Health Care Delivery UNIT II

A charge nurse is discussing with a staff nurse the establishment of credibility when providing nursing care. Which of the following statements made by the staff nurse indicates a need for further teaching? "Being dependable will increase my credibility." "Using consistency will help to build credibility." "Using sympathy will help to build credibility"

"Being dependable will increase my credibility." Being dependable will improve the trusting relationship with the client and build the nurse's credibility. "Using consistency will help to build credibility." Being consistent will improve the trusting relationship with the client and build the nurse's credibility. ✅"Using sympathy will help to build credibility." Showing sympathy involves displaying personal emotions and does not improve the trusting relationship with the client, and it does not build the nurse's credibility. Professional Communication: Types of Communication

A nurse manager is discussing formal and informal structures or processes with a newly licensed nurse. Which of the following statements made by the newly licensed nurse requires further teaching? "Formal structures are generally highly planned." "A written policy is a type of formal structure." "Informal structures are visible."

"Formal structures are generally highly planned." Formal structures are visible and typically highly planned. "A written policy is a type of formal structure." Written policies and procedures are part of formal structures. ✅"Informal structures are visible." Informal structures or processes tend to be hidden and unplanned. Informal processes are not usually discussed or written Professional Communication: Organizational Structure

A client presents at a community shelter after surviving the destruction of her home by a fire. Which of the following questions should the nurse ask to determine the client's ability to cope? "Have you considered rebuilding your home?" "Who do you talk to when you have the feeling of being overwhelmed?" "I am sure you will get through everything fine.

"Have you considered rebuilding your home?" The nurse is displaying nontherapeutic communication. The nurse is offering advice. ✅"Who do you talk to when you have the feeling of being overwhelmed?" The nurse is assessing the client's support systems, which is an important factor in understanding the client's ability to cope with the situation. "I am sure you will get through everything fine." The nurse is displaying nontherapeutic communication. The nurse is offering false reassurance. Professional Communication: Therapeutic Communication

Which of the following statements is an example of a therapeutic communication technique? "I would not be concerned about that." "Why did you not go to your scheduled group therapy?" "Tell me about your relationship with your wife."

"I would not be concerned about that." This is nontherapeutic because it provides false reassurance, and it is dismissive of the client's feelings. "Why did you not go to your scheduled group therapy?" This is nontherapeutic because it implies criticism, which often results in making the client defensive. ✅"Tell me about your relationship with your wife." This is therapeutic because it offers a general lead, which allows the client to control the direction of the discussion. Professional Communication: Therapeutic Communication

A nurse manager is reviewing concepts related to organizational communication with a group of charge nurses. Which of the following statements made by a charge nurse requires additional teaching? "Managers should not provide overwhelming amounts of information to subordinates." "Information should be informally distributed." "Information should be unaffected by perceptions, values, and emotions.

"Managers should not provide overwhelming amounts of information to subordinates." Managers should not provide overwhelming amounts of unnecessary information to subordinates. ✅"Information should be informally distributed." Information should be distributed formally. "Information should be unaffected by perceptions, values, and emotions." Information should be unaffected by perceptions, values, emotions, and expectations. Professional Communication: Organizational Structure

A nurse manager is discussing organizational concepts in a charge nurse meeting. Which of the following statements by a charge nurse indicates a need for further teaching? "Organizations are formed due to a large number of workers requiring a supervisor to oversee work efforts." "Organizational size will impact interactions, communication, and decision-making within the organizational structure." "Smaller organizations find communication more difficult due to size and complex processes."

"Organizations are formed due to a large number of workers requiring a supervisor to oversee work efforts." Organizations are formed due to a large number of workers requiring a supervisor to oversee work efforts. "Organizational size will impact interactions, communication, and decision-making within the organizational structure." Organizational size will impact interactions, communication, and decision-making within the organizational structure. ✅"Smaller organizations find communication more difficult due to size and complex processes." Larger organizations, not smaller ones, find communication difficult due to size and complex processes. Professional Communication: Organizational Structure

A nurse manager is discussing the topic of personal space as it relates to nonverbal behavior with a staff nurse. Which of the following statements by the staff nurse indicates a need for further teaching? "Personal space provides you and your client a sense of control." "Use of personal space varies based on culture." "Use of personal space will increase the client's self-esteem

"Personal space provides you and your client a sense of control." Personal space provides the nurse and the client a sense of control. "Use of personal space varies based on culture." Personal space varies based on cultural needs. ✅"Use of personal space will increase the client's self-esteem." Personal space does not increase the client's self-esteem. Professional Communication: Types of Communication

A nurse is caring for a client who has depression. The client states, "Things are always going to be bad for me. I wish I could just go to sleep and forget about all my problems." Which of the following is an appropriate response by the nurse? "Tell me about the dynamics of your family." "Why do you feel this way?" "It seems as though you're expressing feelings of hopelessness."

"Tell me about the dynamics of your family." This is a nontherapeutic statement that places the focus away from the client's feelings and onto the family, which changes the subject. "Why do you feel this way?" The nurse is using nontherapeutic communication by asking a "why" question, which often can result in the client feeling defensive. ✅"It seems as though you're expressing feelings of hopelessness." The nurse is using therapeutic communication that offers reflection and validation of the client's feelings and encourages him to explore his emotions while facilitating communication. Professional Communication: Therapeutic Communication

Which of the following is an example of the nurse using clarification to facilitate communication? (Select all that apply.) "That sounds hard to believe." "You appear tense." "Tell me more about that." "What would you say is the main point of what you are saying?" "I am not sure I am following you."

"That sounds hard to believe" is incorrect. This statement voices doubt and undermines the client's beliefs. It is not facilitating communication. "You appear tense" is incorrect. This is an example of making observations or calling attention to the client's behavior. "Tell me more about that" is incorrect. This is an example of exploring, which allows for examination of certain ideas, experiences, or relationships in greater detail. ✅"What would you say is the main point of what you are saying?" is correct. This is an example of using clarification to determine the meaning behind communication. It facilitates understanding. ✅"I am not sure I am following you" is correct. This is an example of using clarification to determine the meaning behind communication. It facilitates understanding. Professional Communication: Therapeutic Communication

A nurse is admitting a client who has schizophrenia. The client states, "The FBI has bugged the phone and is monitoring my calls." Which of the following responses by the nurse is appropriate? "You are wrong about the phone being bugged, and you should recognize that you're having delusional thoughts." "I understand that you believe this is true, and it must be very frightening for you." "I know it is difficult for you to talk to me while you are having paranoid ideas."

"You are wrong about the phone being bugged, and you should recognize that you're having delusional thoughts." The nurse is arguing with the client, as well as giving advice. Neither of these are therapeutic techniques. ✅"I understand that you believe this is true, and it must be very frightening for you." The nurse is validating the client's feelings without focusing on the delusion ideas "I know it is difficult for you to talk to me while you are having paranoid ideas." The nurse is minimizing the client's experience and focuses on her own discomfort. This is not a therapeutic technique. Professional Communication: Therapeutic Communication

97. Which is most important for the nurse to do when assisting a female patient with care of the hair? 1. Use rubbing alcohol to remove tangles. 2. Ensure that the patient's hair is left dry, not wet. 3. Ask the patient what should be done with her hair. 4. Comb hair from the proximal to distal end of the hair shaft.

. 1. A small amount of a lubricant, not alcohol, applied to the hair will facilitate the combing out of tangles. 2. After shampooing a patient's hair, it may be dried or just toweled dry until it is free of excess moisture. ✅3. The appearance of one's hair is an extension of self-image. Therefore, the patient's personal preferences should be considered before grooming the hair. 4. Combing or brushing should progress from the ends of the hair, then from the middle to the ends, and finally from the scalp to the ends (distal to proximal). This technique limits discomfort and prevents broken ends and damaged hair shafts. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. Which is most important for the nurse to do when assisting a female patient with care of the hair? ⏺Ask what the question is asking. Which is most essential when grooming a female patient's hair? ⏺Critically analyze each option in relation to the question and the other options. Identify the steps and rationales associated with caring for a patient's hair. Compare and contrast the options relative to these steps and rationales. ⏺Eliminate incorrect options. Eliminate the options that contain inaccuracies or that are not as important as another option. Options 1 and 4 present incorrect information. Option 2 is not as important as option 3. Options 1, 2, and 4 can be eliminated.

99. A nurse discovers that a patient is taking natural herbal remedies. Which action is most important for the nurse to do? 1. Learn about the supplements. 2. Think of the supplements as drugs. 3. Communicate the supplement use to the primary health-care provider. 4. Include the details about supplement use in the patient's health history.

. 1. It is essential for the nurse to be an informed provider of care, but it is not the priority of care for this patient. 2. Although thinking of supplements as drugs should be done, it is not the priority of care for this patient. ✅3. The primary health-care provider should be notified immediately because the herb may interact with prescribed medications or therapies. 4. Although including the details about supplement use in the patient's health history should be done, it is not the priority. Medications or therapies may interact with the herb before the primary health-care provider reads the information in the health history. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse discovers that a patient is taking natural herbal remedies. Which action is most important for the nurse to do? ⏺Ask what the question is asking. Which action is most important when the nurse identifies that the patient is taking natural herbal remedies? ⏺Critically analyze each option in relation to the question and the other options. Consider the significance of the word discover as it relates to the actions in the options— need for an immediate intervention. Identify the action that will protect the patient immediately. Although you first have to recognize that natural supplements are drugs, this will not protect the patient's safety. Analyze the other options and determine which action is most critical to ensure the patient's safety. ⏺Eliminate incorrect options. The actions in options 1 and 2 will not immediately provide for patient safety. Although documentation is important, it is not the priority. Eliminate options 1, 2, and 4.

90. A patient is admitted to the emergency department after sustaining a crushing injury at work. Which characteristic of blood pressure should alert the nurse to impending shock? 1. Rising diastolic 2. Decreasing systolic 3. Widening pulse pressure 4. Robust Korotkoff's sounds

. 1. The diastolic blood pressure decreases, not increases, during shock. ✅2. The initial stage of shock begins when baroreceptors in the aortic arch and the carotid sinus detect a drop in the mean arterial pressure resulting in a decrease in the systolic blood pressure. The systolic pressure is the pressure in the arteries during ventricular contraction. 3. During shock there will be a narrowing, not widening, of pulse pressure. Pulse pressure is the difference between the systolic and diastolic pressures. 4. Weak or absent, not robust, Korotkoff's sounds are associated with shock. Korotkoff's sounds are the five distinct sounds that are heard when auscultating a blood pressure (I—faint, clear tapping; II—swishing sound; III—intense, clear tapping; IV—muffled, blowing sounds; V—absence of sounds). CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient is admitted to the emergency department after sustaining a crushing injury at work. Which characteristic of blood pressure should alert the nurse to impending shock? ⏺Ask what the question is asking. Which abnormality in blood pressure is an early sign of shock? ⏺Critically analyze each option in relation to the question and the other options. Identify the physiological responses to impending shock (reduced oxygenation) and why each occurs. Compare and contrast the options and determine which option is a response to impending shock relative to the information you identified. ⏺Eliminate incorrect options. Options 1 and 4 are opposite of what will happen with impending shock. Korotkoff's sounds are expected and are not a sign of impending shock. Options 1, 3, and 4 can be eliminated.

4. A patient states, "I like to have a bowel movement every morning." Which additional information collected by the nurse supports a concern with perceived constipation? 1. Hard, dry stools defecated daily 2. Laxatives used excessively 3. Abdominal distention 4. Straining at stool

. 1. The passage of hard, dry stools supports the presence of constipation, not a concern with perceived constipation. ✅2. The expectation of a daily bowel movement at the same time every day with the resulting overuse of laxatives, enemas, and/or suppositories supports a concern with perceived constipation. 3. Abdominal distention supports the presence of constipation, not a concern with perceived constipation. 4. Straining at stool supports the presence of constipation, not a concern with perceived constipation CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient states, "I like to have a bowel movement every morning." Which additional information collected by the nurse supports a concern with perceived constipation? ⏺Ask what the question is asking. Which is a clinical finding associated with perceived constipation? ⏺Critically analyze each option in relation to the question and the other options. Analyze the differences between constipation and perceived constipation. ⏺Eliminate incorrect options. Perceived constipation has no relationship with the characteristics of stool but rather the fact that an enema or laxative is used to ensure a daily bowel movement. The clinical findings in options 1, 3, and 4 are associated with characteristics related to actual, not perceived, constipation. Options 1, 3, and 4 can be eliminated.

13. A patient with type 2 diabetes is experiencing blurred vision, generalized weakness, and fatigue. A nurse receives a report from the nurse on the previous shift and obtains additional information from the patient's clinical record. Which should the nurse conclude that the patient is experiencing? ⏺PATIENT'S CLINICAL RECORD 🔘Laboratory Results BUN: 18 mg/dL Creatinine: 1.2 mg/dL Hemoglobin A1c: 8% Serum glucose: 350 mg/dL 🔘I&O Record (past 24 hours) Intake: 2,400 mL Output: 4,200 mL 🔘Nursing Progress Note 10 a.m.—patient reports "being thirsty and urinating a lot" and has lost 20 pounds over the past 2 months; has poor skin turgor and dry mucous membranes. 1. Fluid retention 2. Kidney impairment 3. Hyperglycemic event 4. Hypertensive episode

. 1. The patient is not experiencing fluid retention. The urine output is almost twice the volume of the intake. With fluid retention the skin is taut and shiny, the mucous membranes are moist, and the patient will gain weight. 2. Kidney impairment can be ruled out because the 4,200 mL of urinary output indicates that the kidneys are functioning. Also, with kidney impairment, generally there is weight gain, not loss. The BUN and creatinine levels are within the normal range and indicate that the kidneys are not impaired. ✅3. The serum glucose value of 350 mg/dL is excessive and indicates a hyperglycemic event; the acceptable range is less than 110 mg/dL. A hemoglobin A1c level of 8% indicates inadequate glucose control over the past 90 to 120 days. The acceptable value for hemoglobin A1c for a person with diabetes mellitus is less than 7% (American Diabetes Association) or less than 6.5% (American Association of Clinical Endocrinologists). The acceptable range for hemoglobin A1c in a person without diabetes mellitus is 4.0% to 5.5%. 4. There are no data to support the conclusion that this event is a hypertensive episode. With the degree of polyuria, poor skin turgor, and dry mucous membranes, hypotension resulting from dehydration, not hypertension, is expected. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient with type 2 diabetes is experiencing blurred vision, generalized weakness, and fatigue. A nurse receives a report from the nurse on the previous shift and obtains additional information from the patient's clinical record. Which should the nurse conclude that the patient is experiencing? ⏺Ask what the question is asking. Which is the patient's problem based on the information presented? ⏺Critically analyze each option in relation to the question and the other options. Analyze the information presented in the laboratory results, I&O record, and nursing progress record in relation to the clinical manifestations associated with the four different clinical conditions. ⏺Eliminate incorrect options. The data presented do not support the problems in options 1, 2, and 4. Eliminate options 1, 2, and 4.

30. A nurse is administering oral medications to several patients. Which factor associated with the administration of medication will increase the absorption of oral medications? 1. Given with water 2. Taken on an empty stomach 3. Administered in the morning 4. Provided when the patient is resting

. 1. Water will not increase the absorption of medications administered orally. Water will facilitate the swallowing and moving of medication down the esophagus to the stomach. ✅2. Food can delay the dissolution and absorption of many drugs; therefore, most oral medications should be administered on an empty stomach. Oral medications should be administered with food only when indicated by the manufacturer's directions. 3. The time of day does not influence the rate of absorption of medications administered orally. 4. Physical rest does not influence the rate of absorption of medications administered orally CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is administering oral medications to several patients. Which factor associated with the administration of medication will increase the absorption of oral medications? ⏺Ask what the question is asking. Which factor promotes the absorption of oral medications? ⏺Critically analyze each option in relation to the question and the other options. Identify the absorption rate of medication in relation to each option presented. Then compare and contrast the absorption rates among the options to identify the one that promotes the absorption of oral medication. ⏺Eliminate incorrect options. Options 2 and 4 are related to the time of day and patient activity, respectively. Neither is concerned with an activity that takes place in the stomach or intestines where the process of absorption begins/occurs. Water in option 1 neither promotes nor hinders medication absorption. Food in the presence of medication inhibits/prolongs the process of absorption because both are competing for absorption. Recall that some medication should be taken with food to prevent gastric irritation, not to promote absorption. Options 1, 2, and 4 can be eliminated.

10. A primary health-care provider orders a clear liquid diet for a patient who had abdominal surgery 3 days ago. Which does the nurse conclude is the reason why a clear liquid diet was ordered for this patient? 1. Relieves abdominal distention 2. Stimulates digestive enzymes 3. Prevents postoperative ileus 4. Digests easily

1. A clear liquid diet will not relieve abdominal distention. A clear liquid diet is contraindicated in the presence of abdominal distention because gas has accumulated in the intestines as a result of a lack of intestinal motility. 2. A clear liquid diet will minimally stimulate digestive enzymes. A full-liquid diet or food will more likely stimulate gastric enzymes. 3. A clear liquid diet will not prevent postoperative ileus. A clear liquid diet is administered after a postoperative ileus resolves, not to prevent its occurrence. ✅4. The molecules in clear liquids are less complex and easier to ingest, tolerate, and digest than those in a full-liquid diet or food. CRITICAL-THINKING ⏺STRATEGYRecognize keywords. A primary health-care provider orders a clear liquid diet for a patient who had abdominal surgery three days ago. Which does the nurse conclude is the reason why a clear liquid diet was ordered for this patient? ⏺Ask what the question is asking. Which is the benefit of a clear liquid diet after abdominal surgery? ⏺Critically analyze each option in relation to the question and the other options. Analyze the physiological responses to abdominal surgery, particularly complications such as abdominal distention and postoperative ileus and the benefits of a clear liquid diet after abdominal surgery. ⏺Eliminate incorrect options. A clear liquid diet is contraindicated with abdominal distention and postoperative ileus; therefore, options 1 and 3 can be eliminated. A clear liquid diet will minimally stimulate gastric secretions, and therefore option 2 can be eliminated.

16. A nurse identifies a patient's perception of health. Which can the nurse do as a result of obtaining this information? 1. Identify the patient's needs based on Maslow's Hierarchy of Human Needs. 2. Provide meaningful assistance to help the patient regain a state of health. 3. Help the patient prevent the occurrence of human responses to disease. 4. Choose a place for the patient along the health-illness continuum.

1. A patient's perceptions are only one part of the data that must be collected before the nurse can establish the priority of the patient's needs. Maslow's Hierarchy of Human Needs helps the nurse to determine the patient's needs in order of priority based on the collected data. ✅2. Health perception reflects a person's knowledge, behavior, and attitudes regarding illness, disease prevention, health promotion, and what constitutes a healthy lifestyle. An assessment of these factors captures the uniqueness of each individual and provides essential data that must be considered before needs are identified and a plan formulated. 3. A healthy lifestyle can promote health and prevent some illness or even minimize complications; however, understanding a person's perceptions of health may not prevent human responses to disease. 4. Only a patient, not a nurse, can choose a patient's place along the health-illness continuum. How people perceive themselves is subjective and is influenced by their own attitudes, values, and beliefs MCRITICAL-THINKING ⏺STRATEGYRecognize keywords. A nurse identifies a patient's perception of health. Which can the nurse do as a result of obtaining this information? ⏺Ask what the question is asking. Which can a nurse do after learning about the patient's beliefs about health? ⏺Critically analyze each option in relation to the question and the other options. Appreciate that health beliefs are specific to the individual. This concept must be analyzed in relation to the theories of Maslow's Hierarchy of Human Needs and the health-illness continuum. ⏺Eliminate incorrect options. Options 1, 3, and 4 are incorrect statements as indicated in their rationales and can be eliminated.

44. A nurse is caring for a patient with a pressure ulcer. Which type of stressor is a pressure ulcer? 1. Microbiological 2. Developmental 3. Physiological 4. Physical

1. A pressure ulcer is not a microbiological stressor. If an ulcer becomes infected, the organism causing the infection is a microbiological stressor. 2. A pressure ulcer is not a developmental stressor. Developmental stressors are physiological changes or transitional life events that occur during the expected stages of growth and development. ✅3. A pressure ulcer is a physiological stressor because the change in structure or function causes further stressors (secondary stressors) in the body. 4. Pressure is a physical stressor that stimulates responses that cause an ulcer. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is caring for a patient with a pressure ulcer. Which type of stressor is a pressure ulcer? ⏺Ask what the question is asking. To which classification of stressor does a pressure ulcer belong? ⏺Critically analyze each option in relation to the question and the other options. Define the category of stressor in each option. Explore examples of stressors in each category. Compare your examples to a pressure ulcer. Identify a parallel between a pressure and an example from among those you identified in each option. ⏺Eliminate incorrect options. Microbiological stresses involve pathogens, and developmental stresses involve age-related issues. Options 1 and 2 can be eliminated. Physical stresses involve a stimulus from outside the body, whereas physiological stresses involve a stimulus from inside the body. Pressure ulcers occur within the body. Option 4 can be eliminated.

3. A nurse is assessing several patients who had surgery the previous day. Which sudden patient response should the nurse identify as a potential life-threatening event? 1. Slightly elevated temperature 2. Separation of wound edges 3. Edema of the legs 4. Chest pain

1. A slight elevation of body temperature is expected after surgery because of the body's response to the stress of surgery. 2. Dehiscence, separation of the wound edges, is more likely to occur between the fifth and eighth postoperative days, and it is not life-threatening. 3. Dependent edema indicates problems, such as a fluid and electrolyte imbalance, impaired kidney function, or decreased cardiac output. All are serious but generally manageable. ✅4. An acute onset of chest pain within 24 hours of surgery may indicate myocardial infarction in response to the stress of surgery. Also, it can be caused by a pulmonary embolus, although this is more likely to occur between the 7th and 10th postoperative days. Both of these complications are life-threatening. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is assessing several patients who had surgery the previous day. Which sudden patient response should the nurse identify as a potential life-threatening event? ⏺Ask what the question is asking. Which clinical finding indicates a possible life- threatening event? ⏺Critically analyze each option in relation to the question and the other options. Critically review several expected or potential problems related to the stress of surgery. Then identify the one complication that is life-threatening. ⏺Eliminate incorrect options. Option 1 is an expected outcome; options 2 and 3 are complications that are not as life-threatening as chest pain. Chest pain may indicate a myocardial infarction, which is a life-threatening condition. Options 1, 2, and 3 can be eliminated.

96. A nurse is predicting the success of a teaching program regarding the learning of a skill. Which factor is most relevant? 1. Cognitive ability of the learner 2. Amount of reinforcement 3. Extent of family support 4. Interest of the learner

1. Although a teaching program must be designed within the patient's developmental and cognitive abilities, they are not the most relevant factors when predicting success of the options presented. 2. Although reinforcement is important, it is not the most relevant factor when predicting success of the options presented. 3. Although family support is important, it is not the most relevant factor when predicting success of the options presented. Not all patients have a family support system. ✅4. The motivation of the learner to acquire new attitudes, information, or skills is the most important component for successful learning; motivation exists when the learner recognizes the future benefits of learning. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is predicting the success of a teaching program regarding the learning of a skill. Which factor is most relevant? ⏺Ask what the question is asking. Which factor is essential to the success of a teaching program? ⏺Critically analyze each option in relation to the question and the other options. Examine each option relative to its importance in facilitating learning. Compare and contrast the options. Eliminate incorrect options. Progressively eliminate the least important action until you arrive at a single option. Options 1, 2, and 3 can be eliminated because the factors in these options are not as important as motivation of the learner.

5. A nurse must administer a sedative to a patient before surgery. Which should the nurse do first? 1. Verify that the preoperative checklist is completed. 2. Check that the surgical consent is signed. 3. Ensure an intravenous line is in place. 4. Assess vital signs.

1. Although checking the preoperative checklist is done, it is not the priority. It usually is done last before the intraoperative period. ✅2. The consent for surgery must be signed before preoperative medications are administered because they depress the central nervous system, impairing problem-solving and decision making. 3. Ensuring placement of an IV line is unnecessary. This can be done at any time during the preoperative phase or at the beginning of the intraoperative phase of surgery. 4. Although assessing vital signs is done, it is not the priority. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse must administer a sedative to a patient before surgery. Which should the nurse do first? ⏺Ask what the question is asking. Which intervention is necessary before giving a preoperative sedative? ⏺Critically analyze each option in relation to the question and the other options. Review the components of a preoperative checklist and the legal implications of a preoperative consent form in relation to the administration of a sedative. ⏺Eliminate incorrect options. Options 1, 3, and 4 are unrelated to when a presurgical sedative is administered; all these interventions can be done immediately before surgery and before or after the sedative is administered. Options 1, 3, and 4 can be eliminated.

26. For which most serious complication of intubation associated with the administration of general anesthesia should the nurse assess a postoperative patient? 1. Stomatitis 2. Atelectasis 3. Sore throat 4. Laryngeal spasm

1. Although inflammation of the mouth (stomatitis) can occur from irritation caused by the tube used for delivering general anesthesia, it is uncommon and not life-threatening. 2. Although atelectasis is serious, it is not as serious as a response in another option. Anesthesia delivered by intubation can interfere with the action of surfactant, resulting in the collapse of alveoli (atelectasis). 3. Although the tube used for intubation commonly does irritate the posterior oropharynx, resulting in a sore throat, it is not as serious as a response in another option. ✅4. Laryngeal spasm is a potentially life- threatening complication because it prevents the exchange of gases between the lungs and the atmosphere. Laryngeal spasm can result from irritation caused by the presence of the intubation tube in the space between the vocal cords (glottis) during surgery. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. For which most serious complication of intubation associated with the administration of general anesthesia should the nurse assess a postoperative patient? ⏺Ask what the question is asking. What is the most serious potential consequence of intubation? ⏺Critically analyze each option in relation to the question and the other options. First define each problem and recall the cause of each. Then explore each problem in relation to the stress of intubation. Finally, compare and contrast the problems and determine which is most serious among the options. The concept of airway, breathing, and circulation can be applied when the question requires you to prioritize information. ⏺Eliminate incorrect options. All of the options can occur, but their consequences vary in severity. Options 1 and 3 can be eliminated first because they are similar and not life-threatening. Although atelectasis in option 2 will compromise respiratory function, it is not an obstruction of the airway and therefore can be eliminated.

