valeriehurtado1

A nurse is performing a nasogastric intubation. Which of the following actions should the nurse take immediately after inserting the tube to the predetermined length? A.) Inspect the oropharynx with a penlight and a tongue blade B.) obtain an x-ray examination of the chest and abdomen C.) tape the tube securely in place with a tube holder device D.) aspirate gastric contents

A.) Inspect the oropharynx with a penlight and a tongue blade

An nurse is caring for a patient who has a newly inserted nasogastric tube. which of the following methods is appropriate for verifying the initial placement? A.) X-ray of chest and abdomen B.) auscultation of injected air C.) pH measurement of gastric aspirate D.) color of gastric contents

A.) X-ray of chest and abdomen

The RN is caring for a patient who has a central venous catheter. When flushing the catheter, the RN uses a 10-mL syringe to prevent which of the following complications associated with central vascular access devices? a. Catheter Rupture b. Catheter migration c. Pneumothorax d. Phlebitis

Answer: A) Catheter Rupture Rationale: When injecting fluid through a catheter, a smaller syringe generates more pressure than a larger syringe does. Therefore, to reduce the risk of catheter rupture, syringes that are 10-mL or larger in size are recommended for flushing or injecting fluid into a central venous catheter

Which of the following actions is appropriate for a RN who has witnessed a breach of patient's privacy in a primary care provider's office? a. Complete a health information privacy complaint form & submit it to the appropriate agency b. Anonymously notify the proper governmental agency c. Notify the patient & provide her with a health information privacy complaint form to submit to the appropriate agency d. Inform the primary care provider that a formal complaint will be submitted if another breach is committed privacy

Answer: A) Complete a health information privacy complaint form & submit it to the appropriate agency Rationale: It is the RN's responsibility to submit complaints to the proper agency with regard to a breach of patient

A patient feels his privacy has been violated & wants to file a formal complaint. Through which of the following agencies should the RN instruct the patient to file the complaint? a. Occupational safety b. Joint commission c. Office of Civil Rights d. Privacy & Civil Liberties Office

Answer: C) Office of Civil Rights Rationale: The OCR has been given the authority to receive & investigate complaints by patients & other involved individuals related to the privacy rule

A RN is orienting to his new place of employment. Info is being provided regarding HIPPA's privacy rule. Which of the following comments by the RN indicates an accurate understanding of these standards? a. "Patients do not have the right to read their charts" b. "I can read the charts of other patients on my floor" c. "I will expect a list of patients & their room numbers to be posted on my unit" d. "I can give information about a patient over the phone if the patient gives his permission"

Answer: D) "I can give information about a patient over the phone if the patient gives his permission" Rationale: Information about a patient may be given over the phone if the patient has granted permission for that person to receive information. Many institutions have instituted an access code system that requires the person asking for information to provide the code

During report, a nurse is informed that a patient has a nasogastric tube connected to continuous suction. The nurse should recognize that this patient must have which of the following types of tubes? A.) Levin B.) Sengstaken-Blakemore C.) Salem Sump D.) Ewald

C.) Salem Sump

A nurse should recognize that nasogastric intubation is indicated to relieve gastric distention for which of the following patients? A.) a 6 year old child who drank a toxic substance B.) a 60 year old patient admitted with gastrointestinal hemorrhage C.) a 40 year old with a postoperative bowel obstruction D.) a 20 year old patient with malabsorption syndrome

C.) a 40 year old with a postoperative bowel obstruction

A nurse is removing an IV catheter from a patient whose IV infusion has been discontinued. Which of the following actions is appropriate? A. Apply firm pressure over the vein B. Leave the roller clamp slightly open C. Pull the catheter straight back from the insertion site D. Lift the hub slightly upward away from the skin

Correct Answer: C. Pull the catheter straight back from the insertion site Rationale: With the catheter stabilized and using a slow, steady movement, the nurse should withdraw the catheter straight back and away fro the insertion site, making sure to keep the hub parallel to the skin.

A nurse caring for a patient who has gastric cancer is initiating an infusion of parenteral nutrition via the patient's implanted port. Which of the following is an appropriate action for the nurse to take? a. Use a standard medium-gauge needle to access the port b. Insert the primed needle into the port at a 45 degree angle c. Withdraw the needle after insertion, leaving the needle's sheath in place for the infusion d. Cover the device & the needle with a sterile transparent dressing

Correct Answer: D) Cover the device & the needle with a sterile transparent dressing Rationale: When implanted port remains accessed for an infusion, the needle must first be supported & anchored, then the port & the needle are covered with a transparent dressing

Contact precautions would be mandated for a hospitalized adult patient diagnosed with: A) hepatitis B B) Measles C) meningitis D) infectious diarrhea

Correct Answer: D- infectious diarrhea Rationale: Contact precautions are essential for preventing the spread of certain enteric infections

Which of the following is an important nursing action when converting an IV infusion to a saline lock? A. Open the roller clamp of the primary infusion to prime the saline lock B. Apply pressure with a syringe to clear resistance in the IV catheter C. Attach secondary tubing to allow mobility D. Flush the IV catheter to confirm patency

Correct Answer: D. Flush the IV catheter to confirm patency Rationale: It is essential to attach the primes saline lock adapter to the extension tubing and to flush the tubing with normal saline to confirm its patency.

A nurse is planning on obtaining a urinary specimen from a patient's closed urinary system. Identify the sequence of steps the nurse should take.

Correct answer: 1. Wipe the port with an alcohol swab 2. Insert a 10 mL syringe and needle into the port 3. Withdraw 5 mL of urine 4. Transfer the urine into a sterile specimen container 5. Transport the specimen to the laboratory.

A nurse is preparing to assist a patient with a tub bath. Identify the sequence of steps the nurse should take. 1. Gather all necessary supplies 2. Assist the patient into the bathroom 3. Place rubber mat on the tub floor 4. Instruct the patient on using safety bars when getting in and out of the tub 5. instructor the patient not to stay in longer than 20 min

Correct answer: 1, 3, 2, 4. 5

A patient is to receive 1,000mL of 5% dextrose in lactated Ringer's over 8 hours. Using tubing with a drop factor of 15gtt/mL, the nurse should regulate the fluid to infuse at how many drops per minute? (Round the answer to the nearest whole number)

Correct answer: 31 gtt/min Rationale: Volume (mL)/Time (min) x drop factor (gtt/mL) = IV flow rate (gtt/min) 1,000 x 15 = x 480 Then: 15,000 = x480 Then: 31.25 = x The IV flow rate in gtt/min is 31

A nurse finds a patient's IV insertion site red, warm, and slightly edematous. Which of the following actions should the nurse perform first? A. Check for a blood return B. Elevate the extremity C. Discontinue the IV line D. Apply warm, moist heat

Correct answer: C. Discontinue the IV line Rationale: The patient has classic signs of phlebitis, an inflammation of the vein. The IV line must be discontinued immediately to reduce the risk of thrombophlebitis and embolism

A nurse has just initiated a peripheral IV infusion of 5% dextrose in water. How often should the nurse plan to replace the primary infusion tubing? A. Every 24 hrs. B. Every 48 hrs. C. Every 72 hrs. D. Every 108 hrs.

