204 Exam 2 review

The nurse is educating the patient about the effects of immobility on the body. Which statements by the patient indicate a need for further education? (Select all that apply.) a. "I can become very weak." b. "I will gain weight." c. "I will lose muscle tone." d. "I can get bed sores." e. "I won't have any lung problems."

b. "I will gain weight." e. "I won't have any lung problems." Immobility may cause weakness, instability, anorexia, elimination alterations, decreased muscle tone, circulatory stasis, DVTs, pulmonary embolism, and skin breakdown. Knowing the effects of immobility on various body systems allows the nurse to quickly assess a patient's risk and recognize signs of impending complications.

The nurse is providing discharge education to the patient with diabetes regarding foot care. Which statement by the patient indicates a need for further education? a. "I can go barefoot outside only in the summer." b. "I should wear good fitting shoes." c. "I cannot soak my feet in a hot tub." d. "I can use lotion on my feet."

a. "I can go barefoot outside only in the summer." Diabetic patients should not go barefoot outside even in the summer as they often have neuropathy, which decreases the patient's ability to discern touch, especially in the lower extremities. This can lead to foot injuries that can become infected and are slow to heal. The patient should wear good fitting shoes, should avoid extreme temperatures, and can use lotion to keep their skin moist to avoid overly dry skin.

The nurse is providing discharge education for the patient who is going home with a walker. Which statements by the patient indicate a good level of understanding of safety in the home? (Select all that apply.) a. "I need to remove the throw rugs." b. "I should make sure I only take a bath." c. "I cannot use the stairs." d. "I need to place a nonskid mat in front of the kitchen sink." e. "I wish I had two ways of leaving the house."

a. "I need to remove the throw rugs." d. "I need to place a nonskid mat in front of the kitchen sink." To ensure patients do not have hazards that can cause falls at home, the nurse should evaluate where the living quarters are. If the patient has stairs, they need to be able to safely learn how to use the stairs. They need to remove throw rugs that are a trip hazard and place nonskid mats in front of sinks, tubs, and showers. They can shower with a bench or chair in the shower for sitting. Patients need a clear the exit so they can get out of the house quickly in case of an emergency, but do not specifically need two different exits because of the walker.

The nurse is teaching a patient about ways to decrease risk of bone fractures. Which statements by the patient indicate a good understanding of decreasing this risk? (Select all that apply.) a. "I should do weight-bearing exercises." b. "I should get adequate intake of calcium and vitamin D." c. "I should exercise regularly." d. "I need to do yoga exercises." e. "I wish I could reduce my risk but I can't do anything."

a. "I should do weight-bearing exercises." b. "I should get adequate intake of calcium and vitamin D." c. "I should exercise regularly." Inadequate dietary intake of calcium and vitamin D or impaired calcium metabolism may result in osteoporosis, which increases bone fragility and may lead to fractures. Decreased physical exercise and lack of weight-bearing exercise also contribute to bone fragility, deterioration, and loss of strength. Any type of exercise will help; it does not need to be yoga, but it does need to include weight-bearing exercise.

The nurse is caring for a patient who has been prescribed warfarin (Coumadin) therapy after being diagnosed with atrial fibrillation. The patient asks the nurse what could happen if the prescription doesn't get filled. What is the nurse's best response? a. "You could have a stroke." b. "Your kidneys could fail." c. "You could develop heart failure." d. "You could go into respiratory failure."

a. "You could have a stroke." A major complication of chronic atrial fibrillation is formation of blood clots within the atria due to sluggish blood flow. Anticoagulation therapy is common to prevent blood clot formation that could travel to the brain, causing a stroke.

The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient's pulse oximetry is only 88% on 4 L of oxygen. What is the priority intervention of the nurse? a. Administer the ordered intravenous diuretic. b. Prepare for insertion of a chest tube. c. Suction secretions from the patient's respiratory tract. d. Have the patient use the ordered incentive spirometer.

a. Administer the ordered intravenous diuretic. The patient's respiratory distress is due to pulmonary edema and fluid overload from left-sided congestive heart failure. A diuretic will pull the excess fluid out of the body through the urine and relieve the patient's distress. A chest tube is not needed as the fluid is within the alveoli rather than between the lung and chest wall. Suctioning and use of an incentive spirometer will not address fluid overload or improve the patient's symptoms.

Which patient-specific factors does the nurse include when assessing pulse? (Select all that apply.) a. Age b. Gender c. Religion d. Exercise e.Medications

a. Age b. Gender d. Exercise e.Medications The nurse should consider several patient-specific factors when assessing the pulse, age, gender, exercise, presence of fever, medications, fluid volume status, stress, and underlying disease processes. Religion is not an appropriate response.

The nurse is performing a respiratory assessment on a patient. Which assessment findings indicate to the nurse that the patient has a history of long-standing chronic respiratory disease? (Select all that apply.) a. All the patient's fingernails are noticeably clubbed. b. The patient needs to sleep on at least four to five pillows at night. c. The patient's chest has equal antero-posterior and transverse diameters. d. The patient's lower legs have large areas of brownish spotted discoloration. e. The patient reports puffiness of both feet when standing for long periods. f. The patient's forced vital capacity test result is 3.8 L of air.

a. All the patient's fingernails are noticeably clubbed. b. The patient needs to sleep on at least four to five pillows at night. c. The patient's chest has equal antero-posterior and transverse diameters. Clubbing of fingernails, the need to sleep in an upright position, and a barrel chest are all indicative of long-standing chronic respiratory disease like COPD. Brownish spotted discoloration is indicative of venous insufficiency. Edema can be seen in renal and heart failure. Forced vital capacity of almost 4 L is found in patients with good respiratory function.

The nurse is assessing the extremities of a client who had wrist restraints applied 2 hours ago. Which findings noted by the nurse are indicative of impaired circulation? Select all that apply. a. Areas of pallor b. Areas of erythema c. Decreased movement d. Heightened sensation e. Decreased temperature f. Reports of pain or tingling

a. Areas of pallor c. Decreased movement e. Decreased temperature f. Reports of pain or tingling When assessing the skin of a client with bandages, cast, restraints, or other restrictive devices, assessment findings indicating impaired circulation include the following: areas of pallor, decreased movement, decreased temperature, and reports of pain or tingling. Areas of erythema and heightened sensation are not appropriate findings.

A nurse assesses a patient's radial pulse rate to be 110 beats/min and regular. What action by the nurse is best? a. Assess the patient for causes of tachycardia. b. Take an apical heart rate and compare the two. c. Document the findings in the patient's chart. d. Notify the patient's health care provider.

a. Assess the patient for causes of tachycardia. Tachycardia (rapid heart rate) is often caused by factors such as pain, anxiety, fever, or fluid volume alterations. The nurse should assess the patient thoroughly for possible causative factors. Since the pulse is regular, there is no reason to take an apical pulse. The findings should be documented, but the nurse needs to do more. The provider may or may not need to be notified, depending on the outcome of the nurse's assessment.

The nurse assesses a patient's pulse and finds it hard to obliterate with palpation. What action by the nurse is the most appropriate? a. Assess the patient for fluid volume overload. b. Assess the patient for fluid volume deficit. c. Assess the patient's apical heart rate. d. Assess the patient's pulse deficit.

a. Assess the patient for fluid volume overload. A pulse that is hard to obliterate (a bounding pulse) can be caused by fluid volume overload, or overhydration. The nurse should assess for this situation. The other actions are not necessary.

The nurse assessing respirations understands that problems in what organs can directly affect the process of respiration? (Select all that apply.) a. Brain b. Lungs c. Heart d. Liver e. Skeletal muscle

a. Brain b. Lungs c. Heart Problems in the brain, heart, and lungs can directly lead to changes in respiratory rate and effort. Problems in the liver and skeletal muscle do not affect respirations directly.

The nurse is caring for a patient who has presented to the ER with chest pain. Which diagnostic test will best indicate if there is significant blockage of important blood vessels that provide oxygen to the heart muscle? a. Cardiac catheterization b. Chest x-ray c. Echocardiogram d. Electrocardiogram

a. Cardiac catheterization Cardiac catheterization includes the use of contrast dye to visualize the coronary arteries and determine blood flow to cardiac muscle. The other tests will not allow the physician to determine which (if any) coronary arteries are occluded.