34. A home health-care nurse is helping a patient negotiate the health-care system within the community. Which word best reflects this role of the nurse? 1. Leader 2. Resource 3. Surrogate 4. Counselor

1. Although the leadership role is an important role and can be demonstrated in many different settings, a word in another option has a stronger relationship with the role of the nurse when helping a patient negotiate the health-care system. ✅2. The health-care delivery system in the United States is complex and can be confusing at a time when patients have the least energy to explore and negotiate intervention options. When functioning as a resource person, the nurse identifies resources, provides information, and makes referrals. 3. The surrogate role is not a professional role of the nurse. A surrogate role is assigned to a nurse when a patient believes that the nurse reminds them of another person and projects that role and the feelings he/she has for the other person onto the nurse. 4. The role of counselor is only one area of nursing practice and a word in another option has a stronger relationship with the role of the nurse when helping a patient negotiate the health-care system. Counseling is related only to helping a patient recognize and cope with emotional stressors, improve relationships, and promote personal growth. CRITICAL-THINKING STRATEGY Recognize keywords. A home health-care nurse is helping a patient negotiate the health-care system within the community. Which word best reflects this role of the nurse? Ask what the question is asking. What is a significant role of the nurse who is working in the community? Critically analyze each option in relation to the question and the other options. Define the word in each option. Explore behaviors of a nurse who is functioning in the role in each option. Your list of behaviors should parallel behaviors in the correct option as they relate to helping a patient negotiate the health- care system. Eliminate incorrect options. The patient assumes the role of leader in the nurse-patient relationship. Being a surrogate is not a professional nursing role. Being a counselor relates to providing emotional and psychological support. A resource person provides information and facilitates movement through the multidisciplinary health-care system. Options 1, 3, and 4 can be eliminated.

39. Which response by a patient in the postanesthesia care unit is the priority concern for the nurse? 1. Pain 2. Nausea 3. Reduced level of consciousness 4. Excessive loss of fluid through indwelling drains

1. Although the physical trauma of surgery causes pain and it must be relieved, it is not the priority. 2. Although general anesthesia can cause nausea, it is not the priority problem in the postanesthesia care unit. ✅3. With an altered level of consciousness the pharyngeal, laryngeal, and gag reflexes may be impaired. The inability to cough or swallow can result in aspiration of oral secretions. When considering the ABCs of nursing intervention, the airway has priority. 4. Excessive fluid loss precipitates a deficient fluid volume, but the nurse generally has time to meet this need safely. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. Which response by a patient in the postanesthesia care unit is the priority concern for the nurse? ⏺Ask what the question is asking. Which patient response places a postoperative patient at the highest risk? ⏺Critically analyze each option in relation to the question and the other options. Explore the consequences of the patient responses in each option. Analyze the severity of each response in relation to the other responses. Identify the response that may be life-threatening. Analyze these options in relation to the ABCs (airway, breathing, and circulation) of patient assessment and needs. ⏺Eliminate incorrect options. Pain and nausea are not life-threatening issues in a postanesthesia care unit. Although fluid volume deficit has the potential to be a life-threatening problem if it is related to hemorrhage, it is a lower priority than another option because surgical patients are supported with IV fluids during and after surgery. Options 1, 2, and 4 can be eliminated

33. A newly admitted patient arrives on the unit. Which is most important for the nurse to do to help minimize the development of anxiety. 1. Validate anxious feelings. 2. Teach relaxation techniques. 3. Minimize environmental stimuli. 4. Explain procedures to the patient.

1. Although validating a patient's feelings will help the patient feel accepted, understood, and credible, there is no information indicating that the patient is experiencing anxiety. 2. Relaxation techniques are effective ways to reduce the autonomic nervous system response to a threat. However, it is not as effective as an intervention in another option. 3. Minimizing environmental stimuli may support rest and sleep, which is an essential aspect of stress management in any setting. However, it is not as helpful as another option. ✅4. Anxiety is a response to an unknown threat to the self or self-esteem. Therefore, explaining what, how, why, when, and where of procedures to the patient will prevent and reduce anxiety by minimizing the unknown. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A newly admitted patient arrives on the unit. Which is most important for the nurse to do to help minimize the development of anxiety? ⏺Ask what the question is asking. Which action will limit anxiety in a newly hospitalized patient? ⏺Critically analyze each option in relation to the question and the other options. The interventions in all the options may help reduce anxiety. The words newly admitted set a focus that must be addressed when analyzing the options. You are being asked to identify a priority action in relation to a parameter. ⏺Eliminate incorrect options. Options 2 and 3 are general interventions that address anxiety in any situation. Option 1 may minimize anxiety after it occurs, not before. Options 1, 2, and 3 can be eliminated

41. In which situations is a nurse required to complete an incident report? Select all that apply. 1. ___Patient refused to go to physical therapy as ordered by a primary health- care provider. 2. _____Patient climbed over raised side rails and fell but was not injured. 3. _____Visitor ambulated a patient who should have been on bedrest. 4. _____Nurse left work early without reporting to the supervisor. 5. _____Patient did not receive a prescribed medication. 6. _____Nurse falls in the hall and breaks an arm.

1. An incident report is unnecessary when a patient refuses treatment. Patients have the right to refuse care; however, the patient's refusal of care and the reasons for the refusal should be documented in the patient's clinical record. ✅2. Any incident such as a fall that either results in harm to a patient, employee, or visitor or does not result in an injury must be documented in an incident report. 3. An incident report does not have to be completed when a visitor ambulates a patient who should have been on bedrest. The incident should be documented in the patient's clinical record. 4. A nurse leaving work early without reporting to the supervisor does not require an incident report. The nurse manager should discuss this behavior with the nurse and may document it in the nurse's personnel file. ✅5. Not receiving a prescribed medication may have the potential to cause harm. Therefore, an incident or adverse occurrence report should be completed to document the incident to add to the data so that similar situations can be prevented in the future. ✅6. Any incident such as a fall that either results in harm to a patient, employee,or visitor or does not result in an injury must be documented in an incident report. CRITICAL-THINKING STRATEGY Recognize keywords. In which situations is a nurse required to complete an incident report? Ask what the question is asking. Identify situations that require an incident report. Critically analyze each option in relation to the question and the other options. Recall and make a list of the variety of situations that require an incident report. Compare the situations presented in the options to your identified list of situations. Identify the parallel situations. Eliminate incorrect options. Patients have a right to refuse care. Visitors violating a primary health-care provider's order should be documented in progress notes rather than an incident report. A nurse leaving work early without reporting to the supervisor is an ethical situation that does not require an incident report. Options 1, 3, and 4 can be eliminated.

86. An obese patient asks the nurse, "What should I do to help myself lose weight? " How should the nurse respond considering the best behavior modification strategy for controlling food intake? 1. "Ask family members not to bring tempting food into the house." 2. "Post piggy pictures on the refrigerator." 3. "Avoid snacks between meals." 4. "Maintain a daily food diary."

1. Asking family members not to bring tempting food into the house imposes on family members. A person must learn to cope with temptation regardless of where being exposed to desirable foods. 2. Posting piggy pictures on the refrigerator is degrading and should be avoided. Pictures that reflect a positive outcome are more desirable. 3. The rigidity and limitation of avoiding between-meal snacks may cause periods of hypoglycemia, overeating, and noncompliance. Between-meal snacks should be calculated into the weight- reduction program to meet both physical and emotional needs. ✅4. Behavior modification strategies are most successful when the person has an internal locus of control and is actively involved in self-care. Research demonstrates that self-monitoring of food intake is the single most helpful strategy in weight reduction. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. An obese patient asks the nurse, "What should I do to help myself lose weight?" How should the nurse respond considering the best behavior modification strategy for controlling food intake? ⏺Ask what the question is asking. Which is the best behavior modification strategy to control food intake? ⏺Critically analyze each option in relation to the question and the other options. Examine each option considering certain concepts: promote independence; avoid self-deprecation; physiological responses to dieting; and strategies to achieve dietary success. ⏺Eliminate incorrect options. Option 1 communicates to patients that they are unable to develop an internal locus of control. Option 2 is degrading. Option 3 will not meet the patient's psychological or physical needs. Options 1, 2, and 3 can be eliminated.

54. A nurse is administering medication to an older adult. A decrease in which of the following increases the risk of drug toxicity in this patient? 1. Serum calcium level 2. Red blood cell count 3. Glomerular filtration 4. Frequency of urination

1. Calcium is essential for functioning, but it is unrelated to the risk for drug toxicity inthe older adult. Calcium is essential for cell membrane structure, wound healing, synaptic transmission in nervous tissue, membrane excitability, muscle contraction, tooth and bone structure, blood clotting, and glycolysis. 2. Red blood cells are responsible for delivering oxygen to cells and are unrelated to the risk for drug toxicity in the older adult. ✅3. The glomerular filtration rate is reduced by as much as 46% at 90 years of age. In addition, decreased cardiac output can reduce the amount of blood flow to the kidneys by as much as 50%. When the glomerular filtration rate declines, the time necessary for half of a drug to be excreted increases by as much as 40%, which places the older adult at risk for drug toxicity. 4. Frequency of voiding is unrelated to the risk for drug toxicity in the older adult. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is administering medication to an older adult. A decrease in which of the following increases the risk of drug toxicity in this patient? ⏺Ask what the question is asking. Which factor increases the risk for drug toxicity in older adults? ⏺Critically analyze each option in relation to the question and the other options. Analyze the relationship between the physiological changes associated with aging and drug toxicity while considering the factor in each option. ⏺Eliminate incorrect options. Consider that drug metabolism (biotransformation) occurs in the liver by microsomes that stimulate the enzymatic breakdown of drugs and that most medications are excreted via the kidneys. The efficiency of these organs decreases as people age. Eliminate options 1 and 2 because they are unrelated to the functioning of the liver or kidneys. Inadequate urinary output, not urinary frequency, is related to drug toxicity. Eliminate option 4.

23. Which nursing action is appropriate in relation to the concept, "Bacteria and enzymes in stool are irritating to the skin"? 1. Wearing a pair of sterile gloves when collecting a patient's stool for culture and sensitivity 2. Applying a moisture barrier to the perianal area of incontinent patients 3. Encouraging a patient to drink a cup of cranberry juice daily 4. Toileting a confused patient before each meal

1. Clean gloves are adequate. ✅2. A skin barrier protects the skin from the digestive enzymes in feces. 3. Cranberry juice makes urine more alkaline; it does not influence bacteria and enzymes in stool. 4. Patients should attempt to have a bowel movement after a meal to take advantage of the gastrocolic reflex. CRITICAL-THINKING ⏺STRATEGYRecognize keywords. Which nursing action is appropriate in relation to the concept, "Bacteria and enzymes in stool are irritating to the skin?" ⏺Ask what the question is asking. Which nursing intervention is necessitated by the fact that bacteria and enzymes are irritating to the skin? ⏺Critically analyze each option in relation to the question and the other options. This statement requires the integration of several concepts: bacteria are irritating to the skin; enzymes are irritating to the skin; and moisture barriers can protect the skin from irritating substances. To eliminate the other options, identify that they are either an inaccurate statement or are unrelated to the concept cited in the question. ⏺Eliminate incorrect options. The focus is on the connection between factors that irritate the skin and what can be done to prevent it. Option 1 is an inaccurate statement because sterile gloves are not necessary to obtain a stool specimen for culture and sensitivity and it does not relate to the concept cited in the question. Option 3 may help minimize the risk of a urinary tract infection but is unrelated to preventing irritation of the skin. Although option 4 is a true statement it is unrelated to preventing irritation of the skin. Options 1, 3, and 4 can be eliminated.

22. A nurse must obtain a urine specimen from a patient with a urinary retention catheter (Foley) and drains urine in the tubing down into the collection bag. Which should the nurse do next? 1. Cleanse the exit tube at the bottom of the drainage bag with an alcohol swab. 2. Use a clamp to constrict the tubing immediately distal to the collection port. 3. Position the patient in a semi-Fowler position. 4. Don a pair of clean gloves.

1. Cleansing the exit tube at the bottom of the drainage bag with an alcohol swab is unnecessary. When obtaining a specimen from a retention catheter, the aspiration port of the catheter (not the exit tube) is wiped with a disinfectant before inserting the syringe. Urine specimens from a retention catheter should come from the port, not the bag, because this urine is the most recently excreted. 2. Clamping the tubing immediately distal to the collection port should not be done until a step mentioned in another option is performed first. The drainage tubing should be clamped 1 to 2 inches below the aspiration port for 15 to 20 minutes to allow urine to accumulate. 3. Positioning the patient in a semi-Fowler position is done later in the procedure if necessary. This position moves urine toward the trigone (the triangular area at the base of the bladder where the ureters and urethra enter the bladder) where it is accessible to the catheter. ✅4. Wearing personal protective equipment, such as clean gloves, is a medical asepsis practice. Gloves protect the nurse from the patient's body fluids because the catheter is close to the perineal area and there is a potential for exposure to urine during the procedure. CRITICAL-THINKING ⏺STRATEGYRecognize keywords. A nurse must obtain a urine specimen from a patient with a urinary retention catheter (Foley) and drains urine in the tubing down into the urine collection bag. Which should the nurse do next? ⏺Ask what the question is asking. When collecting a urine specimen from a urinary retention catheter, what should the nurse do after draining urine in the tubing into the collection bag? ⏺Critically analyze each option in relation to the question and the other options. List the step-by-step procedure for collecting a specimen from a urinary retention catheter. Then analyze the four options and select the option that reflects the next step of the procedure after urine in the tubing is drained into the collection bag. ⏺Eliminate incorrect options. Option 1 is not a step in this procedure. Options 2 and 3 are steps that are performed later in the procedure. Options 1, 2, and 3 can be eliminated

72. Which is the most important purpose of the orientation phase of a therapeutic relationship? 1. Collect data. 2. Build rapport. 3. Identify problems. 4. Establish priorities.

1. Collecting data is not the most important purpose of the orientation phase of a therapeutic relationship. ✅2. The orientation phase (also called the introductory or pre-helping phase) of a therapeutic relationship sets the tone for the rest of the relationship. A rapport develops when the patient recognizes that the nurse is willing and able to help and can be trusted. 3. Problems are identified, explored, and dealt with during the working, not orientation, phase of a therapeutic relationship. 4. Priority needs are identified and interventions planned and implemented during the working, not orientation, phase of a therapeutic relationship. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. Which is the most important purpose of the orientation phase of a therapeutic relationship? ⏺Ask what the question is asking. Which is the main function of the orientation phase of a therapeutic relationship? ⏺Critically analyze each option in relation to the question and the other options. Recall the phases of a therapeutic relationship. Determine what is significant about the orientation phase versus the other phases of the therapeutic relationship. Examine the options and identify which one accurately reflects the purposes of the orientation phase that you have identified. ⏺Eliminate incorrect options. Options 3 and 4 relate to the working phase of a therapeutic relationship and can be eliminated. Although data are collected during the orientation phase of the therapeutic relationship, this is not the most important purpose and therefore option 1 can be eliminated.

14. Nurses on a unit are personally and professionally mature and motivated. Which classic leadership style should the nurse manager employ when working with this group? 1. Directive 2. Autocratic 3. Democratic 4. Laissez-faire

1. Directive is not one of the four classic leadership styles. 2. The autocratic leadership style is probably the least effective style to use with a professionally mature and motivated staff. Autocratic leaders give orders and directions and make decisions for the group. There is little freedom and a large degree of control by the leader, which frustrates motivated and professionally mature staff members. 3. The democratic leadership style is the second best style to use when staff is motivated and professionally mature. The democratic style offers fewer opportunities for autonomy for staff members who are mature and motivated than a leadership style in another option. ✅4. The laissez-faire leadership style is appropriate for a group of individuals who have an internal locus of control and desire autonomy and independence. Individuals who are professionally mature and motivated more often have an internal locus of control. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. Nurses on a unit are personally and professionally mature and motivated. Which classic leadership style should the nurse manager employ when working with this group? ⏺Ask what the question is asking. Which classic leadership style works best when nurses are mature and motivated? ⏺Critically analyze each option in relation to the question and the other options. Review the descriptions of leadership styles and explore the situations in which each works best. Then you need to select the style that works best in the situation presented. ⏺Eliminate incorrect options. Option 1 is not a leadership style. Option 2 is too dictatorial for individuals with an internal locus of control. Although option 3 is more independent than an autocratic style, it is more restricted than a laissez-faire style. Eliminate options 1, 2, and 3.

61. A nurse is planning care for a patient in the spiritual realm. Which age group generally is more involved with expanding and refining spiritual beliefs? 1. Adolescents 2. Older adults 3. Young adults 4. Middle-aged adults

1. During adolescence, the individual is beginning to question life-guiding values such as spirituality. However, it is not uncommon for the adolescent to turn away from religious practices as part of dealing with role confusion and exploration of self-identity. Faith becomes centered around the peer group and away from the parents. This stage is called Synthetic-Conventional Faith by James Fowler. 2. People expand and refine spiritual beliefs at an earlier stage of development than older adulthood. 3. Young adults are just beginning to think about spirituality more introspectively at this age. Young adults generally enter a reflective period of time as discovery of values in relation to social goals are explored within their own frame of reference rather from the peer group frame of reference as during adolescence. This stage is called Individuative- Reflective Faith by James Fowler. ✅4. Middle-aged adults tend to engage in refining and expanding spiritual beliefs through questioning. Middle-aged adults are reported to have greater faith, have more reliance on personal spiritual strength, and be less inflexible in spiritual beliefs. Middle-aged adults integrate other viewpoints about faith, which introduces tension while working toward resolution of spiritual beliefs. This stage is called Conjunctive Faith by James Fowler. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is planning care for a patient in the spiritual realm. Which age group generally is more involved with expanding and refining spiritual beliefs? ⏺Ask what the question is asking. At what age are people more involved with expanding and refining spiritual beliefs? ⏺Critically analyze each option in relation to the question and the other options. Review the various age groups presented in relation to their concerns about spirituality. Use developmental and spiritual theories to place the beliefs and activities of the people in these age groups into perspective. ⏺Eliminate incorrect options. Generally adolescents are more concerned about peer relationships than spirituality. Eliminate option 1. Young adults are just beginning to explore spirituality, whereas older adults are refining previously explored beliefs. Eliminate options 2 and 3.

42. A patient who has a transdermal analgesic patch for cancer experiences breakthrough pain with activity. Which is most important for the nurse to do? 1. Encourage the avoidance of moving around. 2. Seek a dose increase in the long-acting opioid. 3. Administer the prescribed shorter-acting opioid. 4. Obtain a prescription for an antianxiety medication.

1. Encouraging the avoidance of moving will not promote absorption via the transdermal patch; it could result in the destructive effects of immobility and may interfere with the quality of life. 2. Seeking a dose increase in the long-acting opioid is not the priority. Although this may eventually be necessary, the patient's pain must be relieved immediately. ✅3. Intermittent episodes of pain that occur despite continued use of an analgesic (breakthrough pain) can be managed by administering an immediate-release analgesic to reduce pain (rescue dosing). This reduces pain during an unanticipated pain episode without unnecessarily raising the dosage of the long-acting analgesic. 4. Antianxiety medication will be ineffective in this situation. The patient has intractable (resistant to treatment) pain that requires an opioid at this time. CRITICAL-THINKING STRATEGY Recognize keywords. A patient who has a transdermal analgesic patch for cancer experiences breakthrough pain with activity. Which is most important for the nurse to do? Ask what the question is asking. Which action will relieve intractable breakthrough pain? Critically analyze each option in relation to the question and the other options. Explore the outcome of the interventions in each option. Compare and contrast the benefits among the proposed interventions. Identify the priority nursing intervention that will relieve the patient's pain immediately. Eliminate incorrect options. Options 2 and 4 involve requesting additional medication. One is not better than the other, and it will take time to obtain a prescription. Options 2 and 4 can be eliminated. Transdermal patches are administered for the intractable pain associated with cancer; therefore, limiting movement will be ineffective to prevent severe pain. Eliminate option 1.

8. A nurse is assisting a patient who has cognitive deficits with a bed bath. Which is important for the nurse to do? 1. Explain in detail everything that will be done during the bath before beginning. 2. Arrange the basin within the center of the patient's visual field. 3. Encourage attention to each task of bathing. 4. Check the patient every few minutes.

1. Explaining about the bath in detail may precipitate anxiety. The patient does not have the cognitive ability or attention span to comprehend a detailed explanation before a procedure. 2. The patient has a problem with cognition, not vision. ✅3. When progressing through each aspect of the bath give simple, direct statements to limit the amount of incoming stimuli at one time. This will promote comprehension and self-care. 4. Patients with dementia do not have the cognitive ability to perform a procedure independently. The patient should be supervised. CRITICAL-THINKING ⏺STRATEGYRecognize keywords. A nurse is assisting a patient who has cognitive deficits with a bed bath. Which is important for the nurse to do? ⏺Ask what the question is asking. Which must the nurse do to safely ensure that a patient with cognitive deficits receives an adequate bath? ⏺Critically analyze each option in relation to the question and the other options. Integrate what a patient with cognitive deficits can and cannot do, that daily-living activities must be accomplished adequately and safely, and that nursing care must address a patient's physical, emotional, and mental needs. ⏺Eliminate incorrect options. Options 1 and 4 are unrealistic for a patient with a cognitive deficit. Although option 2 should be done, it will not ensure an adequate bath. Options 1, 2, and 4 can be eliminated.

43. A nurse must perform a procedure and is unsure of the exact steps of the procedure. Which should the nurse do first? 1. Refer to a fundamentals of nursing skills textbook. 2. Call the staff education department for assistance. 3. Check the nursing policy and procedure manual. 4. Refuse to do the nursing procedure.

1. Fundamental nursing textbooks are not the best source for a step-by-step review of a nursing skill. Generally, fundamental nursing textbooks do not address every nursing skill in a step-by-step approach, nor do they include intermediate or advanced skills. 2. Calling the staff education department for assistance should not be the first thing to do when unsure of the steps in a nursing procedure. Another action should be implemented first. ✅3. Checking the nursing policy and procedure manual is the first resource the nurse should use when unsure of the steps in a nursing procedure. A review of the procedure in the procedure manual may refresh the memory or support the confidence of the nurse so that it is safe to proceed. 4. Refusing to do the procedure is premature. Another action should be implemented first. CRITICAL-THINKING STRATEGY Recognize keywords. A nurse must perform a procedure and is unsure of the exact steps of the procedure. Which should the nurse do first? Ask what the question is asking. Which should be done when unsure of the steps of a procedure? Critically analyze each option in relation to the question and the other options. All of the interventions in the options may eventually be done. Analyze each option in relation to the others to identify what should be done first. You are being asked to set a priority. If you cannot identify what should be done first, eliminate the option that would be done last. Repeat this process with the remaining three options. Make a final selection when you are down to two options. Eliminate incorrect options. Staff education personnel may not be immediately available. A fundamentals of nursing textbook does not provide comprehensive coverage of nursing procedures. Refusing to perform a procedure is a behavior of last resort. Options 1, 2, and 4 can be eliminated.

77. A nurse on a postpartum unit is teaching a class for new mothers about umbilical cord care. The nurse identifies that one mother does not become involved with the discussion and is withdrawn. Which is the best action by the nurse to help this new mother learn about umbilical cord care? 1. Give the mother written material about cord care. 2. Invite the mother to the next class about cord care. 3. Bring an audiovisual cassette into the mother's room about cord care. 4. Provide informal individual instruction for the mother about cord care.

1. Giving the mother written material about cord care assumes that the patient can read at the reading level of the presented material. Also, it does not provide an opportunity for the nurse to communicate with the patient. 2. If the patient was not participating in the present formal class, it is unlikely that the patient will participate in the next class. 3. Although an audiovisual cassette is an excellent strategy to provide instruction, it does not provide the nurse an opportunity to individualize one-on-one instruction. ✅4. The nurse identified that the patient was quiet and withdrawn in the group class. Individual instruction provides the nurse the opportunity to explorethe patient's concerns and address the patient's individual needs in privacy. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse on a postpartum unit is teaching a class for new mothers about umbilical cord care. The nurse identifies that one mother does not become involved with the discussion and is withdrawn. Which is the best action by the nurse to help this new mother learn about umbilical cord care? ⏺Ask what the question is asking. Which teaching intervention is most helpful for a patient who is withdrawn? ⏺Critically analyze each option in relation to the question and the other options. This question requires the integration of several concepts: teaching-learning principles, strengths and weaknesses of various teaching strategies, and how best to teach a patient who is withdrawn. Examine the action presented in each option and determine if it will be effective for this patient considering what you explored about teaching-learning. ⏺Eliminate incorrect options. Options 1 and 3 support withdrawn behavior. Option 2 was not effective in the past and the teaching plan should be revised. Eliminate options 1, 2, and 3.

100. A patient sustained a traumatic brain injury resulting in neurological deficits after falling off a ladder at work. Which setting is most appropriate for assisting this patient to learn how to live with neurological limitations? 1. Hospice program 2. Acute-care setting 3. Extended-care facility 4. Assisted-living residence

1. Hospice care is inappropriate for this patient because the patient is not dying. Hospice programs provide supportive care to dying patients and their family members to promote dying with dignity. 2. An acute-care setting generally is not the best setting to provide extensive rehabilitation services. The acute-care setting provides services that medically and emotionally support the patient during the critical and acute phases right after the traumatic event and until the patient is stable and out of danger. ✅3. An extended-care facility is an inpatient setting where people live while receiving subacute medical, nursing, and rehabilitative care. Extended-care facilities that can meet the needs of this individual include intermediate-care facilities, nursing homes that provide subacute care/skilled nursing care, or rehabilitation centers. 4. Once stabilized and out of danger, the individual in this scenario needs intensive rehabilitation services that generally cannot be provided in an assisted-living residence. An assisted-living residence provides limited assistance with activities of daily living, meal preparation, laundry services, transportation, and opportunities for socialization. Residents are relatively independent. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient sustained a traumatic brain injury resulting in neurological deficits after falling off a ladder at work. Which setting is most appropriate for assisting this patient to learn how to live with neurological limitations? ⏺Ask what the question is asking. Which setting is best for learning how to live with neurological deficits? ⏺Critically analyze each option in relation to the question and the other options. Identify the types of services provided by each of the health-care settings presented in the options. Examine the situation in the question and determine which of the settings best provides services that meet the needs of a patient with neurological deficits. ⏺Eliminate incorrect options. Hospice services, hospitals, and assisted-living residences are not designed to meet the intense rehabilitation needs of a patient learning to live with neurological limitations. Options 1, 2, and 4 can be eliminated.

82. A nurse is teaching a family member how to perform range-of-motion exercises of the hand. Which motion occurs when the angle is reduced between the palm of the hand and forearm? 1. Hyperextension 2. Opposition 3. Abduction 4. Flexion

1. Hyperextension of the condyloid joint of the wrist is accomplished by bending the fingers and hand backward as far as possible. 2. Opposition of the thumb, which is a saddle joint, occurs when the thumb touches the top of each finger on the same hand. 3. Abduction of the fingers (metacarpophalangeal joints—condyloid) occurs when the fingers of each hand spread apart. ✅4. Flexion of the wrist, a condyloid joint, occurs when the fingers of the hand move toward the inner aspect of the forearm. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is teaching a family member how to perform range-of-motion exercises of the hand. Which motion occurs when the angle is reduced between the palm of the hand and forearm? ⏺Ask what the question is asking. Which range of motion is being described when the angle is reduced between the palm of the hand and forearm? ⏺Critically analyze each option in relation to the question and the other options. Review all the motions that are included when performing range-of-motion of the joints of the hand. Specifically recall the name of the motion associated with reducing the angle between the palm of the hand and forearm. ⏺Eliminate incorrect options. Options 1, 2, and 3 can be eliminated because they do not describe the action indicated in the question

32. A nurse is caring for a patient who is practicing Orthodox Judaism. Which should the nurse consider about dietary regulations when assisting the patient to plan meals? Select all that apply. 1. _____Coffee and tea are restricted during Passover. 2. _____Meat from cloven-footed and cud-chewing animals is permitted. 3. _____Dairy products and eggs are forbidden after sundown on Fridays. 4. _____ Dairy foods should not be ingested at the same meal as meat and meat 5. _____ Shellfish is permitted but must be prepared according to biblical religious rituals.