Correct answer: C. Every 72 hrs. Rationale: The Centers for Disease Control and Prevention recommends changing IV tubing no more often than at 72-hour intervals unless the tubing has been contaminated, punctured, or obstructed.

A nurse is likely to received an order for urinary catheterization of a newly admitted patient who A. Has a persistent urinary tract infection B. Has urge incontinence C. Is in the ICU for a gastrointestinal bleed D. Is incontinent due to cognitive decline

Correct answer: C. Is in the ICU for a gastrointestinal bleed Rationale: Precise measurement of urinary output is crucial for managing fluid balance in patients who are critically ill.

A nurse is applying a condom catheter for an older adult patient who is uncircumcised. Which of the following is an appropriate step in the procedure? A. Stretching the catheter along the length of the penis B. Securing the catheter with adhesive tape C. Leaving space between the penis and the catheter's tip D. Repositioning the foreskin after application

Correct answer: C. Leaving space between the penis and the catheter's tip Rationale: A space of 2.5 to 5 cm (1-2 in) should be left between the tip of the penis and the end of the catheter. This space helps prevent irritation of the tip of the penis and allows full drainage of urine.

A patient has a nosocomial infection. This terminology means that the patient A) became infected due to compromised immunity B) was infected during a therapeutic procedure C) inhaled pathogens in a healthcare setting D) acquired the infection while hospitalized

Correct answer: D- Acquired the infection while hospitalized Rationale: A nosocomial infection is one that is acquired in a hospital.

Which of the following demonstrated the correct use of one of the six rights of medication? a. Administering a patient's medication by the route the provider a has prescribed b. Adhering as closely as possible to the medication schedule the patient follows that home c. Gathering a medication history from the patient before administering any drugs d. Respecting a patient's refusal to taking medication provider has prescribed

a. Administering a patient's medication by the route the provider a has prescribed

A nurse should recognize that which of the following is correct regarding albumin level as a diagnostic marker for nutritional status? a. Albumin level is a poor short-term indicator of protein status b. Hydration status does not affect a patient's albumin level c. An albumin level of 3.2g/dL is within the normal reference range d. Albumin level is calculated by keeping a 24hr record of protein intake

a. Albumin level is a poor short-term indicator of protein status

An uncommon, unexpected, or individual drug response thought to result from a genetic predisposition is called: a. An idiosyncratic effect b. An allergic response c. A toxic effect d. A synergistic effect

a. An idiosyncratic effect

Which of the following health care resources or services is most vulnerable to fraud, waste and abuse? a. Durable medical equipment b. Surgical procedures c. Health screening services d. Laboratory tests

a. Durable medical equipment

Which of the following is an example of a best practice strategy to prevent fraud, waste, and abuse? a. Establish procedures for maintaining and distributing medication samples b. Have providers submit claims directly to a health care benefit program c. Document patient encounters and services in the medical record at the end of the workday d. Use upcoding sparingly when submitting claims.

a. Establish procedures for maintaining and distributing medication samples

Which of the following interventions should a nurse use at mealtimes for a patient who has visual deficits? a. Identify the food location as though the plate were a clock b. Direct the order in which food items are consumes c. Have the patient tilt her head forward while eating d. Avoid talking to the patient during mealtime

a. Identify the food location as though the plate were a clock

With which route of drug administrations are there no barriers to absorption? a. Intravenous b. Intramuscular c. Subcutaneous d. Oral

a. Intravenous

To assess a patient for adequate swallowing, the nurse should do which of the following? a. Place fingers on the patient's throat at the level of the larynx and ask him to swallow b. Place the tip of a tongue depressor on the patient's posterior tongue c. With a penlight, inspect the patient's uvula and the soft palate d. Ask the patient to raise his tongue upward and move it from side to side

a. Place fingers on the patient's throat at the level of the larynx and ask him to swallow

A nurse is preparing to administer a cleansing enema to a patient who is prone to fecal incontinence due to poor sphincter control and is unlikely to retain the enema solution. Which of the following interventions is appropriate for this patient? a. Place the patient in the dorsal recumbent position on a bedpan b. Administer the enema while the patient sits on the toilet c. Administer an antidiarrheal medication 3 hour prior to the enema d. Instill 200 mL of fluid at 15-min intervals times four

a. Place the patient in the dorsal recumbent position on a bedpan

When an employee in a provider's office suspect fraudulent activity and uses the Office of Inspector General (OIG) Hotline to report it, the employee should do which of the following? (select all that apply) a. Stop filing suspicious bills and claims b. Pursue knowledgeable legal counsel c. Follow up with the OIG to confirm receipt of the report d. Disengage professionally with the suspected perpetrator e. Report and return overpayments

a. Stop filing suspicious bills and claims b. Pursue knowledgeable legal counsel d. Disengage professionally with the suspected perpetrator e. Report and return overpayments

A nurse is preparing to administer the first of two large volume, cleansing enemas prescribed for a patient in preparation for a diagnostic procedure. Which of the following is an appropriate step in the procedure? a. Warm the enema solution prior to instillation b. Prepare 1,500 mL of enema fluid c. Use tap water as the enema fluid d. Hang the enema container 24 inches above the anus

a. Warm the enema solution prior to instillation

Which of the following are appropriate choices for a patient prescribed a full liquid diet? (select all that apply) a. plain yogurt b. custard c. pureed vegetables d. mashed potatoes e. pureed meat f. gelatin

a. plain yogurt b. custard c. pureed vegetables f. gelatin

a nurse is documenting data about a healing wound on a patient's lower leg. The predominant exudate in the wound is watery in consistency and light red in color. The nurse should document this exudate as a. serosanguineous b. sanguineous c. serous d. purulent

a. serosanguineous

A nurse caring for a patient who has developed a stage I pressure ulcer in the area of the right ischial tuberosity. Which of the following should the nurse plan to apply to the ulcer? a. zinc oxide b. nystatin c. papain-urea d. polymyxin B

a. zinc oxide

A nurse is caring for a hospitalized patient who is performing active ROM exercises. Which of the following body movements should indicate to the nurse the patient has full ROM of the shoulder? a) Adducting the arm so that it lies next to the patient's side b) Flexing the shoulder by raising the arm from a side position to a 180 degree angle c) Abducting the arm to a 90 degree angle from the side of the body d) Circumducting the shoulder in a 180 degree half circle

b) Flexing the shoulder by raising the arm from a side position to a 180 degree angle