The nurse is ambulating a patient back from the bathroom when the patient begins to have a seizure. Which action should the nurse do first? a. Lower the patient to the floor if standing. b. Move sharp or hard objects away from the patient. c. Turn the patient's head to the side to prevent aspiration. d. Attempt to place a tongue blade to prevent choking.

a. Lower the patient to the floor if standing. During a seizure, a patient should be protected from injury by first lowering the patient to the ground if standing. The nurse should then place the head on a soft surface and turn it to the side to prevent aspiration and move sharp or hard objects out of the way. The nurse should never attempt to force any object into a seizing patient's mouth.

The nurse is caring for a patient who will be returning to the nursing unit following a cardiac catheterization via the right femoral artery. Which assessment is the highest priority for the nurse to perform when the patient arrives on the unit? a. Checking the patient's right pedal pulse and warmth of the right leg b. Checking pulse oximetry and listening to the patient's lung sounds c. Checking bilateral radial pulses to check for a pulse deficit d. Estimating the patient's jugular venous pressure

a. Checking the patient's right pedal pulse and warmth of the right leg Cardiac catheterization includes the insertion of a large IV needle into the patient's femoral artery. Occlusion of the femoral artery may develop after the procedure leading to faint or absent pedal pulses and loss of warmth to the right leg. The nurse should check the patient's right pedal pulses and leg warmth to ensure that the femoral artery has not become occluded. The other assessments may be performed once the patient's right leg is found to be warm with strong pulses.

The nurse is caring for a patient with a chest tube who was transported to radiology for testing. When the patient returns to the nursing unit, the transporter shows the nurse the patient's chest tube collection device, which was badly damaged after being caught in the elevator door. What is the priority action of the nurse? a. Clamp the chest tube until the collection device is replaced. b. Cover the insertion site with a new occlusive dressing. c. Ensure that there is gentle bubbling in the water seal chamber. d. Check the patient's lung sounds and pulse oximetry.

a. Clamp the chest tube until the collection device is replaced. The broken collection device may no longer be used to collect chest tube drainage. Clamping the chest tube until the collection device is replaced will prevent air from entering the lung space until the new collection device is attached.

The nurse understands that which factors can increase blood pressure? (Select all that apply.) a. Head injury b. Decreased fluid volume c. Increasing age d. Recent food intake e. Pain

a. Head injury c. Increasing age d. Recent food intake e. Pain Head injury, increasing age, recent food intake, pain, and increased (not decreased) fluid volume all can increase blood pressure.

The nurse knows which items are included in the documentation for a patient on fall precautions? (Select all that apply.) a. History of any falls b. Falls risk assessment scores c. Patient and family education d. Use of assist devices e. Any fall or reported fall

a. History of any falls b. Falls risk assessment scores c. Patient and family education d. Use of assist devices e. Any fall or reported fall The nurse should document the general assessment, include the patient's medical history, subjective and objective data, medication review, musculoskeletal status, and history of falls. Falls assessment and reassessment, patient family education and use of assist devices are also documented. Thoroughly document a fall or reported fall.

The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient is breathing spontaneously but is minimally responsive and having difficulty maintaining a patent airway. Which intervention is the most appropriate for the patient to improve oxygenation? a. Insert an oral airway. b. Lower the head of the bed. c. Turn the patient's head to the side. d.Monitor the patient's pulse oximetry

a. Insert an oral airway. An oral airway will prevent the patient's tongue from falling back and occluding the airway. Lowering the head of the bed will only increase airway occlusion and risk of aspiration. Turning the patient's head to the side will not clear the back of the patient's tongue from the airway. Monitoring the patient's pulse oximetry will not improve oxygenation or clear the airway.

A nurse performs orthostatic blood pressure readings on a patient with the following results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best? a. Instruct the patient not to get up without help. b. Document the findings and continue to monitor. c. Reassure the patient that these findings are normal. d. Reassess the blood pressures in 1 hour.

a. Instruct the patient not to get up without help. This patient has orthostatic hypotension, which is a drop of 20 mm Hg in systolic reading and 10 mm Hg in diastolic reading when the patient stands up from a sitting or lying position. The patient's cardiovascular system does not compensate for this, so the patient is at risk of becoming dizzy and fainting. The nurse instructs the patient to call for assistance before getting up to prevent a fall. The nurse should document the findings but needs to do more. These findings are not normal, so the nurse should not tell the patient that they are. The patient may need to be assessed sooner than 1 hour.

The nursing student learns that the purpose of measuring a patient's vital signs includes which of the following rationale? (Select all that apply.) a. Monitor body systems functioning. b. Identify early signs of problems. c. Evaluate effectiveness of interventions. d. Determine if a cure has been obtained. e. Provide a baseline to compare against.

a. Monitor body systems functioning. b. Identify early signs of problems. c. Evaluate effectiveness of interventions. e. Provide a baseline to compare against. Vital signs give information on the functioning of body systems, can lead the nurse to identify early signs of problems, can be used to evaluate the effectiveness of interventions, and provide a baseline to compare against subsequent readings. They are not used to solely determine if a disease has been cured.

The nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented. What is the priority action of the nurse? a. Obtain an arterial blood gas to check for carbon dioxide retention. b. Increase the patient's oxygen until the pulse oximetry is greater than 98%. c. Lower the head of the patient's bed and insert a nasal airway. d. Administer a mild sedative and reorient the patient as needed.

a. Obtain an arterial blood gas to check for carbon dioxide retention. Confusion and disorientation in a patient with severe COPD may likely be due to carbon dioxide retention. An arterial blood gas should be drawn to determine if this is the case. COPD patients should be kept on low oxygen flow rates whenever possible to avoid impeding the drive to breathe. Lowering the head of the bed will increase the difficulty of breathing as the abdominal contents press on the diaphragm. A sedative will cause respiratory depression and should be avoided.

The nurse is working with a nursing assistant to care for a patient with a new tracheostomy. Which tasks may the nurse delegate to the assistant? (Select all that apply.) a. Obtaining masks, gloves, and suction supplies from the utility room b. Helping to reassure the patient before, during, and after suctioning c. Changing the Velcro or twill ties used to secure the tracheostomy d. Transporting sputum specimens to the lab for culture and sensitivity testing e. Assessing need for suctioning of the oropharynx or tracheostomy f. Teaching the patient how to remove and clean the inner cannula

a. Obtaining masks, gloves, and suction supplies from the utility room b. Helping to reassure the patient before, during, and after suctioning d. Transporting sputum specimens to the lab for culture and sensitivity testing Care of a new tracheostomy may not be delegated to a nursing assistant. Obtaining supplies needed for care, helping to reassure the patient, and bringing specimens to the lab are tasks that may be assigned to the assistant.

The nurse is visiting a patient with cardiac disease who has been experiencing increased episodes of shortness of breath when exercise is attempted. The nurse is concerned that the patient's decrease in activity may lead to which outcome? a. Orthostatic hypotension b. Increase risk of heart disease c. Loss of short-term memory d. Worsening shortness of breath

a. Orthostatic hypotension Inactivity in patients with cardiopulmonary disease can lead to an unsafe drop in blood pressure with position changes, or orthostatic hypotension. The patient already has heart disease. Loss of short-term memory is not related to the shortness of breath. The lack of activity is not likely to worsen the shortness of breath; improving activity level may help things eventually.

The nurse is caring for a woman who had a right-sided mastectomy 2 years ago. What action by the nurse is most appropriate? a. Place a sign above the bed: "No blood pressures on the right arm." b. Place a sign above the bed: "No continuous blood pressures on the right arm." c. Place a sign above the bed: "Blood pressures in legs only." d. No specific action is needed for this situation.

a. Place a sign above the bed: "No blood pressures on the right arm." After a mastectomy or after lymph nodes have been removed, the patient should not have blood pressures taken on the operative side. Doing so can cause lymphedema. The nurse communicates this to all staff with a sign stating that no blood pressures are to be taken on the right side. The other actions are not warranted.

