NUR 111 - Exam 3

The common cold is treated with empiric therapy. How can the nurse interpret this meaning? a. Medications cure the cold b. Medications only treat the symptoms c. Herbal medications are useful to eliminate symptoms d. Prevention with careful use of medications

B Common colds are caused by VIRAL infections, these cannot be treated with antibiotics and only can be used to treat bacterial infections

A nurse is using research findings to improve clinical practice and improved care delivery. Which technique is the nurse using? a. Performance scores b. Integrated delivery networks c. Nursing-sensitive outcomes d. Utilization review committees

a

Which finding indicates the best quality improvement process? a. Staff identifies the wait time in the emergency department is too long. b. Administration identifies the design of the facility's lobby increases patient stress. c. Director of the hospital identifies the payment schedule does not pay enough for overtime. d. Health care providers identify the inconsistencies of some of the facility's policy and procedures.

a

Which finding would the nurse use to support labeling a sacral pressure injury wound as a stage II pressure injury? a. presence of a pink wound bed b. presence of nonblanchable erythema c. presence of a tunnel in the wound d. presence of a lip around the wound

a Stage I is no skin break Stage II is skin break, not to the SQ tissue so it's still pink and beefy Stage III goes to the SQ tissue

The client weighs 175 lbs. The order reads lovenox 0.5mg/kg SQ q12. How much lovenox will the nurse administer for this patients dose? a. 39.77mg b. 79.55mg c. 159.09mg d. 385mg

a remember: divide LBS by 2.2 to get KG then MULTIPLY by the dosage

What factor does the Braden Scale evaluate? a. skin integrity at bony prominences , including any wounds b. risk factors that place the patient at risk for skin breakdown c. the amount of repositioning that the patient can tolerate d. the factors that place the patient at risk for poor healing

b

A nurse is working in a healthcare organization that has achieved Magnet status. Which components are indicators of this status? (Select all that apply.) a. Empirical quality results b. Structural empowerment c. Transformational leadership d. Exemplary professional practice e. Willingness to recommend the agency

a, b, c, d

What are key points related to the administration of corticosteroids? (select all that apply) a. Tapering of the dose may be required b. The client should be protected from exposure to infections or invasive procedures c. The client should be monitored for signs and symptoms of peptic ulcer formation d. Excessive hair growth can be expected e. The client may develop fragile skin

a, b, c, e

The nurse is caring for a patient with severe chronic obstructive pulmonary disease (COPD). The patient has albuterol treatments scheduled every 6 hours and PRN and is on 2 L/min of oxygen via nasal cannula. Respiratory therapy (RT) administered the last breathing treatment 1 hour ago. When entering the patient's room to administer medications, the nurse notes that the patient is in acute respiratory distress. Which priority interventions would the nurse take to safely manage the care of this patient? (Select all that apply.) a. Place patient in upright position. b. Call respiratory therapy. c. Increase oxygen to 7 L/min via nasal cannula. d. Assess vital signs. e. Listen to lung sounds. f. Administer metoprolol.

a, b, d, e

A patient discusses the recent loss of his spouse with the nurse during a routine checkup. Which finding in the patient would indicate a reaction to loss? Select all that apply. a. Lack of energy b. Lack of interest c. Desire to move around d. Increased communication e. Insomnia

a, b, e

The patient has a stage 3 pressure injury. Which finding is characteristic of this type of pressure injury? Select all that apply. a. there is a loss of full-thickness tissue b. the subcutaneous fat may be visible c. the injury may be present as an open serum filled blister d. the tissue may have red-pink wound bed without slough e. the bone, tendon or muscle tissues are not exposed

a, b, e yoost 611, 612

Which symptom(s) is/are indicative of caregiver role stress in the caregiver of a terminally ill patient? Select all that apply. a. Anger b. Fearlessness c. Weight changes d. SLeep disturbance e. Increased concern about appearance

a, c, d

When assessing a patient's wound, the nurse finds the wound is in the proliferative phase of healing. Which wound change would lead the nurse to this conclusion? Select all that apply. a. the wound is filled with granulation tissue b. there is vasodilation of the surrounding capillaries and exudation of serum c. the wound contrats to reduce the area that requires healing d. there is localized redness, edema, warmth and throbbing e. there is re-epithelization of the wound surface

a, c, e Yoost 606 Remember, proliferative= Pro-life: healing! Granulation, congratulations you are healing! Get well soon...

