VN Fundamentals Compilation

When the patient complains about his IV lines and asks if he can have the medication by mouth, what is the most appropriate response by the nurse?

"Medication by mouth is absorbed more slowly than by any other route."

The nurse explains that the measurement of radiation exposure is in multiples of Gy. The number of Gy an individual may absorb before becoming ill with radiation syndrome is _.

0.75.

A nurse is observing isolation precautions by wearing a mask while performing complex patient care. How often should the nurse change masks?

20 to 30 minutes.

The nurse encourages a patient recovering from a hysterectomy to drink at least _ mL of fluid a day.

2000 mL

A nurse is assessing victims in an emergency situation. What will the nurse assess for first?

Abnormal breathing.

Support and defend clients' health, wellness, safety, wishes, and personal rights, including privacy.

Advocacy.

What role is the nurse who diligently works for the protection of patients' interests playing?

Advocate.

When a patient suddenly experiences respiratory difficulty in the cafeteria, the nurse begins assessment for foreign-body airway obstruction. What is the most appropriate question to ask the victim?

"Are you choking?".

The nurse is trying to establish an effective relationship with a patient in pain. What is the best statement for the nurse to make when beginning the assessment?

"I believe you are in pain."

What premise is Maslow's hierarchy of needs based on?

Basic needs must be met before the next level of needs can be met. Self-actualization. Esteem. Love and Belonging. Safety Needs. Physiologic Needs.

Intentional and wrongful physical contact with a person that involves an injury or offensive contact. A nurse restrains a client and administers an injection against their wishes.

Battery.

What landmarks are used for the administration of an intramuscular injection into the gluteal site?

Between the posterior iliac crest and the greater trochanter.

How does an interdisciplinary approach to patient treatment enhance care?

By preventing the fragmentation of patient care.

A patient arrives in the emergency department with a sucking wound to the left chest. What is the first action the nurse should take?

Cover the wound with an airtight dressing taped on three sides.

The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type. This is known as a:

Critical pathway.

During a physical assessment, the nurse notes a patient has a bluish discoloration of the skin and mucous membranes. How should the nurse document this finding?

Cyanosis.

The health care provider orders daily weights on a patient residing in a long-term care setting. What actions should the nurse implement to assess weight accurately?

Encourage patient to void before being weighed. Ensure same amount of clothing is worn by patient. Weigh patient at the same time each day.

The nurse is caring for a patient with a surgical wound. How can the nurse promote healing?

Encourage the consumption of small frequent meals.

What should the nurse do when offering a cup of hot coffee to a frail, older adult patient?

Fill the cup half full.

What objective data should the nurse include after a patient assessment?

Flatulence.

What type of assessment is performed continuously throughout nurse-patient contact?

Focused.

The nurse is irrigating a leg wound of a patient on the trauma unit. Where should the nurse direct the flow of the irrigant?

From the area of least contamination to the area of most contamination.

The nurse teaches noninvasive pain relief techniques, such as guided imagery, biofeedback, and relaxation. What is the primary advantage of these techniques?

Gives the patient some control.

A nurse is admitting a patient to an acute care facility. During the admission procedure, what nursing intervention would best help reduce patient anxiety?

Greet the patient by name.

What should the nurse be diligent in to provide a safe environment for the patient?

Hand hygiene between patient contacts.

The nurse is instructing a patient about the most important preventive technique for breaking the chain of infection. What technique is the patient learning about?

Hand hygiene.

What system of comprehensive patient care considers the physical, emotional and social environmental and spiritual needs of a person.

Holistic health care.

What part of the body maintains a balance between heat production and heat loss, regulating body temperature?

Hypothalamus.

The nurse administered a sedative to an older adult who was having difficulty sleeping. Later, the patient was walking the halls and becoming agitated. What is this drug response known as?

Idiosyncratic.

What form explains the lapse when events are not consistent with facility or national standards of expected care?

Incident report.

Patient care emphasis on wellness , rather then illness , begins as a result of _.

Increased education concerning causes of illness.

Patient care emphasis on wellness, rather than illness, begins as a result of:

Increased education concerning causes of illness.

The signs and symptoms of both infection and inflammation include erythema, edema, and pain. What is considered the major difference between infection and inflammation?

Inflammation is a protective response.