When performing a complete, head-to-toe physical exam, which physical-assessment technique should you perform first? a) Auscultation b) Inspection c) Percussion d) Palpation

b) Inspection

You are performing a physical examination of the spine for an older adult. Which of the following findings is common with aging? a) Lordosis b) Kyphosis c) Ankylosis d) Scoliosis

b) Kyphosis

A nurse is observing an assistive personnel who is using a mechanical lift with a hammock sling to transfer a patient from the bed to a chair. The nurse should intervene if the AP a) Places the sling under the patient from shoulders to knees b) Leaves the bed in the lowest position throughout the procedure c) Locks the hydraulic valve before attaching the sling to the lift d) Raises the head of the bed to a sitting position just before transfer

b) Leaves the bed in the lowest position throughout the procedure

While performing an abdominal assessment, you place your fingertips over the patient's painful area and gradually increase pressure, then quickly release it. The patient reports pain on release of pressure, so you document that your patient has positive a) Borborygmi b) Rebound tenderness c) Tympany d) Abdominal guarding

b) Rebound tenderness

What is your primary goal in performing a comprehensive physical assessment? a) To document accurate data b) To develop a plan of care c) To validate previous data d) To evaluate outcomes of care

b) To develop a plan of care

Which of the following patient is exhibiting drug tolerance? a. Patient continues to take medication despite harmful effects b. A patient requires an increased dose of medication to achieve continued therapeutic benefit c. A patient exhibits signs of withdrawal when The medication is discontinued d. The patient developed an intense craving for drug

b. A patient requires an increased dose of medication to achieve continued therapeutic benefit

Which of the following dietary modifications should an adolescent engaging in sports implement? a. Increase fats to 30% to 40% of daily kilocalories b. Drink water before and after sports activities c. Keep protein intake at the same level d. Decrease carbohydrates to 30% to 40% of daily kilocalories

b. Drink water before and after sports activities

Health Insurance Portability and Accountability Act (HIPPA) mandated that health care entities implement which of the following strategies to help reduce the Medicare fee-for-service error rate and prevent payment for potential fraudulent activity? a. Balance billing b. Electronic health records c. Unbundling d. Whistle blower procedures

b. Electronic health records

Which piece of legislation mandated the establishment of a joint Health Care Fraud and Abuse Control (HCFAC) program? a. The Federal False Claim Act b. Health Insurance Portability and Accountability Act (HIPPA) c. Patient Protection and Affordable Care Act d. Stark Law

b. Health Insurance Portability and Accountability Act (HIPPA)

A patient who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should anticipate receiving an order from the provider for which of the following types of enemas? a. Cleansing b. Return-flow c. Medicated d. Oil-retention

b. Return-flow

A drug's generic name is the a. Chemical name for the medication b. Same as the nonproprietary name c. Name under which the drug is marketed d. Formal name of the particular drug

b. Same as the nonproprietary name

A nurse is caring for a patient who has sustained a head injury and whose level of consciousness fluctuates. The provider prescribes a full liquid diet progressing to a pureed diet as tolerated. Before initiating feedings, it is essential that this patient undergo which of the following? a. Chest x-ray b. Swallowing examination c. Nasogastric tube insertion d. Olfactory nerve evaluation

b. Swallowing examination

This is caring for patient who has multiple sclerosis and has a chronic nonhealing wound. The nurse should recognize that which of The following types of medications is known to delay wound healing? a. tricyclic antidepressants b. corticosteroids c. beta blockers d. anticholinergic

b. corticosteroids

A nurse who is administering a return-flow enema to a patient should instill 100 mL of enema fluid and then a. instruct the patient to retain the fluid b. lower the container to allow the solution to flow back out c. help the patient to the toilet or bedside commode d. wait 5 min and instill another 100mL of fluid

b. lower the container to allow the solution to flow back out

a nurse is documenting data about a deep necrotic wound on a patient's left buttock. The nurse observes a yellow-tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. The nurse should document this type necrotic tissue as a. fibrin b. slough c. gangrene d. eschar

b. slough

While performing a cardiovascular assessment, you might encounter a variety of pulsations and sounds. Which of the following findings is considered normal? a) A continuous sensation of vibration felt over the second and third left intercostal spaces b) A high-pitched, scraping sound heard in the third intercostal space to the left of the sternum c) A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line d) A whooshing or swishing sound over the second intercostal space along the left sternal borde

c) A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line

A nurse is about to transfer to a chair a patient who has a weak left leg. Which of the following actions by the nurse demonstrates correct transfer technique? a) Positioning the chair slightly behind the nurse so that the seat faces the patient's bed b) Placing the patient's left leg in front of her right leg just prior to the transfer c) Aligning the nurse's knees with the patient's knees just before the transfer d) Grasping the patient under the axilla to assist her to her feet

c) Aligning the nurse's knees with the patient's knees just before the transfer

When assessing peripheral vascular status of the lower extremities, you place your fingertips on the top of your patient's foot between the extensor tendons of the great toe and those of the toe next to it. Which pulse are you palpating? a) Posterior tibial b) Popliteal c) Dorsalis pedis d) Femoral

c) Dorsalis pedis

A nurse in the emergency department is caring for a patient who has a knee injury. The patient will be discharged and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include when discharging this patient? a) Lean on the crutches to support body weight when standing. b) Fully extend arms when holding onto the hand grips. c) Hold the crutches on the unaffected side when preparing to sit in a chair. d) Hold the crutches 9 to 12 inches in front of and to the side of each foot.

c) Hold the crutches on the unaffected side when preparing to sit in a chair.

Over which abdominal quadrant are bowel sounds most active and therefore easiest to auscultate? a) Right upper quadrant b) Left upper quadrant c) Right lower quadrant d) Left lower quadrant

c) Right lower quadrant

A nurse is administering an enema medicated with sodium polystyrene sulfonate (Kayexalate) to an older adult patient who has kyperkalemia. The nurse should insert the tip of the rectal tube a. 2.5 cm to 3.75 cm (1 to 1.5 in) b. 5 cm to 7.5 cm (2 to 3 in) c. 7.5 cm to 10 cm (3 to 4 in) d. 10 cm to 12.5 cm (4 to 5 in)

c. 7.5 cm to 10 cm (3 to 4 in)

Which of the following represents the correct administration of the prescribed medication? a. Acetaminophen 650 mg PO prescribed; 5 tsp of 325mg/10 ml liquid given b. Levothyroxine 100 mcg PO prescribed; three 0.025 mg tables given c. Amoxicillin 1 g PO; two 500 mg tablets given d. Diphenhydramine 40 mg IM prescribed; 1.25 ml of 50/1 ml for injection given

c. Amoxicillin 1 g PO; two 500 mg tablets given

A nurse is caring for a patient who has impaired swallowing due to a cerebrovascular accident. Which of the following interventions should the nurse use to assist the patient with feeding? a. Provide the patient with a straw b. Offer the patient thin fluids c. Elevate the head of the bed 45 to 90 degrees d. Place food in the weaker side of the mouth

c. Elevate the head of the bed 45 to 90 degrees

Which of the following is your highest priority action for ensuring overall safety during medication administration? a. Have Another nurse checked the dose you will give b. Teach the patient about possible adverse effects c. Identify the patient to Acceptable methods d. Confronted the patient can swallow adequately

c. Identify the patient to Acceptable methods

While a nurse is administering a cleansing enema, the patient reports abdominal cramping. Which of the following is the appropriate intervention? a. Measure the patient's vital signs b. Notify the primary care provider c. Lower the enema fluid container d. Stop the enema instillation

c. Lower the enema fluid container

Which of the following strategies for enhancing the intake of healthful foods is appropriate for an adolescent? a. Encouraging the adolescent to consume snack foods from the grains food group b. Permitting the adolescent to skip breakfast to enhance appetite at later meals c. Making healthful food choices more convenient and available for the adolescent d. Allowing the adolescent complete autonomy in making food choices

c. Making healthful food choices more convenient and available for the adolescent

