Nursing 101 final

The nurse is caring for a hospitalized older adult who is having an allergic reaction. Diphenhydramine (Benadryl) 50 mg by mouth every 4 hours is prescribed. The patient experiences extreme drowsiness and the nurse calls the health-care provider. The nurse is instructed to give one-half the present dose when the next dose is due. Since the diphenhydramine is in the form of a capsule that cannot be cut in half, the nurse acquires diphenhydramine elixir that states that there is 12.5 mg per 5 mL. How much solution should the nurse administer? Record your answer using a whole number

10 mL

Order: Valium 7.5 mg Supply: Valium 2.5 mg/tab How many tablets, or what portion of a tablet, should be given per dose?

3 tabs/dose

The doctor has ordered 500 mL D5W to infuse over 4 hours with a drop factor of 15. How many gtt/min should the patient receive?

31 gtt/min

1. A postoperative patient asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative patient can lead to which condition? A. Pneumonia B. Hypoxemia C. Fluid Imbalance D. Pulmonary embolism

A

1. A preoperative patient expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the patient and the nurse? A. "If it's any help, everyone is nervous before surgery." B. "I will be happy to explain the entire surgical procedure to you." C. "Can you share with me what you've been told about your surgery?" "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

C

1. Contact precautions are initiated for a patient with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? A. Gloves and gown B. Gloves and goggles C. Gloves, gown, and shoe protectors D. Gloves, gown, goggles, and mask

D

1. A nurse is assisting a moderately cognitively impaired patient with morning care before going to the dining room. What is the nurse's most appropriate verbal intervention to help the patient get dressed? A. "Would you like to put on brown pants or blue pants before you go to breakfast?" B. "Here are your clothes. Would you rather get dressed before or after you have breakfast?" C. "The brown pants look good on you. Put them on and go to the dining room for breakfast." D. "Pick the outfit you would like to wear today and then go to the dining room for your breakfast."

a

1. A nurse is caring for a school-aged child who is to have a bone marrow biopsy. Although a local anesthetic will be used during the biopsy, it may be frightening and uncomfortable for the child. What should the nurse say that will best help the child tolerate the procedure? A. "Let's practice what will happen during the procedure." B. "Do you have any questions about the procedure that you would like to ask?" C. "You need to be strong during the procedure and before you know it will be over." D. "Would you like me to play a disk with your favorite songs during the procedure?"

a

1. A nurse is caring for an older adult who is in the last stage of dying. A family member keeps trying to get their father to ingest some soup. Which response by the nurse is most appropriate? A. "Nourishment is not necessary unless your father asks for it because vital organs are in decline." B. "Applying a protective lip balm on the lips supports comfort rather than encouraging eating." C. "You have been very attentive in trying to get your father to take some nourishment." D. "Ice chips or wetting the lips with a small amount of water is all that is necessary."

a

1. A patient admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? A. Contact the patient's health care provider (HCP). B. Call the patient's family to arrange for transportation. C. Attempt to persuade the patient to stay "for only a few more days." Tell the patient that leaving would likely result in an involuntary commitment

a

1. A patient has refused to eat more than a few spoonfuls of breakfast. The health care provider has prescribed that tube feedings be initiated if the patient fails to eat at least half of a meal because the patient had been losing weight for the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The patient begins crying and tries to eat more. Based on the nurse's actions, the nurse may be accused of which violation? A. Assault B. Battery C. Slander D. Invasion of privacy

a

1. A patient presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this patient? A. Assessment of vital signs B. Completion of abdominal examination C. Insertion of the prescribed nasogastric tube D. Thorough investigation of precipitating events

a

1. A patient stands 6 inches from the nurse and begins to talk to the nurse in a loud voice. The nurse feels uncomfortable with this behavior. What is the most appropriate response by the nurse? A. "I would like to talk to you, but you are standing too close to me." B. "If you come closer to me, you will have to stay in your room." C. "You are much too close to me; you must step back." D. "Please step back because you are scaring me."

