Comprehensive Part 1 (M.S_F21)

A student nurse asks the nursing instructor why older adults are more prone to infection than other adults. What reasons does the nursing instructor give? (Select all that apply.)

-age-related decrease in immune function -Decreased cough and gag reflexes -Diminished acidity of gastric secretions -Thinning skin that is less protective

A nurse notes crepitation when performing range-of-motion exercises on a patient with a fractured left humerus. Which action would the nurse take next? a) Administer prescribed steroids. b) Monitor for signs of infection. c) Assess the patient's distal pulse. d) Immobilize the left arm.

Immobilize the left arm. (A grating sound heard when the affected part is moved is known as crepitation. This sound is created by bone fragments. Because bone fragments may be present, the nurse would immobilize the patient's arm and tell the patient not to move the arm. The grating sound does not indicate circulation impairment or infection. Steroids would not be indicated.)

A nurse answers a call light on the postoperative nursing unit. The patient states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action does the nurse take first?

Perform hand hygiene and apply gloves. (Prior to assessing or treating the drainage from the wound, the nurse performs hand hygiene and dons gloves to protect both the patient and nurse from infection.)

A patient calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate?

"Antihistamines do not help poison ivy." (Since histamine is not the mediator of a type IV reaction such as with poison ivy, antihistamines will not provide relief. The nurse should educate the patient about this. The patient does not need to be seen right away. The patient may or may not need steroids; they may be given either IV or orally.)

A nurse is caring for a patient who is recovering from an above-the-knee amputation. The patient reports pain in the limb that was removed. How would the nurse respond? a) "Would you like to learn how to use imagery to minimize your pain?" b) "The pain you are feeling does not actually exist." c) "This type of pain is common and will eventually go away." d) "How would you describe the pain that you are feeling?"

"How would you describe the pain that you are feeling?" (The nurse would ask the patient to rate the pain on a scale of 0 to 10 and describe how the pain feels. Although phantom limb pain is common, the nurse would not minimize the pain that the patient is experiencing by stating that it does not exist or will eventually go away. Antiepileptic drugs and antispasmodics are used to treat neurologic pain and muscle spasms after amputation. Although imagery may assist the patient, the nurse must assess the patient's pain before determining the best action.)

A nurse has educated a patient on an epinephrine auto-injector (EpiPen). What statement by the patient indicates additional instruction is needed?

"I don't need to go to the hospital after using it." (Patients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen. The medication may wear off before the offending agent has cleared the patient's system. The other statements show good understanding of this treatment.)

A patient with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the patient does not have a history of seizures. What response by the nurse is best?

"This drug helps treat the pain from nerve irritation." (Many classes of medications are used for neuropathic pain, including tricyclic antidepressants and anticonvulsants such as gabapentin. It is not being used to prevent seizures from fungal infections. If the nurse does not know the answer, he or she should find out for the patient.)

An HIV-negative patient who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the patient about this drug?

"Truvada does not reduce the need for safe sex practices." (Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, patients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for post-exposure prophylaxis.)

A nurse prepares a patient who is scheduled for an arthroscopy of the shoulder. Which action by the nurse is most important? a) Position the patient flat after the procedure. b) Assess serum aspartate aminotransferase (AST) levels. c) Reinforce the dressing if it becomes saturated. d) Ensure that informed consent is on the chart.

( Ensure that informed consent is on the chart. (This diagnostic procedure is invasive and requires informed consent. The AST does not need to be assessed prior to the procedure. The patient is positioned with the head of the bed elevated after the test to keep the contrast material out of the brain. The dressing would not become saturated; if it does, the nurse calls the provider.)

A postoperative patient is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the patient? (Select all that apply.)

-"Check all over-the-counter medications for acetaminophen." -"Do not take more pills each day than you are prescribed." -"Eat a diet that is high in fiber and drink lots of water." -"You shouldn't drive while you are taking this medication." (Percocet is a common opioid analgesic that contains acetaminophen. The patient should be taught to check all over-the-counter medications for acetaminophen and to not take more than the prescribed amount of Percocet, as the maximum daily dose of acetaminophen is 3000 mg. Percocet, like all opioid analgesics, can cause constipation, and the patient can minimize this by eating a high-fiber diet and drinking plenty of water. Since Percocet can cause drowsiness, the patient taking it should not drive or operate machinery. The medication is more likely to cause constipation than diarrhea.)

A nurse has taught a patient about safety related to an automatic epinephrine injector and the indicators for obtaining replacements. Which statements by the patient indicate good understanding of this teaching? (Select all that apply.)

-"I need a new pen if the fluid is discolored." -"I will obtain a new pen if the cap comes off." -"If the drug has expired, I will get a new pen." (Indications for obtaining a new auto injector include discoloration of the medication, if the cap is loose or has come off, of if the medication has or is close to expiring. These devices do not need to be replaced every 2 years on a schedule. Of course if the patient uses the pen, it needs to be replaced, but that is not the only indication.)

A patient has been educated on sirolimus (Rapamune). What statements indicate that this education was effective? (Select all that apply.)

