NUR 151 Exam 3 Study Questions
Match the correct entry with the appropriate SOAP (Subjective—Objective—Assessment—Plan) category. 1. Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device. 2. "The pain increases every time I try to turn on my left side." 3. Acute pain related to tissue injury from surgical incision. 4. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.
2=S 4=O 3=A 1=P
Which of the following can alter tissue tolerance and lead to the development of a pressure ulcer? A. Exposure to moisture B. Smoking C. Presence of hypertension D. The client's age.
A
A client is recovering from an infected abdominal wound. Which of the following foods should the nurse encourage the client to eat to support would healing and recovery from the infection? A. Chicken and orange slices B.Cheeseburger and french fries C. Cheese omelet and french fries D. Gelatin salad and tea.
A.
A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? A. "CPOE reduces transcription errors." B. "CPOE reduces the time necessary for health care providers to write orders." C. "Health care providers can write orders from any computer that has Internet access." D. "CPOE reduces the time nurses use to communicate with health care providers."
A. "CPOE reduces transcription errors." Reasoning: CPOE eliminates the need for someone to transcribe the orders because it allows the provider to enter the order directly.
The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. The nurse would recommend which of the following menus? A. Cream of broccoli soup with whole wheat crackers and tapioca for dessert B. Hamburger on soft roll with a side salad and an apple for dessert C. Low-fat turkey chili with sour cream and fresh pears for dessert D. Chicken salad on toast with tomato and lettuce and honey bun for dessert
A. Cream of broccoli soup with whole wheat crackers and tapioca for dessert Reasoning: The dairy and broccoli in the soup, the whole grain crackers, plus the tapioca are all great sources of calcium.
What is the removal of devitalized tissue from a wound called? A. Debridement B. Pressure reduction C. Negative pressure wound therapy D. Sanitization
A. Debridement Reasoning: Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing.
You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: A. Documented medication given by another nursing student. B. Included the date and time of all entries in the chart. C. Stood with his back against the wall while documenting on the computer. D. Signed all documentation electronically.
A. Documented medication given by another nursing student. Reasoning: Nurses only document the care they provide; entries in the chart need to be dated, timed, and signed.
Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.) A. Patient's weight B. Patient's level of cooperation C. Patient's ability to assist D. Presence of medical equipment E. 24-hour calorie intake
A. Patient's weight B. Patient's level of cooperation C. Patient's ability to assist D. Presence of medical equipment Reasoning: By assessing the patient thoroughly you make the correct decision concerning your ability to manage him or her safely, the need for additional personnel, the patient's ability or inability to assist you with the transfer, and the proper equipment to use for the transfer. The calorie intake for the past 24 hours does not affect safe transfer.
Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain? A. Stage I B. Stage II C. Stage III D. Stage IV
A. Stage I Reasoning: A stage I pressure ulcer does not have a break in the skin but has a redness that does not blanch. Depending on the skin color, there may be a discoloration; the area may feel warm because of the vasodilation or cool if blood is constricted in the area; and the tissue may feel firm if there is edema in the area or soft if the blood flow is compromised. The patient may report pain in the area.
You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.) A. The patient's name, age, and admitting diagnosis B. Allergies to food and medications C. Your evaluation that the patient is "needy" D. How much the patient ate for breakfast E. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol
A. The patient's name, age, and admitting diagnosis B. Allergies to food and medications E. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol Reasoning: During change of shift report, include essential background information such as the patient's name, age, diagnosis, and allergies. Also include response to treatments such as response to pain-relieving measures. Information about how much the patient ate for breakfast is not necessary. This information is in the chart if the nurse really needs to know. Do not include critical comments about your patients.
A client is diagnosed with DVT. Which nursing diagnosis should receive highest priority at this time? A. Risk for injury related to edema. B. Ineffective peripheral tissue perfusion related to venous congestion C. Excess fluid volume related to PVD D. Impaired gas exchange related to increased blood flow.
