit. What is the priority consideration when planning a patient's personal hygiene? a. When the patient had his or her most recent bath b. The patient's usual hygiene practices and preferences c. Where the bathing fits in the nurse's schedule d. The time that is convenient for the patient care assistant

b. Bathing practices and cleansing habits and rituals vary widely. The patient's preferences should always be taken into consideration, unless there is a clear threat to health. The patient and nurse should work together to come to a mutually agreeable time and method to accomplish the patient's personal hygiene. The availability of staff to assist may be important, but the patient's preferences are a higher priority.

A nurse caring for patients in a pediatrician's office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones? a. A 4-month-old infant who is unable to roll over b. A 6-month-old infant who is unable to hold his head up himself c. An 11-month-old infant who cannot walk unassisted d. An 18-month-old toddler who cannot jump

b. By 5 months, head control is usually achieved. An infant usually rolls over by 6 to 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump.

A nurse in the rehabilitation division states to the head nurse: "I need the day off and you didn't give it to me!" The head nurse replies, "Well, I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of this exchange, what communication by the nurse would have been more effective? a. "I placed a request to have 8th of August off, but I'm working and I have a doctor's appointment." b. "I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" c. "I will need to call in on the 8th of August because I have a doctor's appointment." d. "Since you didn't give me the 8th of August off, will I need to find someone to work for me?"

b. Effective communication by the sender involves the implementation of nonthreatening information by showing respect to the receiver. The nurse should identify the subject of the meeting and be sure it occurs at a mutually agreed upon time.

A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient's feet to prevent footdrop? a. Supination b. Dorsiflexion c. Hyperextension d. Abduction

b. For a patient who has footdrop, the nurse should support the feet in dorsiflexion and use a footboard or high-top sneakers to further support the foot. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions would not be used to prevent footdrop.

A nurse is caring for a patient in a long-term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient? a. Improved renal blood supply to the kidneys b. Urinary stasis c. Decreased urinary calcium d. Acidic urine formation

b. In a nonerect patient, the kidneys and ureters are level. In this position, urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder, resulting in urinary stasis. Urinary stasis favors the growth of bacteria that may cause urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to increased levels of urinary calcium and alkaline urine, contributing to renal calculi and urinary tract infection, respectively.

A nurse has taught a patient with diabetes how to administer his daily insulin. How should the nurse evaluate the teaching-learning process? a. By determining the patient's motivation to learn b. By deciding if the learning outcomes have been achieved c. By allowing the patient to practice the skill he has just learned d. By documenting the teaching session in the patient's medical record

b. The nurse cannot assume that the patient has actually learned the content unless there is some type of proof of learning. The key to evaluation is meeting the learner outcomes stated in the teaching plan.

A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess the mobility of a hospitalized patient. During the patient interview, the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index? a. 2 b. 4 c. 5 d. 6

b. The total score for this patient is 4. On the Katz Index of Independence in ADLs, one point is awarded for independence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding.

A nurse is caring for a 25-year-old male patient who is comatose following a head injury. The patient has several piercings in his ears and nose. The piercing in his nose appears to be new and is crusted and slightly inflamed. Which action would be appropriate when caring for this patient's piercings? a. Do not remove or wash the piercings without permission from the patient. b. Rinse the sites with warm water and remove crusts with a cotton swab. c. Wash the sites with alcohol and apply an antibiotic ointment. d. Remove the jewelry and allow the sites to heal over.

b. When providing care for piercings, the nurse should perform hand hygiene and put on gloves, then cleanse the site of all crusts and debris by rinsing the site with warm water, removing the crusts with a cotton swab. The nurse should then apply a dab of liquid-medicated cleanser to the area, turn the jewelry back and forth to work the cleanser around the opening, rinse well, remove gloves, and perform hand hygiene. The nurse should not use alcohol, peroxide, or ointments at the site or remove the piercings unless it is absolutely necessary (e.g., when an MRI is ordered.)