-"I should avoid large crowds and sick people." -"I need to use two forms of birth control and not get pregnant."

A patient is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.)

-Admit the patient to a negative-airflow room. -Obtain specialized masks/respirators for caregiving. (A patient with suspected TB is admitted to Airborne Precautions, which includes a negative-airflow room and special N95 or PAPR masks to be worn when providing care. A 3-foot (1 m) distance is required for Droplet Precautions. Chlorhexidine is used for patients with a high risk of infection.)

A nurse is admitting an older patient for surgery to the inpatient surgical unit. The patient relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the patient's plan of care to minimize the potential for this occurring? (Select all that apply.)

-Allow family and friends to visit as the patient desires. -Ask the patient about coping techniques frequently used. -Instruct the nursing assistant to ensure the patient is bathed. -Provide the patient with uninterrupted periods of sleep.

A patient is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.)

-Allow the patient to assume a position of comfort. -Allow the patient's family to remain at the bedside. -Provide warm blankets or cool washcloths as desired. -Pull the curtains around the bed to provide privacy. (There are many nonpharmacologic comfort measures the nurse can employ, such as allowing the patient to remain in the position that is most comfortable, letting the family stay with the patient, providing warmth or cooling measures as requested by the patient, and providing privacy. The patient in the preoperative holding area is NPO, so drinks should not be provided)

A patient is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.)

-Apply stimulation to the contralateral leg. -Assess the patient's willingness to try meditation. -Elevate the patient's operative leg and apply (There are many nonpharmacologic comfort measures for pain, including applying stimulation to the opposite leg, providing opportunities for meditation, elevation of the leg, applying ice, and reducing noxious stimuli in the environment. Participating in diversional activities is another approach, but simply turning the TV on loudly does not provide a good diversion.). Reduce the noise level in the patient's environment.)

The student nurse learns that effective antimicrobial therapy requires which factors to be present? (Select all that apply.)

-Appropriate drug -Proper route of administration -Sufficient dose -Sufficient length of treatment (In order to be effective, antimicrobial therapy must use the appropriate drug in a sufficient dose, for a sufficient length of time, and given via the appropriate route. Some antimicrobials do require monitoring for peak and trough levels, but not all.)

A patient with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

-Assist the patient with oral care every 2 hours. -Offer the patient frequent sips of cool drinks. -Remind the patient to use only a soft toothbrush. (The UAP can help the patient with oral care, offer fluids, and remind the patient of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and would not be used)

A patient with acquired immune deficiency syndrome has an increased risk for developing an opportunistic infection. What would the nurse include in the teaching to prepare the patient for self-management? (Select all that apply.)

-Avoid crowds and exposure to large gatherings of people who might be ill -Do not dig in the garden or work with houseplants. -Wash your dishes between use and do not reuse any dishes.

Which findings are AIDS-defining characteristics? (Select all that apply.)

-CD4+ cell count less than 200/mm3 or less than 14% -Infection with Pneumocystis jiroveci -Presence of HIV wasting syndrome

A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse would recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.)

-Clean drinking water -Cultural beliefs about illness -Lack of antiviral medication -Social stigma

A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.)

-Decreased cardiac output -Decreased oxygenation -Frequent nocturia -Mobility alterations

A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.)

-Disposing of dressings properly -Leaving draining wounds open to air -Performing proper hand hygiene -Removing and replacing wet dressings (Interventions necessary to prevent surgical wound infection include proper disposal of soiled dressings, performing proper hand hygiene, and removing wet dressings as they can be a source of infection. Prophylactic antibiotics are given to patients at risk for infection, but are discontinued after 24 hours if no infection is apparent. Draining wounds would always be covered.)

The nursing student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles? (Select all that apply.)

-Ensuring the patient's safety -Accounting for all sharps -Documenting all care given -Monitoring traffic in the room

A postanesthesia care unit (PACU) nurse is assessing a postoperative patient with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.)

-Hemoglobin: 7.8 mg/dL (78 mmol/L) -pH: 7.68 -Potassium: 2.9 mEq/L (2.9 mmol/L) (Fluid and electrolyte balance are assessed carefully in the postoperative patient because many imbalances can occur. The low hemoglobin may be from blood loss in surgery. The higher pH level indicates alkalosis, possibly from losses through the NG tube. The potassium is very low. The blood glucose is within normal limits for a postsurgical patient who has been fasting. The sodium level is normal.)

The student nurse caring for patients understands that which factors must be present to transmit infection? (Select all that apply.)

-Host -Mode of transmission -Portal of entry -Reservoir (Factors that must be present in order to transmit an infection include a host with a portal of entry, a mode of transmission, and a reservoir. Colonization is not one of these factors.)

The nurse at a weeklong camp observes a child using an EpiPen after having a bee sting. What actions by the child show good understanding of how to use this device? (Select all that apply.) Correct! Injects medication through pants. Washes the deltoid area with soap and water. Correct! Uses the top of the thigh, slightly to the outside. Correct! Requests the nurse call 911.

-Injects medication through pants. -Uses the top of the thigh, slightly to the outside. -Requests the nurse call 911.