1. Leavened bread and cake, not coffee and tea, are forbidden during Passover. ✅2. Meat from cloven-footed and cud- chewing animals is permitted as long as the animal is slaughtered and prepared following strict laws of Kashrut (Kosher diet). 3. There are no restrictions on dairy products and eggs after sundown on Fridays. ✅4. Dairy products and meat/poultry are never served at the same meal or on the same set of dishes. Dairy products are not permitted within 1 to 6 hours after eating meat/poultry. Meat/poultry cannot be eaten for 30 minutes after consuming dairy products. Historically, this was practiced so that one food did not contaminate the other. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is caring for a patient who is practicing Orthodox Judaism. Which should the nurse consider about dietary regulations when assisting the patient to plan meals? ⏺Ask what the question is asking. What are dietary regulations of Orthodox Judaism? ⏺Critically analyze each option in relation to the question and the other options. Recall beverages, dairy products, meat products, and shellfish that are influenced by dietary regulations of Orthodox Judaism. Compare the dietary regulations of Orthodox Judaism with the statements in the options. ⏺Eliminate incorrect options. Options 1, 3, and 5 have statements related to a specific factor (Passover, sundown on Friday, and rituals). After comparing your knowledge with the options and identifying that options 1, 3, and 5 have a factor as a focus and is different than options 2 and 4, which focuses just on food, you may use the test-taking skill of identifying which options are different. This technique may help you eliminate options 1, 3, and 5.

73. A patient has a temperature of 102 F and complains of feeling cold. Which additional responses should the nurse expect during this onset phase (cold or chill phase) of a fever? Select all that apply. 1. _____Letha rgy 2. _____Pale skin 3. _____Shiver 4. _____Diaing phoresis 5. _____Dehydration

1. Lethargy, weakness, and aching muscles occur during the course phase (plateau phase), not onset phase (cold or chill phase), of a fever. ✅2. Pale skin occurs as the peripheral blood vessels constrict in an attempt to increase the core body temperature. ✅3. Feeling cold, chills, and shivering are adaptations associated with the onset phase (cold or chill phase) of a fever. During this phase the body responds to pyrogens by conserving heat to raise body temperature. 4. Profuse diaphoresis (sweating) occurs during the defervescence phase (fever abatement, flush phase) of a fever. During this phase the fever abates and body temperature returns to the expected range. 5. Dehydration can occur during both the course phase (plateau phase) and defervescence phase (fever abatement, flush phase) of a fever CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient has a temperature of 102°F and complains of feeling cold. Which additional responses should the nurse expect during this onset phase (cold or chill phase) of a fever? ⏺Ask what the question is asking. Which are signs associated with the onset phase (cold or chill phase) of a fever? ⏺Critically analyze each option in relation to the question and the other options. List the physiological responses associated with each phase of a fever. Compare the list with the options provided. ⏺Eliminate incorrect options. The response in option 1 is associated with the course phase (plateau phase) of a fever and can be eliminated. The responses in options 4 and 5 are associated with the defervescence phase (fever abatement, flush phase) of a fever and can be eliminated.

18. When caring for patients under stress, which is an important concept that nurses must consider when making assessments about nonverbal behavior? 1. It is controlled by the conscious mind. 2. It carries less weight than what the patient says. 3. It does not have the same meaning for everyone. 4. It is a poor reflection of what the patient is feeling.

1. Nonverbal behavior is controlled more by the unconscious than by the conscious mind. 2. Nonverbal behavior carries more, not less, weight than verbal interactions because nonverbal behavior is influenced by the unconscious mind. ✅3. Transculturally, nonverbal communication varies widely. For example, gestures, facial expressions, eye contact, and touch may reflect opposite messages among cultures and among individuals within a culture. 4. The opposite is true. Nonverbal behaviors often directly reflect feelings. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. When caring for patients under stress, which is an important concept that nurses must consider when making assessments about nonverbal behavior? ⏺Ask what the question is asking. Which is important about nonverbal behavior that influences nursing assessments? ⏺Critically analyze each option in relation to the question and the other options. Review the variety of statements about nonverbal behavior, and determine their accuracy. Then select the option that is a true statement. ⏺Eliminate incorrect options. Options 1, 2, and 4 can be eliminated because the statements in the options are incorrect as indicated in the rationales.

93. A primary health-care provider prescribes 1 g of an antibiotic to be administered via the intramuscular route twice a day. Which nursing action reflects the planning step of the nursing process? 1. Sending a copy of the order to the hospital pharmacy 2. Identifying body landmarks before giving the injection 3. Determining the times when the medication should be given 4. Verifying the patient's allergies in the chart and on the patient's allergy band

1. Obtaining the medication is part of the procedure associated with giving medication, and therefore, this is an example of the implementation step of the nursing process. 2. Identifying body landmarks before giving an injection is part of the procedure for administering an injection and, therefore, is an example of the implementation step of the nursing process. ✅3. Determining when medications should be administered requires planning and therefore is part of the planning step of the nursing process. 4. Collecting data from a patient involves assessment, and therefore, verifying a patient's allergies is an example of the assessment step of the nursing process. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A primary health-care provider prescribes 1 g of an antibiotic to be administered via the intramuscular route twice a day. Which nursing action reflects the planning step of the nursing process? ⏺Ask what the question is asking. Identify the action that is part of the planning step of the nursing process. ⏺Critically analyze each option in relation to the question and the other options. Recall the steps in the nursing process—assessment, analysis, planning, implementation, and evaluation. Review nursing actions associated with each step. Examine each option and identify which step of the nursing process is reflected by the action presented. ⏺Eliminate incorrect options. Options 1 and 2 are examples of actions in the implementation phase of the nursing process. Collecting data in option 4 is related to the assessment phase. Options 1, 2, and 4 can be eliminated.

29. A nurse is teaching a group of nursing assistants about the administration of enemas. Which enema solution that works by irritating the intestinal mucosa should be included in the teaching? 1. Oil 2. Soap 3. Tap water 4. Normal saline

1. Oil lubricates, not irritates, the intestinal mucosa. ✅2. Soap irritates the intestinal mucosa and thus stimulates the circular and longitudinal muscles of the intestinal wall, which respond with wave-like movements (peristalsis) that propel intestinal contents toward the anus. 3. Tap water is a hypotonic solution that exerts a lower osmotic pressure than the surrounding interstitial fluid, causing water to move from the colon into interstitial spaces. In addition, the volume of the fluid distends the lumen of the intestine. These processes stimulate peristalsis and defecation. 4. Normal saline, a solution having the same osmotic pressure of surrounding interstitial fluid (isotonic), works by drawing fluid from interstitial spaces into the colon. This fluid, in addition to the original volume of saline instilled, exerts pressure against the intestinal mucosa, which stimulates peristalsis and defecation. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is teaching a group of nursing assistants about the administration of enemas. Which enema solution that works by irritating the intestinal mucosa should be included in the teaching? ⏺Ask what the question is asking. Which enema solution promotes fecal elimination by irritating the intestinal mucosa? ⏺Critically analyze each option in relation to the question and the other options. Recall the physiological action of each type of enema presented in the question. Then make the connection between the type of enema and its action, whether or not it works by irritating the intestinal mucosa. ⏺Eliminate incorrect options. An oil-retention enema, a tap-water enema, and an enema that uses normal saline each work by another action than irritating the intestinal mucosa. Eliminate options 1, 3, and 4.

51. While in a restaurant, a pregnant woman exhibits a total airway obstruction because of a bolus of food. How should the nurse modify the thrusts of the abdominal thrust (Heimlich) maneuver for this person? 1. Perform them when the woman is in the supine, rather than standing, position. 2. Use the pinkie finger side of the fist, rather than the thumb side, against the woman's body. 3. Compress against the middle of the woman's sternum rather than between the umbilicus and xiphoid process. 4. Initiate the procedure after the woman becomes unconscious, and discontinue it after six tries if unsuccessful.

1. Placing the patient in the supine position is unnecessary. This is done when the person is unconscious. 2. When attempting to clear an airway of an obstruction, the thumb side of the hand should always be against the person's body. ✅3. This is the appropriate modification of the abdominal thrust (Heimlich) maneuver for a pregnant woman. This provides thoracic compression while preventing pressure against the uterus that can result in trauma to the woman or the fetus. 4. Waiting until the person becomes unconscious wastes valuable time and is unsafe. Delaying or discontinuing the maneuver before the obstruction is cleared will result in death. CRITICAL-THINKING STRATEGY Recognize keywords. While in a restaurant, a pregnant woman exhibits a total airway obstruction because of a bolus of food. How should the nurse modify the thrusts of the abdominal thrust (Heimlich) maneuver for this person? Ask what the question is asking. How should the abdominal thrust maneuver be adapted for a pregnant woman? Critically analyze each option in relation to the question and the other options. List the steps of the abdominal thrust maneuver. Recall the physiological changes in a woman's body when pregnant. Compare these physiological changes with the steps of the procedure, and determine what step may harm the woman or fetus. Identify the modification of the procedure that will help dislodge the obstruction while protecting the woman and fetus. Eliminate incorrect options. Options 1 and 4 delay the initiation of the procedure. Eliminate options 1 and 4. Option 2 will be physically difficult to perform and will still compress the woman's abdominal area, which may harm the woman or fetus. Eliminate option 2.

7. Which mechanism is designed to facilitate tracking a patient's progress as a cost- containment strategy in managed care? 1. Primary nursing 2. Critical pathways 3. Functional method 4. Q uality management

1. Primary nursing is not a cost-containment strategy in managed care but rather a nursing-care delivery system that ensures a comprehensive and consistent approach to identifying and meeting patients' needs. Primary nursing occurs when one nurse is assigned the 24-hour responsibility for the planning and deliver of nursing care to a specific patient for the duration of the patient's hospitalization. ✅2. Critical pathways are a case management system that identifies specific protocols and timetables for care and treatment by various disciplines designed to achieve expected patient outcomes within a specific time frame. The purpose is to discharge patients sooner, thereby reducing the cost of health care. 3. Functional method refers to a model of nursing-care delivery that assigns a specific task for a group of patients to one person. Although it is efficient, it is impersonal and contributes to fragmentation of care because it is task oriented rather than patient centered. 4. Q uality management (also known as continuous quality improvement, total quality management, or persistent quality improvement) refers to a program designed to improve, not just ensure, the quality of care delivered to patients. Also, it includes an educational component to support gr CRITICAL-THINKING STRATEGY ⏺Recognize keywords. Which mechanism is designed to facilitate tracking a patient's progress as a cost-containment strategy in managed care? ⏺Ask what the question is asking. Which cost-containment measure manages and documents a patient's progress through the health- care system? ⏺Critically analyze each option in relation to the question and the other options. Recall the definition and components of each of the presented mechanisms. Determine which is a strategy that facilitates tracking a patient's progress as a cost-containment measure. ⏺Eliminate incorrect options. Options 1 and 3 are two different types of nursing- care delivery and are not strategies that track a patient's progress through the health-care system. Option 4 addresses ongoing activities designed to improve the quality of health care. Options 1, 3, and 4 can be eliminated.

55. A nurse instills medicated drops into the ear of an adult. Which should the nurse do to ensure that the medication flows toward the eardrum? 1. Pull the pinna of the ear backward and downward. 2. Insert the drops into the center of the auditory canal. 3. Press the tragus of the ear several times after insertion. 4. Roll the patient from the side-lying to the supine position.

1. Pulling the pinna of the ear backward and downward is done to straighten the ear canal of an infant or a young child, not an adult. 2. Inserting the drops into the center of the auditory canal can injure the eardrum. Drops should be directed along the wall of the ear canal. ✅3. Pressing gently on the tragus facilitates the flow of medication toward the eardrum. 4. Rolling the patient from the side-lying position to the supine position can result in medication flowing out of the ear. The side-lying position with the involved ear on the uppermost side should be maintained for 2 to 3 minutes after the medication is instilled. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse instills medicated drops into the ear of an adult. Which should the nurse do to ensure that the medication flows toward the eardrum? ⏺Ask what the question is asking. Which action disperses medication in the ear canal of an adult? ⏺Critically analyze each option in relation to the question and the other options. List the steps of administering medicated drops into a patient's ear. Recall the difference in the procedure for an adult versus an infant/ young child. Compare the list and the difference identified to the options presented. ⏺Eliminate incorrect options. Option 1 is a technique used with infants and young children. Option 2 can harm the eardrum and is unsafe. Option 4 will result in fluid draining away from the eardrum. Eliminate options 1, 2, and 4.

91. A primary health-care provider orders antiembolism stockings for a patient. Which is an important action the nurse should teach the patient? 1. Put them on after the legs have been dependent for 5 minutes . 2. Monitor the heels and toes for redness every 8 hours. 3. Apply body lotion before putting them on. 4. Remove and reapply them once a day.

1. Putting the stockings on after the legs are dependent is unsafe because pressure injures fluid-filled tissue. They should be applied before the legs are dependent because there will be less fluid in the tissues. ✅2. Elastic stockings provide external pressure on the patient's legs to prevent pooling of blood in the veins while not interfering with arterial circulation. However, if redness is observed the stockings may be too tight. Redness of the skin (erythema) is an early sign of tissue damage to skin resulting from a decrease in oxygen to cells. 3. When applying elastic stockings, lotion increases friction that can injure tissue. 4. Removing and reapplying the stockings only once a day can lead to tissue damage because of impaired circulation. Elastic stockings should be removed for 30 minutes three times a day; some orders require elastic stockings to be worn only when the patient is out of bed. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A primary health-care provider orders antiembolism stockings for a patient. Which is an important action the nurse should teach the patient? ⏺Ask what the question is asking. Which action is essential in relation to antiembolism hose? ⏺Critically analyze each option in relation to the question and the other options. Recall the steps and the rationale for each step in the procedure for applying and wearing antiembolism stockings. Identify the benefits and consequences of the action presented in each option. Compare and contrast the options relative to this information. ⏺Eliminate incorrect options. Eliminate options 1, 3, and 4 because these actions can injure tissue.

21. A patient has a diagnosis of osteoporosis. Which nutrients should the nurse encourage this patient to eat? Select all that apply. 1. _____Ric e 2. _____Milk 3. _____Y ogurt 4. _____Sa rdines 5. _____A lmonds 6. _____T omatoes

1. Rice, regardless of the type, is not high in calcium. One cup of rice contains approximately 5 to 33 mg of calcium. ✅2. Milk and products made with milk such as various forms of cheese are an excellent source of calcium. Eight ounces of 1% low-fat milk contain approximately 290 mg of calcium. Eight ounces of 2% reduced-fat milk contain approximately 285 mg of calcium. ✅3. Yogurt is an excellent source of calcium. Eight ounces of plain non-fat yogurt contains approximately 452 mg of calcium. Eight ounces of low-fat yogurt contains approximately 415 mg of calcium. ✅4. Sardines, which contain soft edible bones, are an excellent source of dietary calcium. Three ounces of sardines contain approximately 371 mg of calcium. ✅5. Almonds are an excellent source of calcium. One ounce of almonds (about 24) contains approximately 75 mg of calcium. 6. Tomatoes are not high in calcium. One tomato (2 inches in diameter) CRITICAL-THINKING ⏺STRATEGYRecognize keywords. A patient has a diagnosis of osteoporosis. Which nutrients should the nurse encourage this patient to eat? ⏺Ask what the question is asking. Which foods facilitate bone maintenance? Critically analyze each option in relation to the question and the other options. ⏺Recall that osteoporosis is the reduction of bone mass and that an increase in calcium will support bone maintenance. Recall how much calcium is contained in each nutrient, and then compare and contrast the nutrients among the options. The options with the highest calcium content are the correct answers. ⏺Eliminate incorrect options. Options 1 and 6 can be eliminated because the nutrients in these options contain small amounts of calcium compared with the amounts of calcium in the nutrients in options 2, 3, 4, and 5.

67. A patient is using the call bell numerous times an hour and requesting assistance with activities that the patient is capable of achieving independently. Which should the nurse do to help this patient? 1. Set limits verbally. 2. Alternate care with another nurse. 3. Point out the behavior to the patient. 4. Attempt to see the situation from the patient's perspective.

1. Setting limits will make the patient more anxious and demanding. Demanding behavior generally is an attempt to gain control over events in an effort to protect the self. 2. Alternating care with another nurse can be confusing to the patient and increase anxiety. Maintaining continuity in the nurse assignment will support the development of a trusting relationship and enable the nurse to explore the patient's feelings, as well as plan and implement interventions that encourage choices, all of which support feeling in control. 3. Pointing out demanding behavior is too confrontational at this time. Demanding behavior generally is a defense mechanism that reduces anxiety generated by powerlessness. To confront the behavior and take away the patient's coping mechanism will cause the patient to become more anxious. ✅4. Attempting to see the situation from the patient's perspective is an example of empathy, which is understanding a patient's emotional point of view. An empathic response communicates that the nurse is listening and cares. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient is using the call bell numerous times an hour and requesting assistance with activities that the patient is capable of achieving independently. Which should the nurse do to help this patient? ⏺Ask what the question is asking. Which should the nurse do when a patient calls the nurse excessively? ⏺Critically analyze each option in relation to the question and the other options. Review concepts related to psychological responses to stress. Identify that the patient's behavior reflects anxiety. Explore nursing actions that support emotional needs and reduce anxiety. Then examine each option in light of whether the action will increase or decrease anxiety. ⏺Eliminate incorrect options. Options 1, 2, and 3 will increase, not decrease, anxiety and can be eliminated.

71. A patient who self-administers an aerosol medication by a metered-dose inhaler complains of "the nasty taste of the medication." Which should the nurse encourage the patient to do? 1. Suck on a hard candy after the procedure. 2. Shake the cartridge longer before using it. 3. Perform oral hygiene before inhalation of medication. 4. Attach an aerosol chamber to the metered-dose cartridge.

1. Sucking on a hard candy after the procedure addresses the problem after, rather than before, it occurs. 2. Shaking the cartridge longer before using it will ensure that the medication is dispersed throughout solution in the cartridge. It will not change the taste of the medication. 3. Oral hygiene should be performed after, not before, the procedure. ✅4. The aerosolized medication enters the aerosol chamber, where the larger droplets fall to the bottom of the chamber. The smaller droplets are inhaled deep into the lungs rather than falling on the patient's tongue. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient who self-administers an aerosol medication by a metered-dose inhaler complains of "the nasty taste of the medication." Which should the nurse encourage the patient to do? ⏺Ask what the question is asking. Which action will reduce the "nasty taste" of medication taken via a metered-dose inhaler? ⏺Critically analyze each option in relation to the question and the other options. Review the rationale for each step of the procedure when using a metered-dose inhaler. Identify the equipment that may be used when administering medication via a metered- dose inhaler. Compare and contrast this information in relation to resolution of the patient's problem. ⏺Eliminate incorrect options. The action in option 1 will not prevent the problem. The action in option 2 will not change the taste of the medication. The action in option 3 is done after, not before, the procedure. Options 1, 2, and 3 can be eliminated.

92. Which is the important consequence of the use of Diagnosis Related Groups (DRGs) on the health-care system? 1. Increased quality of medical care 2. Increased reliability of research data 3. Decreased acuity of hospitalized patients 4. Decreased length of an average hospital stay

1. The DRGs were not designed to increase the quality of medical care. 2. DRGs are unrelated to increasing or decreasing reliability of research data. Reliability is the degree of consistency with which a research study measures a hypothesis and depends on how well the measurement tool and the research methods are designed. 3. DRGs have increased, not decreased, the acuity of the hospitalized population. Patients who in the past were treatedin the hospital are now treated in the home, in ambulatory care settings, or in less acute care settings, such as rehabilitation or extended-care centers. ✅4. The DRGs, pretreatment diagnoses reimbursement categories, were designed to decrease the average length of a hospital stay, which in turn reduces costs. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. Which is the important consequence of the use of Diagnosis Related Groups (DRGs) on the health-care system? ⏺Ask what the question is asking. Which is the effect of DRGs on the health-care system? ⏺Critically analyze each option in relation to the question and the other options. List the purposes of the DRGs. Compare the list to the options presented in the question. ⏺Eliminate incorrect options. Identify those options that are either an inaccurate statement or are unrelated to the purpose of DRGs. The outcomes identified in options 1 and 2 are unrelated to the purpose of DRGs as indicated in the rationales. DRGs increase, not decrease, the acuity of hospitalized populations. Eliminate options 1, 2, and 3.

74. Which patient should the nurse identify will benefit the most from soaking the feet for several minutes as part of a bath? 1. Has a personal preference for taking showers 2. Has lower extremity arterial disease 3. Is ambulating with paper slippers 4. Is on bedrest

1. The feet can be washed thoroughly when taking a shower. ✅2. The warm water used to soak the feet promotes vasodilation, which improves circulation to the most distal portions of the feet. Soaking the feet loosens dirt and limits scrubbing, which prevent trauma to the skin. Soaking the feet should be done for just several minutes because prolonged soaking removes natural skin oils, which dries the skin and makes it prone to cracking. 3. Extra care with the feet is unnecessary because paper slippers provide a barrier between the feet and the floor. 4. When on bedrest, the feet do not get soiled with dirt. Bedrest does not necessitate soaking the feet during a bed bath. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. Which patient should the nurse identify will benefit the most from soaking the feet for several minutes as part of a bath? ⏺Ask what the question is asking. Which patient will benefit the most from soaking the feet? ⏺Critically analyze each option in relation to the question and the other options. Identify that warm bath water will increase vasodilation and improve circulation. Then compare and contrast each patient situation and establish which patient will benefit most from increased peripheral circulation. ⏺Eliminate incorrect options. The patients in options 1, 3, and 4 do not require an intervention that will increase peripheral circulation. These options can be eliminated.

19. Which action should the nurse use to landmark the left dorsogluteal site for an intramuscular injection that is to be administered to a patient? 1. Locate the lower edge of the acromion and the midpoint of the lateral aspect of the arm. 2. Identify the line from the posterior superior iliac spine to the greater trochanter. 3. Place the heel of the hand on the greater trochanter. 4. Palpate the anterior lateral aspect of the thigh.

1. The lower edge of the acromion and the midpoint of the lateral aspect of the arm are anatomical landmarks that help to identify the deltoid muscle. ✅2. The line from the posterior superior iliac spine to the greater trochanter is an anatomical landmark that helps to identify the dorsogluteal site. This site contains the well-developed gluteus muscles, particularly the gluteus maximus, in the buttocks. 3. Placing the heel of the hand on the greater trochanter is the initial placement of the hand when identifying landmarks for the ventrogluteal site. 4. Palpating the anterior lateral aspect of the thigh is associated with identifying the vastus lateralis site. It is between one handbreadth above the knee and one handbreadth below the greater trochanter on the anterior lateral aspect of the thigh. CRITICAL-THINKING ⏺STRATEGYRecognize keywords. Which action should the nurse use to landmark the left dorsogluteal site for an intramuscular injection that is to be administered to a patient? ⏺Ask what the question is asking. What is the landmark for a dorsogluteal intramuscular injection? ⏺Critically analyze each option in relation to the question and the other options. List the steps in the procedure—landmarking the dorsogluteal injection site. Then identify the specific action included in one of the options that relates to the dorsogluteal site. ⏺Eliminate incorrect options. Options 1, 3, and 4 are options that present steps that are related to sites other than the dorsogluteal site and can be eliminated.

59. A patient is admitted to the hospital with a medical diagnosis of diverticulitis. Which is the best question the nurse should ask when obtaining an admission history from this patient? 1. "What did you eat yesterday?" 2. "How long have you had diverticulitis?" 3. "What led up to your coming to the hospital today?" 4. "Have you ever had any previous episodes of diverticulitis?"

1. This question is too focused. 2. Although determining how long the patient has had diverticulitis is information that eventually may be obtained, it is not the immediate priority. ✅3. This question invites the patient to expand on and develop a topic of importance that relates to the current problem. 4. Although identifying previous episodes of diverticulitis is information that eventually may be obtained, it is not the immediate priority. ⏺Recognize keywords. A patient is admitted to the hospital with a medical diagnosis of diverticulitis. Which is the best question the nurse should ask when obtaining an admission history from this patient? ⏺Ask what the question is asking. Which question will obtain the patient's perspective of the situation? ⏺Critically analyze each option in relation to the question and the other options. Review the purpose of obtaining an admission history from a patient. Analyze each question to determine what information will be collected by the patient's response. Identify the most significant information the nurse should collect. CRITICAL-THINKING STRATEGY

49. A patient is told by the primary health-care provider that the patient has metastatic lung cancer and is seriously ill. After the provider leaves the room, the patient has a severe episode of coughing and shortness of breath and says, "This is just a cold. I'll be fine once I get over it." How should the nurse respond? 1. "What did you just find out about having a serious illness? " 2. "Didn't you receive some bad news today?" 3. "This is not a cold; it's lung cancer." 4. "Tell me more about your illness."

1. This response is a challenging statement and is inappropriate. It may take away the patient's coping mechanism and cut off communication; the patient is using denial to cope with the diagnosis. Also, it does not address what the patient thinks or feels about the diagnosis. 2. This response may take away the patient's coping mechanism, is demeaning, and may cut off communication. The use of the word "bad" may increase the patient's anxiety. The patient is using denial to cope with the diagnosis. 3. This response is too direct and demeaning and may cut off communication. The patient is using denial to cope with the diagnosis. ✅4. This provides an opportunity to discuss the illness; eventually a developing awareness will occur and the patient will move on to other coping mechanisms. CRITICAL-THINKING ⏺STRATEGYRecognize keywords. A patient is told by the primary health-care provider that the patient has metastatic lung cancer and is seriously ill. After the provider leaves the room, the patient has a severe episode of coughing and shortness of breath and says, "This is just a cold, I'll be fine once I get over it." How should the nurse respond? ⏺Ask what the question is asking. Which response will encourage a patient in denial to talk? ⏺Critically analyze each option in relation to the question and the other options. Review therapeutic communication skills and barriers to communication. Examine the options and identify the action that is therapeutic and the ones that are not therapeutic. ⏺Eliminate incorrect options. Options 1, 2, and 3 are challenging and should be avoided. Responses should not take away a patient's coping mechanism. Eliminate options 1, 2, and 3.

46. A patient appears agitated and states, "I'm not sure that I want to go through with this surgery." Which response by the nurse uses the technique of paraphrasing? 1. "Are you saying that you want to postpone the surgery?" 2. "You are undecided about having this surgery?" 3. "You seem upset about this surgery." 4. "Tell me more about your concerns."