a

1. A public health nurse is visiting an 80-year-old widow who recently was discharged from a rehabilitation center after recovering from a fall. The woman shares that her three children and their families live several states away. The nurse identifies that the patient looks fatigued, used a walker to her around the house, and lives independently in her own home. She receives a little help from the community in the way of supermarket deliveries and a cleaning person who comes every other week. Which should the nurse identify as the main concern? A. Risk for falls B. Potential for loneliness C. Decline in distant memory D. Hopelessness regarding the situation

a

1. The maternity nurse is providing instructions to a new mother regarding the psychological development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure? A. Allow the newborn infant to signal a need. B. Anticipate all the needs of the newborn infant. C. Attend to the newborn infant immediately when crying. D. Avoid the newborn infant during the first 10 minutes of crying.

a

1. The nurse has just reassessed the condition of a postoperative patient who was admitted 1 hour ago to the surgical unit. The nurse plans to intervene on which assessment finding first? A. Urinary output of 20 mL/hour B. Temperature of 37.6° C (99.6° F) C. Blood Pressure of 100/70mm Hg D. Serous drainage on the surgical dressing

a

1. The nurse inspects the color of the drainage from a nasogastric tube on a postoperative patient approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider? A. Dark red drainage B. Dark brown drainage C. Green-tinged drainage D. Light yellowish brown drainage

a

1. The nurse is administering a cleansing enema to a patient with a fecal impaction. Before administering the enema, the nurse should place the patient in which position? A. Left Sims' position B. Right Sims' position C. On the left side of the body, with the head of the bed elevated 45 degrees D. On the right side of the body, with the head of the bed elevated 45 degrees

a

1. The nurse is monitoring the status of a postoperative patient. The nurse would become most concerned with which sign that could indicate an evolving complication? A. Increasing restlessness B. A pulse of 86 beats/minute C. Blood pressure of 100/70 mm Hg D. Hypoactive bowel sounds in all four quadrants

a

1. The nurse is preparing to discontinue a patient's nasogastric tube. The patient is positioned properly, and the tube has been flushed with 15 mL of saline to clear secretions. Before removing the tube, the nurse should make which statement to the patient? A. "Take a deep breath when I tell you and hold it while I remove the tube." B. "Take a deep breath when I tell you and bear down while I remove the tube." C. "Take a deep breath when I tell you and slowly exhale while I remove the tube." D. "Take a deep breath when I tell you and breathe normally while I remove the tube."

a

1. The nurse receives a telephone call from post anesthesia care unit stating that a patient is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? A. Assess the patency of the airway. B. Check tubes of drains for patency. C. Check the dressing to assess for bleeding. D. Assess the vital signs to compare with preoperative measurements.

a

1. The nursing instructor asks a nursing student to identify the priorities of care for an assigned patient. Which statement indicates that the student correctly identifies the priority patient needs? A. Actual or life-threatening concerns are the priority. B. Completing care in a reasonable time frame is the priority. C. Time constraints related to the patient's needs are the priority. Obtaining needed supplies to care for the patient is the priority.

a

1. When reviewing the admission assessment, the nurse notes that a patient was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this patient? A. Monitor closely for harm to self or others B. Assist in completing an application for admission C. Supply the patient with written information about their mental illness D. Provide an opportunity for the family to discuss why they felt the admission was needed

a

1. Which educational intervention is most specific to teaching older adults? A. Teaching about safety precautions in the home environment B. Providing suggestions about maintaining a healthy diet C. Presenting strategies to avoid the empty nest syndrome D. Exploring actions that support a healthy lifestyle

a

1. Which is the most important outcome of the nursing process? A. Meet the nursing needs of each patient. B. Ensure that unit resources are allocated appropriately. C. Decrease the risk of an error regarding the admitting medical diagnosis. D. Reduce the risk of missing important data when collecting information about the patient.

a

1. A nurse is obtaining a health history and performing a physical assessment of an older adult. Which clinical manifestations associated with aging should the nurse expect? Select all that apply. A. Impaired balance B. Close vision impairment C. Diminished muscle strength D. Intermittent urinary incontinence E. Decreased hearing of low-pitched sounds

a, b, c

1. A nurse working in a nursing home is caring for a patient whose wife died several years ago. The nurse believes that the patient is experiencing dysfunctional grieving. Which of the following clinical manifestations by the patient specifically support dysfunctional grieving rather than normal grieving? Select all that apply. A. Focuses on little else but the death of his wife B. Focuses excessively on memories of his wife C. Feels that there is nothing to live for D. Feels sad at the thought of his wife E. Feels tired

a, b, c

1. An emergency department nurse is caring for parents whose 15-year-old daughter, while walking to school, was killed by a hit-and-run driver. Identify statements made by the nurse that are based on principles of therapeutic communication. Select all that apply. A. "I am so sorry for your loss." B. "Losing a child is awful. It is okay to cry." C. "I'm here if you want to talk." D. "I hope that the police find the driver and that justice is served." E. "You have to believe that God wanted her close to Him as an angel in heaven."

