Intro to Clinical Nursing EXAM 2

10. The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask? a."Is there anything that you are stressed about right now that I should know?" b."What reasons do you think are contributing to your fatigue?" c."What are your normal work hours?" d."Are you sleeping 8 hours a night?"

"What reasons do you think are contributing to your fatigue?"

14. Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation? a."Data interpretation occurs before data validation." b."Validation involves looking for patterns in professional standards." c."Validation involves comparing data with other sources for accuracy." d."Data interpretation involves discovering patterns in professional standards."

"validation involves comparing data with other sources for accuracy"

The nurse is assessing the characteristics of a patient's pain. Match the characteristic to the question a nurse will ask to determine that specific characteristic. a.Could you rate your pain on a scale of 0 to 10? b.How often does it recur? c.Could you point to the area of pain? d.Do certain activities worsen the pain? e.What does the pain feel like? 1.Timing 2.Location 3.Severity 4.Quality 5.Aggravating factors

1. Timing= B. How often does it recur? 2. Location= C. Could you point to the area of pain? 3. Severity= A. Could you rate your pain on a scale of 0 to 10? 4. Quality= E. What does the pain feel like? 5. Aggravating factors= D. Do certain activities worsen the pain?

A nurse is assessing a patient's hearing. Which of the following items does the nurse gather before conducting the assessment? (Select all that apply.) A. Tuning fork B. Ophthalmoscope C. Cotton-tipped applicator D. Current list of medications E. Snellen chart

A and D.

4.A nurse is planning care for an older-adult patient who is experiencing pain. Which statement made by the nurse indicates the supervising nurse needs to follow up? a. "As adults age, their ability to perceive pain decreases." b. "Older patients may have low serum albumin in their blood, causing toxic effects of analgesic drugs." c. "Patients who have dementia probably experience pain, and their pain is not always well controlled." d. "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication."

A. "As adults age, their ability to perceive pain decreases" Aging does not affect the ability to perceive pain. This misconception must be corrected by the supervising nurse. All the other statements are true and require no follow-up. Opioids are safe to use in older adults as long as they are slowly titrated and the nurse frequently monitors the patient. Patients with dementia most likely experience unrelieved pain because their pain is difficult to assess. Older adults frequently eat poorly, resulting in low serum albumin levels. Many drugs are highly protein bound. In the presence of low serum albumin, more free drug (active form) is available, thus increasing the risk for side and/or toxic effects.

A nurse teaches the patient about the prescribed buccal medication. Which statement by the patient indicates teaching by the nurse is successful? A. "I should let the medication dissolve completely." B. "I will place the medication in the same location." C. "I can only drink water, not juice, with this medication." D. "I better chew my medication first for faster distribution."

A. "I should let the medication dissolve completely." Buccal medications should be placed in the side of the cheek and allowed to dissolve completely. Buccal medications act with the patient's saliva and mucosa. The patient should not chew or swallow the medication or take any liquids with it. The patient should rotate sides of the cheek to avoid irritating the mucosal lining.

3.A nurse teaches the patient about the gate control theory. Which statement made by a patient reflects a correct understanding about the relationship between the gate control theory of pain and the use of meditation to relieve pain? a. "Meditation controls pain by blocking pain impulses from coming through the gate." b. "Meditation alters the chemical composition of pain neuroregulators, which closes the gate." c. "Meditation will help me sleep through the pain because it opens the gate." d. "Meditation stops the occurrence of pain stimuli."

A. "Meditation controls pain by blocking pain impulses from coming through the gate" According to this theory, gating mechanisms located along the central nervous system regulate or block pain impulses. Pain impulses pass through when a gate is open and are blocked when a gate is closed. Nonpharmacologic pain-relief measures, such as meditation, work by closing the gates, which keeps pain impulses from coming through. Meditation does not open pain gates or stop pain from occurring. Meditation also does not have an effect on pain neuroregulators.

12.A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with hydrocodone. Which important patient education does the nurse provide? a. "You need to drink plenty of fluids and eat a diet high in fiber." b. "Narcotics can be addictive, so do not take them unless you are in severe pain." c. "Be sure to eat a meal high in fat before taking the medication, to avoid a stomach ulcer." d. "As your pain severity lessens, you will begin to give yourself once-daily intramuscular injections."

A. "You need to drink plenty of fluids and eat a diet high in fiber" A common side effect of opioid analgesics is constipation. Therefore, the nurse encourages the patient to drink fluids and eat fiber to prevent constipation. Although medications can be irritating to the stomach, eating a diet high in fat does not prevent gastric ulcers. To best manage pain, the patient needs to take pain medication before painful procedures or activities or before pain becomes severe. As the patient's pain gets better, the strength of the medications will decrease. IM, IV, and topical analgesics are used for more severe and chronic pain.

A patient has an order to receive 12.5 mg of hydrochlorothiazide. The nurse has on hand a 25 mg tablet of hydrochlorothiazide. How many tablet(s) will the nurse administer? A. 1/2 tablet B. 1 tablet C. 1 1/2 tablets D. 2 tablets

A. 1/2 tablet

The nurse is planning to administer a tuberculin test with a 27-gauge, ⅝-inch needle. At which angle will the nurse insert the needle? A. 15 degree B. 30 degree C. 45 degree D. 90 degree

A. 15 degree A 27-gauge, 5 8 -inch needle is used for intradermal injections such as a tuberculin test, which should be inserted at a 5- to 15-degree angle, just under the dermis of the skin. Placing the needle at 30 degrees, 45 degrees, or 90 degrees will place the medication too deep.

A patient who is being discharged today is going home with an inhaler. The patient is to administer 2 puffs of the inhaler twice daily. The inhaler contains 200 puffs. When should the nurse appropriately advise the patient to refill the medication? A. 6 weeks from the start of using the inhaler B. As soon as the patient leaves the hospital C. When the inhaler is half empty. D. 50 days after discharge

A. 6 weeks from the start of using the inhaler Six weeks will be about the time the inhaler will need to be refilled. The inhaler should last the patient 50 days (2 puffs × 2/twice daily = 4; 200/4 = 50); the nurse should advise the patient to refill the prescription when there are 7 to 10 days of medication remaining. -Refilling it as soon as the patient leaves the hospital or when the inhaler is half empty is too early. -If the patient waits 50 days, the patient will run out of medication before it can be refilled.

23.A nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient who received morphine and has a pulse of 62 beats/min, respirations 10 breaths/min, and blood pressure 110/60 mm Hg b. A patient lying very still in bed who reports no pain but is pale with warm, dry skin c. A patient with severe pain who is nauseated and feels like he or she is about to vomit d. A patient writhing and moaning from abdominal pain after abdominal surgery

A. A patient who received morphine and has a pulse of 62 beats/min, respirations 10 breaths/min, and blood pressure 110/60 mm Hg A respiratory rate of 10 indicates respiratory depression. A rare adverse effect of opioids in opioid-naïve patients (patients who have used opioids around the clock for less than approximately 1 week) is respiratory depression. Naloxone (Narcan) may be administered. While the other patients are experiencing pain and do need to be seen, they are not the priority since respirations are not affected.

31.The nurse is caring for a group of patients. Which task may the nurse delegate to the nursing assistive personnel (NAP)? a. Administer a back massage to a patient with pain. b. Assessment of pain for a patient reporting abdominal pain. c. Administer patient-controlled analgesia for a postoperative patient. d. Assessment of vital signs in a patient receiving epidural analgesia.

A. Administer a back massage to a patient with pain. A massage may be delegated to an NAP. Pain assessment is a nursing function and cannot be delegated to an NAP. Administration of patient-controlled analgesia (PCA) cannot be delegated to an NAP. Assessment of vital signs is a licensed nursing function; the NAP can take vital signs for a patient receiving epidural analgesia.

The nurse is administering medications to several patients. Which action should the nurse take? A. Advise a patient after a corticosteroid inhaler treatment to rinse mouth with water. B. Administer an intravenous medication through tubing that is infusing blood. C. Pinch up the deltoid muscle of an adult patient receiving a vaccination. D. Aspirate before administering a subcutaneous injection in the abdomen.

A. Advise a patient after a corticosteroid inhaler treatment to rinse mouth with water. If the patient uses a corticosteroid, have him or her rinse the mouth out with water or salt water or brush teeth after inhalation to reduce risk of fungal infection. -Piercing a blood vessel during a subcutaneous injection is very rare. Therefore, aspiration is not necessary when administering subcutaneous injections. -When giving immunizations to adults: to avoid injection into subcutaneous tissue, spread the skin of the selected vaccine administration site taut between the thumb and forefinger, isolating the muscle. -Never administer IV medications through tubing that is infusing blood, blood products, or parenteral nutrition solutions.

The best term for breath sounds created by air moving through large lung airways is A. Bronchovesicular. B. Rhonchi. C. Bronchial. D. Vesicular.

A. Bronchovesicular.

A nurse is preparing to administer an antibiotic medication at 1000 to a patient but gets busy in another room. When should the nurse give the antibiotic medication? A. By 1030 B. By 1100 C. By 1130 D. By 1200

A. By 1030

An order is written for phenytoin 500 mg IM q3-4h prn for pain. The nurse recognizes that treatment of pain is not a standard therapeutic indication for this drug. The nurse believes that the health care provider meant to write hydromorphone. What should the nurse do? A. Call the health care provider to clarify the order. B. Give the patient hydromorphone, as it was meant to be written. C. Administer the medication and monitor the patient frequently. D. Refuse to give the medication and notify the nurse supervisor.

A. Call the health care provider to clarify the order. If there is any question about a medication order because it is incomplete, illegible, vague, or not understood, contact the health care provider before administering the medication. The nurse cannot change the order without the prescriber's consent; this is out of the nurse's scope of practice. Ultimately, the nurse can be held responsible for administering an incorrect medication. If the prescriber is unwilling to change the order and does not justify the order in a reasonable and evidence-based manner, the nurse may refuse to give the medication and notify the supervisor.

During a sexually transmitted illness presentation to high school students, the nurse recommends the HPV vaccine series to prevent A. Cervical cancer. B. Genital lesions. C. Vaginal discharge. D. Swollen perianal tissues.

A. Cervical cancer.

The patient is a 50-year-old African American male who has come in for his routine annual physical. Which of the following preventive screenings does the nurse recommend? A. Digital rectal examination of the prostate (DRE) annually B. Ca125 blood test once a year C. Complete eye examination every year D. Colonoscopy every 3 years

A. Digital rectal examination of the prostate (DRE) annually

A nurse is caring for a patient who is receiving pain medication through a saline lock. After obtaining a good blood return when the nurse is flushing the patient's peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm and tender to the touch. What is the nurse's initial action? A. Do not administer the pain medication. B. Administer the pain medication slowly. C. Apply a warm compress to the site. D. Apply a cool compress to the site.

A. Do not administer the pain medication. The patient has phlebitis; the initial nursing action is do not administer the medication. -The medication should not be given slowly. -A cool or warm compress may be used later depending upon protocol, but it is not the first action.

The nurse prepares a pain injection for a patient but had to check on another patient and asks a new nurse to give the medication. Which action by the new nurse is best? A. Do not give the medication. B. Administer the medication just this once. C. Give the medication for any pain score greater than 8. D. Avoid the issue and pretend to not hear the request.

A. Do not give the medication. Because the nurse who administers the medication is responsible for any errors related to it, nurses administer only the medications they prepare. You cannot delegate preparation of medication to another person and then administer the medication to the patient. The right medication cannot be verified by the new nurse; do not violate the six rights. Do not administer the medication even one time. Do not administer the medication regardless of the pain rating. Avoiding the issue is not appropriate or safe.

A patient needs assistance in eliminating an anesthetic gaseous medication (nitrous oxide). Which action will the nurse take? A. Encourage the patient to cough and deep-breathe. B. Suction the patient's respiratory secretions. C. Suggest voiding every 2 hours. D. Increase fluid intake.

A. Encourage the patient to cough and deep-breathe. Gaseous and volatile medications are excreted through gas exchange (lungs). Deep breathing and coughing will assist in clearing the medication more quickly. It is a gaseous medication and cannot be suctioned out of the lungs. It is not excreted through the kidneys so fluids and voiding will not help.

The patient has had a stroke that has affected her ability to speak, and she becomes extremely frustrated when she tries to speak. She responds correctly to questions and instructions but cannot form words coherently. This patient is showing signs of _____ aphasia. A. Expressive B.Receptive C. Sensory D. Combination

A. Expressive

The nurse administers a central nervous system stimulant to a patient. Which assessment finding indicates to the nurse that an idiosyncratic event is occurring? A. Falls asleep during daily activities B. Presents with a pruritic rash C. Develops restlessness D. Experiences alertness

A. Falls asleep during daily activities An idiosyncratic event is a reaction opposite to what the effects of the medication normally are, or the patient overreacts or underreacts to the medication. Falls asleep is an opposite effect of what a central nervous system stimulant should do. A stimulant should make a patient restless and alert. A pruritic (itch) rash could indicate an allergic reaction.

On admission, a patient weighs 250 pounds. The weight is recorded as 256 pounds on the second inpatient day. The nurse should evaluate the patient for A. Fluid retention. B. Fluid loss. C. Decreased nutritional reserves. D. Anorexia.

A. Fluid retention.

32.A nurse is caring for a patient with chronic pain from arthritis. Which action is best for the nurse to take? a. Give pain medications around the clock. b. Administer pain medication before any activity. c. Give pain medication after the pain is a 7/10 on the pain scale. d. Administer pain medication only when nonpharmacological measures have failed.

A. Give pain medications around the clock. When a patient with arthritis has chronic pain, the best way to manage pain is to take medication regularly throughout the day to maintain constant pain relief. "Before any activity" is nonspecific, and the medication may not have time to work before activity. If the patient waits until having pain (7/10) to take the medication, pain relief takes longer. Nonpharmacological measures are used in conjunction with medications unless requested otherwise by the patient.

A nurse has withdrawn a narcotic from the medication dispenser and must waste a portion of the medication. What should the nurse do? A. Have another nurse witness the wasted medication. B. Return the wasted medication to the medication dispenser. C. Place the wasted portion of the medication in the sharps container. D. Exit the medication room to call the health care provider to request an order that matches the dosages.

A. Have another nurse witness the wasted medication. The nurse should follow Nurse Practice Acts and safe narcotic administration guidelines by having a nurse witness the "wasted" medication. The nurse cannot return the wasted medication to the medication dispenser. Wasted portions of medications are not placed in sharps containers. The nurse should not leave the narcotic unattended and call the health care provider to obtain matching dosages; the nurse is expected to obtain the correct dose.

5.The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients? a. Meaning of pain b. Neurological factors c. Competency of the surgeon d. Postoperative support personnel

A. Meaning of pain The degree and quality of pain perceived by a patient are related to the meaning of the pain. The patient's perception of pain is influenced by psychological factors, such as anxiety and coping, which in turn influence the patient's experience of pain. Each patient's experience is different. Neurological factors can interrupt or influence pain perception, but neither of these patients is experiencing alterations in neurological function. The knowledge, attitudes, and beliefs of nurses, health care providers, the surgeon, and other health care personnel about pain affect pain management but do not necessarily influence a patient's pain perceptions.

29.A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain. Which part of the patient's social history is the nurse most concerned about? a. Patient drinks 1 to 2 glasses of wine every night. b. Patient smokes 2 packs of cigarettes a day. c. Patient occasionally uses marijuana. d. Patient takes antianxiety medications.

A. Patient drinks 1 to 2 glasses of wine every night. The major adverse effect of acetaminophen is hepatotoxicity (liver toxicity). Because both alcohol and acetaminophen are metabolized by the liver, when taken together, they can cause liver damage. Smoking cigarettes and smoking marijuana are not healthy behaviors, but their effects on health are not affected by acetaminophen. Antianxiety medications can be taken with acetaminophen.

1.The nurse is administering ibuprofen (Advil) to an older patient. Which assessment data causes the nurse to hold the medication? (Select all that apply.) a. Patient states allergy to aspirin. b. Patient states joint pain is 2/10 and intermittent. c. Patient reports past medical history of gastric ulcer. d. Patient reports last bowel movement was 4 days ago. e. Patient experiences respiratory depression after administration of an opioid medication.

A. Patient states allergy to aspirin C. Patient reports past medical history of gastric ulcer NSAIDs can cause bleeding, especially in the gastrointestinal (GI) tract; therefore, NSAIDs are most likely contraindicated in this patient. Patients with an allergy to aspirin or have asthma are sometimes also allergic to other NSAIDs. The nurse needs to verify that the health care provider is aware of the history of GI bleeding and of allergy to aspirin before administering ibuprofen. NSAIDs do not interfere with bowel function and are used for the treatment of mild to moderate acute intermittent pain. NSAIDs also do not suppress the central nervous system by causing respiratory depression.

A 2-year-old child is ordered to have eardrops daily. Which action will the nurse take? A. Pull the auricle down and back to straighten the ear canal. B. Pull the auricle upward and outward to straighten the ear canal. C. Sit the child up for 2 to 3 minutes after instilling drops in ear canal. D. Sit the child up to insert the cotton ball into the innermost ear canal.

A. Pull the auricle down and back to straighten the ear canal.

What is the nurse's priority action to protect a patient from medication error? A. Reading medication labels at least 3 times before administering B. Administering as many of the medications as possible at one time C. Asking anxious family members to leave the room before giving a medication D. Checking the patient's room number against the medication administration record

A. Reading medication labels at least 3 times before administering

The nurse closely monitors an older adult for signs of medication toxicity. Which physiological change is the reason for the nurse's action? A. Reduced glomerular filtration B. Reduced esophageal stricture C. Increased gastric motility D. Increased liver mass

A. Reduced glomerular filtration The reduced glomerular filtration rate DELAYS EXCRETION, increasing chance for toxicity. In older adults, gastric motility and liver mass decrease. Esophageal stricture is not a physiological change associated with normal aging.

The nurse is preparing to administer medications to two patients with the same last name. After the administration, the nurse realizes that did not check the identification of the patient before administering medication. Which action should the nurse complete first? A. Return to the room to check and assess the patient. B. Administer the antidote to the patient immediately. C. Alert the charge nurse that a medication error has occurred. D. Complete proper documentation of the medication error in the patient's chart.

A. Return to the room to check and assess the patient. When an error occurs, the patient's safety and well-being are the top priorities. You first assess and examine the patient's condition and notify the health care provider of the incident as soon as possible. The nurse's first priority is to establish the safety of the patient by assessing the patient. -Second, notify the charge nurse and the health care provider. -Administer antidote if required. -Finally, the nurse needs to complete proper documentation.

