NURS 202 Final Exam prep (Quiz ?'s & mainly..Modules 1-3, 6/7)

The nurse is discussing various sexual issues with a group of patients who have experienced spinal cord injuries. Which of the following statements best addresses the issue of alternative methods of personal sexual gratification?

"Any form of stimulation that is mutually agreed and satisfying is acceptable sexual practice." *Rationale Counseling clients with altered sexual functions can be facilitated by using the PLISSIT model, permission giving, limited information, specific suggestions, and intensive therapies. "Any form of stimulation that is mutually agreed and satisfying is acceptable sexual practice", is the most appropriate response based on this model (p.949)

The patient asks whether herbal medicines are a "good idea." What should the nurse respond?

"Are there specific ones you're wondering about?" *Rationale Although herbs can be effective, it is important to caution people about becoming dependent on them or using them with certain medications or health conditions. Nurses must be open to exploring and discussing their clients' uses and questions on herbal medications. Asking an open-ended question like which ones they are curious about helps start this conversation (p.298).

A patient is admitted to the hospital with a history of dementia. The patient has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the most appropriate reality orientation for this patient?

"Good morning. You are in the hospital. I am your nurse Elaine Smith." *Rationale Introductions, constant care givers, and other orientation clues such as day of the week, time of day, month or year can promote a therapeutic environment for those individuals suffering from dementia/delirium. (p.917)

The nurse recognizes that a patient with pain disorder is improving when the patient states which of the following?

"I need to have a good cry about all the pain I've been in and then not dwell on it." *Rationale Nurses can help by intervening with patients who are anxious, are sad, or express overly pessimistic, or helpless point of views. Therapeutic communication with an emphasis on listening, providing encouragement, and teaching self-management skills, sharing vicarious experiences, and persuading them to act on their own behalf are strategies that promote coping. The first statement indicates that this patient has developed coping methods (p.1119)

The nurse is instructing the unlicensed assistant on the correct technique for obtaining a clean-catch mid-stream urine culture from a female patient. Which of the following statements indicates that the assistant has understood the instructions?

"I will ask the patient to clean her labia, void in the toilet, and then into the specimen cup." *Rationale During this test, the female patient should be instructed to clean her genitals with provided towelette or soap and water from front to back and instruct to begin voiding into the toilet. The urine cup should then be placed into the urine stream and sample collected (p.733).

An adolescent female student, who is sexually active, visits the office of the school nurse. Which of the following statements best reflects her understanding of the effective use of contraception devices?

"We have decided that I should use a diaphragm inserted and contraceptive cream with each intercourse." *Rationale Response: "We have decided that I should use a diaphragm inserted and contraceptive cream with each intercourse" given by the adolescent female demonstrates that she has a knowledge of effective use of contraception devices. All other statements indicate a lack of knowledge and a need for further education (p.950).

A 55-year-old male patient is explaining to the nurse that he does not sleep well at night. The patient explains all the different medications that he is taking. The nurse understands that what type of medications often may disrupt REM sleep? (Select all that apply)

-Alcohol -Bronchodilators -Caffeine *Rationale Medications can affect sleep. Hypnotics can interfere with deep sleep and suppress REM. Beta blockers have been known to cause insomnia and nightmares. Narcotics are known to suppress Rem sleep and cause frequent awakenings and drowsiness. Other medications include alcohol, amphetamines, antidepressants, bronchodilators, caffeine, decongestants, and steroids. (p.1072)

Which of the following are pain relief interventions for patients with arthritis? (Select all that apply)

-Diversionary activities (i.e. guided imagery, yoga) -Warm, moist heat -Medications *Rationale Pain relief interventions that can be used at home include diversionary activities like guided imagery, relaxation, distraction, music, massage, medications, and heat/cold therapies (p.1102).

Which of the following should be included in a discussion on responsible sexual behavior? (Select all that apply.)

-Effectiveness and cost of various contraceptive methods -Talk openly to your partner about how to have "safer sex" -Limit the number of sexual partners *Rationale When having a discussion on responsible sexual behavior the nurse should include points such as limit the number of sexual partners, talk openly with sexual partners about how to have safer sex, abstain from high risk sexual activity with those known to have STIs, use condoms in relationships that have potential for STIs, follow safe sex practices during oral sex, report a health facility for examination whenever in double about a possible exposure, notify partners if positive for STI and different contraceptive methods (p.949, 950)

A patient is experiencing acute confusion. What nursing actions would be appropriate for this patient? (Select all that apply)

-Keep room well-lit during waking hours. -Place a calendar in the room, and identify each day. -Keep eyeglasses within reach. -Eliminate unnecessary noise. *Rationale In those experiencing acute confusion it would be appropriate to complete interventions such as placing a clock or calendar in the room, keep room bright and uncluttered, encouraging family to visit, eliminate unnecessary noise or medications, keep familiar items in room, keep eyeglasses and hearing aids within reach, schedule activities, identify time and place, and wearing a name tag. (p.917)

The nurse suspects that an adolescent is working through the stages of spiritual development. Which of the following observations did the nurse make to come to this conclusion? (Select all that apply)

-Met with the church priest to talk about the differences in spiritual beliefs -Determined differences between spiritual beliefs as being right or wrong -Compartmentalized differences between spiritual beliefs with friends *Rationale Spiritual development is when adolescents or young adults are exposed to a variety of wide options, beliefs, and behaviors regarding religious matters and begin to reconcile the differences by deciding any differences are wrong, compartmentalizing the differences, and obtaining advice from a significant other such as a parent or minister.