1. This response is clarifying, not paraphrasing. In addition, to respond more accurately when using clarification the nurse should have said, "Are you saying that you do not want to have this surgery?" Not wanting surgery and postponing surgery are two different concepts. ✅2. This response is an example of paraphrasing, which restates the content of the patient's message in similar words. 3. This response is an example of reflective technique, which focuses on feelings. 4. This response is an example of an open- ended statement, which invites the patient to elaborate on the stated concern. CRITICAL-THINKING ⏺STRATEGYRecognize keywords. A patient appears agitated and states, "I'm not sure that I want to go through with this surgery." Which response by the nurse uses the technique of paraphrasing? ⏺Ask what the question is asking. Which statement uses the technique of paraphrasing? ⏺Critically analyze each option in relation to the question and the other options. Define paraphrasing. Identify the communication technique being used in each nursing statement. Make a correlation between paraphrasing and the statement that restates what the patient said. ⏺Eliminate incorrect options. Option 1 uses clarification. Option 3 uses reflection. Option 4 is an open-ended statement. Eliminate options 1, 3, and 4.

12. A nurse causes harm to a hospitalized patient because of improper use of medical equipment. Which is this tort specifically called? 1. Battery 2. Assault 3. Negligence 4. Malpractice

1. This situation is not an example of battery. Battery is the purposeful, angry, or negligent touching of a patient without consent. 2. This situation is not an example of assault. Assault is an attempt, or threat, to touch another person unjustly. 3. Although negligence occurs when a nurse's actions do not meet appropriate standards of care and result in injury to another, this term is not as specific as another term. ✅4. Malpractice is misconduct, an act of commission or omission, performed in professional practice that results in harm to another. With malpractice the nurse and patient have a professional nurse-patient relationship. CRITICAL-THINKING ⏺STRATEGYRecognize keywords. A nurse causes harm to a hospitalized patient because of improper use of medical equipment. Which is this tort specifically called? ⏺Ask what the question is asking. Which is the name of the tort when a nurse caring for a patient causes harm to the patient? ⏺Critically analyze each option in relation to the question and the other options. Review the definitions and examples of situations that relate to a variety of intentional and unintentional torts. Use this information to assign a name of a tort to the situation presented. ⏺Eliminate incorrect options. Options 1 and 2 include intentional behaviors that are a threat to touch another unjustifiably (assault) or actual touching another unjustifiably (battery). Option 3 is a tort that does not address behaviors within a professional relationship. Options 1, 2, and 3 can be eliminated.

78. A nurse is teaching a patient with dysphagia how to eat safely. Which should the nurse encourage the patient to do? Select all that apply. 1. _____Tilt the head backward when swallowing. 2. _____Drink fluids when eating bites of solid food. 3. _____Reduce environmental stimuli to a minimum. 4. _____Make sure that the mouth is empty after eating. 5. _____Keep food in the front of the mouth when chewing.

1. Tilting the head backward increases the risk of aspiration because it straightens the trachea and anatomically makes it easier for food and fluid to enter the trachea rather than the esophagus. 2. Food and fluid should be consumed separately in the presence of dysphagia. Fluid is more difficult to control with dysphagia, and it may flush the solid food toward the trachea, where it can cause choking or a partial or total airway obstruction. ✅3. A patient with dysphagia should concentrate on the acts of chewing and swallowing. Environmental stimuli can be distracting and can result in inadequate chewing or premature swallowing, which in turn can result in choking and aspiration. ✅4. Ensuring that the mouth is empty after eating reduces the risk of aspiration 5. Chewing food in the front of the mouth will increase the risk for aspiration. Food should be placed in the posterior, not anterior, part of the mouth toward the side. The molars in the back of the mouth are designed for chewing. Placing food to the side keeps it close to the molars for chewing and out of direct line with the trachea. Placing food in the posterior of the mouth limits the need for the tongue to manipulate the bolus of food toward the back of the mouth in preparation for swallowing (deglutition). CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is teaching a patient with dysphagia how to eat safely. Which should the nurse encourage the patient to do? ⏺Ask what the question is asking. Which should a patient with dysphagia do when eating? ⏺Critically analyze each option in relation to the question and the other options. Identify the major problem associated with dysphagia— risk for aspiration. Identify a patient's response to each of the actions presented in the options. Determine if the action in each option is safe or unsafe. Identify the option that will have a safe outcome. ⏺Eliminate incorrect options. Eliminate the options that increase the risk of aspiration. Options 1, 2, and 5 can be eliminated

70. Health teaching regarding a kitchen fire should include what to do if grease in a frying pan catches on fire. A nurse teaches that in this situation people should first call 911. Which should people be taught to do next? 1. Pour water in the pan. 2. Put the lid on the pan. 3. Close the door to the kitchen. 4. Use a class A fire extinguisher.

1. Water is ineffective against a grease fire. It will scatter the flames and the fire will spread. ✅2. The lid of the frying pan deprives the fire of oxygen. Without oxygen to support combustion the fire will go out. 3. Although closing the door to the kitchen will help to contain the fire to the kitchen, there is a more appropriate intervention to contain the fire to the frying pan. 4. Using a class A fire extinguisher is inappropriate. A class A fire extinguisher is designed for fires consisting of paper, wood, upholstery, rags, and ordinary rubbish. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. Health teaching regarding a kitchen fire should include what to do if grease in a frying pan catches on fire. A nurse teaches that in this situation people should first call 911. Which should people be taught to do next? ⏺Ask what the question is asking. Which should be done after calling 911 in the event of a grease fire? ⏺Critically analyze each option in relation to the question and the other options. Identify the steps to follow when confronted with a fire and integrate the concept "oxygen supports combustion." Refer to the mnemonic RACE (Rescue patients in immediate danger, Activate the alarm, Confine the fire, Extinguish the fire). ⏺Eliminate incorrect options. No one needs to be rescued, and 911 was called. The next steps include confining and then extinguishing the fire. Placing a cover on the pan accomplishes both because it eliminates oxygen, which supports combustion. Eliminate options 1 and 4 because the actions are inappropriate and unsafe. Although the action in option 3 may confine the fire, it does not extinguish the fire. Eliminate options 1, 3, and 4.

76. A nurse is caring for a patient using an incentive spirometer. Which behaviors observed by the nurse indicate that further teaching is necessary? Select all that apply. 1. _____Inhales slowly and deeply using the spirometer 2. _____Tilts the incentive spirometer while breathing in 3. _____Raises the inspiratory goal on the spirometer once a day 4. _____Takes several regular breaths and then uses the spirometer again 5. _____Exhales while keeping the mouth sealed firmly around the mouthpiece

1.Inhaling slowly and deeply using the spirometer is the correct way to inhale when using an incentive spirometer; it helps to keep the airways open. ✅2.. The patient is using the incentive spirometer incorrectly and needs further teaching. An incentive spirometer must be held in an upright position. A tilted flow-oriented device requires less effort to reach the desired inspiratory volume. A tilted volume- oriented device will not function correctly. 3. Inspiratory goals progressively should be increased daily or more frequently depending on the patient's ability to maximize the inspiratory volume continually, which promotes alveoli ventilation. 4. Taking several breaths using the spirometer and then breathing without using the spirometer and then using the spirometer again are desirable practices because they prevent hyperventilation and respiratory alkalosis. ✅5. The patient should be taught to remove the mouthpiece from the mouth before exhalation. An incentive spirometer is designed to encourage inhalation, not exhalation. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is caring for a patient using an incentive spirometer. Which behaviors observed by the nurse indicate that further teaching is necessary? ⏺Ask what the question is asking. Which actions demonstrate incorrect use of an incentive spirometer? ⏺Critically analyze each option in relation to the question and the other options. List the steps of the procedure—use of an incentive spirometer. The behavior in each option must be compared with the steps in the procedure. This question has negative polarity and expects you to identify the action that demonstrates the incorrect use of an incentive spirometer. ⏺Eliminate incorrect options. Options 1, 3, and 4 are correct actions when using an incentive spirometer and can be eliminated.

27. A patient in pain tells the nurse, "It feels like something is on fire." Which characteristic of pain is associated with this statement? 1. Intensity 2. Location 3. Q uality 4. Pattern

1.Intensity refers to the strength or amount of pain experienced, which often is rated from mild to excruciating. Pain scales (e.g., numerical scale, Wong-Baker FACES Rating Scale) can facilitate pain assessment. 2. The word "something" is too general to be related to the location of pain, which is the actual site where the pain is felt. ✅3. Quality refers to the description of the pain sensation. A total pain assessment is facilitated by the use of the mnemonic COLDERR (character, onset, location, duration, exacerbation, relief, and radiation). 4. The pattern of pain refers to time of onset, duration, recurrence, and remissions. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient in pain tells the nurse, "It feels like something is on fire." Which characteristic of pain is associated with this statement? ⏺Ask what the question is asking. Which characteristic of pain is related to the statement, "It feels like something is on fire?" ⏺Critically analyze each option in relation to the question and the other options. First review the characteristics of pain. Use of the mnemonic COLDERR for pain assessment may be helpful for review of these characteristics. Then identify the characteristic that is reflected in the patient's statement. ⏺Eliminate incorrect options. Option 1 relates to the severity of the pain. Option 2 is related to location but the patient's statement is too general to identify the actual site of the pain. According to COLDERR, option 4 relates to onset, duration, exacerbation, and relief factors. Options 1, 2, and 4 can be eliminated because none of them refers to the character of the pain, which is reflective of the patient's statement.

56. A nurse identifies that an adult patient is exhibiting antisocial behavior. According to Erikson, the negative resolution of which stage of development is most commonly associated with antisocial behavior? 1. Preschool age 2. Adolescence 3. School age 4. Infancy

1.Preschoolers (age 3 to 5 years—Initiative versus Guilt) learn to separate from parents and develop a sense of initiative. Negative resolution will result in guilt, rigidity, and a hesitancy to explore new skills or challenge abilities. ✅2. Adolescents (age 12 to 20 years— Identity versus Role Confusion) strive to develop a personal identity and autonomy. This is a turbulent time as the adolescent internalizes the dramatic physical changes and the psychological stressors of new social conflicts. It is common for adolescents to experience mood swings, make decisions without having all the facts, challenge authority, and assert the self. However, these behaviors are left behind when the developmental tasks of adolescence are positively resolved. Negative resolution results in assertive, rebellious, and antisocial behavior. 3. School-aged children (age 6 to 12 years— Industry verses Inferiority) learn to compete, compromise, and cooperate; develop relationships with peers; and win recognition through productivity. Negative resolution results in feelings of inadequacy, low self-esteem, and a reluctance to explore the environment. 4. Infants (birth to 18 months—Trust versus Mistrust) learn to depend on others to meet their needs, thereby developing trust and a beginning sense of self. Negative resolution of this task results in mistrust, dependency, lack of self-confidence, and shallow relationships in later stages of development. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse identifies that an adult patient is exhibiting antisocial behavior. According to Erikson, the negative resolution of which stage of development is most commonly associated with antisocial behavior? ⏺Ask what the question is asking. To which stage of Erikson's theory of development is antisocial behavior most related? ⏺Critically analyze each option in relation to the question and the other options. Consider the developmental task and related behaviors associated with each age group presented. Recall the behaviors of a person with an antisocial personality disorder. Identify the stage that reflects behavior associated with behaviors of people with an antisocial personality disorder. ⏺Eliminate incorrect options. Infants are developing trust, preschoolers are developing initiative, and school-aged children are learning to compromise and cooperate. Usually infants, preschoolers, and school-aged children are not irresponsible and do not abuse substances, engage in illegal activities, or challenge authority. Eliminate options 1, 3, and 4.

52. A nurse is planning care to support a patient's ability to sleep. Which factor from among the options presented most commonly interferes with the sleep of hospitalized patients? 1. Napping during the day 2. Disrupted bedtime rituals 3. Medication administration 4. Difficulty finding a comfortable position

1.The lights, noise, and activity in the hospital environment can interfere with napping during the day. However, naps when they do occur usually are short and rarely reach stage IV restorative sleep. 2. Hospitalized patients can follow their usual bedtime rituals. 3. Most medications are administered by 10 p.m. to 11 p.m. and should not interfere with sleep. ✅4. Studies support the fact that finding a comfortable position is one of the most common factors that interferes with sleep as reported by hospitalized patients. Patients frequently find hospital beds unfamiliar and uncomfortable. In addition, therapeutic regimens restrict movement or require patients to assume sleeping positions other than their preference. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is planning care to support a patient's ability to sleep. Which factor from among the options presented most commonly interferes with the sleep of hospitalized patients? ⏺Ask what the question is asking. Which most hinders hospitalized patients' abilities to sleep? ⏺Critically analyze each option in relation to the question and the other options. Analyze each option in relation to a patient in the hospital environment. Then identify the option that most interferes with sleep. ⏺Eliminate incorrect options. The hospital environment impedes the ability to take naps. Eliminate option 1. Bedtime rituals can be maintained in a hospital. Eliminate option 2. Most medications are not administered between 11 p.m. and 6 a.m. Eliminate option 3.

24. A nurse decides to give a partial bath to a patient instead of a complete bath. How was the nurse working when this decision was made? 1. Dependently 2. Independently 3. Collaboratively 4. Interdependently

1.The nurse does not need a primary health-care provider's order to provide nursing care that is within the realm of nursing practice. ✅2.Providing hygiene, an activity of daily living, is within the scope of nursing practice. 3. The nurse does not need to collaborate with other health-care professionals to provide nursing care. 4. The nurse does not need a primary health-care provider's order to implement nursing care that is within the realm of nursing practice. CRITICAL-THINKING STRATEGY Recognize keywords. A nurse decides to give a partial bath instead of a complete bath. How was the nurse working when this decision was made? Ask what the question is asking. How is the nurse functioning in relation to the legal definition of nursing when giving a partial bed bath? Critically analyze each option in relation to the question and the other options. Each state has a nurse practice act that defines and describes the scope of nursing practice. You need to know that legally the nurse can work dependently, independently, collaboratively, and interdependently when implementing nursing care. Now analyze the situation and identify in what role the nurse is working. Eliminate incorrect options. Providing for a patient's hygiene needs is not a dependent, collaborative, or interdependent function of the nurse and therefore options 1, 3, and 4 can be eliminated

60. A primary health-care provider orders peak and trough levels for a patient receiving an intravenous antibiotic. What time should the nurse obtain a blood sample to determine a trough level when the antibiotic was administered at 12 noon? 1. 11 a.m. 2. 11:30 a.m. 3. 12:30 p.m. 4. 1 p.m.

60. 1. 11 a.m. is too soon. The drug will not be at its lowest concentration in the blood. ✅2. Thirty minutes before or closer to the next scheduled dose is the most appropriate time for a trough blood level to be obtained. The serum level of the drug will be at its lowest. 3. Peak, not trough, levels are obtained 30 minutes after completion of drug administration. 4. The blood level of the drug increases after the drug is administered. A value taken at this time will not reflect the lowest serum level, which is the purpose of identifying a trough level. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A primary health-care provider orders peak-and- trough levels for a patient receiving an intravenous antibiotic. What time should the nurse obtain a blood sample to determine a trough level when the antibiotic was administered at 12 noon? ⏺Ask what the question is asking. When should a blood specimen for a trough level of a drug be obtained? ⏺Critically analyze each option in relation to the question and the other options. Recall the parameters for obtaining a specimen for a trough level of a drug. Identify the interrelationship of when the drug was administered and the times offered in each of the options. ⏺Eliminate incorrect options. A specimen of blood for a trough level should be obtained when the drug is at its lowest level (about 30 minutes before the next dose). Options 3 and 4 are too soon after the drug was administered. Eliminate options 3 and 4. Option 1 is too early compared with option 2. Eliminate option 1.

63. Which is the most effective nursing intervention to promote sleep that is appropriate for a patient in any situation? 1. Providing a backrub 2. Playing relaxing music 3. Offering a glass of warm milk 4. Following a routine at bedtime

63. 1. A backrub is the therapeutic manipulation of muscles and tissues that relaxes tense muscles, relieves muscle spasms, and induces rest or sleep. However, it may be contraindicated, and some people do not like a backrub or consider it an invasion of their personal space. 2. Music can be relaxing or stimulating depending on the music and the individual. 3. Although milk contains the amino acid l-tryptophan that promotes sleep, many people do not like milk or avoid fluids before bedtime to limit voiding during the night (nocturia). ✅4. Following routines provides consistency and comfort in an unfamiliar environment. Bedtime rituals meet basic physiological needs and usually include physically and emotionally relaxing behaviors. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. What is the most effective nursing intervention to promote sleep that is appropriate for a patient in any situation? ⏺Ask what the question is asking. Which is the best method to promote sleep? ⏺Critically analyze each option in relation to the question and the other options. Identify the commonalities and differences of nursing interventions that relate to promoting sleep. A commonality is an intervention that may work regardless of the patient situation. A difference is an intervention that may work for a patient in a specific situation. ⏺Eliminate incorrect options. Options 1, 2, and 3 may work for certain patients in specific situations. The nursing interventions in these options cannot be implemented for all patients. Eliminate options 1, 2, and 3.

64. A nurse is performing an assessment of a patient. Place an X on the figure of the body where the nurse should place the stethoscope to assess for the presence of borborygmi Upper right Upper left Lower left Lower right

64. An X in any part of the shaded area across the abdomen is a correct answer. A nurse should auscultate all four quadrants of the abdomen to determine the presence of borborygmi. Borborygmi are audible high-pitched, loud, gurgling sounds caused by the propulsion of gas through the intestine. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is performing an assessment of a patient. Place an X on the figure of the body where the nurse should place the stethoscope to assess for the presence of borborygmi. ⏺Ask what the question is asking Where on the body are. borborygmi heard? ⏺Critically analyze each option in relation to the question and the other options. Define borborygmi. Consider where these sounds are produced within the body. Place an X where a stethoscope should be placed to auscultate these sounds. ⏺Eliminate incorrect options. Other areas of the body will be eliminated when an X is placed over the shaded area indicated in the answer.

65. Which is the most important nursing intervention to help prevent falls from physical hazards in a hospital? 1. Positioning the telephone within easy reach 2. Storing belongings in a safe place 3. Ensuring adequate lighting 4. Using an over-bed table

65. 1. Although positioning the telephone within easy reach should be done, because it avoids reaching for a phone that can result in a loss of balance and a fall, it is not the most important intervention to prevent injury in a hospital. 2. Although storing belongings in a safe place should be done, this is not a physical hazard. ✅3. Adequate lighting provides for the safety of patients, staff, and visitors within a hospital. Inadequate lighting causes shadows, a dark environment, and the potential for misinterpreting stimuli (illusions) and is a major cause of accidents in the hospital setting. 4. An over-bed table has wheels and therefore cannot provide a firm base of support. Over-bed tables are physical hazards that may contribute to falls if used inappropriately. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. Which is the most important nursing intervention to help prevent falls from physical hazards in a hospital? ⏺Ask what the question is asking. How can the nurse best prevent falls in a hospital? ⏺Critically analyze each option in relation to the question and the other options. Analyze the outcome of each intervention in relation to safety. Compare and contrast options to eventually identify the best intervention. ⏺Eliminate incorrect options. Option 2 is unrelated to safety and option 4 is unsafe. Eliminate options 2 and 4. Options 1 and 3 both relate to safety. Option 1 relates to just one limited aspect of a safe environment. Option 2 relates to a more pervasive issue—inadequate lighting. Therefore, eliminate option 1.

75. A nurse is assessing the skin of an older adult. Which assessment is the greatest concern? 1. Flat, brown spots on the skin 2. Thin, translucent skin 3. Tenting of the skin 4. Dry, flaky skin

75. 1. Flat, brown spots on the skin are an expected integumentary change in older adults. Brown spots (lentigo senilis) on the skin are caused by a clustering of melanocytes, which are pigment- producing cells. 2. A loss of subcutaneous fat and a reduced thickness and vascularity of the dermis that occur with aging result in thin, translucent skin in the older adult. ✅3. Tenting occurs when the skin of a dehydrated person remains in a peak or tent position after the skin is pinched together. This is a sign of a fluid volume deficit. Care must be takenwhen assessing an older person because some degree of tenting may occur, even when hydrated, because of the decrease in skin elasticity and decrease in tissue fluid associated with aging; however, in the hydrated patient tenting will slowly resolve. 4. A decrease in tissue fluid and sebaceous gland activity associated with aging commonly results in dry, flaky skin. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is assessing the skin of an older adult. Which assessment is the greatest concern? ⏺Ask what the question is asking. Which skin condition in an older adult is most serious? ⏺Critically analyze each option in relation to the question and the other options. Explore the causes and consequences of the clinical finding presented in each option. Review the expected skin changes associated with aging. Compare and contrast the options in relation to this information to identify the most serious clinical finding. ⏺Eliminate incorrect options. The signs in options in 1, 2, and 4 are expected changes associated with aging and are not as serious as tenting of the skin, which indicates dehydration. Options 1, 2, and 4 can be eliminated.

A nurse who displays a selfless concern for others is exhibiting which of the following? ​Accountability ​Altruism ​Responsibility

Accountability Accountability is an obligation to accept responsibility. Nurses are accountable for the outcomes included in the professional role. ​✅Altruism MY ANSWER ​Altruism is the selfless concern for others. ​Responsibility ​Responsibility refers to duties or the tasks that must be performed as part of nursing care.

​According to Patricia Benner, which of the following is a characteristic of the advanced beginner nurse? (Select all that apply.) Anticipates outcomes based on experience Provides efficient and organized care Performs at an acceptable level ​Exhibits a high level of proficiency ​Bases actions on principles and experience

Anticipates outcomes based on experience is incorrect. The proficient nurse anticipates outcomes based on experience. Provides efficient and organized care is incorrect. The competent nurse provides efficient and organized care. ✅Performs at an acceptable level is correct. The advanced beginner nurse performs at an acceptable level. ​Exhibits a high level of proficiency is incorrect. The expert nurse exhibits a high level of proficiency. ​ ✅Bases actions on principles and experience is correct. The advanced beginner nurse bases actions on principles and experience. Becoming a Professional Nurse: Socialization into Professional Nursing

​Which of the following is an evidence-based documentation tool for effective communication between health care professionals? ​Core measures ​Charting by exception ​Clinical pathway

Core measures ​Core measures were established by The Joint Commission and are national standards proved to enhance client outcomes. Core measures do not enhance effective communication between health care professionals. ​Charting by exception ​Charting by exception involves the documentation of deviations from expected findings. Although appropriate in some situations, this method is primarily used for nursing documentation and does not enhance effective communication between health care professionals. ​✅Clinical pathway ​A clinical pathway is an evidence-based plan of care that includes client problems, implemented or planned interventions, and identifies expected outcomes. It is a multidisciplinary plan of care that is an effective method of communicating between health care professionals. Becoming a Professional Nurse: Socialization into Professional Nursing

Which of the following should not be included when discussing modes of computer-mediated communication? Electronic health records Email Voice mail

Electronic health records Electronic health records are a mode of computer-mediated communication. Email Email is a mode of computer-mediated communication . ✅Voice mail Voice mail is not a mode of computer-mediated communication and should not be included in the discussion. Professional Communication: Types of Communication

1. Which early responses indicate to the nurse that the patient is experiencing hypoxia? Select all that apply. 1. _____Inc reased heart rate 2. _____Dif ficulty breathing 3. _____Restlessness 4. _____Br adypnea 5. _____Ir ritabili

FUNDAMENTALS SUCCESS ✅1. More than 100 beats per minute (tachycardia) is an early response to hypoxia. Hypoxia is insufficient oxygen anywhere in the body. To compensate for this lack of oxygen, the heart increases its rate to improve cardiac output, thereby increasing oxygen to all body cells. 2. Difficulty breathing (dyspnea) is a late, not early, sign of hypoxia. ✅3. Restlessness is an early sign of hypoxia. Restlessness occurs with hypoxia because of a decrease in oxygen to the brain. 4. An increase in respirations more than 20 breaths per minute (tachypnea), not a decrease in respirations less than 12 breaths per minute (bradypnea), occurs as the body attempts to deliver more oxygen to body cells. ✅5. Irritability is an early sign of hypoxia. Irritability occurs with hypoxia because of a decrease in oxygen to the brain. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. Which early responses indicate to the nurse that the patient is experiencing hypoxia? ⏺Ask what the question is asking. Which are early signs of hypoxia? ⏺Critically analyze each option in relation to the question and the other options. Examine each option from the perspective of whether or not the response is associated with reduced oxygenation in the body. This requires an understanding of physiological responses to reduced oxygenation and why each occurs. ⏺Eliminate incorrect options. Options 2 and 4 are late signs of hypoxia and can be eliminated.

Which of the following is a component of biculturalism? ​Following a single value system Evaluation of personal values ​Development of professional identity

Following a single value system ​Biculturalism involves integrating two contradictory value systems instead of choosing and following a single value system. ✅Evaluation of personal values In order to integrate conflicting value systems, an evaluation of personal values must occur; therefore, evaluation of personal values is a component of biculturalism. ​Development of professional identity ​Professional identity is a set of beliefs, attitudes, and understanding of the nursing role. It is not a component of biculturalism. Becoming a Professional Nurse: Socialization into Professional Nursing

A nurse engages in verbal communication with a client. Which of the following is reflective of the nurse's word selection? Gender Familial history Personal values

Gender Gender is not associated with word selection while engaging in verbal communication. Familial history Familial history is not associated with word selection while engaging in verbal communication. ✅Personal values Personal values, perceptions, culture, age, education, and socioeconomic background are reflective of word selection while engaging in verbal communication. Professional Communication: Types of Communication

A nurse is caring for a client who states, "I would like to go out on a date with you." Which of the following is an appropriate response by the nurse? Ignore the client's behavior. Suggest to the client that he spend time in his room. Inform the client that this is an inappropriate statement.