A parent calls the school nurse with questions regarding the recent school vision screening. Snellen chart examination revealed 20/60 for both eyes. Considering the visual acuity results, the nurse informs the parent that the child A. Should have an optometric examination. B. Is suffering from strabismus. C. May have presbyopia. D. Has vision issues most likely due to cataracts.

A. Should have an optometric examination.

In preparation for a rectal examination of a nonambulatory male patient, the patient is informed of the need to be placed in which position? A. Sims' position B. Forward bending with flexed hips C. Knee-chest D. Dorsal recumbent

A. Sims' position

Which methods will the nurse use to administer an intravenous (IV) medication that is incompatible with the patient's IV fluid? (Select all that apply.) A. Start another IV site. B. Administer slowly with the IV fluid. C. Do not give the medication and chart. D. Flush with 10 mL of sterile water before and after administration. t E. Flush with 10 mL of normal saline before and after administration.

A. Start another IV site. D. Flush with 10 mL of sterile water before and after administration. t E. Flush with 10 mL of normal saline before and after administration. When IV medication is incompatible with IV fluids: -stop the IV fluids, -clamp the IV line above the injection site, -flush with 10 mL of normal saline or sterile water, -give the IV bolus over the appropriate amount of time, -flush with another 10 mL of normal saline or sterile water at the same rate as the medication was administered, -restart the IV fluids at the prescribed rate.

While preparing medications, the nurse knows one of the drug is an acidic medication. In which area does the nurse anticipate the drug will be absorbed? A. Stomach B. Mouth C. Small intestine D. Large intestine

A. Stomach Acidic medications pass through the gastric mucosa rapidly. Medications that are basic are not absorbed before reaching the small intestine.

An elderly patient has been on high doses of antibiotics and is experiencing a sudden loss of hearing. The nurse should contact the health care provider and A. Stop antibiotic use until the physician responds. B. Tell the patient that older patients often lose low-frequency hearing. C. Explain that hearing loss usually occurs with thinning of the eardrum. D. Assure the patient that rapid hearing loss is normal in the elderly.

A. Stop antibiotic use until the physician responds.

The school nurse is assessing the tympanic membranes of a 3-year-old child. Which of the following demonstrates proper technique? A. Using an inverted otoscope grip while pulling the auricle downward B. Pulling the auricle upward and backward C. Holding the handle of the otoscope between the thumb and index finger while the child lies on the weight scale D. Using an inverted otoscope grip while pulling the auricle upward

A. Using an inverted otoscope grip while pulling the auricle downward

A febrile preschool-aged child presents to the after-hours clinic. Varicella is diagnosed on the basis of the illness history and the presence of small, circumscribed skin lesions filled with serous fluid. The nurse documents the varicellar lesions as which type of skin lesion? A. Vesicle B. Wheal C. Papule D. Pustule

A. Vesicle

A nurse suspects an abnormal thyroid shape during the physical examination. The nurse offers the patient a glass of water and observes her drinking to A. Visualize an enlarged thyroid gland. B. Evaluate for exostosis. C. Test the patient's gag reflex. D. Visualize the uvula and soft palate.

A. Visualize an enlarged thyroid gland.

3. The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next? a.Administer the acetaminophen. b.Notify the health care provider to obtain a verbal order. c.Direct the nursing assistive personnel to give the acetaminophen. d.Perform a pain assessment only after administering the acetaminophen.

ANS: A A standing order is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. The nurse will administer the medication. Notifying the health care provider is not necessary if a standing order exists. The nursing assistive personnel are not licensed to administer medications; therefore, medication administration should not be delegated to this person. A pain assessment should be performed before and after pain medication administration to assess the need for and effectiveness of the medication.

4. Which action indicates a nurse is using critical thinking for implementation of nursing care to patients? a.Determines whether an intervention is correct and appropriate for the given situation b.Reads over the steps and performs a procedure despite lack of clinical competency c.Establishes goals for a particular patient without assessment d.Evaluates the effectiveness of interventions

ANS: A As you implement interventions, use critical thinking to confirm whether the interventions are correct and still appropriate for a patient's clinical situation. You are responsible for having the necessary knowledge and clinical competency to perform interventions for your patients safely and effectively. The nurse needs to recognize the safety hazards of performing an intervention without clinical competency and seek assistance from another nurse. The nurse cannot evaluate interventions until they are implemented. Patients need ongoing assessment before establishing goals because patient conditions can change very rapidly.

12. A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome? a.States feels better after talking with family and friends b.Consumes high-carbohydrate foods when stressed c.Dislikes the support group meetings d.Spends most of the day in bed

ANS: A Evaluative data that show signs of effective coping will help the nurse determine whether the patient has met the outcome. Talking to family and friends is the only positive option. During evaluation, you perform evaluative measures that allow you to compare clinical data, patient behavior measures, and patient self-report measures collected before implementation with the evaluation findings gathered after administering nursing care. Next, you evaluate whether the results of care match the expected outcomes and goals set for a patient. Consuming high-carbohydrate foods (patient is a diabetic), disliking support group, and spending the day in bed indicate unsuccessful progress toward meeting the patient's goal.

18. A nurse is evaluating an expected outcome for a patient that states heart rate will be less than 80 beats/min by 12/3. Which finding will alert the nurse that the goal has been met? a.Heart rate 78 beats/min on 12/3 b.Heart rate 78 beats/min on 12/4 c.Heart rate 80 beats/min on 12/3 d.Heart rate 80 beats/min on 12/4

ANS: A Heart rate 78 beats/min on 12/3 indicates the goal has been met. Comparing expected and actual findings allows you to interpret and judge a patient's condition and whether predicted changes have occurred. Expected outcome states less than 80, not 80. The date is by 12/3, not 12/4.

8. A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next? a.Reassess the patient and situation. b.Revise the turning schedule to increase the frequency. c.Delegate turning to the nursing assistive personnel. d.Apply medication to the area of skin that is broken down.

ANS: A If a nursing diagnosis is unresolved or if you determine that a new problem has perhaps developed, reassessment is necessary. A complete reassessment of patient factors relating to an existing nursing diagnosis and etiology is necessary when modifying a plan. The nurse must assess before revising, delegating and applying medication. The breakdown may be a result of inadequate nutritional intake and medication cannot be applied unless there is an order.

20. The nurse is revising the care plan. In which order will the nurse perform the tasks, beginning with the first step? 1. Revise specific interventions. 2. Revise the assessment column. 3. Choose the evaluation method. 4. Delete irrelevant nursing diagnoses. a.2, 4, 1, 3 b.4, 2, 1, 3 c.3, 4, 2, 1 d.4, 2, 3, 1

ANS: A Modification of an existing written care plan includes four steps: 1. Revise data in the assessment column to reflect the patient's current status. Date any new data to inform other members of the health care team of the time that the change occurred. 2. Revise the nursing diagnoses. Delete nursing diagnoses that are no longer relevant and add and date any new diagnoses. Revise related factors and the patient's goals, outcomes, and priorities. Date any revisions. 3. Revise specific interventions that correspond to the new nursing diagnoses and goals. Be sure that revisions reflect the patient's present status. 4. Choose the method of evaluation for determining whether you achieved patient outcomes.

17. A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided? a."This system can help medical students determine the cost of the care they provide to patients." b."If the nursing department uses this system, communication among nurses who work throughout the hospital may be enhanced." c."We could use this system to help organize orientation for new nursing employees because we can better explain the nursing interventions we use most frequently on our unit." d."The NIC system provides one way to improve safe and effective documentation in the hospital's electronic health record."

ANS: A NIC does not help determine the cost of services provided by nurses. The staff development nurse would need to correct this misconception. Because this system is specific to nursing practice, it would not help medical students determine the costs of care. The NIC system developed by the University of Iowa differentiates nursing practice from that of other health care disciplines. All the other statements are true. Benefits of using NIC include enhancing communication among nursing staff and documentation, especially within health information systems such as an electronic documentation system. NIC also helps nurses identify the nursing interventions they implement most frequently. Units that identify routine nursing interventions can use this information to develop checklists for orientation.

13. Which initial intervention is most appropriate for a patient who has a new onset of chest pain? a.Reassess the patient. b.Notify the health care provider. c.Administer a prn medication for pain. d.Call radiology for a portable chest x-ray.

ANS: A Preparation for implementation ensures efficient, safe, and effective nursing care; the first activity is reassessment. The cause of the patient's chest pain is unknown, so the patient needs to be reassessed before pain medication is administered or a chest x-ray is obtained. The nurse then notifies the patient's health care provider of the patient's current condition in anticipation of receiving further orders. The patient's chest pain could be due to muscular injury or a pulmonary issue. The nurse needs to reassess first.

19. The nurse is intervening for a patient that has a risk for a urinary infection. Which direct care nursing intervention is most appropriate? a.Teaches proper handwashing technique b.Properly cleans the patient's toilet c.Transports urine specimen to the lab d.Informs the oncoming nurse during hand-off

ANS: A Teaching proper handwashing technique is a direct care nursing intervention. All the rest are indirect nursing care: cleaning the toilet, transporting specimens, and performing hand-off reports.

16. A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse's priority when evaluating the patient? a.Identify factors interfering with goal achievement. b.Counsel the nursing assistive personnel on duty when the patient fell. c.Remove the fall risk sign from the patient's door because the patient has suffered a fall. d.Request that the more experienced charge nurse complete the documentation about the fall.

ANS: A When goals and outcomes are not met, you identify the factors that interfere with their achievement. The nurse identifies factors that interfered with goal achievement to determine the cause of the fall. The fall may not have been due to an error by the nursing assistive personnel; therefore, counseling should be reserved until after the cause has been determined. The patient remains a fall risk, so the fall risk sign should remain on the door. The nurse witnessing the fall or the nurse assigned to the patient needs to complete the documentation. The charge nurse can be consulted to review the documentation.

10. A nurse is teaching a patient about meridians. Which technique is the nurse preparing the patient to receive? a. Acupuncture b. Naturopathic c. Latin American traditional healing d. Native American traditional healing

ANS: A Acupuncture regulates or realigns the vital energy (qi), which flows like a river through the body in channels that form a system of 20 pathways called meridians. Naturopathic therapeutics include herbal medicine, nutritional supplementation, physical medicine, homeopathy, lifestyle counseling, and mind-body therapies with an orientation toward assisting the person's internal capacity for self-healing (vitalism). Tribal traditions are individualistic, but similarities across traditions include the use of sweating and purging, herbal remedies, and ceremonies in which a shaman (a spiritual healer) makes contact with spirits to ask their direction in bringing healing to people to promote wholeness and healing. Curanderismo is a Latin American traditional healing system that includes a humoral model for classifying food, activity, drugs, and illnesses and a series of folk illnesses. The goal is to create a balance between the patient and his or her environment, thereby sustaining health.

10. A home health nurse is assembling a puzzle with an older-adult patient and notices that the patient is having difficulty connecting two puzzle pieces. Which aspect of sensory deprivation will the nurse document as being most affected? a. Perceptual b. Cognitive c. Affective d. Social

ANS: A Alterations in spatial orientation and in visual/motor coordination are signs of perceptual dysfunction. Cognitive function is the ability to think and the capacity to learn; the patient is not disoriented or unable to learn. Affective problems include boredom and restlessness; the patient is participating in an activity. The patient is interacting with the home health nurse, so socialization is not a problem.

7. A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with communication and becomes tearful at times. Which intervention will the nurse include in the patient's plan of care? a. Teach the patient about special assistive devices. b. Make the patient talk as much as possible. c. Obtain an order for antidepressant medications. d. Place a consult for a home health nurse.

ANS: A Because a stroke often causes partial or complete paralysis of one side of a patient's body, the patient needs special assistive devices. The nurse should include interventions that help the patient adapt to this deficit while maintaining independence. Teaching the patient to use assistive devices allows the patient to care for him- or herself. Making the patient talk can be inappropriate and demeaning. A home health nurse is not necessary as long as the patient is able to care for him- or herself. Instead of placing the patient on antidepressants, assist the patient in attempting to adapt behavior to the sensory deficit.

2. A teen with an anxiety disorder is referred for biofeedback because the parents do not want their child to take anxiolytics. Which statement from the teen indicates successful learning? a. "Biofeedback will help me with my thoughts and physiological responses to stress." b. "Biofeedback will direct my energies in an intentional way when stressed." c. "Biofeedback will allow me to manipulate my stressed out joints." d. "Biofeedback will let me assess and redirect my energy fields."

ANS: A By using electromechanical instruments, a person can receive information or feedback on his or her stress level. Having this knowledge allows the patient to develop awareness and voluntary control over his or her physiological symptoms. Biofeedback does not address energy fields; healing touch, reiki, and therapeutic touch are energy fields. Directing energies is therapeutic touch. Manipulation of body alignment and joints is done by a chiropractor.

23. A nurse is caring for an older-adult patient on bed rest with potential sensory deprivation. Which action will the nurse take? a. Offer the patient a back rub. b. Hang a "Do not disturb" sign on patient's door. c. Ask the patient "Would you like a newspaper to read?" d. Place the patient in the room farthest from the nurses' station.

ANS: A Comfort measures such as washing the face and hands and providing back rubs improve the quality of stimulation and lessen the chance of sensory deprivation. The patient with sensory deprivation needs meaningful stimuli, and therapeutic massage helps establish a humanistic relationship that the patient is missing. All of the other options do not promote patient-nurse interaction and promote further social isolation.

29. A nurse is caring for a patient with a right hemisphere stroke and partial paralysis. Which action by the nursing assistive personnel (NAP) will cause the nurse to praise the NAP? a. Dressing the left side first b. Dressing the right side first c. Dressing the lower extremities first d. Dressing the upper extremities first

ANS: A Dressing the left side first will be praised by the nurse. If a patient has partial paralysis and reduced sensation, the patient dresses the affected side first; in this case, the left. A stroke on the right hemisphere affects the left side of the body. The right side or upper and lower extremities are not as effective.

14. A new nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient is becoming malnourished because nothing tastes good. Which recommendation by the nurse will be most appropriate for this patient? a. "Rinse your mouth several times a day to hydrate your taste buds." b. "Avoid adding spices or lemon juice to food to prevent nausea." c. "Blend foods together in interesting flavor combinations." d. "Eat soft foods that are easy to chew and swallow."

ANS: A Good oral hygiene keeps the taste buds well hydrated. Having an unpleasant taste in the mouth discourages the patient from eating. Well-seasoned, differently textured food eaten separately heightens taste perception. Avoid blending foods together because this makes it difficult to identify tastes. Texturized, spicy, and aromatic foods stimulate and make eating more enjoyable. Flavored vinegar or lemon juice adds tartness to food.

A hospital's wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient's dressing changes. Which action should the nurses take next? a. Include dressing change instructions and frequency in the care plan. b. Assume that the wound nurse will perform all dressing changes. c. Request that the health care provider look at the wound. d. Encourage the patient to perform the dressing changes.

ANS: A Incorporate the consultant's recommendations into the care plan. The wound nurse clearly recommends that nurses on the unit, not the patient, should continue dressing changes. The nurses should not make a wrong assumption that the wound nurse is doing all the dressing changes. The recommendation states for the nurses to do the dressing changes. If the nurses feel strongly about obtaining another opinion, then the health care provider should be contacted. No evidence in the question suggests that the patient needs a second opinion.

25. The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except location. Which nursing intervention will the nurse add to the care plan to reduce confusion? a. Keep a day-by-day calendar at the patient's bedside. b. Place a patient observer in the patient's room for safety. c. Assess the patient's level of consciousness and document every 4 hours. d. Prepare to discharge once the patient is awake, alert, and oriented.

ANS: A Keeping a calendar in the patient's room helps to orient the patient to the dates. In the home meaningful stimuli include pets, music, television, pictures of family members, and a calendar and clock. The same stimuli need to be present in health care settings. Assessing the patient's level of consciousness is not an action that will directly affect the patient's confusion. A patient observer is unnecessary unless the patient is in danger from the confusion. The nurse should encourage the patient toward recovery but should be sensitive to the time it takes for progression.

4. A patient asks the nurse for a nonmedical approach for excessive worry and work stress. Which therapy should the nurse recommend? a. Meditation b. Acupuncture c. Ayurvedic herbs d. Chiropractic care

ANS: A Meditation is indicated for stress-related illness and is a nonmedical approach. In addition, meditation increases productivity, improves mood, increases sense of identity, and lowers irritability. Acupuncture, ayurvedic, and chiropractic are all medical approaches. The use of ayurvedic herbs has been available for centuries to treat illness and is a type of whole medical system. Acupuncture focuses on redirecting vital energy (qi) in the body's meridian energy lines to influence deeper internal organs. Chiropractic therapy involves manipulation of the spinal column and includes physiotherapy and diet therapy.

5. A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment? a. Impaired night vision b. Difficulty hearing low pitch c. Heightened sense of smell d. Increased taste discrimination

ANS: A Night vision becomes impaired as physiological changes in the aging eye occur. Older adults lose the ability to distinguish high-pitched noises and consonants. Senses of smell and taste are also decreased with aging.

8. The group leader is overheard saying to the gathering of patients, "Focus on your breathing once again .... Notice how it is regular .... Now focus on your left arm .... Notice how relaxed your left arm feels .... Notice the relaxation going down the left arm to the hand." A patient asks the nurse what the group is doing. What is the nurse's best response? a. It is progressive relaxation training. b. It is group biofeedback. c. It is guided imagery. d. It is meditation.

ANS: A Progressive relaxation training teaches the individual how to effectively rest and reduce tension in the body. The technique used in this scenario involves the use of slow, deep abdominal breathing while tightening and relaxing an ordered succession of muscle groups. Although meditation does include abdominal breathing, along with guided imagery and biofeedback, it does not include tightening and relaxing of muscle groups in an ordered succession.

17. A patient is proficient at meditation from long-time use of the technique. Which finding in the medication history will cause the nurse to follow up? a. Takes thyroid-regulating medication b. Takes corticosteroid medication c. Takes loop diuretic medication d. Takes anticoagulant medication

ANS: A Prolonged practice of meditation techniques sometimes reduces the need for antihypertensive, thyroid-regulating, and psychotropic medications (e.g., antidepressants and antianxiety agents). In these cases, adjustment of the medication is necessary. Corticosteroid, loop diuretic, and anticoagulant medications are not affected by meditation.

27. The nurse is caring for a patient who is taking gentamicin for an infection. Which assessment is a priority? a. Hearing b. Vision c. Smell d. Taste

ANS: A Some antibiotics (e.g., streptomycin, gentamicin, and tobramycin) are ototoxic and permanently damage the auditory nerve, whereas chloramphenicol sometimes irritates the optic nerve. Smell and taste are not as affected.