A nurse plans care for a patient who is at risk for infection. Which interventions will the nurse implement to prevent infection? (Select all that apply.)

-Monitor white blood cell count and differential. -Screen all visitors for infections. -Promote sufficient nutritional intake.

A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.)

-Phase I care may last for several days in some patients. -Phase II ends when the patient is stable and awake. -Vital signs may be taken only once a day in phase III.

The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.)

-Type I—examples include hay fever and anaphylaxis -Type III—immune complex deposits in blood vessel walls -Type IV—examples are poison ivy and transplant rejection (Type I reactions are mediated by immunoglobulin E (IgE) and include hay fever, anaphylaxis, and allergic asthma. Type III reactions consist of immune complexes that form and deposit in the walls of blood vessels. Type IV reactions include responses to poison ivy exposure, positive tuberculosis tests, and graft rejection. Type II reactions are mediated by immunoglobulin G, not IgM. Type IV hypersensitivity reactions do not involve either antibodies or complement.)

A nurse cares for several patients on an oncology unit. Which standard precautions will the nurse implement? (Select all that apply.)

-Wear a gown when contact of clothing with body fluids is anticipated. -Teach patients and visitors respiratory hygiene techniques -Disinfect frequently touched surfaces in patient-care areas. (Standard precautions include hand hygiene with alcohol-based hand rub or soap between patient contact, procedures for routine care, cleaning and disinfection of frequently contaminated surfaces, and wearing personal protective equipment when contamination is anticipated. Patients and visitors should be instructed on appropriate respiratory hygiene and cough etiquette.)

Dr. Wiley is a 67 year-old retired Director of Nursing who presents to the ER with anxiety and restlessness . She is very upset and worried that her former nursing students may not know how to do dosage calculations and could potentially harm their patients. The orders are the following:Order: Promethazine35mg IM stat for anxiety and restlessness. The vial reads 25mg/ml. How many ml do you give?

1.4 mL

Solucortef is available in a 5 mg/ml solution. Your patient is to receive 50 mg IM. What amount will you give Mrs. Griffith in milliliters?

10 mL

A patient received an order for narcan 0.8mg IM. The vial reads narcan 0.4mg/ml. How many ml do you give?

2 mL

Scopolamine is available in 20mg/ml. Order for Ms. Salesberry is Scopolamine 500mg. How many ml will you give?

25 mL

Order: Depakote 0.15g po tid. Supply: Depakote suspension 100mg/5ml. How many ml do you give?

7.5 mL

A trauma nurse cares for several patients with fractures. Which patient would the nurse identify as at highest risk for developing deep vein thrombosis? a) A 74-year-old man who smokes and has a fractured pelvis b) An 18-year-old male athlete with a fractured clavicle c) A 55-year-old woman prescribed aspirin for rheumatoid arthritis d) A 36-year-old female with type 2 diabetes and fractured ribs

A 74-year-old man who smokes and has a fractured pelvis (Deep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures are sustained in the lower extremities and the patient has additional risk factors for thrombus formation. Other risk factors include obesity, smoking, oral contraceptives, previous thrombus events, advanced age, venous stasis, and heart disease. The other patients do not have risk factors for DVT.)

The nurse is presenting information to a community group on safer sex practices. The nurse would teach that which sexual practice is the riskiest?

Anal intercourse (Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immunodeficiency virus.)

A patient in the operating room has developed malignant hyperthermia. The patient's potassium is 6.5 mEq/L (6.5 mmol/L). What action by the nurse takes priority?

Administer 10 units of regular insulin. (For hyperkalemia in a patient with malignant hyperthermia, the nurse administers 10 units of regular insulin in 50 mL of 50% dextrose. This will force potassium back into the cells rapidly. Nifedipine is a calcium channel blocker used to treat hypertension and dysrhythmias, and should not be used in a patient with malignant hyperthermia. Assessing the urine for blood or myoglobin is important, but does not take priority. Monitoring the patient for dysrhythmias is also important due to the potassium imbalance, but again does not take priority over treating the potassium imbalance.)

A nurse assesses an older adult patient who was admitted 2 days ago with a fractured hip. The nurse notes that the patient is confused and restless. The patient's vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action would the nurse take first? a) Increase the intravenous flow rate. b) Re-position to a high-Fowler's position. c) Assess response to pain medications. d) Administer oxygen via nasal cannula.

Administer oxygen via nasal cannula. (The patient is at high risk for a fat embolism and has some of the clinical manifestations of altered mental status and dyspnea. Although this is a life-threatening emergency, the nurse would take the time to administer oxygen first and then notify the health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia. The nurse would not restrain a patient who is confused without further assessment and orders. Sitting the patient in a high-Fowler's position will not decrease hypoxia related to a fat embolism. The IV rate is not related. Pain medication most likely would not cause the patient to be restless.)

A postoperative patient has just been admitted to the post-anesthesia care unit (PACU). What assessment by the PACU nurse takes priority? Correct!

Airway (Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of the circulation assessment, as is cardiac rhythm.)