Which of the following steps must the nurse complete in order to change the IV container correctly? (select all that apply)

-Verify the label of the new container -Inspect the IV site for inflammation -Document all relevant information *Rationale To change the IV container correctly, first verify the right container, patient, additives, and dose is selected. Assess the IV site for presence of inflammation or infiltration because if these are present the IV needs to be removed. The nurse then can disconnect the tube or remove the cap with clean gloves and using a sterile swab. Clamp and remove old IV tubing and connect new tubing or reestablish the infusion. Regulate the flow of the infusion and document all pertinent information - no second verification is needed. (p.1353)

The nurse is applying a transdermal pain patch to a patient's upper arm. Which nursing actions are appropriate? (select all that apply)

-Wear clean gloves when applying the patch -Remove the previous pain patch prior to applying the new one -Place time, date, and initials on the patch *Rationale When applying a transdermal patch, the patch should be applied to a dry clean area that is free of hair and matches the manufactures recommendations. Remove the patch from its protective coating and hold it without touching the adhesive edges and apply by pressing firmly with the palm of hand for 10 seconds. Place time, date, and initials on the patch. Previous patches should be removed before applying another and the patches should be removed at the appropriate time. Clean gloves would be appropriate for the procedure and to keep medication from getting on the nurses' hands. (p.812).

What type of IV solution would be the most appropriate for the patient experiencing dehydration?

0.9% NaCl (normal saline) *Rationale Normal saline 0.9% initially remains in the vascular compartment and expands vascular volume. This makes this solution ideal for restoring vascular volume. (p.1336)

A patient has been given Vicodin one tablet by mouth for complaints of a level 7/10 pain in the right knee. When should the nurse re-assess the patient's pain?

1 hour *Rationale The most critical period after giving an oral pain medication is an hour after the medication is giving. Checking after an hour allows the nurse to assess the patients pain but also their sedation and respiratory status. (p.1110)

The nurse is assisting a patient with a bowel training program. The nurse knows that the bowel training routine must be maintained for how long in order to be effective?

2-3 weeks *Rationale A bowel training program must be maintained for 2-3 weeks along with proper exercise, diet, fluid, positioning, and medication use (p.1231).

In order to minimize the risk of contamination the nurse knows that all IV solution bags should be changed how often?

24 hours *Rationale All IV bags should be changed every 24 hours regardless of how much solution remains to minimize the risk of contamination (p.1352)

Psychologic homeostasis is maintained by a variety of mechanisms. Which patient should the nurse identify as being the most likely candidate to obtain psychologic homeostasis?

A young adult who is in a long-term relationship. *Rationale Psychological homeostasis refers to emotion or psychological balance or a state of mental well-being and is maintained by various mechanisms. To have a stabilize homeostasis balance a person should have a stable physical environment, a stable psychological environment, a stable social environment, and lifer experience that provides satisfaction. In the above example, the most stable balance is the young adult in the long-term relationship (p.246)

Which of the following factors is most important for healing an infected decubitus ulcer?

Adequate circulatory status *Rationale Good circulation brings oxygen and nourishment to the wound and leads to increased wound healing (p.836).

When administering a medication by the buccal route the nurse understands that the medication should be placed where?

Against the mucous membranes of the cheek *Rationale Buccal means pertaining to the cheek. In this medication administration, the medication is held in the mouth against the mucous membranes of the cheek until it is dissolved (p. 759).

The nurse is caring for a postoperative patient following abdominal surgery when the nurse observes that the wound has eviscerated. What would be the priority nursing action?

Apply a sterile dressing moistened with normal saline *Rationale Evisceration is the protrusion of the internal viscera through an incision. When this occurs, the wound should be quickly supported by larger sterile dressings soaked in sterile normal saline. The patient should be placed in bed with knees bent to decrease pill on the incision. The physician should then be notified. (p.836)

A nurse is assessing a patient who has a wound on the leg as a result of a bicycle accident. Which clinical finding indicates a localized inflammatory response?

Area around wound is swollen *Rationale During an inflammatory response, the blood supply to the wound increases bringing with it red and edematous results. This inflammatory process is essential to wound healing. The other options in this question are signs of an infection. (p.835)

The nurse is admitting a patient to the emergency department with complaints of severe abdominal pain. What is the nurse's priority action?