12. A nurse is assessing cognitive functioning of a patient. Which action will the nurse take? a. Administer a Mini-Mental State Examination (MMSE). b. Ask the patient to state name, location, and what month it is. c. Ask the patient's family if the patient is behaving normally. d. Administer the hearing handicap inventory for the elderly (HHIE-S).

ANS: A The MMSE is a formal diagnostic tool that is used to assess a patient's level of cognitive functioning. The Mini-Mental State Examination (MMSE) is a tool you can use to measure disorientation, change in problem-solving abilities, and altered conceptualization and abstract thinking. Asking the patient orientation questions evaluates only the patient's orientation to self and surroundings, not abstract reasoning or critical thinking ability. Family members are not the most reliable source of information about the patient, although information received from the family should be considered. The HHIE-S is a 5-minute, 10-item questionnaire that assesses how the individual perceives the social and emotional effects of hearing loss. The higher the HHIE-S score, the greater the handicapping effect of a hearing impairment.

13. The nurse is using the Snellen chart. Which patient is the nurse assessing? a. A patient who frequently reports the incorrect time from the clock across the room. b. A patient who is having difficulty remembering how to perform familiar tasks. c. A patient who turns the television up as loud as possible. d. A patient who has trouble saying words.

ANS: A The Snellen chart is used to assess vision. Difficulty remembering how to perform familiar tasks indicates the need to further assess mental and cognitive status. Turning the television up louder indicates the need for a hearing assessment. For a patient having trouble saying words a picture board/chart may be used.

A nurse is preparing to make a consult. In which order, beginning with the first step, will the nurse take? 1. Identify the problem. 2. Discuss the findings and recommendation. 3. Provide the consultant with relevant information about the problem. 4. Contact the right professional, with the appropriate knowledge and expertise. 5. Avoid bias by not providing a lot of information based on opinion to the consultant. a. 1, 4, 3, 5, 2 b. 4, 1, 3, 2, 5 c. 1, 4, 5, 3, 2 d. 4, 3, 1, 5, 2

ANS: A The first step in making a consultation is to assess the situation and identify the general problem area. Second, direct the consultation to the right professional such as another nurse or social worker. Third, provide a consultant with relevant information about the problem area and seek a solution. Fourth, do not prejudice or influence consultants. Fifth, be available to discuss a consultant's findings and recommendations.

26. A nurse is establishing a relationship with the patient who is severely visually impaired and is teaching the patient how to contact the nurse for assistance. Which action will the nurse take? a. Place a raised Braille sticker on the call button. b. Explain to the patient that a staff person will stop by once an hour to see if the patient needs anything. c. Instruct the patient to tell a family member to get the attention of the staff. d. Color code the call light system.

ANS: A The nurse should devise a plan of care that is accommodating of the patient's visual deficit. Placing a sticker on the call light allows the patient to page the nurse for assistance as needed. Using family members is not the best option. Making hourly rounds is not sufficient; the nurse needs to ensure that the patient can get in touch at any time. Color coding the call light will not help a severely visually impaired patient.

11. A Native American patient is asking for a spiritual healer. Which person should the nurse try to contact for the patient? a. Shaman b. Vitalist c. Ayurvedic d. Curanderismo

ANS: A Tribal traditions are individualistic, but similarities across traditions include the use of sweating and purging, herbal remedies, and ceremonies in which a shaman (a spiritual healer) makes contact with spirits to ask their direction in bringing healing to people to promote wholeness and healing. Naturopathic therapeutics include herbal medicine, nutritional supplementation, physical medicine, homeopathy, lifestyle counseling, and mind-body therapies with an orientation toward assisting the person's internal capacity for self-healing (vitalism). One of the oldest systems of medicine (Ayurvedic) has been practiced in India since the first century AD. Curanderismo is a Latin American traditional healing system that includes a humoral model for classifying food, activity, drugs, and illnesses and a series of folk illnesses.

17. The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient? a. Speaking with hands, face, and expressions b. Using a loud voice, enunciating every syllable c. Having direct conversation with the patient in the affected ear d. Repeating the phrase again, if the patient does not understand what the nurse said

ANS: A Use visible expressions. Speak with your hands, your face, and your eyes. Do not shout. Speaking in loud tones can distort a patient's ability to hear; the nurse should speak in normal low tones. If the patient does not understand the first time, try rephrasing instead of repeating the message. The nurse can direct conversation toward the patient's unaffected ear.

4. The nurse will be most concerned about the risk of malnutrition for a patient with which sensory deficit? a. Xerostomia b. Dysequilibrium c. Diabetic retinopathy d. Peripheral neuropathy

ANS: A Xerostomia is a decrease in production of saliva; this decreases the ability and desire to eat and can lead to nutritional problems. The other options do not address taste- or nutrition-related concerns. Dysequilibrium is balance. Diabetic retinopathy affects vision. Peripheral neuropathy includes numbness and tingling of the affected areas and stumbling gait.

20. Which patient will cause the nurse to question an order for acupuncture? a. A patient with AIDS b. A patient with osteoarthritis c. A patient with low back pain d. A patient with migraine headaches

ANS: A You need to exercise caution when using acupuncture with pregnant patients and those who have a history of seizures, are carriers of hepatitis, or are immune compromised (AIDS). Acupuncture is a safe therapy for low back pain, migraine headaches, and osteoarthritis.

2. A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.) a.Ambulating a patient b.Inserting a feeding tube c.Performing resuscitation d.Documenting wound care e.Teaching about medications

ANS: A, B, C, E All of the interventions listed (ambulating, inserting a feeding tube, performing resuscitation, and teaching) are direct care interventions involving patient and nurse interaction, except documenting wound care. Documenting wound care is an example of an indirect intervention.

4. Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.) a.Perform dressing changes twice a day as ordered. b.Teach the patient about signs and symptoms of infection. c.Instruct the family about how to perform dressing changes. d.Gently refocus patient from discussing body image changes. e.Administer medications to control the patient's blood sugar as ordered.

ANS: A, B, C, E Nursing priorities include interventions directed at enhancing wound healing. Teaching the patient about signs and symptoms of infection will help the patient identify signs of appropriate wound healing and know when the need for calling the health care provider arises. Performing dressing changes, controlling blood sugars through administration of medications, and instructing the family in dressing changes all contribute to wound healing. As long as a patient is stable and alert, it is appropriate to allow family to assist with care. The patient should be allowed to discuss body image changes.

20. A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient's responses to nursing care? (Select all that apply.) a.Observations of wound healing b.Daily blood pressure measurements c.Findings of respiratory rate and depth d.Completion of nursing interventions e.Patient's subjective report of feelings about a new diagnosis of cancer

ANS: A, B, C, E You examine the results of care by using evaluative measures, which are assessment skills and techniques (e.g., observations, physiological measurements, use of measurement scales, and patient interview). Examples of evaluative measures include assessment of wound healing and respiratory status, blood pressure measurement, and assessment of patient feelings. You conduct evaluative measures to determine if your patients met expected outcomes, not if nursing interventions were completed.

3. A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.) a.Equipment b.Safe environment c.Confidence d.Assistive personnel e.Creativity

ANS: A, B, D A nurse will organize time and resources in preparation for implementing nursing care. Most nursing procedures require some equipment or supplies. Before performing an intervention, decide which supplies you need and determine their availability. Patient care staff (assistive personnel) work together as patients' needs demand it. A patient's care environment needs to be safe and conducive to implementing therapies. Confidence and creativity are needed to provide safe and effective patient care; however, these are critical thinking attitudes, not resources.

30. A home care nurse is inspecting a patient's house for safety issues. Which findings will cause the nurse to address the safety problems? (Select all that apply.) a. Stairway faintly lit b. Bathtub with grab bars c. Scatter rugs in the kitchen d. Absence of smoke alarms e. Low-pile carpeting in the living room f. Level thresholds between bathroom and bedroom

ANS: A, C, D Assess the patient's home for common hazards, including the following: (1) loose area rugs and runner placed over carpeting, (2) poor lighting in stairways, and (3) absence of smoke alarms. Because of reduced depth perception, patients can trip on throw rugs, runners, or the edge of stairs. A bathtub with grab bars is safe and does not need to be addressed. Teach patients and family members to keep all flooring in good repair, and advise them to use low-pile carpeting. Thresholds between rooms need to be level with the floor.

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.) a. Rank all the patient's nursing diagnoses in order of priority. b. Do not change priorities once they've been established. c. Set priorities based solely on physiological factors. d. Consider time as an influencing factor. e. Utilize critical thinking.

ANS: A, D, E By ranking a patient's nursing diagnoses in order of importance and always monitoring changing signs and symptoms (defining characteristics) of patient problems, you attend to each patient's most important needs and better organize ongoing care activities. Prioritizing the problems, or nursing diagnoses, will help the nurse decide which problem to address first. Symptom pattern recognition from your assessment database and certain knowledge triggers help you understand which diagnoses require intervention and the associated time frame to intervene effectively. Planning requires critical thinking applied through deliberate decision making and problem solving. The nurse avoids setting priorities based solely on physiological factors; other factors should be considered as well. The order of priorities changes as a patient's condition and needs change, sometimes within a matter of minutes.

26.The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates effective teaching? a. "You cannot use a pain scale to compare the pain of my patient with the pain of your patient." b. "When patients say they don't need pain medication, they aren't in pain." c. "A patient's behavior is more reliable than the patient's report of pain." d. "Pain assessment scales determine the quality of a patient's pain."

ANS: A. "You cannot use a pain scale to compare the pain of my patient with the pain of your patient." Do not use a pain scale to compare the pain of one patient to that of another. Pain is subjective and cannot be compared to the pain of another patient. Some patients do not express their pain (stoic) or do not wish to take medications to relieve the pain. This does not mean they aren't in pain. A patient's behavior is not more reliable than the patient's report of pain. Pain scales help determine severity or intensity, not quality.

22.The nurse is caring for a 4-year-old child who has pain. Which technique will the nurse use to best assess pain in this child? a. Use the FACES scale. b. Check to see what previous nurses have charted. c. Ask the parents if they think their child is in pain. d. Have the child rate the level of pain on a 0 to 10 pain scale.

ANS: A. Use the FACES scale The FACES scale assesses pain in children who are verbal. Because a 4-year-old is verbal, this is an appropriate scale to use with this child. Assessing pain intensity in children requires special techniques. Young children often have difficulty expressing their pain. Parents' statement of pain is not an effective way to assess pain in children because children's statements are the most important. The 0 to 10 pain scale is too difficult for a 4-year-old child to understand. Previous documentation by nurses will tell you what the child's pain has been but will not tell you the child's current pain intensity.

2. The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching? a.Protocols are guidelines to follow that replace the nursing care plan. b.Protocols assist the clinician in making decisions and choosing interventions for specific health care problems or conditions. c.Protocols are policies designating each nurse's duty according to standards of care and a code of ethics. d.Protocols are prescriptive order forms that help individualize the plan of care.

ANS: B A clinical practice guideline or protocol is a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations. This guideline establishes interventions for specific health care problems or conditions. The protocol does not replace the nursing care plan. Evidence-based guidelines from protocols can be incorporated into an individualized plan of care. A clinical guideline is not the same as a hospital policy. Standing orders contain orders for the care of a specific group of patients. A protocol is not a prescriptive order form like a standing order.

11. The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse's next action? a.Wait and change the dressing at 1800 as ordered. b.Revise the plan of care and change the dressing now. c.Reassess the dressing and the wound in 2 hours. d.Discontinue the plan of care for wound care.

ANS: B Because the dressing is saturated and leaking, the nurse needs to revise the plan of care and change the dressing now. Reflection-in-action involves a nurse's ability to recognize how a patient is responding and then adjusting interventions as a result. A nurse will either change the frequency of an intervention, change how the intervention is delivered, or select a new intervention. Waiting until 1800 or for another 2 hours is not appropriate because assessment data reflect that the dressing is saturated and needs to be changed now. Data are insufficient to support discontinuing the plan of care. Instead, data at this time indicate the need for revision of the plan of care.

18. The nurse is intervening for a family member with role strain. Which direct care nursing intervention is most appropriate? a.Assisting with activities of daily living b.Counseling about respite care options c.Teaching range-of-motion exercises d.Consulting with a social worker

ANS: B Family caregivers need assistance in adjusting to the physical and emotional demands of caregiving. Sometimes they need respite (i.e., a break from providing care). Counseling is an example of a direct care nursing intervention. The other options do not address the identified problem of role strain (activities of daily living and range-of-motion exercises). Consulting is an indirect care nursing intervention.

10. A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take? a.Act as a leader of the health care team. b.Develop good communication skills. c.Work solely with nurses. d.Avoid conflict.

ANS: B Good communication between other health care providers builds trust and is related to the acceptance of your role in the health care team. As a beginning nurse, you will not be considered a leader of the health care team, but your input as an interdisciplinary team member is critical. Interdisciplinary involves other health care providers, not just nurses. Organizational culture includes leadership, communication processes, shared beliefs about the quality of clinical guidelines, and conflict resolution.

13. A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate? a.Health status b.Health behavior c.Psychological self-control d.Health service utilization

ANS: B Health behavior involves demonstrating a psychomotor skill such as self-injection. Health status is a clinical indicator such as exercise tolerance or blood pressure control. The skill is psychomotor, not psychological self-control. Health service utilization is readmission within 30 days or emergency department use.

19. A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks? 1. Revise nursing diagnosis. 2. Reassess blood pressure reading. 3. Retake blood pressure after medication. 4. Administer new blood pressure medication. 5. Change goal to blood pressure less than 140/90. a.1, 5, 2, 4, 3 b.2, 1, 5, 4, 3 c.4, 3, 1, 5, 2 d.5, 4, 5, 1, 2

ANS: B If a nursing diagnosis is unresolved or if you determine that a new problem has perhaps developed, reassessment is necessary. A complete reassessment of patient factors relating to an existing nursing diagnosis and etiology is necessary when modifying a plan. After reassessment, determine which nursing diagnoses are accurate for the situation; revise as needed. When revising a care plan, review the goals and expected outcomes for necessary changes after the diagnosis. Then evaluate and revise interventions as needed.

8. A patient visiting with family members in the waiting area tells the nurse "I don't feel good, especially in the stomach." What should the nurse do? a.Request that the family leave, so the patient can rest. b.Ask the patient to return to the room, so the nurse can inspect the abdomen. c.Ask the patient when the last bowel movement was and to lie down on the sofa. d.Tell the patient that the dinner tray will be ready in 15 minutes and that may help the stomach feel better.

ANS: B In this case, the environment needs to be conducive to completing a thorough assessment. A patient's care environment needs to be safe and conducive to implementing therapies. When you need to expose a patient's body parts, do so privately by closing room doors or curtains because the patient will then be more relaxed; the patient needs to return to the room for an abdominal assessment for privacy and comfort. The family can remain in the waiting area while the nurse assists the patient back to the room. Beginning the assessment in the waiting area (lie down on the sofa) in the presence of family and other visitors does not promote privacy and patient comfort. Telling the patient that the dinner tray is almost ready is making an assumption that the abdominal discomfort is due to not eating. The nurse needs to perform an assessment first.

15. The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using? a.Cognitive b.Interpersonal c.Psychomotor d.Judgmental

ANS: B Nursing practice includes cognitive, interpersonal, and psychomotor skills. Interpersonal skills involve developing trusting relationships with patients, conveying caring and compassion, and communicating clearly. Cognitive skills include critical thinking and decision-making skills. Psychomotor skill requires the integration of cognitive and motor abilities, such as administering the injection. Being judgmental is not appropriate in nursing; nurses are nonjudgmental.

6. The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome? a.The nurse provides assistance while the patient is walking in the hallways. b.The patient is able to ambulate in the hallway with crutches. c.The patient will deny pain while walking in the hallway. d.The patient's level of mobility will improve.

ANS: B The patient's being able to ambulate in the hallway with crutches is an expected outcome of nursing care. The outcomes of nursing practice are the measurable conditions of patient, family or community status, behavior, or perception. These outcomes are the criteria used to judge success in delivering nursing care. The option stating, "The patient's level of mobility will improve" is a broader goal statement. The nurse's assisting a patient to ambulate is an intervention. The patient's denying pain is an expected outcome for pain, not for physical mobility problems.

9. A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? a."Evaluative measures are multiple-page documents used to evaluate nurse performance." b."Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals." c."Evaluative measures are used by quality assurance nurses to determine the progress a nurse is making from novice to expert nurse." d."Evaluative measures are objective views for completion of nursing interventions."

ANS: B You conduct evaluative measures to determine if your patients met expected outcomes, not if nursing interventions were completed. Evaluative measures are assessment skills and techniques. Evaluative measures are not multiple-page documents, and they are used to assess the patient's status, not the nurse's performance or progress from novice to expert.

5. A nurse is getting ready to discharge a patient who has a problem with physical mobility. What does the nurse need to do before discontinuing the patient's plan of care? a.Determine whether the patient has transportation to get home. b.Evaluate whether patient goals and outcomes have been met. c.Establish whether the patient has a follow-up appointment scheduled. d.Ensure that the patient's prescriptions have been filled to take home.

ANS: B You evaluate whether the results of care match the expected outcomes and goals set for a patient before discontinuing a patient's plan of care. The patient needs transportation, but that does not address the patient's mobility status. Whether the patient has a follow-up appointment and ensuring that prescriptions are filled do not evaluate the problem of mobility.

22. The nurse is caring for a group of patients and is monitoring for sensory deprivation. Which patient will the nurse monitor most closely? a. A patient in the ICU under constant monitoring following a myocardial infarction b. A patient on the unit with tuberculosis on airborne precautions c. A patient who recently had a stroke and has left-sided weakness d. A patient receiving hospice care for end-stage lung cancer

ANS: B A group at risk includes patients isolated in a health care setting or at home because of conditions such as active tuberculosis. Sensory deprivation occurs when a person has decreased stimulation and limited sensory input. A patient in isolation (airborne precautions) is at risk for sensory deprivation because of limited exposure to meaningful stimuli. A patient in the ICU would be at risk for sensory overload with all the monitors and visitors. A patient with a stroke may have difficulty with tactile sensation but is not at as high a risk for sensory deprivation as is one in isolation. A patient with lung cancer may have deficits, but hospice is present so the patient is at home with others

19. A nurse is working to prevent blindness. Which preventive action is a priority? a. Screen young adults early for visual impairments. b. Include rubella and syphilis screening in the preconception care plan. c. Instruct parents to report reduced eye contact from their child immediately. d. Administer eye prophylactic antibiotics to newborns within 24 hours after birth.