Why would a nurse apply a warm, moist compress? Select all that apply a. to improve blood flow to an injured body part b. for a patient who is shivering c. to relieve edema d. to protect bony prominences from pressure ulcers e. to promote consolidation of purulent drainage

a, c, e yoost 632

The nurse completes a focused respiratory assessment on an adult client. Which abnormal respiratory assessment data will the nurse document in the electronic health record? Select all that apply. a. Dyspnea. b. Inspiration half as long as expiration. c. Respiratory rate 20 breaths per minute. d. Asymmetrical chest expansion. e. Intercostal retractions.

a. Dyspnea d. Asymmetrical chest expansion e. Intercostal retractions. REMEMBER TO WATCH FOR WORDS LIKE ABNORMAL, C IS INCORRECT FOR THIS QUESTION BECAUSE 12-20 IS THE NORMAL RANGE Normal respiratory rate for an adult is 12-20. Inspiration half as long as expiration is a normal finding for an adult.

A meal tray arrives for a patient who is receiving 24% oxygen via a Venturi mask. Which should the nurse do to meet this patient's needs? a. Request an order to use a nasal cannula during meals. b. Discontinue the oxygen when the client is eating meals. c. Obtain an order to change the mask to a nonrebreather mask during meals. d. Arrange for liquid supplements that can be administered via a straw through a valve in the mask.

a. Request an order to use a nasal cannula during meals A Venturi mask interferes with eating because it covers the nose and mouth. Using a nasal cannula during meals will help meet both the nutritional and oxygen needs of the client. A nasal cannula delivers oxygen via prongs placed in the client's nares, leaving the mouth unobstructed, which promotes talking and eating. Specific oxygen delivery systems require an order and are a dependent function of the nurse, except in emergency situations. Discontinuing oxygen when the client is eating is unsafe because it can compromise the client's respiratory status while the oxygen is disconnected. A Venturi mask and a nonrebreather mask are both masks that cover the mouth, which interferes with eating. Liquid supplements are unnecessary. The client should eat the diet ordered by the health care provider.

The nurse is caring for a neonate with respiratory distress. Which sign appears early for the neonate with respiratory distress syndrome? a. Tachypnea more than 60 breaths/minute. b. Pale gray skin color. c. Bilateral crackles. d. Capillary filling time four seconds.

a. Tachypnea more than 60 breaths/minute. Tachypnea and expiratory grunting occur early in respiratory distress syndrome to help improve oxygenation. Poor capillary filling time, a later manifestation, occurs if signs and symptoms aren't treated. A pale gray skin color obscures earlier cyanosis as respiratory distress symptoms persist and worsen. Crackles occur as the respiratory distress progressively worsens.

What is the desired outcome related to the nursing diagnosis of Impaired Airway Clearance? a. Patient's respiratory secretions will become thicker so they are not moved when coughing. b. Patient's respiratory secretions will have a thinner consistency after being given a mucolytic agent. c. Patient will have improved range of motion while in bed. d. Patient's respiratory rate will increase from 16 to 28 breaths/min during hospitalization.

b

The nurse is caring for a client with chronic obstructive pulmonary disease who is prescribed a precise oxygen concentration. Which oxygen delivery system will the nurse select as the best option for the client? a. Venturi mask. b. Nasal cannula. c. Nasogastric tube. d. Face mask.

a. Venturi mask. A Venturi mask delivers a precise concentration of oxygen despite client variations in respiratory rate, depth or tidal volume. It is a high flow delivery device that can deliver precise concentrations of oxygen up to 50% FIO2. Face mask can be used but does not deliver a precise amount of oxygen. Nasal cannula delivers approximate concentrations of oxygen that can ran from 24-44% at rates of 1L to 6L/min flow rate. The concentration is dependent on flow rates and client respiratory depth and rate of breathing. A nasogastric (NG) tube is not an oxygen delivery device.

