Vsim Questions

The nurse titrates the patient's oxygen to 3L per nasal cannula in order to maintain an oxygen saturation of at least 94%, per the provider's orders. What is the rationale for this order? (select all that apply) 1. allows the body to meet metabolic demands 2. promotes a decrease in myocardial workload 3. promotes a decrease in respiratory effort 4. prevents atelectasis in a pt with pneumonia 5. allows the patient to receive 100% O2

1. allows the body to meet metabolic demands 2. promotes a decrease in myocardial workload 3. promotes a decrease in respiratory effort

When completing discharge instructions with a patient, the nurse notices the patient is short of breath. What is the priority nursing action at this time? 1. listen to the pt's lungs 2. ask if the pt has support at home 3. determine if the pt has any questions 4. reassure the pt

1. listen to the pt's lungs

A patient in semi Fowler's position is having difficulty breathing. What is the priority action of the nurse? 1. raise the head of the bed. 2. call respiratory therapy 3. conduct a pain assessment 4. auscultate the lungs

1. raise the head of the bed.

Expected assessment findings of a patient with pneumonia may include which of the following? (select all that apply) 1. tachypnea 2. use of accessory muscles 3. malaise 4. enuresis 5. fever

1. tachypnea 2. use of accessory muscles 3. malaise 5. fever

Which patients have an increased risk for developing colorectal cancer? (Select all that apply.) 1.A 30 y.o. with a 13- year history of Crohn's disease 2.A 50 y.o. whose diet includes red meat daily 3.A 63 y.o. who is healthy 4.A 70 y.o. who has been diagnosed as obese 5.A 40 y.o. with a history of lupus

1.A 30 y.o. with a 13- year history of Crohn's disease 2.A 50 y.o. whose diet includes red meat daily 3.A 63 y.o. who is healthy 4.A 70 y.o. who has been diagnosed as obese

What pathology is responsible for metabolic acidosis? 1.A decrease in bicarbonate or an increase in hydrogen icons 2.A decrease of carbonic acid 3.An excess of HCO3 and/or a decrease in H+ ions 4.An increase of CO2

1.A decrease in bicarbonate or an increase in hydrogen icons

A patient with a low body mass index (BMI) is found to have low albumin and prealbumin levels. Which of the following nursing actions should be considered? (Select all that apply.) 1.Assess gastrointestinal function 2.Assess for signs and symptoms of infection 3.Monitor input and output for the patient 4.Request a nutrition consult 5.Encourage oral intake of foods and fluids as ordered

1.Assess gastrointestinal function 3.Monitor input and output for the patient 4.Request a nutrition consult 5.Encourage oral intake of foods and fluids as ordered

Which intervention takes priority when the nurse determines that a postoperative patient has hypoactive bowel sounds? 1.Assess the abdomen for signs of distention 2.Notify the surgeon of this assessment finding 3.Advance the patient's diet to soft, solid food 4.Assess the patient for indications of hypotension

1.Assess the abdomen for signs of distention

The nurse is preparing discharge education for a patient with a permanent colostomy. What information concerning diet and nutrition will the nurse include? (Select all that apply). 1.Avoid foods that previously caused diarrhea 2.Gradually add new foods into the diet 3.Drink at least two quarts of water daily 4.Avoid high fiber foods for eight weeks after the surgery 5.Be aware that colostomies are prone to develop food blockages

1.Avoid foods that previously caused diarrhea 2.Gradually add new foods into the diet 3.Drink at least two quarts of water daily 4.Avoid high fiber foods for eight weeks after the surgery

What information should the nurse include in the documentation associated with the changing of a patient's colostomy pouch? (Select all that apply.) 1.Condition of the skin around the stoma 2.How often the process will be done 3.Description of the stoma 4.Characteristics of the fecal matter 5.Patient's response to the process

1.Condition of the skin around the stoma 3.Description of the stoma 4.Characteristics of the fecal matter 5.Patient's response to the process

A nurse has just finished placing a nasogastric tube into a patient for the purposes of administering feedings. What should the nurse do first? 1.Confirm the placement of the nasogastric tube per facility policy. 2.Assess how much of the tube was inserted into the patient to verify placement. 3.Irrigate the nasogastric tube with 30 to 60 mL of water. 4.Administer the tube feeding as ordered.

1.Confirm the placement of the nasogastric tube per facility policy.

The nurse is caring for a patient who is unable to urinate voluntarily since a gunshot injury. Patient data associated with which intervention will provide information regarding the patient's kidney function? 1.Daily serum creatinine levels 2.Results of precatheterization bladder scans 3.Number of times the patient requests oxybutynin over a 24-hour period 4.Urinary output over eight hours

1.Daily serum creatinine levels

Which interventions will the nurse implement to help minimize a postoperative patient's risk for surgical site complications? (Select all that apply.) 1.Following strict aseptic techniques when changing surgical dressing 2.Monitoring for elevation in body temperature 3.Providing sufficient fluids to maintain hydration 4.Advancing diet as appropriate to provide adequate nutrition 5.Encouraging deep, sustained breathing and supported coughing

1.Following strict aseptic techniques when changing surgical dressing 2.Monitoring for elevation in body temperature 3.Providing sufficient fluids to maintain hydration 4.Advancing diet as appropriate to provide adequate nutrition