The nurse is caring for a patient who has been intubated with an oral endotracheal tube for several weeks. The physicians predict that the patient will need to remain on a ventilator for at least several more weeks before he will be able to maintain his airway and breathe on his own. What procedure does the nurse anticipate will be planned for the patient to facilitate recovery? a. Placement of a tracheostomy tube b. Diagnostic thoracentesis c. Pulmonary angiogram d. Lung transplantation surgery

a. Placement of a tracheostomy tube Placement of a tracheostomy tube will secure the patient's airway directly through the trachea, eliminating the need for the endotracheal tube. This will make the patient more comfortable and may allow eating while minimizing damage to the oropharynx from the endotracheal tube.

The staff nurse knows that many health care facilities use the fire emergency response defined by which acronym? a. RACE b. PASS c. PACE d. QSEN

a. RACE RACE stands for rescue, alarm, contain, and extinguish. QSEN is the Quality and Safety Education for Nurses. PASS is pull, aim, squeeze, and sweep for fire extinguishers. PACE is not a health care acronym.

The home care nurse is caring for a patient who has severe COPD and home oxygen therapy. The patent tells the nurse that she feels much better after increasing the oxygen flowmeter from 2 L to 5 L/min. The patient's pulse oximetry is 98%. What is the priority action of the nurse? a. Reduce the oxygen flow rate until the patient's pulse oximetry value is more than 90%. b. Inform the patient's physician and obtain an order for oxygen at 5 L/min. c. Document the intervention and findings in the patient's medical record. d.Listen to the patient's lung fields and reinforce pursed-lip breathing techniques.

a. Reduce the oxygen flow rate until the patient's pulse oximetry value is more than 90%. The goal of long-term therapy for the patient with COPD is usually to have an oxygen saturation level of more than 90%, which represents adequate delivery of oxygen to the tissues. Oxygen saturation may decrease during exercise, sleep, or deterioration of the respiratory status. For the patient with COPD, use low-flow oxygen delivery only ( 2 L/min) unless a higher level of oxygen administration is indicated by low oxygen saturation levels. High-flow oxygen may lead to respiratory suppression caused by loss of the patient's drive to breathe. The nurse should reduce the oxygen flow rate until the patient's pulse oximetry is more than 90% and educate the patient about oxygen therapy for COPD.

The nurse notes the following findings when assessing a patient with COPD. Which require prompt nursing intervention? (Select all that apply.) a. The patient is unable to speak without gasping. b. The patient's fingernails are noticeably clubbed. c. The patient's sputum has turned from yellow to greenish-brown. d. The patient has stridor with wheezes heard in all lung fields. e. The patient's forced vital capacity has increased from 2.8 to 3.4 L. f. The patient has become confused and mildly disoriented.

a. The patient is unable to speak without gasping. c. The patient's sputum has turned from yellow to greenish-brown. d. The patient has stridor with wheezes heard in all lung fields. f. The patient has become confused and mildly disoriented. A patient who is unable to speak without gasping is indicative of poor airflow through the airways, which must be addressed promptly. Greenish-brown sputum may indicate pneumonia requiring antibiotic treatment. Stridor and wheezes are indicative of an acute asthma attack. Confusion and disorientation in a patient with COPD may indicate retention of carbon dioxide. Clubbed fingernails are indicative of a chronic respiratory condition. Increased forced vital capacity is a positive sign.

The nurse is caring for a patient who developed a pulmonary embolism after surgery. Which goal statement is the highest priority for the nurse to include in the patient's care plan for the diagnosis impaired gas exchange r/t impaired pulmonary blood flow from embolus? a. The patient will maintain pulse oximetry values of at least 95% on room air. b. The patient will verbalize understanding of ordered anticoagulants. c. The patient will report chest pain of no greater than 3 on a 1 to 10 scale. d. The patient will ambulate 50 feet in hallway without shortness of breath.

a. The patient will maintain pulse oximetry values of at least 95% on room air. Oxygenation is the most important human need, so adequate oxygenation of tissues as evidenced by pulse oximetry values of at least 95% on room air is the highest priority goal. The other goals may be addressed once the oxygenation goal has been met.

The nurse appropriately delegates care of the unit's patients to the properly trained UAP when that UAP is assigned which tasks? (Select all that apply.) a. UAP assigned to reposition the patient. b. UAP assigned to complete the MORSE falls risk scale. c. UAP assigned to provide range-of-motion exercises. d. UAP assigned to ambulate the patient in the hallway. e. UAP assigned to time the patient on a TUG test.

a. UAP assigned to reposition the patient. c. UAP assigned to provide range-of-motion exercises. d. UAP assigned to ambulate the patient in the hallway. UAPs provide hands-on care for immobilized patients under the direct supervision of registered nurses. Turning and positioning of patients, range-of-motion exercises, transfers, and assistance with ambulation may be delegated to properly trained UAP. UAPs may not assess patients because that is a nursing responsibility. The MORSE falls risk scale is a risk assessment as is the Timed Up and Go (TUG) test.

The home care nurse is performing an environmental assessment in the home of an older client. Which observation by the nurse requires intervention? a. Unsecured scatter rugs b. Clear exit passageways c. An operable smoke detector d. A prefilled medication cassette

a. Unsecured scatter rugs Trauma to the older client in the home may be caused by a variety of factors. These include an unsteady gait, the presence of unsecured scatter rugs, cluttered passageways, inoperable smoke detectors, and a history of previous falls. Any assessment findings that could lead to injury or trauma in the home would be addressed immediately.

The nurse is providing education to a community group on environmental safety. Which safety measures are effective in improving their environmental safety? (Select all that apply.) a. Use of night-lights throughout the home b. Illumination of stairwells and pathways c. Installation of motion-activated lighting on the exterior of the home d. Application of wax to all floors to increase shine e. Staying indoors when air pollution is high

a. Use of night-lights throughout the home b. Illumination of stairwells and pathways c. Installation of motion-activated lighting on the exterior of the home e. Staying indoors when air pollution is high Inadequate lighting presents safety concerns in home, work, community, and health care environments. For an individual to safely and successfully navigate pathways and perform various activities while avoiding potential obstacles and hazards, the environment must be well illuminated. Well-lit, glare-free halls, stairways, rooms, and work spaces help to reduce the risk of tripping, slipping, and falling. Night-lights reduce the risk of injuries to children, guests, and older adults. Lighting the exterior of the house will also reduce the risk of falling. Staying indoors during episodes when air pollution is high can help prevent chronic lung disease. Waxed floors are slippery.

The patient has a nursing diagnosis of Risk for Falls. The nurse identifies which goal to be most important? a. Patient will ambulate twice a day. b. Patient will have no symptoms of infection. c. Patient will perform activities of daily living. d. Patient will have no injuries during hospital stay.

d. Patient will have no injuries during hospital stay. All the goals except lack of infection are appropriate for a patient with a Risk for Falls diagnosis; however, the most important goal is for the patient to have no injuries during the hospitalization.

The nurse is caring for a postoperative patient who has just been diagnosed with a deep vein thrombosis (DVT) in the right leg. Which focused assessment question has the highest priority for this patient? a. "Do you have a headache or any dizziness?" b. "Do you have any chest pain or shortness of breath?" c. "When did you first notice the swelling and redness in your leg?" d. "Do you have any cramping or muscle spasms in your leg?"

b. "Do you have any chest pain or shortness of breath?" The highest risk of a DVT is the potential for the clot to break free and travel through the bloodstream to cause a pulmonary embolus (PE). The nurse should ask the patient about chest pain or shortness of breath to assess if a PE may have occurred.

The nurse is providing discharge instructions to an older adult who is being discharged with orthostatic hypotension. Which response by the patient indicates a need for further education? a. "I should take my blood pressure once a day at home." b. "I should get up quickly to avoid my blood pressure dropping." c. "I should drink plenty of water during the day." d. "I should get up slowly and carefully."

b. "I should get up quickly to avoid my blood pressure dropping." In orthostatic hypotension, dizziness and loss of consciousness may occur if a patient changes position too quickly. Instead they should change positions slowly. A patient can take their blood pressure at home to monitor it. Drinking water will keep them hydrated.