Assess pain using a scale of 1 to 10. *Rationale Assessing vital signs is the first step that should be taken to help assess the patients abdominal pain. Information gained from this assessment will help guide further interventions for this patient like fluids, medications, or foley placement. ((p1110-tb46-10)

Your patient has a Braden score of 20. Which of the following is the most appropriate nursing action?

Assess the patient again in 24 hours; the score is within normal limits *Rationale Those who have a Braden scale score under 18 are at risk for pressure ulcers. In someone who has a Braden scale score of 20, it would be appropriate to assess the patient again later as they are not currently at risk for skin breakdown (p.832).

The nurse realizes that a medication error has been made and a patient has received the wrong medication. What should be the nurse's first action when realizing an error has been made?

Assess the patient's condition *Rationale When a medication error occurs, the first action the nurse should complete is to assess the patient's condition as patient safety is a top priority. It then should be reported to the charge nurse, nurse manager, and provider. (p.769)

The parent of a 20-month-old is very concerned because the baby touches the genital area during diaper changes. How should the nurse respond to this concern?

At 20 months, this touching is not a sexual experience *Rationale In toddlers, body exploration and genital fondling is normal as the toddler continues to develop gender identity (p. 935).

In preparing for insertion of the peripheral intravenous catheter, the nurse must select an appropriate site. Which of the following areas should the nurse try first if an appropriate vein is found?

Back of the hand *Rationale The nurse should first try the back of the hand because using the more distal veins first allows the nurse to move up on the arm for further attempts. IV starts should be proximal to the previous sites (p.1337).

During the admission assessment, the nurse asks the patient to run the heel of the right foot down the lower anterior surface of the left leg. The nurse notices rhythmic tremors of the right leg and concludes that the patient has what type of alteration?

Balance and coordination *Rationale The heel down opposite shin test is done to demonstrate balance and coordination. During this test, if there is a tremor or awkwardness - like the heel moving off the shin- a alteration is balance and coordination is shown. (p.587)

The nurse is developing a plan of care for a patient diagnosed with narcolepsy. Which intervention is appropriate to include in this plan of care?

Be certain the patient has the prescription for modafinil (Provigil) filled. *Rationale Narcolepsy is a disorder of excessive daytime sleepiness and caused by the lack of the chemical hypocretin in the area of the CNS that regulates sleep. Modafinil (Provigil) has psychoactive effects to alter mood, perception, and thinking to control excessive daytime sleepiness in narcoleptic clients with fewer side effects and lower potential of abuse. Oxybate is used to treat cataplexy and is tightly controlled by the FDA. OTC medications will not typically be helpful for these patients. Antihistamines are not indicated (p.1073-74).

The nurse is planning to administer medications to a new patient. What is the nurse's greatest priority in administering these medications?

Before giving the medications, know what the intended effects are for this patient *Rationale When giving a patient medication, it is essential that the nurse understands the intended effects or the reason the drug is prescribed. Knowing this, the nurse understands what should be expected versus other signs and symptoms that could be side effects, adverse reactions, or an allergic reaction (p.755)

A patient is diagnosed with liver disease. The nurse realizes that which element of pharmacokinetics will be affected in this patient?

Biotransformation *Rationale Biotransformation or metabolism is the process by which a medication is converted to a less active form that takes place in the liver where enzymes await to detoxify the drugs. Biotransformation is altered in a patient who has an unhealthy liver. Drugs in these patients can accumulate and lead to toxicity (p.755)

When discontinuing an IV infusion the nurse should always perform what action?

Check the catheter to make sure it is intact *Rationale When discontinuing an IV infusion it is important that the nurse examines the catheter to ensure that it is intact. If a piece of tubing remains in the patients vein it could move centrally towards the lungs or heart (p.1354).

The nurse is preparing to administer an enteric-coated medication to a patient through their gastrostomy tube. What is the first action the nurse should take?

Check with the pharmacy if the medication comes in liquid form *Rationale When administering medications through a gastrostomy tube, it is important to first check with pharmacy to see if the medication comes in a liquid form as this helps ensure the tube does not become clogged. Enteric coated medications cannot be crushed making it essential to see if it comes in another form (p.780).

The nurse is caring for an elderly patient who has experienced a sensorineural hearing loss. The nurse anticipates that the patient will exhibit which one of the following symptoms?

Difficulty hearing high-pitched sounds *Rationale Sensorineural hearing loss is the result of damage to the inner ear, the auditory nerve, or the hearing center in the brain leading to the difficulty in hearing high pitched sounds. (p. 542)

Nursing interventions for a client having a transfusion reaction include all but which of the following?

Discontinue the current IV site and restart the infusion at a different site *Rationale When a patient is suspected of having a transfusion reaction, the transfusion should be stopped immediately and keep the line open with normal saline using new IV tubing. Continue to monitor vital signs. Do not restart the transfusion. (p.1358)

The nurse teaches the patient with a Foley catheter to attach it to a standard urine collection bag at night. What is the rationale for this action?