Which statements will guide the nurse when preparing to educate a patient whose condition requires a permanent colostomy? (Select all that apply.) 1.Help the patient get accustomed to looking at the ostomy 2.Encourage the patient to take part in the care process 3.Assess the patient for signs of depression 4.If the patient is accepting, include family members in the teaching 5.Schedule the teaching two to three days after the surgery

1.Help the patient get accustomed to looking at the ostomy 2.Encourage the patient to take part in the care process 3.Assess the patient for signs of depression 4.If the patient is accepting, include family members in the teaching

Which statements best support the nurse's evaluation that a patient who recently experienced a sigmoid colostomy has begun to accept the body change? (Select all that apply.) 1.I'm anxious to get a bathing suit that accommodates my colostomy 2.My stoma continues to be red and moist 3.My ostomy nurse always has helpful suggestions about daily care routine 4.Having a colostomy is a small price to pay for being healthy 5.I really hope no one else I know has to ever deal with a colostomy

1.I'm anxious to get a bathing suit that accommodates my colostomy 2.My stoma continues to be red and moist 3.My ostomy nurse always has helpful suggestions about daily care routine 4.Having a colostomy is a small price to pay for being healthy

A nurse is creating a care plan for a young adult patient with a chronic illness. Which of the following nursing diagnoses might be included in the care plan? (Select all that apply.) 1.Ineffective health maintenance 2.Social isolation 3.Risk-prone health behavior 4.Caregiver role strain 5.Activity intolerance

1.Ineffective health maintenance 2.Social isolation 3.Risk-prone health behavior 5.Activity intolerance

While inserting an intermittent urinary catheter in a female patient, the nurse accidentally inserts the catheter into the vagina. What is the appropriate action by the nurse? 1.Leave the catheter in the vagina as a landmark and begin the procedure again with new supplies 2.Remove the catheter and re-start the procedure using a new sterile kit 3.Allow the patient a period of rest and attempt the procedure at a later time 4.Carefully remove the catheter and reinsert it into the urethra

1.Leave the catheter in the vagina as a landmark and begin the procedure again with new supplies

Christopher Parrish has a low body mass index and has lost 12 pounds over the past two weeks. Which method could the nurse use to assess his overall dietary intake in order to provide nutrition education? 1.Obtain a food frequency assessment 2.Ask the patient to keep a food diary log 3.Ask the patient if he has a healthy diet. 4.Track the percentage of food eaten at each meal while in the hospital

1.Obtain a food frequency assessment

The nurse is caring for a patient with lower extremity edema resulting from chronic venous insufficiency. What should the nurse include in the plan of care for this patient? (Select all that apply.) 1.Perform neurovascular checks to look for changes 2.Provide meticulous skin care 3.Maintain strict bed rest 4.Assist with range of motion exercises to lower extremities 5.Monitor patient for signs of skin breakdown

1.Perform neurovascular checks to look for changes 2.Provide meticulous skin care 4.Assist with range of motion exercises to lower extremities 5.Monitor patient for signs of skin breakdown

The nurse is providing discharge education on complications associated with intermittent self-catheterization. Which possible complication should the nurse include in the teaching session? (Select all that apply.) 1.Urinary tract infections 2.Nephrotic syndrome 3.Bladder perforation 4.Urethral strictures 5.Bladder spasms

1.Urinary tract infections 3.Bladder perforation 4.Urethral strictures 5.Bladder spasms

What information will the nurse include when providing education for a patient who is scheduled for a sigmoid colostomy? (Select all that apply.) 1.When an ostomy is needed, intestinal mucosa is brought through the abdominal wall 2.The fecal matter that will pass through the stoma will be liquid in form 3.A healthy stoma is bright red, moist, and rounded 4.A stoma is the portion of the intestinal mucosa that is secured to the skin of the abdomen 5.The term ostomy refers to an opening from the inside of an organ to the outside of the body.

1.When an ostomy is needed, intestinal mucosa is brought through the abdominal wall 3.A healthy stoma is bright red, moist, and rounded 4.A stoma is the portion of the intestinal mucosa that is secured to the skin of the abdomen 5.The term ostomy refers to an opening from the inside of an organ to the outside of the body.

Which statement concerning the measurement of intake and output is true? 1.When possible, intake and output should be measured rather than estimated. 2.Health care agencies have adopted standard volumes for common beverage containers 3.Only foods that are consumed as liquids are included in intake calculations 4.Liquid medications are not considered when calculating intake

1.When possible, intake and output should be measured rather than estimated.