A nurse is teaching patients of all ages in a hospital setting. Which examples demonstrate teaching that is appropriately based on the patient's developmental level? Select all that apply. a. The nurse plans long teaching sessions to discuss diet modifications for an older adult diagnosed with type 2 diabetes. b. The nurse recognizes that a female adolescent diagnosed with anorexia is still dependent on her parents and includes them in all teaching sessions. c. The nurse designs an exercise program for a sedentary older adult male patient based on the activities he prefers. d. The nurse includes an 8-year-old patient in the teaching plan for managing cystic fibrosis. e. The nurse demonstrates how to use an inhaler to an 11-year-old male patient and includes his mother in the session to reinforce the teaching. f. The nurse continues a teaching session on STIs for a sexually active male adolescent despite his protest that "I've heard enough already!"

c, d, e. Successful teaching plans for older adults incorporate extra time, short teaching sessions, accommodation for sensory deficits, and reduction of environmental distractions. Older adults also benefit from instruction that relates new information to familiar activities or information. School-aged children are capable of logical reasoning and should be included in the teaching-learning process whenever possible; they are also open to new learning experiences but need learning to be reinforced by either a parent or health care provider as they become more involved with their friends and school activities. Teaching strategies designed for an adolescent patient should recognize the adolescent's need for independence, as well as the need to establish a trusting relationship that demonstrates respect for the adolescent's opinions.

During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after communicating the nursing care plan. What would be appropriate nurse responses in this situation? Select all that apply. a. Fill the silence with lighter conversation directed at the patient. b. Use the time to perform the care that is needed uninterrupted. c. Discuss the silence with the patient to ascertain its meaning. d. Allow the patient time to think and explore inner thoughts. e. Determine if the patient's culture requires pauses between conversation. f. Arrange for a counselor to help the patient cope with emotional issues.

c, d, e. The nurse can use silence appropriately by taking the time to wait for the patient to initiate or to continue speaking. During periods of silence, the nurse should reflect on what has already been shared and observe the patient without having to concentrate simultaneously on the spoken word. In due time, the nurse might discuss the silence with the patient in order to understand its meaning. Also, the patient's culture may require longer pauses between verbal communication. Fear of silence sometimes leads to too much talking by the nurse, and excessive talking tends to place the focus on the nurse rather than on the patient. The nurse should not assume silence requires a consult with a counselor.

The nurse practices using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTIs is: a. Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice b. Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice d. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice.

A nurse is caring for a patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? a. Dorsal recumbent position b. Lateral position c. Fowler's position d. Sims' position

c. Fowler's position promotes maximal breathing space in the thoracic cavity and is the position of choice when someone is having difficulty breathing. Lying flat on the back or side or Sims' position would not facilitate respiration and would be difficult for the patient to maintain.

A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient's knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action? a. Wait a few minutes and then continue the move to the chair. b. Call for assistance and continue the move with the help of another nurse. c. Lower the patient back to the side of the bed and pivot her back into bed. d. Have the patient sit down on the bed and dangle her feet before moving.

c. If a patient becomes faint and knees buckle when moving from bed to a chair, the nurse should not continue the move to the chair. The nurse should lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient's vital signs and for the presence of other symptoms. Another attempt should be made with the assistance of another staff member if vital signs are stable. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to a change in position, and avoid hypotension related to a sudden change in position.

A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come for my therapy anymore." The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process? a. The nurse judges whether the patient database is adequate to address the problem. b. The nurse considers whether or not to suggest a counseling session for the patient. c. The nurse reassesses the patient and decides how best to intervene in her care. d. The nurse identifies several options for intervening in the patient's care and critiques the merit of each option.

c. The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. Reassessing the patient helps to discipline thinking by directing all thoughts toward the goal. Once the problem is addressed, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision.