Which of the following agencies of the US government has the authority to exclude individuals and entities from participating in federal health care programs? a. Medicare Recovery Audit Contractors (RACs) b. Health Care Fraud Prevention and Enforcement Action Team (HEAT) c. Office of Inspector General (OIG) d. Department of Justice (DOJ)

c. Office of Inspector General (OIG)

You are giving a patient several PO Medications to take. The patient tells you She can only take one at time. It is appropriate to: a. Place all the medications in a cup and let the patient decide the order in which take them b. Crush the pills and mix them in applesauce c. Remained at the bedside until you are sure the patient has taken all the medication d. Leaves the pills at the bedside for the patient to take

c. Remained at the bedside until you are sure the patient has taken all the medication

A nurse is performing a nutritional assessment. When obtaining and interpreting anthropometric values, the nurse should recognize which of the following? a. Isolated measurements of height and weight are of greater significance than changes over time b. A weight increase of 4lb in a patient with renal failure indicates retention of 1,000 mL of fluid c. The patient should be weighed on the same scale at the same time each day d. The ratio of height-to-wrist circumference is the most accurate way to identify obesity

c. The patient should be weighed on the same scale at the same time each day

A nurse caring for a patient who has a heavily draining wound that continues to show evidence of bleeding. Which of the following types of dressing should The nurse select to help promote hemostasis a. transparent b. hydrofiber c. alginate d. biologic

c. alginate

a nurse is caring for a patient with a stage IV sacral pressure ulcer for which the provider has prescribed mechanical debridement. Which of the following should the nurse plan for the patient? a. placing a transparent dressing over the ulcer b. applying larvae to the wound bed c. changing dressings using the wet to dry method d. using a topical enzyme solution in the wound's base

c. changing dressings using the wet to dry method

a patient admitted with community-acquired pneumonia has been receiving oxygen therapy for several days. which of the following assessment findings indicates an adverse effect of oxygen therapy?

cracks in the oral mucosa

While performing a head-to-toe assessment, you perform the Romberg test. You do this to test the patient's a) Gait b) Hearing c) Vision d) Balance

d) Balance

As a nurse ambulates an unsteady patient, the patient becomes light-headed and begins to fall. Which of the following interventions by the nurse is appropriate in this situation? a) Wrap both arms around the patient's arms and shoulders. b) Move both feet together when the patient begins to fall. c) Protect the patient's extremities while lowering him to the floor. d) Extend one leg and allow the patient to slide down it.

d) Extend one leg and allow the patient to slide down it.

As part of your general patient survey, you find that your patient has a body mass index of 23. From this finding, you can conclude that your patient a) Has no nutritional problems or deficits b) Is at high risk for obesity-related health problems c) Needs a referral to a nutritional counselor d) Has a body mass index within normal limits

d) Has a body mass index within normal limits

While examining your patient's head and face, you determine that cranial nerve 1 is intact when the patient follows your instructions and successfully a) Sticks his tongue out b) Smiles symmetrically c) Hears whispered words d) Identifies a minty scent

d) Identifies a minty scent

The patient drinks 8oz of water. Which of the following is the correct conversion of the patient's intake? a. 1 pint b. 4 tablespoons c. 2 cups d. 240 ml

d. 240 ml

You are reading the physicians orders and note date and time of the prescription, As well as the physician signature. Which of the following prescriptions is complete? a. Aspirin PO 1 tablet daily b. Ferrous sulfate 624 mg PO c. Hydrocodone/acetaminophen (vicodin) 5/325 mg PRN d. Digoxin (lanoxin) 1.25 mg PO daily

d. Digoxin (lanoxin) 1.25 mg PO daily

When teaching the parents of a toddler about feeding and eating, the nurse should include which of the following safety measures? a. Do not give the child peanut butter b. Have the child drink 28 to 32 oz of milk daily c. Give the child 8 to 12 oz of fruit juice daily d. Do not offer the child raw vegetables

d. Do not offer the child raw vegetables

A nuse is preparing an older adult patient for an enema. The nurse should assist the patient to which of the following positions? a. Prone b. Dorsal recumbent c. Right lateral with both knees at chest d. Left lateral with the right leg flexed

d. Left lateral with the right leg flexed

A nurse is assessing a pressure ulcer over a patient's right heel area observes a deep crate with no eschar or slough and no exposed muscle or bone. The nurse should document that this patient has a pressure ulcer that is a. Unstageable b. A suspected deep tissue injury c. Stage 4 d. Stage 3

d. Stage 3

Which of the following is the most appropriate documentation of a patient's response to pain medication? a. The patient states, "I feel better" 10 minutes after medication administration b. The patient is sleeping 1 hour after administration c. The patient is up and waking in the hall 2 hours after administration d. The patient reports pain decreased to 3/10, 30 minutes after med administration

d. The patient reports pain decreased to 3/10, 30 minutes after med administration

Which of the following is the primary purpose for asking a patient to keep a 3- to 7-day food diary? a. To allow the patient to rely on health professionals to identify problem areas b. To determine any changes in the patient's appetite c. To evaluate any significant changes in body weight d. To assess the pattern of intake and compare with daily reference intakes

d. To assess the pattern of intake and compare with daily reference intakes

According to recent estimates, which of the following sources of health care waste has had the largest financial impact? a. Lack of care coordination b. Preventable conditions and avoidable care c. Administrative system inefficiencies d. Unwarranted use of medical resources or services

d. Unwarranted use of medical resources or services

A nurse is caring for a patient who is admitted with multiple wounds Sustained in a motor vehicle crash. Understanding the patient specific names during this initial stage of wound healing, The nurse should incorporate which of the following into the patient's plan of care to prevent a prolongation of this phase? a. leave nonbleeding wounds open to the air b. administer 325 mg aspirin PO as needed for pain c. initiate mechanical debridement d. apply oxygen at 2 L/min via nasal cannula

d. apply oxygen at 2 L/min via nasal cannula

A nurse is preparing to administer an oil-retention enema to a patient who has constipation. The nurse explains that the patient should try to retain the instilled oil for: a. as long as it takes to complete the procedure b. about 10 to 15 minutes c. until the next time he feels the urge to defecate d. at least 30 minutes, but preferably as long as he can

d. at least 30 minutes, but preferably as long as he can

A patient who has a full thickness wound continues to experience considerable pain during dressing changes, Despite administration of the prescribed analgesics prior to the wound care. Which of the following types of dressing should the nurse select to help minimize the pain of dressing changes? a. wet-to-dry b. antimicrobial c. gauze d. hydrogel

d. hydrogel

a nurse is caring for a patient who is dyspneic and slightly cyanotic, with a respiratory rate of 28/min. the nurse determines that the patient has impaired gas exchange during which of the following phases of the nursing process?