What instruction should the nurse provide to a patient concerning how often the colostomy pouch should be emptied? 1.Whenever the pouch is one-third full of fecal drainage 2.When the pouch isn't well attached to the skin 3.After each meal 4.At least four to five times daily

1.Whenever the pouch is one-third full of fecal drainage

The nurse is providing Mr. Johnson with discharge education about intermittent self-catheterization. What statement, if made by the patient, would indicate the need for further instruction? 1.It is important that I self-catheterize at regular intervals 2.There are risks associated with self-catheterization, such as bleeding and infection 3.I should maintain sterile technique throughout the procedure 4.If I do not catheterize myself, I may develop urinary problems

3.I should maintain sterile technique throughout the procedure

Which statement by Mr. Ahmed best reflects his ability to assume some responsibility in tracking his urinary output? 1.I understand that it is important to measure my urine with the calibrated urinal 2.I listened as you discussed the instructions about the calibrated urinal 3.I will always use the calibrated urinal to measure my urine 4.I will notify staff when I need to use the calibrated urinal

3.I will always use the calibrated urinal to measure my urine

A patient is concerned about a medication the nurse is administering. The patient states that the medication is not normally something that is administered. What is the best response by the nurse? 1.The provider has ordered it for you. 2.It is probably a generic medication for something you normally get. 3.I will hold the medication and find out for you. 4.We should probably update your medical reconciliation forms.

3.I will hold the medication and find out for you.

A patient with cystic fibrosis has five capsules of pancrelipase (amylase, lipase, and protease) ordered to be administered now with his breakfast. The patient is currently experiencing nausea and intermittent vomiting. What should the nurse do with this medication? 1.Crush the medication to administer to the patient 2.Administer the medication as ordered 3.Call the provider immediately 4.Hold the medication until the patient is able to eat again

4.Hold the medication until the patient is able to eat again

Which physical finding poses the greatest safety risk for a patient diagnosed with hyponatremia? 1.Cold, clammy skin 2.Dry mucous membranes 3.Anxiety 4.Orthostatic hypotension

4.Orthostatic hypotension

The nurse is reviewing the patient's laboratory results. Which lab test most accurately represents current nutritional status? 1.Iron 2.Calcium 3.Albumin 4.Prealbumin

4.Prealbumin

Which of Mr. Ahmed's lab results best supports his diagnosis of dehydration? 1.Creatinine 1.1 2.WBC 21 x 10^9 3.HgB 16.7 4.Sodium 130

4.Sodium 130

The nurse is irrigating a patient's wound when the patient complains of pain. What is the appropriate action by the nurse? 1.Administer the ordered analgesic when the procedure is finished 2.Discontinue the irrigation and notify the provider 3.Complete a pain assessment and finish the procedure 4.Stop the procedure and administer the ordered analgesic

4.Stop the procedure and administer the ordered analgesic

In preparation for calculating the infusion rate for a newly ordered intravenous (IV) solution, the nurse must first secure what information? 1.When the IV is to be started 2.The status of the patient's IV site 3.Patient's history of allergies 4.The infusion set's drop factor

4.The infusion set's drop factor

Ms. Morrow's daughter asks the nurse why it is necessary to irrigate her mother's wound. What is the appropriate response by the nurse? 1.Irrigation helps to sterilize the wound 2.The application of fluid helps hydrate the surrounding tissue 3.The irrigation fluid contains medication for the wound 4.The procedure helps remove drainage and debris from the wound

4.The procedure helps remove drainage and debris from the wound

Which statement by the nurse indicates a need for further education on the role of water as a body fluid? 1.Tissue lubrication is facilitated by water 2.Water helps maintain normal body temperature 3.Waste products are removed from the cells by water 4.Water is transported to cells when it is attached to electrolytes

4.Water is transported to cells when it is attached to electrolytes

Which statement concerning fluid balance demonstrated a need for additional instruction concerning fluid intake and output? 1.A desirable amount of fluid intake and output in adults ranges from 1,500 to 3,500 mL daily 2.It is recommended that a healthy adult consume 1.5 quarts of water daily 3.Fluid output is comprised of feces, sweat, and exhaled air 4.The balance between fluid intake and output must be achieved each day to maintain homeostasis

4The balance between fluid intake and output must be achieved each day to maintain homeostasis

After completing an intermittent catheterization, what information concerning the procedure will the nurse include in Ms. Johnson's medical record? (Select all that apply.) 1.Characteristics of the urine obtained 2.Time procedure was performed 3.Size of catheter used 4.Description of the cleansing process preceding the procedure 5.Description of the patient's tolerance for the procedure

1.Characteristics of the urine obtained 2.Time procedure was performed 3.Size of catheter used 5.Description of the patient's tolerance for the procedure

A nurse is assessing an adolescent patient. Which of the following questions best represents therapeutic communication techniques? 1.What do you hope happens here today? 2.Are you feeling well? 3.Do you know what to do to stay healthy? 4.You don't smoke, do you?

1.What do you hope happens here today?

When should the nurse caring for a patient with a new colostomy plan to change the pouching system? 1.After any meal 2.Before breakfast 3.Right before bed 4.Before the patient showers

2.Before breakfast

The nurse is recording fluid intake for Mr. Johnson. Which items on the dinner trap should the nurse include when completing this documentation? (Select all that apply.) 1.Applesauce 2.Ice cream 3.Tomato soup 4.Iced tea 5.Creamed corn

2.Ice cream 3.Tomato soup 4.Iced tea

Considering Mr. Ahmed's diagnosis of dehydration and the possibility of neurological impairment, which nursing intervention is directed toward minimizing his risk for possible injury? 1.Educating the patient on the use of a calibrated urinal 2.Implementing falls precaution 3.Administrating ondansetron with a full glass of water 4.Assessing for orthostatic hypertension daily