The nurse manager is providing an in-service regarding a "safe hospital environment." What will this education mainly focus on preventing?

Injury.

Why is documentation especially significant in managed care?

Institutions are reimbursed only for patient care is documented.

A patient is required to provide a sample of body excretions per health care provider order. What action can the nurse take when providing proper instructions to lessen the patient's embarrassment?

Instruct patient to obtain his or her own specimen.

What are the two primary methods used to collect data?

Interview and physical examination.

The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry. This drying process causes it to adhere to the wound. What is the result of this intervention when the dressing is removed?

Mechanical debridement.

A farm worker who has been kicked in the stomach by a mule passes a foul, black, tarry stool. What is this called?

Melena.

When removing the dressing on a patient, the nurse discovers that the gauze dressing has adhered to the wound. What intervention should the nurse implement?

Moisten the dressing with sterile water.

A nurse is caring for a patient who requires long-term management for severe pain. What should be the drug of choice for this patient?

Morphine.

The nurse clarifies that the term peripheral analgesics describes the group of drugs also referred to as _.

NSAIDS

When other methods have failed to stop the bleeding and the victim's life is in danger, the rescuer at the scene applies a tourniquet to a young woman's leg above the knee. What is another step that is essential for the rescuer to follow?

Never release the tourniquet.

The nurse is preparing to bathe a patient. What should the room temperature be set at?

No cooler than 68°F (20°C). The recommended room temperature is 68° to 74°F (20° to 23.3°C).

The nurse discovers a reddened area over a patient's hip. What should be the nurse's first intervention?

Press the area gently to assess for blanching.

The nurse is assessing a patient's skin for signs of impaired skin integrity. Which finding by the nurse is considered a major manifestation?

Pressure injury.

A patient is suspected of having a cardiac arrhythmia. The nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80. What is the term for the difference between these two rates?

Pulse deficit.

The nurse assessing a patient's wound notes thick, yellow drainage. How will the nurse most accurately document this finding?

Purulent drainage.

What is the term used to describe a disease where there has been a partial or complete disappearance of clinical and subjective characteristics of the disease?

Remission.

What is the term for a fever that rises and falls but does not return to normal until the patient is well?

Remittent.

Willingness to respect obligations and follow through on promises.

Responsibility.

What is classified as information provided by the family when a patient is unable to provide data during assessment?

Secondary.

The nurse assessing a patient's wound notes pale red watery drainage. How will the nurse most accurately document this finding?

Serosanguineous drainage.

The nurse assessing a patient's wound notes a clear watery drainage. How will the nurse most accurately document this finding?

Serous drainage.

When should discharge planning begin?

Shortly after admission.

The nurse is collecting data during an initial assessment. What can be seen, heard, measured, or felt and is objective?

Sign.

Although denying pain, a patient is irritable, responds slowly, and exhibits periods of tachycardia. What should the nurse assess for in this patient?

Sleep deprivation.

Where can a nurse refer the family of a patient to find a source of financial aid to meet medical expenses?

Social services.

The patient in isolation may experience psychological or emotional deprivation. What should the nurse do to help minimize these feelings?

Spend extra time with the patient.

The patient in isolation may experience psychological or emotional deprivation. What should the nurse do to help minimize these feelings?

Spend time with the patient.

What technique will the nurse implement to assist the postoperative patient to cough?

Splint the abdomen with a pillow.

What are the universal guidelines that define appropriate measures for all nursing interventions?

Standard of care.

As part of an assessment, the nurse asks the patient for subjective information related to the present illness. What are the subjective findings perceived by the patient?

Symptoms.

The nurse cautions a patient taking an anticoagulant that he should avoid taking aspirin because one drug may increase the action of the other drug. What is the correct term for this effect?

Synergism.

When assessing vital signs on a 40-year-old male, the nurse identifies a pulse rate of 120 beats/min. What is this pulse interpreted as by the nurse?

Tachycardia.

_ is a violent or dangerous act used to intimidate or coerce a person or government to further a political or social agenda.

Terrorism

The nurse is instructing a patient who has a drain in a surgical wound. How will the nurse indicate that the wound will heal?

Tertiary intention.

Which of the following must the nurse recognize regarding the health care delivery system?

The major goal is to achieve optimal levels of health.