B
When assessing the lower extremities of a client with PVD, the nurse notes bilateral ankle edema. The edema is related to: A. Competent venous valves B. Increased venous pressure C. Decreased blood volume D. Increase in muscular activity
B
Which statement is a guideline to help nurses protect themselves from liability? A. Obtain malpractice insurance. B. Practice within the scope of the nursing standards of practice. C. Follow all physician's orders. D. Do what the client desires even though the nurse may disagree.
B
The patient at greatest risk for developing multiple adverse effects of immobility is a: A. 1-year-old child with a hernia repair. B. 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA). C. 51-year-old woman following a thyroidectomy. D. 38-year-old woman undergoing a hysterectomy.
B. 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA). Reasoning: The older the patient and the greater the period of immobility, which can be significant following a hemorrhagic stroke, the greater is the number of systems that can be affected by the immobility.
On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system? A. Information technology. B. Electronic health record. C. Personal health information. D. Administrative information system.
B. Electronic health record. Reasoning: This is an example of an electronic health record. The electronic health record is an electronic record of patient health information generated whenever a patient accesses medical care in any health care delivery setting. In this question you are able to access information about the patient from the current hospitalization and from four previous times when the patient accessed care.
A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: A. Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report. B. Gives a newly ordered medication before entering the order in the patient's medical record. C. Reads the orders back to the health care provider after receiving them and verifies their accuracy. D. Asks the preceptor to listen in on the phone conversation.
B. Gives a newly ordered medication before entering the order in the patient's medical record. Reasoning: Nurses enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur.
For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? A. Binder B. Ice bag C. Elastic bandage D. Absorptive diaper
B. Ice bag Reasoning: An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to control bleeding, and can decrease pain where the ice bag is placed.
A patient asks for a copy of her medical record. The best response by the nurse is to: A. State that only her family may read the record. B. Indicate that she has the right to read her record. C. Tell her that she is not allowed to read her record. D. Explain that only health care workers have access to her record.
B. Indicate that she has the right to read her record. Reasoning: Patients have the right to read their medical records, but the nurse should always know the facility policy regarding personal access to medical records because some require a nurse manager or other official to be present to answer questions about what is in the record. Families may read the records only when the patient has given permission.
Which is an outcome for a patient diagnosed with osteoporosis? A. Maintain serum level of calcium. B. Maintain independence with activities of daily living (ADLs). C. Reduce supplemental sources of vitamin D. D. Reverse bone loss through dietary manipulation.
B. Maintain independence with activities of daily living (ADLs). Reasoning: The main goal is to maintain independence in ADLs once osteoporosis is diagnosed. It is best to identify individuals at risk and work toward preventing the disease.
An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment you note that the patient cannot tolerate lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.) A. B/P = 128/84 B. Respirations 26 per minute on room air C. HR 114 D. Crackles heard on auscultation E. Pain reported as 3 on scale of 0 to 10 after medication
B. Respirations 26 per minute on room air C. HR 114 D. Crackles heard on auscultation Reasoning: Patients with reduced mobility are at risk for retained pulmonary secretions, and this risk increases in postoperative patients. As a result of retained secretions, the respiratory rate increases. The heart rate also increases because the heart is trying to improve oxygen levels. These symptoms are of concern for older adults because, if left untreated, further complications such as heart failure can occur.
What 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. Risk factors that place the patient at risk for skin breakdown Reasoning: The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds.
A patient of any age can develop a contracture of a joint when: A. The adductors muscles are weakened as a result of immobility. B. The muscle fibers become shortened because of disuse. C. The calcium-to-phosphorus ratio becomes disrupted. D. There is a deficiency in vitamin D.
B. The muscle fibers become shortened because of disuse. Reasoning: The adductor muscles are stronger than the abductor muscles; when patients are immobile and the joint is not exercised through their ROM, the adductor muscle fibers shorten, resulting in the contracture of that joint, which is usually permanent.
While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because: A. The nurses forgot to document on the pulmonary system. B. The nurses were charting by exception. C. The computer is not working correctly. D. The physician does not have authorization to view the nursing assessment.
B. The nurses were charting by exception. Reasoning: Given that the initial assessment indicated that the pulmonary system was within normal limits, the facility is most likely documenting by exception. There is no need for further documentation unless the pulmonary assessment changes and is no longer within normal limits.