2.Implementing falls precaution

Which diagnostic test is used as a screening tool for the possible diagnosis of colon cancer? 1.Stool pinworms 2.Occult blood 3.Timed stool specimen 4.Stool culture

2.Occult blood

The need for a sigmoid colostomy is generally a result of cancer at what point in the intestinal tract? 1.Anywhere in the descending colon 2.Anywhere in the transverse colon 3.Near the rectum 4.Near the ileocecal valve

3.Near the rectum

During her hospitalization for pneumonia, the provider orders arterial blood gases for Mona Hernandez. What is the best explanation for why this is ordered? 1. pt has fever and malaise 2. pt has a productive cough with rust colored sputum 3. pt has a hx of smoking half a pact of cigarettes per day 4. pt has shallow, ineffective breathing

4. pt has shallow, ineffective breathing

The nurse is preparing to irrigate a patient's wound. Upon assessment, the wound appears to be healing and the wound bed is beefy red. Which solution should the nurse select for this procedure? 1.Dakin's solution 2.Isopropyl alcohol 3.Tap water 4.Normal saline

4.Normal saline

As the nurse administers Mona Hernandez's prescribed medication, guaifenesin, the patient states: "I don't like this medication. It makes me cough too much." How should the nurse respond? 1. this med will help make your breathing easier 2. this med is given to you bc of your pneumonia 3. when you cough out secretions, oxygenation is more effective 4. i will let your provider know you have questions about your meds

3. when you cough out secretions, oxygenation is more effective

A patient demonstrated correct use of the incentive spirometer when the patient places the mouthpiece in the mouth and does which of the following? 1. exhales quickly and forcefully 2. inhales quickly and forcefully 3. exhales slowly and deeply 4. inhales slowly and deeply

4. inhales slowly and deeply

A nurse is teaching a patient with cystic fibrosis about nutrition in the high-fat, high-carbohydrate diet that has been recommended. Which of the following should be included in this education? 1.It is important to focus on eating calorie-dense foods 2.It is not necessary to monitor dietary intake 3.It is important to only eat high-fat, high-protein and high- carbohydrate foods 4.It is important to select a variety of nutrient-dense foods

4.It is important to select a variety of nutrient-dense foods

The nurse is preparing to insert an intermittent urinary catheter in a paralyzed female patient. What would be the appropriate action by the nurse? 1.Call for a co-worker to help hold the patient's legs in position 2.Instruct the patient to turn over on her side 3.Notify the provider that the procedure could not be completed because the patient is paralyzed 4.Ask a family member to assist you with the catheterization

1.Call for a co-worker to help hold the patient's legs in position

Identify the following potential problems or actual problems that the nurse should include when planning care for the patient diagnosed with pneumonia? 1.Difficulty breathing 2.Not able to tolerate activity 3.Ineffective respiratory gas exchange 4.Acute pain 5. metabolic acidosis

1.Difficulty breathing 2.Not able to tolerate activity 3.Ineffective respiratory gas exchange 4.Acute pain

What assessment data will the nurse expect to find to support the assumption that Mr. Haye's surgical incision is in the inflammatory phase of wound healing? (Select all that apply.) 1.Increased white blood cell count 2.Incision is slightly edematous 3.Incisional site pain 4.Redness surrounding the incision 5.Signs of scabbing are noted at the incision site

1.Increased white blood cell count 2.Incision is slightly edematous 3.Incisional site pain 4.Redness surrounding the incision

The nurse has an order to check a patient's post-void residual urine. How would the nurse carry out this order? 1.Measure the amount of urine in the bladder using a bladder scanner 2.Insert a straight catheter and measure the urinary output in two hours 3.Calculate the difference between the patient's intake and output 4.Palpate the bladder for distention and record findings in the chart

1.Measure the amount of urine in the bladder using a bladder scanner

Which nursing interventions are implemented primarily to prevent respiratory complication in a patient after abdominal surgery? (Select all that apply.) 1.Prompting to cough 2.Assisting in early ambulation 3.Encouraging deep breathing 4.Providing pain medication as required 5.Education on incentive spirometer use

1.Prompting to cough 2.Assisting in early ambulation 3.Encouraging deep breathing 5.Education on incentive spirometer use

The nurse is preparing to discharge Mona Hernandez from the hospital. Which of the following instructions should the nurse include in the discharge education? (Select all that apply). 1.Use the incentive spirometer every one to two hours to move secretions out of your lungs 2. Continue to focus on ambulating several times per day 3.Take your antibiotics as directed, even if you are feeling better. 4.Quitting smoking will improve your recovery. 5. stop taking your antibiotics once you are feeling better.

1.Use the incentive spirometer every one to two hours to move secretions out of your lungs 2. Continue to focus on ambulating several times per day 3.Take your antibiotics as directed, even if you are feeling better. 4.Quitting smoking will improve your recovery.