The nurse is delegating taking vital signs to an unlicensed assistive personnel (UAP). What instructions does the nurse provide the UAP? (Select all that apply.) a. "Let me know if Mr. Smith's blood pressure is low." b. "Take Mrs. Jones' blood pressure every 15 minutes." c. "Call me if Ms. Walsh's systolic blood pressure drops to under 100 mm Hg." d. "Do you want me to demonstrate using the electronic blood pressure cuff?" e. "I'll take Mr. Derby's blood pressure since he is not stable."

b. "Take Mrs. Jones' blood pressure every 15 minutes." c. "Call me if Ms. Walsh's systolic blood pressure drops to under 100 mm Hg." d. "Do you want me to demonstrate using the electronic blood pressure cuff?" e. "I'll take Mr. Derby's blood pressure since he is not stable." The nurse can delegate measuring vital signs to UAPs if the patient is stable. The nurse must ensure the UAP knows the proper technique for taking vital signs and knows which readings must be reported. Telling the UAP to report a blood pressure that is "too low" is too vague.

A nursing student is caring for a patient with metabolic acidosis. The student asks the registered nurse why the patient's respiratory rate is so high. What response by the nurse is best? a. "The patient's metabolic rate is increased from being ill." b. "The lungs are trying to rid the body of extra carbon dioxide." c. "The patient is trying to reduce his temperature through panting." d. "Patients who are acutely ill often have abnormal vital signs."

b. "The lungs are trying to rid the body of extra carbon dioxide." The body tries to compensate for excess carbon dioxide (seen in acidosis) by increasing the rate and depth of respirations to "blow off" the carbon dioxide.

The nurse is teaching a student nurse about restraint use in patients. Which statement by the student nurse indicates a learning need regarding restraints? a. "Having all four side rails up on the bed is considered a restraint." b. "The use of restraints has been shown to decrease fall-related injuries." c. "Death has been associated with the use of restraints." d. "Medications administered to control behavior are considered a chemical restraint."

b. "The use of restraints has been shown to decrease fall-related injuries." Restraints may be physical or chemical. A physical restraint is a mechanical or physical device, such as material or equipment attached or adjacent to the patient's body, used to restrict movement. Examples of physical restraints are wrist or ankle restraints, a jacket or vest, and side rails. A medication that is administered to a patient to control behavior is a chemical restraint. The use of restraints has been associated with patient injury including death and does not prevent patient falls.

Which patient assessment result would require the nurse to assess that patient further? a. A 40-year-old woman with a radial pulse of 68 b. A 65-year-old man with a respiratory rate of 10 c. A 12-year-old with a pulse of 92 after ambulating in the hallway d. A 50-year-old man with a BP of 112/60 upon awakening in the morning

b. A 65-year-old man with a respiratory rate of 10 The normal respiratory rate is 12 to 20 breaths/min for an adult, so a rate of 10 would require further assessment. The other options are all within normal limits. normal pusle rate: 60-100

The nurse knows which findings indicate orthostatic hypotension? (Select all that apply.) a. A decrease in systolic blood pressure by 30 mm Hg b. A decrease in diastolic blood pressure by 10 mm Hg c. An increase in heart rate by 30 beats/min d. An increase in systolic blood pressure by 20 mm Hg e. A decrease in heart rate by 20 beats/min

b. A decrease in diastolic blood pressure by 10 mm Hg d. An increase in systolic blood pressure by 20 mm Hg A drop in systolic blood pressure of 20 mm Hg, an increase in heart rate of 20 beats/min, or a drop of diastolic blood pressure of 10 mm Hg when a patient stands is classified as orthostatic hypotension.

The nurse is caring for a confused, combative patient. Which action would be considered last by the nurse to control behavior of the client? a. Orient the patient frequently. b. Apply restraints. c. Move the patient to a room close to the nurse's station. d. Encourage the family to spend time with the patient.

b. Apply restraints. All alternatives to physical restraints should be considered prior to their use.

The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The pulse oximeter does not provide a good reading. What action by the nurse is best? a. Move the oximeter probe to another finger. b. Assess the fingers for good circulation. c. Document that the reading cannot be obtained. d. Remove any fingernail polish present on the fingernail.

b. Assess the fingers for good circulation. A patient who is hypothermic may not have good circulation to the extremities. The nurse should assess the patient's circulation, and if it is poor to the extremities, choose another spot at which to measure the oxygen saturation. Moving the probe to another finger or removing nail polish will not help if the problem is poor circulation. The nurse should document appropriately but needs to do more than just charting that the reading could not be obtained.

The student nurse is assessing a patient's pulses. What action by the student requires the nurse to intervene? a. Assessing apical pulse between the fifth and sixth intercostal spaces b. Assessing the dorsalis pedis pulse by palpating behind the patient's knee c. Assessing the radial pulse on the patient's wrist d. Assessing the brachial pulse on the patient's inner elbow

b. Assessing the dorsalis pedis pulse by palpating behind the patient's knee The dorsalis pedis pulse is palpated on the top of the foot. The other assessment locations and pulses are correct.

The nurse finds the patient in cardiopulmonary arrest with no pulse or respirations. Which oxygen delivery device will the nurse use for this patient? a. Non-rebreather mask b. Bag-valve-mask unit c. Continuous positive airway pressure (CPAP) d. High-flow nasal cannula

b. Bag-valve-mask unit The priority of the nurse is to ventilate the patient manually using a bag-valve-mask unit (also called by the proprietary name Ambu bag). This allows air to be forced into the patient's lungs when there are no spontaneous respirations. The non-rebreather mask and nasal cannula require the patient to breathe on his or her own. CPAP is used for patients who are awake, oriented, and in respiratory failure.

The family of a patient who was in a motor vehicle accident tells the nurse "I'm just not the person I was before the crash." The nurse recognizes this is likely because of the injury to what area of brain? a. Parietal lobes b. Frontal lobes c. Occipital lobes d. Temporal lobes

b. Frontal lobes The frontal lobes of the cerebrum are the areas of the brain responsible for voluntary motor function, concentration, communication, decision making, and personality. The parietal lobes are responsible for the sense of touch, distinguishing the shape and texture of objects. The temporal lobes are concerned with the senses of hearing and smell. The occipital lobes process visual information.

The nurse is instructing a client who had a stroke and has weakness on one side how to ambulate with the use of a cane. Which instruction would the nurse provide to the client? a. Hold the cane on the affected (weak) side. b. Hold the cane on the unaffected (strong) side. c. Move the cane forward first along with the unaffected (strong) leg. d. Move the cane and the unaffected (strong) leg down first when going down stairs.

b. Hold the cane on the unaffected (strong) side. The cane is kept on the strong side of the body. It would be hard to hold the cane on the weak side. The cane is assisting the weakened leg, so the weakened leg moves with the cane, or right after it, in ambulating or in going down stairs. (Cane, affected leg, normal leg)

A nurse is teaching a patient and the patient's family about self-care measures for hypertension. Which topics should the nurse include? (Select all that apply.) a. Increase exercise on most days. b. Maintain a normal body weight. c. Abstain from any alcohol. d. Reduce dietary sodium to 2.4 g/day. e. Follow the DASH diet.

b. Maintain a normal body weight. d. Reduce dietary sodium to 2.4 g/day. e. Follow the DASH diet. Self-care measures for hypertension include 30 minutes of aerobic exercise on most days of the week, maintaining a normal body weight, limiting alcohol to two drinks/day for men and one drink/day for women, reducing sodium intake to 2.4 g/day, and following the DASH diet.

The nurse is caring for an older client following surgical repair of a hip fracture. On assessment of the client, the nurse notes that the client is disoriented and is attempting to get out of bed. Which is the most appropriate initial nursing intervention? a. Apply restraints to the client. b. Place a mattress sensor pad on the bed. c. Have the assistive personnel check the client every half-hour. d. Collaborate with the primary health care provider for a prescription for a sedative.

b. Place a mattress sensor pad on the bed. A client would not be placed in a physical restraint or sedated just because he or she is older and disoriented. Alternative methods would be used before applying any types of restraints. For example, a mattress sensor pad will alert the nursing staff of movement. Physical restraints may cause further disorientation and would not be applied unless specifically prescribed. Agency policies and procedures need to be followed before the application of restraints.