A home care nurse is preparing the home for a patient who is discharged to home following a left-sided stroke. The patient is cooperative and can ambulate with a quad-cane. Which of the following must be corrected or removed for the patient's safety? (Select all that apply.) A. The rubber mat in the walk-in shower B. The three-legged stool on wheels in the kitchen C. The braided throw rugs in the entry hallway and between the bedroom and bathroom D. The night-lights in the hallways, bedroom, and bathroom E. The cordless phone next to the patient's bed
B. The three-legged stool on wheels in the kitchen C. The braided throw rugs in the entry hallway and between the bedroom and bathroom Reasoning: Stools on wheels and braided throw rugs are hazards that put the patient at risk for falls. By planning ahead and collaborating, the home care nurse can provide a safe home environment for the patient after discharge.
Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem? A. Hematocrit (HCT) of 35%. B. White blood cell count (WBC) of 20,000/mm3 (0.02 L) C. Blood glucose level of 200 mg/dl (11.1 mmol/L) D. Potassium level of 3.5 mEq/L (3.5 mmol/L)
B. White blood cell count (WBC) of 20,000/mm3 (0.02 L)
You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet? A. The new federal laws require that teaching sheets be e-mailed to patients after they are discharged. B. You need to use words the patients can understand when writing the directions. C. The form needs to be given to patients in a sealed envelope to protect their health information. D. The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home.
B. You need to use words the patients can understand when writing the directions. Reasoning: Patients need to be able to understand information that you provide to them; ensure that written instructions are provided at a level that matches the patients' reading ability.
A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? A. Avoid rushing when charting an entry. B. Use correction fluid to remove the entry C. Draw a single line through the statement and initial it. D. Enter only objective and factual information about the patient.
D. Enter only objective and factual information about the patient. Reasoning: Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incorrect, it should be left on the record. Never use correction fluid in a written medical record.
A nurse administers morphine sulfate as ordered for pain. The client experiences nausea and vomiting, and a decrease in respiratory rate. When documenting this event in the health record, which of the following would be considered subjective data? A. "Client's respiratory rate was 8 and labored." B. "Client vomited 250 mL of yellow liquid" C. "Client seems very nauseated" D. "Promethazine 25 mg IM is administered. "
C.
The nurse is caring for a child in Bryant's traction. The nurse should: A. Adjust the weights on the legs until the buttocks rests on bed. B. Remove the elastic leg wraps every 8 hours for 10 minutes. C. Provide frequent skin care. D. Place a pillow under the buttocks.
C.
A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding? A. "Increase in redness of the ulcer means better blood flow." B. "Increase in redness of the ulcer means better blood flow." C. "I'll eat plenty of fruits and vegetables." D. "I'll make sure that I keep the site covered at all times."
C. "I'll eat plenty of fruits and vegetables."
A patient has her call bell on and looks frightened when you enter the room. She has been on bed rest for 3 days following a fractured femur. She says, "It hurts when I try to breathe, and I can't catch my breath." Your first action is to: A. Call the health care provider to report this change in condition. B. Give the patient a paper bag to breathe into to decrease her anxiety. C. Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen. D. Explain that this is normal after such trauma and administer the ordered pain medication.
C. Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen. Reasoning: These are signs of possible pulmonary emboli, which can be life threatening. You must assess your patient, be prepared to start oxygen, and have someone call the surgeon while you stay with the patient to continue to monitor her status.
Which description best fits that of serous drainage from a wound? A. Fresh bleeding B. Thick and yellow C. Clear, watery plasma D. Beige to brown and foul smelling
C. Clear, watery plasma Reasoning: Serous fluid generally is serum and presents as light red, almost clear fluid.
A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system? A. Electronic health record B. Clinical documentation C. Clinical decision support system D. Computerized physician order entry
C. Clinical decision support system Reasoning: A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user.
Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence? A. Keeping the buttocks exposed to air at all times B. Using a large absorbent diaper, changing when saturated C. Using an incontinence cleaner, followed by application of a moisture-barrier ointment D. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel
C. Using an incontinence cleaner, followed by application of a moisture-barrier ointment Reasoning: Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode.