The nurse has created a sterile field and is preparing to catheterize a patient. While using sterile cotton balls to clean the patient prior to the procedure, the nurse drops a contaminated cotton ball in the middle of the sterile field. What is the correct action of the nurse at this time? 1.Obtain a new catheter kit and restart the procedure 2.Remove the contaminated cotton ball from the field with the non-dominant hand 3.Continue with the procedure while avoiding the contaminated cotton ball 4.Ask a co-worker to remove the contaminated cotton ball from the field

1.Obtain a new catheter kit and restart the procedure

A nurse is preparing to admit a patient with cystic fibrosis and altered nutrition status. The nurse plans to implement which precautions to be used in the patient's care? 1.Standard precautions 2.Contact precautions 3.Airborne precautions 4.Droplet precautions

1.Standard precautions

Calculate the IV infusion rate using the following provider's order: 1000 mL of NS over 8 hours. Infusion set has a drip rate of 10drops/mL. 1.41 2.21 3.10 4.30

2.21

Hypokalemia is confirmed by what serum blood result? 1.Potassium 5.5 2.Sodium 146 3.Sodium 133 4.Potassium 3.0

4.Potassium 3.0

A patient states he does not want to use the incentive spirometer because it makes the patient cough up too much sputum, and it is difficult to breathe. What is the correct information to teach the patient about the incentive spirometer? 1. the incentive spirometer will cause you to cough less bc you are moving more air through your lungs 2. the incentive spirometer helps you to maximize lung function and minimize the risk of atelectasis 3. you have to use your incentive spirometer bc your provider has ordered it for you 4. you should wait to use your incentive spirometer until you are not coughing up so much

2. the incentive spirometer helps you to maximize lung function and minimize the risk of atelectasis

The nurse is conducting a skin assessment using the Braden Scale. How would the nurse interpret a score of 12? 1.Low risk 2.High risk 3.Moderate risk 4.Not at risk

2.High risk

Reduced skin turgor is characteristically altered among which population? 1.Smokers 2.Older adults 3.Infants 4.Premenstrual females

2.Older adults

The nurse is completing documentation following the insertion of an intermittent urinary catheter. What should be included in the documentation? (Select all that apply.) 1.The length of time for completion of the procedure 2.Size of the catheter 3.Patient's tolerance of the procedures 4.Date the procedure was performed 5.Time the procedure was performed

2.Size of the catheter 3.Patient's tolerance of the procedures 4.Date the procedure was performed 5.Time the procedure was performed

Mona Hernandez complains of shortness of breath with activity and does not want to exacerbate her condition by moving to the chair or ambulating three times a day as ordered. How should the nurse respond? 1. you really need to walk as much as possible in order to prevent your pneumonia from getting worse 2. you should wait until your breathing improves to try to get out of bed again, bc it makes you short of breath 3. even short activities such as moving to the chair will help you cough mucus out of your lungs 4. pneumonia causes thick secretions in your lungs, making if difficult to breathe.

3. even short activities such as moving to the chair will help you cough mucus out of your lungs

Mona Hernandez's laboratory work indicates an elevated white blood cell count with a left shift in the differential. The nurse interprets this to mean which of the following? 1.there is a high number of wbc to fight the infection, and the rbc are compensating 2. a left shift in the differential means that there is no infection present 3. there is a high number of wbc and immature wbc present to fight the infection 4. there is a high number of wbc but not immature wbc, present in the circulation

3. there is a high number of wbc and immature wbc present to fight the infection

A nurse is planning on administering a tube feeding to a patient with a nasogastric tube. The patient appears asleep flat in bed. What should the nurse do first? 1.Carefully connect the nasogastric tube to the tube feeding 2.Administer the feeding quietly without waking the patient 3.Assist the patient to a semi-Fowler's position or higher 4.Flush the nasogastric tube with 30 to 60 mL water

3.Assist the patient to a semi-Fowler's position or higher

The nurse is providing patient education on self-catheterization. What statement by Mr. Johnson indicates the need for additional teaching? 1.I should store my reusable catheters in a clean, dry container 2.I should report signs and symptoms of potential complications to the provider immediately 3.I can use either an indwelling or intermittent catheter 4.I may be eligible for free catheters through Medicare

3.I can use either an indwelling or intermittent catheter

A postoperative patient is receiving enoxaparin sodium therapy. Which assessment data would the nurse report immediately to the patient's health care provider? 1.A platelet reading of 260,000 per mcL 2.Small amount of gum bleeding after completing oral hygiene 3.Patient has reported self-medicating with aspirin three times since surgery 4.Patient reports no bowel movement for two days

3.Patient has reported self-medicating with aspirin three times since surgery

A nurse is caring for an 18-year-old patient who has recently started living on his own and has experienced a greater than 5% weight loss over two weeks. He has a low body mass index (BMI) and complains of feeling fatigued. According to Maslow's hierarchy of needs, the nurse identifies which of the following as the patient's priority need at this time? 1.Safety and security needs 2.Self-esteem needs 3.Physiological needs 4.Love and belonging needs

3.Physiological needs

The nurse removes a dressing and assesses yellow, foul smelling drainage. How would the nurse document this finding? 1.Serous 2.Serosanguineous 3.Purulent 4.Sanguineous

3.Purulent

The nurse is providing education to Ms. Morrow and her daughter on management of venous stasis in the lower extremities. What would be appropriate for the nurse to include in the teaching session? 1.Keep skin surrounding the wound dry and inspect it at least once a week 2.Avoid ambulation as this may aggravate you condition 3.Put on antiembolism stockings as soon as you get up in the morning and wear them all day 4.Sit with your legs in the dependent position so that blood will drain to lower extremities