Distention of the bladder *Rationale Attaching the catheter to a standard urine collection bag decreases distention of the bladder and backup of urine from the leg bag into the tubing as the standard urine collection bag is larger and can contain a larger amount of urine for the extended night period.

A hospitalized patient tells the nurse that he has experienced pain and burning the last two times he urinated. The nurse accurately refers to this as which of the following?

Dysuria *Rationale Dysuria is voiding that is painful or difficult. Polyuria is increased urination. Pyuria is when the urine contains a large amount of white blood cells or pus. Oliguria is a low urinary output. (p.1179-1180)

The 70-year-old patient tells the nurse, "I can go to sleep without a problem, but then I wake up in a couple of hours and can't go back to sleep." What nursing action would help promote rest and sleep in this patient?

Evaluate if the patient perceives sleeplessness to be a serious problem. *Rationale There are different factors that can affect an individuals sleep. It is first important to see if this change in sleep pattern is a problem for the patient. If the patient identifies it as a problem, the cause and different interventions can then be discussed (p.1071)

Which of the following factors can alter tissue tolerance and lead to the development of a pressure ulcer?

Exposure to moisture *Rationale Moisture from incontinence can lead to skin maceration and makes the epidermis more easily eroded and susceptible to injury. Any accumulation of secretions or excretions is irritating to the skin, harbors bacteria, and makes an individual prone to skin breakdown and infection (p.830).

A nurse is developing a plan of care for a school-aged child with a knowledge deficit related to the use of inhalers and peak flow meters. What is the most appropriate outcome to be included in the plan of care for this child?

Express feelings of mastery and competence with breathing devices *Rationale For the school aged child, a nurse should demonstrate interest in the child and enthusiasm for the child's strengths and include the child actively in the exam, explaining and encouraging the child to ask questions and participate. Having the school aged child have a positive feelings and competence with breathing device would demonstrate a positive outcome for this group as they grow, become more independent and confident.

The nurse is caring for a patient who states that she has not had a bowel movement for eight days and is having stool seepage on her bed sheets. What does the nurse anticipate the patient is experiencing?

Fecal impaction *Rationale Fecal impaction is a mass or collection of hardened feces in the folds of the rectum resulting from prolonged retention and accumulation of fecal material. A patient who has fecal impaction will experience the passage of liquid seepage and no normal stool. The liquid portion seeps out around mass of stool. (p.1216)

The nurse is preparing to discharge a patient home with a prescription for ibuprofen (Motrin). What should the nurse instruct as a common side effect of this medication?

Gastrointestinal (GI) distress *Rationale Side effects from use of ibuprofen (motrin) include GI distress, GI uclers, diminished renal blood flow and inhibiting of clotting. (p.1107)

The nurse is providing pre-employment physicals to a group of adults aged 40 to 50. In which generation would the nurse categorize these adults?

Generation X *Rationale Baby boomers were born between 1945-1964. Generation X are those born between 1965-1978. Generation Y, also known as millennials, are those born between 1979-2000.

A young adult has never lived away from his parents and feels unable to make decisions on his own. According to Freud's theory of development, the nurse should suspect that this person would be fixated at which stage of development?

Genital *Rationale The nurse should suspect that the young adult would be the state of development of Genital. In this stage, the goal is to work towards independence. Fixation is the immobilization or the inability of the personality to proceed to the next stage because of anxiety. Being unable to be independent/make decision their own indicates that this adult is fixated at the genital stage.

The Babinski reflex is a test of the central nervous system and in babies it will be positive. In adults without pathology, this reflex will be negative (p.584).

Glaucoma *Rationale In those over 40, the most frequent cause of vision loss is glaucoma although it can occur at younger ages. Cataracts occur in those over 65 years old. Myopia is nearsightedness. Hyperopia is farsightedness. (p.533)

Which of the following characteristics is distinct to dementia?

Gradual onset of symptoms *Rationale In dementia, it is common that the symptoms are gradual and irreversible (p.915).

While inspecting the inside of a pressure ulcer, the nurse observes new tissue growth which is pinkish-red in color. The nurse documents the presence of what..?

Granulation tissue *Rationale Granulation tissue develops as capillary networks come together and appears as tissue that is translucent and red in color and indicates healthy healing. Necrotic tissue (eschar) is dead tissue and is black or dark in nature which often requires debridement. (p.846) Hyperemia is an excess of blood vessels leading to increasing bleeding in certain areas. Epithelialization occurs when a wound is healing as cellular components come together.

To help relieve pain, the patient concentrates on a favorite vacation setting. What is this known as?

Guided imagery *Rationale Guided imagery is a state of focused attention that encourages changes in attitudes, behaviors, and physiological reactions. Tai Chi is a discipline that combines physical fitness, mediation, and self-defense. Yoga is exercise with the goal of managing stress, learning to relax, increase vitality, and wellbeing. Reflexology is a form of acupuncture mostly commonly preformed on the feet but the hands or ear may also be manipulated. (p.301, 302, 304)

Which of the following interventions would be most appropriate for a patient who has urge incontinence?