The nurse is performing a morning assessment and notes the patient to be experiencing dyspnea. Which patient assessment findings would most indicate this respiratory condition? (Select all that apply.) a. Occasional productive cough b. Pulse oximetry 89% c. Patient in orthopneic position d. Respirations 26 & shallow e. Temperature 100.1 °F

b. Pulse oximetry 89% c. Patient in orthopneic position d. Respirations 26 & shallow Dyspnea is difficult, labored breathing, usually with a rapid, shallow pattern, that may be painful. Anxiety usually is present as well. Accessory muscles in the chest and neck are used in dyspneic breathing. Many patients experiencing dyspnea find it easier to breath in an upright position. Difficulty breathing experienced in positions other than sitting or standing is termed orthopnea. Occasional productive cough and slight temperature elevation are not indicators of dyspnea.

A nurse is caring for a patient who has an elevated temperature. The nurse plans to help the patient regain a normal temperature through conduction. What technique does the nurse use? a. Placing a cooling fan in the patient's room b. Putting ice packs in the patient's axillae c. Spraying the patient with a fine mist of water d. Turning the temperature down in the room

b. Putting ice packs in the patient's axillae Conduction is the transfer of heat through direct contact with another object, such as an ice pack. A cooling fan would help lower temperature by convection. Spraying the patient with a mist of water would lead to evaporative cooling. Turning the temperature down is an example of radiation.

The nurse identifies which instruction to be appropriate to delegate to the UAP (Unlicensed assistive personnel)? a. Assess the patient's skin during a bath. b. Reposition the patient using the trapeze. c. Assess the patient's ability to perform range-of-motion exercises. d. Notify the health care provider of any changes.

b. Reposition the patient using the trapeze. Repositioning a patient can be delegated to unlicensed assistive personnel (UAP); the nurse should provide proper instruction regarding specific positioning techniques, individualized patient concerns, and circumstances that require notifying a nurse. UAP may not perform assessments or evaluations but should notify the nurse about any skin or musculoskeletal issues (not the health care provider).

A nurse is going to take an oral temperature on a patient who has just consumed a cup of coffee. What action by the nurse is best? a. Have the patient drink room temperature water. b. Return in 30 minutes to take the patient's temperature. c. Take the patient's temperature rectally instead. d. Document that temperature is unable to be obtained.

b. Return in 30 minutes to take the patient's temperature. Oral temperatures will be inaccurate if the patient has been drinking or eating hot or cold foods. The nurse instructs the patient not to continue drinking the coffee and returns in 30 minutes to take the temperature. Drinking room temperature water will not "even out" the patient's mouth temperature. The rectal route is not preferred by patients and should not be used in this situation. The nurse needs a temperature and so should not document that it was not obtained.

The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the AP? a. Placing a safety knot in the safety device straps b. Safely securing the safety device straps to the side rails c. Applying safety device straps that do not tighten when force is applied against them d. Securing so that two fingers can slide easily between the safety device and the client's skin

b. Safely securing the safety device straps to the side rails The safety device straps are secured to the bed frame and never to the side rails to avoid accidental injury in the event that the side rails are released. A half-bow or safety knot or device with a quick-release buckle would be used to apply a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in case of an emergency. The safety device needs to be secure, and one or two fingers would slide easily between the safety device and the client's skin.

A nurse observes a student taking an adult patient's tympanic temperature. What action by the student requires the nurse to intervene? a. Student washes hands prior to patient contact. b. Student pulls the pinna of the patient's ear down and back. c. Student explains the procedure to the patient.

b. Student pulls the pinna of the patient's ear down and back. For an adult, the correct procedure for taking a tympanic temperature includes pulling the pinna of the patient's ear up and back. Children's pinnae are pulled down and back. Washing hands and explaining the procedure are appropriate.

A nurse is told in the hand-off report that a patient is afebrile. What assessment finding correlates with this statement? a. Blood pressure 152/98 mm Hg b. Temperature 98.4 °F (36.8 °C) c. Apical pulse 82 beats/min d. Respirations 16 breaths/min

b. Temperature 98.4 °F (36.8 °C) A temperature of 98.4 °F is normal. "Afebrile" means having a normal temperature. The other readings are not related to this term.

The nurse is correctly demonstrating the use of a transfer belt when engaging in which actions? (Select all that apply.) a. The belt is placed around the patient's hips. b. The belt is secure, leaving only enough room for the nurse to grasp the belt. c. The nurse stands on the weaker side. d. The nurse holds the belt on the side of the patient. e. The nurse stands behind the patient while ambulating.

b. The belt is secure, leaving only enough room for the nurse to grasp the belt. c. The nurse stands on the weaker side. Transfer belts are used for patients with an unsteady gait or generalized weakness. Canvas transfer or gait belts are applied snugly around the patient's waist, leaving only enough room for the nurse to grasp the belt firmly during ambulation. Some belts may have handles. If the patient has a weaker side, the nurse should stand on that side and hold the gait belt firmly at the back of the patient's waist while ambulating.

The preceptor is working with a new nurse to provide care for a patient with a chest tube to relieve a pneumothorax. Which action by the new nurse indicates need for additional teaching about chest tube care? a. The suction is discontinued when the patient is ambulated to the bathroom. b. The collection device is emptied at the end of the shift and output recorded in the chart. c. The patient's bed is placed in the semi-Fowler's position to facilitate lung reexpansion. d. The patient is encouraged to use his incentive spirometer at least 10 times every hour.

b. The collection device is emptied at the end of the shift and output recorded in the chart. The chest tube collection device is not emptied at the end of the shift. Instead, the amount of drainage present at the end of the shift (or specified time) is marked on the collection device and the amount of drainage is documented in the patient's chart.

The preceptor is working with a new nurse to suction a patient through a new tracheostomy. Which actions by the new nurse indicate need for additional teaching about the procedure? (Select all that apply.) a. The suction is not applied to the catheter until it is being withdrawn. b. The patient is placed in the supine position prior to suctioning. c. The suction catheter is twirled side to side as it is being withdrawn. d. Suction is applied continuously as the catheter is withdrawn. e. The patient's oxygen is reapplied between suction attempts. f. Water-soluble lubricant is applied to the suction catheter before insertion.

b. The patient is placed in the supine position prior to suctioning. d. Suction is applied continuously as the catheter is withdrawn. f. Water-soluble lubricant is applied to the suction catheter before insertion. The head of the patient's bed should be elevated prior to suctioning to facilitate coughing out secretions. Suction is always applied intermittently as the catheter is withdrawn. Water-soluble lubricant is used when suctioning the naris but not a tracheostomy because the secretions negate the need for additional lubrication.

The nurse correctly selects which intervention to avoid causing shear or friction when moving a patient in bed? a. Using an airflow bed b. Using a slide board c. Using a trochanter roll d. Using a gel mattress

b. Using a slide board A transfer or slide board is made of plastic-like material that reduces friction. Linens easily slide over the board, facilitating bed linen changes. Patients can be repositioned or transferred with a minimum of force required. A trochanter roll prevents outward rolling of the hip when a patient is lying on his/her back. An air-fluidized bed uses airflow to move silicone particles in the bed, creating a watery, fluid-like movement and resulting in lower pressure to avoid or alleviate decubitus ulcers. A foam or gel combination mattress reduces pressure.