3.Put on antiembolism stockings as soon as you get up in the morning and wear them all day

In addition to regular monitoring of serum potassium level, which intervention will the nurse implement to address the safety needs of a patient prescribed intravenous potassium chloride? 1.Shading windows to minimize sun exposure 2.Delivering the medication by slow IC push 3.Securing electrocardiograms (ECG) regularly 4.Monitoring for hyperactivity

3.Securing electrocardiograms (ECG) regularly

Hyponatremia is associated with a decrease of which electrolyte? 1.Phosphorus 2.Potassium 3.Sodium 4.Chloride

3.Sodium

What determines the acidity of a substance like body fluids? 1.The body's ability to trigger chemical reactions 2.The fluid's pH measurement 3.The number of existing H+ ions 4.The amounts of available HCO3

3.The number of existing H+ ions

What information will the nurse include when providing education for a patient scheduled for a colostomy as treatment for rectal cancer? 1.The surgeon will determine whether the ostomy can be temporary once surgery has begun 2.Permanency will depend on how much colon function has been affected by the surgery 3.The ostomy will be permanent because of the nature of the illness 4.Once the inflammation in the colon subsides, the ostomy will be reversed

3.The ostomy will be permanent because of the nature of the illness

Mr. Johnson is being discharged with an order to continue the medication oxybutynin. What information should be included in the teaching session? 1.You may have to urinate more frequently while taking this medication 2.You may experience excessive saliva production while taking this medication 3.This medication helps reduce bladder spasms 4.Your urine may appear reddish-orange

3.This medication helps reduce bladder spasms

The nurse has received an order to collect a urine sample. Which characteristics would the nurse observe for when assessing the patient's specimen? (Select all that apply.) 1.Color 2.Odor 3.pH 4.Sediment 5.Clarity

1.Color 2.Odor 4.Sediment 5.Clarity

The nurse is caring for an adolescent patient who appears withdrawn and isolated. What strategy should the nurse use to work with this patient? 1.Develop a therapeutic, trusting relationship with the patient. 2.Leave the patient alone as much as possible. 3.Talk to the patient's parents about what is going on with the patient. 4.Tell the patient what the patient needs to do in order to get better.

1.Develop a therapeutic, trusting relationship with the patient.

What information will the nurse provide to a patient to best assure minimizing the risk of side effects associated with sulfamethoxazole-trimethoprim therapy? 1.Increase fluid intake in order to remain well hydrated 2.Notify health care provider immediately if experiencing palpitations 3.Increase dietary consumption of dairy products 4.Arrange for a yearly flu vaccine

1.Increase fluid intake in order to remain well hydrated

The nurse is completing an admission assessment on a patient admitted for an infected, non-healing wound. Which factors in the patient's history may contribute to this condition? (Select all that apply.) 1.Poor circulation 2.Poor hygiene 3.Obesity 4.Diabetes Mellitus 5.Hypertension

1.Poor circulation 2.Poor hygiene 3.Obesity 4.Diabetes Mellitus

Mona Hernandez's blood gas results indicate respiratory acidosis. Her oxygen saturation is 95% per the pulse oximeter. Which interventions should the nurse provide? 1.Provide supplemental oxygen as ordered 2. none; the pt has a 95% oxygenation 3.Ensure the patient is well hydrated 4.Promote voluntary coughing activities to clear secretions 5.Assist the patient with adequate ventilation

1.Provide supplemental oxygen as ordered 3.Ensure the patient is well hydrated 4.Promote voluntary coughing activities to clear secretions 5.Assist the patient with adequate ventilation

With information presented to a patient concerning a bladder scan will assist in addressing anxieties about the procedure? (Select all that apply.) 1.The patient's body is draped to promote modesty 2.The scan typically does not cause the patient any pain 3.The scan produces an image of the patient's bladder and the amount of urine it contains 4.The scanner is moved over the skin of the patient's lower abdomen 5.The procedure is necessary when a patient experienced difficulty voiding

1.The patient's body is draped to promote modesty 2.The scan typically does not cause the patient any pain 4.The scanner is moved over the skin of the patient's lower abdomen

A nurse rounding on a patient with pneumonia notices the patient is more confused than at the beginning of the shift. What is the best response by the nurse? 1. ensure a sitter is available to watch the patient 2. document findings in the medical record 3. notify the provider 4. check oxygen sat level

4. check oxygen sat level

The nurse is performing a sterile dressing change. After donning sterile gloves, the nurse drops the dressing on the bed and does not have a replacement. What is the appropriate action at this time? 1.Reapply the original dressing until a new one can be obtained 2.Pick up the dressing and use the side that did not touch the bed 3.Remove gloves and go to the supply room to obtain more supplies 4.Ask the patient to press the call bell to summon a co-worker to obtain another dressing

4.Ask the patient to press the call bell to summon a co-worker to obtain another dressing

The nurse is completing an admission assessment on a paitent afmitted for impaired skin integrity. Which questions would be appropriate for the nurse to ask the patient? (Select all that apply.) 1.Do some areas of your skin seem warmer or colder than others? 2.Do you have any sores on your body? 3.What kind of activities cause you to be fatigued? 4.Have you used pads or special pants because you can't control your urine? 5.Have you noticed any swelling on your feet, ankles, or fingers?