a, b, c

1. A patient who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply. A. Contact the surgeon. B. Instruct the patient to remain as still as possible. C. Prepare the patient for wound closure. D. Document the findings and actions taken. E. Place a sterile saline dressing and ice packs over the wound. F. Place the patient in a supine position without a pillow under the head.

a, b, c, d

1. The clinic nurse prepares to perform a focused assessment on a patient who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. A. Auscultating lung sounds B. Obtaining the patient's temperature C. Assessing the strength of peripheral pulses D. Obtaining information about the patient's respirations E. Performing a musculoskeletal and neurological examination F. Asking the patient about a family history of any illness or disease

a, b, d

1. A nurse is assessing a patient who had numerous sutures several days ago for a traumatic injury to the base of the right index finger. Which assessments indicate that the inflammatory response has progressed to an infectious process? Select all that apply. A. Foul odor B. Yellow exudate C. Swelling around the site D. Inability to flex the finger E. Elevated body temperature F. Feeling of heat when touched

a, b, e

1. A nurse identifies that patients are experiencing middle-adulthood developmental crises. Which information supports the nurse's conclusion? Select all that apply. A. Inability to carry a wanted pregnancy to term B. Failure to develop friendships with peers C. Demotion to a lesser position at work D. Powerless to postpone gratification E. Unable to discuss eventual death

a, c

1. A nurse formulates the following goal with a patient: "The patient will ambulate in the hall without experiencing activity intolerance." Which statements address the status of this goal? Select all that apply. A. It is not measurable. B. It is not patient-centered. C. It is missing a parameter. D. It is missing a target time. E. It is a correctly written goal.

a, c, d

1. An older adult who was hospitalized has been experiencing sundowning syndrome. What interventions should the nurse include in the patient's plan of care? Select all that apply. A. Follow the preset daily routine. B. Hurry through direct patient care. C. Provide a nonstimulating environment. D. Explain in detail what care will be performed. E. Use a motion sensor device on the patient's bed.

a, c, e

1. A nurse is assessing a patient who has a wound on the leg as the result of a bicycle accident. Which clinical manifestations indicate a localized inflammatory response? Select all that apply. A. Surrounding area is warm. B. Body temperature is 101.4°F. C. Heart rate is 102 beats/minute. D. Area around the wound is swollen.

a, d

1. A parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychological development theory, which instruction(s) should the nurse provide to the parent? Select all that apply. A. Set limits on the child's behavior. B. Ignore the child when this behavior occurs. C. Allow the behavior, because this is normal at this age period. D. Provide a simple explanation of why the behavior is unacceptable. E. Punish the child every time the child says "no" to change behavior.

a, d

1. A nurse is removing personal protective equipment when exiting an isolation room. Place the following steps in the order in which they should be implemented. A. Untie the gown at the waist. 1 B. Release the ties of the mask and dispose of the mask in an appropriate trash container. 4 C. Place fingers of the dominant hand inside cuff of other sleeve and pull gown over nondominant hand. 5 D. Remove one glove by touching the outside of the glove with the other gloved hand and without contaminating oneself; dispose of it in an appropriate trash container. 2 E. With the ungloved hand, slip a finger inside the cuff of the other glove and remove it without contaminating oneself and dispose of it in an appropriate trash container. 3 F. With a gown covered hand, pull gown down over the dominant hand, pull gown down over the dominant hand, folding the gown inward and gathering it together as it is pulled down; dispose of it in an appropriate container. 6

a, d, e, b, c, f

1. A nurse is caring for a patient who is dying. The patient is withdrawn and quiet. What should the nurse do? Select all that apply. A. Avoid talking unnecessarily. B. Engage in cheerful dialogue. C. Provide constant reassurance. D. Encourage interaction with family. E. Sit quietly by the bedside periodically.