While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following? a. Wheezes. b. Crackles c. Pleural friction rub. d. Rhonchi.

a. Wheezes. Wheezes, usually heard on expiration, are continuous, musical, high pitched, and whistle-like sounds caused by air passing through narrowed airways. Often, wheezes are associated with asthma. Rhonchi are low-pitched, continuous sounds with a snoring quality that occur when air passes through secretions. Crackles are bubbling, cracking or popping, low- to high-pitched, discontinuous sounds that occur when air passes through fluid in the airways. A pleural friction rub is an adventitious breath sound heard on auscultation of the lung. The pleural rub sound results from the movement of inflamed and roughened pleural surfaces against one another during movement of the chest wall.

A nurse is planning to assess the structure of a family (CFAM). Which question should the nurse ask? a. Who lives with you in this home? b. Who does the grocery shopping? c. Woo provides support in your family? d. How old are the members of your family?

a. Who lives with you in this home? This question is asking about the STRUCTURE portion of the CFAM model

Which process is the removal of devitalized tissue from a wound? a. debridement b. pressure reduction c. negative pressure wound therapy d. sanitization

b Debridement is the removal of dead or necrosis tissue, it cleans out the wound site to promote healing

A 94-year-old patient has a severe dry cough. He has coughed so hard that the muscles in his chest are hurting. He is unsteady on his feet and slightly confused. Which drug would be the best choice for this patient's cough? a. Benzonatate capsules b. Dextromethorphan oral solution c. Codeine cough syrup d. Guaifenesin

b Dextromethorphan does not cause respiratory or CNS depression, and it is not an opioid. Guaifenesin is an expectorant that is used to thin excessive mucus, which this patient does not have.

The nurse notes the edges of the patient's surgical incision are approximated and without visible drainage. Which type of healing would the nurse associate with these findings? a. granulation b. primary intention c. tertiary intention d. secondary intention

b Primary intention is the use of sutures or other closures to approximate the edges of an incision. Think of a surgical incision being closed. Primary, normal circumstances

When developing a teaching plan for a client who is taking warfarin (Coumadin), which foods would the nurse suggest the client consume to maintain a consistent intake of vitamin K? a. Liver, milk and eggs b. Brussel sprouts, cauliflower, and spinach c. Fortified cereals, whole grains and nuts d. Dried peas and beans, wheat germ and seeds

b leafy greens!!!!!

A nurse is evaluating care based upon the nursing quality indicators. Which areas should the nurse evaluate? (Select all that apply.) a. Patient satisfaction level b. Hospital readmission rates c. Nursing hours per patient day d. Patient falls/falls with injuries e. Value stream analysis for quality

b, c, d

Which information would help the family cope with the patient's hearing impairment when a nurse concludes that a patient has a progressive hearing disorder and that an assistive device could be beneficial? Select all that apply. a. install regular smoke detectors b. provide an amplified telephone c. allow the phone to ring for a longer time d. do not leave the patient alone e. install lamps that turn on in response to sounds like the doorbell, the telephone or alarms

b, c, e

A client is receiving oxygen through a nasal cannula. Which should the nurse do to prevent skin breakdown around the patient's nares? a. Remove the tubing for 15 minutes every 2 hours. b. Adjust the cannula so it is comfortable. c. Provide the client with oral hygiene whenever necessary. d. Reposition the patient every 2 hours.

b. Adjust the cannula so it is comfortable. REMEMBER LEAST INVASIVE OPTION FIRST, REMOVING OXYGEN ENTIRELY WOULD BE INVASIVE If the cannula comfortably rests in the nares, it avoids pressure on the nares that can cause skin breakdown. The cannula should not be too tight. Although oral hygiene is important, it is mainly pressure that causes skin breakdown; oral hygiene alone does not prevent skin breakdown. Fifteen minutes is too long to remove oxygen from a client who needs oxygen. Repositioning the client prevents pressure ulcers of dependent areas of the body but does not prevent skin breakdown around the nares.