A circulating nurse has transferred an older patient to the operating room. What action by the nurse is most important for this patient?

Allow the patient to keep hearing aids in until anesthesia begins. (Many older patients have sensory loss. To help prevent disorientation, facilities often allow older patients to keep their eyeglasses on and hearing aids in until the start of anesthesia. The other actions are appropriate for all operative patients.)

The postoperative nurse is caring for a patient who reports feeling "something popped" after vomiting. What action by the nurse is a priority?

Apply a sterile nonadherent dressing (The priority is to protect the wound when a dehiscence occurs. All other actions would be performed but are not the priority.)

A patient with osteoporosis is going home, where the patient lives alone. What action by the nurse is best? a) Arrange a home safety evaluation. b) Refer the patient to Meals on Wheels. c) Ensure that the patient has a walker at home. d) Help the patient look into assisted living.

Arrange a home safety evaluation (This patient has several risk factors that place him or her at a high risk for falling. The nurse should consult social work or home health care to conduct a home safety evaluation. The other options may or may not be needed based upon the patient's condition at discharge.)

A patient has been advised to perform weight-bearing exercises to help minimize osteoporosis. The patient admits to not doing the prescribed exercises. What action by the nurse is best? a) Instruct the patient to increase calcium. b) Ask the patient about fear of falling. c) Tell the patient to try weight lifting. d) Suggest other exercises the patient can do.

Ask the patient about fear of falling. (Fear of falling can limit participation in activity. The nurse would first assess if the patient has this fear and then offer suggestions for dealing with it. The patient may or may not need extra calcium, other exercises, or weight lifting.)

A patient is distressed at body changes related to kyphosis. What response by the nurse is best? a) Explain that these changes are irreversible. b) Offer to help select clothes to hide the deformity. c) Tell the patient that safety is more important than looks. d) Ask the patient to explain more about these feelings.

Ask the patient to explain more about these feelings. (Assessment is the first step of the nursing process, and the nurse would begin by getting as much information about the patient's feelings as possible. Explaining that the changes are irreversible discounts the patient's feelings. Depending on the extent of the deformity, clothing will not hide it. While safety is more objectively important than looks, the patient is worried about looks and the nurse needs to address this issue.)

A patient is undergoing computed tomography (CT) of a joint. What action by the nurse is most important before the test? a) Assess for seafood or iodine allergy. b) Administer sedation as prescribed. c) Ensure that the patient has no metal on the body. d) Provide preprocedure pain medication.

Assess for seafood or iodine allergy (CT uses iodine-based contrast material, the nurse assesses the patient for allergies to iodine or seafood (which often contains iodine). The other actions are not needed.)

A postoperative nurse is caring for a patient whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate?

Assess other indicators of oxygenation. (If a postoperative patient's oxygen saturation (SaO2) drops below 95% (or the patient's baseline), the nurse would notify the anesthesia provider. If the SaO2 drops by 10% or more, the nurse would call the Rapid Response Team. Since this is approximately a 3% drop, the nurse would further assess the patient. Intubation (if the patient is not intubated already) is not warranted.)

A patient with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action would the nurse take first?

Assess the patient for adherence to the drug regimen. (Adherence to the complex drug regimen needed for HIV treatment can be daunting. Patients must take their medications on time and correctly at a minimum of 90% of the time. Since this patient's viral load has increased dramatically, the nurse would first assess this factor. After this, the other assessments may or may not be needed.)

A clinic nurse is teaching a patient prior to surgery. The patient does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?

Assess the patient for anxiety. (Anxiety can interfere with learning, coping, and cooperation. The nurse should assess the patient for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the patient is highly anxious.)

A patient is in the internal medicine clinic reporting bone pain in the lower leg. The patient's alkaline phosphatase level is elevated. What action by the nurse is most appropriate? a) Teach the patient about ibuprofen (Motrin). b) Assess the patient for leg swelling. c) Instruct the patient on fluid restrictions. d) Facilitate an oncology workup.

Assess the patient for leg swelling. (This patient has manifestations of a bone tumor. The nurse should assess for other manifestations such as swelling at the site of pain. Other care measures can be instituted once the patient has a confirmed diagnosis.)

The nurse assesses the woman pictured below. What action by the nurse is best? a) Allow the patient to rest in a position of comfort. b) Assist the patient with ambulating and position changes. c) Position the patient on one side propped with pillows. d) Assess the patient's cardiac and respiratory systems.

Assess the patient's cardiac and respiratory systems. (This degree of curvature of the spine affects cardiac and respiratory function. The nurse's priority is to assess those systems. Positioning is up to the patient. The patient may or may not need assistance with movement.)

A patient with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best address the patient's psychosocial needs? a) Refer the patient to the social worker or hospital chaplain. b) Explain that the surgery leads to a longer life expectancy. c) Assess the patient's coping skills and support systems. d) Reinforce physical therapy to aid with ambulating normally.

Assess the patient's coping skills and support systems. (The first step in the nursing process is assessment. The nurse should assess coping skills and possible support systems that will be helpful in this patient's treatment. Explaining that a limb salvage procedure will extend life does not address the patient's psychosocial needs. Referrals may be necessary, but the nurse should assess first. Reinforcing physical therapy is also helpful but again does not address the psychosocial needs of the patient.)