a, e

1. A nurse identifies that an older adult has long, torturous, yellow toenails. What should the nurse do? A. File the patient's toenails with an emery board. B. Get a referral to a podiatrist to trim the toenails. C. Cut the toenails straight across with a nail clipper. D. Soak the patient's feet in hot water to soften the toenails.

b

1. A nurse is caring for a patient who has no family and has been battling ovarian cancer for 5 years. The patient is now in the terminal stage of the disease and is told that there are no viable curative care options left and is offered a referral to a hospice facility. The nurse sits with the patient after the primary health-care provider leaves. Which statement by the nurse is most appropriate after exploring the patient's feelings? A. "It is unfortunate that there no longer any medical therapies that can be done." B. "Let's explore what we can do together to control your pain and make you comfortable." C. "You'll find that the staff members at the hospice agency will become like family to you." D. "The agency the doctor suggested is excellent, and the people who work there are very supportive."

b

1. After several years of caring for his wife who has Alzheimer's disease, a man admits his wife to a nursing home because he no longer is able to provide the level of care that she needs. When visiting his wife, he begins to cry softly and makes the following comment to the nurse: "I always thought that we would have time to enjoy retirement, but I spent the last few years caring for my wife who no longer knows who I am. I worry about my wife, who is slowly dying, but I am very tired and need some relief." What type of grief is the man experiencing? A. Normal grief B. Anticipatory grief C. Complicated grief D. Dysfunctional grief

b

1. An infant born with an imperforate anus returns from surgery with a colostomy. The nurse assesses the stoma and notes that it is red and edematous. What is the best nursing action based on this finding? A. Elevate the buttocks. B. Document the findings. C. Apply ice immediately. D. Call the health care provider.

b

1. Many people who are independent and perform all of their activities of daily living become dependent and demanding when physically ill and hospitalized. Which defense mechanism should the nurse conclude they are exhibiting? A. Denial B. Regression C. Compensation D. Reaction formation

b

1. The nurse assesses a patient's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? A. Red, hard skin B. Serous drainage C. Purulent drainage D. Warm, painful skin

b

1. The nurse checks for residual before administering a bolus tube feeding of 300 mL to a patient with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take? A. Hold the feeding. B. Re-instill the amount and continue with administering the feeding. C. Elevate the patient's head at least 45 degrees and administer the feeding. D. Discard the residual amount and proceed with administering the feeding.

b

1. Three days after a stressful event, a person can no longer remember what there was to worry about. What defense mechanism should the nurse conclude that the person may be using? A. Regression B. Repression C. Displacement D. Intellectualization

b

On assessment of a middle-aged patient, where should the nurse expect to auscultate bronchovesicular lung sounds? a. Throughout all lung fields b. In the main bronchi. c. In the lower lobes bilaterally d. In the upper and middle lobes bilaterally

b

The nurse is preparing to care for a patient with a diagnosis of metastatic cancer and notes documentation in the patient's chart that the patient is experiencing cachexia. Which finding would the nurse expect to note on assessment of the patient? A. An elevated blood pressure and ascites B. Sunken eyes and a hollow cheek appearance C. Periorbital edema and swelling around the ears D. Generalized edema and the presence of weight gain

b

1. For which physical changes associated with aging should a nurse assess when assisting an older adult with a bath? Select all that apply. A. Increased sweat gland activity B. Decreased pigment cells in hair C. Decreased vascularity of the skin D. Increased sebaceous gland activity E. Increased collagen fibers in the dermis

b, c

1. Protective isolation (neutropenic precautions) is prescribed for a patient who is immunocompromised. What should the nurse do? Select all that apply. A. Wear gloves when entering the patient's room. B. Remove fresh flowers from the patient's room. C. Place a N95 respirator on the patient during transport when outside the room. D. Ensure positive room air pressure of the patient's room relative to the corridor. E. Have people with a respiratory infections wear a mask when in the patient's room. F. Ensure that housekeeping staff use a dry mop when cleaning the floor of the patient's room.

b, c, d

1. A nurse in a home health-care agency is teaching a class about infection control to a group of nursing assistants. Which interventions did the nurse include that interrupts the chain of infection at the mode of transmission stage? Select all that apply. A. Maintain a urinary collection bag below the level of the patient's bladder. B. Shut off the handles of water faucets with a clean, dry paper towel. C. Clean bedside tables routinely with a disinfectant. D. Reposition patients every two hours. E. Keep your fingernails short.