What must the nurse realize when assessing physical and social environmental factors affecting health and illness?

They affect one another.

What is the rationale for the nurse to assess a patient's knowledge of an ordered procedure?

To determine health teaching required.

What is the primary purpose of nursing interventions?

To provide direction for all caregivers.

One reason the nurse focuses on oral hygiene is to maintain a healthy state of the oral cavity. What is another reason to promote oral hygiene?

To stimulate appetite.

_ is a violent or dangerous act used to intimidate or coerce a person or government to further a political or social agenda.

Tort.

How should the nurse position the earpieces on a stethoscope to ensure optimum reception?

Toward the face.

A nurse instructs a unlicensed assistive personnel about the proper use of a gait belt and is observing a return demonstration. What action by the unlicensed assistive personnel should cause the nurse to intervene?

Unlicensed assistive personnel is walking on the patient's strong side.

Why should a nurse promptly administer a prescribed analgesic after a pain assessment?

Unrelieved pain can cause setbacks.

What is the best approach for a nurse to use when planning pain relief measures?

Use a variety of pain relief methods.

Personal beliefs about the worth of an object, idea, custom, or attitude that influence a person's behavior in a given situation are referred to as _.

Values.

A commitment to tell the truth.

Veracity.

A machinist visits the industrial nurse's clinic with a deep laceration of the thigh. What should be the nurse's first action?

Wash the laceration with an antiseptic.

The nurse is assessing a patient who is severely bleeding and at risk for hypovolemic shock. What can the nurse anticipate?

Weak, thready pulse.

Human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement are known as a _ patient problem

Wellness. Different from "Actual".

Triage.

When administering first aid in emergency situations, the nurse must first survey victims for severity of injuries. What term correctly describes this process? The Good Samaritan law

A patient with a respiratory infection reports that he is not yet on an antibiotic. The nurse explains that the health care provider is waiting on the results of the culture and sensitivity. What does this test determine?

Which antibiotics stop bacterial growth.

The nurse is preparing a patient for a barium enema. What color will the nurse inform the patient his stools will be following this procedure?

White.

The nurse is assisting a patient to clarify values by encouraging the expression of feelings and thoughts related to the situation. What is the most appropriate action for the nurse?

Withhold an opinion.

When assessing factors that may influence the patient's pulse rate, what should the nurse take into consideration? (Select all that apply.)

a. Age. b. Emotion. c. Sex. d. Temperature.

The home health nurse is preparing to educate a patient regarding electronic self-blood pressure measurement. What information should the nurse provide regarding this procedure?

a. Cuff fits over clothing. b. Stethoscope is not required. c. Proper measurement techniques are necessary.

A patient tells the nurse he is reluctant to report his pain because he does not want to be a bother. What problems is the nurse aware that unrelieved pain can cause?

a. Depression. b. Respiratory dysfunction. c. Decrease GI mobility.

The nurse is planning interventions for a patient experiencing pain. For what type of synergistic relationship should the nurse assess?

a. Explain all procedures and treatments. b. Frequent orientation to surroundings. c. Maintain toileting routines.

Which are the phases of wound healing? (Select all that apply.

a. Homeostasis. b. Inflammation. c. Maturation. d. Reconstruction.

How can the nurse help reduce the stress of a hospital admission? (Select all that apply.)

a. Involve the patient in the plan of care. b. Show the patient how bedside equipment works. c. Give simple explanation of policies. d. Explain the need to establish a clear source of reimbursement.

When the nurse ambulates with a patient who has left-sided weakness, what actions should the nurse take?

a. Keep the leg nearest the patient behind the patient's knee. b. Use a gait belt.

A patient is admitted to a medical surgical unit. What factors will determine how frequently vital signs will be assessed?

a. Orders of the health care provider. b. Patient's condition. c. Judgment of need by the nurse.

A patient tells the nurse he is reluctant to report his pain because he does not want to be a bother. What problems is the nurse aware that unrelieved pain can cause? (Select all that apply.)

a. Respiratory dysfunction. b. Decreased GI motility. c. Depression. d. Irritability.

What are the basic purposes of written patient records?

a. Teaching. b. Permanent record for accountability. c. Written communication. d. Reason and date collection. e.Legal record of care.