A long term care facility encourages nurses to assess patients at risk of developing pressure injuries based on six subscales: moisture, sensory perception, activity, mobility, nutrition and friction or shear. WHich tool is the facility using for risk assessment of pressure ulcer development? a. GNASC tool b. Braden Scale c. Bates - Jensen tool d. WONC scale

b. Braden scale pg 615 yoost

Which action by the nurse will provide relief to the caregiver of a patient with cognitive alterations and in the terminal stages of cancer after learning that the patient's caregiver is extremely stressed and has not been able to make time for a personal life? a. asking the caregiver to withhold caregiving activities b. helping the caregiver set a regular time for respite c. explaining the need to focus more on the patient now and less on the caregivers personal life d. encouraging the caregiver by praising them

b. helping the caregiver set a regular time for respite Provide relief for the caregiver (pg707), always chose the answer that supports the caregivers health. You have two patients in this example and you must keep both's health in mind

A patient has serosanguineous drainage from a wound. Which description is characteristic of serosanguineous drainage? a. bright red fluid b. pink to pale red fluid c. clear and watery plasma fluid d. thich and yellow or greenish fluid

b. pink to pale red fluid yoost pg 618

A nurse is caring for a patient in the hospital. When should the nurse begin discharge planning? a. When the patient is ready. b. Close to the time of discharge. c. Upon admission to the hospital. d. After an order is written/prescribed.

c

After surgery, the patient with a closed abdominal wound reports a sudden "pop" after performing deep breathing and coughing therapy. Upon examining the surgical wound site, the sutures are open, and oeices of small bowel are noted at the bottom of the now opened wound. What action would the nurse take? a. allow exposure of the area to air, until all wound drainage has stopped b. place several cold packs over the area to protect the patient's skin surrounding the wound c. cover the area with sterile, saline soaked towels and immediately notify the surgical team, this is likely a wound evisceration d. cover the area with sterile gauze, place a binder over it, and ask the patient to remain in bed for 30 minutes because this should fix itself because it is a minor opening

c

The nurse caring for a patient would identify a need for additional interventions related to family dynamics when a. extended family offers to help. b. family members express concern. c. the ill member demands attention. d. memories are shared.

c

The nurse is applying for a position with a home care organization that specializes in spinal cord injury. In which type of health care facility does the nurse want to work? a. Secondary acute b. Continuing c. Restorative d. Tertiary

c

The nurse is caring for a patient whose insurance coverage is Medicare. The nurse should consider which information when planning care for this patient? a. Capitation provides the hospital with a means of recovering variable charges. b. The hospital will be paid for the full cost of the patient's hospitalization. c. Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost. d. Medicare will pay the national average for the patient's condition.

c

Two women have an established long-term relationship and are attending parenting classes in anticipation of finalizing adoption of a baby. The nurse identifies them as which type of family? a. Cohabiting b. Nuclear c. Same-sex d. Single parent

c

When reviewing the purposes of a family assessment, the nurse educator would identify a need for further teaching if the student responded that family assessment is used to gain an understanding of which aspect of the family? a. Development b. Function c. Political views d. Structure

c

Which vitamin is given in large doses to facilitate wound and bone healing? a. Vitamin A b. Vitamin D c. Vitamin C d. Niacin

c

What teaching should the nurse give a client with a virus who intents to purchase an OTC (over the counter) combination cold remedy? a. Recommend an antitussive, like dextromethorphan if they have a productive cough b. These agents are best used in conjunction with an antibiotic c. It is safer to use a single-agent preparation if you are only experiencing one symptom d. Since these agents are available over the counter, it is safe to use any of them as long as needed

c Only take what you need!!!! Avoid overdosing and taiing medications that you do not need to avoid making symptoms and illness worse

Which description would the nurse associate with serous drainage from a wound? a. fresh bleeding b. thick and yellow c. clear, watery plasma d. beige to brown and foul smelling

c Remember that serious is clear, sanguineous is bloody and a combo of both, pink drainage, is serosanguinous. Purulent, PU! Yellow to green, can smell, PU!