Have the patient urinate on a timed schedule *Rationale Bladder training requires that the patient postpone voiding, resist or inhibit the sensation of urgency, and void according to a timetable rather than the urge to void with the goal to gradually lengthen the intervals between urination to correct frequent urination, stabilize the bladder, and diminished frequency (p.1188).

A patient comes to the clinic seeking information regarding smoking cessation classes and ways to improve respiratory function. This patient is modeling which behavior?

Health protection *Rationale Health protection is a behavior modified by a desire to actively avoid illness, detect it early, or maintain functioning within the constraints of disease. Health protection is injury or illness specific, motivated by avoidance of illness, and seeks to stop the potential for health occurrence of insults to health and wellbeing. Health promotion is not disease oriented, motivated by personal positive approach to wellness, and seeks to expand positive outcomes. Since the patient in the example is looking to improve a health condition - respiratory function - this would be considered health protection.

The nurse is testing a patient's extraocular eye movements. The nurse knows that this exam tests which cranial nerves? (Select all that apply)

III, IV, VI *Rationale There are six ocular movements to determine eye alignment and coordination. These tests look at cranial nerves III, IV, VI. (p.537)

When assessing a pressure ulcer, the nurse observes damage to the patient's subcutaneous, muscle tissue, and fascia. The coccyx bone is visible. The nurse determines that this pressure ulcer is at what stage?

IV *Rationale A stage four ulcer is one where there is full thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures such as a tendon or joint. A stage three ulcer is full thickness skin loss involving damaging or necrosis of subcutaneous tissue. A stage two is partial thickness skin loss, abrasion, blister, or shallow crater. A stage 1 is a non-blanchable erythema signaling potential ulceration. An unstable ulcer is one where there is full thickness skin or tissue loss, but the depth is unknown as it is covered in slough or eschar. (p.831)

The nurse understands that IVP (intravenous push) medications should never be administered into what type of IV line?

IV line infusing blood *Rationale IVP or a bolus is the intravenous administration of an undiluted medication into systemic circulation. It can be given directly into a vein or in an existing IV line. IVP medications can never be administered into a line that is infusing blood or blood products or parenteral nutrition. (p.807)

Which of the following interventions is recommended protocol for all patients who are at risk for pressure sore development?

Identify at-risk patients on admission to the health care facility *Rationale On admission to the hospital, all patients should be assessed for the risk for pressure ulcers. This early identification process identifies those who are at risk or who currently already have skin breakdown. It is a healthy people 2020 preventive health measure to reduce the rate of pressure ulcers in the hospital setting. (p.832, 829).

The 45-year old patient reports that she has no interest in sex and that she and her husband have not had intercourse in 16 years. How does the nurse interpret this assessment data?

If both partners share the same lack of desire, there is often no problem *Rationale For most people sexual desire varies day to day and over the years. If both individuals in a relationship are similarly uninterested in sex there is not a problem. More typically, there is a disparity of sexual needs and the person with greater desire becomes dissatisfied with the sexual relationship. (p.943)

After teaching a mother about the neonate's positive Babinski reflex, the nurse determines that the mother understands the instructions when she says that a positive Babinski's reflex indicates what?

Immature central nervous system *Rationale The Babinski reflex is a test of the central nervous system and in babies it will be positive. In adults without pathology, this reflex will be negative (p.584).

A nurse is delivering a workshop regarding health promotion to a group of elderly patients. In describing Healthy People 2020, which goal should the nurse emphasize for this group?

Increasing quality and years of life *Rationale As a part of the Healthy People 2020 framework, the goal should be to attain high quality, longer lives free of preventable disease, disability, and premature death. When talking to a community of elderly individuals, the nurse should emphasize promoting quality and quantity of life.

Which of the following techniques is correct when administering a subcutaneous injection?

Insert the needle at a 45-degree angle to the skin *Rationale When giving a subcutaneous injection, the need should be inserted using a 45-degree angle to the skin while the palm is facing to the side or upward. The needle used in these injections should be only 3/8ths or 5/8ths inch long, and the skin should spread gently or pinched depending on the amount of adipose tissue present. No air should be drawn into the syringe before administration. (p.795)

Before performing a venipuncture to initiate continuous intravenous (IV) therapy, which action should the nurse complete?

Inspect the IV solution and expiration date *Rationale As a part of the six rights of medication administration, the nurse should first verify the IV solution is correct and it is not expired (p.1352).

A patient has a reddened area over a bony prominence. The nurse finds an unlicensed assistant massaging this area. What action should the nurse take?

Instruct the nursing assistant that massage is contraindicated because it causes damage to skin tissue *Rationale Skin over a bony prominence is already showing redness due to increased pressure is showing signs of damage and breakdown. By massaging this area, the skin is further damaged. If the redness does not disappear after relief from pressure, there is tissue damage. If the redness disappears, there is no tissue damage. (p.830-831).