Ignore the client's behavior. Ignoring the client's behavior does not address the situation. Suggest to the client that he spend time in his room. Suggesting that the client remain in his room does not address the situation. ✅Inform the client that this is an inappropriate statement. The nurse needs to set clear limits on the client's expected behavior. Therefore, this is the appropriate intervention. This is an attempt to maintain professional boundaries with the client. Professional Communication: Therapeutic Communication

Which of the following should a nurse include in the verbal SBAR report to a provider? (Select all that apply.) Introduction Background Assessment Situation Recommendation

Introduction is incorrect. This is included in the ISBAR. ✅Background is correct. Background is the second component of Situation, Background, Assessment, Recommendation. ✅Assessment is correct. Assessment is the third component of Situation, Background, Assessment, Recommendation. ✅Situation is correct. Situation is the first component of Situation, Background, Assessment, Recommendation. ✅Recommendation is correct. Recommendation is the last component of Situation, Background, Assessment, Recommendation. Professional Communication: Organizational Structure

CONTINUITY OF CARE

I—Introduction: People involved in the handoff identify themselves, their roles, and their jobs S—Situation: Complaint, diagnosis, treatment plan, and patient's wants and needs B—Background: Vital signs, mental and code status, list of medications, and lab results A—Assessment: Current provider's assessment of the situation R—Recommendation: Identify pending lab results and what needs to be done over the next few hours and other recommendations for care Q—Question and answer: An opportunity for questions and answers CHAPTER 12 Collaborative Practice and Care Coordination Across Settings

​Participation in health policy development and the political process is a significant part of which of the following nursing roles? ​Manager ​Collaborator ​Advocate

Manager ​Managers plan, direct, monitor, and evaluate the nursing care provided to a variety of patient populations. They may be involved in health policy development and the political process, but they are fulfilling their role as advocates in this capacity. ​Collaborator ​As a collaborator, it is the nurse's role to plan and coordinate care in cooperation with other disciplines. ​✅Advocate Health policy determines who provides healthcare, who pays - and gets paid - for healthcare, what kind of care can be provided, where care can be provided, when care can be provided, and how care is provided. Because these factors impact safety, quality, and nursing's scope of practice, involvement in policy development and the political process is a significant part of the nurse's role as advocate - for patients and the profession. Becoming a Professional Nurse: Professional Nursing Practice

A nurse is reviewing professional communication skills with a newly licensed nurse. Which of the following is a form of effective communication? Passive Assertive Passive-aggressive

Passive Passive communication is an ineffective communication style frequently used to avoid confrontation and difficult decision-making. ✅Assertive Assertive communication is the most effective communication technique that is used to convey information in an informative and professional manner. Passive-aggressive Passive-aggressive communication uses manipulation to avoid confrontation in order to attain personal goals. Professional Communication: Organizational Structure

​Which of the following makes it acceptable to report confidential client information if abuse, neglect, or exploitation is suspected? ​Patient Self-Determination Act ​Health Insurance Portability and Accountability Act ​Americans with Disabilities Act

Patient Self-Determination Act The Patient Self-Determination Act requires all health care facilities receiving Medicare or Medicaid reimbursement to provide information about confidentiality, consent, client rights, and advance directives to clients. ​✅Health Insurance Portability and Accountability Act ​The Health Insurance Portability and Accountability Act (HIPAA) establishes standards for privacy and confidentiality in the health care setting, granting clients the right to prevent disclosure of health information without consent. An exception to HIPAA requirements is circumstances where abuse, neglect, or exploitation is suspected. Nurses have a legal responsibility to report suspected abuse, neglect, or exploitation. ​Americans with Disabilities Act ​The Americans with Disabilities Act prohibits discrimination on the basis of disability in employment, public services, and public accommodations. Becoming a Professional Nurse: Professional Nursing Practice

A nurse is preparing to provide education to a group of newly licensed nurses about methods to enhance communication with clients. Which of the following statements should the nurse include? (Select all that apply.) "Interrupt the client occasionally during the conversation." "Respect the client during the conversation." "Use complex terms when explaining with the client." "Allow time for reflection during the conversation with the client." "Show empathy during the conversation with the client."

RN Communication Assessment

A nurse is providing discharge instructions to a client during a follow-up telephone call. Based on the Shannon-Weaver communication model, which of the following components of the model is the nurse demonstrating? Receiver Sender Channel Decode

Receiver The person who receives the message is the receiver; therefore, the client is the receiver. ✅Sender The nurse is initiating the message; therefore, the nurse is the sender. Channel The channel is the method used to send the message from the sender to the receiver, such as a phone line or cable. Decoder The decoder receives the transmission from the channel and converts it back to a message. RN Communication Assessment

Which of the following should not be included when discussing components of the communication process? Sender Receiver Tone of voice

Sender The sender, the person sending the message, is a component of the communication process. Receiver The receiver, the person who is listening or reading and responding to the message, is a component of the communication process ✅Tone of voice Tone of voice is not a component of the communication process. Professional Communication: Types of Communication

​Which of the following relates to the concept of caring in professional nursing? Straying from current values Promoting role excellence Reflecting historical evidence

Straying from current values ​Caring should reflect or mirror current values and trends of the health care system. ✅Promoting role excellence ​The concept of caring is holistic and, therefore, promotes high-quality care, and excellence in care delivery. Reflecting historical evidence ​Caring should include up-to-date practice, which follows recent research findings and evidence. Becoming a Professional Nurse: Professional Behaviors in Nursing

Which of the following are characteristics of effective written communication? (Select all that apply.) Subjective Factual Objective Accurate Concise

Subjective is incorrect. Effective written communication is not subjective, and opinions should be avoided. ✅Factual is correct. Effective written communication is factual. ✅Objective is correct. Effective written communication is objective. ✅Accurate is correct. Effective written communication is accurate. ✅Concise is correct. Effective written communication is concise. Professional Communication: Types of Communication

2. A discharge nurse is evaluating patients and their families to determine the need for a formal discharge plan or referrals to another facility. Which patients would most likely be a candidate for these services? Select all that apply. A. An older adult who is diagnosed with dementia in the hospital B. A 45-year-old man who is diagnosed with Parkinson's disease C. A 35-year-old woman who is receiving chemotherapy for breast cancer D. A 16-year-old boy who is being discharged with a cast on his leg E. A new mother who delivered a healthy infant via a cesarean birth F. A 59-year-old man who is diagnosed with end-stage bladder cancer

a, b, f. The patients who are most likely to need a formal discharge plan or referral to another facility are those who are emotionally or mentally unstable (e.g., those with dementia), those who have recently diagnosed chronic disease (e.g., Parkinson's disease), and those who have a terminal illness (e.g., end-stage cancer). Other candidates include patients who do not understand the treatment plan, are socially isolated, have had major surgery or illness, need a complex home care regimen, or lack financial services or referral sources. CHAPTER 12 Collaborative Practice and Care Coordination Across Settings

9. A nurse decides to become a home health care nurse. Which personal qualities are key to being successful as a community-based nurse? Select all that apply. A. Making accurate assessments B. Researching new treatments for chronic diseases C. Communicating effectively D. Delegating tasks appropriately E. Performing clinical skills effectively F.Making independent decisions

a, c, e, f. Nurses working in the community must have the knowledge and skills to make accurate assessments, work independently, communicate effectively, and perform clinical skills accurately. Community-based nurses may be researchers and occasionally delegate care, but these are not key qualities for this type of nursing. CHAPTER 12 Collaborative Practice and Care Coordination Across Settings

5. A nurse researcher keeps current on the trends to watch in health care delivery. What trends are likely included? Select all that apply. Globalization of the economy and society Slowdown in technology development Decreasing diversity Increasing complexity of patient care Changing demographics Shortages of key health care professionals and educators

a, d, e, f. Trends to watch in health care delivery include globalization of the economy and society, increasing complexity of patient care, changing demographics, shortages of key health care professionals and educators, technology explosion, and increasing diversity CHAPTER 11 The Health Care Delivery System

10. A nurse cares for dying patients by providing physical, psychological, social, and spiritual care for the patients, their families, and other loved ones. What type of care is the nurse providing? Respite care Palliative care Hospice care Extended care

a, d, e. The Advanced Practice Registered Nurse (APRN) is a registered nurse educated at the master's or post-master's level in a specific role and for a specific population. Whether they are nurse practitioners, clinical nurse specialists, nurse anesthetists, or nurse midwives, APRNs play a pivotal role in the future of health care. APRNs are often primary care providers and are at the forefront of providing preventive care to the public. Hospitalists are health care providers who provide care to patients when they visit the emergency department or are admitted to the hospital. A physical therapist completes a specific training program to learn to help patients restore function or to prevent further disability in a patient after an injury or illness. A pharmacist, prepared at the doctoral level, is licensed to formulate and dispense medications. CHAPTER 11 The Health Care Delivery System

3. A nurse working in a primary care facility prepares insurance forms in which the provider is given a fixed amount per enrollee of the health plan. What is the term for this type of reimbursement? Capitation Prospective payment system Bundled payment Rate setting

a. Capitation plans give providers a fixed amount per enrollee in the health plan in an effort to build a payment plan that consists of the best standards of care at the lowest cost. The prospective payment system groups inpatient hospital services for Medicare patients into DRGs. With bundled payments, providers receive a fixed sum of money to provide a range of services. Rate setting means that the government could set targets or caps for spending on health care services. CHAPTER 11 The Health Care Delivery System

8. A nurse caring for patients in a primary care setting submits paperwork for reimbursement from managed care plans for services performed. Which purpose best describes managed care as a framework for health care? A design to control the cost of care while maintaining the quality of care Care coordination to maximize positive outcomes to contain costs The delivery of services from initial contact through ongoing care Based on a philosophy of ensuring death in comfort and dignity

a. Managed care is a way of providing care designed to control costs while maintaining the quality of care. CHAPTER 11 The Health Care Delivery System

7. A caregiver asks a nurse to explain respite care. How would the nurse respond? "Respite care is a service that allows time away for caregivers." "Respite care is a special service for the terminally ill and their family." "Respite care is direct care provided to people in a long-term care facility." "Respite care provides living units for people without regular shelter."

a. Respite care is provided to enable a primary caregiver time away from the day-to-day responsibilities of homebound patients. CHAPTER 11 The Health Care Delivery System

6. A patient is being transferred from the ICU to a regular hospital room. What must the ICU nurse be prepared to do as part of this transfer? A. Provide a verbal report to the nurse on the new unit. B. Provide a detailed written report to the unit secretary. C. Delegate the responsibility for providing information. D. Make a copy of the patient's medical record.

a. The ICU nurse gives a verbal report on the patient's condition and nursing care needs to the nurse on the new unit. This information is not given to a unit secretary, nor is its provision delegated to others. The medical record is transferred with the patient; a copy is not made. CHAPTER 12 Collaborative Practice and Care Coordination Across Settings

2. A nurse is providing health care to patients in a health care facility. Which of these patients are receiving secondary health care? Select all that apply. A patient enters a community clinic with signs of strep throat. A patient is admitted to the hospital following a myocardial infarction. A mother brings her son to the emergency department following a seizure. A patient with osteogenesis imperfecta is being treated in a medical center. A mother brings her son to a specialist to correct a congenital heart defect. A woman has a hernia repair in an ambulatory care center.

b, c, f. Secondary health care treats problems that require specialized clinical expertise, such as an MI, a seizure, and a hernia repair. Treating strep throat is primary health care. Tertiary health care involves management of rare and complex disorders, such as osteogenesis imperfecta and congenital heart malformations. CHAPTER 11 The Health Care Delivery System

1. A nurse who is a discharge planner in a large metropolitan hospital is preparing a discharge plan for a patient after a kidney transplant. Which actions would this nurse typically perform to ensure continuity of care as the patient moves from acute care to home care? Select all that apply. A. Performing an admission health assessment B. Evaluating the nursing plan for effectiveness of care C.Participating in the transfer of the patient to the postoperative care unit D Making referrals to appropriate facilities E. Maintaining records of patient satisfaction with services F. Assessing the strengths and limitations of the patient and family

b, d, f. The primary roles of the discharge planner as patients move from acute to home care are evaluating the nursing plan for effectiveness of care, making referrals for patients, and assessing the strengths of patients and their families. Although in smaller facilities a discharge planner may perform an admission health assessment and assist with patient transfers, it is not the usual job of the discharge planner. In most facilities, maintaining records of patient satisfaction is the role of the public relations manager or office manager. CHAPTER 12 Collaborative Practice and Care Coordination Across Settings

6. A nurse is caring for patients in a primary care center. What is the most likely role of this nurse based on the setting? Assisting with major surgery Performing a health assessment Maintaining patients' function and independence Keeping student immunization records up to date

b. Performing patient health assessments is a common role of the nurse in a primary care center. Assisting with major surgery is a role of the nurse in the hospital setting. Maintaining patients' function and independence is a role of the nurse in an extended-care facility, and keeping student immunization records up to date is a role of the school nurse. CHAPTER 11 The Health Care Delivery System

4. A nurse working in a pediatric clinic provides codes for a patient's services to a third-party payer who pays all or most of the care. This is an example of what mode of health care payment? Out-of-pocket payment Individual private insurance Employer-based group private insurance Government financing

b. The four basic modes of paying for health care are out-of-pocket payment, individual private insurance, employer-based group private insurance, and government financing. With individual private insurance, members pay monthly premiums either by themselves or in combination with employer payments. These plans are called third-party payers because the insurance company pays all or most of the cost of care. Out-of-pocket payment is paying for health care with cash payments. Employer-based private insurance is employer-sponsored coverage and government financing is provided through Medicare and Medicaid, and other federally funded programs. CHAPTER 11 The Health Care Delivery System

7. Which statement or question MOST exemplifies the role of the nurse in establishing a discharge plan for a patient who has had major abdominal surgery? A. "I'll bet you will be so glad to be home in your own bed." B. "What are your expectations for recovery from your surgery?" C. "Be sure to take your pain medications and change your dressing." D. "You will just be fine! Please stop worrying."

b. The purpose of planning for continuity of care, commonly referred to in hospitals and community facilities as discharge planning, is to ensure that patient and family needs are consistently met as the patient moves from a care setting to home. Essential components of discharge planning include assessing the strengths and limitations of the patient, the family or support person, and the environment; implementing and coordinating the care plan; considering individual, family, and community resources; and evaluating the effectiveness of care. Answers a and c are not MOST reflective of the role of the nurse in discharge planning, although teaching and communication are elements of this process. The statement "You will just be fine! Please stop worrying." is a cliché and should not be used. CHAPTER 12 Collaborative Practice and Care Coordination Across Settings

3. A home health care nurse is scheduled to visit a 38-year-old woman who has been discharged from the hospital with a new colostomy. Which duties would the nurse perform for this patient in the entry phase of the home visit? Select all that apply. A. Collect information about the patient's diagnosis, surgery, and treatments. B. Call the patient to make initial contact and schedule a visit. C. Develop rapport with the patient and her family. D. Assess the patient to identify her needs. E. Assess the physical environment of the home. F. Evaluate safety issues including the neighborhood in which she lives.

c, d, e. In the entry phase of the home visit, the nurse develops rapport with the patient and family, makes assessments, determines nursing diagnoses, establishes desired outcomes, plans and implements prescribed care, and provides teaching. In the pre-entry phase of the home visit, the nurse collects information about the patient's diagnoses, surgical experience, socioeconomic status, and treatment orders. In the pre-entry phase, the nurse also gathers supplies needed, makes an initial phone contact with the patient to arrange for a visit, and assesses the patient's environment for safety issues. CHAPTER 12 Collaborative Practice and Care Coordination Across Settings

1. Nursing students are reviewing information about health care delivery systems in preparation for a quiz the next day. Which statements describe current U.S. health care delivery practices? Select all that apply. Access to care depends only on the ability to pay, not the availability of services. The Patient Protection and Affordable Care Act provides private health care insurance to underserved populations. Every health insurance plan in the Health Insurance Marketplace offers comprehensive coverage, from doctors to medications to hospital visits. The uninsured pay for more than one third of their care out of pocket and are usually charged lower amounts for their care than the insured pay. Fifty years ago, half of the doctors in the United States practiced primary care, but today fewer than one in three do. Quality of care can be defined as the right care for the right person at the right time

c, e, f. The Health Insurance Marketplace is designed to help people more easily find health insurance that fits their budget. Every health insurance plan in the Marketplace offers comprehensive coverage, from doctors to medications to hospital visits. Fifty years ago, half of the doctors in the United States practiced primary care, but today fewer than one in three do. Quality is the right care for the right person at the right time. Access to care depends on both the ability to pay and the availability of services. The Patient Protection and Affordable Care Act provides Medicaid or subsidized coverage to qualifying people with incomes up to 400% of poverty. The uninsured pay for more than one third of their care out of pocket and are often charged higher amounts for their care than the insured pay. CHAPTER 11 The Health Care Delivery System

5.A nurse is preparing an infant and his family for a hernia repair to be performed in an ambulatory care facility. What is the primary role of the nurse during the admission process? A. To assist with screening tests B. To provide patient teaching C. To assess what has been done and what still needs to be done D. To assist with hernia repair

c. Although all the actions may be performed by the ambulatory care nurse, it is the nurse's primary responsibility to assess what has been done and to tailor the care plan to the patient's needs. Screening tests and teaching are usually completed before the patient enters an ambulatory care facility

9. A nurse cares for dying patients by providing physical, psychological, social, and spiritual care for the patients, their families, and other loved ones. What type of care is the nurse providing? Respite care Palliative care Hospice care Extended care

c. The hospice nurse combines the skills of the home care nurse with the ability to provide daily emotional support to dying patients and their families. Respite care is a type of care provided for caregivers of homebound ill, disabled, or older adults. Palliative care, which can be used in conjunction with medical treatment and in all types of health care settings, is focused on the relief of physical, mental, and spiritual distress. Extended-care facilities include transitional subacute care, assisted-living facilities, intermediate and long-term care, homes for medically fragile children, retirement centers, and residential institutions for mentally and developmentally or physically disabled patients of all ages. CHAPTER 11 The Health Care Delivery System

10. A nurse ensures that a hospital room prepared by an aide is ready for a new ambulatory patient. Which condition would the nurse ask the aide to correct? The bed linens are folded back. A hospital gown is on the bed. Equipment for taking vital signs is in the room. The bed is in the highest position.

d. A properly prepared hospital room includes a bed in the lowest position for an ambulatory patient, an open bed with top linens folded back, routine equipment and supplies and special equipment and supplies assembled, and the physical environment of the room adjusted. CHAPTER 12 Collaborative Practice and Care Coordination Across Settings

4. A hospital nurse is admitting a patient who sustained a head injury in a motor vehicle accident. Which activity could the nurse delegate to licensed assistive personnel? Collecting information for a health history Performing a physical assessment Contacting the health care provider for medical orders Preparing the bed and collecting needed supplies

d. The nurse may delegate preparation of the bed and collection of needed supplies to unlicensed personnel but would perform the other activities listed CHAPTER 12 Collaborative Practice and Care Coordination Across Settings

8. A nurse is counseling an older woman who has been hospitalized for dehydration secondary to a urinary tract infection. The patient tells the nurse: "I don't like being in the hospital. There are too many bad bugs in here. I'll probably go home sicker than I came in." She also insists that she is going to get dressed and go home. She has the capacity to make these decisions. What is the legal responsibility of the nurse in this situation? A. To inform the patient that only the primary health care provider can authorize discharge from a hospital B. To collect the patient's belongings and prepare the paperwork for the patient's discharge C. To request a psychiatric consult for the patient and inform her PCP of the results D. To explain that the choice carries a risk for increased complications and make sure that the patient has signed a release form

d. The patient is legally free to leave the hospital AMA; however, patients who leave the hospital AMA must sign a form releasing the health care provider and hospital from legal responsibility for their health status. This signed form becomes part of the medical record. CHAPTER 12 Collaborative Practice and Care Coordination Across Settings

​A nurse is reviewing information related to balancing autonomy with boundaries. Which of the following phrases should the nurse expect to find related to the concept of boundaries? ​Allow for increased flexibility in caregiving ​Impede design and delivery of safe care ​Guided by state nurse practice acts

​Allow for increased flexibility in caregiving ​Boundaries balance autonomy by restricting some freedoms and flexibility in order to promote safe care. ​Impede design and delivery of safe care ​Boundaries promote safety in care by ensuring that individuals follow certain key standards. ​✅Guided by state nurse practice acts ​Boundaries are outlined in each state's nurse practice acts; agency protocols and boundaries must fall within state restrictions. Becoming a Professional Nurse: Professional Behaviors in Nursing

​Which of the following professional associations established the Code of Ethics, Social Policy Statement, and Scope and Standards of Practice? ​American Association of Colleges of Nursing ​American Nurses Association ​National League for Nursing

​American Association of Colleges of Nursing ​The American Association of Colleges of Nursing represents university-level nursing education programs. The association's activities include educational research, government advocacy, data collection, and publishing. ​✅American Nurses Association The American Nurses Association seeks to influence the social, political, and economic conditions affecting nursing practice. This organization has established a Code of Ethics, Social Policy Statement, and Scope and Standards of Practice to inform decision-making, guide practice, and influence the quality of nursing practice. ​National League for Nursing ​The National League for Nursing represents nursing education programs at all levels and offers an accreditation process through its National League for Nursing Accrediting Commission. Becoming a Professional Nurse: Professional Nursing Practice

​A nurse is compiling an orientation handout related to accountability and responsibility. Which of the following should the nurse use to describe responsibilities? ​An internal obligation to others ​Duty to report quality of work ​Basic care needs of clients

​An internal obligation to others ​Accountability refers to an individual's internal obligation to report concerns or violations. ​Duty to report quality of work ​Accountability refers to the duty of a worker to report quality or how well work tasks are completed. ​✅Basic care needs of clients ​Responsibilities include tasks, skills, and the basic care needs of clients. Becoming a Professional Nurse: Professional Behaviors in Nursing

​A nurse acting to accomplish goals in an efficient manner with other people is fulfilling which of the following roles? ​Change agent ​Manager ​Educator

​Change agent ​As a change agent, the nurse identifies problems in health care delivery affecting client care, client safety, access to care, or the work environment. ​✅Manager ​Nurse managers plan, direct, monitor, and evaluate the nursing care provided to a variety of patient populations. But even a nurse with no formal title functions in the manager role whenever the nurse acts to accomplish something in an efficient manner with other people. ​Educator ​In the role of educator, the nurse assists clients in recognizing choices, evaluating alternatives, and developing a sense of control over their environment and health. Becoming a Professional Nurse: Professional Nursing Practice

​In what role does a nurse assess resources, strengths and weaknesses, coping behaviors, and the environment to help the client regain health to a maximum level of independent functioning? ​Client advocate ​Collaborator ​Care provider

​Client advocate ​In the role of client advocate, the nurse promotes what is best for the client, ensures that the client's needs are met, and protects the client's human and legal rights. ​Collaborator ​As a collaborator, the nurse plans and coordinates care in cooperation with other disciplines. ​✅Care provider ​In the role of care provider, the nurse assesses resources, strengths and weaknesses, coping behaviors, and the environment to help the client regain health and a maximum level of independent function. Becoming a Professional Nurse: Professional Nursing Practice

​A nurse is acting as a preceptor for a student studying the concept of autonomy. The nurse confirms the student's clear understanding of autonomy when the student describes it as which of the following? ​Critical thinking ​Team collaboration ​Individual choice

​Critical thinking ​Critical thinking is a decision-making concept. ​Team collaboration ​Collaboration is a group process; autonomy promotes independence. ​✅Individual choice MY ANSWER ​Autonomy upholds the right of the individual to make choices; autonomy promotes independence. Becoming a Professional Nurse: Professional Behaviors in Nursing

​Which of the following is an example of an unintentional tort? ​False imprisonment ​Battery ​Negligence

​False imprisonment ​False imprisonment is an example of an intentional tort. ​Battery ​Battery is an example of an intentional tort. ​✅Negligence ​Negligence is an example of an unintentional tort. Becoming a Professional Nurse: Professional Nursing Practice

​Which of the following is a characteristic of a mentor? ​Formally assigned by the nurse manager ​Assists protégé in professional development ​Orients new graduates to a specific work

​Formally assigned by the nurse manager ​A preceptor, not a mentor, is identified through a formal assignment. ​✅Assists protégé in professional development ​Mentors make a conscious decision to assist protégés in professional development, as well as in the attainment of professional status. ​Orients new graduates to a specific work environment ​The preceptor, not the mentor, orients the new graduate nurse to a specific work area. Becoming a Professional Nurse: Socialization into Professional Nursing

​A nurse is telling the truth, keeping promises, and doing no harm while caring for a client who is experiencing conflict with his family. Which of the following is the nurse demonstrating? ​Honoring client autonomy Primary commitment to the client ​Accountability for professional practice

​Honoring client autonomy Nurses demonstrate autonomy by ensuring the client fully understands the purpose, benefits, risks, and alternatives for treatment and honoring the client's right to make his or her own choices. ✅Primary commitment to the client When conflicts of interest arise, demonstrating a primary commitment to the client involves the ethical principles of veracity (telling the truth), fidelity (keeping your promises), and nonmaleficence (doing no harm). Abiding by these principles demonstrates courage and ensures professional integrity. ​Accountability for professional practice Accountability is an ethical principle demonstrated by maintaining the competence required for a role and seeking help from others when needed. Accountability also involves delegating activities to the appropriate, competent personnel. Becoming a Professional Nurse: Professional Nursing Practice

​Which of the following professional organizations provides specific guidance to licensed practical nurses? ​IPNRC ​NAPNES ​AACN

​IPNRC ​IPNRC is the International Parish Nurse Resource Center. It does not provide specific guidance to licensed practical nurses. Instead, this association works with communities and nurses in an effort to incorporate parish nursing with faith traditions. ​✅NAPNES ​NAPNES is the National Association for Practical Nurse Education and Service, Inc. It provides specific guidance to licensed practical nurses. ​AACN ​AACN is the American Association of Critical-Care Nurses. It does not provide specific guidance to licensed practical nurses. Instead, this association represents the interests of nurses who care for acutely and critically ill clients. Nurse's Touch: Becoming a Professional Nurse (4)

​According to Patricia Benner, a novice nurse demonstrates which of the following behavior? ​Intuition ​Improved decision-making ​Inflexibility

​Intuition The expert nurse demonstrates flexibility and an intuitive grasp of clinical situations. ​Improved decision-making ​The proficient nurse demonstrates improved decision-making skills, due in part to an ability to see the "big picture." ​✅Inflexibility ​The novice, or beginner with no experience, applies general rules learned in school to all situations and demonstrates inflexible behavior. Becoming a Professional Nurse: Socialization into Professional Nursing

​Which of the following will assist the new graduate nurse with the development of knowledge and skills necessary for the nursing role? ​Mentor ​Collaborator ​Preceptor

​Mentor ​A mentor makes a conscious decision to help an individual attain expert status and further career development, and assists with the development of attitudes and values. ​Collaborator ​Collaboration involves working with others to meet mutually defined goals. ​✅Preceptor ​The preceptor will assist the new graduate nurse with the development of knowledge and skills necessary for the nursing role. Becoming a Professional Nurse: Socialization into Professional Nursing

Which of the following resources provides guidance on the legal responsibilities of nurses to clients and society? ​Nursing's Social Policy Statement ​Code of Ethics for Nurses ​Scope and Standards of Practice

​Nursing's Social Policy Statement Nursing's Social Policy Statement serves as a source of information about nursing for consumers, government officials, and other health care professionals. ​✅Code of Ethics for Nurses ​The American Nursing Association's (ANA) Code of Ethics for Nurses provides guidance on the legal responsibilities of nurses to clients and society. ​Scope and Standards of Practice ​The Scope and Standards of Practice describe the professional responsibilities of nurses.