ANS: B Actions to prevent blindness must occur before vision impairment takes place. Screening for diseases such as rubella, syphilis, chlamydia, and gonorrhea that affect development of vision in the fetus is a preventative measure. Vision testing after birth is important to begin steps to correct or identify the problem early on so the child can develop as normally as possible; waiting until children are young adults is too late. Another technique is administering eye prophylaxis in the form of erythromycin ointment approximately 1 hour after an infant's birth. Reporting reduced eye contact is recommended but is not a preventative measure.

5. A nurse is teaching about the therapy that is more effective in treating physical ailments than in preventing disease or managing chronic illness. Which therapy is the nurse describing? a. Complementary b. Allopathic c. Alternative d. Mind-body

ANS: B Despite the success of allopathic or biomedicine (conventional Western medicine), many conditions such as chronic back and neck pain, arthritis, gastrointestinal problems, allergies, headache, and anxiety continue to be difficult to treat. Complementary, alternative, and mind-body types of medicines can be used in tandem with allopathic medicines but are distinctly different.

13. A nurse is using caring-healing relationships to support whole person/whole systems healing. Which type of nursing is the nurse using? a. Holistic nursing b. Integrative nursing c. Interprofessional nursing d. Complementary and alternative nursing

ANS: B Grounded in six principles, integrative nursing is defined as "a way of being-knowing-doing that advances the health and well-being of persons, families, and communities through caring-healing relationships." Integrative nurses use evidence to inform traditional and emerging interventions that support whole person/whole systems healing. Holistic nursing treats the mind-body-spirit of the patient, using interventions such as relaxation therapy, music therapy, touch therapies, and guided imagery. Integrative health care, a strategy that is gaining popularity, involves interprofessional group practices where patients receive care simultaneously from more than one type of practitioner; nurses must interact with other health care professionals for any type of nursing. An integrative nurse will use complementary and alternative therapies to provide integrative nursing.

18. The home health nurse is caring for a patient with tactile and visual deficits. The nurse is concerned about injury related to inability to feel harmful stimuli and teaches the patient safety strategies to maintain independence. Which action by the patient indicates successful learning? a. Asks the nurse to test the temperature of the water before entering the bath. b. Places colored stickers on faucet handles to indicate temperature. c. Replaces all lace-up shoes with Velcro straps for ease. d. Uses a heating pad on a low setting to keep warm.

ANS: B If a patient with tactile deficits also has a visual impairment, it is important to be sure that water faucets are clearly marked "hot" and "cold," or use color codes (i.e., red for hot and blue for cold). Discourage the use of heating pads in this population. Asking the nurse to test the water does not promote independence, although it does promote safety. Velcro is easier for a patient with a tactile deficit to manipulate and promotes self-care but not safety.

16. The nurse is caring for a patient who is having difficulty understanding the written and spoken word. Which type of aphasia will the nurse report to the oncoming shift? a. Expressive b. Receptive c. Global d. Motor

ANS: B Sensory or receptive aphasia is the inability to understand written or spoken language. A patient is able to express words but is unable to understand questions or comments of others. Expressive aphasia, a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing. Global aphasia is the inability to understand language or communicate orally.

Which action will the nurse take after the plan of care for a patient is developed? a. Place the original copy in the chart, so it cannot be tampered with or revised. b. Communicate the plan to all health care professionals involved in the patient's care. c. File the plan of care in the administration office for legal examination. d. Send the plan of care to quality assurance for review.

ANS: B Setting realistic goals and outcomes often means you must communicate these goals and outcomes to caregivers in other settings who will assume responsibility for patient care. The plan of care communicates nursing care priorities to nurses and other health care professionals. Know also that a plan of care is dynamic and changes as the patient's needs change. All health care professionals involved in the patient's care need to be informed of the plan of care. The plan of care is not sent to the administrative office or quality assurance office.

A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces? a. Administer pain medication every 4 hours as needed. b. Turn the patient every 2 hours, even hours. c. Monitor vital signs, especially rhythm. d. Keep the bed side rails up at all times.

ANS: B The most appropriate intervention for the diagnosis of Impaired skin integrity is to turn the patient. Choose interventions to alter the etiological (related to) factor or causes of the diagnosis. The other options do not directly address the shearing forces. The patient may need pain medication, but Acute pain would be another nursing diagnosis. Monitoring vital signs does not have when or how often these should be done. Keeping the side rails up addresses safety, not skin integrity.

2. Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.) a.Set priorities for patient care. b.Determine whether outcomes or standards are met. c.Ambulate patient 25 feet in the hallway. d.Document results of goal achievement. e.Use self-reflection and correct errors.

ANS: B, D, E The expected outcomes established during planning are the standards against which you judge whether goals have been met and if care is successful. You evaluate whether the results of care match the expected outcomes and goals set for a patient. Documentation and reporting are important parts of evaluation because it is crucial to share information about a patient's progress and current status. Using self-reflection and correcting errors are indicators a nurse is performing evaluation. Setting priorities is part of planning, and ambulating with a patient in the hallway is an intervention, so it is included in the implementation step of the nursing process.

24.A nurse is caring for a patient with chronic pain. Which statement by the nurse indicates an understanding of pain management? a. "This patient says the pain is a 5 but is not acting like it. I am not going to give any pain medication." b. "I need to reassess the patient's pain 1 hour after administering oral pain medication." c. "It wasn't time for the patient's medication, so when it was requested, I gave a placebo." d. "The patient is sleeping, so I pushed the PCA button."

ANS: B. "I need to reassess the patient's pain 1 hour after administering oral pain medication." Be sure to evaluate after an appropriate period of time. For instance, oral medications usually peak in about 1 hour, whereas IVP medications peak in 15 to 30 minutes. Ask a patient if a medication alleviates the pain when it is peaking. Because oral medications usually peak in about an hour, you need to reassess the patient's pain within an hour of administration. Nurses must believe any patient report of pain, even if nonverbal communication is not consistent with pain ratings. The patient is the only person who should push the PCA button. Pushing the PCA when a patient is sleeping is dangerous and may lead to narcotic overdose or respiratory depression. Giving the patient a placebo and telling the patient it is medication is unethical.

25.The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate? a. "Have you considered working with a physical therapist?" b. "What activities, if any, has your pain prevented you from doing?" c. "Would you please rate your pain on a scale from 0 to 10 for me?" d. "When does your pain medication typically take effect on your pain?"

ANS: B. "What activities, if any, has your pain prevented you from doing?" Because the nurse is interested in knowing whether the patient's pain is affecting mobility, the priority assessment question is to ask the patient how the pain affects ability to participate in normal activities of daily living. Although a physical therapist is a good resource to have, especially if pain is severely affecting mobility, considering working with a physical therapist does not describe the effect of pain on the patient's mobility. Assessing quality of pain and effectiveness of pain medication does not help the nurse to understand how it is affecting the patient's mobility.

17.The nurse is caring for a patient to ease modifiable factors that contribute to pain. Which areas did the nurse focus on with this patient? a. Age and gender b. Anxiety and fear c. Culture and ethnicity d. Previous pain experiences and cognitive abilities

ANS: B. Anxiety and fear Some examples of modifiable contributors to pain are anxiety and fear. The nurse can take measures to ease the patient's anxiety and fear related to pain. Age, gender, culture, ethnicity, cognitive abilities, and previous pain experience are all nonmodifiable factors that the nurse can help the patient to understand, but the nurse cannot alter them.

16.A patient who had a motor vehicle crash 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). Which assessment finding indicates effective pain management with the PCA? a. The patient is sleeping and is difficult to arouse. b. The patient rates pain at a level of 2 on a 0 to 10 scale. c. The patient has sufficient medication left in the PCA syringe. d. The patient presses the control button to deliver pain medication.

ANS: B. Patient rates pain at a level of 2 on a 0 to 10 scale A level of 2 on a scale of 0 to 10 is evidence of effective pain management. The effectiveness of pain-relief measures is determined by the patient. If the patient is satisfied with the amount of pain relief, then pain measures are effective. A patient who is sleeping and is difficult to arouse is possibly oversedated; the nurse needs to assess this patient further. The amount of medication left in the PCA syringe does not indicate whether pain management is effective or not. Pressing the button shows that the patient knows how to use the PCA but does not evaluate pain management.

28.The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse's assessment? a. The patient needed a substantial dose of naloxone (Narcan). b. The patient needs increasingly higher doses of opioid to control pain. c. The patient no longer experiences sedation from the usual dose of opioid. d. The patient asks for pain medication close to the time it is due around the clock.

ANS: B. The patient needs increasingly higher doses of opioid to control pain. Opioid tolerance occurs when a patient needs higher doses of an opioid to control pain. Naloxone (Narcan) is an opioid antagonist that is given to reverse the effects of opioid overdose. Taking pain medications regularly around the clock is an effective way to control pain. The pain medication for this patient is most likely effectively managing the patient's pain because the patient is not asking for the medication before it is due. A patient no longer experiencing a side effect (sedation) of an opioid does not indicate opioid tolerance.

7. The nurse is caring for a patient who requires a complex dressing change. While in the patient's room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing? a.Gathers and organizes needed supplies b.Decides on goals and outcomes for the patient c.Assesses the patient's readiness for the procedure d.Calls for assistance from another nursing staff member

ANS: C Always be sure a patient is physically and psychologically ready for any interventions or procedures. After determining the patient's readiness for the dressing change, the nurse gathers needed supplies. The nurse establishes goals and outcomes before intervening. The nurse needs to ask another staff member to help if necessary after determining readiness of the patient.

9. A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially? a.Ask for at least two other assistive personnel to come to the room. b.Medicate the patient to alleviate discomfort while ambulating. c.Review the patient's activity orders. d.Offer the patient a walker.

ANS: C Before beginning care, review the plan to determine the need for assistance and the type required. Before intervening, the nurse must check the patient's orders. For example, if the patient is on bed rest, the nurse will need to explain the use of a bedpan rather than helping the patient get out of bed to go to the bathroom. Asking for assistive personnel is appropriate after making sure the patient can get out of bed. If the patient is obese, the nurse will likely need assistance in getting the patient to the bathroom. Medicating the patient before checking the orders is not advised in this situation. Before medicating for pain, the nurse needs to perform a pain assessment. Offering the patient a walker is a premature intervention until the orders are verified.

12. Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. What is the nurse's first action? a.Follow the clinical protocol for a stroke. b.Review the most recent lab results for the patient's potassium level. c.Assess the patient for other symptoms or problems, and then notify the health care provider. d.Administer an antihypertensive medication from the stock supply, and then notify the health care provider.

ANS: C Communication to other health care professionals must be timely, accurate, and relevant to a patient's clinical situation. The best answer is to reassess the patient for other symptoms or problems, and then notify the health care provider according to the orders. Reviewing the potassium level does not address the problem of high blood pressure. The nurse does not follow the protocol since the order says to notify the health care provider. The orders read to notify the health care provider, not administer medications.

3. A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate? a."An evaluation helps you determine whether all nursing interventions were completed." b."During evaluation, you determine when to downsize staffing on nursing units." c."Nurses use evaluation to determine the effectiveness of nursing care." d."Evaluation eliminates unnecessary paperwork and care planning."

ANS: C Evaluation is a methodical approach for determining if nursing implementation was effective in influencing a patient's progress or condition in a favorable way. During evaluation, you do not simply determine whether nursing interventions were completed. The evaluation process is not used to determine when to downsize staffing or how to eliminate paperwork and care planning.

1. A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse? a.Assessment b.Planning c.Implementation d.Evaluation

ANS: C Implementation, the fourth step of the nursing process, formally begins after a nurse develops a plan of care. With a care plan based on clear and relevant nursing diagnoses, a nurse initiates interventions that are designed to assist the patient in achieving the goals and expected outcomes needed to support or improve the patient's health status. The nurse gathers data during the assessment phase and mutually sets goals and prioritizes care during the planning phase. During the evaluation phase, the nurse determines the achievement of goals and effectiveness of interventions.

16. The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using? a.Cognitive b.Interpersonal c.Psychomotor d.Judgmental

ANS: C Nursing practice includes cognitive, interpersonal, and psychomotor skills. Psychomotor skill requires the integration of cognitive and motor abilities. The nurse in this example displayed the psychomotor skill of inserting an intravenous catheter while following standards of care and integrating knowledge of anatomy and physiology. Cognitive involves the application of critical thinking and use of good judgment in making sound clinical decisions. Interpersonal skills involve developing trusting relationships with patients, conveying caring and compassion, and communicating clearly.

5. A nurse is reviewing a patient's care plan. Which information will the nurse identify as a nursing intervention? a.The patient will ambulate in the hallway twice this shift using crutches correctly. b.Impaired physical mobility related to inability to bear weight on right leg. c.Provide assistance while the patient walks in the hallway twice this shift with crutches. d.The patient is unable to bear weight on right lower extremity.

ANS: C Providing assistance to a patient who is ambulating is a nursing intervention. The statement, "The patient will ambulate in the hallway twice this shift using crutches correctly" is a patient outcome. Impaired physical mobility is a nursing diagnosis. The statement that the patient is unable to bear weight and ambulate can be included with assessment data and is a defining characteristic for the diagnosis of Impaired physical mobility.

14. A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first? a.Reinforce the wound dressing as needed with 4 × 4 gauze. b.Perform the ordered dressing change twice daily. c.Observe wound appearance and edges. d.Document wound characteristics.

ANS: C The most appropriate initial intervention is to assess the wound (observe wound appearance and edges). The nurse must assess the wound first before the findings can be documented, reinforcement of the dressing, and the actual skill of dressing changes.

14. A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal? a."I'm worried about what those other girls will think of me." b."I can't wear that color. It makes my hips stick out." c."I'll wear the blue dress. It matches my eyes." d."I will go to the pool next summer."

ANS: C The nurse is evaluating the improvement in body image. The only positive comment made is that the patient is wearing the blue dress to match her eyes. Worrying about others, making my hips stick out, and going to the pool next summer do not reflect positive changes in body image.

4. After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient's headache. Which action by the nurse is priority for this patient? a.Eliminate headache from the nursing care plan. b.Direct the nursing assistive personnel to ask if the headache is relieved. c.Reassess the patient's pain level in 30 minutes. d.Revise the plan of care.

ANS: C The nurse's priority action for this patient is to evaluate whether the nursing intervention of administering acetaminophen was effective. The nurse does not have enough evaluative data at this point to determine whether headache needs to be discontinued. Assessment is the nurse's responsibility and is not to be delegated to nursing assistive personnel. The nurse does not have enough evaluative data to determine whether the patient's plan of care needs to be revised.

10. The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take? a.Ask the nursing assistive personnel if the wound looks better. b.Document the progress of wound healing as "better" in the chart. c.Measure the wound and observe for redness, swelling, or drainage. d.Leave the dressing off the wound for easier access and more frequent assessments.

ANS: C You examine the results of care by using evaluative measures, which are assessment skills and techniques (e.g., observations, physiological measurements, use of measurement scales, and patient interview). The nurse performs evaluative measures, such as completing a wound assessment, to evaluate wound healing. Nurses do not delegate assessment to nursing assistive personnel. Documenting "better" is subjective and does not objectively describe the wound. Leaving the dressing off for the nurse's benefit of easier access is not a part of the evaluation process.

15. The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis will the nurse include in the care plan to address a safety complication of the sensory deficit? a. Body image disturbance b. Social isolation c. Risk for falls d. Fear

ANS: C A visual disturbance poses great risk for injury due to falling from impaired depth perception and inability to see obstacles. Body image disturbance, social isolation, and fear are all valid nursing diagnoses that apply to a patient with vision deficit; however, they do not address the greatest risk for injury.

7. A patient asks about the new clinic in town that is staffed by allopathic and complementary practitioners. Which response from the nurse is best? a. It is probably an ayurvedic clinic. b. It is probably a homeopathic clinic. c. It is probably an integrative medical clinic. d. It is probably a naturopathic medical clinic.

ANS: C An integrative medical program allows health care consumers to be treated by a team of providers consisting of both allopathic and complementary practitioners. Several therapies are always considered alternative because they are based on completely different philosophies and life systems from those used by allopathic medicine. Alternative therapies include ayurvedic, homeopathic, and naturopathic.

12. A nurse is using the holistic approach to care. Which goal is the priority? a. Integrate spiritual treatments. b. Join physical care with a vegan diet. c. Incorporate the mind-body-spirit connection. d. Use complementary and alternative therapies.

ANS: C Beliefs and values that are consistent with an approach to health that incorporates the mind, body, and spirit comprise the holistic approach. Holistic nursing treats the mind-body-spirit of the patient, using interventions such as relaxation therapy, music therapy, touch therapies, and guided imagery. Spiritual treatments are a part of holistic care but not the priority. A vegan diet is an aspect of dietary treatment, but it does not allow for alternative viewpoints or well-rounded care. A holistic nurse may use complementary and alternative therapies to meet the priority goal of incorporating body-mind-spirit.

14. A nurse is teaching a patient relaxation techniques to decreases stress. Which finding will support the nurse's evaluation that the therapy is effective? a. Dilated pupils b. Increased blood sugar c. Decreased heart rate d. Elevated blood pressure

ANS: C Decreased heart and respiratory rates, blood pressure, and oxygen consumption and increased alpha brain activity and peripheral skin temperature characterize the relaxation response. The physiological cascade of changes associated with the stress response includes increased heart and respiratory rates, muscle tightening, increased metabolic rate, a sense of foreboding, fear, nervousness, irritability, and a negative mood. Other physiological responses include elevated blood pressure; dilated pupils; stronger cardiac contractions; and increased levels of blood glucose, serum cholesterol, circulating free fatty acids, and triglycerides.

8. A patient has both hearing and visual sensory impairments. Which psychological nursing diagnosis will the nurse add to the care plan? a. Risk for falls b. Self-care deficit c. Social isolation d. Impaired physical mobility

ANS: C In focusing on the psychological aspect of care, the nurse is most concerned about social isolation for a patient who may have difficulty communicating owing to visual and hearing impairment. Self-care deficit, impaired physical mobility, and fall risk are physiological risks for the patient.