A patient is most likely to experience sensory alterations when admitted to which of the following hospital units?

Intensive care unit *Rationale Those with sensory alterations would benefit from admission to the intensive care unit due to a greater control of stimuli on this kind of unit (p.908).

When administering a medication as an IVPB (intravenous piggyback) the nurse understands that this setup is for what type of drug administration?

Intermittent *Rationale Intravenous piggyback medications are medications mixed in a small amount of IV solution and are to be given for short periods of time intermittently (p.805). In a IVPB a second set connects the second container to the tubing of the primary container at the upper port.

A nurse understands that health professionals are a part of which environment in the Health Promotion Model?

Interpersonal *Rationale The role of the nurse is to work with people and not for the people, and to act as a facilitator of the process of assessing, evaluating and understanding health. This is an interpersonal role. (p.253)

When administering intramuscular injections, the nurse uses the Z-tract technique when the medication does what?

Is irritating to the tissues *Rationale The use of the Z tract method is recommended when the medication can be an irritate as the Z tract method has been shown to be a less painful technique and decreases the leakage of irritating medications into the subcutaneous tissues (p.800).

The nurse understands that what type of IV solution has the same concentration of solutes as blood plasma?

Isotonic *Rationale Isotonic solutions like normal saline and lactated ringers have the same concentration of solutes as blood plasma and are often used to restore vascular volume. (p.1336) Hypertonic solutions have greater concentration of solutes than plasma and hypotonic solutions have a lesser concentration of solutes.

Which of the following activities would be least effective in preventing sensory deprivation during a patient's stay in the cardiac care unit?

Keep the door close to provide pricacy *Rationale Sensory deprivation is generally thought of as a decrease in a or a lack of meaningful stimuli. Keeping a patient's door closed and would increase the patients risk for sensory deprivation. The other options are examples of how to decrease a patient's risk for sensory deprivation. (p.906)

A nurse is collecting a 24-hour urine specimen on a patient. Which of the following is an appropriate nursing action?

Keep the voided urine in a jug on ice *Rationale Timed specimens are either kept refrigerated or on ice to prevent bacterial growth or decomposition of urine components. (p.734)

A patient has tearing of the tissue with irregular wound edges. The nurse would document this finding as which of the following?

Laceration *Rationale A laceration appears as an open wound with jagged edges. A contusion is a closed wound where skin appears ecchymosis or bruised due to damage to blood vessels. An abrasion is an open wound in the skin. Colonization is the presence of microorganism. (p.829).

A patient has prescription for "enemas until clear" before bowels surgery. Which of the following positions should the nurse place the patient?

Left lateral side lying *Rationale When giving an edema, a left lateral side lying position with the right leg flexed is an appropriate position for the patient to be in as it encourages the flow by gravity (p.1228).

A patient comes to the family planning clinic for follow-up and is currently taking an oral contraceptive. During the interview assessment, the patient states she has been using some "natural medicines." Which herbal preparation should alert the nurse to a possible interaction with oral contraceptives?

Milk thistle *Rationale Milk thistle is a natural remedy for enhancing flow in gallbladder, liver, spleen and stomach however it can also decrease the effectiveness of oral contraceptives. The other herbs do not affect birth control use. (p.299)

The nurse is admitting a critically ill patient to the intensive care unit. What question should the nurse ask regarding this patient's sleep history?

No questions should be asked. *Rationale A sleep history should be obtained for all patients entering a health care facility, however, it should be differed or omitted if the patient is critically ill. (p.1075)

The nurse obtains an amber-colored, clear urine sample from a patient and determines that the urine pH is 6.0 with a specific gravity of 1.020. The nurse understands that these findings indicate which of the following?

Normal findings *Rationale Straw, amber, transparent urine with a pH between 4.5-8 and a specific gravity between 1.010-1.015 is a normal finding. See chart on page 1183

The nurse is removing morphine from the automatic dispensing cart and notices that the count by the machine does not match the count in the drawer. What is the first action the nurse should take?

Notify the nurse manager and pharmacy immediately *Rationale The nurse has the responsibly to investigate and correct the discrepancy before proceeding any further. If the totals do not tally and the discrepancy cannot be resolved, then the nurse must notify the nurse manager and pharmacy immediately (p.752)

When preparing to give medications, the nurse should review the "six rights" of medication administration to ensure client safety. They include which of the following?

Person, route, dose, drug, time, documentation *Rationale The six rights of medication administration are the right medication, the right dose, the right time, the right route, right client, and right documentation. There are other rights included in some models such as right to education, right to refuse, right assessment, and right evaluation however room number, action, and expiration date are not apart of the six rights. (p.773)

A patient recovering from a left below-the-knee amputation is experiencing left foot pain. The nurse realizes the patient is experiencing which type of pain?