The nurse is educating the family to care for a patient at home with cognitive alterations. Which statement by the family indicates a need for further education? a. "I should keep the home free of scissors." b. "I should minimize the number of visitors." c. "I should use push-button door locks." d. "24-hour supervision may become necessary."

c. "I should use push-button door locks." Use of door locks that require a key may be necessary if the patient wanders. Keep the environment free of hazards such as sharp objects and minimize distractions. If the patient is not safe to be left alone, 24-hour supervision may be necessary

The nurse is providing discharge instructions to a patient with visual alterations. Which statement by the patient indicates a need for further education? a. "I should make sure the passageways are wide." b. "I should remove all the throw rugs." c. "I should keep the lights dim." d. "I can use a cane to feel for objects in front of me."

c. "I should keep the lights dim." Bright lighting in hallways and stairways prevents falls by the patient who has limited vision. Furniture is placed to allow wide passageways. Throw rugs, which are a tripping hazard, are removed. If vision is severely limited, use of a cane or walking stick held slightly in front helps the patient feel objects in his/her path.

The nurse is delegating care to an unlicensed assistive personnel (UAP) to a patient who has sensory overload. Which statement by the UAP indicates a need for further orientation? a. "I should keep the noise levels low." b. "I should schedule all the care together." c. "I should keep the room well lit." d. "I should allow the family to visit."

c. "I should keep the room well lit." To prevent or alleviate overload, the nurse reduces sensory stimuli, dimming unnecessary lights and turning down the sound on alarms if possible. Nursing care is planned so that the patient is not constantly disturbed. Visitation by family provides reality orientation and a soothing, recognizable presence for some patients experiencing overload.

The nurse is educating the family of a patient on falls risk precautions. Which statement by the family indicates a need for further education? a. "I should keep the wheelchair locked unless using it to move Mom." b. "I should leave the bathroom light on as she does at her home." c. "I should leave her slippers by the wheelchair." d. "I should keep her cell phone close to her bed."

c. "I should leave her slippers by the wheelchair." Leave lights on or off at night, depending on the patient's cognitive status and personal preference. Keep the wheels of any wheeled device (e.g., bed, wheelchair) in the locked position. Keep patient belongings (e.g., tissues, water, urinals, personal items) within the patient's reach. If the patient is ambulatory, require the use of nonskid footwear (socks or shoes).

Which statement by the patient indicates to the nurse a teaching need regarding safety in the home? a. "I will put a night-light in every room." b. "I will not use an extension cord to plug in multiple items." c. "I will wash my throw rugs in the bathroom regularly." d. "I will keep all cleaning supplies out of reach of children."

c. "I will wash my throw rugs in the bathroom regularly." Throw rugs present a fall or tripping hazard. Night-lights help light halls to prevent falls, extension cords can present a trip hazard, and cleaning supplies can contain poisonous materials.

The nurse is educating the patient about the proper disposal of medications in the home. Which statement by the patient indicates a good understanding of the information? a. "Remove the label from the bottle and throw in the trash." b. "Flush the medication down the disposal." c. "Mix the medications with kitty litter, place the mixture in a jar, and put the jar in the trash." d. "Dissolve the medication in water and pour down the drain."

c. "Mix the medications with kitty litter, place the mixture in a jar, and put the jar in the trash." Flushing or pouring the medication down the drain can contaminate the water system. Throwing the medication in the trash poses potential for someone to remove the medication and use it. This can be avoided by mixing it with an undesirable substance like kitty litter or coffee grounds.

Which statement by the nurse correctly identifies the UAP role in patient restraint use? a. "The UAP can perform initial assessment." b. "The UAP can apply a restraint." c. "The UAP can assist with applying and monitoring of a physical restraint." d. "The UAP can contact the health care provider and request an order for restraints."

c. "The UAP can assist with applying and monitoring of a physical restraint." The UAP cannot perform the initial assessment, and most facilities require that a registered nurse or licensed practical nurse. Applying a restraint. The health care provider should be contacted by the nurse, not the UAP. The UAP can assist with applying the restraint and can perform monitoring checks under the direction of a Registered Nursing.

The nurse is educating the family of a patient in the intensive care unit about the patient's cognitive status, including the current problem of delirium. Which statement by the family indicates a need for further education? a. "The delirium can be caused by sensory overload." b. "The delirium is reversible." c. "The delirium is a mood disorder." d. "The delirium is a state of confusion."

c. "The delirium is a mood disorder." Delirium is a reversible state of acute confusion. It is characterized by a disturbance in consciousness or a change in cognition that develops over 1 to 2 days and is caused by a medical condition. Delirium may occur in intensive care patients as a result of sensory overload. It is not a mood disorder.

A nurse notes a patient has abnormal vital signs. What action by the nurse is best? a. Document the findings. b. Notify the provider. c. Compare with prior readings. d. Retake the vital signs in 15 minutes.

c. Compare with prior readings. Individual vital signs are not as important as the trends. For instance, a patient may have a blood pressure higher than "normal" that is normal for the patient. Trends give more useful information than a single reading. Documentation is important, but the nurse needs to do more. If the readings are significantly abnormal, the provider should be notified. The nurse may retake the vital signs if he/she is not confident of the first set of measurements, but should not wait for time to pass.

The nursing faculty member is observing a student taking a patient's carotid pulse. What action by the student requires intervention by the faculty member? a. Counts pulse for 30 seconds and multiplies by two. b. Performs hand hygiene prior to patient contact. c. Compares pulses in both carotid arteries at the same time. d. Assesses pulse on one side then assesses the other side.

c. Compares pulses in both carotid arteries at the same time. The carotid arteries are the main supply route of blood to the brain. Compressing both sides of the carotid arteries at the same time can lead to ischemia. The other actions are appropriate.

The nurse hears a loud murmur when listening to the patient's heart. Which diagnostic test will best display the condition of the valves and structures within the patient's heart that could be causing the murmur? a. Chest x-ray b. Cardiac catheterization c. Echocardiogram d. Electrocardiogram

c. Echocardiogram Echocardiograms allow for ultrasound visualization of the structures of the heart along with function of the heart valves and cardiac musculature.

The nurse is caring for a patient who has a history of congestive heart failure with generalized pitting edema. Which laboratory results will the nurse expect to find in the patient's chart? a. Glycosylated hemoglobin 12% b. Platelet count 450,000/mm3 c. Hematocrit 32% d. Prothrombin time 8.8 seconds

c. Hematocrit 32% Hemodilution is a common finding when patients are in fluid overload caused by congestive heart failure. A normal hematocrit result is 42% to 52% for a male and 37% to 47% for a female, so the patient's 32% hematocrit level is markedly low. The other laboratory results are not expected due to congestive heart failure or fluid overload.

The nurse knows changes in which body system affect overall mobility increasing the propensity of falling? a. Neurologic b. Hepatic c. Cardiopulmonary d. Musculoskeletal

d. Musculoskeletal Impairments in the musculoskeletal system can impact mobility through restrictions of range of motion and strength, increasing the chances of falling. Changes to the neurologic system can impair cognitive functioning, changes to the hepatic system can affect mental status, and changes to the cardiopulmonary system can affect activity tolerance.

The nurse has instructed a client with a continuous passive motion device applied to the leg about the device and its use. The nurse determines that the client has misunderstood one of the teaching points if the client asks which question? a. How to use the "stop-go" button b. About reporting discomfort in the knee to the nurse c. How to reset the degrees of flexion or extension according to comfort d. Whether the knee would stay aligned with the hinged joint on the machine

c. How to reset the degrees of flexion or extension according to comfort The client would not adjust the flexion and extension settings. These settings are determined by the orthopedic surgeon and are maintained as prescribed. The client is instructed about how to stop and start the machine and about the need to notify the nurse if the client experiences knee discomfort. The client also would be aware of proper positioning so that the nurse can be notified if the leg slips. Other important actions by the nurse with use of this device are to assess the neurovascular status of the extremity and to ensure that the device is padded with manufactured disposable padding before the client's leg is placed in the device.

The nurse is caring for a patient who is hospitalized for pneumonia. Which Nursing diagnosis has the highest priority? a. Activity intolerance r/t generalized weakness and hypoxemia b. Impaired nutritional intake r/t poor appetite and increased metabolic needs c. Impaired airway clearance r/t thick secretions in trachea and bronchi d. Lack of knowledge r/t use of nebulizer and inhaled bronchodilators

c. Impaired airway clearance r/t thick secretions in trachea and bronchi Airway maintenance and patency is the highest priority for all patients, especially patients with respiratory disorders. Oxygenation is the most important human need. The other diagnoses can apply once the patient's airway is kept patent.