A nurse is caring for a patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side? a. Have the patient extend his arms outward and cross his legs on top of a pillow. b. Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side. c. Have the patient cross his arms on his chest and place a pillow between his knees. d. Place a cervical collar on the patient's neck and gently roll him to the other side of the bed.

c. The procedure for logrolling a patient is: (1) Have the patient cross the arms on the chest and place a pillow between the knees; (2) have two nurses stand on one side of the bed opposite the direction the patient will be turned with the third helper standing on the other side and if necessary, a fourth helper at the head of the bed to stabilize the neck; (3) fanfold or roll the drawsheet tightly against the patient and carefully slide the patient to the side of the bed toward the nurses; (4) have one helper move to the other side of the bed so that two nurses are on the side to which the patient is turning; (5) face the patient and have everyone move on a predetermined time, holding the drawsheet taut to support the body, and turn the patient as a unit toward the two nurses.

A nurse is teaching a 50-year-old male patient how to care for his new ostomy appliance. Which teaching aid would be most appropriate to confirm that the patient has learned the information? a. Ask Me 3 b. Newest Vital Sign (NVS) c. Teach-back method d. TEACH acronym

c. The teach-back tool is a method of assessing literacy and confirming that the learner understands health information received from a health professional. The Ask Me 3 is a brief tool intended to promote understanding and improve communication between patients and their providers. The NVS is a reliable screening tool to assess low health literacy, developed to improve communications between patients and providers. The TEACH acronym is used to maximize the effectiveness of patient teaching by tuning into the patient, editing patient information, acting on every teaching moment, clarifying often, and honoring the patient as a partner in the process.

A nurse is about to bathe a female patient who has an intravenous access in place in her forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What is the appropriate nursing action? a, Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeve. b. Cut the gown with scissors to allow arm movement. c. Thread the bag and tubing through the gown sleeve, keeping the line intact. d. Temporarily disconnect the tubing from the IV container, threading it through the gown

c. Threading the bag and tubing through the gown sleeve keep the system intact. Opening an IV line, even temporarily, causes a break in a sterile system and introduces the potential for infection. Cutting a gown is not an alternative except in an emergency.

A nurse enters a patient's room and examines the patient's IV fluids and cardiac monitor. The patient states, "Well, I haven't seen you before. Who are you?" What is the nurse's BEST response? a. "I'm just the IV therapist checking your IV." b. "I've been transferred to this division and will be caring for you." c. "I'm sorry, my name is John Smith and I am your nurse." d. "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."

d. The nurse should identify himself, be sure the patient knows what will be happening, and the time period he will be with his patient.

A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient correctly tells the aide not to place the patient in which position? a. Side-lying b. Fowler's c. Sims' d. Prone

d. The prone position is contraindicated in patients who have spinal problems because the pull of gravity on the trunk when the patient lies prone produces a marked lordosis or forward curvature of the lumbar spine

A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admission interview, the nurse should implement which communication techniques to elicit the most information from the parents? a. The use of reflective questions b. The use of closed questions c. The use of assertive questions d. The use of clarifying questions

d. The use of the clarifying question or comment allows the nurse to gain an understanding of a patient's comment. When used properly, this technique can avert possible misconceptions that could lead to an inappropriate nursing diagnosis. The reflective question technique involves repeating what the person has said or describing the person's feelings. Open-ended questions encourage free verbalization and expression of what the parents believe to be true. Assertive behavior is the ability to stand up for yourself and others using open, honest, and direct communication

A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which response by the nurse is the most therapeutic action? a. The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill." b. The nurse places a hand on the patient's arm and states, "You feel so alone." c. The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." d. The nurse holds the patient's hand and asks, "What makes you feel so alone?"

d. The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely.

When logrolling a client, the nurse should use supportive devices in turning the client in order to: prevent the blood stasis that can lead to skin breakdown. maximize the client's participation. maintain the natural alignment of the client's body. allow the client's leg to rest on the bed.

maintain the natural alignment of the client's body.