The nurse is preparing to perform a dressing change on a patient following a total hip replacement. When should the nurse administer an analgesic drug in an attempt to promote patient comfort during the dressing change?

At least 30 minutes before the dressing change.

The nurse has strong moral convictions that abortions are wrong. When assigned to assist with an abortion, what is the most appropriate action for the nurse to take?

Ask for another assignment.

What organization established during world war 2 provided nursing education and training.

Cadet nurse corps.

What site should be selected if a peripheral pulse needs to be assessed quickly?

Carotid pulse.

When preparing to remove a dressing, the nurse should don _ gloves.

Clean.

What should the nurse assess the patient for before administration of contrast media?

Is allergic to iodine.

What additional complication does a disease caused by a virus have compared to a disease caused by bacteria?

Is not killed by antibiotics.

The nurse is collecting a specimen for a wound culture. What should be avoided when collecting this specimen?

Old drainage.

What type of stool specimen must be sent to the laboratory immediately?

Ova and parasites.

The emergency department nurse quickly assesses the temperature of an unconscious patient who has been outside all night in below-freezing temperatures. What temperature is the nurse aware of that can lead to death?

93.2°F (34°C). Death can occur if the temperature falls below 93.2° F (34°C).

The worried mother of an accident victim asks the nurse how much circulating blood an average adult male is supposed to have. What will the nurse reply?

12 pints.

The home health nurse is caring for a patient with an implanted pacemaker. What type of pain management would be contraindicated?

A TENS unit may interfere with the function of the pacemaker.

The nurse attempts to avoid a pressure injury for a bedridden patient by turning the patient frequently. What is the most favorable position for the nurse to move this patient into?

30-degree lateral.

The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain. What is the maximum amount of drainage considered normal?

300 mL

The nurse is using a pain scale of 0 to 10 to assess pain in a postoperative patient. What is considered the maximum pain level at which a patient can usually function effectively?

4.

When a patient demands to be discharged without a health care provider's order and is leaving the unit with his belongings, what should the nurse ask the patient to sign?

A discharge against medical advice form.

What is required by the health care team to identify the needs of a patient and to design care to meet those needs ?

An individualized care plan.

The nurse is preparing a patient for a diagnostic examination. What can the nurse implement to assist with reducing anxiety?

Answer questions for clarification.

Ability to answer for one's own actions.

Accountability.

Which solutions can be used on a wet-to-dry dressing? (Select all that apply.)

Acetic acid. Dakins. Lactated ringer. Normal saline.

The human responses to health conditions/life processes that exist in an individual, family, or community are known as a(n) _ patient problem.

Actual.

When admitting a patient to the hospital, the nurse observes that the patient is distracted and tense. What does this behavior suggest as a common reaction to hospitalization?

Fear of the unknown.

Hemostasis begins as soon as the injury occurs and a clot begins to form. What is the substance in the clot that holds the wound together?

Fibrin.

Fulfillment of promises.

Fidelity.

What important principle should be taken to prevent medication errors?

Following the six rights of medication administration.

The nurse is caring for a patient following a bronchoscopy and maintains NPO status for 2 hours. What additional assessment will indicate to the nurse that this patient's risk for aspiration has decreased?

Gag reflex has returned.

The nurse determines clinical death and initiates CPR immediately. How long is resuscitation considered possible?

If cardiopulmonary arrest has existed for no more 4 minutes.

What is important for the nurse to determine in order to decrease the risk for injury to a patient?

If patient is left-handed.

What type of body temperature remains relatively constant?

Core.

When a patient comes into the emergency department with a narcotic overdose, the nurse anticipates that the patient will be treated with Narcan. What drug classification is Narcan?

Antagonist.

The nurse is attempting to control bleeding in a patient with a profusely bleeding scalp wound. What is the most effective initial treatment of this bleeding?

Apply direct pressure.

When collecting data related to the present illness, the nurse must obtain detailed and comprehensive data. What does this data help to establish?

Appropriate interventions.

The conduct of one person makes another person fearful and apprehensive A nurse threatens to place an NG tube in a client who is refusing to eat.

Assault.

CPR has been initiated on an adult patient. How will the nurse confirm the effectiveness of CPR?

Assessing a palpable carotid pulse during each compression.