diagnosis

A patient has finished a 16-oz container of orange juice. The intake and output sheet documents fluid in milliliters. Which of the following should the nurse document? (fill in the blank)

480 mL (because 1oz= 30mL)

A nurse is caring for a patient with type 1 diabetes mellitus who reports feeling anxious and having palpitations. The glucometer reads 50 mg/dL. The nurse should give the patient

6 oz of apple juice

A RN is preparing to flush a persons PICC line. Because the patients catheter has a valved tip, the RN: a. Uses non-heparinized saline solution for the flush b. Exerts slow, steady pressure on the syringe plunger c. Injects 2-4 mL of flush solution into the catheter d. Plans to flush the catheter every 24 hours

Answer: A) Uses non-hepranized saline solution for the flush Rationale: Valve-tip or closed-end valve catheters incorporate a valve that opens from positive or negative pressure generated by flushing or aspirating. Otherwise, the valve remains closed to keep blood from entering the catheter. Because blood does not back up into the catheter's lumen (where is could clot), catheters with these types of valves do not require heparinized flushes

Which of the following methods of information exchange is in compliance with HIPPA? a. Walking rounds that involve two nurses discussing an assigned patient at his bedside in a private room b. Taped shift report during which all staff hear report on all patients on the unit c. Request by a primary care provider for patient information from the RN assigned to that patient during an in-service d. A phone request by an employer for verification that an employee is currently being treated in the hospital

Answer: A) Walking rounds that involve two nurses discussing an assigned patient at his bedside in a private room Rationale: This practice is acceptable if the two RNs are both assigned to this patient & no one else is in the room. It is within the patient's rights to hear information about his care & treatment

A RN is passing by a computer at the RN's station notes that patient information is currently being displayed. Which of the following actions should the RN take? a. Close out the patient's electronic chart b. Locate the RN responsible for the information & have that person log off c. Allow the computer to log off automatically after a period of time d. Ask the unit clerk to restrict access to the computer until the RN returns

Answer: B) Locate the RN responsible for the information & have that person log off Rationale: It is responsibility of the person documenting to protect information that other could access

A nurse is caring for a patient who has a CVL & suddenly develops dyspnea, tachycardia & dizziness. The RN suspects air embolism & clamps the catheter immediately. The RN should reposition the patient in which of the following positions? a. Supine with a pillow beneath the knees b. On his left side in Trendelenburg position c. Upright & leaning over the overbed table d. On his right side with the head of the bed elevated 15 degrees

Answer: B) On his left side in trendelenburg position Rationale: This position helps trap the air in the apex of the R atrium rather than allowing it to enter the R ventricle &, from there, move into the pulmonary arterial system

5. RNs on a clinical unit wish to research the incidence of falls among patients following joint replacement surgery. Which of the following should they do to ensure the study complies with the HIPPA Privacy Rules? a. Contact the medical record department to obtain permission to access patients' charts b. Submit their proposal to the institutional review board for review & describe how they will de-identify patient info c. Notify the patients that they will be included in the study & should submit a written request if they choose not to participate d. Obtain permission from the risk management department to gain access to incident reports that were filed due to patient falls

Answer: B) Submit their proposal to the institutional review board for review & describe how they will de-identify patient info Rationale: Research using patient records can be done if patient information de-identified. It is responsibility of institutional review boards to determine if a study meets this criterion.

A parent calls a pediatrician's office to make an appointment for her school-aged child. The RN should instruct the parent to call the previous pediatrician's office & request that: a. The records be phontocopied & sent to the new pediatrician's office b. The original records be sent to the new pediatrician's office c. A form authorizing release of copies of the records be sent to her to sign & return d. A form authorizing release of the records be sent to the new pediatrician to sign & return

Answer: C) A form authorizing release of copies of the records be sent to her to sign & return Rationale: A written authorization by the responsible party, in this case the parent, must be provided to the previous pediatrician's office prior to making copies of the health care records available to the new pediatrician

A patient who sustained trauma from a motor-vehicle crash is transported to an emergency department. The provider determines the need for immediate central venous access for fluid & blood replacement & prophylactic antibiotic therapy. The appropriate central venous access device for this patient is a. A tunneled central catheter b. An implanted port c. A non-tunneled percutaneous central catheter d. A peripherally inserted central catheter

Answer: C) A non-tunneled percutaneous central catheter Rationale: This type of central catheter is ideal for emergency situations where short-term (less than 6 weeks) central venous access is required for multiple therapies. This is the appropriate choice for this patient

A RN is caring for a patient who has a central venous access device in place. Which of the following routine measures should the RN use specifically to prevent lumen occlusion? a. Applying a skin securement device to the catheter b. Removing the dressing from the insertion site slowly & carefully c. Clamping the extension tubing while removing a syringe from the injection cap d. Having the patient lie flat when changing administration sets or injection caps

Answer: C) Clamping the extension tubing while removing a syringe from the injection cap Rationale: This is an example of a positive-pressure technique designed for use when a CVL does not have a specialized positive fluid-displacement needleless connector. This type of technique prevents the reflux of blood back into the catheter, which can clot & obstruct the catheter

A nurse stands facing a patient to demonstrate active ROM exercises. Which of the following should the nurse do when demonstrating hyperextension of the hip? a) Move the leg behind the body b) Move the leg forward and up c) Move the leg medially toward the leg d) Turn the foot and leg away from the other leg

a) Move the leg behind the body

A RN is preparing to obtain a blood sample from a patient who has triple-lumen central catheter in place for multiple therapies. Which of the following is an appropriate action for the RN to take? a. Discard the first 15 mL of aspirated blood before collecting the sample b. Maintain the patient in Trendelenburg position while withdrawing the blood sample c. Withdraw the blood sample from the lumen that has the smallest diameter d. Turn off the distal infusions for 1-5 minutes before obtaining the blood sample

Answer: D) Turn off the distal infusions for 1-5 minutes before obtaining the blood sample Rationale: To help ensure that the lab results won't be altered by the solutions infusing through the central access device, it is recommended that the RN stop the distal infusions & clamp the tubing for 1-5 minutes before obtaining the blood sample. How long to stop the infusion varies with the type of infusion

A patient is brought to the emergency department after a motor-vehicle crash. She is unresponsive due to a head injury. Permission for emergency surgical stabilization of a cervical injury was obtained over the phone from her husband, who is currently overseas. Which of the following should the assigned RN document to verify HIPPA guidelines were maintained? a. Document that the primary care provider informed the patient of her condition and the need for surgery b. Document the patients condition & surgeon's rationale for taking her to surgery c. Document the patients physical condition & avoid addressing the conversation the primary care provider had with the husband d. Document the patient's condition & that consent was obtained after the primary care provider discussed the proposed surgery with the husband

Answer:D) Document the patient's condition & that consent was obtained after the primary care provider discussed the proposed surgery with the husband Rationale: Since the patient is not cognitively or physically able to provide consent, it is within HIPPA guidelines to discuss the patient's condition with a spouse or close relative or friend. Consent can be obtained from this individual in this emergency situation because it is deemed in the best interest of the patient