What response would the nurse give the patient when questioned about the effect of rheumatoid arthritis on the musculoskeletal system? a. Muscle weakness b. Muscle wasting c. Joint inflammation d. Joint spasticity

c. Joint inflammation Rheumatoid arthritis and osteoarthritis cause inflammation of joints, resulting in pain and limited joint mobility, not muscle mobility. Genetic disorders such as muscular dystrophy result in muscle weakness and gradual muscle wasting. Spasticity (increased muscle tone) occurs in developmental disorders, such as cerebral palsy, and results in reduced range of motion (ROM) and abnormal movement patterns.

A nurse is caring for a patient who has orthopnea. What action by the nurse is most appropriate? a. Encourage deep breathing and coughing. b. Medicate the patient for pain as needed. c. Keep the head of the bed elevated. d. Monitor the length of time the patient doesn't breathe.

c. Keep the head of the bed elevated. Orthopnea is difficulty breathing in positions other than sitting up. To assist the patient who has orthopnea, the nurse keeps the head of the bed elevated to ease breathing.

The nurse is caring for a patient with advanced COPD who reports feeling short of breath. The nurse notes that the patient's lung sounds are diminished bilaterally and the patient's pulse oximetry is 91% on 2 L/min oxygen via nasal cannula. What actions will the nurse take to make the patient more comfortable? (Select all that apply.) a. Increase the patient's oxygen to 4 L/min via nasal cannula. b. Suction the patient's airway using sterile technique. c. Maintain eye contact and provide calm reassurance. d. Turn the patient onto the side for postural drainage. e. Administer the ordered nebulized bronchodilator. f. Elevate the head of the patient's bed to fully upright.

c. Maintain eye contact and provide calm reassurance. e. Administer the ordered nebulized bronchodilator. f. Elevate the head of the patient's bed to fully upright. Patients who are acutely short of breath due to advanced COPD will benefit from nebulized bronchodilator medication to open the airways. Elevating the head of the bed will prevent pressure on the diaphragm from the abdominal contents. A caring demeanor with eye contact will help the patient remain calm until the medication begins to work and the shortness of breath is eased. Patients with COPD should be kept on low-flow oxygen to maintain pulse oximetry of more than 90%.

A nurse is caring for a patient with a stroke that has altered her ability to see. The nurse knows which area of the brain was likely impacted by the stroke that is responsible for visual function? a. Parietal lobes b. Frontal lobes c. Occipital lobes d. Temporal lobes

c. Occipital lobes The occipital lobes process visual information. The frontal lobes of the cerebrum are the areas of the brain responsible for voluntary motor function, concentration, communication, decision making, and personality. The parietal lobes are responsible for the sense of touch, distinguishing the shape and texture of objects. The temporal lobes are concerned with the senses of hearing and smell.

The nurse identifies which goal to be appropriate for the patient who is postoperative day one from abdominal surgery and on bed rest with the nursing diagnosis impaired skin integrity? a. Patient will ambulate twice a day. b. Patient will eat 50% of meals. c. Patient will have no further skin breakdown. d. Patient will interact with others.

c. Patient will have no further skin breakdown. The patient already has a wound, so the goal is focused on no further skin breakdown as a result of the bed rest and immobility. Although nutrition is important to wound healing, it is not the focus of this Nursing diagnosis. Ambulating and interacting with others are not goals for this diagnosis.

The nurse receives a hand-off report on four patients. Which patient finding should the nurse assess first? a. Pulse oximetry 96% b. Blood pressure 102/62 mm Hg c. Pulse 42 beats/min d. Respiratory rate 18 breaths/min

c. Pulse 42 beats/min A pulse of 42 beats/min is considered bradycardia and the patient should be assessed first because perfusion could be compromised. The blood pressure, pulse oximetry, and respiratory rate are normal.

The nurse is caring for a client with impaired mobility that occurred as the result of a stroke. The client has right-sided arm and leg weakness. Which assistive device would the nurse suggest that the client use to provide the best stability for ambulating? a. Walker b. Crutches c. Quad cane d. Single straight-legged cane

c. Quad cane Crutches and a walker can be difficult to maneuver for a client with weakness on one side. A cane is better suited for the client with weakness of the arm and leg on one side, and a quad cane would provide the most stability because of the structure of the cane and because a quad cane has four legs.

The nurse is performing passive range-of-motion exercises on a patient when the patient begins to complain of pain. What is the first thing the nurse should do? a. Notify the health care provider. b. Hyperextend the joint. c. Stop the range of motion. d. Switch to active range of motion.

c. Stop the range of motion. Stop range-of-motion exercises if the patient begins to complain of pain or if resistance to movement is experienced. Never hyperextend or flex a patient's joints beyond the position of comfort. Active range of motion is when the patient moves the joint. Notifying the health care provider would happen later.

The home care nurse visits a client at home who has been experiencing increased weakness. The client tells the nurse that he is using a cane that was purchased at a local pharmacy. The home care nurse assesses the client's use of the cane and determines that the cane is sized correctly if which observation is made? a. The handle of the cane is even with the client's waist. b. The client's elbow is straight when ambulating with the cane. c. The client's elbow is flexed at a 15- to 30-degree angle when ambulating with the cane. d. The client's elbow is flexed at a 50- to 75-degree angle when ambulating with the cane.

c. The client's elbow is flexed at a 15- to 30-degree angle when ambulating with the cane. The height of a cane would be even with the greater trochanter. This allows the elbow to be held at approximately 15 to 30 degrees of flexion. The flexion is necessary to allow the client to push off without bending over when ambulating. Options 1, 2, and 4 are incorrect and present an unsafe situation.

The nurse is correctly assisting the patient in using a cane when the patient demonstrates which activities? (Select all that apply.) a. The top of the cane is level with the patient's bent elbow. b. The patient holds the cane on his/her weaker side. c. The patient moves the cane forward first. d. The patient's arm is comfortably bent when walking. e. The patient moves the strong leg forward first.

c. The patient moves the cane forward first. d. The patient's arm is comfortably bent when walking. The top of the cane should be level with the hip joint, and the patient's arm should be comfortably bent when the patient is walking. The patient should hold the cane on his/her stronger side and move the cane forward first, followed by the weaker leg and then the stronger leg. This ensures that another point of support is always on the ground when the weaker leg is bearing weight and gives the patient a wide base of support. A patient using a cane should be encouraged to stand up straight and look forward. Leaning to one side or looking down can jeopardize safety and cause poor posture.

The nurse identifies which goal to be most appropriate for the Nursing diagnosis of acute confusion? a. The patient will use the call light before getting out of bed within 48 hours. b. The patient will use a calendar to remember the date within 48 hours. c. The patient will respond appropriately to questions about place within 48 hours. d. The patient will remain within the unit while in long-term care.

c. The patient will respond appropriately to questions about place within 48 hours. The patient has acute confusion and therefore an appropriate early goal as the confusion resolves is to remember where they are. Remembering to use a call light would be appropriate for risk for falls. Using a calendar is appropriate for impaired memory and remaining in the unit is appropriate for chronic confusion.

The nurse is supervising an assistive personnel (AP) performing mouth care on an unconscious client. The nurse would intervene if the AP is observed taking which action? a. Turning the client's head to one side b. Using small volumes of fluid to rinse the mouth c. Using a gloved finger to open the client's mouth d. Placing an emesis basin under the client's mouth

c. Using a gloved finger to open the client's mouth The client who is unconscious is at great risk for aspiration. The AP turns the client's head to the side and places an emesis basin underneath the mouth. A bite stick or a padded tongue blade, not a gloved finger, is used to open the mouth to prevent injury to the caregiver. Small volumes of fluids are used to rinse the mouth.