After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first? A. Allow the area to be exposed to air until all drainage has stopped B. Place several cold packs over the area, protecting the skin around the wound C. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration D. Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly
C. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration Reasoning: If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.
You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response? A. HIPAA allows all hospital staff access to your medical record. B. HIPAA limits the information that is documented in your medical record. C. HIPAA provides you with greater control over your personal health care information. D.HIPAA enables health care institutions to release all of your personal information to improve continuity of care.
C. HIPAA provides you with greater control over your personal health care information. Reasoning: HIPAA provides patients with control over who receives and accesses their medical records. It does not allow uncontrolled access to the medical records. HIPAA also does not dictate what must be documented in the patient's medical record.
What is an appropriate way for a nurse to dispose of printed patient information? A. Rip several times and place in a standard trash can B. Place in the patient's paper-based chart C. Place in a secure canister marked for shredding D. Burn the documents
C. Place in a secure canister marked for shredding Reasoning: Confidential patient information should be shredded. It is generally collected in large secure containers and shredded at scheduled times.
Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? A. Collection of wound drainage B. Reduction of abdominal swelling C. Reduction of stress on the abdominal incision D. Stimulation of peristalsis (return of bowel function) from direct pressure
C. Reduction of stress on the abdominal incision Reasoning: A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.
A client is admitted with severe abdominal pains and the diagnosis of acute pancreatitis. The nurse should develop a plan of care during the acute phase of pancreatitis that will involve interventions to manage which of the following problems? A.Risk for injury. B. Ineffective airway clearance. C. Severe pain. D. Drug and alcohol abuse.
C. Severe pain.
Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher? A.The patient is 5 feet 6 inches and weighs 120 lbs. B. The patient speaks and understands English. C. The patient received an injection of morphine 30 minutes ago for pain. D. You feel comfortable handling a patient of his size and with his level of cooperation.
C. The patient received an injection of morphine 30 minutes ago for pain. Reasoning: The morphine injection would change the patient's ability to safely follow directions and participate in the transfer; therefore additional help would be needed to safely transfer the patient from the bed to the stretcher.
When is an application of a warm compress indicated? (Select all that apply.) A. To relieve edema B. For a patient who is shivering C. To improve blood flow to an injured part D. To protect bony prominences from pressure ulcers
C. To improve blood flow to an injured part Reasoning: Warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat.
On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer? A. Stage II B. Stage IV C. Unstageable D. Suspected deep tissue damage
C. Unstageable Reasoning: To determine the stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged.
Immobilized patients are at risk for impaired skin integrity. Which of the following interventions would reduce this risk? (Select all that apply.) A. Repositioning patient every 1 to 2 hours while awake B. Using an objective, valid scale to assess patient's risk for pressure ulcer development C. Using a device to relieve pressure when patient is seated in chair D. Teaching patient how to shift weight at regular intervals while sitting in a chair E. A good rule is: the higher the risk for skin breakdown, the shorter the interval between position changes
C. Using a device to relieve pressure when patient is seated in chair D. Teaching patient how to shift weight at regular intervals while sitting in a chair Reasoning: Patients must be repositioned around the clock, not just when they are awake. An objective assessment scale allows the nurse to assess for pressure ulcer risk over time. Once the risk is identified, the assessment tool guides the nurse in selecting appropriate pressure-relief devices. Showing the patient how to reduce his or her risk by shifting pressure is also important. Frequent and meaningful position changes that are in concert with the patient’s condition and risk factors are necessary to reduce pressure ulcer developments.
When the client who has had a hip replacement is lying on the side, the nurse should place pillows or an abductor splint between the legs to prevent: A. Flexion of the knees B. Abduction of the thighs C. Hyperextension of the knees D. Adduction of the hip joint.
D
A patient with left-sided weakness asks his nurse, "Why are you walking on my left side? I can hold on to you better with my right hand." What would be your best therapeutic response? A. "Walking on your left side lets me use my right hand to hold on to your arm. In case you start to fall, I can still hold you." B. "Would you like me to walk on your right side so you feel more secure?" C. "Either side is appropriate, but I prefer the left side. If you like, I can have another nurse walk with you who will hold you on the right side." D. "By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint.