A patient is having surgery. The circulating nurse notes that the patient's oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best?

Assess the patient's end-tidal carbon dioxide level. (Malignant hyperthermia is a rare but serious reaction to anesthesia. The triad of early signs includes decreased oxygen saturation, tachycardia, and elevated end-tidal carbon dioxide (CO2) level. The nurse should quickly check the end-tidal CO2 and then report findings to the anesthesia provider and surgeon. Documentation is vital, but not the most important action at this stage. Dantrolene sod)

An emergency department nurse cares for a patient who sustained a crush injury to the right lower leg. The patient reports numbness and tingling in the affected leg. Which action would the nurse take first? a) Apply oxygen by nasal cannula. b) Assess the pedal pulses. c)Loosen the traction. d) Increase the IV flow rate.

Assess the pedal pulses. (These symptoms represent early warning signs of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider would be notified as soon as possible. Vital signs need to be obtained to determine if oxygen and intravenous fluids are necessary. Traction, if implemented, would never be loosened without a provider's prescription.)

A patient with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition?

Assessing mucous membranes (Cryptosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse would assess signs of hydration/dehydration as the priority, including checking the patient's mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment.)

The peri-operative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best?

Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. (The SCIP project contains core measures that are mandatory for all surgical patients and focuses on preventing infection, serious cardiac events, and venous thromboembolism. The managers should start by reviewing charts to see if the guidelines of this project were implemented. The other actions may be necessary too, but first the managers need to assess the situation.)

A postoperative patient vomited. After cleaning and comforting the patient, which action by the nurse is most important?

Auscultate lung sounds. (Vomiting after surgery has several complications, including aspiration. The nurse would listen to the patient's lung sounds. The patient should be allowed to rest after an assessment. Documenting is important, but the nurse needs to be able to document fully, including an assessment. The patient should not eat until nausea has subsided.)

A patient is in stage 2 of general anesthesia. What action by the nurse is most important?

Being prepared to suction the airway (During stage 2 of general anesthesia (excitement, delirium), the patient can vomit and aspirate. The nurse must be ready to react to this potential occurrence by being prepared to suction the patient's airway. Keeping the room quiet and calm does help the patient enter the anesthetic state, but is not the priority. Positioning the patient usually occurs during stage 3 (operative anesthesia). Keeping the patient warm is important throughout to prevent hypothermia.)

A nurse works in an allergy clinic. What task performed by the nurse takes priority?

Checking emergency equipment each morning (All actions are appropriate for this nurse; however, patient safety is the priority. The nurse should ensure that emergency equipment is available and in good working order and that sufficient supplies of emergency medications are on hand as the priority responsibility. When it is appropriate for a patient to give informed consent, the nurse ensures the signed forms are on the chart. Providing educational materials in several languages is consistent with holistic care. Teaching is always a major responsibility of all nurses.)

The circulating nurse and preoperative nurse are reviewing the chart of a patient scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority?

Consent for MIS procedure only (All MIS procedures have the potential for becoming open procedures depending on findings and complications. The patient's consent should include this possibility. The nurse should report this finding to the surgeon prior to surgery taking place. Having allergies noted and an allergy band applied is the standard procedure. Not having any prior surgical or anesthesia exposure is not the priority. Maintaining NPO status as prescribed is the standard procedure although individual surgeons may not require being NPO for an entire 8 hours.)

The nurse providing direct patient care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from patients. Which practice is most effective?

Consistent use of Standard Precautions (According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 ft (1 m) of the patient is part of Airborne Precautions and is not necessary with every patient contact.)

Which action by the nurse is most helpful to prevent patients from acquiring infections while hospitalized?

Consistently using appropriate hand hygiene (Consistent practice of proper hand hygiene is the best method to prevent infection, as most healthcare-associated infections are due to staff members' contaminated hands. Assessing the patient and monitoring laboratory values will help the nurse catch signs of infection quickly but will not prevent infection from occurring. Teaching visitors not to come to see the patient when they are ill will also help prevent infection, but not to the degree that hand hygiene will.

A nurse assesses a patient in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best

Consult the surgeon about a postoperative dietitian referral. (This patient has signs of malnutrition, which can impact recovery from surgery. The nurse should consult the surgeon about prescribing a consultation with a dietitian in the postoperative period. The nurse should document the findings but needs to do more. Encouraging the patient to eat more may be helpful, but the patient needs a professional nutritional assessment so that the appropriate diet and supplements can be ordered. The patient may or may not need Meals on Wheels after discharge.)

A patient with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important?

Consult with the pharmacy about drug interactions. (The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be given at specific times of the day, and that have many interactions with other drugs. The nurse would consult with a pharmacist about possible interactions. Patient teaching is important but does not take priority over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms.)

A nurse is assessing an older patient and discovers back pain with tenderness along T2 and T3. What action by the nurse is best? a) Have the patient perform hip range of motion. b) Place the patient in a rigid cervical collar. c) Consult with the provider about an x-ray. d) Encourage the patient to use ibuprofen (Motrin).