Phantom limb pain *Rationale Below the knee amputation indicates that the patients leg from the knee down has been removed, thus this client does not physically have a left foot. This type of pain is known as phantom limb pain. This can be acute or chronic in nature depending on the amount of time since the surgery however phantom limb pain is specific. (p1118-tb46-6)

A nurse has just finished assisting the physician in placing a central intravenous line. Which of the following is a priority nursing intervention after central line insertion?

Prepare the client for a chest radiograph *Rationale The priority nursing intervention for this situation is to prepare the patient for a chest radiograph to ensure that the central line is in the correct place and can be used. Labeling the dressing is important but not the priority. Assessing temperature and monitoring blood pressure will continuously be done but are not time urgent and not the priority. (p.1349)

The nurse explains to the patient that some form of skin barrier must be used around the stoma at all times. What is the primary function of a skin barrier?

Protect against irritation from ileostomy drainage *Rationale The skin barrier helps prevent skin breakdown and irritation from the ileostomy drainage bag as these bags have adhesive material to stick to the patients skin. Skin barriers can also help achieve the best possible seal. (p.1231, 1232)

When utilizing the otoscope on a twelve-year-old child, what is the best way to visualize the ear drum?

Pull the pinna up and back *Rationale When assessing the ear of a young adults or adult, the best way to visualize is to pull the pinna up and back straightening the ear canal and the tympanic membrane (p.541).

While cleaning a pressure ulcer of a patient, the nurse observes a thick green exudate. What type of drainage is this?

Purulent *Rationale Serous drainage is clear portion of the blood derived from blood and the serous membranes of the body. This appears watery. A purulent exudate is thicker than serous drainage because it contains pus and may vary in color from blue, green, or yellow. Eschar is dried plasma proteins and dead cells and is dark in appearance. Penrose is a type of drain that can be placed in a wound to drain secretions (p.835, 836).

The nurse is teaching a patient measures to promote wound healing. Which of the following would the nurse include in the teaching?

Report signs and symptoms of infection *Rationale During assessment and nursing care, signs and symptoms of an infected wound should be noted and identified such as redness, warmth, swelling, pain, odor, and exudate. Identifying a wound infection quickly can help promote wound healing (p.842)

Which medication right is being violated when the nurse does not return to follow-up with the patient after pain medication is administered?

Right evaluation *Rationale Right evaluation is apart of the 10 rights of medication administration. After administrating pain medication, it would be appropriate to follow up to see if the medication was effective. Were any side effects noted? Adverse reactions? Were the desired effects achieved? (p.773)

What is the nurse's most appropriate response when finding a sealed container of IV 50% dextrose in a catch-all bin on the unit?

Send it to the pharmacy *Rationale Any questionable or contaminated solutions should be return to the pharmacy or IV therapy department (p.1340).

A patient's Glasgow coma scale is 5. What does this finding indicate?

Severe head injury *Rationale A Glasgow scale of 7 or below indicates a comatose patient. In a patient with a scale of 5 this would indicate a severe head injury (p.581).

When administering an intramuscular injection in the ventrogluteal muscle, which is the best position for the nurse to place the patient for ease in locating the muscle?

Side-lying with knee bent and raised slightly to chest *Rationale The best position in which to administer an IM injection into the ventrogluteal muscle is the side lying position as this help locate the site more easily (p.798)

Mrs. Jones is complaining to the nurse about how her husband's sleep habits are keeping her awake at night. She states, "My husband will snore loudly and then suddenly stop for periods lasting about 30 seconds, then restart." The nurse understands that this sleep disorder would be classified as which of the following?

Sleep apnea *Rationale Sleep apnea is characterized by frequent short breathing pauses during sleep. Symptoms include loud snoring, frequent nocturnal awakenings, excessive daytime sleepiness, difficulties falling asleep at night, morning headaches, and memory and cognitive problems. (p.1074)

Based on knowledge of the gastrointestinal tract, what type of stools would the nurse assess in a patient with an illness that causes the stool to pass through the large intestine quickly?

Soft, watery *Rationale Soft, watery stool or diarrhea is stool that moves quickly through the digestion tract due to increased intestinal mobility (p.1217).

A patient who is experiencing extreme drowsiness but will respond to stimuli is described as what?

Somnolent *Rationale Somnolent is extreme drowsiness but will response to stimuli. Disoriented means not oriented to person place time. Confused indicates reduced awareness easily bewildered poor memory and impaired judgement. Semi-comatose indicates the patient can be aroused by extreme or repeated stimuli.

A patient tells the nurse, "every time I sneeze I wet my pants." What is this type of involuntary escape of urine called?

Stress incontinence *Rationale Stress incontinence occurs due to weak pelvic floor muscles and urethral hypermobility causing urine leakage with activities like laughing, coughing, and sneezing. Urge incontinence is an urgent need to void and the inability to stop midstream. Urinary incontinence is the involuntary leakage of urine or loss of bladder control. (p.1183)

Which of the following is the most reliable indicator of the existence and intensity of acute pain?