Which of the following is one of the foundations of the nursing profession? ​Personal morals ​Professional identity ​Professional values

​Personal morals ​Personal morals are internal factors that contribute to the delivery of nursing care. ​Professional identity ​Professional identity is a set of beliefs, attitudes, and understanding about the nursing role. ​✅Professional values MY ANSWER ​Professional values are one of the foundations of the nursing profession Nurse's Touch: Becoming a Professional Nurse (4)

​A nurse is working as a member of an interprofessional team. Which of the following actions should the nurse take? ​Plan client care based on the nursing perspective ​Separate client goals by discipline ​Use assertive communication

​Plan client care based on the nursing perspective ​Client care should be planned based on the needs of the client and include the perspectives of the client and all participating health care disciplines, as well as the family and other caregivers as necessary. ​Separate client goals by discipline ​Client plans should focus on the common goals of the team, rather than separating goals by discipline. ​✅Use assertive communication ​The use of assertive communication is an appropriate action by the nurse. Effective communication is necessary for high-quality outcomes and reduction of errors. This can be accomplished by stating personal beliefs and understandings about client needs without controlling or pushing others Becoming a Professional Nurse: Socialization into Professional Nursing

​A nurse is engaged as a mentor for a new graduate nurse. Which of the following actions by the mentor is characteristic of the role of a coach? ​Provides support on personal issues ​Expands the protégé's network of contacts ​Shares ideas and provides feedback

​Provides support on personal issues ​In the role of encourager or supporter, a mentor listens to concerns, provides insight into possible opportunities, and provides support on personal issues when appropriate. ​Expands the protégé's network of contacts ​Serving as a resource, a mentor expands the protégé's network of contacts within the profession. ​✅Shares ideas and provides feedback ​In the role of coach or adviser, a mentor shares ideas and provides feedback. The mentor also shares the unwritten rules for success in an organization's culture. Becoming a Professional Nurse: Socialization into Professional Nursing

​Which of the following provisions in the ANA resource Code of Ethics for Nurses with Interpretive Statements describes the duty of nurses to develop collaborative solutions to broad health issues? ​Provision 4 ​Provision 6 ​Provision 8

​Provision 4 ​Provision 4 of the Code of Ethics for Nurses with Interpretive Statements says that nurses are responsible and accountable for their own actions. ​Provision 6 ​Provision 6 of the Code of Ethics for Nurses with Interpretive Statements says that nurses are responsible for the provision of quality patient care, both individually and collectively. ​✅Provision 8 ​Provision 8 of the Code of Ethics for Nurses with Interpretive Statements says that the nurse has a responsibility to be aware of and collaborative with other health professionals and community members in order to address and intervene in broad health concerns, such as hunger, pollution, and lack of access to health care.

​Which of the following tenets in the ANA resource Scope and Standards of Practice describes the use of evidence-based knowledge in the provision of nursing care? ​Tenet 2 ​Tenet 4 ​Tenet 5

​Tenet 2 ​The second tenet of the Scope and Standards of Practice says that nurses coordinate care by establishing partnerships and shared goals. ​✅Tenet 4 ​The fourth tenet of the Scope and Standards of Practice says that nurses use evidence-based knowledge in the provision of nursing care. ​Tenet 5 ​The fifth tenet of the Scope and Standards of Practice says that there is a strong link between the professional work environment and the nurse's ability to provide high-quality health care and achieve optimal outcomes.

​A nurse manager is developing an evaluation form for employees. Which of the following descriptions should be used to measure integrity? ​Utilizes good decision-making ​Performs wound care successfully ​Follows standards and protocols

​Utilizes good decision-making ​Good decision-making is a positive personality attribute; integrity is an overall measure of reliability. ​Performs wound care successfully ​Single task performance does not reveal overall performance; integrity is an overall measure of reliability. ​✅Follows standards and protocols ​Following standards and protocols are cues to the trustworthiness and reliability of an individual, both marks of integrity. Becoming a Professional Nurse: Professional Behaviors in Nursing

Where are the formal expectations of the nursing profession first learned? ​Working as a new nurse in a health care facility ​Through classroom and clinical experiences in nursing school ​During a relationship with an informal mentor

​Working as a new nurse in a health care facility While formal expectations of the nursing profession will continue to be learned while working as a new nurse in a health care facility, this is not the first place these expectations are learned. ​✅Through classroom and clinical experiences in nursing school MY ANSWER ​The formal expectations of the nursing profession are first learned through classroom and clinical experiences in nursing school. ​During a relationship with an informal mentor While formal expectations of the nursing profession will continue to be learned during a relationship with an informal mentor, this is not the first place these expectations are learned.

​Which of the following is a characteristic associated with Kramer's honeymoon phase of reality? ​Complacency Excitement ​Fear

​✅Complacency ​Complacency is a characteristic associated with Kramer's shock phase of reality. Excitement ​Excitement is a characteristic associated with Kramer's honeymoon phase of reality. ​Fear ​Fear is a characteristic associated with Kramer's shock phase of reality. Becoming a Professional Nurse: Socialization into Professional Nursing

​A nurse educator is describing positive peer-to-peer interactions during a staff meeting. Which of the following should he use to accurately describe coaching? ​Helps overall care delivery Has a defined time frame ​Outlines clear initial goals

​✅Helps overall care delivery ​Coaching is a distant, observational relationship that is not time-bound. The overarching goal is improved quality of care, not meeting specific goals or performance points. Has a defined time frame ​Precepting has a defined time frame. ​Outlines clear initial goals ​Precepting has specific goals; coaching is general guidance. Becoming a Professional Nurse: Professional Behaviors in Nursing

Which of the following defines nursing's scope of practice in each state? ​Nurse Practice Acts ​American Nursing Association ​Department of Health and Human Services

​✅Nurse Practice Acts ​The laws defining nursing's scope of practice in each state, together with the Board of Nursing's rules and procedures, are known as Nurse Practice Acts and serve to protect the health, safety, and welfare of the general public. ​American Nursing Association ​The American Nurses Association is a professional association representing all registered nurses in the United States and its territories. It has established a Scope and Standards of Nursing Practice as a professional guide for nurses, but this document is not legally binding. ​Department of Health and Human Services ​The Department of Health and Human Services is the U.S. government's principal agency for protecting the health of all Americans and providing essential human services, but it does not define nursing's scope of practice. Becoming a Professional Nurse: Professional Nursing Practice

Which of the following is responsible for authorizing the practice of nursing? ​State board of nursing ​NCLEX ​American Nurses Association

​✅State board of nursing ​The board of nursing of each state is responsible for authorizing the practice of nursing in that state. ​NCLEX The National Council Licensure Exam, or NCLEX, is an examination for nursing licensure. The exam is a requirement for nursing practice, but it does not authorize the practice of nursing. ​American Nurses Association ​The American Nurses Association is a professional association that uses a variety of means to promote professional nursing practice, but it does not authorize the practice of nursing. Nurse's Touch: Becoming a Professional Nurse (4)

50. A patient develops diarrhea after receiving several intermittent tube feedings. Which should the nurse consider is the cause of the diarrhea? 1. A high osmolarity of the feeding 2. An inadequate volume of the feeding 3. Failure to test for a residual before the feeding 4. Lying in the high-Fowler position during the feeding

✅ 1. A tube feeding formula usually is hypertonic, which exerts an osmotic force that pulls fluid into the stomachand intestine, resulting in intestinal cramping and diarrhea. 2. An inadequate volume of the feeding may result in fluid volume deficit and malnutrition, not diarrhea. 3. Failure to test for a residual before the feeding may result in vomiting, not diarrhea. If there is still fluid remaining from the previous feeding, failure to test for a residual before administering a tube feeding can result in adding more fluid than the patient's stomach can tolerate. 4. Placing a patient in the high-Fowler position during the administration of a tube feeding is done to prevent aspiration of the formula and will not cause diarrhea. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient develops diarrhea after receiving several intermittent tube feedings. Which should the nurse consider is the cause of the diarrhea? ⏺Ask what the question is asking. Why can intermittent tube feedings cause diarrhea? ⏺Critically analyze each option in relation to the question and the other options. Review the physiological response of the body to a hypertonic solution and an inadequate volume of formula. Explore why testing for a residual is performed before and a high-Fowler position is used during an intermittent tube feeding. Compare and contrast the information you gathered in your review with the reasons for diarrhea presented in each option. ⏺Eliminate incorrect options. Options 1 and 2 address the formula (osmolarity and volume). Options 3 and 4 address nursing interventions during the procedure. Option 2 is related to fluid and nutritional deficiencies, not diarrhea. Failure to test for a residual in option 3 may result in vomiting, not diarrhea. A high-Fowler position in option 4 prevents aspiration, not diarrhea. Eliminate options 2, 3, and 4

84. A nurse is administering a lozenge to a patient's buccal area of the mouth. Which should the nurse do? Select all that apply. 1. _____Ensu re the patient stays awake while the lozenge dissolves. 2. _____Instr uct the patient to take occasional sips of water. 3. _____Place the medication under the patient's tongue. 4. _____Alternate the cheeks from one dose to another. 5. _____Administer the lozenge just before meals.

✅ 1. If the patient falls asleep the patient may aspirate the lozenge, which can cause an airway obstruction. 2. Fluid will interfere with the action and absorption of the lozenge. This action is unsafe because it can cause the patient to aspirate or swallow the lozenge. 3. Medication that dissolves under the tongue is administered via the sublingual, not buccal, route. ✅4. Alternating cheeks when placing a lozenge will limit irritation to the mucous membranes in the buccal area. 5. A lozenge should be administered after, or between, meals. Food will interfere with the action and absorption of the medication. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is administering a lozenge to a patient's buccal area of the mouth. Which should the nurse do? ⏺Ask what the question is asking. Which interventions are implemented when administering a lozenge? ⏺Critically analyze each option in relation to the question and the other options. List the steps of the procedure—administering a lozenge to a patient's buccal cavity. Examine the behavior in each option and compare it with the list. ⏺Eliminate incorrect options. Eliminate the options that have actions that are not on your identified list, which are associated with another route of administration, or are contraindicated. Options 2 and 5 are incorrect actions. Option 3 addresses the sublingual route. Eliminate options 2, 3, and 5.

36. A patient has a prescription for a vaginal suppository. Which actions should the nurse perform when administering this medication? Select all that apply. 1. _____Lubricate the suppository and the index finger of a gloved hand before insertion of the suppository. 2. _____Instruct the patient to remain flat in bed for twenty minutes after insertion of the suppository. 3. _____Irrigate the vagina with normal saline before inserting the suppository. 4. _____Place the patient in the dorsal recumbent position for the procedure 5. _____Advance the suppository along the posterior vaginal wall. 6. _____Inser t the suppository while wearing clean gloves. .

✅ 1. Lubricating the suppository and index finger of a gloved hand before insertion facilitates insertion and limits trauma to vaginal mucous membranes. ✅2. Remaining flat in bed for 20 minutes will maintain the medication in place, which facilitates absorption. 3. Perineal care, not a vaginal irrigation, should be performed before inserting a vaginal suppository. ✅4. The patient should be placed in the supine position with the knees flexed (dorsal recumbent) to facilitate insertion of a vaginal suppository. ✅5. Advancing the suppository along the posterior vaginal wall facilitates the placement of the vaginal suppository just outside the cervical os so that when it melts it will eventually disperse through the entire vaginal canal. ✅6. The vagina is not a sterile cavity. Only medical asepsis is required for the insertion of a vaginal suppository. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient has a prescription for a vaginal suppository. Which actions should the nurse perform when administering this medication? ⏺Ask what the question is asking. Which are steps in the procedure for administering a vaginal suppository? ⏺Critically analyze each option in relation to the question and the other options. List the steps in the procedure for administering a vaginal suppository. Compare the statements in the options with your list. ⏺Eliminate incorrect options. Delete from consideration those options that do not correlate to your list of steps for administering a vaginal suppository. Eliminate option 3.

40. Which should the nurse do when the vent of a patient's double-lumen nasogastric tube for decompression becomes obstructed? 1. Instill 10 mL of air into the vent lumen. 2. Place the patient in the high-Fowler position. 3. Position the vent below the level of the stomach. 4. Withdraw 30 mL of gastric contents from the drainage lumen.

✅ 1. The only way to reestablish patency of the air vent lumen of a double-lumen nasogastric tube is to instill air into the lumen. The injected air will push the secretions blocking the lumen back into the stomach, where the fluid can be removed by the drainage lumen. Keeping the end of the air vent lumen higher than the stomach prevents reflux of gastric contents into the air vent lumen. 2. Repositioning the patient will not reestablish patency of the air vent lumen. The patient is placed in this position as the tube is being inserted to facilitate its passage into the stomach. 3. Placing the vent below the level of the stomach will draw fluid from the stomach into the air vent lumen by the principle of gravity. 4. Withdrawing 30 mL of gastric contents from the drainage lumen will not reestablish patency of the air vent lumen. Withdrawing 30 mL of gastric contents via the drainage lumen is done to ensure that the catheter is in the correct anatomical location. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. Which should the nurse do when the vent of a patient's double-lumen nasogastric tube for decompression becomes obstructed? ⏺Ask what the question is asking. How do you correct an obstruction in a double-lumen gastric tube? ⏺Critically analyze each option in relation to the question and the other options. Distinguish between what the nurse should do regarding routine care of a double-lumen nasogastric tube versus what specifically should be done when the tube is clogged. ⏺Eliminate incorrect options. Options 2, 3, and 4 are nursing interventions that will not clear the air vent of gastric fluid, which will permit effective functioning of the system

Which of the following is an example of closed-ended questioning? (Select all that apply.) "Are you going to group therapy tomorrow?" "How long have you been depressed?" "Tell me about your concerns." "Do you not want to take your medication?" "Do you have a family history of depression?"

✅"Are you going to group therapy tomorrow?" is correct. This is an example of a closed-ended question, which elicits a one-word response, such as yes or no. ✅"How long have you been depressed?" is correct. This is an example of a closed-ended question, which elicits a one-word or short factual response. "Tell me about your concerns." is incorrect. This is an example of an open-ended question, which invites the client to expand the conversation. ✅"Do you not want to take your medication?" is correct. This is an example of a closed-ended question, which elicits a one-word response, such as yes or no. ✅"Do you have a family history of depression?" is correct. This is an example of a closed-ended question, which elicits a one-word response, such as yes or no. Professional Communication: Therapeutic Communication

A nurse is planning to document a conversation with a client who is preparing for a surgical procedure. Which of the following client information is an accurate and factual form of written communication? (Select all that apply.) "Client states, 'I have a throbbing pain on my left foot.'" "Client states, 'I feel nervous about having my foot removed.'" "Client seems angry with everyone." "Client appears upset." "Client is apparently avoiding the issue with his mother."

✅"Client states, 'I have a throbbing pain on my left foot'" is correct. It is accurate and factual information about what the client said. ✅"Client states, 'I feel nervous about having my foot removed'" is correct. It is accurate and factual information about what the client said. "Client seems angry with everyone" is incorrect. This statement is the nurse's opinion and should not be included in the written communication. It needs to be clarified by the client. "Client appears upset" is incorrect. This statement is the nurse's opinion and should not be included in the written communication. It needs to be clarified by the client. "Client is apparently avoiding the issue with his mother" is incorrect. This statement is the nurse's opinion and should not be included in the written communication. It needs to be clarified by the client. Professional Communication: Types of Communication

A nurse is caring for an older adult client who recently lost his spouse following lung cancer. The client states, "No one understands. She was my life." Which of the following responses is appropriate? "This must be a difficult time for you." "Now she is no longer suffering." "I felt the exact same when my husband died."

✅"This must be a difficult time for you." The nurse's therapeutic response reflects the client's feelings and allows for further expression of feelings. "Now she is no longer suffering." The nurse's response is dismissive of the client's feelings. "I felt the exact same when my husband died." The nurse's response is sympathetic, not empathetic, and places focus on the nurse instead of the client. Professional Communication: Therapeutic Communication

87. Which general concept related to growth and development should be considered by the nurse when caring for patients? 1. Individuals experience growth and development at their own pace. 2. Each task must be achieved before moving on to the next task. 3. Family members provide safe and supportive environments. 4. Once a task is achieved, regression is minimal.

✅. 1. Although there is a predictable sequence to growth and development, there are individual differences in the rate and pace in which developmental milestones are achieved. Therefore, achievement of milestones is measured in ranges of time to allow for individual differences. 2. Task achievement refers to Erikson's Theory of Personality Development, which is only one aspect of growth and development. Erikson believed that each stage of personality development is characterized by the need to achieve a specific developmental task and that achievement of each task is affected by the social environment and influence of significant others. The success or failure to achieve a task at one stage will influence task achievement in subsequent stages, but it does not have to be achieved before moving on to the next task. 3. Unfortunately, not all families provide safe and supportive environments. In addition, the family is only one of many factors that influence the stages of growth and development. 4. Thinking that once a task is achieved regression is minimal is untrue. Regression is possible at any stage when one attempts to cope with a threat to the self. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. Which general concept related to growth and development should be considered by the nurse when caring for patients? ⏺Ask what the question is asking. Which general principle related to growth and development should be considered when caring for patients? ⏺Critically analyze each option in relation to the question and the other options. Review the basic concepts associated with various growth and development theorists (e.g., Erikson, Freud, Gesell, Havighurst, and Piaget). Examine each option in light of the basic concepts you have identified. The word "general" must be addressed when analyzing the options. ⏺Eliminate incorrect options. Eliminate those options that are untrue or that are specific to a particular theorist rather than a general concept. Task achievement in option 2 is specific to Erikson. Not all families provide safe and supportive environments as indicated in option 3. Option 4 is untrue. Options 2, 3, and 4 can be eliminated.

11. For which common problem associated with prolonged diarrhea should the nurse assess a patient with this problem? 1. Skin breakdown 2. Self-care deficit 3. Sexual dysfunction 4. Disturbed body image

✅. 1. Diarrhea is related directly to a risk for damage to epidermal and dermal tissue. The gastric and intestinal enzymes present in feces are acids capable of eroding the skin. 2. Diarrhea is unrelated to the ability to provide self-care. The inability to care for self is the state in which the individual experiences an impaired motor or cognitive function, causing a decreased ability to perform self-care activities. 3. Diarrhea is not related directly to sexual dysfunction, which is the state in which an individual experiences or is at risk of experiencing a change in sexual function that is viewed as unrewarding or inadequate. 4. Diarrhea is not related directly to body image disturbance, which is the state in which an individual experiences, or is at risk of experiencing, a disruption in the way one perceives one's body image. CRITICAL-THINKING ⏺STRATEGYRecognize keywords. For which common problem associated with prolonged diarrhea should the nurse assess a patient with this problem? ⏺ Ask what the question is asking. Which common problem is caused by prolonged diarrhea? ⏺Critically analyze each option in relation to the question and the other options. Explore the consequences of diarrhea and identify the most common human response to diarrhea. Consider Maslow's Hierarchy of Needs when analyzing these options. ⏺Eliminate incorrect options. Preventing skin breakdown in option 1 is addressing a physiological need, which is a first-level need when compared with later level needs such as sexuality and body image. Options 3 and 4 can be eliminated. Just because a patient has diarrhea does not mean that the person cannot provide self-care. There are no data that indicate the patient is dependent. Option 2 can be eliminated.

9. When interviewing the wife of a patient, which statements about her husband support the presence of obstructive sleep apnea? Select all that apply. 1. _____" He snores and gasps all night long and wakes me up." 2. _____"He falls asleep sometimes when he drives, so now I do all the 3. _____ "He kicks and thrashes so much that the bed linen is upside down by morning. 4. _____ "He has nightmares that are so scary that he wakes me up because he is afraid." 5. _____"He has these episodes and never wakes up but I do and then I can't get back to sleep."

✅. 1. Episodes of sleep apnea begin with loud snoring followed by silence, during which the person struggles to breathe against a blocked airway. Decreasing oxygen levels cause the person to awaken abruptly with a loud snort. 2. Falling asleep abruptly describes narcolepsy, which is a sudden overwhelming sleepiness (hypersomnia) in the daytime. 3. Kicking and thrashing describe restless legs syndrome, a feeling of creeping or itching sensation occurring in the lower extremities causing an irresistible urge to move and kick the legs. 4. Dreams that cause fear describe nightmares. Nightmares are vivid frightening dreams that occur during REM sleep and awaken the sleeper. ✅5. Patients with obstructive sleep apnea usually are not aware of awakening during an episode. CRITICAL-THINKING ⏺STRATEGYRecognize keywords. When interviewing the wife of a patient, which statements about her husband support the presence of obstructive sleep apnea? ⏺Ask what the question is asking. Which statements describe clinical findings related to obstructive sleep apnea? ⏺Critically analyze each option in relation to the question and the other options. Distinguish among behaviors associated with obstructive sleep apnea versus other sleep disorders. ⏺Eliminate incorrect options. Options 2, 3, and 4 are descriptions of narcolepsy, restless legs syndrome, and nightmares, respectively. Options 2, 3, and 4 can be eliminated.

80. A charge nurse is delegating assignments to a Registered Nurse and Nursing Assistant on the nursing team. Which actions should be implemented only by a Registered Nurse? Select all that apply. 1. _____Eva luating a patient's response to activity 2. _____Taking the pulse of a patient with a dysrhythmia 3. _____Teaching a patient how to change a colostomy bag 4. _____Applying a condom catheter on a patient who is incontinent 5. _____Changing the linen on an occupied bed for a comatose patient

✅. 1. Evaluating a patient's response to activity requires the knowledge and judgment of a Registered Nurse. This evaluation requires multiple assessments (e.g., breathing, heart rate, and fatigue) and may require immediate nursing intervention if an activity intolerance is identified. ✅2. A task of this complexity requires the knowledge and judgment of a Registered Nurse. This assessment requires more than just obtaining a pulse rate. It requires an additional assessment of rhythm and volume. ✅3. Patient teaching is a complex task. It requires knowledge of principles, such as identifying readiness to learn, progressing from simple to complex information, using motivational theory, and evaluating outcomes. Also, it requires knowledge of principles related to colostomy care, such as the bag opening must be at least 1⁄8 inch larger than the stoma, a pale stoma may indicate ischemia, and what to include in an assessment of the characteristics of intestinal output. 4. Applying a condom catheter is not a complex task. It requires simple problem-solving skills, involves a predictable outcome, and employs a simple level of interaction with the patient. Although this task has the potential to cause harm if the critical elements of the skill are not implemented, it is within the scope of practice of a Nursing Assistant. It does not require the more advanced competencies of a Registered Nurse. 5. Making an occupied bed is not a complex task. It requires simple problem-solving skills, involves a predictable outcome, and employs a simple level of interaction with the patient. Although this task has the potential to cause harm if the critical elements of the skill are not implemented, it is within the scope of practice of a Nursing Assistant. It does not require the more advanced competencies of a Registered Nurse. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A charge nurse is delegating assignments to a Registered Nurse and a Nursing Assistant on the nursing team. Which actions should be implemented only by a Registered Nurse? ⏺Ask what the question is asking. Which actions are within the legal scope of practice for a Registered Nurse. ⏺Critically analyze each option in relation to the question and the other options. In general terms contrast the responsibilities of a Registered Nurse and a Nursing Assistant. Assess each option and designate which member of the team can perform the assignment. ⏺Eliminate incorrect options. Health teaching and assessing patients experiencing complex problems or who are in high-risk situations are responsibilities of a Registered Nurse. Assignments that include the activities of daily living can be assigned to a Nursing Assistant. Eliminate options 4 and 5.

28. A nurse places a patient who had abdominal surgery in the semi-Fowler position. What is the rationale for this nursing intervention? 1. Supports ventilation 2. Promotes the passing of flatus 3. Encourages urinary elimination 4. Facilitates drainage in the portable wound drainage system

✅. 1. In the semi-Fowler position the abdominal organs drop by gravity, which permits maximum thoracic excursion. In addition, slight flexion of the hips reduces abdominal muscle tension, which limits pressure on the suture line and facilitates diaphragmatic (abdominal) breathing. 2. Resting in bed in any position promotes flatus retention. Ambulation promotes intestinal motility, which promotes the passage of flatus. 3. Inactivity results in decreased detrusor muscle tone, incomplete bladder emptying, and urinary stasis. The high- Fowler position and ambulation use gravity to promote urinary elimination. 4. The semi-Fowler position does not facilitate drainage via a portable wound drainage system. Although negative pressure creates the vacuum that draws fluid into a portable wound drainage system, the collection container should be lower than the insertion site because its CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse places a patient who had abdominal surgery in the semi-Fowler position. What is the rationale for this nursing intervention? ⏺Ask what the question is asking. Why is it beneficial to place a patient who had abdominal surgery in the semi-Fowler position? ⏺Critically analyze each option in relation to the question and the other options. First establish the relationship between abdominal surgery and the semi-Fowler position. Then explore nursing interventions that achieve the outcome identified in each option. Then connect the information among abdominal surgery, the semi-Fowler position, and each option. ⏺Eliminate incorrect options. For each option compare your list of nursing interventions that should accomplish the objective stated in the option. If the semi-Fowler position was not among your list, that option can be eliminated

98. A patient who is secretly smoking in bed falls asleep and the cigarette ignites the patient's gown. Which should the nurse do first after discovering the fire? 1. Smother the flames with a blanket. 2. Roll the patient from side to side. 3. Activate the fire alarm. 4. Close the door.

✅. 1. Smothering the flames with a blanket deprives the fire of oxygen. Without oxygen to support combustion, the fire will go out. Rescuing the patient is the first step of fire safety. 2. Rolling the patient from side to side fans the flames, which will increase the intensity of the fire. 3. Activating the alarm is premature at this time, but it will be done eventually. 4. Closing the door will impede the evacuation of the patient from the room if it becomes necessary. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient who is secretly smoking in bed falls asleep and the cigarette ignites the patient's gown. Which should the nurse do first after discovering the fire? ⏺Ask what the question is asking. What is the first action when a patient's gown is on fire? ⏺Critically analyze each option in relation to the question and the other options. Identify the steps to follow when confronted with a fire and integrate the concept "oxygen supports combustion." Refer to the mnemonic RACE (Rescue patients in immediate danger, Activate the alarm, Confine the fire, Extinguish the fire). Identify the fact that to rescue the patient the nurse has to extinguish the fire. Identify ways in which the nurse can cut off oxygen that supports a fire. Examine options in light of the information you have explored. ⏺Eliminate incorrect options. Option 1 will impede departure from the room if it becomes necessary. Option 2 is premature. Option 3 is unsafe. Options 1, 2, and 3 can be eliminated.

20. Which level need in Maslow's Hierarchy of Needs is supported when the nurse places the patient's get-well cards where the patient can see them? 1. Love and belonging 2. Safety and security 3. Self-actualization 4. Physiological

✅. 1. Taping a patient's get-well cards to the wall where the patient can see them supports the patient's need to feel loved and appreciated and meets love and belonging needs according to Maslow's Hierarchy of Needs. 2. Placing get-well cards where the patient can see them does not support a patient's safety and security needs. Safety and security needs are related to being and feeling protected in the physiological and interpersonal realms. 3. Placing get-well cards where the patient can see them does not support a patient's self-actualization needs. Self-actualization involves the need to achieve the highest potential within abilities. 4. Placing get-well cards where the patient can see them does not support a patient's physiological needs. Physiological needs are related to having adequate air, food, water, rest, shelter, and the ability to eliminate and regulate body temperature. CRITICAL-THINKING ⏺STRATEGYRecognize keywords. Which level need in Maslow's Hierarchy of Needs is supported when the nurse places the patient's get-well cards where the patient can see them? ⏺Ask what the question is asking. Exhibiting cards is related to which level of Maslow's Hierarchy of Needs? ⏺Critically analyze each option in relation to the question and the other options. Recall behaviors related to each level of Maslow's Hierarchy of Needs. Then compare the situation presented with this recalled information. ⏺Eliminate incorrect options. Options 1, 3, and 4 can be eliminated because they are associated with needs on levels other than love and belonging.