A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client? client's allergies to soap since shaving cream is contraindicated in the hospital the last time shaving was performed because clients can only shave twice weekly in the hospital medications listed on the client's medication administration record (MAR) cultural views and attitudes toward facial hair and grooming

medications listed on the client's medication administration record (MAR)

When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness upon standing. For what adverse condition is the nurse assessing the client? hypertension circulatory alterations deep vein thrombosis orthostatic hypotension

orthostatic hypotension

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk? increase in the movement of secretions in the respiratory tract increased metabolic rate increase in circulating fibrinolysin predisposition to renal calculi

predisposition to renal calculi

The pediatric nurse is caring for a 3-week-old infant. In which position will the nurse place the infant to sleep? prone lateral Sims' supine

supine

The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep? Sims' prone supine lateral

supine

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client? "When your crutches fit right, most of your body weight will be supported by your armpits." "We'll have the nursing assistant watch you while you walk around the unit the first time." "Your elbows will be slightly bent when you are using your crutches." "If you feel tired while walking with your crutches, rest your weight on your armpits for a moment and then continue slowly."

"If you feel tired while walking with your crutches, rest your weight on your armpits for a moment and then continue slowly."

The 55-year-old client who is newly diagnosed with osteoarthritis of the hips asks the nurse why it hurts when walking. What is the nurse's best response? "Osteoarthritis is painful and very common as you age." "You have lost the padding in your joints and the friction causes pain." "If you recently fell, you might have a fractured hip." "Because you lose muscle tone with age, it hurts to walk."

"Osteoarthritis is painful and very common as you age."

Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding? "I know these spots are called senile lentigines and they are likely cancer." "All of these spots are called seborrheic keratosis and they should be taken off." "These brown spots are senile lentigines and are common when you get older." "Older people often have splotchy skin due to seborrheic keratoses."

"These brown spots are senile lentigines and are common when you get older."

The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response? "That is fine if you want to transfer without my help; ring your call bell after you have transferred and are ready to go." "You are free to move onto the stretcher without assistance, but I will supervise for your safety." "I can only allow you to transfer without assistance based upon a physician's order, so I will now help you." "You cannot transfer without my help because you need a friction-reducing device to prevent harm to your skin."

"You are free to move onto the stretcher without assistance, but I will supervise for your safety."

Which of the following clients would be an appropriate candidate to move by using a powered stand-assist device? A) A comatose client who is being taken for x-rays B) An alert client after knee replacement surgery who is being assisted to ambulate C) An obese client who has Alzheimer's disease and is being escorted to the shower room D) A car accident victim with fractures in both legs who is being moved to another room

Ans: B

Which of the following clients ia at an increased risk for oral problems? Select all that apply. A) Comatose client B) Confused client C) Depressed client D) Client undergoing chemotherapy E) Hypertensive client

Ans: A, B, C, D

A nurse is providing perineal care to a female client. In which direction would the nurse move the washcloth? A) From the pubic area toward the anal area B) From the anal area to the pubic area C) From side to side within the labia D) The direction does not make any difference

Ans: A

A nurse uses proper body mechanics to move a client up in bed. Which of the following is a guideline for using these techniques properly? A) Face the direction of movement. B) Twist body at the waist when lifting. C) Keep body weight higher than center of gravity. D) Keep feet together to provide a base of support.

Ans: A

A staff development nurse is discussing techniques to prevent back injury with a group of nursing assistants. The nurse informs the group that back stress and injury can be prevented by doing which of the following? A) Spreading feet shoulder-width apart to broaden the base of support B) Using the strength of the back muscles during strenuous activities C) Holding the object that you are lifting or moving away from the body D) Pulling equipment, rather than pushing it, when possible

Ans: A

When the nurse assesses the client's blood sugar, what is the term for the type of skill the nurse is using? A) Technical B) Therapeutic C) Interactional D) Adaptive

Ans: A Feedback: Technical skills are used to carry out treatments and procedures

Legally speaking, how would the nurse ensure that care was not negligent? A) Verbally reporting assessments to the client's physician B) Keeping private notes about the care given to each assigned client C) Documenting the nursing actions in the client's record D) Tape recording complete information for each oncoming shift

C) Documenting the nursing actions in the client's record

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do? Administer an additional liter of intravenous fluids. Determine whether the prescribed treatment was effective. Formulate a plan of care based on risk for dehydration. Check the client's skin turgor.

Determine whether the prescribed treatment was effective.