b, c, e

1. A nurse is changing a patient's sterile dressing and performing wound irrigation. Which actions by the nurse maintained sterile technique? Select all that apply. A. Wore an eye shield and a gown B. Used a new sterile piston syringe C. Started the flow of irrigating solution just inside the top edge of the wound D. Dried the skin on either side of the wound by using one gauze pad for each swipe E. Held sterile gloved hands below the waist as much as possible during the procedure F. Poured fluid from a previously opened bottle of normal saline sitting on the patient's bedside table

b, c, e

1. A nurse is caring for several older adults. Which statements by older adults indicate the conflict of ego integrity versus despair according to Erik Erikson's theory of development? Select all that apply. A. "I really don't trust any of my doctors and their treatment plan." B. "I wish that I took more vacations before I got too sick to travel." C. "I don't care what the doctor says; I will do it my way or no way." D. "I hope that in my next lifetime I get the chance to become a doctor." E. "I feel that I will never get better because nothing ever goes well for me."

b, d

1. The day after surgery, a patient says to the nurse, "Since surgery yesterday, I have been having pain when I urinate." Which two types of data is this information? Select all that apply. A. Objective data B. Subjective data C. Tertiary source of data D. Primary source of data E. Secondary source of data

b, d

1. A nurse is caring for a patient with low self-esteem. What can the nurse do to promote the patient's self-esteem? Select all that apply. A. Provide simple choices. B. Assist with setting achievable goals. C. Teach the patient relaxation techniques. D. Point out the patient's past achievements. E. Help the patient to identify personal strengths.

b, d, e

1. An emergency department nurse is caring for a patient who dies unexpectedly. Which of the following should the nurse understand when advising a family member about an autopsy? Select all that apply. A. It can be performed only with the consent of a family member. B. It is an examination of a body to establish the cause of death. C. It is necessary before a certificate of death is issued. D. It is mandatory in the event of a suspicious death. E. It is required in the event of a violent death.

b, d, e

1. Which actions are associated with droplet precautions? Select all that apply. A. Keeping the door of the patient's room closed B. Keeping visitors three feet away from the patient C. Wearing gloves when entering the patient's room D. Wearing a surgical mask when working within three feet of the patient E. Placing a surgical mask on the patient when transporting for procedures

b, d, e

1. An older adult is living in a nursing home because of multiple chronic health problems. Which nursing actions are appropriate to assist the older adult to achieve the task associated with Erikson's stage of integrity versus despair? Select all that apply. A. Engage the patient in social activities. B. Encourage the patient to reminiscence. C. Provide the patient with opportunities to make choices. D. Teach the patient the importance of balancing exercise and rest. E. Give the patient recognition for accomplishments attained during life.

b, e

1. The long-term care nurse is performing assessments on several of the geriatric residents. Which are normal age-related physiological change(s) the nurse expects to note in this age group? Select all that apply. A. Increased heart rate B. Decline in visual acuity C. Decreased respiratory rate D. Decline in long-term memory E. Increased susceptibility to urinary tract infections F. Increased incidence of awakening after sleep onset

b, e, f

1. A 4-year-old is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed on the child because acute lymphocytic leukemia is suspected. The nurse understands that which diagnostic study should confirm this diagnosis? A. Platelet count B. Lumbar puncture C. Bone marrow biopsy D. White blood cell count

c

1. A Spanish-speaking patient arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take? A. Have one of the patient's family members interpret. B. Have the Spanish-speaking triage receptionist interpret. C. Page an interpreter from the hospital's interpreter services. D. Obtain a Spanish-English dictionary and attempt to triage the patient.

c

1. A middle-aged adult fell in the driveway at home and came to the emergency department to ensure that he had not sustained a bone fracture. Which statement made by a patient to the emergency department nurse indicates the developmental task of this age group? A. "If I get a cast, my fiancé will be furious because we're getting married next month and this will ruin the pictures." B. "I don't want you to call my place of employment about health insurance coverage." C. "I must be out of here in a few hours because I have to coach my son's baseball team." D. "If my arm is broken, my friends will get another guy for our golf foursome."