Consult with the provider about an x-ray. (Back pain with tenderness is indicative of a spinal compression fracture, which is the most common type of osteoporotic fracture. The nurse would consult the provider about an x-ray. Motrin may be indicated but not until there is a diagnosis. Range of motion of the hips is not related, although limited spinal range of motion may be found with a vertebral compression fracture. Since the defect is in the thoracic spine, a cervical collar is not needed.)

A patient has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The patient's partner is listed as the emergency contact, but the patient's mother insists that she should be listed instead. What action by the nurse is best?

Contact the social worker to assist the patient with advance directives. (The patient should make his or her wishes known and formalize them through advance directives. The nurse would help the patient by contacting someone to help with this process. Ignoring the mother or telling the patient that nurses cannot be involved does not help the situation. Legal statutes vary by state; as more states recognize gay marriage, this issue will continue to evolve.)

The nurse is caring for patients on the medical-surgical unit. What action by the nurse will help prevent a patient from having a type II hypersensitivity reaction?

Correctly identifying the patient prior to a blood transfusion (A classic example of a type II hypersensitivity reaction is a blood transfusion reaction. These can be prevented by correctly identifying the patient and cross-checking the unit of blood to be administered. Serum sickness is a type III reaction. Avoidance therapy is the cornerstone of treatment for a type IV hypersensitivity to substances that are known and can be avoided such as poison ivy and insect stings. Latex allergies are a type I hypersensitivity.)

The nurse is caring for a patient diagnosed with human immune deficiency virus. The patient's CD4+ cell count is 399/mm3. What action by the nurse is best?

Counsel the patient on safer sex practices/abstinence. (This patient is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and would be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease.)

A patient with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi's sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important?

Disposing of soiled dressings properly (All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital.)

A patient in a nursing home refuses to take medications. The patient is at high risk for osteomalacia. What action by the nurse is best? a) Hide vitamin D supplements in favorite foods. b)Give the patient daily vitamin D injections. c) Plan to serve foods naturally high in vitamin D. d) Ensure that the patient gets at least 5 minutes of sun exposure daily.

Ensure that the patient gets at least 5 minutes of sun exposure daily. (Sunlight is a good source of vitamin D, and the nursing staff can ensure some sun exposure each day. A minimum of 5 minutes is needed. Vitamin D is not given by injection. Hiding the supplement in food is unethical. Very few foods are naturally high in vitamin D, but some are supplemented.)

A hospitalized patient is placed on Contact Precautions. The patient needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate?

Ensure that the radiology department is aware of the isolation precautions. (Patients in isolation will leave their rooms only when necessary, such as for a CT scan that cannot be done portably in the room. The nurse will ensure that the receiving department is aware of the isolation precautions needed to care for the patient. The other options are not needed.)

A patient is scheduled for a below-the-knee amputation. The circulating nurse ensures that the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate?

Facilitate marking the site with the patient and surgeon. (The Joint Commission now recommends that both the patient and the surgeon mark the operative site together in order to prevent wrong-site surgery. The nurse should facilitate this process.)

The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best?

Get another piece of equipment. ( The circulating nurse is responsible for patient safety. If an electrical cord is frayed, the risk of fire or sparking increases. The nurse should obtain a replacement. The nurse should also tag the original equipment for repair as per agency policy. Checking the equipment is not important as the nurse should not even attempt to use it. Calling maintenance or requesting maintenance per facility protocol is important, but first ensure patient safety by having a properly working piece of equipment for the procedure about to take place. The charge nurse probably does need to know of the need for equipment repair, but ensuring patient safety is the priority.)

A patient waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)?

Give the patient a back rub (A back rub reduces anxiety and can be delegated to the UAP. Once teaching has been done, the UAP can remind the patient to turn, but this is not related to relieving anxiety. Assessing anxiety and teaching are not within the scope of practice for the UAP.)

A patient in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best?

Give the patient a bedpan or urinal to use (Although possibly uncomfortable or embarrassing for the patient, the patient should not be allowed out of bed after receiving sedation. The patient may be drowsy and fall. The nurse should get the patient a bedpan or urinal. The patient may or may not need a urinary catheter. The nurse's aide could help the patient with a urinal or bedpan, but how that person should help the patient is not specified.)

A hospitalized patient is being treated for Ewing's sarcoma. What action by the nurse is most important? a) Assessing and treating the patient for pain as needed b) Educating the patient on the disease and its treatment c) Providing emotional support for the patient and family d) Handling and disposing of chemotherapeutic agents per policy

Handling and disposing of chemotherapeutic agents per policy (All actions are appropriate for this patient. However, for safety, the nurse should place priority on proper handling and disposal of chemotherapeutic agents.)

A patient with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this patient problem?

Has a weight gain of 2 lbs (1 kg)/1 month (The weight gain is the best indicator that goals for this patient problem have been met because it demonstrates that the patient not only is eating well but also is able to absorb the nutrients.)