The nurse understands that research has demonstrated that a common source of hospital-acquired infections in clients with IV infusions is the hub on the IV tubing. Which nursing practice competency is displayed when health care institutions recommend that health care providers always wash hands and wear gloves when accessing the hubs of IV tubing? Person-centered care Informatics Evidence-based practice Teamwork and collaboration

Evidence-based practice

A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client? Sims' Fowler's supine prone

Fowler's

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure? Make sure the bed brakes are unlocked. Put the chair at the foot of the bed. Raise the head of the bed to a sitting position Place the bed in the highest position

Raise the head of the bed to a sitting position

A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response? "To prevent foot drop." "To prevent the legs from rotating outward." "To preserve the client's functional ability to grasp and pick up objects." "To avoid contractures."

To prevent the legs from rotating outward."

A head and neck physical examination is completed on a 50-year-old female patient. All physical findings are normal except for fine brittle hair. Which laboratory test will the nurse expect to be ordered, based upon the physical findings? a. Oxygen saturation b. Liver function test c. Carbon monoxide d. Thyroid-stimulating hormone test

d

The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristic of the nursing process? a. Systematic b. Interpersonal c. Dynamic d. Universally applicable in nursing situations

b. Interpersonal. All of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process

A nurse is providing foot care for patients in a long-term care facility. Which actions are recommended guidelines for this procedure? Select all that apply. a. Bathe the feet thoroughly in a mild soap and tepid water solution. b. Soak the feet in warm water and bath oil. c. Dry feet thoroughly, including the area between the toes. d. Use an alcohol rub if the feet are dry. e. Use an antifungal foot powder if necessary to prevent fungal infections. f. Cut the toenails at the lateral corners when trimming the nail.

a, c, e. The following are recommended guidelines for foot care: bathe the feet thoroughly in a mild soap and tepid water solution; dry feet thoroughly, including the area between the toes; and use an antifungal foot powder if necessary to prevent fungal infections. The nurse should avoid soaking the feet, use moisturizer if the feet are dry, and avoid digging into or cutting the toenails at the lateral corners when trimming the nails.

A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient? a. Support weight on stronger leg and cane and advance weaker foot forward. b. Hold the cane in the same hand of the leg with the most severe deficit. c. Stand with as much weight distributed on the cane as possible. d. Do not use the cane to rise from a sitting position, as this is unsafe.

a. The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position.

A febrile preschool-aged child presents to the after-hours clinic. Varicella (chickenpox) is diagnosed on the basis of the illness history and the presence of small, circumscribed skin lesions filled with serous fluid. Which type of skin lesion will the nurse report? a. Vesicles b. Wheals c. Papules d. Pustules

a. Vesicles

A nurse is examining a child two years of age. Based on her findings, she initiates a care plan for a potential problem with normal growth and development. Which step of the nursing process identifies actual and potential problems? A) Assessing B) Diagnosing C) Planning D) Implementing

b

A nurse caring for patients in a skilled nursing facility performs risk assessments on the patients for foot and nail problems. Which patients would be at a higher risk? Select all that apply. a. A patient who is taking antibiotics for chronic bronchitis b. A patient diagnosed with type II diabetes c. A patient who is obese d. A patient who has a nervous habit of biting his nails e. A patient diagnosed with prostate cancer f. A patient whose job involves frequent handwashing

b, c, d, f. Variables known to cause nail and foot problems include deficient self-care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity.

A nurse is caring for a patient who is admitted to the hospital with injuries sustained in a motor vehicle accident. While he is in the hospital, his wife tells him that the bottom level of their house flooded, damaging their belongings. When the nurse enters his room, she notes that the patient is visibly upset. The nurse is aware that the patient will most likely be in need of which type of counseling? a. Long-term developmental b. Short-term situational c. Short-term motivational d. Long-term motivational

b. Short-term counseling might be used during a situational crisis, which occurs when a patient faces an event or situation that causes a disruption in life, such as a flood. Long-term counseling extends over a prolonged period; a patient experiencing a developmental crisis, for example, might need long-term counseling. Motivational interviewing is an evidence-based counseling approach that involves discussing feelings and incentives with the patient. A caring nurse can motivate patients to become interested in promoting their own health.