The nurse is providing instructions to the assistive personnel (AP) who will be caring for a client with hand restraints. The nurse asks the AP to repeat the instructions to ensure that the AP understands the care. Which statement, if made by the AP, indicates an understanding of the care for this client? a. "I need to remove the restraints every 4 hours." b. "I need to make sure that the restraints are securely tied to the side rails." c. "If the family comes in to visit, I can tell them to take the restraints off if they want to." d. "I need to remove the restraints at least every 2 hours to perform range-of-motion exercises."

d. "I need to remove the restraints at least every 2 hours to perform range-of-motion exercises." The nurse would instruct the AP to check restraints, circulatory status, and skin integrity every 30 minutes. Additionally, restraints need to be removed at least every 2 hours to permit muscle exercise and promote circulation. Restraints are not to be secured to the bedrails because this could cause injury to the client if the rails are lowered. The responsibility of the client would not be placed on the family members. Agency guidelines regarding the use of restraints would always be followed.

The nurse has delegated to the UAP to assist a patient with ambulating in the hallway with a cane. Which statement by the UAP indicates a need for further education? a. "I should report any complaints of soreness to the nurse." b. "I should watch for indications that the patient has difficulties using the cane." c. "I should let the nurse or PT know if the cane doesn't seem to fit correctly." d. "I should teach the patient how to walk with the cane."

d. "I should teach the patient how to walk with the cane." Educating patients on how to walk with assistive devices may not be delegated to unlicensed assistive personnel (UAP). UAP should report any of the following: noticeable incorrect usage or fit of assistive devices, complaints of soreness or weakness, difficulties involving balance or strength, or difficulties in performing the procedure or other concerns verbalized by the patient.

A patient's blood pressure is 142/76 mm Hg. What does the nurse chart as the pulse pressure? a. 28 b. 42 c. 58 d. 66

d. 66 The pulse pressure is the difference between the systolic and diastolic blood pressure readings. In this case, 142 - 76 = 66.

The nurse identifies which patient who would benefit from postural drainage? a. A patient with a heart murmur and jugular venous distention b. A patient with asthma and audible wheezing c. A patient with right-sided heart failure and pitting edema d. A patient with chronic bronchitis and congested cough

d. A patient with chronic bronchitis and congested cough Postural drainage is used for patients who have difficulty removing thick secretions from the airway. A patient with chronic bronchitis and a congested, productive cough would benefit from postural drainage because it would help clear the airway.

The nurse is instructing a client to perform a 2-point gait for crutch walking. The nurse would tell the client to perform which action? a. Advance the right foot and then the left foot, followed by both crutches. b. Advance both crutches forward, followed by the left foot and then the right foot. c. Move the left foot and then the left crutch forward, followed by the right crutch and then the right foot. d. Advance the right crutch and the left foot forward, followed by advancing the right foot and the left crutch forward.

d. Advance the right crutch and the left foot forward, followed by advancing the right foot and the left crutch forward. The 2-point gait is used when weight bearing is allowed on both feet. Only 2 points are in contact with the floor. The 2-point gait closely resembles normal walking. Options 1 and 2 describe 3 points of contact. Option 3 describes 4 points of contact.

The nurse is assigned to care for a client who is experiencing episodes of postural hypotension. Which action would the nurse take to ensure safety while transferring the client from the bed to the chair? a. Arrange for a transfer board to be used. b. Perform the transfer using a hydraulic lift only. c. Put the client's shoes on so that the client will not slip on the floor during the transfer. d. Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

d. Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair. Having the client sit on the side of the bed before transfer allows the body to adjust to position changes, thereby avoiding a fall resulting from postural hypotension. The nurse would remain with the client and assist in the transfer to the chair. Options 1 and 2 are not necessary. Although option 3 is an important measure, it is not related to preventing postural hypotension.

The nurse discovers a fire in the trash basket in a client's bathroom. The nurse assists the client out of the hospital room to a safe place, activates the fire alarm, and takes which action next? a. Extinguishes the fire b. Sweeps the extinguisher side to side c. Pulls the pin on the fire extinguisher d. Closes the doors to the other clients' rooms

d. Closes the doors to the other clients' rooms In the event of a fire, the first priority is to rescue the client and protect the client from injury. The next priority is to activate the fire alarm and report the exact location of the fire to emergency personnel to aid in the rescue process. Next, the nurse would contain the fire by closing doors and placing towels under the doorways to prevent the spread of smoke. The nurse then would obtain the fire extinguisher, pull the pin, and extinguish the fire by sweeping side to side. (RACE acronym)

Which collaborative team member would be most effective in assisting the nurse to identify medication alternatives that are less likely to cause drowsiness and dizziness to reduce the risk of falls in the elderly patient? a. Nursing case manager b. Charge nurse c. Physical therapist d. Pharmacist

d. Pharmacist The nurse collaborates with the pharmacist and health care provider to identify and implement safe medication alternatives for older adults to minimize side effects such as drowsiness, dizziness, and orthostatic hypotension, which can increase fall risk. Although case managers and charge nurses might have some experience in this area, pharmacists are educated to focus on medication. Physical therapists evaluate the patient's ability to perform and maintain balance during routine activities such as sitting, standing, and walking.

A patient returned from a procedure and has vital sign measurements ordered every hour. The patient's blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg. What priority action by the nurse is most appropriate? a. Take the vital signs again in another hour. b. Document the findings in the patient's chart. c. Have another nurse recheck the vital signs. d. Plan to take the vital signs more often.

d. Plan to take the vital signs more often. The nurse uses clinical judgment to determine how often the patient's vital signs should be checked when there is a change in patient condition. The nurse should plan to assess vital signs more often in this patient. Since this is a significant change, the nurse should not wait another hour even though this is what the provider prescribed. It is not necessary for another nurse to double-check the vital signs. Documentation needs to occur, but the priority is to plan to take the vitals more often.

The nurse knows which method to be an appropriate way to tie restraints? a. Knot tied to the bed frame b. Quick-release knot tied to the side rail c. Bow tied to the bed rail d. Quick-release ties attached to the bed frame

d. Quick-release ties attached to the bed frame Restraints should never be tied in a knot because the knot may prohibit a quick exit in the event of an emergency requiring evacuation. Instead, use quick-release ties or mechanisms such as buckles. Restraints are never be tied to side rails because injuries may result when they are raised or lowered. They should be tied to a stable part of the bed such as the frame

The nurse is preparing to reposition the patient in bed. What is the first step in this process? a. Position the patient's arms across his/her chest. b. Lower the side rails. c. Grasp the draw sheet. d. Raise the bed to a working height.

d. Raise the bed to a working height. Raising the bed to a working height is the first step before beginning the procedure. Proper positioning of equipment prevents provider discomfort and reduces the chance of possible injury. Then lower the side rails as appropriate and safe and ensure that the bed wheels are locked. Then you can have the patient position his/her arms and/or grasp the draw sheet.

The nurse is concerned about helping the patient find resources to obtain assistive equipment to be used in the home. Which team member should the nurse contact first? a. Occupational therapist b. Physical therapist c. Health care provider d. Social worker

d. Social worker The nurse should collaborate with the social worker to identify community resources for obtaining assistive equipment. The social worker facilitates contact with insurance companies or other agencies to assist with the financing of recommended therapeutic assistive and specialty devices. Occupational therapists evaluate the patient for safe performance of activities of daily living (ADLs) such as bathing, dressing, and grooming, and they make recommendations to enhance safe performance of these activities, such as the use of specialty equipment (e.g., grippers for pants, oversized shoehorns). Physical therapists evaluate the patient's ability to perform and maintain balance during routine activities such as sitting, standing, and walking. They make recommendations for assistive devices such as canes and walkers to promote safe performance of these activities. Health care providers order the equipment.

The nurse is caring for a patient with high cholesterol who has been prescribed atorvastatin (Lipitor). Which laboratory result indicates that the patient has been taking the medication as ordered and following the physician's dietary recommendations? a. Serum triglyceride level 325 mg/dL b. High-density lipoproteins (HDL) 56 mg/dL c. Low-density lipoproteins (LDL) 155 mg/dL d. Total cholesterol level 185 mg/dL

d. Total cholesterol level 185 mg/dL Total cholesterol levels should be less than 200 mg/dL, so a cholesterol level of 185 mg/dL indicates that the patient has been compliant with the prescribed therapy. The other laboratory results are abnormal and would not indicate compliance.