A nurse assesses a patient with a pelvic fracture. Which assessment finding would the nurse identify as a complication of this injury? a) Hypertension b) Constipation c) Hematuria d) Infection

Hematuria (The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral damage that may manifest as blood in the urine (hematuria) or stool. The nurse would also assess for signs of hemorrhage and hypovolemic shock, which include hypotension and tachycardia. Constipation and infection are not complications of a pelvic fracture.)

A nurse is providing community education about preventing traumatic musculoskeletal injuries related to car crashes. Which group does the nurse target as the priority for this education? a) Older adult women b) Middle-aged men c) High school homeroom class d) High school football team

High school football team (Young men are at highest risk for musculoskeletal injury due to trauma, especially due to motor vehicle crashes. The high school football team, with its roster of young males, is the priority group.)

A patient having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important?

Instruct the patient not to get up without help. (Antihistamines can cause drowsiness, so for the patient's safety, he or she should be instructed to call for assistance prior to trying to get up. Hyperglycemia and tachycardia are side effects of sympathomimetics. Fluid and sodium retention are side effects of corticosteroids.)

A nurse cares for a patient recovering from an above-the-knee amputation of the right leg. The patient reports pain in the right foot. Which prescribed medication would the nurse administer first? a) Intravenous calcitonin b) Oral acetaminophen c) Oral ibuprofen d) Intravenous morphine

Intravenous calcitonin (The patient is experiencing phantom limb pain, which usually manifests as intense burning, crushing, or cramping. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. Opioid analgesics such as morphine are not as effective for phantom limb pain as they are for residual limb pain. Oral acetaminophen and ibuprofen are not used in treating phantom limb pain.)

A nurse cares for a patient in skeletal traction. The nurse notes that the skin around the patient's pin sites is swollen, red, and crusty with dried drainage. Which action would the nurse take next? a) Apply an antibiotic ointment and a clean dressing. b) Obtain a prescription to culture the drainage. c) Request a prescription to decrease the traction weight. d) Cleanse the area, scrubbing off the crusty areas.

Obtain a prescription to culture the drainage. (These clinical manifestations indicate inflammation and possible infection. Infected pin sites can lead to osteomyelitis and should be treated immediately. The nurse would obtain a culture and assess vital signs. The provider would be notified. By decreasing the traction weight, applying a new dressing, or cleansing the area, the infection cannot be significantly treated.)

A patient is admitted with possible sepsis. Which action will the nurse perform first?

Obtain specified cultures. (Prior to administering antibiotics, the nurse obtains the prescribed cultures. Broad-spectrum antibiotics will be administered until the culture and sensitivity results are known. Antipyretics are given if the patient is uncomfortable; fever is a defense mechanism. Giving antipyretics does not take priority over obtaining cultures. The patient may or may not need isolation.)

A nurse works on the postoperative floor and has four patients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the healthcare team for post-discharge care?

Older adult who lives at home despite some memory loss (The older adult has the most potentially complex discharge needs. With memory loss, the patient may not be able to follow the prescribed home regimen. The patient's physical abilities may be limited by chronic illness. This patient has several safety needs that should be assessed. The other patients all have evidence of a support system and no known potential for serious safety issues.)

A nurse sees patients in an osteoporosis clinic. Which patient would the nurse see first? a) Patient taking ibandronate (Boniva) who cannot remember when the last dose was b) Patient taking raloxifene (Evista) who reports unilateral calf swelling c) Patient taking calcium with vitamin D (Os-Cal) who reports flank pain 2 weeks ago d) Patient taking risedronate (Actonel) who reports occasional dyspepsia

Patient taking raloxifene (Evista) who reports unilateral calf swelling (The patient on raloxifene needs to be seen first because of the manifestations of deep-vein thrombosis, which is an adverse effect of raloxifene. The patient with flank pain may have had a kidney stone but is not acutely ill now. The patient who cannot remember taking the last dose of ibandronate can be seen last. The patient on risedronate may need to change medications.)

The nurse sees several patients with osteoporosis. For which patient would bisphosphonates not be a good option? a) Patient who recently fell and has vertebral compression fractures b) Patient with diabetes who has a serum creatinine of 0.8 mg/dL (61 mcmol/L) c) Hypertensive patient who takes calcium channel blockers d) Patient with a spinal cord injury who cannot tolerate sitting up

Patient with a spinal cord injury who cannot tolerate sitting up (Patients on bisphosphonates must be able to sit upright for 30 to 60 minutes after taking them. The patient who cannot tolerate sitting up is not a good candidate for this class of drug. Poor renal function also makes patients bad candidates for this drug, but the patient with a creatinine of 0.8 mg/dL (61 mcmol/L) is within normal range. Diabetes and hypertension are not related unless the patient also has renal disease. The patient who recently fell and sustained fractures is a good candidate for this drug if the fractures are related to osteoporosis.)

A patient has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important when the patient arrives in the PACU?