When using chilled normal saliene solution during gastric lavage, the nurse should watch for which of the following complications? A.) rapid reflix of electrolytes B.) hypothermia C.) hyponatremia D.) increased heart rate

B.) hypothermia **look for signs such as bradycardia and cardiac dysrhythmias

A patient recovering from gastic surgery remains NPO and has a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membranes? A.) allow the patient to suck on ice chips B.) provide frequent mouth care C.) apply petroleum jelly to the patient's naris D.) offer throat lozenges for the patient to use

B.) provide frequent mouth care

Standard Precautions mandate: A) rinsing gloves that become visibly soiled during use B) Using antimicrobial soap for routine handwashing C) disinfecting hands immediately after removing gloves D) keeping gloves on when touching environmental surfaces

Correct Answer: C- disinfecting hands immediately after removing gloves Rationale: Although it might seem as though hands covered by intact gloves would be as clean as they were when you donned the gloves, it is an essential component of standard precautions to disinfect your hands immediately after glove removal.

You are about to irrigate a patient's open wound. Besides gloves, which other of personal protective equipment (PPE) must you wear? A) a sterile gown B) googles C) a face shield D) An N95 respirator

Correct Answer: C- face shield Rationale: A face shield protects the face, mouth, nose and eyes from any potential splashes of blood or other body fluids. Irrigating a wound certainly has the potential for splashing irrigating fluid containing blood, body fluids and tissue particles onto your face.

A nurse is about to use the Wong-Baker FACES pain level. Which of the following should the nurse know in order to use this pain scale? A- Face #10 is chosen when the patient is crying because of severe pain B- Face #0 is chosen when the patient "hurts a little bit" C- This scale is useful for adult patients who have cognitive impairments D- The nurse matches a face on the scale with that of the patient's face when he is in pain

Correct Answer: C- this scale is useful for adult patients who have cognitive impairments Rationale: This pain scale is used for young children as well as for adult patients who have cognitive impairments that create difficulty with descriptive and numeric pain scales.

Which of the following is an advantage of using alcohol-based gel? A) Its use takes less time than washing with soap and water does. B) It removes gross contamination better than soap and water does. C) Its protective nature reduces the need for frequent handwashing D) it provides adequate protection before surgical applications

Correct Answer: A) Its use takes less time than washing with soap and water does Rationale: During an 8-hour shift, an estimated 1 hour of an intensive care unit nurse's time is saved by handrubbing with an alcohol-based gel.

A nurse is caring for a patient just transferred from the PACU following an abdominal hysterectomy. The patient receiving PCA with IV morphine sulfate 2mg every 15 min with a 30mg/4hr lockout. One hour after the patient has returned to the unit, the patient tells the nurse that her pain is still unbearable. The nurse checks the PCA monitor and determines that the patient has made six attempts within the last hour. Which of the following actions should the nurse take after performing a pain assessment? A- Check the IV site and PCA pump for proper functioning B- Teach the patient proper use of the PCA system C-Ask the provider to increase the morphine dose and shorten the interval between doses D- Encourage family members to "push the pain button" when the patient is in too much pain to do it herself

Correct Answer: A- check the IV site and PCA pump for proper functioning Rationale: The PCA delivery system should be assessed to determine if there is any malfunction in the delivery of the medication

After completing a procedure that required donning personal protective equipment consisting of a gown, a N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately? A) the gloves B) the gown C) the face shield D) the N95 respirator

Correct Answer: A-the gloves Rationale: Gloves are considered the most contaminated and should be removed first, followed by face/eye protection, gown, and mask/respirator.

A nurse is discontinuing an IV infusion. For which of the following reasons is it important to verify and document the integrity and condition of the IV catheter? A. A broken-off catheter tip indicates the risk for an embolus B. Catheter erosion indicates that it was left in place too long C. Blood within the catheter could indicate clot formation D. Discoloration of the catheter could be a sign of phlebitis

Correct Answer: A. A broken-off catheter tip indicates the risk for an embolus Rationale: The tip of the catheter can break off, thus creating an embolus. To limit the movement of the embolus, the nurse should apply a tourniquet high on the extremity where the IV line was located and notify the provider immediately.

An older adult patient who adheres to a regular cardiovascular rehabilitation schedule that includes water aerobics & swimming requires long-term central venous access. Which of the following CVADs is the best choice for allowing him to continue his aquatic program? A) A tunneled Central Catheter B) An Implanted port C) A non-tunneled percutaneous central catheter D) A peripherally inserted central catheter

Correct Answer: B) An implanted port Rationale: Because the entire device lies beneath the skin, the patient can be immersed in water when the device is not in use without any increased risk of infection. This is the best choice for patients who wish to continue aquatic activities

You are washing your hands with nonantimicrobial soap and water prior to repositioning a patient in bed. During the handwashing procedure, it is important to: A) make sure that the water is hot B) continue for at least 15 seconds C) Use a liquid soap preparation D) remove rings and watches first

Correct Answer: B- Continue for at least 15 seconds Rationale: Handwashing with nonantimicrobial soap and water for at least 15 seconds reduces bacterial counts and can remove adherent transient flora.

A nurse is caring for two patients of different cultural backgrounds. Both patients returned from the same type of surgery 2 hours ago. Which of the following should the nurse expect to be the same for both patients? A- Patient perception of the intensity of postoperative pain B- Class of medication used to treat acute postoperative pain C- Goal of pain management for each patient D- Level of pain indicated by each patient on a numeric pain scale

Correct Answer: B- class of medication used to treat acute postoperative pain Rationale: Opioid analgesics are the class of medication used to treat acute postoperative pain;this is true regardless of the patient's cultural background.

You are caring for a patient diagnosed with mycoplasmal pneumonia. Droplet precautions have been instituted, so you must: A) wear a respirator B) Protect your eyes C) Use an air filter D) Wear shoe covers

Correct Answer: B- protect your eyes Rationale: Droplet transmission involves contact of infectious, large-particle drops with the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person.

After assisting a newly admitted patient in removing his shoes and outerwear, you notice what appears to be soil or grime on your hands. You: A) cleanse your hands with an alcohol-based gel. B) Wash your hands with soap and water C) Brush off the soil against a cloth surface D) Use a wet paper towel to remove the soil

Correct Answer: B- wash your hands with soap and water Rationale: The CDC and Prevention recommends washing with soap and water whenever hands are visibly dirty.

Which product affect the permeability? A) Antimicrobial soap and water B) Alcohol-based antiseptic gel C) Petroleum-based hand lotion D) Water-based hand lotion

Correct Answer: C) Petroleum- based hand lotion Rationale: The use of petroleum-based hand lotions or creams can impair the integrity of latex gloves, weakening them and increasing their permeability.