1.Do some areas of your skin seem warmer or colder than others? 2.Do you have any sores on your body? 4.Have you used pads or special pants because you can't control your urine? 5.Have you noticed any swelling on your feet, ankles, or fingers?

The nurse is completing a focused assessment on a female patient admitted for altered urinary elimination. What questions would the nurse include when assessing the patient? (Select all that apply.) 1.How often do you urinate? 2.Is there anything that you do that helps you urinate? 3.Do you ever leak urine? 4.When was your last menstrual period? 5.Have you noticed any change in your usual voiding pattern?

1.How often do you urinate? 2.Is there anything that you do that helps you urinate? 3.Do you ever leak urine? 5.Have you noticed any change in your usual voiding pattern?

The nurse is preparing to catheterize a female patient and is positioning the patient. Which position(s) would be appropriate for this procedure? (Select all that apply.) 1.Side lying 2.Supine 3.Semi-Fowler's 4.Dorsal recumbent 5.Lithotomy

1.Side lying 4.Dorsal recumbent

Which statement by the nurse indicates a thorough understanding of the purpose of postoperative nursing care? 1.The goal is to ensure uneventful recovery from surgery 2.The goal is well-managed postoperative pain 3.The goal is to prevent infection 4.The goal is frequent assessment of the surgical incision site

1.The goal is to ensure uneventful recovery from surgery

The nurse is performing an assessment of Ms. Morrow's wound. What should be included in the documentation? (Select all that apply.) 1.Turgur 2.Tunneling 3.Odor 4.Drainage 5.Location

2.Tunneling 3.Odor 4.Drainage 5.Location

The nurse is caring for a patient experiencing the effects of paraplegia. What urinary condition is associated with this diagnosis? 1.Chronic cystitis 2.Oliguria 3.Neurogenic bladder 4.Stress incontinence

3.Neurogenic bladder

A patient is placed on omeprazole 20 mg daily. When will the nurse administer the medication? 1.At bedtime 2.One hour after any meal 3.One hour before breakfast 4.With breakfast

3.One hour before breakfast

The nurse assesses a wound and documents it as stage III. What did the nurse observe when the wound was assessed? 1.Intact skin with nonblanchable redness of a localized area 2.Full-thickness tissue loss with exposed bone, tendon, or muscle 3.Partial-thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed 4.Full-thickness tissue loss, possibly with visible subcutaneous fat

4.Full-thickness tissue loss, possibly with visible subcutaneous fat

The nurse is caring for a patient admitted with bilateral lower extremity edema. What questions should the nurse ask when completing a health history?

When did the edema start? Can you describe the edema? What were you doing just before you noticed the edema? Do you have any recent history of surgery or illness? What are your usual daily activities? Do you stand a lot? What medications do you take? Do you have heart disease or blood vessel disease?

Upon entering the room, the nurse observes Mona Hernandez slumped over in a semi-Fowler's position, struggling to catch her breath. What is the priority nursing action at this time? 1. titrate her O2 so that her O2 is greater than or equal to 95% 2. assist the pt into a high Fowler's position 3. obtain vital signs 4. obtain an O2 saturation level

2. assist the pt into a high Fowler's position

Mona Hernandez asks the nurse why it is necessary to use the incentive spirometer when she is already having difficulty breathing. What is the best response by the nurse? 1. it was ordered by your provider 2. it helps prevent atelectasis or collapsing of the alveoli in the lungs 3. it decreases cardiac workload during inspiration 4. it increases the O2 taken in by the lungs when you inhale

2. it helps prevent atelectasis or collapsing of the alveoli in the lungs

What is the initial step in assessing a patient for orthostatic hypotension? 1.Encourage the patient to drink eight ounces of fluid, then take and record blood pressure and pulse 2.After having the patient lie in a supine position for three to 10 minutes, take and record blood pressure and pulse 3.After having the patient sit upright with legs dangling for one to three minutes, take and record blood pressure and pulse 4.Assist patient into a standing position lasting two to three minutes, then take and record blood pressure and pulse

2.After having the patient lie in a supine position for three to 10 minutes, take and record blood pressure and pulse

What information should be included when documenting a change in the infusion rate of an IV solution? (Select all that apply.) 1.Original flow rate 2.Change made to flow rate 3.Date and time change was made 4.Nurse's initials 5.Patient's response to IV therapy

2.Change made to flow rate 3.Date and time change was made 4.Nurse's initials 5.Patient's response to IV therapy

A nurse is assessing a patient with cystic fibrosis. Based on a diagnosis of cystic fibrosis, the nurse expects to find which of the following common physical symptoms upon assessment? 1.Increased activity, diaphoresis, and tachycardia 2.Cyanosis or pallor, dyspnea, and arrhythmias 3.Nausea, vomiting, and hyperreflexia 4.Shortness of breath, headache, and vision changes

2.Cyanosis or pallor, dyspnea, and arrhythmias

A provider orders a high-fat, high-protein, high-carbohydrate diet for a patient with cystic fibrosis. What is the best rationale for this diet order? 1.Cystic fibrosis is a chronic disease characterized by altered electrolytes. 2.Cystic fibrosis interferes with the digestions of food and absorption of nutrients. 3.Thickened mucus secretions predispose the patient to anemia. 4.The diet was ordered according to the patient's preferred food intake.