D. "By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint. Reasoning:Walking on the affected (weak side) side and holding the patient around the waist or using a gait belt gives you better control if the patient starts to fall. If you were holding the patient's arm as he was falling, you might dislocate his shoulder.
Which of the following describes a hydrocolloid dressing? A. A seaweed derivative that is highly absorptive B. Premoistened gauze placed over a granulating wound C. A debriding enzyme that is used to remove necrotic tissue D. A dressing that forms a gel that interacts with the wound surface
D. A dressing that forms a gel that interacts with the wound surface Reasoning: A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.
When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch? A. A local skin infection requiring antibiotics B. Sensitive skin that requires special bed linen C. A stage III pressure ulcer needing the appropriate dressing D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.
D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode. Reasoning: When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.
A patient had a left-sided cerebrovascular accident 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The patient is receiving enteral feedings through a small-bore nasogastric (NG) tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately? A. Pale yellow urine B. Unilateral neglect C. Slight movement noted on the R side D. Coffee ground-like aspirate from the feeding tube
D. Coffee ground-like aspirate from the feeding tube Reasoning: When patients are receiving medications such as heparin or enoxaparin (Lovenox), you must assess for signs of bleeding. These include overt signs such as bleeding from their gums or covert signs, which can be detected by testing their stool or observing their aspirate from NG tubes for coffee ground-like matter. These are signs of bleeding in the gastrointestinal tract.
A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition? A. Recording fluid intake and output B. Ensuring that the TPN tubing has an in-line filter C. Ensuring that the TPN tubing has an in-line filter D. Monitoring the client's weight every day
D. Monitoring the client's weight every day
Which of the following charting entries is most accurate? A. Patient walked up and down hallway with assistance, tolerated well. B.Patient up, out of bed, walked down hallway and back to room, tolerated well. C. Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk. D. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.
D. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise. Reasoning: The statement "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise" provides the most accurate, objective information for the chart.
The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to: A. Prevent varicose veins. B.Prevent muscular atrophy. C. Ensure joint mobility and prevent contractures. D. Promote venous return to the heart.
D. Promote venous return to the heart. Reasoning: Elastic stockings maintain external pressure on the lower extremities and assist in promoting venous return to the heart. This increase in venous return helps reduce the stasis of blood and in turn reduces the risk for deep vein thrombosis (DVT) formation in the lower extremities.
An older adult who was in a car accident and fractured his femur has been immobilized for 5 days. Which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the first time? A. Chronic pain. B. Impaired skin integrity C. Risk for ineffective cerebral tissue perfusion D. Risk for activity intolerance
D. Risk for activity intolerance Reasoning: Patients on bed rest are at risk for activity intolerance, which increases patients' risk for falling.
When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? A. Necrotic tissue B.Wound drainage C. Drainage on the dressing D. Wound after it has first been cleaned with normal saline
D. Wound after it has first been cleaned with normal saline Reasoning: Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection. By cleaning the area before obtaining the culture, the skin flora is removed.
A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements made by a woman in the audience reflects a need for further education? A. "I usually go swimming with my family at the YMCA 3 times a week." B. "I need to ask my doctor if I should have a bone mineral density check this year." C. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." D."I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill. "
D."I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill. " Reasoning: Just because a multivitamin has calcium in it does not mean that the woman is receiving enough to meet her needs. She must know her requirement and make the decision based on that rather than on the value for calcium on the label.
As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? A. The patient has a defiant attitude and is demanding his test results. B. The patient appears to be upset with his nurse because he wants his test results immediately. C. The patient is demanding and complains frequently about his doctor. D.The patient stated that he felt frustrated by the lack of information he received regarding his tests.
D.The patient stated that he felt frustrated by the lack of information he received regarding his tests. Reasoning: This is a nonjudgmental statement regarding the nurse's observations about the patient. Documenting that the patient had a defiant attitude or was demanding and frequently complaining is judgmental, and information in the medical record should be factual and nonjudgmental. Documenting that the patient appears upset needs to be more specific regarding the reason for the patient's concern.