When planning morning hygiene care for a postoperative patient, which of the following actions should the nurse include? A) Inform the patient when morning hygiene care is provided at the hospitla B) schedule to provide care to the patient and her roommate at the same time C) Ask the patient in what order she typically performs her morning routine D) Plan to provide care before the next scheduled dose of pain medication

Correct Answer: C- Ask the patient in what order she typically performs her mourning routine Rationale: The patient's plan for routine morning care should be tailored to the uniqueness of the patient's typical routine

A nurse is caring for an unconscious patient. Which of the following statements by the nurse indicates an understanding of providing good oral hygiene for patient? A- "I'll swab the patient's mouth with lemon-glycerin swabs" B- I'll swab the patient's mouth with mouthwash C- I'll swab the patient's mouth with diluted hydrogen peroxide D- I'll swab the patient's lips with a very small amount of mineral oil

Correct Answer: C- I'll swab the patient's mouth with diluted hydrogen peroxide Rationale: Hydrogen peroxide is appropriate to use because it aids in loosening and removing secretions and crust from the patient's mouth. It must be diluted because full-strength hydrogen peroxide can cause superficial burns

a nurse is providing discharge teaching to a patient who will continue oxygen therapy at home. the nurse should instruct patient that turning the knob on the oxygen flow meter all the way to the right

stop the flow of oxygen

To decontaminate your hands with an alcohol-based gel, you rub them together until all of the gel has evaporated and your hands are dry. The primary reason you do this is that: A) drying provides the full antiseptic effect B) residual alcohol can easily stain clothing C) excess gel could transfer to patient D) slippery gel can make you drop supplies

Correct answer: A- drying provides the full antiseptic effect Rationale: A dry environment offers better protection against the proliferation of pathogens than a moist environment does. The bactericidial alcohol components of these gels further enhance their superior antiseptic effect.

A patient who has been experiencing frequent, severe migraine headaches tells the nurse she has heard that biofeedback is effective in treating migraines. The patient asks the nurse to describe how this pain-relief method works. The nurse should reply that biofeedback involves: A- measuring skin tension and using learned techniques to relieve pain B- relating soothing visual images identified by the patient to promote relaxation C- listening to an increasing volume of music until the pain subsides D- stimulating the skin with a mild electric current when pain occurs

Correct answer: A- measuring skin tension and using learned techniques to relieve pain Rationale-

While performing a complete bed bath for a patient, the nurse should: A) raise the room temperature B) completely remove the linens C) add soap to the water in the basin before beginning the bath D) complete the bathing for one side of the body at a time

Correct answer: A- raise the room temperature Rationale: Raising the temperature of the room will keep the patient warm while various parts of the body are exposed and washed.

A nurse is preparing to insert an indwelling urinary catheter for a female patient. When beginning the insertion procedure, the nurse should instruct the patient to A. Bear down B. Take deep breaths C. Sip water D. Hold her breath

Correct answer: A. Bear down Rationale: Bearing down as if to void relaxes the external sphincter and aids in the insertion procedure. This is the appropriate instruction for the patient.

A nurse has just inserted a peripheral IV catheter for a continuous infusion. To secure the catheter, the nurse should A. Leave the connection between the hub and the tubing uncovered B. Wrap tape around the circumference of the patient's arm C. Tape a piece of paper tape over the insertion site D. Place a piece of paper tape over the insertion site

Correct answer: A. Leave the connection between the hub and the tubing uncovered Rationale: This makes it possible to replace the tubing without removing the dressing.

A nurse is caring for a patient admitted to the emergency department with severe pain following a fall from a ladder. The initial assessment reveals long-term use of opioids for chronic pain. Which of the following provider prescriptions for initial pain relief should the nurse question? A- morphine sulfate B- Pentazocine (Talwin) C- Meperidine (Demerol) D- Hydromorphone (Dilaudid)

Correct answer: B- Pentazocine (Talwin)

A nurse is caring for an adult patient who is NPO. Te patient is refusing oral care. Which of the following is an appropriate response by the nurse? A) Since you're not eating, we can wait and do it before bedtime B) Oral care is still important even though you are not eating C) I'll give you a sip of water to swish around in your mouth, and then you can spit it out D) We will wait until your family gets here to help

Correct answer: B- oral care is still important even though you are not eating Rationale: Bacteria are still present in the oral cavity regardless of NPO status. It is important to perform oral care to help reduce oral bacteria and keep the oral cavity moist.

A nurse who is preparing to insert a straight urinary catheter for a male patient should A. Grasp the penis at it's base B. Apply light traction to the penis C. Hold the penis parallel to the patient's body D. Lift the penis to a 45 degree angle to the patient's body

Correct answer: B. Apply light traction to the penis Rationale: Lifting the penis to a position perpendicular to the body while applying light traction straightens the urethral canal to facilitate catheter insertion

Which of the following actions should a nurse take when removing a patient's indwelling urinary catheter? A. Pull the catheter out as quickly as possible B. Deflate the balloon completely before removal C. Make sure the patient has voided within 12 hr post removal. D. Tell the patient to expect to feel a tugging sensation on removal.

Correct answer: B. Deflate the balloon completely before removal Rationale: If any inflation solution remains in the balloon, trauma to the urethral canal is likely with removal of the catheter.

A patient in early stage renal failure is prescribed an infusion of 0.45% sodium chloride. This type of solution is appropriate because it A. Pulls fluid from the cells and increases vascular volume B. Dilutes extracellular fluid and rehydrates the cells C. Replaces extracellular volume and maintains intravascular volume D. Draws fluid into blood vessels and reduces interstitial compartments

Correct answer: B. Dilutes extracellular fluid and rehydrates the cells. Rationale: Infusing a hypotonic solution such as 0.45% sodium chloride moves fluid into the cells, thus enlarging and rehydrating them.

A nurse initiating a peripheral IV infusion punctures the skin and selected vein and observes blood return in the flashback chamber of the IV catheter. Which of the following actions should the nurse perform next? A. Secure the catheter to the skin with a transparent dressing B. Lower the catheter until it is almost flush with the skin. C. Advance the catheter about ¼ inch into the vein D. Remove the stylet slowly from the lumen of the catheter

Correct answer: B. Lower the catheter until it is almost flush with the skin. Rationale: Lowering the angle and then advancing the catheter slightly facilitates full penetration of the wall of the vein, thus placing the catheter within the vein's lumen and making it easy to advance the catheter off the stylet.

During a pain assessment, a nurse asks questions about the quality of an adult patient's pain. Which of the following statements by the patient refers to pain quality? A- The pain in my abdomen began last night and has gotten worse and worse B- My pain is at a 9 on a scale of 0 to 10 C- My pain feels like I'm being stabbed by a knife. D- The pain is worse when I bend over at my waist

Correct answer: C- My pain feels like I'm being stabbed by a knife

A nurse is planning to administer a dose of intravenous morphine sulfate for a postoperative patient. Which of the following is a pain management protocol that should be used by the nurse in this situation? A- Withhold this medication for a respiratory rate of less than 14/min B- Perform the intravenous injection over 1 min C- Avoid administering opioid agonists on a fixed schedule D- Have an opioid antagonist available during the administration

Correct answer: D- Have an opioid antagonist available during the administration Rationale: The nurse should assure that an opioid antagonist, such as naloxone (Narcan), is available, as well as equipment for providing respiratory support

A nurse is assisting a patient with personal hygiene care. Which of following actions by the nurse will reduce the risk of infection? A- massaging reddened areas of the patient's skin B- Washing eyes from the outer canthus to the inner canthus C- Washing the patient from the shoulder down to the fingertips with smooth, short strokes D- Cleaning the least-soiled areas prior to cleaning the most- soiled areas

Correct answer: D- cleaning the least-soiled areas to cleaning the most-soiled areas Rationale: The least-soiled areas should be cleaned first to prevent moving more contaminants into the cleaner areas.