28. A nurse is teaching a patient about vision. In which order will the nurse describe the pathway for vision, beginning with the first structure? 1. Lens 2. Pupil 3. Retina 4. Cornea 5. Optic nerve a. 2, 1, 4, 5, 3 b. 1, 2, 4, 3, 5 c. 4, 2, 1, 3, 5 d. 5, 2, 4, 1, 3

ANS: C Light rays enter the convex cornea and begin to converge. An adjustment of light rays occurs as they pass through the pupil and lens. Change in the shape of the lens focuses light on the retina. The sensory retina contains the rods and cones (i.e., photoreceptor cells sensitive to stimulation from light). Photoreceptor cells send electrical potentials by way of the optic nerve to the brain

6. A nurse is caring for an older-adult patient who was in a motor vehicle accident because the patient thought the stoplight was green. The patient asks the nurse "Should Istop driving?" Which response by the nurse is most therapeutic? a. "Yes, you should stop driving. As you age, your cognitive function declines, and becoming confused puts everyone else on the road at risk." b. "Yes, you should ask family members to drive you around from now on. Your reflex skills have declined so much you can't avoid an accident." c. "No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is lit up, it means stop, and if the bottom is lit up, it means go." d. "No, instead you should see your ophthalmologist and get some glasses to help you see better."

ANS: C Part of the normal aging process is reduced ability to see colors. The nurse should teach the patient new ways to adapt to this deficit. This patient's accident was not due to impaired cognitive function or reflexes. Glasses will not assist the patient in color discrimination.

18. A patient is taking an antidepressant medication. The nurse discovers that the patient uses herbs. Which herb will cause the nurse to intervene? a. Aloe b. Garlic c. Chamomile d. Saw palmetto

ANS: C Potential drug interactions with chamomile include drugs that cause drowsiness like antidepressants. Aloe, garlic, and saw palmetto do not interfere with antidepressants.

3. A nurse is caring for a patient with presbycusis. Which assessment finding indicates an adaptation to the sensory deficit? a. The patient frequently cleans out eyes with saline washes. b. The patient applies different spices during mealtime to food. c. The patient turns one ear toward the nurse during conversation. d. The patient isolates self from social situations with groups of people.

ANS: C Presbycusis is impaired hearing due to the aging process. Adaptation for a sensory deficit indicates that the patient alters behavior to accommodate for the sensory deficit, such as turning the unaffected ear toward the speaker. Cleaning the eye and applying spices to food would not have an effect for a patient with presbycusis. Avoiding others because of a sensory deficit is maladaptive.

24. The nurse is caring for a patient who is a well-known surgeon at the hospital. The nurse notices the patient becoming more agitated and withdrawn with each group of surgeon visitors. The nurse and patient agree to place a "Do not disturb" sign on the door. A few hours later, the nurse notices a surgeon who is not involved in the patient's care attempting to enter the room. Which response by the nurse is most appropriate? a. Call for security to remove the surgeon. b. Allow the surgeon to enter. c. Firmly explain that the patient does not wish to have visitors at this time. d. Scold the surgeon for not obeying the sign and respecting the patient's wishes.

ANS: C The nurse acts as an advocate for the patient (who is experiencing sensory overload and would benefit from a quiet environment) by firmly and politely asking the surgeon to leave regardless of position in the hospital. A creative solution to decrease excessive environmental stimuli that prevents restful, healing sleep is to institute "quiet time" in ICUs. Data collected from one hospital that implemented 1 hour of quiet time daily found decreased staff and unit noise and improved patient satisfaction. The nurse should not allow anyone to enter unless the patient approves it. Security is not a necessary measure at this time. The nurse should handle the situation with professionalism when addressing the surgeon; scolding the visitor is not appropriate.

9. A therapeutic touch practitioner scans the patient's body. What is the purpose of the practitioner's actions? a. To identify blocked moxibustion b. To identify universal life energy c. To identify energy obstructions d. To identify structural and functional imbalance

ANS: C The practitioner scans the body of the patient with the palms (roughly 2 to 6 inches [5 to 15 cm] from the body) from head to toe. While assessing the energetic biofield of the patient, the practitioner focuses on the quality of the qi and areas of energy obstructions, redirecting the energy to harmonize and move. Chiropractic therapy involves balancing structural and functional imbalance through spinal manipulation. Moxibustion is a traditional Chinese medicine technique that involves burning moxa, a cone or stick of dried herbs that have healing properties, on or near the skin. Reiki therapy transfers "universal life energy."

11. Which assessment question should the nurse ask to best understand how visual alterations are affecting the patient's self-care ability? a. "Have you stopped reading books or switched to books on audiotape?" b. "What do you do to protect yourself from injury at work?" c. "Are you able to prepare a meal or write a check?" d. "How does your vision impairment make you feel?"

ANS: C To best understand how vision is affecting self-care ability, the nurse wants to target questions to encompass what self-care tasks the patient has difficulty doing, such as preparing meals and writing checks. Switching to books on audiotape gives the nurse an idea of the severity of the deficit but not its impact on activities of daily living. Assessing whether the patient is taking measures for protection is important, but this does not address self-care activities. Emotional assessment of a patient is also important but does not properly address the goal of determining the effect of visual alterations on self-care ability.

3. An older-adult patient is newly admitted to a skilled nursing facility with the diagnoses of Alzheimer's dementia, lipidemia, and hypertension, and a history of pulmonary embolism. Medications brought on admission included lisinopril (Zestril, Prinivil), hydrochlorothiazide (Microzide), warfarin (Coumadin), low-dose aspirin, ginkgo biloba, and echinacea. Which potential interaction will cause the nurse to notify the patient's health care provider? a. Echinacea and warfarin b. Lisinopril and echinacea c. Warfarin and ginkgo biloba d. Lisinopril and hydrochlorothiazide

ANS: C Warfarin and blood thinners interact with ginkgo biloba (designed to improve memory). All herbal supplements should be evaluated with current pharmacological medications. The other options do not have interactions with each other.

1. A nurse is administering a vaccine to a child who is visually impaired. After the needle enters the arm, the child says, "Ow, that was sharp!" How will the nurse interpret the finding when the child said that it was sharp? a. The child's sensation is intact. b. The child's reception is intact. c. The child's perception is intact. d. The child's reaction is intact.

ANS: C When a person becomes conscious of a stimulus and receives the information, perception takes place. Perception includes integration and interpretation of stimuli based on the person's experiences. Sensation is a general term that refers to awareness of sensory stimuli through the body's sense mechanisms. Reception begins with stimulation of a nerve cell called a receptor, which is usually for only one type of stimulus such as light, touch, taste, or sound. Reaction is how a person responds to a perceived stimulus.

1. A nurse is implementing interventions for a group of patients. Which actions are nursing interventions? (Select all that apply.) a.Order chest x-ray for suspected arm fracture. b.Prescribe antibiotics for a wound infection. c.Reposition a patient who is on bed rest. d.Teach a patient preoperative exercises. e.Transfer a patient to another hospital unit.

ANS: C, D, E A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. Repositioning, teaching, and transferring a patient are examples of nursing interventions. Ordering a chest x-ray and prescribing antibiotics are examples of medical interventions performed by a health care provider.

A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which information should the nurse include in the teaching session? (Select all that apply.) a. Includes seven domains for level 1 b. Uses an easy 3-point Likert scale c. Adds objectivity to judging a patient's progress d. Allows choice in which interventions to choose e. Measures nursing care on a national and international level

ANS: C, E Nursing Outcomes Classification (NOC) links outcomes to NANDA International nursing diagnoses. Such a rating system adds objectivity to judging a patient's progress. Using standardized nursing terminologies such as NOC makes it more possible to measure aspects of nursing care on a national and international level. The indicators for each NOC outcome allow measurement of the outcomes at any point on a 5-point Likert scale from most negative to most positive. This resource is an option you can use in selecting goals and outcomes (not interventions) for your patients. The Nursing Interventions Classification model includes three levels: domains, classes, and interventions for ease of use. The seven domains are the highest level (level 1) of the model, using broad terms (e.g., safety and basic physiological) to organize the more specific classes and interventions.

20.The nurse has brought a patient the scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic? a. "This medication will still be providing you relief at the time of your dressing change." b. "OK, swallow this pain pill, and I will return in a minute to change your dressing." c. "Would you like medication to be given for dressing changes in addition to your regularly scheduled medication?" d. "Your medication is scheduled for this time, and I can't adjust the time for you. I'm sorry, but you must take your pill right now."

ANS: C. "Would you like medication to be given for dressing changes in addition to your regularly scheduled medication?" Additional doses of medication can be given to patients in certain circumstances, as with an extensive dressing change, when the health care provider is notified that more medication is needed. It is the nurse's responsibility to communicate with the provider and with the patient about a pain-control plan that works for both. By asking to hold off on the dose, the patient is indicating that the dressing changes are extremely painful. The regularly scheduled dose might not be as effective for the patient 2 hours later when the dressing change is scheduled. Oral medications take 30 to 60 minutes to take effect. If the nurse began the dressing change right then, the medication would not have been absorbed yet. The patient has the right to refuse to take a medication.

21.A nurse receives an order from a health care provider to administer hydrocodone and acetaminophen (Vicodin ES 7.5/750), to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurse's next best action? a. Give the Vicodin ES to the patient immediately because the patient is experiencing severe pain. b. Ask the health care provider for a nonsteroidal antiinflammatory drug (NSAID) order. c. Ask the health care provider to verify the dosage and frequency of the medication. d. Give the Vicodin ES in addition to playing soothing music for the patient.

ANS: C. Ask the health care provider to verify the dosage and frequency of the medication. The maximum 24-hour dosage for acetaminophen is 4 grams. If the patient took 2 tablets of Vicodin ES every 6 hours, the patient would take in 6 grams of acetaminophen in 24 hours (2 tablets = 750 + 750 = 1500 4 [could have 4 doses in 24 hours every 6 hours] = 6000 mg = 6 g). This exceeds the safe dosage of acetaminophen, so the best action is to question this order. Giving the medication as ordered would possibly result in the patient's taking more acetaminophen than is considered a safe dose. Acetaminophen overdose can result in liver failure. NSAIDs are used to treat mild to moderate pain. At this moment, the patient is experiencing severe pain. Implementing music therapy is a nursing intervention and is an independent nursing action that can be instituted with pain medication, but the possible acetaminophen dose is the priority.

18.The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which finding best indicates the effectiveness of guided imagery? a. The patient's facial expressions are stoic during the procedure. b. The patient rates pain during the dressing change as a 6 on a scale of 0 to 10. c. The patient's need for analgesic medication decreases during the dressing changes. d. The patient asks for pain medication during the dressing changes only once throughout the procedure.

ANS: C. The patients need for analgesic medication decreases during the dressing changes If the patient needs less pain medication during dressing changes, then guided imagery is helping to manage the patient's pain. The purpose of guided imagery is to allow the patient to alter the perception of pain. Guided imagery works in conjunction with analgesic medications, potentiating their effects. A rating of 6 on a 0 to 10 scale indicates that the patient is having moderate pain and shows that this patient is not experiencing pain relief at this time. A person who is stoic is not showing feelings, which makes it difficult to know whether or not the patient is experiencing pain. Having to ask for pain medication during the dressing changes indicates the guided imagery is not effective.

11. Which action should the nurse take first during the initial phase of implementation? a.Determine patient outcomes and goals. b.Prioritize patient's nursing diagnoses. c.Evaluate interventions. d.Reassess the patient.

ANS: D Assessment is a continuous process that occurs each time the nurse interacts with a patient. During the initial phase of implementation, reassess the patient. Determining the patient's goals and prioritizing diagnoses take place in the planning phase before choosing interventions. Evaluation is the last step of the nursing process.

1. A nurse determines that the patient's condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting? a.Assessment b.Planning c.Implementation d.Evaluation

ANS: D Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the first four steps of the nursing process, a patient's condition or well-being improves and if goals have been met. Assessment, the first step of the process, includes data collection. Planning, the third step of the process, involves setting priorities, identifying patient goals and outcomes, and selecting nursing interventions. During implementation, nurses carry out nursing care, which is necessary to help patients achieve their goals.

2. A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next? a.Assessment b.Planning c.Implementation d.Evaluation

ANS: D Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the first four steps of the nursing process, a patient's condition or well-being improves. Assessment involves gathering information about the patient. During the planning phase, patient outcomes are determined. Implementation involves carrying out appropriate nursing interventions.

17. A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal? a.No sputum or cough present in 4 days b.Congestion throughout all lung fields in 2 days c.Shallow, fast respirations 30 breaths per minute in 1 day d.Lungs clear to auscultation following use of inhaler

ANS: D In this case, the patient's goal is to not experience shortness of breath with activity in 3 days. If the lung sounds are clear following use of inhaler, the nurse can determine that the patient is making progress toward achieving the expected outcome. One way for the nurse to evaluate the expected outcome is to assess the patient's lung sounds. Goals are broad statements that describe changes in a patient's condition or behavior. Expected outcomes are measurable criteria used to evaluate goal achievement. When an outcome is met, you know that the patient is making progress toward goal achievement. The time frame of 4 days in the first option is not appropriate because this time frame exceeds the time frame stated in the goal. Congestion indicates fluid in the lungs, and a respiratory rate of 30 breaths per minute is elevated/abnormal. This indicates that the patient is still probably experiencing shortness of breath and secretions in the lungs.

15. A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion? a.Patient wanders halls at night. b.Patient's side rails are up with bed alarm activated. c.patient denies pain while ambulating with assistance. d.Patient correctly states names of family members in the room.

ANS: D The goal for this patient would address a decrease or absence of confusion. Thus, one possible sign that a patient's confusion is improving is seen when a patient can correctly state the names of family members in the room. You examine the results of care by using evaluative measures that relate to goals and expected outcomes. Keeping the side rails up and using a bed alarm are interventions to promote patient safety and prevent falls. The patient's denying pain indicates positive progress toward resolving pain. The patient's wandering the halls is a sign of confusion.

6. A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority? a.Assist the patient to walk in the room with crutches. b.Obtain a walker for the patient. c.Consult physical therapy. d.Administer pain medication.

ANS: D The patient's pain is a 7, indicating the priority is pain relief (administer pain medication). Acute pain is the priority because the nurse can address the problem of immobility after the patient receives adequate pain relief. Assisting the patient to walk or obtaining a walker will not address the pain the patient is experiencing.

7. The nurse is evaluating whether a patient's turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule? a.Staff documentation of turning the patient every 2 hours b.Presence of redness only on the heels of the patient c.Patient's eating 100% of all meals d.Absence of skin breakdown

ANS: D To determine whether a turning schedule is successful, the nurse needs to assess for the presence of skin breakdown. Redness on any part of the body, including only the patient's heels, indicates that the turning schedule was not successful. Documentation of interventions does not evaluate whether patient outcomes were met. Eating 100% of meals does not evaluate the effectiveness of a turning schedule.

19. A nurse is teaching a patient about the use of biofeedback. Which goal should the nurse add to the care plan? a. Opens emotional channels b. Uses music to calm the mind c. Holds various postures with breathing d. Controls autonomic physiological functions

ANS: D Biofeedback is a process providing a person with visual or auditory information about autonomic physiological functions of the body such as muscle tension, skin temperature, and brain wave activity through the use of instruments. Breathwork can open emotional channels. Music therapy uses music to address physical, psychological, cognitive, and social needs of certain individuals. Yoga focuses on body musculature, holding of postures, and proper breathing mechanisms.

1. A patient describes practicing a complementary and alternative therapy involving breathwork and yoga. The nurse also recommends using energy field therapies. Which techniques did the nurse suggest? a. Prayer and tai chi b. The "zone" and acupressure c. Massage therapy and ayurveda d. Reiki therapy and therapeutic touch

ANS: D Both yoga and breathwork are mind-body therapies, whereas both reiki and therapeutic touch therapies are energy field therapies. Tai chi is mind-body intervention. Acupressure and massage are body-based methods. Ayurvedic is a type of whole medical system.

20. The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over the inability to sleep. Which action by the nurse is most appropriate for this patient? a. Administer an opioid medication to help the patient sleep. b. Keep the door open during the night. c. Open the shades at night. d. Provide the patient with earplugs.

ANS: D Control of excessive stimuli becomes an important part of a patient's care; earplugs provide relief. Quiet time means dimming the lights throughout the unit, closing the shades, and shutting the doors. Allow patients to shut their room door to decrease noise. Opioid medications (for pain relief) should not be the first option; however, antianxiety medications and sleep aids may be considered.

21. The nurse is caring for a patient with expressive aphasia from a traumatic brain injury. Which goal will the nurse include in the plan of care? a. Patient will carry a pen and a pad of paper around for communication. b. Patient will recover full use of speech vocabulary in 1 day. c. Patient will thicken drinks to prevent aspiration. d. Patient will communicate nonverbally.

ANS: D Expressive aphasia, a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing. To adapt to expressive aphasia, the nurse and the patient need to work on ways to communicate nonverbally through means such as pointing and gestures. Goals and outcomes need to be realistic and measurable; recovery in 1 day is not realistic. A patient who has expressive aphasia may not be able to speak or write words with a pen and paper. Thickening drinks prevents aspiration risk and is not included in a plan of care for this patient.

6. During a relaxation therapy skills group, the instructor discusses the cognitive skill of learning to tolerate uncertain and unfamiliar experiences. Which skill is the nurse describing? a. Passivity b. Focusing c. Mindfulness d. Receptivity

ANS: D Receptivity is defined as the ability to tolerate and accept experiences that are uncertain, unfamiliar, or paradoxical. Passivity is the ability to stop unnecessary goal-directed and analytical activity. Focusing is the ability to identify, differentiate, maintain attention on, and return attention to simple stimuli for an extended period. Mindfulness is not a cognitive skill needed in relaxation therapy but is needed for meditation

A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls? a. Keep all side rails down at all times. b. Encourage patient to remain in bed most of the shift. c. Place patient in room away from the nurses' station if possible. d. Assist patient into and out of bed every 4 hours or as tolerated.

ANS: D Risk for falls is a risk (potential) nursing diagnosis; therefore, the nurse needs to implement actions that will prevent a fall. Assisting the patient into and out of bed is the most appropriate intervention to prevent the patient from falling. Encouraging activity builds muscle strength, and helping the patient with transfers ensures patient safety. Encouraging the patient to stay in bed will not promote muscle strength. Decreased muscle strength is the risk factor placing the patient in jeopardy of falling. The side rails should be up, not down, according to agency policy. This will remind the patient to ask for help to get up and will keep the patient from rolling out of bed. The patient should be placed near the nurses' station, so a staff member can quickly get to the room and assist the patient if necessary.

15. A nurse is providing different types of therapies to a patient with excessive fatigue and cancer. Which technique will cause the nurse manager to intervene? a. Meditation b. Guided imagery c. Passive relaxation d. Active progressive relaxation

ANS: D The nurse manager needs to intervene if the nurse uses active progressive relaxation. Active progressive relaxation is not appropriate for patients with advanced disease or decreased energy reserves. Passive relaxation or guided imagery or meditation is more appropriate for these individuals.