95. A nurse is giving a patient a bed bath. Which should the nurse do to increase circulation? 1. Wash the extremities with firm strokes toward the heart. 2. Soak the feet in warm water for at least 20 minutes. 3. Expose just the areas that are being washed. 4. Ensure that the water is 120 F to 125 F.

✅. 1. The pressure of firm strokes on the skin moving from distal to proximal areas increases venous return. When venous return increases, cardiac output increases. 2. Prolonged soaking removes the protective oils on the skin; the result is dry, cracked skin that is prone to further injury. 3. Exposing just the areas that are being washed prevents chilling, not increases circulation. 4. A temperature of 120 F to 125 F is too hot for bath water because it may cause tissue injury. Bath water should be 110 F to 115 F. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is giving a patient a bed bath. Which should the nurse do to increase circulation? ⏺Ask what the question is asking. Which action will increase circulation during a bed bath? ⏺Critically analyze each option in relation to the question and the other options. Identify the consequences of the action in each option. Then compare and contrast the options relative to whether the action will or will not increase circulation. ⏺Eliminate incorrect options. Options 2 and 4 may cause tissue injury. Option 3 does not increase circulation. Options 2, 3, and 4 can be eliminated.

81. A nurse wants to influence a patient's beliefs so that new healthy behaviors are incorporated into the patient's lifestyle. Within which learning domain does the nurse need to direct teaching? 1. Affective 2. Cognitive 3. Psychomotor 4. Physiological

✅. 1. This is an example of learning in the affective domain. In the affective domain, learning is concerned with feelings, emotions, values, beliefs, and attitudes. 2. Assuming new healthy behaviors is not an example of learning in the cognitive domain. In the cognitive domain, learning is concerned with intellectual understanding and includes thinking on many levels, with progressively increasing complexity. 3. Assuming new healthy behaviors is not an example of learning in the psychomotor domain. Learning in the psychomotor domain includes using motor and physical abilities to master a skill. It requires the learner to practice to improve coordination and dexterity manipulating the equipment associated with the skill. 4. There is no learning domain known as physiological. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse wants to influence a patient's beliefs so that new healthy behaviors are incorporated into the patient's lifestyle. Within which learning domain does the nurse need to direct teaching? ⏺Ask what the question is asking. Which learning domain is associated with influencing beliefs? ⏺Critically analyze each option in relation to the question and the other options. Explore what you know about the three domains of learning— affective, cognitive, and psychomotor. Identify examples of learning that occur in each domain. Determine the domain in which beliefs, attitudes, feelings, emotions, and values are addressed ⏺Eliminate incorrect options. Option 2 reflects the cognitive domain. Option 3 reflects the psychomotor domain. Option 4 is not related to any learning domain. Eliminate options 2, 3, and 4.

83. A patient with terminal cancer says to the nurse, "I've been fairly religious, but sometimes I wonder if the things I did were acceptable to God." How should the nurse respond? 1. "Not knowing what the future brings can be a frightening thought." 2. "God will appreciate that you went to religious services." 3. "If you were good, you have nothing to fear." 4. "In life, all we have to do is try to be good."

✅. 1. This response recognizes the patient's feelings. 2. This response denies the patient's feelings and gives false reassurance. 3. This response denies the patient's feelings and gives false reassurance. 4. This response denies the patient's feelings. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient with terminal cancer says to the nurse, "I've been fairly religious, but sometimes I wonder if the things I did were acceptable to God." How should the nurse respond? ⏺ Ask what the question is asking. Identify the therapeutic response by the nurse in this situation. ⏺ Critically analyze each option in relation to the question and the other options. Review therapeutic communication techniques and barriers to communication. Examine the options and identify the response that promotes communication and the responses that are barriers to communication. ⏺ Eliminate incorrect options. Options 2 and 3 are examples of false reassurance. Option 4 denies the patient's feelings. Options 2, 3, and 4 can be eliminated.

79. A patient consistently eats only 25% of every meal. Which should the nurse do to encourage the dietary intake of this patient? 1. Help the patient to select preferred foods. 2. Teach the patient to avoid fluids and foods that cause flatus. 3. Encourage the patient to engage in light exercise before meals. 4. Persuade the patient to drink between-meal supplements twice daily.

✅1. A person's cultural, religious, educational, economic, and experiential background influences eating behaviors and food preferences. When familiar, preferred foods are available and personally selected, patients may feel that the care is individualized and that they are in more control, resulting in eating a greater percentage of the meal. 2. Teaching the patient to avoid fluids and foods that cause flatus assumes that the inadequate intake is related to discomfort associated with flatus. This must be validated before engaging in this teaching. 3. Research indicates that exercise decreases appetite and increases the need for calories. Exercise releases beta-endorphin, which results in a state of relaxation and satisfaction with less food. 4. Drinking between-meal supplements may further decrease the consumption of food at mealtimes. Supplements are given in addition to, not to replace, the nutrients that are consumed with meals. 🔘CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient consistently eats only 25% of every meal. Which should the nurse do to encourage the dietary intake of this patient? ⏺Ask what the question is asking. Which action will help increase food intake? Critically analyze each option in relation to the question and the other options. ⏺Determine the nursing actions that support nutritional intake. Compare and contrast the benefits among the proposed interventions in relation to this information. Eliminate those actions that are contraindicated and determine which is most effective of the remaining options. ⏺Eliminate incorrect options. Option 2 reads into the question and makes the assumption that the patient may have discomfort from flatus. Options 3 and 4 are inaccurate and contraindicated. Eliminate options 2, 3, and 4.

62. Which actions are specifically related to the principle, the greater the base of support, the more stable the body? Select all that apply. 1. _____A ssisting a patient to walk 2. _____Using a walker when ambulating 3. _____Locking the wheels of a wheelchair 4. _____Holding objects close to the body when walking 5. _____Keeping the back straight when lifting an object

✅1. Assisting a patient to walk widens the patient's base of support because the base extends to include the nurse's feet on the floor in addition to the patient's feet on the floor. ✅2. Walkers surround a person on three sides and provide four points of contact with the floor. This wide base provides the best support available for assisted ambulation. 3. Locking the wheels of a wheelchair follows the principle, an object w ith w heels that are locked w ill remain stationary. 4. Holding objects close to the body when walking follows the principle, the closer an object is held to the center of gravity, the greater the stability and the easier the object is to move. 5. Keeping the back straight when lifting an object follows the principle, balance is maintained and muscle strain is limited as long as the line of gravity passes through the base of support. ⏺Recognize keywords. Which actions are specifically related to the principle, the greater the base of support, the more stable the body? ⏺Ask what the question is asking. Which actions provide a wide base of support? ⏺Critically analyze each option in relation to the question and the other options. Identify the projected outcome for the behavior in each option. Then consider the principle that underlines the behavior and its outcome. ⏺Eliminate incorrect options. Option 3 relates to safety, not a wide base of support. Options 4 and 5 relate to principles associated with body mechanics, rather than a wide base of support. Eliminate options 3, 4, and 5.

17. An older adult asks the nurse, "I want to make sure I get enough vitamin A to keep my eyes healthy. Which fruits can I eat because I am not fond of vegetables?" Which fruits should the nurse explain are excellent sources of vitamin A? Select all that apply. 1. _____Cantaloupe 2. _____Apricots 3. _____Peaches 4. _____Raisins 5. _____Prunes

✅1. Cantaloupe is an excellent source of vitamin A. A half cup of melon balls contains approximately 2,993 International Units of vitamin A. ✅2. Apricots are an excellent source of vitamin A. A 31⁄2-ounce serving of apricots contains approximately 7,240 International Units of vitamin A. ✅3. Peaches are an excellent source of vitamin A. A 31⁄2-ounce serving of peaches contains approximately 2,160 International Units of vitamin A. 4. Raisins are not high in vitamin A. A 3‰- ounce serving of raisins contains approximately 10 International Units of vitamin A. ✅5. Prunes are an excellent source of vitamin A. A 31⁄2-ounce serving of prunes contains approximately 1,990 International Units of vitamin A. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. An older adult asks the nurse, "I want to make sure I get enough vitamin A to keep my eyes healthy. Which fruits can I eat because I am not fond of vegetables?" Which fruits should the nurse explain are excellent sources of vitamin A? ⏺Ask what the question is asking. Which fruits have the highest vitamin A content? ⏺Critically analyze each option in relation to the question and the other options. Recall how much vitamin A is contained in each nutrient and then compare and contrast the nutrients among the options. The options with high vitamin A content are the correct answers. ⏺Eliminate incorrect options. Option 4 can be eliminated because raisins contain only small amounts of vitamin A versus larger amounts of vitamin A in the fruits in options 1, 2, 3, and 5.

25. A primary health-care provider orders a 2-g sodium diet for a patient. Which fluids should the nurse teach are high in sodium? Select all that apply. 1. _____C ocoa 2. _____Seltz er 3. _____Lemo nade 4. _____Lo w-fat milk 5. _____T omato juice

✅1. Cocoa powder, containing non-fat dry milk, contains approximately 173 mg of sodium when mixed with 6 ounces of water and should be avoided when on a 2-g sodium diet. 2. Seltzer contains no sodium and is permitted on a 2-g sodium diet. 3. Twelve fluid ounces of lemonade contains approximately 12 mg of sodium and is permitted on a 2-g sodium diet. ✅4. One cup of low-fat milk contains approximately 103 mg of sodium and should not be included in large amounts on a 2-g sodium diet. ✅5. One cup of tomato juice contains approximately 877 mg of sodium and should be avoided on a 2-g sodium diet. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A primary health-care provider orders a 2-g sodium diet for a patient. Which fluids should the nurse teach are high in sodium? ⏺Ask what the question is asking. Which fluids have the highest sodium content? ⏺Critically analyze each option in relation to the question and the other options. Identify the sodium content of a variety of fluids. Compare and contrast the fluids in the options presented, and identify the options with the highest sodium content. ⏺Eliminate incorrect options. Options 2 and 3 can be eliminated because these fluids contain no or small amounts of sodium versus the large amounts of sodium in fluids presented in options 1, 4, and 5.

38. A patient sustains soft tissue injuries from a motor vehicle collision. Which intervention is helpful in limiting the stress of both edema and bleeding into tissue? 1. Applying a cold compress 2. Exerting direct pressure 3. Performing effleurage 4. Providing massage

✅1. Cold lowers the temperature of skin and underlying tissue, which causes vasoconstriction, reducing bloodflow to the area. This controls bleeding and slows the passage of fluid from the intravascular to the interstitial compartment, which limits edema. 2. Direct pressure may limit bleeding by compressing injured blood vessels, but it will not affect edema. 3. Long, smooth strokes sliding over the skin (effleurage) will not limit edema or bleeding into tissues. However, effleurage reduces pain by using the Gate-Control Theory of Pain. Peripheral stimuli transmitted via large-diameter nerves close the gate to painful stimuli that use small- diameter nerves, thereby blocking the perception of pain. 4. Cutaneous stimulation (massage) will not limit edema or bleeding into tissues. However, massage uses the Gate-Control Theory of Pain to limit pain. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient sustains soft tissue injuries from a motor vehicle collision. Which intervention is helpful in limiting the stress of both edema and bleeding into tissue? ⏺Ask what the question is asking. What can be done to limit edema and bleeding? ⏺Critically analyze each option in relation to the question and the other options. Explore the purpose and outcomes of cold compresses, direct pressure, effleurage, and massage. Then consider this information in relation to just edema, just bleeding into tissue, and both edema and bleeding into tissue. Eliminate incorrect options. Pressure only limits bleeding. Eliminate option 2. Effleurage and massage do not influence bleeding or edema. However, they are similar in that both may limit pain. When options are similar (one is not better than the other), usually they both can be eliminated. Eliminate options 3 and 4.

94. A nurse working in a nursing home routinely administers digoxin 0.125 mg by mouth to a patient every morning. Which patient responses should alert the nurse to withhold the medication? Select all that apply. 1. _____Diplopia 2. _____Vomiting 3. _____Tachypnea 4. _____Bradycardia 5. _____Dysrhythmias

✅1. Digoxin can cause sensory changes, such as diplopia (double vision), halos, colored vision, blind spots, and flashing lights. If any of these symptoms of toxicity occurs, the medication should be withheld and a serum digoxin level assessed to determine if the drug is exceeding its therapeutic range of 0.5 to 2 ng/mL. ✅2. Nausea and vomiting are common clinical indicators of digoxin toxicity resulting from irritation of the gastrointestinal system caused by an excessive dose. 3. A respiratory rate more than 20 breaths per minute (tachypnea) is not a sign of digoxin toxicity. ✅4. Digoxin prolongs conduction through the SA and AV nodes, which slows the heart rate (negative chronotropic effect). When the heart rate is less than 60 beats per minute (bradycardia), the medication should be held to prevent a further decrease in the heart rate. Some primary health-care providers will stipulate the low and high levels of pulse rates at which the drug should be held. ✅5. Dysrhythmias are a common sign of digoxin toxicity because of the negative effect of digoxin on cardiac tissue when a dose is excessive. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse working in a nursing home routinely administers digoxin 0.125 mg by mouth to a patient every morning. Which patient responses should alert the nurse to withhold the medication? Ask what the question is asking. Which patient responses indicate digoxin toxicity? Critically analyze each option in relation to the question and the other options. Review the physiological action of digoxin. Analyze each option to determine if the response is unrelated to digoxin or is a toxic effect (plasma concentration of the drug that causes serious/ life-threatening responses) of digoxin, requiring its discontinuation. Eliminate incorrect options. As indicated in the rationales, option 3 is unrelated to digoxin toxicity and can be eliminated.

48. Which should the nurse do when providing a backrub for a patient? 1. Use continuous light gliding strokes with fingertips when finishing. 2. Concentrate deep circular motions across the scapulae and sacrum. 3. Knead firmly and quickly over the shoulders and the entire back. 4. Massage gently over the bony prominences of the vertebrae.

✅1. Effleurage involves long, smooth strokes sliding over the skin that have a relaxing, sedative effect. When performed slowly with light pressure at the end of a backrub, it is called "feathering off." 2. Firm, not deep, circular motions are used with backrub. 3. Kneading (potrissage) is not performed over the vertebrae because it is stimulating and traumatic for the vertebral column and spinal cord. 4. Rubbing the back over the vertebrae is contraindicated because it is traumatic to the vertebral column and spinal cord. A backrub should be performed on either side of the vertebrae CRITICAL-THINKING STRATEGY ⏺Recognize keywords. Which should the nurse do when providing a backrub for a patient? ⏺Ask what the question is asking. Which action is part of a backrub? ⏺Critically analyze each option in relation to the question and the other options. List the steps associated with a backrub. Identify what will happen if each action in the options is implemented. Identify the option that reflects a safe, correct action by the nurse. ⏺Eliminate incorrect options. Actions in options 2, 3, and 4 are contraindicated when providing a backrub. Eliminate these options.

31. A nurse in the postanesthesia care unit is assessing several patients in pain. Patients in which age group should the nurse anticipate will be most sensitive to pain? 1. Infants 2. Adolescents 3. Older adults 4. Pregnant women

✅1. Infants react to pain in an intense way including physical resistance and lack of cooperation. Separation of an infant from the usual comforting contact with parents contributes to separation anxiety, which in turn lowers pain tolerance, which intensifies the pain experience. Infants express pain by irritability, rolling of the head, flexing the extremities, overreacting to common stimuli, an inability to be comforted by holding and rocking, and physical responses indicating stimulation of the sympathetic nervous system. 2. Adolescents are less sensitive to pain than an age group in another option. Adolescents generally want to behave in an adult manner and therefore demonstrate a controlled behavioral response to pain. 3. Older adults have a decreased capacity to sense pain and pressure. Older adults often fail to notice situations that will cause acute pain in younger people. 4. Pregnant women generally are not more sensitive to pain than when not pregnant. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse in the postanesthesia care unit is assessing several patients in pain. Patients in which age group should the nurse anticipate will be most sensitive to pain? ⏺Ask what the question is asking. Which age patients are most sensitive to pain? ⏺Critically analyze each option in relation to the question and the other options. Recall the age groups most at risk for health-related issues, specifically pain. Compare and contrast the identified age groups to identify the one that is most sensitive to pain. ⏺Eliminate incorrect options. The age groups most at risk for health-related issues are children and older adults. Eliminate options 2 and 4. Review the physiological differences between infants and older adults. Infants have immature neurological systems and have limited experiential backgrounds to have learned to cope with pain. Older adults have declining physiological responses to stressors and the experiential background to have learned to cope with pain. Eliminate options 2, 3, and 4

45. At which day and time did the patient have a respiratory rate of 15 breaths per minute? 1. 9-9 at 04 2. 9-9 at 08 3. 9-10 at 08 4. 9-10 at 16

✅1. On 9-9 at 04 the respiratory rate was 15 breaths per minute. 2. On 9-9 at 08 the respiratory rate was 20 breaths per minute. 3. On 9-10 at 08 the patient's respiratory rate was 30 breaths per minute. 4. On 9-10 at 16 the patient's respiratory rate was 25 breaths per minute. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. At which day and time did the patient have a respiratory rate of 15 breaths per minute? ⏺Ask what the question is asking. Interpret a graphic record to identify the date and time at which a patient had a respiratory rate of 15 breaths per minute. ⏺Critically analyze each option in relation to the question and the other options. Identify the location of the date and time for each option at the top of the graphic chart, and carefully proceed down the column to identify the rate of respirations indicated by the position of the dot. Repeat this action for each date and time indicated in each option. Identify the option that has a dot on the line that indicates 15 respirations. ⏺Eliminate incorrect options. Eliminate the 3 options where the dot is located on a line that is more than 15 respirations.

85. Which question by the nurse assesses a patient's pain tolerance? 1. "At what point on a scale of 0 to 10 do you feel that you must have pain medication? " 2. "What activities help distract you so that you don't feel the need for medication?" 3. "How intense on a scale of 0 to 10 is the pain that you feel right now?" 4. "Do you take pain medication frequently?"

✅1. Pain tolerance is the maximum amount and duration of pain that a person is willing to tolerate. It is influenced by psychosociocultural factors and usually increases with age. 2. This question focuses on an alleviating factor, distraction, rather than on the concept of pain tolerance. 3. This question is determining the patient's perception of the intensity of pain, not pain tolerance. 4. This question focuses on an alleviating factor, medication, rather than on the concept of pain tolerance. CRITICAL-THINKING STRATEGY Recognize keywords. ⏺Which question by the nurse assesses a patient's pain tolerance? ⏺Ask what the question is asking. Which statement assesses pain tolerance? ⏺Critically analyze each option in relation to the question and the other options. Several concepts must be explored: characteristics of pain, the difference between pain threshold and pain tolerance, and how the nurse can best assess each characteristic of pain. Use of the mnemonic COLDERR (character, onset, location, duration, exacerbation, relief, and radiation) and an intensity pain scale (e.g., numerical scale, Wong-Baker FACES Rating Scale) may help to answer this question. ⏺Eliminate incorrect options. Options 2 and 4 focus on alleviating factors. Option 3 focuses on intensity. Options 2, 3, and 4 can be eliminated.

53. A nurse is providing dietary teaching for a patient who is a pure vegan. Which food combinations that are substitutes for a complete protein should the nurse include in the dietary teaching? Select all that apply. 1. _____Pasta and peas 2. _____Yogurt and fruit 3. _____Bread and cheese 4. _____Legu mes and rice 5. _____P eanut butter and jelly

✅1. Pasta is made from grains, and peas are legumes, which together provide amino acids that make a complete protein. Complete proteins supply all eight essential amino acids. Essential amino acids are those that cannot be manufactured by the human body and must be obtained from food sources. 2. Yogurt and fruit together do not provide a complete protein. In addition, pure vegetarians (vegans) eat only plants. Lactovegetarians eat vegetables and milk products; lacto-ovovegetarians eat vegetables, milk products, and eggs (some may occasionally eat fish or poultry). 3. Bread and cheese together provide a complete protein. However, pure vegetarians (vegans) eat only plants (which includes grains), not dairy products. ✅4. Grains and legumes lack different amino acids. When these foods are combined, they substitute for a complete protein. Complete proteins supply all eight essential amino acids. Essential amino acids are those that cannot be manufactured by the human body and must be obtained from food sources. 5. Peanut butter combined with a grain, not jelly, is a substitute for a complete protein CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is providing dietary teaching for a patient who is a vegan. Which food combinations that are substitutes for a complete protein should the nurse include in the dietary teaching? ⏺Ask what the question is asking. Which combination of food provides essential amino acids for a vegan? ⏺Critically analyze each option in relation to the question and the other options. Recall what a vegan does or does not eat. Identify the type of protein presented in each food combination. Analyze the food combinations presented, and conclude if they provide essential amino acids and are included in a vegan diet. ⏺Eliminate incorrect options. Eliminate options, 2, 3, and 5 because pure vegans eat only plants and the food combinations in the options do not provide essential amino acids.

2. A patient has a history of chronic pain because of arthritis but dislikes taking large doses of analgesics. Which concept unique to unrelieved chronic pain should the nurse consider when caring for this patient? 1. Generally, pain is better tolerated as the duration of exposure increases. 2. Pain minimally interferes with activities of daily living. 3. Usually, pain is related to the current pathology. 4. Pain rarely affects the immune response.

✅1. Persistent chronic pain becomes an unchanging part of life. As the duration of exposure increases, the individual may learn cognitive and behavioral strategies to cope with the pain. 2. Chronic pain can markedly impair activities of daily living. 3. Chronic pain may, or may not, have an identifiable cause. 4. Acute pain and chronic pain both decrease the efficiency of the immune system. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient has a history of chronic pain because of arthritis but dislikes taking large doses of analgesics. Which concept unique to unrelieved chronic pain should the nurse consider when caring for this patient? ⏺Ask what the question is asking. Which concept is related only to unrelieved chronic pain? ⏺Critically analyze each option in relation to the question and the other options. Compare and contrast the commonalities and differences between chronic and acute pain and then identify the one statement that is associated only with unrelieved chronic pain. ⏺Eliminate incorrect options. Options 2, 3, and 4 are inaccurate statements as indicated in their rationales and can be eliminated.

57. Which nursing techniques will result in an accurate measurement when obtaining a patient's blood pressure? Select all that apply. 1. _____P ositioning the arm at the level of the heart 2. _____W rapping the lower edge of the cuff over the antecubital space 3. _____ Pumping the cuff about 30 mm Hg above the point where the brachial pulse is lost on palpation 4. _____ Releasing the valve on the cuff so that the pressure decreases at the rate of 2 to 3 mm Hg per second 5. _____ Deflating the cuff completely and waiting 2 minutes before reinflating the blood pressure cuff to take the pressure again

✅1. Positioning the arm at the level of the heart will result in an accurate blood pressure reading. If the arm is positioned higher than the level of the heart, the blood pressure will be inaccurately low. If the arm is positioned lower than the level of the heart, the blood pressure will be inaccurately high. 2. Wrapping the lower edge of the cuff over the antecubital space will cover the brachial artery and interfere with the accurate assessment of blood pressure. The lower edge of the cuff should be approximately 1 inch (2.5 cm) above the antecubital space. ✅3. The sphygmomanometer should be pumped up 20 to 30 mm Hg above the palpatory blood pressure reading. This ensures an accurate systolic reading without exerting undue pressure on the tissues of the arm. ✅4. Releasing the valve slowly ensures that all five Korotkoff's sounds are heard accurately. Deflating the cuff too rapidly can result in a falsely low systolic reading, and deflating the cuff too slowly can result in a falsely high diastolic reading. ✅5. When repeating a blood pressure the cuff should be completely deflated and the caregiver should wait 2 minutes before reinflating the blood pressure cuff. This action prevents congestion of the veins and an inaccurately high blood pressure reading. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. Which nursing techniques will result in an accurate measurement when obtaining a patient's blood pressure? ⏺Ask what the question is asking. Which are steps in obtaining a blood pressure measurement? ⏺Critically analyze each option in relation to the question and the other options. List the steps of the procedure for performing a blood pressure measurement. Compare and contrast the list with the options presented. ⏺Eliminate incorrect options. Inappropriate placement of the cuff and the sphygmomanometer will result in an inaccurate measurement. Eliminate option 2.

15. A nurse transfers a patient from a bed to a wheelchair. Which is an important nursing intervention after placing the patient in the wheelchair? 1. Ensure the patient's popliteal areas are not touching the seat edge. 2. Attach the patient's transfer belt to clips on the wheelchair. 3. Support the patient's back with a pillow. 4. Put the patient's feet flat on the floor.

✅1. Pressure on the popliteal areas can cause damage to nerves and interferes with circulation and must be avoided. 2. The transfer belt should be removed after the transfer is totally completed. 3. A pillow will move the patient too close to the front of the seat and is unsafe. 4. The patient's feet should be positioned flat on the footrests of the wheelchair, not the floor, to protect the feet if the wheelchair is moved. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse transfers a patient from a bed to a wheelchair. Which is an important nursing intervention after placing the patient in the wheelchair? ⏺Ask what the question is asking. Which action is essential when a patient is in a wheelchair? ⏺Critically analyze each option in relation to the question and the other options. List the steps of the procedure—transferring a patient from a bed to a wheelchair. Then the behavior in each option must be compared with the steps in the transfer procedure. Finally, you must identify the option that reflects a safe, correct action by the nurse. ⏺Eliminate incorrect options. Options 3 and 4 are both unsafe interventions and may jeopardize the patient. Option 2 is unnecessary and may be uncomfortable for the patient. Eliminate options 2, 3, and 4.

47. A nurse is planning to apply a transdermal patch to a patient. Which actions should the nurse implement? Select all that apply. 1. _____Use different sites each time to limit skin irritation and excoriation. 2. _____Rub the area to promote comfort and vasodilation before applying the patch. 3. _____ Shave the area to facilitate adherence of the patch and medication absorption. 4. _____ Wear clean gloves to protect one's self from absorbing the medication through the hands 5. _____Remove the old patch an hour after applying the new patch to ensure a therapeutic blood level of the drug. .