A patient with multiple serious injuries sustained in a motorcycle accident is lying beside his wrecked motorcycle unconscious and bleeding when the rescuer arrives at the scene. What will be the rescuer's priority action?

Assessing respiratory status.

Where does the nurse recognize that many institutions are now including pain assessment in implementing patient care?

Assessing vital signs.

Which are considered phases of the nursing process?

Assessment. Diagnosis. Outcome identification / Planning. Implementation. Evaluation.

The right to make one's own personal decisions, even when those decisions might not be in that person's own best interest.

Autonomy.

Action that promotes good for others, without any self‑interest.

Beneficence.

When assessing the adult victim for pulselessness, the CPR rescuer should palpate the most reliable and accessible pulse. Which pulse will be palpated?

Carotid.

What is a cost effective delivery of care used by many hospitals that's allows the lpn/lvn to work with an RN to meet the needs of a patient ?

Case management.

The nurse is preparing a presentation regarding the effects of diabetes mellitus. What will the nurse include regarding the effects of diabetes mellitus?

Causes hemoglobin to have a greater affinity for oxygen.

What is the defining term for continuous or intermittent pain that does not serve as a warning of tissue damage?

Chronic.

The patient arrived at the emergency department in pain and bleeding profusely with the following vital signs: BP 80/54, P 102, RR 22. What does the nurse recognize that these symptoms indicate?

Circulatory shock.

What is the classification for the Jackson-Pratt drainage removal system?

Closed drainage system.

Auscultating the heart sounds should result in a "lub-dup" sound when using the bell and the diaphragm of the stethoscope. What causes the "lub" sound?

Closing of the AV valves.

The nurse assures a patient that the purple, raised, immature scar of a surgical wound is normal and caused by _ formation.

Collagen.

A nurse assesses an area of sustained redness on the coccyx area of a resident in long-term care. What is the most likely cause of this pressure area?

Collapse of blood vessels.

A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?

Complains of diplopia.

A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?

Complains of pruritus.

When a nurse protects the information in a patient's record, what ethical responsibility is the nurse fulfilling?

Confidentiality.

What are the advantages of a transparent dressing?

Contains the exudate. Adheres to undamaged skin. Reduces wound contamination. Serves as a barrier to external bacteria.

What is the pulse—the expansion and contraction of an artery— produced by?

Contraction of the left ventricle.

The patient's lower chest has been punctured with a knife that is still in place. What should the nurse's first action be?

Immobilize the knife with dressings and tape.

A sputum specimen is ordered on a patient diagnosed with pneumonia. When is the best time for the nurse to the attempt to collect this specimen?

In the early morning.

To help relax the anal sphincter during the insertion of a suppository, the nurse should ask the patient to _.

Exhale.

A person is confined or restrained against their will. A nurse uses restraints on a competent client to prevent their leaving the health care facility.

False imprisonment.

The nurse is planning interventions for a patient experiencing pain. For what type of synergistic relationship should the nurse assess?

Fatigue

The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?

Cover the bowel with a sterile saline dressing.

During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a patient problem plan. What does this data represent?

Data clustering.

The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated. What does the nurse recognize that this indicates?

Dehiscence.

An older adult patient is being assessed for skin turgor. The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised. What can the nurse conclude is responsible for this assessment?

Dehydration.

The nurse must be sensitive to an older adult patient experiencing separation anxiety when admitted to the hospital. When a child experiences separation anxiety, they will usually cry. What will an older adult often demonstrate when experiencing separation anxiety?

Depression.

What is the system that classifies patients by age, diagnosis, and surgical procedure, and produces 300 different categories used for predicting the use of hospital resources?

Diagnosis-related groups (DRGs).

What is the system that classifies patients by age, diagnosis, and surgical procedure, and produces 300 different categories used for predicting the use of hospital resources?

Diagnosis-related groups.

The full disclosure of the facts the patient needs to make an intelligent (informed) decision before any invasive treatment or procedure is performed.

Doctrine of Informed Consent.

The best defense against malpractice claims associated with nursing care is accurate _.

Documentation.

How should the nurse position the ear pinna when using the tympanic thermometer on a child?

Downward and back.

The nurses employed at a wound therapy clinic are preparing an educational in-service about the vacuum-assisted closure (VAC) device for hospital nurses. What accurate information will be included in this in-service?