Which skin care measures would the nurse use to manage a patient experiencing fecal and urinary incontinence? a. keeping the buttocks exposed to air at all times b. using a large absorbent diaper, change when saturated c. using an incontinence cleaner followed by the application of a moisture barrier ointment d. frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel

c yoost 622

Which clinical finding is an indication for placement of a binder around a patient with a new abdominal wound secondary to a surgical procedure? a. collection of wound drainage b. reduction of abdominal swelling c. reduction of stress on the abdominal incision d. stimulation of peristalsis from direct pressure

c yoost 629

For a patient with a stage 4 pressure injury who needs to have a dressing change, at which time would the nurse perform the dressing change in relation to administering an analgesic? a. before the administration b. immediately after administration c. 30 minutes after administration d. 90 minutes after administration

c yoost 634

Which process would the nurse associate with the proliferative phase of wound healing in a patient? a. homeostasis b. wound cleaning c. scar tissue formation d. granulation tissue formation

d Wound repair happens during the proliferative phase, granulation forms and fills the wound Granulation is Good for healing

When obtaining a wound culture, from which site would the nurse obtain the specimen? a. necrotic tissue b. wound drainage c. drainage on the dressing d. wound bed, after cleaning with normal saline

d yoost 643/644

A nurse with an oncology outpatient has been seeing the patient and her spouse since the patient received the diagnosis of breast cancer. After noting conflicting observations between the patient and her spouse, which question will the nurse ask to reassess their psychosocial situation? a. "In which way does the pain you have affect you on a daily basis?" b. "Describe to me what you eat in a typical day?" c. "Tell me how you think your spouse and you are dealing with your cancer." d. "Are the two of you having any relational difficulties because of your cancer?"

c. "Tell me how you think your spouse and you are dealing with your cancer." Remember, always ask open ended questions!

A client with COPD reports steady weight loss and being "too tired from just breathing to eat." Which of the following nursing diagnoses would be most appropriate when planning nutritional interventions for this client? a. Ineffective breathing pattern related to alveolar hypoventilation. b. Weight loss related to COPD. c. Imbalanced nutrition: Less than body requirements related to fatigue. d. Activity intolerance related to dyspnea.

c. Imbalanced nutrition: Less than body requirements related to fatigue. The client's problem is altered nutrition—specifically, less than required. The cause, as stated by the client, is the fatigue associated with the disease process. Instruct the patient to frequently eat high caloric foods in smaller portions. Encourage rest before and after meals. COPD patients expend an extraordinary amount of energy simply on breathing and require high caloric meals to maintain body weight and muscle mass.Activity intolerance is a likely diagnosis but is not related to the client's nutritional problems.Weight loss is not a nursing diagnosis.Ineffective breathing pattern may be a problem, but this diagnosis does not specifically address the problem of weight loss and nutrition described by the client.

Upon assessing a patient's sacral pressure injury, the nurse notes the tissue over the sacrum is dark, hard and adherent to the wound edge. Which pressure injury stage would the nurse document in the patient's electronic medical record? a. stage 2 b. stage 4 c. unstageable d. suspected deep tissue damage

c. unstageable page 612 yoost

An older-adult patient has extensive wound care needs after discharge from the hospital. Which facility should the nurse discuss with the patient? a. Hospice b. Respite care c. Assisted living d. Skilled nursing

d

For a patient admitted with a stage II pressure injury, which characteristic would the nurse likely find during the wound assessment? a. the subcutaneous fat is visible b. Undermining and tunneling may be present c. the wound extends to muscle and bone d. the wound bed is a red-pink without slough

d

The most appropriate initial nursing intervention when the nurse notes dysfunctional interactions and lack of family support for a patient would be to a. enforce hospital visiting policies. b. monitor the dysfunctional interactions. c. notify the primary care provider. d. role model appropriate support.

d

Which factors which would alert the nurse to negative/dysfunctional family dynamics? a. Aging of family members b. Chronic illness of a family member c. Disability of a family member d. Intimate partner violence

d

What is the correct order of wound healing? a. Proliferative, inflammatory, maturation b. inflammatory, maturation, proliferative c. maturation, inflammatory, proliferative d. inflammatory, proliferative, maturation

d The three stages are inflammatory: homeostasis, proliferative and then maturation pg 606