A nurse who has just initiated an IV infusion explains to the patient that complications are possible and that she will monitor the infusion regularly. The nurse should teach the patient that which of the following findings is an early indication of infiltration? A. Moisture B. Bruising C. Tingling D. Coolness

Correct answer: D. Coolness Rationale: Coolness is a classic sign of infiltration, along with swelling, pallor, and possibly tenderness. Infiltration is a leakage of IV solution out of the intravascular compartment into the surrounding tissue.

A nurse is assessing a patient's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. Which of the following actions should the nurse take first after checking for kinks? A. Irrigate the catheter B. Assess for a peripheral edema C. Palpate for bladder distension D. Milk the catheter

Correct answer: D. Milk the catheter Rationale: Output that is considerably less than intake is a sign that the catheter is blocked. The first action the nurse should take is to milk the tubing by squeezing then releasing the drainage tube, starting from near the patient and moving upward toward the drainage bag. This should dislodge any buildup of blood, pus, or sediment.

When providing perineal care for a female patient who has an indwelling urinary catheter, which of the following areas should the nurse cleanse last? A. The urethral meatus B. The labia minora C. The perineum D. The anus

Correct answer: D. The anus Rationale: The basic aseptic principle to perineal care is to cleanse from the area of least contamination to the area that is most contaminated. The anal area is typically contaminated with coliform bacteria and should be cleansed last.

A nurse observes an assistive personnel (AP) make a client's bed while the client is out of the room. Which of the following actions by the AP is appropriate for this task? A) The AP records the task when it is completed B) The AP wears sterile gloves while making the bed C) The AP makes a mitered corner with the blanket and spread D) The AP reuses the blanket and spread

Correct answer: The AP reuses the patient's blanket and spread. Just making the bed not changing the bed. Changing the linens would be documented.

A nurse is caring for a patient who is on long-term bedrest and requires frequent linen changes due to excessive diaphoresis. Which of the following is the priority rationale for frequent linen changes? A) moisture from excessive diaphoresis can cause skin breakdown B) moisture on the sheets can cause discomfort to the patients C) it provides an opportunity to frequently reevaluate the patient's skin on his backside D) It provides an opportunity to turn the patient from side to side to facilitate clearing potential fluid from the lungs

Correct answer; A- moisture from excessive diaphoresis can cause skin breakdown Rationale: The greatest risk to the patient is skin breakdown, which can result from increased contact with the moist sheets causing skin irritation and promoting bacteria growth. Therefore linens should be changed frequently.

A nurse is caring for a patient who has a nasogastric tube connected to suction. Which of the following should indicate to the nurse that the tube has become ocluded? A.) active bowel sounds B.) passing flatus C.) increase in gastric secretions D.) patient's report of nausea

D.) patient's report of nausea

a nurse is caring for a patient who has a tracheostomy. which of the following must the nurse use when administering oxygen to this patient?

a tracheostomy cannula

A nurse is performing a physical assessment on a patient and instructs the patient to stand with his feet together and arms at his sides. The purpose of positioning the patient in this manner is to test which of the following? a) Balance b) Muscle strength c) Reflexes d) Coordination

a) Balance

When performing a respiratory assessment, you auscultate wet, popping sounds at the inspiratory phase of each respiratory cycle. These sounds are best identified as a) Crackles b) Stridor c) Wheezes d) Friction rub

a) Crackles

When using and maintaining your stethoscope, it is important to a) Insert the earpieces at an angle toward your nose. b) Use the diaphragm for listening to low-pitched sounds c) Drape the stethoscope over your neck when not in use d) Clean your stethoscope by immersing it in soapy water

a) Insert the earpieces at an angle toward your nose.

oxygen therapy is prescribed for a patient who is brought to an emergency department in the early stages of hypoxia. when assessing this patient, the nurse should expect to find which of the following clinical indicators?

elevated blood pressure

a nurse is reviewing the results of routine laboratory tests performed as part of 50-year-old woman's annual physical examination. the nurse notes a blood glucose level of 120 mg/dL. the nurse should interpret this as an abnormal result for a

fasting blood glucose measurement

a nurse is teaching a patient newly diagnosed with type 1 diabetes mellitus how to check blood glucose levels. which of the following is the appropriate instruction for transferring the patient's blood to the reagent portion of the test strip/monitor in most situations.

hold the test strip next to the blood on the patients fingertip.

A nurse is documenting the plan of care for a patient who has type 1 diabetes mellitus that has remained unstable despite conventional insulin therapy. the provider has explained to the patient that the new plan will incorporate the use of a long-acting insulin preparation. the nurse should anticipate seeing a prescription for the addition of which of the following insulin preparations?

insulin glargine (Lantus)

a nurse is reviewing self-administration of insulin using a pre filled pen administration system with a patient who started using the pen system the previous week. the patient asks what he can do to reduce injection pain. the nurse should suggest that he

keep the pen at room temperature for a few minutes.

a patient who is prescribed oxygen therapy 24 hr/day is concerned about being confined to bed. which of the following should the nurse do to provide mobility for this patient?

make sure the patient has up to 50 ft of connecting tubing

a nurse is teaching a patient with type 1 diabetes mellitus who is beginning a complex regimen of glycemic control about the properties and actions of the various types of insulin. the nurse should explain that the type of insulin that has an onset of 60-120 minutes, peaks in 6-14 hours, and has a duration of 16-24 hours is

neutral protamine hagedorn (NPH) insulin.

administering oxygen therapy with a nonrebreather mask has which of the following advantages?

offers the highest oxygen concentration of the low-flow systems

a nurse is teaching a patient newly diagnosed with type 2 diabetes mellitus about the biguanide she has been prescribed, which is metformin (Glucophage). The nurse should explain that this type of medication acts by

reducing hepatic glucose production.

a home health nurse is instructing a patient who has just started receiving oxygen therapy via mask. the nurse should emphasize that the patient must

reposition the elastic band frequently.

a patient has been receiving oxygen PRN via nasal cannula for 4 hr. which of the following assessment findings help indicate that oxygen therapy has been effective?

respiratory rate 14/min

a nurse should recognize that which of the following is an indication for oxygen therapy?

tachypnea; SaO2 90%

a nurse instructing a patient about using an insulin pump should explain that the risk of diabetic ketoacidosis (DKA) increases with the use of a pump because

the tube could become occluded

a nurse is caring for a critically ill patient with COPD who requires delivery of a precise concentration of oxygen. which of the following types of oxygen-delivery is indicated for this patient?

venturi mask