16. A nurse is emphasizing the use of touch to decrease "skin hunger" in caring for patients. Which age group is the nurse primarily describing? a. Infants b. Children c. Middle age d. Older adults

ANS: D Touch is a primal need, as necessary as food, growth, or shelter. Touch is like a nutrient transmitted through the skin, and "skin hunger" is like a form of malnutrition that has reached epidemic proportions in the United States, especially among older adults. While infants, children, and middle age may be affected, it is the older adult who is most affected.

9. During an assessment of a patient, the nurse finds the patient experiences vertigo. Which sensory deficit will the nurse assess further? a. Neurological deficit b. Visual deficit c. Hearing deficit d. Balance deficit

ANS: D Vertigo is a result of vestibular dysfunction and often is precipitated by a change in head position. Neurological deficits include peripheral neuropathy and stroke. Visual deficits include presbyopia, cataracts, glaucoma, and macular degeneration. Hearing deficits include presbycusis and cerumen accumulation.

2. A nurse is describing the transmission of sound to a patient. In which order will the nurse list the pathway of sound, beginning with the first structure? 1. Eardrum 2. Perilymph 3. Oval window 4. Bony ossicles 5. Eighth cranial nerve a. 1, 5, 2, 4, 3 b. 1, 3, 4, 2, 5 c. 1, 2, 4, 5, 3 d. 1, 4, 3, 2, 5

ANS: D Vibration of the eardrum transmits through the bony ossicles. Vibrations at the oval window transmit in perilymph within the inner ear to stimulate hair cells that send impulses along the eighth cranial nerve to the brain.

19.A nurse is providing medication education to a patient who just started taking ibuprofen. Which information will the nurse include in the teaching session? a. Ibuprofen helps to depress the central nervous system to decrease pain perception. b. Ibuprofen reduces anxiety, which will help you cope with your pain. c. Ibuprofen binds with opiate receptors to reduce your pain. d. Ibuprofen inhibits the production of prostaglandins.

ANS: D. Ibuprofen inhibits the production of prostaglandins NSAIDs like ibuprofen likely work by inhibiting the synthesis of prostaglandins to inhibit cellular responses to inflammation. Ibuprofen does not depress the central nervous system, nor does it enhance coping with pain. Opioids bind with opiate receptors to modify perceptions of pain.

27.The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first? a. The patient who needs to be premedicated before walking b. The patient who has a PCA running that needs the syringe replaced c. The patient who needs to take a scheduled dose of maintenance pain medication d. The patient who is experiencing 8/10 pain and has an immediate order for pain medication

ANS: D. The patient who is experiencing 8/10 pain and has an immediate order for pain medication Immediate (STAT) medications need to be given as soon as possible. In addition, this patient is the priority because of the report of severe pain. The other patients need pain medication, but their situations are not as high a priority as that of the patient with the STAT medication order.

15.A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." Which type of pain does the nurse document the patient is having at this time? a. Superficial pain b. Idiopathic pain c. Chronic pain d. Visceral pain

ANS: D. Visceral pain Visceral pain arises from visceral organs, such as those from the gastrointestinal tract. Visceral pain is diffuse and radiates in several directions and can have a burning quality. Superficial pain has a short duration and is usually a sharp pain arising from the skin. Pain of an unknown cause is called idiopathic pain. Chronic pain lasts longer than 6 months.

9. A nurse has already set the agenda during a patient-centered interview. What will the nurse do next? a.Begin with introductions. b.Ask about the chief concerns or problems. c.Explain that the interview will be over in a few minutes. d.Tell the patient "I will be back to administer medications in 1 hour."

Ask about the chief concerns or problems

3. After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? a.Administer scheduled medications assuming that the NAP would have reported abnormal vital signs. b.Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return. c.Ask the NAP to record the patient's vital signs before administering medications. d.Omit the vital signs because the patient is presently in no distress.

Ask the NAP to record the patient's vital signs before administering medications

17. A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's initial action in response to these observations? a.Proceed to the next patient's room to make rounds. b.Determine the patient does not want any pain medicine. c.Ask the patient about the facial grimacing with movement. d.Administer the pain medication ordered for moderate to severe pain.

Ask the patient about the facial grimacing with movement.

12. While the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take? a.Tell the patient to just focus on the leg and cast right now. b.Document the sleep patterns and information in the patient's chart. c.Explain that a more thorough assessment will be needed next shift. d.Ask the patient about usual sleep patterns and the onset of having difficulty resting.

Ask the patient about usual sleep patterns and the onset of having difficulty resting

16. While completing an admission database, the nurse is interviewing a patient who states "I am allergic to latex." Which action will the nurse take first? a.Immediately place the patient in isolation. b.Ask the patient to describe the type of reaction. c.Proceed to the termination phase of the interview. d.Document the latex allergy on the medication administration record.

Ask the patient to describe the type of reaction.

A nurse is teaching a patient about patient-controlled analgesia (PCA). Which statement made by the patient indicates to the nurse that teaching is effective? a. "I will only need to be on this pain medication." b. "I feel less anxiety about the possibility of overdosing." c. "I can receive the pain medication as frequently as I need to." d. "I need the nurse to notify me when it is time for another dose."

B. "I feel less anxiety about the possibility of overdosing" A PCA is a device that allows the patient to determine the level of pain relief delivered, reducing the risk of overdose. The PCA infusion pumps are designed to deliver a specific dose that is programmed to be available at specific time intervals (usually in the range of 8 to 15 minutes) when the patient activates the delivery button. A limit on the number of doses per hour or 4-hour interval may also be set. This can help decrease a patient's anxiety related to possible overdose. Its use also often eases anxiety because the patient is not reliant on the nurse for pain relief. Other medications, such as oral analgesics, can be given in addition to the PCA machine. One benefit of PCA is that the patient does not need to rely on the nurse to administer pain medication; the patient determines when to take the medication.

A nurse is attempting to administer an oral medication to a child, but the child refuses to take the medication. A parent is in the room. Which statement by the nurse to the parent is best? A. "Please hold your child's arms down, so I can give the full dose." B. "I will prepare the medication for you and observe if you would like to try to administer the medication." C. "Let's turn the lights off and give your child a moment to fall asleep before administering the medication." D. "Since your child loves applesauce, let's add the medication to it, so your child doesn't resist."

B. "I will prepare the medication for you and observe if you would like to try to administer the medication." Children often have difficulties taking medication, but it can be less traumatic for the child if the parent administers the medication and the nurse supervises. -Another nurse should help restrain a child if needed; the parent acts as a comforter, not a restrainer. -Holding down the child is not the best option because it may further upset the child. -Never administer an oral medication to a sleeping child. -Don't mix medications into the child's favorite foods, because the child might start to refuse the food.

A nurse is teaching a patient about medications. Which statement from the patient indicates teaching is effective? A. "My parenteral medication must be taken with food." B. "I will rotate the sites in my left leg when I give my insulin." C. "Once I start feeling better, I will stop taking my antibiotic." D. "If I am 30 minutes late taking my medication, I should skip that dose."

B. "I will rotate the sites in my left leg when I give my insulin." Instrasite rotation (Rotating injections within the same body part) provides greater consistency in absorption of medication

A patient prefers not to take the daily allergy pill this morning because it causes drowsiness throughout the day. Which response by the nurse is best? A. "The physician ordered it; therefore, you must take your medication every morning at the same time whether you're drowsy or not." B. "Let's see if we can change the time you take your pill to 9 PM, so the drowsiness occurs when you would normally be sleeping." C. "You can skip this medication on days when you need to be awake and alert." D. "Try to get as much done as you can before you take your pill, so you can sleep in the afternoon."

B. "Let's see if we can change the time you take your pill to 9 PM, so the drowsiness occurs when you would normally be sleeping."

A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment. Which of the following statements made by the new graduate nurse requires the preceptor to intervene? A. "I will use the information from my assessment to figure out if your antihypertensive medication is working effectively." B. "Nursing assessment data are used only to provide information about the effectiveness of your medical care." C. "Nurses use data from their patient's physical assessment to determine a patient's educational needs." D. "Information gained from physical assessment helps nurses better understand their patients' emotional needs." ANS: B

B. "Nursing assessment date are used only to provide information about the effectiveness of your medical care."

The patient is to receive phenytoin (Dilantin) at 0900. When will be the ideal time for the nurse to schedule a trough level? A. 0800 B. 0830 C. 0900 D. 0930

B. 0830 TROUGH levels are generally drawn 30 minutes before the drug is administered.

A health care provider orders lorazepam (Ativan) 1 mg orally 2 times a day. The dose available is 0.5 mg per tablet. How many tablet(s) will the nurse administer for each dose? A. 1 B. 2 C. 3 D. 4

B. 2

Which patient using an inhaler would benefit most from using a spacer? A. A 15 year old with a repaired cleft palate who is alert B. A 25 year old with limited coordination of the extremities C. A 50 year old with hearing impairment who uses a hearing aid D. A 72 year old with left-sided hemiparesis using a dry powder inhaler

B. A 25 year old with limited coordination of the extremities A spacer is indicated for a patient who has difficulty coordinating the steps, like patients with limited mobility/coordination.

A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. When performing an abdominal assessment, the nurse should A. Recommend that the patient take more laxatives. B. Ask the patient about the color of her stools. C. Avoid sexual references such as possible pregnancy. D. Assess first the spots that are most tender.

B. Ask the patient about the color of her stools.

1.An oriented patient has recently had surgery. Which action is best for the nurse to take to assess this patient's pain? a. Assess the patient's body language. b.Ask the patient to rate the level of pain. c.Observe the cardiac monitor for increased heart rate. d.Have the patient describe the effect of pain on the ability to cope.

B. Ask the patient to rate the level of pain One of the most subjective and therefore most useful characteristics for reporting pain is its severity. Therefore, the best way to assess a patient's pain is to ask the patient to rate the pain. Nonverbal communication, such as body language, is not as effective in assessing pain, especially when the patient is oriented. Heart rate sometimes increases when a patient is in pain, but this is not a symptom that is specific to pain. Pain sometimes affects a patient's ability to cope, but assessing the effect of pain on coping assesses the patient's ability to cope; it does not assess the patient's pain.

A nurse is performing the three accuracy checks before administering an oral liquid medication to a patient. When will the nurse perform the second accuracy check? A. At the patient's bedside B. Before going to the patient's room C. When checking the medication order D. When selecting medication from the unit-dose drawer

B. Before going to the patient's room

During a routine physical examination of a 70-year-old patient, a blowing sound is auscultated over the carotid artery. The nurse notifies the medical provider of the unexpected physical finding known as A. Clubbing. B. Bruit. C. Right-sided heart failure. D. Phlebitis.

B. Bruit.

While assessing the skin of an 82-year-old male patient, a nurse discovers nonpainful ruby red papules on the patient's trunk. What is the nurse's next action? A. Explain that the patient has basal cell carcinoma and should watch for spread. B. Document cherry angiomas as a normal geriatric skin finding. C. Tell the patient that he has a benign squamous cell carcinoma. D. Document the presence of edema.

B. Document cherry angiomas as a normal geriatric skin finding.

During a preschool readiness examination, the nurse prepares to perform visual acuity screenings. Given the children's age, the best equipment to test central vision is which of the following? A. Snellen test B. E chart C. Reading test D. Penlight

B. E chart

A patient is at risk for aspiration. Which nursing action is most appropriate? A. Give the patient a straw to control the flow of liquids. B. Have the patient self-administer the medication. C. Thin out liquids so they are easier to swallow. D. Turn the head toward the stronger side.

B. Have the patient self-administer the medication. -Aspiration occurs when food, fluid, or medication intended for GI administration inadvertently enters the respiratory tract. -To minimize aspiration risk, allow the patient, if capable, to self-administer medication. -Patients should also hold their own cup to control how quickly they take in fluid. -Some patients at risk for aspiration may require thickened liquids; thinning liquids does not decrease aspiration risk. -Patients at risk for aspiration should not be given straws because use of a straw decreases the control the patient has over volume intake. -Turning the head toward the weaker side helps the medication move down the stronger side of the esophagus.

A patient is receiving vancomycin. Which function is the priority for the nurses to assess? A. Vision B. Hearing C. Heart tones D. Bowel sounds

B. Hearing A side effect of vancomycin is ototoxicity—hearing.

A patient is in need of immediate pain relief for a severe headache. Which medication will the nurse administer to be absorbed the quickest? A. Acetaminophen 650 mg PO B. Hydromorphone 4 mg IV C. Ketorolac 8 mg IM D. Morphine 6 mg SQ

B. Hydromorphone 4 mg IV IV is the fastest route for absorption owing to the increase in blood flow. The richer the blood supply to the site of administration, the faster a medication is absorbed. Medications administered intravenously enter the bloodstream and act immediately, whereas those given in other routes take time to enter the bloodstream and have an effect.

34.The nurse is caring for an infant in the intensive care unit. Which information should the nurse consider when planning care for this patient? a. Infants cannot be assessed for pain. b. Infants respond behaviorally and physiologically to painful stimuli. c. Infants cannot tolerate analgesics owing to an underdeveloped metabolism. d. Infants have a decreased sensitivity to pain when compared with older children.

B. Infants respond behaviorally and physiologically to painful stimuli Infants cannot verbally express their pain, but they do express pain with behavioral cues (facial expressions, crying) and physiological indicators (changes in vital signs). Infants can tolerate analgesics, but proper dosing and close monitoring are essential. Infants and older children have the same sensitivity to pain. Pain can be assessed even though the neonate cannot verbalize; the nurse can observe behavioral clues. Nurses use behavioral cues and physiological responses to assess pain in infants.

An elderly patient is being seen for a chronic entropion. The nurse realizes that entropion places the patient at risk for which of the following? A. Ectropion B. Infection C. Exophthalmos D. Strabismus

B. Infection

7.A patient is receiving opioid medication through an epidural infusion. Which action will the nurse take? a. Restrict fluid intake. b. Label the tubing that leads to the epidural catheter. c. Apply a gauze dressing to the epidural catheter insertion site. d. Ask the nursing assistive personnel to check on the patient at least once every 2 hours.

B. Label the tubing that leads to the epidural catheter To reduce the accidental administration of IV medications into the epidural catheter, the tubing that leads to the epidural catheter needs to be labeled clearly. The epidural insertion site needs to be covered by a transparent dressing to prevent infection and allow the nurse to assess the site. Patients receiving epidural anesthesia need to be monitored every 15 minutes until stabilized and then at least hourly for 12 to 24 hours.

A nurse is administering oral medications to patients. Which action will the nurse take? A. Remove the medication from the wrapper, and place it in a cup labeled with the patient's information. B. Place all of the patient's medications in the same cup, except medications with assessments. C. Crush enteric-coated medication, and place it in a medication cup with water. D. Measure liquid medication by bringing liquid medication cup to eye level.

B. Place all of the patient's medications in the same cup, except medications with assessments. Placing medications that require preadministration assessment in a separate cup serves as a reminder to check before the medication is given, making it easier for the nurse to withhold medication if necessary. -Medications should not be removed from their package until they are in the patient's room because this makes identification of the pill easier and reduces contamination. -When measuring a liquid, the nurse should use the meniscus level to measure; make sure it is at eye level on a hard surface like a countertop. -Enteric coated medications should not be crushed.

During a genitourinary examination of a 30-year-old male patient, the nurse identifies a small amount of a white, thick substance on the patient's uncircumcised glans penis. The nurse's next step is to A. Notify his provider about a suspected STI. B. Recognize this as a normal finding. C. Tell the patient to avoid doing self-examinations until symptoms clear. D. Avoid embarrassing questions about sexual activity.

B. Recognize this as a normal finding.

The nurse is caring for two patients with the same last name. In this situation which right of medication administration is the priority to reduce the chance of an error? A. Right medication B. Right patient C. Right dose D. Right route

B. Right patient

13.A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. Which nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider? a. Reassures the patient that the provider will come to the emergency department soon b. Softly plays music that the patient finds relaxing c. Frequently reassesses the patient's pain scores d. Teaches the patient how to do yoga

B. Softly plays music that the patient finds relaxing The appropriate nonpharmacological pain-management intervention is to quietly play music that the patient finds relaxing. Music diverts a person's attention away from pain and creates relaxation. Reassessing the patient's pain scores is done during evaluation. Building the patient's expectation of the provider's arrival does not address the patient's pain. Although yoga promotes relaxation, nurses teach relaxation techniques only when a patient is not experiencing acute pain. Because the patient is having acute pain, this is not an appropriate time to provide patient teaching.

33.A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. The patient describes the pain as throbbing. Which type of pain does the nurse document in this patient's medical record? a. Visceral pain b. Somatic pain c. Centrally generated pain d. Peripherally generated pain

B. Somatic pain Somatic pain comes from bone, joint, connective tissue, or muscle. Visceral pain arises from the visceral (internal) organs such as the GI tract and pancreas. Peripherally generated pain in the peripheral nerves can be caused by polyneuropathies or mononeuropathies. Centrally generated pain results from injury to the central or peripheral nervous system, causing deafferentation or sympathetically maintained pain.

11.A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient's behavior? a. The surgery successfully cured the patient's pain. b. The patient's culture is possibly influencing the patient's experience of pain. c. The primary health care provider did not prescribe the correct amount of medication. d. The nurse is allowing personal beliefs about pain to influence pain management at this time.

B. The patients culture is possibly influencing the patients experience of pain A patient's culture or beliefs about pain often influence the patient's expression of pain. In this case, the patient has just had surgery, and the nurse knows that this surgical procedure usually causes patients to experience pain. It is important at this time for the nurse to examine cultural and ethnic factors that are possibly affecting the patient's lack of expression of pain at this time. Even if surgery corrects neurological factors that create chronic pain, surgery causes pain in the acute period. The patient has not taken any pain medication so this is an unrealistic assumption; most pain medications have standard dosages. The nurse is not allowing personal beliefs to influence pain management because the nurse is attempting to determine the reason why the patient is not verbalizing the experience of pain.

The nurse is giving an IM injection. Upon aspiration, the nurse notices blood return in the syringe. What should the nurse do? A. Administer the injection at a slower rate. B. Withdraw the needle and prepare the injection again. C. Pull the needle back slightly and inject the medication. D. Give the injection and hold pressure over the site for 3 minutes.

B. Withdraw the needle and prepare the injection again. Blood return upon aspiration indicates improper placement, and the injection should not be given. Instead withdraw the needle, dispose of the syringe and needle properly, and prepare the medication again. Administering the medication into a blood vessel could have dangerous adverse effects, and the medication will be absorbed faster than intended owing to increased blood flow.