A nursing student is preparing to administer morning care to a patient. What is the MOST important question that the nursing student should ask the patient about personal hygiene? a. "Would you prefer a bath or a shower?" b. "May I help you with a bed bath now or later this morning?" c. "I will be giving you your bath. Do you use soap or shower gel?" d. "I prefer a shower in the evening. When would you like your bath?"

b. The nurse should ask permission to assist the patient with a bath. This allows for consent to assist the patient with care that invades the patient's private zones.

A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient? a. Use the axillae to bear body weight. b. Keep elbows close to the sides of the body. c. When rising, extend the uninjured leg to prevent weight bearing. d. To climb stairs, place weight on affected leg first.

b. The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg to prevent weight bearing when rising from a chair, and advance the unaffected leg first when climbing stairs

A nurse is ambulating a patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient: a. Grasp the gait belt. b. Stay with the patient and call for help. c. Place feet wide apart with one foot in front. d. Gently slide patient down to the floor, protecting her head. e. Pull the weight of the patient backward against your body. f. Rock your pelvis out on the side of the patient

c, f, a, e, d, b. If a patient being ambulated starts to fall, you should place your feet wide apart with one foot in front, rock your pelvis out on the side nearest the patient, grasp the gait belt, support the patient by pulling her weight backward against your body, gently slide her down your body toward the floor while protecting her head, and stay with the patient and call for help.

A patient has an eye infection with a moderate amount of discharge. Which action is an appropriate step for the nurse to perform when cleaning this patient's eyes? Use hydrogen peroxide on a clean washcloth to wipe the eyes. Wipe the eye from the outer canthus to the inner canthus. Position the patient on the opposite side of the eye to be cleansed. Cleanse the eye using a different section of the cleaning cloth for each stroke until clean.

d

A nurse is performing oral care on a patient who is in traction. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What should be the nurse's next action? a. Make a recommendation for the patient to see an oral surgeon. b. Report the condition to the primary care provider. c. Gently scrape the oral cavity with a tongue depressor. d. Increase the frequency of the oral hygiene and apply e. mouth moisturizer to oral mucosa.

d. If the mouth is extremely dry with crusts that remain after oral care provided, the nurse should increase frequency of oral hygiene, apply mouth moisturizer to oral mucosa, and monitor fluid intake and output to ensure adequate intake of fluid. It is not necessary to report this condition prior to providing the interventions mentioned above. The crusts should not be scraped with a tongue depressor.

A patient states, "I have been experiencing complications of diabetes." The nurse needs to direct the patient to gain more information. What is the MOST appropriate comment or question to elicit additional information? a. "Do you take two injections of insulin to decrease the complications?" b. "Most health care providers recommend diet and exercise to regulate blood sugar." c. "Most complications of diabetes are related to neuropathy." d. "What specific complications have you experienced?"

d. Requesting specific information regarding complications of diabetes will elicit specific information to guide the nurse in further interview questions and specific assessment techniques.

A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes whose theory? a. Travelbee's b. Watson's c. Benner's d. Swanson's

d. Swanson (1991) identifies five caring processes and defines caring as "a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility."

During rounds, a charge nurse hears the patient care technician yelling loudly to a patient regarding a transfer from the bed to chair. Upon entering the room, what is the nurse's BEST response? a. "You need to speak to the patient quietly so you don't disturb the other patients." b. "Let me help you with your transfer technique." c. "When you are finished, be sure to apologize for your rough demeanor." d. "When your patient is safe and comfortable, meet me at the desk."

d. The charge nurse should direct the patient care technician to determine the patient's safety. Then the nurse should address any concerns regarding the patient care technician's communication techniques privately. The nurse should direct the patient care technician on aspects of therapeutic communication

When moving a client up in bed with the assistance of another caregiver, the nurse should: maintain a pillow under the client's head. ask another nurse about the plan of care. have the client fold the arms across the chest. elevate the head of the bed.

have the client fold the arms across the chest.