✅1. Sites for a transdermal patch should be rotated because doing so limits skin irritation and excoriation. Also, it allows time for the site to recover if irritated. 2. Both irritation of the skin and vasodilation can result from rubbing the skin, which can alter absorption of the medication. ✅3. A hairless site will ensure that there is effective contact with the skin. ✅4. When preparing and applying the patch, the nurse may be exposed to the medication on the patch. Clean gloves provide a barrier and protect the nurse from absorbing some of the medication. 5. The old patch should be removed at the same time that the new patch is applied. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is planning to apply a transdermal patch to a patient. Which actions should the nurse implement? ⏺Ask what the question is asking. Which steps are associated with applying a transdermal patch? ⏺Critically analyze each option in relation to the question and the other options. List the steps of the procedure for applying a transdermal patch. Identify which options are among your list of interventions. ⏺Eliminate incorrect options. Option 2 may harm the patient and is contraindicated. Permitting two patches to remain on the skin concurrently may result in absorption of excessive medication, which may harm the patient. Eliminate options 2 and 5.

69. A nurse is bathing a patient. Which nursing actions support a principle associated with medical asepsis? Select all that apply. 1. _____Washing from the inner canthus to the outer canthus of the eye 2. _____Replacing the top covers with a clean flannel bath blanket 3. _____Changing the bath water after washing the perineal area 4. _____Having the patient void before beginning the bed bath 5. _____Wearing clean gloves when washing the perineum area

✅1. The eye should always be washed from the inner to the outer canthus to prevent secretions from entering the lacrimal ducts, which may result in an infection. 2. A bath blanket promotes privacy and prevents heat loss during a bath and is unrelated to asepsis. If not soiled, a patient's bath blanket can be reused. ✅3. Changing bath water after cleaning the perineum prevents transferring microorganisms from the perianal, urinary meatus, and vaginal area in women to subsequent areas of the body that are being washed. This action promotes medical asepsis. 4. Having a patient void before beginning the bed bath is related to a patient's comfort and elimination needs, rather than asepsis. ✅5. Clean gloves are required during this procedure to protect the nurse because the nurse may be exposed to body fluids. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse is bathing a patient. Which nursing actions support a principle associated with medical asepsis? ⏺Ask what the question is asking. Which actions are based on principles of medical asepsis? ⏺Critically analyze each option in relation to the question and the other options. Visualize the steps of the procedure for bathing a patient. Recall principles associated with maintaining medical asepsis. Integrate the principles of medical asepsis with the visualized steps of the procedure. Analyze the options in relation to this information. ⏺Eliminate incorrect options. Although options 2 and 4 are part of the procedure of bathing, they are unrelated to principles of medical asepsis. Eliminate options 2 and 4.

35. Which patient statement indicates to the nurse that an older adult understands the teaching about how to care for dry skin effectively? 1. "I will increase the amount of water that I drink." 2. "I can use baby powder on my skin rather than lotion." 3. "I should have a bath every day using a moisturizing soap." 4. "I ought to wear clothing made of wool rather than cotton."

✅1. The percentage of body water dramatically decreases with age, and older adults have altered thirst mechanisms that place them at risk for inadequate fluid intake and dehydration. In addition, the skin of older adults is drier because of a decreased ability to sweat and a decreased production of sebum. 2. Lotion is preferable to baby powder because lotion lubricates the skin. Also, baby powder should be avoided because, when aerosolized, it is a respiratory irritant. 3. Having a bath daily, even when using a moisturizing soap, is drying to the skin of older adults. Two to three times a week is adequate for an older adult who is continent. 4. Wool fabrics are coarse and irritate the skin and therefore should be avoided. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. Which patient statement indicates to the nurse that an older adult understands the teaching about how to care for dry skin effectively? ⏺Ask what the question is asking. Which is the best intervention to treat dry skin? ⏺Critically analyze each option in relation to the question and the other options. Only one option is correct because you are not asked to identify a priority action. Explore interventions that can prevent or care for dry skin, particularly in the older adult. Compare your list to the options presented. Eliminate incorrect options. Having a daily bath is too drying for the skin of older adults. Eliminate option 3. Option 2 can be eliminated because lotion is preferable to baby powder. Eliminate option 4 because it is an incorrect statement.

66. A patient prefers and excessively maintains the supine position. For which potential problem associated with this position should the nurse assess the patient? 1. Pressure on the heels 2. Pressure on the trochanters 3. Internal rotation of the hips 4. Flexion contracture of the knees

✅1. The supine position is a back-lying position that results in pressure on the heels (calcanei), which have minimal tissue between the bone and skin, making them vulnerable to the development of pressure ulcers. 2. There is no pressure on either greater trochanter when in the supine position. Pressure on a greater trochanter occurs when the patient is in a lateral (side-lying) position. 3. External, not internal, rotation of the hips tends to occur when a patient is in the supine position. 4. The knees are extended, not flexed, when in the supine position. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient prefers and excessively maintains the supine position. For which potential problem associated with this position should the nurse assess the patient? ⏺Ask what the question is asking. Which problem is associated with the supine position? ⏺Critically analyze each option in relation to the question and the other options. Visualize a patient in the supine position. Examine each option in relation to the visualization. Identify the option that may place the patient at risk for a negative outcome. ⏺Eliminate incorrect options. Pressure on the trochanters does not occur in the supine position. External, not internal, rotation of the hips occurs with the supine position if trochanter rolls are not used to maintain functional alignment. Hyperextension of the knees, not flexion contractures of the knees, can occur in the supine position. Options 2, 3, and 4 can be eliminated.

68. A nurse going off duty is making rounds with the nurse coming on duty and provides a report on each patient in the district. Which information reported by the nurse is most complete? 1. The patient was given an antiemetic and reports resolution of the nausea. 2. The patient's family members just visited and the patient appears happy. 3. The patient seems less anxious than earlier in the day. 4. The patient's blood pressure is now stable.

✅1. This information includes a nursing intervention and an evaluation of the outcome, which is the most specific and complete of all the options. 2. No data are given to support the assumption that the patient is happy. 3. The words "less anxious" are relative and do not clearly evaluate the patient's status. 4. Every patient has his or her own baseline. Indicating that a blood pressure is stable is incomplete and unclear. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A nurse going off duty is making rounds with the nurse coming on duty and provides a report on each patient in the district. Which information reported by the nurse is most complete? ⏺Ask what the question is asking. Which information is most thorough? ⏺Critically analyze each option in relation to the question and the other options. Examine each option to determine if the information included is objective and comprehensive. ⏺Eliminate incorrect options. Options 2 and 3 use the terms "happy" and "less anxious," which are subjective and not measurable. Option 4 fails to provide the before and after blood pressures, making the information meaningless. Options 2, 3, and 4 can be eliminated.

58. Which should the nurse use to best provide oral care to an unconscious patient? 1. Gauze-wrapped tongue blades with a saline solution 2. Half-strength mouthwash and saline 3. Packaged glycerin swabs 4. Nonfoaming toothpaste

✅1. Unconscious patients often bite down when something is placed in the mouth. Therefore, a padded tongue blade should be placed between the upper and lower teeth to help keep the mouth open during oral care. Other padded tongue blades, wetted with a small amount of saline, should be used to clean the oral cavity. This technique does not require flushing the oral cavity with fluid, which may compromise the airway. 2. Although half-strength mouthwash and saline may be used, it is not the best intervention because mouthwash contains ingredients that can be irritating to the mucous membranes. 3. Glycerin is not a cleansing agent and is not effective in cleaning the oral cavity. 4. Toothpaste should be avoided because it requires flushing the mouth with adequate amounts of water to prevent leaving an irritating residue on the mucous membranes. An unconscious patient usually has a diminished gag reflex and is at risk for aspiration. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. Which should the nurse use to best provide oral care to an unconscious patient? ⏺Ask what the question is asking. What should be used to clean the oral cavity of an unconscious patient? Critically analyze each option in relation to the question and the other options. ⏺Consider the unique needs of a patient who is unconscious, particularly in relation to the ABCs (airway, breathing, and circulation). Analyze each option in relation to how it will impact on the patient's physical status. ⏺Eliminate incorrect options. Airway patency is always the priority. Options 2 and 4 require flushing the oral cavity with fluid, which may compromise the airway. Glycerin coats, rather than cleans, the oral mucosa. Eliminate options 2, 3, and 4.

37. A nurse is taking a patient's temperature using the instrument in the illustration. Place the following steps in the order in which they should be implemented. 1. While holding the button down and keeping the probe flat against the forehead, slide the instrument across the forehead, stopping when the hairline on the side of the face is reached. 2. Position the probe flat on the middle of the forehead halfway between the hairline and the eyebrow and hold the button down. 3. While continuing to hold the button, touch the probe to the soft area behind the earlobe and below the mastoid. 4. Clean the probe following the manufacturer's directions. 5. Release the button. Answer: _ ____________

✅4,2,1,3,5 4. Cleaning the probe minimizes cross contamination from one patient to another. 2. Placing the temporal artery scanner in the middle of the forehead positions the instrument so that it is over the temporal artery as it is moved across the forehead and down toward the hairline on the side of the face. 1. The temporal artery is a major artery close to the heart via the carotid artery, which directly leads from the aorta. The temporal artery is close to the skin and provides easy access to measure true body temperature accurately. Holding the probe flat against the forehead keeps the instrument in contact with the skin and provides for a more accurate reading. 2. Touching the probe to the soft area just behind the earlobe helps to ensure an accurate reading if a person is sweating. Sweating causes cooling of the skin, and a reading given by a temporal scanner may be low. Research demonstrates that gently positioning the probe on the neck directly behind the earlobe below the mastoid provides accurate results. 5. Releasing the button instructs the instrument to display the temperature reading on the LCD display screen on the instrument CRITICAL-THINKING STRATEGY Recognize keywords. A nurse is taking a patient's temperature using the instrument in the illustration. Place the following steps in the order in which they should be implemented. Ask what the question is asking. List the steps of using a temporal thermometer. Critically analyze each option in relation to the question and the other options. Identify the sequential steps when using a temporal thermometer. Refer to your list as you examine the options presented. Order the steps presented according to the order you identified. Eliminate incorrect There are no incorrect options. options.

Which of the following situations is an example of horizontal violence? ​A nurse blames a peer for her error ​A provider openly scorns a charge nurse ​An assistive personnel is belittled by a nurse manager

✅A nurse blames a peer for her error ​Horizontal violence occurs between persons at the same or equal level or rank. A nurse blaming a peer is horizontal violence. Becoming a Professional Nurse: Professional Behaviors in Nursing

88. A primary health-care provider orders the insertion of an indwelling urinary catheter (retention, Foley) as part of the patient's preoperative orders. Place the following steps of the procedure in the order in which they should be performed by the nurse. 1. Don sterile gloves. 2. Open the catheterization package. 3. Place a fenestrated drape over the patient's perineal area. 4. Maintain spread of labia while swiping directly over the urinary meatus. 5. Maintain spread of labia while swiping each labium with a separate cotton ball. Answer: _ ______________

✅ANS: 2,1,3,5,4 2.The outside of the catheterization package is contaminated and should be opened with hands that have been washed with soap and water. 1. The inside of the catheterization package is sterile. Sterile gloves are on the top of the supplies included because all subsequent equipment in the package must remain sterile. 3. The nurse's sterile gloved hands then place the fenestrated drape over the patient's perineal area to continue with the establishment of a sterile field. 5. Cleansing the labia moves from areas that are less likely to be contaminated than the urinary meatus as well as reduces the spread of microorganisms toward the urinary meatus. 4. Cleansing the urinary meatus last reduces the possibility of introducing microorganisms into the urinary meatus and bladder. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A primary health-care provider orders the insertion of an indwelling urinary catheter (retention, Foley) as part of the patient's preoperative orders. Place the following steps of the procedure in the order in which they should be performed by the nurse. ⏺Ask what the question is asking. What is the progression of steps for inserting an indwelling urinary catheter? ⏺Critically analyze each option in relation to the question and the other options. List the sequential steps of inserting an indwelling urinary catheter. Refer to your list as you examine the options presented. Order the steps presented according to the order you identified. ⏺Eliminate incorrect options. There are no incorrect options.

A nurse is using a health-related Internet blog. Which of the following is an acceptable use of this form of communication? Access information Discuss client's diagnosis Post a picture of a client's incision

✅Access information A nurse should use blogs to access information and discover the most up-to-date evidence-based practice information available to health professionals. Discuss client's diagnosis A nurse should never discuss a client's diagnosis on a blog. It violates the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Post a picture of a client's incision A nurse should never post a picture of a client's body part on a blog. It violates the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Professional Communication: Types of Communication

​Which of the following professional associations advances the nursing profession by creating high standards for nursing practice? ​American Nurses Association ​National League for Nursing ​American Association of Colleges of Nursing

✅American Nurses Association MY ANSWER ​The American Nurses Association (ANA) advances the nursing profession by creating high standards for nursing practice. ​National League for Nursing ​The National League for Nursing (NLN) is a professional association that seeks to build a strong, diverse nursing work force. ​American Association of Colleges of Nursing ​The American Association of Colleges of Nursing represents university-level nursing education programs. Nurse's Touch: Becoming a Professional Nurse (4)

89. A patient's vital signs are: apical heart rate—100 beats/min, radial heart rate—84 beats/min, respirations—20 breaths/min, blood pressure—140/84 mm Hg. What is the patient's pulse deficit? Record your answer using a whole number. Answer: _ _________

✅Answer: 16. The pulse deficit is the difference between the apical and radial pulse rates. Therefore, 100 (apical rate) minus 84 (radial rate) equals 16. The patient's pulse deficit is 16. CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A patient's vital signs are: apical heart rate—100 beats/ min, radial heart rate—84 beats/min, respirations—20 breaths/min, blood pressure—140/84 mm Hg. What is the patient's pulse deficit? Record your answer using a whole number. ⏺Ask what the question is asking. Calculate a pulse deficit from the information provided. ⏺Critically analyze each option in relation to the question and the other options. Define a pulse deficit. Analyze the situation to extract the information needed to calculate the pulse deficit. Perform the calculation. ⏺Eliminate incorrect options. There are no incorrect options.

6. A primary health-care provider prescribes 500 mg of an antibiotic to be administered IVPB every 6 hours for a patient with a systemic infection. The vial dispensed by the hospital pharmacist contains 1 g of the prescribed antibiotic in powder form. The instructions on the vial state: "Instill 9.6 mL to yield 10 mL." How many milliliters of the antibiotic should the nurse add to the IVPB bag? Record your answer using a whole number. Answer: __________________ mL

✅Answer: 5 mL. Use ratio and proportion to first convert 500 mg to its equivalent in grams as well as to solve the problem. Now proceed to solve the problem using ratio and proportion. Desire0.5gram= xmL Have 1 gram 1x = 0.5 ÷ 10 x = 5 mL CRITICAL-THINKING STRATEGY ⏺Recognize keywords. A primary health-care provider prescribes 500 mg of an antibiotic to be administered IVPB every 6 hours for a patient with a systemic infection. The vial dispensed by the hospital pharmacist contains 1 g of the prescribed antibiotic in powder form. The instructions on the vial state: "Instill 9.6 mL to yield 10 mL." How many milliliters of the antibiotic should the nurse add to the IVPB bag? ⏺Ask what the question is asking. Compute the dose of the prescribed medication. ⏺Critically analyze each option in relation to the question and the other options. Use a mathematical formula to convert milligrams to grams. Then use a mathematical formula to compute the correct dose of medication prescribed. The information you need to insert into the formula is the Desired (prescribed: 500 mg [0.5 g]) dose and what you Have (how the medication is supplied: 1 g/10 mL). ⏺Eliminate incorrect options. There is no need to eliminate options because this is a fill-in-the-blank question.

​Which of the following can threaten professional integrity? (Select all that apply.) ​Anxiety ​Beneficence ​Fast-paced environment ​Substance abuse ​Assertiveness

✅Anxiety is correct. Anxiety can threaten professional integrity. Beneficence is incorrect. Beneficence, or doing good, is a component of professional nursing practice and does not threaten professional integrity. ✅Fast-paced environment is correct. The fast-paced health care environment can threaten professional integrity. ✅Substance abuse is correct. Substance abuse can threaten professional integrity. Assertiveness is incorrect. Assertiveness promotes positive interactions and information sharing in a respectful environment, and it does not threaten professional integrity. Becoming a Professional Nurse: Professional Behaviors in Nursing

​Which of the following actions demonstrates the professional concept of assertiveness? ​Boldly sharing conflicting ideas ​Using a team-based approach ​Feelings of strong self-esteem

✅Boldly sharing conflicting ideas ​Assertiveness refers to speaking up, or boldness, in sharing ideas and information, even in the midst of conflicting opinions and values. ​Using a team-based approach ​A team approach is a separate, important characteristic related to group processes; assertiveness is an individual characteristic. ​Feelings of strong self-esteem ​Self-esteem is an internal feeling and relates to confidence. Becoming a Professional Nurse: Professional Behaviors in Nursing

Electronic health records capture data for which of the following? (Select all that apply.) Continuous quality improvement Utilization review Human resources Resource planning Risk management

✅Continuous quality improvement is correct. Electronic health records capture data for continuous quality improvement. ✅Utilization review is correct. Electronic health records capture data for utilization review. Human resources is incorrect. Electronic health records do not capture data for human resources. ✅Resource planning is correct. Electronic health records capture data for resource planning. ✅Risk management is correct. Electronic health records capture data for risk management. Professional Communication: Types of Communication

​The inclusion of autonomy in the provision of client care incorporates which of the following traits? (Select all that apply.) ​Decision making ​Sympathy ​Flexibility ​Prioritization ​Affirmation

✅Decision making is correct. Decision making is a trait that is incorporated when including autonomy in the provision of client care. ​​Sympathy is incorrect. Sympathy is not a trait that is incorporated when including autonomy in the provision of client care. Sympathy is a display of understanding the suffering of another person. ✅Flexibility is correct. ​​Flexibility is a trait that is incorporated when including autonomy in the provision of client care. ​​✅Prioritization is correct. Prioritization is a trait that is incorporated when including autonomy in the provision of client care. ​​Affirmation is incorrect. Affirmation is not a trait that is incorporated when including autonomy in the provision of client care. Affirmation is declaring that something is true, or right. The nurse should not express an opinion about a client's treatment decision. Becoming a Professional Nurse: Professional Behaviors in Nursing

A nurse is planning a presentation about skin care for a group of older adult clients at a senior center. Which of the following actions should the nurse take to enhance client learning? Ensure the room is well lit. Have soft music playing in the background. Hand out samples of products during the teaching. Speak quickly during the teaching.

✅Ensure the room is well lit. The nurse should identify that a well-lit room can allow the participants to better see the presentation as well as the nurse during the teaching. Have soft music playing in the background. The nurse should identify that distractions such as background music can limit learning by the clients. Instead, the nurse should ensure the teaching environment is free of distractions. Hand out samples of products during the teaching. The nurse should identify that the use of samples can enhance learning. However, the nurse should distribute the samples prior to or following the presentation to avoid distractions during the teaching. Speak quickly during the teaching. The nurse should identify that teaching is enhanced when clients can see and hear the speaker and when the speech is clear and delivered at a slower pace. RN Communication Assessment

​A mentor is assisting a new graduate nurse develop strategies to transition successfully from student to professional nurse. The mentor should intervene if the new nurse incorporates which of the following strategies? ​Evaluates growth by comparing progress with peers ​Actively participates in professional nursing association activities ​Utilizes resources available through the employing facility

✅Evaluates growth by comparing progress with peers MY ANSWER ​Growth should be evaluated realistically and by comparing progress with short- and long-term goals instead of comparing to peers. The inclusion of this strategy requires intervention by the mentor. ​Actively participates in professional nursing association activities ​Actively participating in professional nursing association activities is an appropriate strategy to transition successfully from student to professional nurse and does not require intervention by the mentor. ​Utilizes resources available through the employing facility ​Utilizing resources available through the employing facility is an appropriate strategy to transition successfully from student to professional nurse and does not require intervention by the mentor. Becoming a Professional Nurse: Socialization into Professional Nursing

Which of the following are examples of a nurse using nontherapeutic communication techniques? (Select all that apply.) Focusing on the nurse rather than the client Changing the subject Making value judgments Giving advice Seeking clarification

✅Focusing on the nurse rather than the client is correct. This is a nontherapeutic communication technique. ✅Changing the subject is correct. This is nontherapeutic because it invalidates the client's needs or feelings. ✅Making value judgments is correct. This is a nontherapeutic communication technique. Making value judgements prevents problem-solving by the client. ✅Giving advice is correct. This is nontherapeutic because it inhibits problem-solving and assumes the nurse knows what is best for the client. Seeking clarification is incorrect. This is a therapeutic communication technique that allows the client to clearly state his thoughts. Professional Communication: Therapeutic Communication

Which of the following types of communication is informal, becomes distorted, and typically involves three or four individuals? Grapevine Horizontal Upward

✅Grapevine Grapevine communication is informal and generally involves three or four people at one time. The message often contains errors as it is communicated because the sender bears little accountability for the message. Horizontal Horizontal communication is when a manager interacts with other nursing managers. Upward Upward communication is when a manager communicates with a superior. Professional Communication: Organizational Structure

A nurse manager is discussing aggressive communication with a nurse who is having conflicts with peers due to her ineffective communication patterns. Which of the following should the nurse manager identify as a characteristic of aggressive communication? Infringes on the rights of others Says no without guilt Congruent facial expressions

✅Infringes on the rights of others Individuals who infringe on the rights of others are using aggressive communication patterns. Says no without guilt Saying no without guilt is a characteristic of assertive communication. Congruent facial expressions Using congruent facial expression is a characteristic of assertive communication. Professional Communication: Organizational Structure

A charge nurse is reviewing organizational structure with a group of newly licensed nurses. Which of the following should she include in her discussion? (Select all that apply.) Lines of authority Organizational size Formal structures Informal structures Interprofessional relationships

✅Lines of authority is correct. Organizational structure involves lines of authority. ✅Organizational size is correct. Organizational structure involves organizational size. ✅Formal structures is correct. Formal structures are a part of organizational structure. ✅Informal structures is correct. Informal structures are a part of organizational structure. Interprofessional relationships is incorrect. Interprofessional relationships are a component of collaborative relationships, not organizational structure Professional Communication: Organizational Structure

A nurse manager is conducting an in-service on ineffective communication patterns. Which of the following should she include when discussing components of passive communication? (Select all that apply.) Puts others' needs and wants ahead of self Avoids conflicts Difficult time saying 'no' Uses "I" or "me" statements Intimidating

✅Puts others' needs and wants ahead of self is correct. This is a component of passive communication. ✅Avoids conflicts is correct. This is a component of passive communication. ✅Difficult time saying "no" is correct. This is a component of passive communication. Uses "I" or "me" statements is incorrect. This is a component of assertive communication. Intimidating is incorrect. This is a component of aggressive communication.

Which of the following should be included in an interprofessional or interdisciplinary team? (Select all that apply.) Respiratory therapist Provider Nurses Family members Dietitian

✅Respiratory therapist is correct. Interprofessional relationships are a group of various disciplines who utilize their own individual professional theories to promote health care. ✅Provider is correct. The provider should be included in the interprofessional or interdiscipilinary team. ✅Nurses is correct. The nurse should be included in the interprofessional or interdisciplinary team. Family members is incorrect. Family members are not included in interprofessional teams. ✅Dietitian is correct. The dietitian should be included in the interprofessional or interdiscpilinary team. Professional Communication: Organizational Structure

​Which of the following are characteristics exhibited by a professional? (Select all that apply.) ​Technical competence ​Self-centeredness ​Concern for others ​Interpersonal skills ​Ethnocentrism

✅Technical competence is correct. Technical competence is a characteristic exhibited by a professional. Self-centeredness is incorrect. Self-centeredness is a primary concern with one's own interests and goals, and it is not a characteristic exhibited by a professional. ✅Concern for others is correct. Concern for others is a characteristic exhibited by a professional. ✅Interpersonal skills is correct. Interpersonal skills are a characteristic exhibited by a professional. Ethnocentrism is incorrect. Ethnocentrism is the belief that one's culture or group is superior to others, and it is not a characteristic exhibited by a professional.

​When obtaining written consent for a procedure to be performed by someone else, the nurse's signature confirms which of the following? (Select all that apply.) ​The client appears competent to agree to the procedure ​The client understands the risks of the procedure ​The client has been notified of alternatives to the procedure ​The client consents voluntarily to the procedure ​The family supports the client's decision to have the procedure

✅The client appears competent to agree to the procedure is correct. When obtaining informed consent for a procedure to be performed by someone else, the nurse's signature confirms that the client appears competent to agree to the procedure. ​ The client understands the risks of the procedure is incorrect. Ensuring that the client understands involved risks of the procedure is the responsibility of the provider who is performing the procedure. It is not confirmed by the nurse's signature. ​ The client has been notified of alternatives to the procedure is incorrect. Ensuring that the client is notified of alternatives to the procedure is the responsibility of the provider who is performing the procedure. It is not confirmed by the nurse's signature. ​ ✅The client consents voluntarily to the procedure is correct. When obtaining informed consent for a procedure to be performed by someone else, the nurse's signature confirms that the client voluntarily consents to the procedure. ​ The family supports the client's decision to have the procedure is incorrect. Informed consent does not indicate that the family supports the client's decision to have the procedure. As long as the client is a legal, competent adult, family agreement is not a consideration. Becoming a Professional Nurse: Professional Nursing Practice

A nurse is implementing therapeutic communication techniques with a client in an outpatient mental health facility. Which of the following actions allows the client an opportunity to organize thoughts, consider a topic, or think through a point? Use of silence Offering self Reflection of feelings

✅Use of silence Silence is a useful therapeutic technique when the client is confronted with decisions. Silence allows the client the opportunity to organize thoughts, consider a topic, or think through a point. Offering self Offering self is a therapeutic technique that demonstrates the genuine interest that the nurse has for the client. Reflection of feelings Reflection of feelings is a therapeutic communication technique that encourages the client to acknowledge thoughts and feelings Professional Communication: Therapeutic Communication

A nurse is counseling a client who recently received a diagnosis of type 1 diabetes mellitus. Which of the following is a component of nonverbal communication the nurse may display? (Select all that apply.) Vocal inflection Volume Posture Gestures Channels

✅Vocal inflection is correct. Vocal inflection is a component of nonverbal communication. ✅Volume is correct. Volume is a component of nonverbal communication. ✅Posture is correct. Posture is a component of nonverbal communication. ✅Gestures are correct. Gestures are a component of nonverbal communication. Channels are incorrect. Channels are a component of verbal communication. Professional Communication: Types of Communication

​Which of the following actions represents the professional value of altruism? ​A nurse mentoring a colleague in professional growth ​A nurse respecting a client's decision to refuse treatment ​A nurse encouraging a clinic to treat a homeless man who is unable to pay for his care

✅​A nurse mentoring a colleague in professional growth ​Altruism is concern for the well-being of others. One way nurses demonstrate altruism is through unselfish support of others, especially mentoring colleagues in their professional growth. ​A nurse respecting a client's decision to refuse treatment ​Nurses demonstrate a respect for autonomy by respecting a client's decision to refuse treatment. ​A nurse encouraging a clinic to treat a homeless man who is unable to pay for his care ​Nurses demonstrate the value of social justice when supporting the right of all patients to have access to health care without discrimination. Becoming a Professional Nurse: Professional Nursing Practice