Drops bacterial level in wound. Promotes formulation of granulation tissue. Reduces local and peripheral edema.

During a physical assessment, the nurse listens for adventitious lung sounds. Crackles are classified as fine, medium, or coarse. When are these sounds most often auscultated?

During inspiration.

The nurse assesses respirations of a patient demonstrating pursed-lip breathing, flared nostrils, and retractions. How will the nurse describe these respirations?

Dyspnea. Stertous breathing - Stertor, from Latin 'stertere' to snore, and first used in 1804, is a noisy breathing sound like snoring. It is caused by partial obstruction of the upper airways, at the level of the pharynx and nasopharynx.

The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient?

Every 120 minutes.

The nurse is caring for a patient during the first 24 hours following surgery. How often will the nurse assess for bleeding under the dressing?

Every 2 to 4 hours.

Upon admission, the nurse notes that a patient without family members present has a billfold filled with cash. Where can the nurse suggest the money be placed?

In the hospital safe.

What phase is a wound in when blood and fluid flow into the vascular space and produce edema, erythema, heat, and pain?

Inflammatory.

The nurse assessing a postoperative patient discovers that the pulse is rapid, blood pressure has decreased, urinary output has decreased, and the dressing is dry. What can the nurse determine is indicated by these findings?

Internal hemorrhage.

What is the term for the exchange of carbon dioxide and oxygen that takes place at the alveolar level?

Internal respiration.

What does documentation of type of care, time of care, and signature of the person prove?

Interventions were implemented to meet the patient's needs.

A patient is admitted to a medical surgical unit. What factors will determine how frequently vital signs will be assessed?

Judgment of need by the nurse. Orders of the health care provider. Patient's condition

Fairness in care delivery and use of resources.

Justice.

What intervention should the nurse implement when preparing the patient for a glucose tolerance test (GTT)?

Keep patient NPO 8 hours before the test.

What action exemplifies a nurse practicing medical asepsis in performing daily care?

Keeping the bed linens of the floor.

The nurse is removing every other staple from a surgical wound, which has been closed with 15 staples. The wound begins to separate after removal of 3 of the 15. What nursing action should be implemented?

Leave the 12 staples in place and record the separation.

The nurse reassures a patient that most acute pain is intense and of short duration. How long does can acute pain usually last?

Less than 6 months.

What is the main organ that inactivates and metabolizes drugs?

Liver.

What is the probable source of bright red blood in the stool?

Lower gastrointestinal tract.

What does the nurse use the diaphragm of the stethoscope to best assess?

Lung sounds.

When giving a subcutaneous injection to a very thin patient, how does the nurse alter the injection technique?

Pinching up the skin and inserting the needle at a 45-degree angle.

The nurse is teaching a patient with epistaxis about the best way to control bleeding. What information will the nurse relay to this patient?

Place ice on the nose and pinch the nostrils.

When performing a nursing physical assessment, the nurse uses a head-to-toe approach. Where will the nurse begin when using this method?

Neurologic assessment.

The nurse who was going off shift had prepared the medications for the nurse who was going to relieve her to save the oncoming nurse time. What would be the correct action of the oncoming nurse?

Never give medications another person has prepared.

A commitment to do no harm.

Nonmaleficence.

A nurse assesses a patient's dorsalis pedis pulse. The pulse is easily felt but not palpable when moderate pressure is applied. How should the nurse document this finding?

Normal pulse.

A patient who is alert and oriented is threatening to leave the hospital against medical advice (AMA). What action should the nurse take?

Notify the health care provider that the patient is threatening to leave AMA.

What document identifies the roles and responsibilities of the LPN/LVN?

Nurse Practice Act.

What health care professional has the responsibility for notifying the health care provider when laboratory and diagnostic studies deviate from the norm?

Nurse.

The nurse is developing a nursing care plan for a newly admitted patient. What is the first step the nurse will take in developing this care plan?

Nursing assessment.

What does the nurse use a basis for documentation in focus charting?.

Nursing diagnosis

The relationship among nursing, patients, health , and the environment are the basis for :

Nursing models.

CPR has been initiated at an accident site. When can CPR be terminated?

Paramedics arrive.

The nurse is assessing a patient for collection of subjective and objective data. What will this data provide the basis for making?

Patient problem.