A nurse is preparing to administer an injection to a patient. Which statement made by the patient is an indication for the nurse to use the Z-track method? A. "I am allergic to many medications." B. "I'm really afraid that a big needle will hurt." C. "The last shot like that turned my skin colors." D. "My legs are too obese for the needle to go through."

C. "The last shot like that turned my skin colors." The Z-track is indicated when the medication being administered has the potential to irritate sensitive tissues. It is recommended that, when administering IM injections, the Z-track method be used to minimize local skin irritation by sealing the medication in muscle tissue.

10.A nurse is caring for a patient who is experiencing pain following abdominal surgery. Which information is important for the nurse to share with the patient when providing patient education about effective pain management? a. "To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain." b. "You should take your medication after you walk to make sure you do not fall while you are walking." c. "We should work together to create a schedule to provide regular dosing of medication." d. "When you experience severe pain, you will need to take oral pain medications."

C. "We should work together to create a schedule to provide regular dosing of medication" One way to maximize pain relief while potentially decreasing opioid use is to administer analgesics around the clock (ATC) rather than on a prn basis. This approach ensures a more constant therapeutic blood level of an analgesic. Working with the patient to design a schedule allows the patient to be a full partner in the care provided. The nurse should not wait until pain is experienced because it takes medications 10-30 minutes to begin to relieve pain. The nurse administers pain medications before painful activities, such as walking, and administers intravenous medications when a patient is having severe pain.

2.A nurse is caring for a patient who recently had abdominal surgery and is experiencing severe pain. The patient's blood pressure is 110/60 mm Hg, and heart rate is 60 beats/min. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic? a. "Your vitals do not show that you are having pain; can you describe your pain?" b. "OK, I will go get you some narcotic pain relievers immediately." c. "What would you like to try to alleviate your pain?" d. "You do not look like you are in pain."

C. "What would you like to try to alleviate your pain?" Be sure the patient is a partner in making decisions about the best approaches for managing pain. A patient knows the most about his or her pain and is an important partner in selecting successful pain therapies. The nurse must believe that a patient is in pain whenever the patient reports that he or she is in pain, even if the patient does not appear to be in pain. The nurse must be careful to not judge the patient based on vital signs or nonverbal communication and must not assume that the patient is seeking narcotics. The patient is a partner in pain management, so going to get narcotics to treat the pain without consulting with the patient first is not appropriate.

The nurse considers several new female patients to receive additional health education on the need for more frequent Pap smears and gynecological examinations. Which of the following assessment findings reveals the patient at highest risk for cervical cancer and thus having the greatest need for patient education? A. Nonsmoker, 13 years old, not sexually active B. Social smoker, 15 years old, celibate C. 22 years old, smokes 1 pack of cigarettes per day, has multiple sexual partners D. 50 years old, stopped smoking 30 years ago, history of hysterectomy

C. 22 years old, smokes 1 pack of cigarettes per day, has multiple sexual partners

The nurse is preparing to administer an injection into the deltoid muscle of an adult patient. Which needle size and length will the nurse choose? A. 18 gauge × 1 1/2 inch B. 23 gauge × 1/2 inch C. 25 gauge × 1 inch D. 27 gauge × 5/8 inch

C. 25 gauge × 1 inch For an intramuscular injection into an adult deltoid muscle, a 25-gauge, 1-inch needle is recommended. An 18-gauge needle is too big. While a 23-gauge needle can be used, a 1/2-inch needle is too small. A 27-gauge, 5/8 -inch needle is used for intradermal.

A nurse is preparing to administer a medication from a vial. In which order will the nurse perform the steps, starting with the first step? 1. Invert the vial. 2. Fill the syringe with medication. 3. Inject air into the airspace of the vial. 4. Clean with alcohol swab and allow to dry. 5. Pull back on the plunger the amount to be drawn up. 6. Tap the side of the syringe barrel to remove air bubbles. A. 4, 1, 5, 3, 6, 2 B. 1, 4, 5, 3, 2, 6 C. 4, 5, 3, 1, 2, 6 D. 1, 4, 5, 3, 6, 2

C. 4, 5, 3, 1, 2, 6 Clean with alcohol swab and allow to dry Pull back on the plunger the amount to be drawn up Inject air into the airspace of the vial Invert the vial Fill the syringe with medication Tap the side of the syringe barrel to remove air bubbles

The paramedics transport an adult involved in a motor vehicle accident to the emergency department. On physical examination, the patient's level of consciousness is reported as opening eyes to pain and responding with inappropriate words and flexion withdrawal to painful stimuli. The nurse correctly identifies the patient's Glasgow Coma Scale score as A. 5. B. 7. C. 9. D. 11.

C. 9.

6.The nurse is preparing pain medications. To which patient does the nurse anticipate administering an opioid fentanyl patch? a. A 15-year-old adolescent with a fractured femur b. A 30-year-old adult with cellulitis c. A 50-year-old patient with prostate cancer d. An 80-year-old patient with a broken hip

C. A 50-year old adult with prostate cancer Transdermal fentanyl (patch), which is 100 times more potent than morphine, is available for opioid-tolerant patients with cancer or chronic pain (prostate cancer). It delivers predetermined doses that provide analgesia for up to 72 hours. The other patients are expected to experience acute pain (fractured femur, cellulitis, and broken hip). Therefore, they will most likely benefit from oral or IV opioids for short-term pain relief.

The supervising nurse is observing several different nurses. Which action will cause the supervising nurse to intervene? A. A nurse administers a vaccine without aspirating. B. A nurse gives an IV medication through a 22-gauge IV needle without blood return. C. A nurse draws up the NPH insulin first when mixing a short-acting and intermediate-acting insulin. D. A nurse calls the health care provider for a patient with nasogastric suction and orders for oral meds.

C. A nurse draws up the NPH insulin first when mixing a short-acting and intermediate-acting insulin. If regular and intermediate-acting (NPH) insulin is ordered, prepare the regular insulin first to prevent the regular insulin from becoming contaminated with the intermediate-acting insulin. -The CDC no longer recommends aspiration when administering immunizations to reduce discomfort. -In some cases, especially with a smaller gauge (22) IV needle, blood return is not aspirated, even if the IV is patent. -If the IV site shows no signs of infiltration and IV fluid is infusing without difficulty, proceed with IV push slowly. -Oral meds are contraindicated in patients with nasogastric suction.

Asking an adult what the statement "A stitch in time saves nine" means to him is a mental status examination technique used to assess A. Knowledge. B. Long-term memory. C. Abstract thinking. D. Recent memory.

C. Abstract thinking.

An advanced practice nurse is preparing to assess the external genitalia of a 25-year-old American woman of Chinese descent. Which of the following nursing actions does the nurse do first? A. Place the patient in the lithotomy position. B. Drape the patient to enhance patient comfort. C. Assess the patient's feelings and explain the purpose of the examination. D. Ask the patient if she would like her mother to be present in the room during the examination.

C. Assess the patient's feelings and explain the purpose of the examination.

The patient is a 54-year-old male with a medium frame. He weighs 148 pounds and is 5 feet 8 inches tall. The nurse realizes that this patient is A. Overweight. B. Underweight. C. At his desired weight. D. Obese.

C. At his desired weight.

The advanced practice nurse is conducting a comprehensive eye examination on an 80-year-old African American woman. Which of the following findings requires the nurse to contact the patient's physician for further examination? A. A thin white ring along the margin of the iris B. A black pupil C. Dilated pupils D. A black fundus of the eye

C. Dilated pupils

A teen patient is tearful and reports locating lumps in her breasts. Other history obtained is that she is currently menstruating. Physical examination reveals soft and movable cysts in both breasts that are painful to palpation. The nurse also notes that the patient's nipples are erect, but the areolae are wrinkled. The next nursing step is which of the following? A. Reassure patient that her symptoms are normal. B. Consult a breast surgeon because of the abnormal nipples and areolae. C. Discuss fibrocystic disease as the likely cause. D. Tell the patient that the symptoms may get worse when her period ends.

C. Discuss fibrocystic disease as the likely cause.

When the nurse administers an IM corticosteroid injection, the nurse aspirates. What is the rationale for the nurse aspirating? A. Prevent the patient from choking. B. Increase the force of the injection. C. Ensure proper placement of the needle. D. Reduce the discomfort of the injection.

C. Ensure proper placement of the needle. The purpose of aspiration is to ensure that the needle is in the MUSCLE and not in the VASCULAR system. Blood return upon aspiration indicates improper placement, and the injection should not be given.

A patient is to receive a proton pump inhibitor through a nasogastric (NG) feeding tube. Which is the most important nursing action to ensure effective absorption? A. Thoroughly shake the medication before administering. B. Position patient in the supine position for 30 minutes to 1 hour. C. Hold feeding for at least 30 minutes after medication administration. D. Flush tube with 10 to 15 mL of water, after all medications are administered.

C. Hold feeding for at least 30 minutes after medication administration. If a medication needs to be given on an empty stomach or is not compatible with the feeding (e.g., phenytoin, carbamazepine [Tegretol], warfarin [Coumadin], fluoroquinolones, proton pump inhibitors), hold the feeding for at least 30 minutes before or 30 minutes after medication administration.

The nurse is urgently called to the gymnasium regarding an injured student. The student is crying in severe pain with a malformed fractured lower leg. The proper sequence for the nurse's initial assessment is A. Deep palpation, light palpation, inspection. B. Light palpation, deep palpation, inspection. C. Inspection, light palpation. D. Auscultation, deep palpation, light palpation.

C. Inspection, light palpation.

A nurse identifies Pediculosis humananus capitis. Considering the possible complications of treatment, the nurse knows to not use which of the following treatment products? A. Fine-toothed comb B. Pediculicide C. Lindane-based shampoo D. Vinegar hair rinse

C. Lindane-based shampoo

The nurse is caring for a female victim of rape. To perform the proper evaluation, the nurse should place the patient in which of the following positions? A. Sitting B. Dorsal recumbent C. Lithotomy D. Knee-chest

C. Lithotomy

A nurse is following safety principles to reduce the risk of needlestick injury. Which actions will the nurse take? (Select all that apply.) A. Recap the needle after giving an injection. B. Remove needle and dispose in sharps box. C. Never force needles into the sharps disposal. D. Use clearly marked sharps disposal containers. E. Use needleless devices whenever possible.

C. Never force needles into the sharps disposal. D. Use clearly marked sharps disposal containers. E. Use needleless devices whenever possible.

During a school physical examination, the nurse reviews the patient's current medical history. With a positive medical history of asthma, eczema, and allergic rhinitis, the nurse expects which physical finding on nasal examination? A. Polyp B. Yellow discharge C. Pale nasal mucosa D. Puffiness of nasal mucosa

C. Pale nasal mucosa

Which is the best examination position for a complete geriatric physical examination on a weak patient with bilateral basilar pneumonia? A. Prone position B. Sims' position C. Supine position D. Lateral recumbent

C. Supine position

A male student comes to the college health clinic. He hesitantly describes that his testis has lumps. The nurse recognizes this as a potential sign of which of the following? A. Inguinal hernia B. Sexually transmitted infection C. Testicular cancer D. Diuretic use

C. Testicular cancer

A head and neck physical examination is completed on a 50-year-old female patient. All physical findings are normal except for fine brittle hair. Based on the physical findings, which of the following laboratory tests would the nurse expect to be ordered? A. Liver function test B. Lead level C. Thyroid-stimulating hormone test D. Complete blood count

C. Thyroid-stimulating hormone test

An older-adult patient needs an IM injection of antibiotic. Which site is best for the nurse to use? A. Deltoid B. Dorsal gluteal C. Ventrogluteal D. Vastus lateralis

C. Ventrogluteal The ventrogluteal site is the preferred and safest site for all adults, children, and infants.

1. The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase? a.Completes a comprehensive database b.Identifies pertinent nursing diagnoses c.Intervenes based on priorities of patient care d.Determines whether outcomes have been achieved

Completes a comprehensive database

8. While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do? a.Consider cultural differences during this assessment. b.Ask the patient to make eye contact to determine her affect. c.Continue with the interview and document that the patient is depressed. d.Notify the health care provider to recommend a psychological evaluation.

Consider cultural differences during this assessment

14.A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower leg. The nurse is providing education to the patient to prevent injury to the feet by wearing shoes or slippers when walking. Which statement made by the nurse best explains the rationale for this instruction? a. "Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet." b. "Shoes provide nonpharmacological pain relief to people with diabetes and peripheral neuropathy." c. "The neurological gates open when wearing shoes, which protects your feet." d. "If you step on something without shoes, you might not feel it; this could possibly cause injury to your foot."

D. "If you step on something without shoes, you might not feel it; this could possibly cause injury to your foot." Any factor that interrupts or influences normal pain reception or perception (e.g., spinal cord injury, peripheral neuropathy, or neurological disease) affects a patient's awareness of and response to pain. The patient will no longer have protective reflexes to prevent injury to the feet. Wearing shoes prevents the patient from injuring the feet because they protect the feet. Shoes do not block pain perception, and they do not help people adapt to pain. Shoes are not a form of nonpharmacological pain relief. Wearing shoes will not have an effect on opening or closing the pain gates.

A nurse is preparing an intravenous IV piggyback infusion. In which order will the nurse perform the steps, starting with the first one? 1. Compare the label of the medication with the medication administration record at the patient's bedside. 2. Connect the tubing of the piggyback infusion to the appropriate connector on the upper Y-port. 3. Hang the piggyback medication bag above the level of the primary fluid bag. 4. Clean the main IV line port with an antiseptic swab. 5. Connect the infusion tubing to the medication bag. 6. Regulate flow. A. 5, 2, 1, 4, 3, 6 B. 5, 2, 1, 3, 4, 6 C. 1, 5, 4, 3, 2, 6 D. 1, 5, 3, 4, 2, 6

D. 1, 5, 3, 4, 2, 6

A health care provider prescribes aspirin 650 mg every 4 hours PO when febrile. For which patient will this order be appropriate? A. 7 year old with a bleeding disorder B. 21 year old with a sprained ankle C. 35 year old with a severe headache from hypertension D. 62 year old with a high fever from an infection

D. 62 year old with a high fever from an infection Aspirin is an analgesic, an antipyretic, and an anti-inflammatory medication. The provider wrote the medication to be given for a fever (febrile). Fevers are common in infections. If a child is bleeding, aspirin would be contraindicated; aspirin increases the likelihood of bleeding. Although it can be used for inflammatory problems (sprained ankle) and pain/analgesia (severe headache), this is not how the order was written.

30.The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority? a. Call the rapid response team. b. Start an intravenous (IV) line. c. Administer pain-relief medications. d. Ask the patient to rate and describe the pain.

D. Ask the patient to rate and describe the pain. The nurse's ability to establish a nursing diagnosis, plan and implement care, and evaluate the effectiveness of care depends on an accurate and timely assessment. The other responses are all interventions; the nurse cannot know which intervention is appropriate until the nurse completes the assessment.

Having misplaced his stethoscope, a nurse borrows a colleague's stethoscope. He next enters the patient's room and identifies himself, washes his hands with soap, and states the purpose of his visit. He performs proper identification of the patient before he auscultates her lungs. Which critical health assessment step was not performed? A. Running warm water over stethoscope for patient comfort B. Cleaning stethoscope with Betadine C. Using alcohol-based hand disinfectant D. Cleaning stethoscope with alcohol

D. Cleaning stethoscope with alcohol

A school nurse recognizes a belt buckle-shaped ecchymosis on a 7-year-old student. When privately asked about how the injury occurred, the student described falling on the playground. Upon suspecting abuse, the school nurse's best next action is which of the following? A. Interviewing the patient in the presence of his/her teacher B. Ignoring the findings because child abuse is a declining problem C. Realizing that abuse victims usually report abusive situations D. Contacting Social Services and reporting suspected abuse

D. Contacting Social Services and reporting suspected abuse

A patient refuses medication. Which is the nurse's first action? A. Educate the patient about the importance of the medication. B. Discreetly hide the medication in the patient's favorite gelatin. C. Agree with the patient's decision and document it in the chart. D. Explore with the patient reasons for not wanting to take the medication.

D. Explore with the patient reasons for not wanting to take the medication.

During a routine pediatric history and physical, the parents report that their child was a premature infant and was so small that he had to stay in the neonatal intensive care unit longer than usual. They state that the infant was yellow when born, and that he developed an infection that required "every antibiotic under the sun" to cure him. Considering the neonatal history, the nurse determines that it is especially important to perform a focused _____ examination. A. Cardiac B. Respiratory C. Ophthalmic D. Hearing acuity

D. Hearing acuity

A patient in the emergency department is complaining of left lower abdominal pain. The comprehensive abdominal examination would include, in proper order, which of the following? A. Inspection, palpation, auscultation B. Percussion, inspection, auscultation C. Inspection, palpation, percussion D. Inspection, auscultation, palpation

D. Inspection, auscultation, palpation

The prescriber wrote for a 40-kg child to receive 25 mg of medication 4 times a day. The therapeutic range is 5 to 10 mg/kg/day. What is the nurse's priority? A. Change the dose to one that is within range. B. Administer the medication because it is within the therapeutic range. C. Notify the health care provider that the prescribed dose is in the toxic range. D. Notify the health care provider that the prescribed dose is below the therapeutic range.

D. Notify the health care provider that the prescribed dose is below the therapeutic range. The dosage range is 200 to 400 mg a day (5 × 40 = 200 and 10 × 40 = 400). The prescribed dose is 100 mg/day (4 × 25 = 100), which is below therapeutic range. The nurse should notify the health care provider first and ask for clarification on the order. The dose is not above the therapeutic range and is not at a toxic level. The nurse should never alter an order without the prescriber's approval and consent.

A registered nurse interprets that a scribbled medication order reads 25 mg. The nurse administers 25 mg of the medication to a patient and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error? A. Health care provider B. Pharmacist C. Hospital D. Nurse

D. Nurse

The patient presents to the clinic with dysuria and hematuria. How does the nurse proceed to assess for kidney inflammation? A. Lightly palpates each abdominal quadrant B. Inspects abdomen for abnormal movement or shadows using indirect lighting C. Uses deep palpation posteriorly D. Percusses posteriorly the costovertebral angle at the scapular line

D. Percusses posteriorly the costovertebral angle at the scapular line

The supervising nurse is watching nurses prepare medications. Which action by one of the nurses will the supervising nurse stop immediately? A. Rolls insulin vial between hands B. Administers a dose of correction insulin C. Draws up glargine (Lantus) in a syringe by itself D. Prepares NPH insulin to be given intravenously (IV)

D. Prepares NPH insulin to be given intravenously (IV) -The only insulin that can be given IV is regular. -NPH cannot be given IV and must be stopped. -All the rest demonstrate correct practice. -Insulin is supposed to be rolled, not shaken. -Glargine is supposed to be given by itself; it cannot be mixed with another medication. -Correction insulin, also known as sliding-scale insulin, provides a dose of insulin based on the patient's blood glucose level. The term correction insulin is preferred because it indicates that small doses of rapid- or short-acting insulins are needed to correct a patient's elevated blood sugar.

A woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? a. Transcutaneous electrical nerve stimulation (TENS) b. Herbal supplements with analgesic effects c. Pudendal block (regional anesthesia) d. Relaxation and guided imagery

D. Relaxation and guided imagery In the case of a patient in labor, relaxation with guided imagery is often an effective supplement for pain management because it provides women with a sense of control over their pain. Relaxation and guided imagery can be used during any phase of health or illness. TENS units are typically used to manage postsurgical and procedural pain. Herbal supplements need to be evaluated for safety during pregnancy. Additionally, some patients consider herbal supplements to be another form of medication, and they are not typically used to control acute pain. A pudendal block is a type of regional anesthesia (injection or infusion of local anesthetics to block a group of sensory nerve fibers); use of it does not respect the patient's wishes for nonpharmacological pain control.

During an annual gynecological examination, a college student discusses her upcoming college break at a tropical location. After the student receives an oral contraceptive prescription, the nurse identifies the importance of skin cancer prevention education by discussing which evidence-based prevention health topic? A. Applying water-based sunscreen only before swimming B. Using tanning bed daily for 7 days before college break trip C. Applying broad-spectrum sunscreen of SPF 5 D. Taking extra precautions in the sun secondary to the prescription

D. Taking extra precautions in the sun secondary to the prescription

Which patient does the nurse most closely monitor for an unintended synergistic effect? A. The 4 year old who has mistakenly taken a half bottle of vitamins B. The 35 year old who has ingested meth mixed with several household chemicals C. The 50 year old who is prescribed a second blood pressure medication D. The 72 year old who is seeing four different specialists

D. The 72 year old who is seeing four different specialists -The 72 year old seeing four different providers is likely to experience polypharmacy. --Polypharmacy places the patient at risk for unintended mixing of medications that potentiate each other. -When two medications have a synergistic effect, their combined effect is greater than the effect of the medications when given separately. -The child taking too much of a medication by mistake could experience overdose or toxicity. -The 50 year old is prescribed two different blood pressure medications for their synergistic effect, but this is a desired, intended event. -A patient taking meth and mixing chemicals can be toxic.

Objective physical data describe air moving through small airways over the lung's periphery. The expected inspiratory-to-expiratory phase of this normal vesicular breath sound is which of the following? A. The inspiratory phase lasts exactly as long as the expiratory phase. B. The expiration phase is longer than the inspiration phase. C. The expiration phase is two times longer than the inspiration phase. D. The inspiratory phase is three times longer than the expiratory phase.

D. The inspiratory phase is three times longer than the expiratory phase.

A patient has an order to receive 0.3 mL of U-500 insulin. Which syringe will the nurse obtain to administer the medication? A. 3-mL syringe B. U-100 syringe C. Needleless syringe D. Tuberculin syringe

D. Tuberculin syringe Because there is no syringe currently designed to prepare U-500 insulin, many medication errors result with this kind of insulin. To prevent errors, ensure that the order for U-500 specifies units and volume (e.g., 150 units, 0.3 mL of U-500 insulin), and use tuberculin syringes to draw up the doses.

2. A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first? a.Complete the questions in chronological order. b.Focus on the patient's presenting situation. c.Make accurate interpretations of the data. d.Conduct an observational overview.

Focus on the patient's presenting situation

4. The nurse is gathering data on a patient. Which data will the nurse report as objective data? a.States "doesn't feel good" b.Reports a headache c. Respiration 16 d.Nauseated

Nauseated

11. A nurse is conducting a nursing health history. Which component will the nurse address? a.Nurse's concerns b.Patient expectations c.Current treatment orders d.Nurse's goals for the patient

Patient expectations

7. A nurse is gathering information about a patient's habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information? a.Carefully review lab results. b.Conduct the physical assessment. c.Perform a thorough nursing health history. d.Prolong the termination phase of the interview.

Perform a thorough nursing health history

6. Which method of data collection will the nurse use to establish a patient's database? a.Reviewing the current literature to determine evidence-based nursing actions b.Checking orders for diagnostic and laboratory tests c.Performing a physical examination d.Ordering medications

Performing a physical examination

13. The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using? a.Gordon's Functional Health Patterns b.Activity-exercise pattern assessment c.General to specific assessment d.Problem-oriented assessment

Problem-oriented assessment

15. Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? a.The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. b.The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done. c.The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps. d.The nurse elevates a leg cast when the patient reports decreased mobility.

The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage.

19. A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient's daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse? a.The nurse makes eye contact with the patient. b.The nurse speaks only to the patient's daughter. c.The nurse leans forward while talking with the patient. d.The nurse nods periodically while the patient is speaking.

The nurse speaks only to the patient's daughter.

5. A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data? a.The patient can now perform the dressing changes without help. b.The patient can begin retaking all of the previous medications. c.The patient is apprehensive about discharge. d.The patient's surgery was not successful.

The patient is apprehensive about discharge

18. The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview? a.The patient's room with the door closed b.The waiting area with the television turned off c.The patient's room before administration of pain medication d.The waiting room while the occupational therapist is working on leg exercises

The patient's room with the door closed

A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care? a. Patient will have one soft, formed bowel movement by end of shift. b. Patient will walk unassisted to bathroom by the end of shift. c. Patient will be offered laxatives or stool softeners this shift. d. Patient will not take any pain medications this shift.

a. Patient will have one soft, formed bowel movement by end of shift.

A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which goal statement is realistic for the nurse to assign to this patient? a. Patient will increase activity level this shift. b. Patient will turn side to back to side with assistance every 2 hours. c. Patient will use the walker correctly to ambulate to the bathroom as needed. d. Patient will use a sliding board correctly to transfer to the bedside commode as needed.

a. Patient will increase activity level this shift.

14. A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk for loneliness related to impaired verbal communication? a. Provide the patient with a writing board each shift. b. Obtain an interpreter for the patient as soon as possible. c. Assist the patient in performing swallowing exercises each shift. d. Ask the family to provide a sitter to remain with the patient at all times.

a. Provide the patient with a writing board each shift.

The following statements are on a patient's nursing care plan. Which statement will the nurse use as an outcome for a goal of care? a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. b. The patient will demonstrate increased tolerance to activity over the next month. c. The patient will understand needed dietary changes by discharge. d. The patient will demonstrate increased mobility in 2 days.

a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.

19. A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention? a."Do you feel like you need to go to the bathroom?" b."Are you able to walk to the bathroom by yourself?" c."When was the last time you took your medicine?" d."Do you have a safety rail in your bathroom at home?"

a."Do you feel like you need to go to the bathroom?"

20. A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use. 1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma 2. Writes a diagnostic label of impaired gas exchange 3. Organizes data into meaningful clusters 4. Interprets information from patient 5. Writes an etiology a.1, 3, 4, 2, 5 b.1, 3, 4, 5, 2 c.1, 4, 3, 5, 2 d.1, 4, 3, 2, 5

a.1, 3, 4, 2, 5

20. In which order will the nurse use the nursing process steps during the clinical decision-making process? 1. Evaluating goals 2. Assessing patient needs 3. Planning priorities of care 4. Determining nursing diagnoses 5. Implementing nursing interventions a.2, 4, 3, 5, 1 b.4, 3, 2, 1, 5 c.1, 2, 4, 5, 3 d.5, 1, 2, 3, 4

a.2, 4, 3, 5, 1

9. A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? a.Assessment b.Diagnosis c.Implementation d.Evaluation

a.Assessment

6. A nursing instructor needs to evaluate students' abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor's needs? a.Concept mapping b.Reflective journaling c.Lecture and discussion d.Reading assignment with a written summary

a.Concept mapping

15. A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document? a.Decreased cardiac output related to altered myocardial contractility. b.Patient needs a low-fat diet related to inadequate heart perfusion. c.Offer a low-fat diet because of heart problems. d.Acute heart pain related to discomfort.

a.Decreased cardiac output related to altered myocardial contractility.

7. The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review? a.Diagnosis b.Planning c.Implementation d.Evaluation

a.Diagnosis

4. The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise? a.Etiology b.Nursing diagnosis c.Collaborative problem d.Defining characteristic

a.Etiology

11. A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? a.Explore other options for pain relief. b.Discuss the surgical procedure and reason for the pain. c.Explain to the patient that nothing else has been ordered. d.Offer to notify the health care provider after morning rounds are completed.

a.Explore other options for pain relief.

1. Which findings will alert the nurse that stress is present when making a clinical decision? (Select all that apply.) a.Tense muscles b.Reactive responses c.Trouble concentrating d.Very tired feelings e.Managed emotions

a.Tense muscles b.Reactive responses c.Trouble concentrating d.Very tired feelings

Which action indicates the nurse is using a PICOT question to improve care for a patient? a. Practices nursing based on the evidence presented in court b. Implements interventions based on scientific research c. Uses standardized care plans for all patients. d. Plans care based on tradition

b. Implements interventions based on scientific research

18. Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea? a."What types of foods do you think caused your upset stomach?" b."How many bowel movements a day have you had?" c."Are you able to get to the bathroom in time?" d."What medications are you currently taking?"

b."How many bowel movements a day have you had?"

2. Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved? a.Sore throat b.Acute pain c.Sleep apnea d.Heart failure

b.Acute pain

13. While caring for a hospitalized older-adult female post hip surgery, the nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. Which action should the nurse take? a.Postpone catheter insertion until the next shift. b.Adapt the positioning technique to the situation. c.Notify the health care provider for a urologist consult. d.Follow textbook procedure with contraindicated position.

b.Adapt the positioning technique to the situation.

16. A nurse is pulled from the surgical unit to work on the oncology unit. Which action by the nurse displays humility and responsibility? a.Refusing the assignment b.Asking for an orientation to the unit c.Admitting lack of knowledge and going home d.Assuming that patient care will be the same as on the other units

b.Asking for an orientation to the unit

15. A patient is having trouble reaching the water fountain while holding on to crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing him or herself with two hands on the water fountain. Which critical thinking attitude did the nurse use in this situation? a.Humility b.Creativity c.Risk taking d.Confidence

b.Creativity

11. The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance? a.Decreased oral intake and decreased oxygen saturation when ambulating b.Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed c.Reports of shortness of breath when getting out of bed and a productive cough d.Productive cough and decreased oral intake

b.Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed

13. A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing diagnosis will cause the nurse manager to intervene? a.Wandering b.Hemorrhage c.Urinary retention d.Impaired swallowing

b.Hemorrhage

19. A nurse is reviewing care plans. Which finding, if identified in a plan of care, should the registered nurse revise? a.Patient's outcomes for learning b.Nurse's assumptions about hospital discharge c.Identification of several actual health problems d.Documentation of patient's ability to meet the goal

b.Nurse's assumptions about hospital discharge

3. Which action indicates a registered nurse is being responsible for making clinical decisions? a.Applies clear textbook solutions to patients' problems b.Takes immediate action when a patient's condition worsens c.Uses only traditional methods of providing care to patients d.Formulates standardized care plans solely for groups of patients

b.Takes immediate action when a patient's condition worsens

1. After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions? a.To form a language that can be encoded only by nurses b.To distinguish the nurse's role from the physician's role c.To develop clinical judgment based on other's intuition d.To help nurses focus on the scope of medical practice

b.To distinguish the nurse's role from the physician's role

The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform? a. Dependent b. Independent c. Interdependent d. Physician-initiated

c. Interdependent

Which information indicates a nurse has a good understanding of a goal? a. It is a statement describing the patient's accomplishments without a time restriction. b. It is a realistic statement predicting any negative responses to treatments. c. It is a broad statement describing a desired change in a patient's behavior. d. It is a measurable change in a patient's physical state.

c. It is a broad statement describing a desired change in a patient's behavior.

The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process? a. Assessment b. Diagnosis c. Planning d. Implementation

c. Planning

A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse? a. The patient will ambulate in hallways. b. The nurse will monitor the patient's heart rhythm continuously this shift. c. The patient will feed self at all mealtimes today without reports of shortness of breath. d. The nurse will administer pain medication every 4 hours to keep the patient free from discomfort.

c. The patient will feed self at all mealtimes today without reports of shortness of breath.

10. A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic? a.Decreased gastrointestinal motility b.Pain medication c.Abdominal distention d.Constipation

c.Abdominal distention

12. Which action should the nurse take to best develop critical thinking skills? a.Study 3 hours more each night. b.Attend all inservice opportunities. c.Actively participate in clinical experiences. d.Interview staff nurses about their nursing experiences.

c.Actively participate in clinical experiences.

6. A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care? a.Posttrauma syndrome b.Constipation c.Acute pain d.Anxiety

c.Acute pain

2. Which patient scenario of a surgical patient in pain is most indicative of critical thinking? a.Administering pain-relief medication according to what was given last shift b.Offering pain-relief medication based on the health care provider's orders c.Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past d.Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed

c.Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past

1. Which action should the nurse take when using critical thinking to make clinical decisions? a.Make decisions based on intuition. b.Accept one established way to provide care. c.Consider what is important in a given situation. d.Read and follow the heath care provider's orders.

c.Consider what is important in a given situation.

17. A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient? a.Adult failure to thrive b.Hypothermia c.Deficient fluid volume d.Nausea

c.Deficient fluid volume

16. A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up? a.Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous (IV) antibiotics b.Completing an interview and physical examination before adding a nursing diagnosis c.Developing nursing diagnoses before completing the database d.Including cultural and religious preferences in the database

c.Developing nursing diagnoses before completing the database

5. A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing? a.Assigning clinical cues b.Defining characteristics c.Diagnostic reasoning d.Diagnostic labeling

c.Diagnostic reasoning

12. A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain? a.Discomfort while changing position b.Reports pain as a 7 on a 0 to 10 scale c.Disruption of tissue integrity d.Dull headache

c.Disruption of tissue integrity

8. A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write? a.Risk b.Problem focused c.Health promotion d.Collaborative problem

c.Health promotion

21. A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.) a.Anxiety related to barium enema b.Impaired gas exchange related to asthma c.Impaired physical mobility related to incisional pain d.Nausea related to adverse effect of cancer medication e.Risk for falls related to nursing assistive personnel leaving bedrail down

c.Impaired physical mobility related to incisional pain d.Nausea related to adverse effect of cancer medication

14. A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient's care plan? a.Infection b.Risk for infection c.Impaired skin integrity d.Staphylococcal leg infection

c.Impaired skin integrity

5. Which action demonstrates a nurse utilizing reflection to improve clinical decision making? a.Obtains data in an orderly fashion b.Uses an objective approach in patient situations c.Improves a plan of care while thinking back on interventions effectiveness d.Provides evidence-based explanations and research for care of assigned patients

c.Improves a plan of care while thinking back on interventions effectiveness

10. The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether there is any history of heart problems. The nurse is utilizing which critical thinking skill? a.Evaluation b.Explanation c.Interpretation d.Self-regulation

c.Interpretation

20. A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.) a.Patient's temperature b.Patient's wound appearance c.Patient describing excitement about discharge d.Patient pacing the floor while awaiting test results e.Patient's expression of fear regarding upcoming surgery

c.Patient describing excitement about discharge e.Patient's expression of fear regarding upcoming surgery

9. A nurse is using the critical thinking skill of evaluation. Which action will the nurse take? a.Examine the meaning of data. b.Support findings and conclusions. c.Review the effectiveness of nursing actions. d.Search for links between the data and the nurse's assumptions.

c.Review the effectiveness of nursing actions.

The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse? a. "Choose all the interventions and perform them in order of time needed for each one." b. "Make sure you identify the scientific rationale for each intervention first." c. "Decide on goals and outcomes you have chosen for the patients." d. "Begin with the highest priority diagnoses, then select appropriate interventions."

d. "Begin with the highest priority diagnoses, then select appropriate interventions."

A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which initial action will the nurse take next to revise the plan of care? a. Consult physical therapy. b. Establish a new plan of care. c. Set new priorities for the patient. d. Assess the patient.

d. Assess the patient.

A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing? a. Collaborative b. Independent c. Interdependent d. Dependent

d. Dependent

A patient's son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do? a. Individualize the care plan only according to the patient's needs. b. Request that the son leave at bedtime, so the patient can rest. c. Suggest that a female member of the family stay with the patient. d. Involve the son in the plan of care as much as possible.

d. Involve the son in the plan of care as much as possible.

A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient? a. Risk for impaired skin integrity b. Risk for infection c. Spiritual distress d. Reflex urinary incontinence

d. Reflex urinary incontinence

14. The nurse enters a room to find the patient sitting up in bed crying. How will the nurse display a critical thinking attitude in this situation? a.Provide privacy and check on the patient 30 minutes later. b.Set a box of tissues at the patient's bedside before leaving the room. c.Limit visitors while the patient is upset. d.Ask the patient about the crying.

d.Ask the patient about the crying.

3. A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write? a.Ineffective breathing pattern related to pneumonia b.Risk for infection related to chest x-ray procedure c.Risk for deficient fluid volume related to dehydration d.Impaired gas exchange related to alveolar-capillary membrane changes

d.Impaired gas exchange related to alveolar-capillary membrane changes

18. A nurse who is caring for a patient with a pressure ulcer applies the recommended dressing according to hospital policy. Which standard is the nurse following? a.Fairness b.Intellectual standards c.Independent reasoning d.Institutional practice guidelines

d.Institutional practice guidelines

4. A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene? a.Making an ethical clinical decision b.Making an informed clinical decision c.Making a clinical decision in the patient's best interest d.Making a clinical decision based on previous shift assessments

d.Making a clinical decision based on previous shift assessments

7. A nurse is using a critical thinking model to provide care. Which component is first that helps a nurse make clinical decisions? a.Attitude b.Experience c.Nursing process d.Specific knowledge base

d.Specific knowledge base

17. A nurse is using professional standards to influence clinical decisions. What is the rationale for the nurse's actions? a.Establishes minimal passing standards for testing b.Utilizes evidence-based practice based on nurses' needs c.Bypasses the patient's feelings to promote ethical standards d.Uses critical thinking for the highest level of quality nursing care

d.Uses critical thinking for the highest level of quality nursing care

8. Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions? a.Drawing on past clinical experiences to formulate standardized care plans b.Relying on recall of information from past lectures and textbooks c.Depending on the charge nurse to determine priorities of care d.Using the nursing process

d.Using the nursing process