The patient's self-report of pain *Rationale Given the highly subjective and individual nature of pain it is essential that staff complete a comprehensive assessment. Health care providers must learn to accept the patients report of pain and include pain as part of the health assessment to help promote a trusting relationship (p.1095-96).

When administering blood, the nurse must check the name on the label of the blood with the name on which of the following?

The patient's wristband in the presence of another nurse *Rationale When administering blood products, a two-person verification process or a one person process with a bar code system must occur. This includes checking the written order, ensuring a consent form has been filled, name and identification number of the client's wristband must match the blood bag and order identically along with expiration date, blood type, and compatibility (p.1360). This all must be done in the presence of another nurse.

The nurse evaluates the patient's stoma during the initial postoperative period. Which of the following observations should be reported immediately to the physician?

The stoma is dark red to purple *Rationale The stoma should appear red, similar in color to the mucosal lining of the inner cheek and slightly moist. A stoma that appears pale or darker-colored stomas with a dusky blue or purple hue indicated impaired blood circulation and the surgeon should be notified immediately (p.1232).

During an interview assessment, the patient states a belief in nutritional lifestyle counseling and that the body's vital energy circulates through the body and believes this energy can be manipulated through specific anatomical points. Which type of healing practice should the nurse identify that this patient is following?

Traditional Chinese medicine *Rationale Traditional Chinese medicine is based on the premise that the body's vital energy or qi circulates through pathways or meridians and can be accessed and manipulated through specific anatomic points along the surface of the body. Ayurveda see illness as an imbalance among the body's systems and emphasizes an individual's health with their quality of social life. Native American healers see spirituality and medicine are inseparable and people are channels through which the great power helps other achieve wellbeing in mind, body, and spirit. Curanderismo is a cultural healing tradition found in Latin America with healers called curanderos or curanderas that specialize as herbalists, midwives, counselors, joint workers, and massage therapists. (p. 298,297).

In order to reduce the risk of a transfusion reaction what type of test is performed on the blood of the donor prior to administration to the recipient?

Type and crossmatch *Rationale Blood typing and cross matching is completed to determine the ABO blood group and RH factor as well as minor antigens with their corresponding antibodies. This helps avoid transfusing incompatible red blood cells (p.1358)

When assessing the patient, the nurse notes slough and eschar covering the entire wound bed, as well as loss of the dermis and epidermis. What is the proper way for the nurse to identify this finding?

Unstageable pressure ulcer to right heel *Rationale A stage four ulcer is one where there is full thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures such as a tendon or joint. A stage three ulcer is full thickness skin loss involving damaging or necrosis of subcutaneous tissue. A stage two is partial thickness skin loss, abrasion, blister, or shallow crater. A stage 1 is a non-blanchable erythema signaling potential ulceration. An unstable ulcer is one where there is full thickness skin or tissue loss, but the depth is unknown as it is covered in slough or eschar. (p.831)

When administering an ophthalmic medication where should the nurse instruct the patient to look?

Up at the ceiling *Rationale When giving an ophthalmic medication, instruct the patient to look towards the ceiling as the patient is less likely to blink if looking up and the cornea is protected by the lid. (p.814)

A nurse is preparing to administer an IM injection to a 2-year-old child. The best site to select for the injection is the....?

Vastus lateralis muscle *Rationale The vastus lateralis muscles is the site preferred for infants and young children because it is the largest muscle mass and there are no major blood vessels or nerves in this area (p.798).

A patient has been treated for diabetes mellitus since childhood. Currently, the patient's blood glucose reading is 180 mg/dl. For which sensory disturbance should the nurse assess in this patient?

Vision loss *Rationale Uncontrolled diabetes can impair vision and is a leading cause of blindness in the US. (p.906).

Which of the following is the most appropriate intervention when assisting a visually impaired patient with ambulation?

Walk 1 foot in front of the patient *Rationale When assisting a visually impaired individual with ambulation, it is best to stand by the client's side walking about 1 foot ahead of them and allowing the person to grasp the nurses arm (p.910)

The nurse is assigned to care for a patient who has just undergone cataract surgery. The nurse plans to instruct the patient that which of the following activities is permitted in the postoperative period?

Watching television *Rationale Discharge instruction for those undergoing cataract surgery include instructions not to bend, lift, or exercise to prevent increased eye pressure. Precautions should be taken to prevent coughing or sneezing. Some may be required to wear an eye patch temporarily. One should refrain from rubbing or touching the eye as well as getting it wet. It would be okay for these clients to watch TV.

A nurse is doing a dressing change on a venous stasis ulcer that is clean and has a growing bed of granulation tissue. The nurse avoids which of the following dressing materials on this wound?

Wet-to-dry dressing *Rationale A wet to dry dressing change or unnecessary cleaning can delay wound healing by traumatizing newly produced, delicate tissues, reducing the surface temperature of the wound and removing exudate which has bacterial properties. This type of wound would not need to be debrided and a wet to dry dressing would not be appropriate (p.849,851).