What does the nurse use as a basis for documentation in focus charting?

Patient problems.

What action should the nurse take when evaluating the effectiveness of new or revised therapies for pain relief?

Perform evaluation of outcome goals.

A patient is unable to obtain a sputum specimen by coughing and expectorating. What is the best way for the nurse to collect this specimen?

Perform tracheal suctioning.

During a head-to-toe assessment, the nurse assesses the patient's abdomen. Which area should the nurse assess next?

Perineal area.

The nurse is obtaining a throat culture. What area will the nurse swab with a cotton-tipped applicator?

Pharynx.

According to Maslow's hierarchy of needs, what is an individual's most basic need?

Physiologic.

An American Indian patient requests that an egg yolk be placed in a saucer and put under his bed to absorb the pain. What should the nurse do?

Place the egg in a saucer under the bed.

The nurse is providing hand and foot care to a patient and notices the patient has extremely hard nails. Who is the person best prepared to provide nail care for patients with extremely hard nails?

Podiatrist.

What is the documentation format that uses the acronym SOAPE?

Problem-oriented.

What subjective data does the nurse record following a head-to-toe examination?

Prolonged nausea.

What is the purpose of licensing laws for LPN/LVNs?

Protection of the public from unqualified people.

What is the best way for a nurse to avoid a lawsuit?

Provide compassionate, competent care.

What should the nurse do with an injection of 2 mL of Demerol that the patient has refused?

Record in the narcotic log that the drug was wasted. Chart in the patient's record the reason the medication was refused. Confirm the count is correct on the narcotic log.

A patient has pain in the left arm secondary to coronary insufficiency. This is an example of what type of pain?

Referred pain.

In some health care facilities, the LPN/LVN is allowed to take telephone orders from a health care provider. What is one precaution the nurse must take when receiving a verbal order?

Repeat the order to the health care provider.

The nurse uses a systematic method for collecting data on all body systems, including normal functioning and any noted changes. What is this method?

Review of systems.

A nurse assesses an accident victim who has bright red blood spurting from a laceration on his right forearm. Where will the nurse apply pressure after applying direct pressure and elevating the limb?

Right brachial artery.

What can result from the nurse consistently performing hand hygiene and using sterile supplies when caring for patients in the hospital setting?

Risk for infection is reduced.

What can result from the nurse consistently performing hand hygiene and using sterile supplies when caring for patients in the hospital setting?

Risk of infection is reduced.

Human responses to health conditions and life processes that may develop in a vulnerable individual, family, or community are known as a(n) _ patient problem.

Risk.

The nurse is preparing to collect a urine specimen. What will this nurse include when labeling this specimen?

Room number. Medical record number. Date and time of collection.

What assessment does the nurse recognize as an inflammatory response in a surgical wound on the leg of a patient?

Rubor and edema appear around the wound.

The nurse assessing a patient's wound notes bright red drainage. How will the nurse most accurately document this finding?

Sanguineous drianage.

The day following surgery, the nurse notes bloody drainage on the dressing. How will the nurse describe this drainage when documenting?

Sanguineous.

What does the nurse recognize as the initial step in conducting an assessment of a patient?

The nursing health history.

Before the actual discharge occurs, what must the nurse ensure?

The patient understands the discharge instructions.

The Good Samaritan law will protect all people who offer assistance. What is necessary for this protection?

The person acts prudently.

When giving a tubal medication, the nurse should flush the tubing with 30 to 50 _ of water.

mL.

What must the nurse realize when assessing physical and social environmental factors affecting health and illness?

They affect one another.

The nurse explains that electrocardiograms are graphic representations of electric impulses generated by the heart. What type of abnormalities can an electrocardiogram identify?

Those that interfere with electric conduction.

A nurse assesses a patient's dorsalis pedis pulse. The pulse is easily felt but not palpable when moderate pressure is applied. How should the nurse document this finding?

Thready pulse.

The following information is included in a health care provider's order: Jane Doe September 23 Amoxicillin 250 mg PO every 6 hours for 10 days Dr. John Smith The essential component missing is the _.

Time.

What screening test is accomplished by performing an intradermal injection?

Tuberculosis.

What important safety precaution should the home health nurse teach parents in order to prevent burns to small children?

Turn pot handles on stoves away from reach.