2.Cystic fibrosis interferes with the digestions of food and absorption of nutrients.

A patient with newly diagnosed pneumonia has an oxygen saturation of 94% on room air, an increased respiratory rate, and an increased pulse. The patient is pale and anxious. The nurse questions the oxygen saturation results and looks up which of the following test results? 1. white blood cell count 2. chest x-ray 3. hemoglobin 4. gram stain

3. hemoglobin

Which diagnostic test serves as the basis for determining acid-base imbalances? 1.Specific gravity of urine 2.Blood urea nitrogen (BUN) 3.Arterial blood gas (ABG) 4.Serum potassium

3.Arterial blood gas (ABG)

A patient has just completed a tube feeding that has run throughout the night. What is the best education the nurse can provide to the patient at this time? 1.You should wear your pneumatic compression device when you are in bed. 2.You should remain upright for the next hour. 3.You should lie down to get some sleep. 4.It is important that you ambulate three times today.

2.You should remain upright for the next hour.

The nurse is providing education to Mr. Morrow and her daughter on nutrition. What is the best dietary choice to promote wound healing? 1.Green leafy vegetables 2.Whole grain bread 3. Baked Chicken 4.Baked potato

3. Baked Chicken

The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower extremity. What would the nurse expect to find when assessing the leg? 1.Pale, white toes with decreased sensation 2.Dark discoloration of the skin surrounding the wound site 3.Shiny skin with hair loss over legs, feet, and toes 4.Scaly rash between the toes with itchiness

2.Dark discoloration of the skin surrounding the wound site

A patient complains of nausea after a tube feeding. What is the priority action of the nurse at this time? 1.Position the patient on left side. 2.Ensure the head of the bed remains elevated. 3.Aspirate the tube feeding contents from the patient's stomach. 4.Flush the tube with 30 to 60 mL water

2.Ensure the head of the bed remains elevated.

A nurse is planning patient education about a prescribed medication for a patient. What should the nurse do first? 1.Education the patient about potential allergic reactions to the medication. 2.Find out what the patient already knows about the medication. 3.Review the signs and symptoms of drug toxicity with the patient. 4.Educate the patient about potential drug interactions.

2.Find out what the patient already knows about the medication.

The nurse is preparing to irrigate a wound. Which statement, if made by the nurse, indicates an understanding of the procedure? 1.I will make sure the tip of the syringe touched the wound bed while performing the irrigation? 2.I will gently direct a stream of fluid into the wound, keeping the syringe tip at least one inch from the upper tip of the wound 3.I will use a sterile specimen cup to slowly pour irrigation solution over the entire wound bed 4.In order to debride the wound, I will use a moderate amount of force to instill the solution

2.I will gently direct a stream of fluid into the wound, keeping the syringe tip at least one inch from the upper tip of the wound

Which statement made by the patient indicates an understanding of diet progression after surgery? 1.I know it is important to get my strength back, so I will ask for a milkshake after surgery 2.I'll start drinking water as soon this nausea subsides 3.I love coffee, so I'll have some as soon as I get back from surgery 4.I can't tolerate a soft diet, so I'll simply go back to drinking clear liquids

2.I'll start drinking water as soon this nausea subsides

Which statements indicate that a patient who recently required a colostomy has achieved the outcomes set for regular bowel elimination? (Select all that apply.) 1.Getting a short nap each afternoon makes me feel so much better 2.I've learned to implement the techniques I learned in stress management 3.I've gotten accustomed to drinking at least two quarts of water a day 4.My routine includes about 30 minutes of exercise daily 5.I know that what I eat has a large impact on my bowel function

2.I've learned to implement the techniques I learned in stress management 3.I've gotten accustomed to drinking at least two quarts of water a day 4.My routine includes about 30 minutes of exercise daily 5.I know that what I eat has a large impact on my bowel function

A nurse plans on assessing the patient's gastrointestinal system. Which statement below reflects the best prioritization of this assessment? 1.The nurse should percuss and then auscultate the abdomen 2.The nurse should auscultate and then palpate the abdomen 3.The nurse should palpate and then auscultate the abdomen 4.The nurse should percuss and then inspect the abdomen

2.The nurse should auscultate and then palpate the abdomen

The nurse has received an order to apply a hydrocolloid dressing to Mr. Morrow's right lower extremity. Which statement, if made by the nurse, would indicate the need for further education? 1.Hydrocolloid dressings help to maintain a moist wound environment 2.This dressing will need to be held in place by surgical tape 3.I can leave this dressing in place for three to seven days 4.It will help protect the wound from contamination

2.This dressing will need to be held in place by surgical tape

Ms. Johnson asks: why do I need to self-catheterize at regular intervals? What would be the appropriate response by the nurse? 1.You will only need to self-catheterize once daily 2.This helps prevent your bladder from becoming over distended 3.Self-catheterization helps reduce your risk of infection 4.This allows you to accurately measure your urine

2.This helps prevent your bladder from becoming over distended