Which assessment finding supports the nursing diagnosis of impaired airway clearance? Select all that apply a. elevated oral temperature b. slow gait c. fatigue d. thick sputum e. prolonged coughing

d, e

The nurse provides teaching to the client about oxygen safety. Which statement by the client about oxygen safety indicates an understanding of the teaching? a. "I can apply petroleum jelly to my nose and lips when they are dry." b. "I will store my oxygen tank in my car to keep it dry." c. "I can smoke with my oxygen as long I do strike a match next to my tank." d. "I will contact the local fire department to let them know I have oxygen in use at my home."

d. "I will contact the local fire department to let them know I have oxygen in use at my home." Oxygen safety in the home includes: Know NOT to smoke or be around people who are smoking while using oxygen. Post "No Smoking—Oxygen In Use" signs on doors. Notify local fire department and electric company of oxygen use in home. Never use paint thinners, cleaning fluids, gasoline, aerosol sprays, and other flammable materials while using oxygen. Keep all methods of oxygen delivery at least 15 ft away from matches, candles, gas stove, or other source of flame, and 5 ft away from television, radio, and other appliances. Keep oxygen tank out of direct sunlight. When traveling in automobile, place oxygen tank on floor behind front seat. If traveling by airplane, notify air carrier of need for oxygen at least 2 weeks in advance. The client should not smoke with oxygen as it is flammable. Petroleum jelly is flammable and should not be used by patients on oxygen. Oxygen tanks should not be stored in cars and should be kept out of direct sunlight.

The nursing is performing a respiratory assessment on a three-month-old. Which technique will the nurse use to obtain an accurate respiratory rate? a. Place the infant flat on the bed with the chest exposed. b. Assess respirations after checking temperature and blood pressure. c. Assess respirations while the infant is crying. d. Assess respirations while the infant is being held by the parent.

d. Assess respirations while the infant is being held by the parent. REMEMBER HOW THIS RELATES TO THE STAGES OF DEVELOPMENT AND COMFORT The most accurate respiratory rate is obtained before disturbing the infant or child. This can often be done easily when the parent/caregiver is holding the child before any clothing is removed. The infant's respirations should be taken before disturbing the infant. Respiratory rate often changes when infants or young children cry, feed, or become more active. They also tend to breathe faster when they are anxious or scared. Count the respiratory rate for a full minute to ensure accuracy. Infants' respirations are primarily diaphragmatic, so count the abdominal movements. After 1 year of age, count the thoracic movements.

Which should the nurse do first when caring for a nonverbal patient who is restless, agitated, and irritable? a. Reduce environmental stimuli. b. Administer oxygen. c. Suction the oropharynx. d. Determine patency of the airway.

d. Determine patency of the airway. REMEMBER ABCs COME FIRST!!!!! Early signs of hypoxia are restlessness, agitation, and irritability resulting from reduced oxygen to brain cells. A partial or completely obstructed airway prevents the passage of gases into and out of the lungs. The ABCs (Airway, Breathing, Circulation) of emergency care identify airway as the priority. Administering oxygen may or may not be necessary. The need for oxygen administration will depend on the results of other interventions that should be done first. Suctioning the oropharynx is premature. Mucus or sputum may not be the cause of the problem. Reducing environmental stimuli will serve no purpose at this time and is not the priority.

When administering oxygen to a patient, the nurse recognizes that using which oxygen delivery system places a patient in danger of receiving inadequate oxygen? a. Nasal cannula at a flow rate of 2 L/min b. Nasal cannula at a flow rate of 5 L/min c. Simple mask at a flow rate of 6 L/min d. Non rebreather mask at a flow rate of 5 L/min

d. Non rebreather mask at a flow rate of 5 L/min The rate for this is 10-15 mL per minute, anything less than 10 can be harmful to the patient and can cause them to suffocate

The nurse identifies the family with a child graduating from college as having which effect on the family life cycle? a. minimal impact b. considered to be a negative impact on the family unit c. leads to role confusion d. expectation of role change

d. expectation of role change