Place the patient on a cardiac monitor and pulse oximeter. (Intravenous anesthetic agents have the potential to cause respiratory and circulatory depression. The nurse should ensure that the patient is on a cardiac monitor and pulse oximeter. Muscle relaxants are not indicated for this patient at this time. Intravenous anesthetics have a lower rate of postoperative nausea and vomiting than other types. Shivering can occur in any patient, but is more common after inhalation agents.)

An older patient with diabetes is admitted with a heavily draining leg wound. The patient's white blood cell count is 38,000/mm3 (38 × 109/L) but the patient is afebrile. What action does the nurse take first? a) Administer acetaminophen (Tylenol). b) Refer the patient to the wound care nurse. c) Educate the patient on amputation. d) Place the patient on contact isolation.

Place the patient on contact isolation. (In the presence of a heavily draining wound, the nurse should place the patient on contact isolation. If the patient has discomfort, acetaminophen can be used, but this patient has not reported pain and is afebrile. The patient may or may not need an amputation in the future. The wound care nurse may be consulted, but not as the first action.)

A preoperative nurse is reviewing morning laboratory values on four patients waiting for surgery. Which result warrants immediate communication with the surgical team?

Potassium: 2.9 mEq/L (2.9 mmol/l) (The potassium level is critically low and can affect cardiac and respiratory status. The nurse should communicate this laboratory value immediately. The creatinine is at the high end of normal, the hemoglobin is normal, and the sodium is only slightly low so these values do not need to be reported immediately.)

A nurse is caring for a patient who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate?

Prepare to administer vancomycin (Vancocin). (Vancomycin is one of a few drugs approved to treat MRSA. The others include linezolid (Zyvox) and ceftaroline fosamil (Teflaro). Visitation does not need to be limited to immediate family only. Hand hygiene is performed before and after wearing gloves. A respirator is not needed, but if splashing is anticipated, a face shield can be used.)

A patient on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The patient denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What would the nurse assess next?

Psychosocial status (After ensuring the patient's physiologic status is stable, these manifestations would lead the nurse to assess the patient's psychosocial status. Anxiety especially can be demonstrated with elevations in vital signs. Cognitive and nutrition status are not related. Family stress is a component of psychosocial status.)

A home health nurse assesses a patient with diabetes who has a new cast on the arm. The nurse notes the patient's fingers are pale, cool, and slightly swollen. Which action would the nurse take first? a) Apply heat to the affected hand. b) Raise the arm above the level of the heart. c) Encourage range of motion. d) Bivalve the cast to decrease pressure.

Raise the arm above the level of the heart. (Arm casts can impair circulation when the arm is in the dependent position. The nurse would immediately elevate the arm above the level of the heart, ensuring that the hand is above the elbow, and would re-assess the extremity in 15 minutes. If the fingers are warmer and less swollen, the cast is not too tight and adjustments do not need to be made, but a sling should be worn when the patient is upright. Encouraging range of motion would not assist the patient as much as elevating the arm. Heat would cause increased edema and should not be used. If the cast is confirmed to be too tight, it could be bivalved.)

A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN?

Securing the drain's safety pin to the sheets (The safety pin that prevents the drain from slipping back into the patient's body would be pinned to the patient's gown, not the bedding. Pinning it to the sheets will cause it to pull out when the patient turns. The other actions are appropriate.)

A nurse is observing as an unlicensed assistive personnel (UAP) performs hygiene and changes a patient's bed linens. What action by the UAP requires intervention by the nurse?

Shaking dirty linens and placing them on the floor (Shaking dirty linens (or even clean linens) can spread microbes through the air. Placing linens on the floor contaminates the floor surface and can lead to infection spread via shoes. The other actions are appropriate. If the patient has a scalp infection or infestation, the UAP will wear gloves; otherwise it is not required.)

The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection?

Skin and mucous membranes (The skin and mucous membranes are the most important barrier against infection. The other options are also barriers, but are considered secondary to skin and mucous membranes.)

A hospital unit is participating in a bioterrorism drill. A "patient" is admitted with inhalation anthrax. Under what type of precautions does the charge nurse admit the "patient"?

Standard Precautions (Only Standard Precautions are needed. No other special precautions are required for the "patient" because inhalation anthrax is not spread person to person)

A hospitalized patient's strength of the upper extremities is rated at 3. What does the nurse understand about this patient's ability to perform activities of daily living (ADL a) The patient would need near-total assistance with ADLs. b) The patient is unable to perform ADLs alone. c) No difficulties are expected with ADLs. d) The patient is able to perform ADLs but not lift some items.

The patient is able to perform ADLs but not lift some items. (This rating indicates fair muscle strength with full range of motion against gravity but not resistance. The patient could complete ADLs independently unless they required lifting objects)

A postoperative patient has an abdominal drain. What assessment by the nurse indicates that goals for the priority patient problems related to the drain are being met?

There is no redness, warmth, or drainage at the insertion site. (The priority patient problem related to a surgical drain is the potential for infection. An insertion site that is free of redness, warmth, and drainage indicates that goals for this patient problem are being met. The other assessments are normal, but not related to the drain.)

An HIV-positive patient is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate?

Use Standard Precautions consistently. (Toxoplasma gondii infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this patient.)