c

1. A nurse is caring for a patient who is reporting pain in the jaw as a result of cardiac ischemia. What word should the nurse use to describe this pain when writing progress notes? A. Cutaneous B. Radiating C. Referred D. Visceral

c

1. A nurse is teaching a group of older adults about safety precautions. What instruction should the nurse give them to prevent the leading cause of injuries in older adults? A. Have your vision evaluated yearly. B. Limit drinking alcohol to one glass a day. C. Rise slowly when moving from a sitting to a standing position. D. Wash your hands with an antimicrobial soap several times a day.

c

1. A patient is admitted to the emergency department with epigastric pain. The nurse asks the patient to identify the intensity of pain using a scale of 0 to 10, with 0 being pain free and 10 reflecting excruciating pain. Which step of the nursing process does this action reflect? A. Analysis B. Planning C. Assessment D. Implementation

c

1. An elderly woman who lost her husband suddenly due to a massive heart attack one week ago came back to the emergency department to thank the nurses for being so kind to her husband. The woman stated, "I am very lonely and can hardly believe that he is gone." Which is an appropriate response by the nurse? A. "I am sure that you have many loving memories that will help when you feel sad." B. "The senior center has various programs to join so you are involved with others." C. "You will be experiencing feelings of grief and loss as you journey forward." D. "Take one day at a time because things will get better as time goes on."

c

1. The emergency department nurse is caring for a patient who has been identified as a victim of physical abuse. In planning care for the patient, which is the priority nursing action? A. Adhering to the mandatory abuse-reporting laws B. Notifying the case worker of the family situation C. Removing the patient from any immediate danger D. Obtaining treatment for the abusing family member

c

1. The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychological development theory, the nurse should make which response? A. "You need to be concerned." B. "You need to monitor the child's behavior closely." C. "At this age the child is developing his own personality." D. "You need to provide more praise to the child to discourage this behavior."

c

1. The nurse develops a plan of care for a patient with deep vein thrombosis. Which patient position or activity in the plan should be included? A. Out-of-bed activities as desired B. Bed rest with the affected extremity kept flat C. Bed rest with elevation of the affected extremity D. Bed rest with the affected extremity in a dependent position

c

1. The nurse is caring for a patient who is on strict bed rest and develops a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? A. Restricting fluids B. Placing a pillow under the knees C. Encouraging active range-of-motion exercises D. Applying a heating pad to the lower extremities

c

1. The nurse is preparing to administer medications through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? A. Position the patient in supine to assist in medication absorption. B. Aspirate the nasogastric tube after medication administration to maintain patency. C. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication. D. Change the suction setting to low intermittent suction for 30 minutes after medication administration.

c

1. The nurse is preparing to insert a nasogastric tube into a patient. The nurse should place the patient in which position for insertion? A. Right side B. Low Fowler's C. High Fowler's D. Supine with the head flat

c

1. The nurse is providing care to a Puerto Rican-American patient who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the most appropriate nursing action for this patient? A. Restrict the number of family members visiting at one time. B. Inform the family that emotional outbursts are to be avoided. C. Make the necessary arrangements so family members can visit. D. Contact the health care provider to speak to the family regarding their behaviors.

c

1. The nurse is providing instructions to the unlicensed assistive personnel (UAP) regarding care of an older patient with hearing loss. Which should the nurse tell the UAP about older patients with hearing loss? A. They are often distracted B. They have middle ear changes C. They respond to low-pitched tones D. They develop moist cerumen production

c

1. The nurse on the day shift walks into a client's room and finds the patient unresponsive. The patient is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which is the next nursing action? A. Open the airway. B. Give the client oxygen. C. Start chest compressions. D. Ventilate with a mouth-to-mask device

c

1. The nurse recognizes that which intervention is unlikely to facilitate effective communication between a dying patient and family? A. The nurse encourages the patient and family to identify and discuss feelings openly. B. The nurse assists the patient and family in carrying out spiritually meaningful practices. C. The nurse makes decisions for the patient and family to relieve them of unnecessary demands. D. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

c

1. The registered nurse is preparing to insert a nasogastric tube in an adult patient. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action? A. Mark the tube at 10 inches. B. Mark the tube at 32 inches. C. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. D. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum.

c

1. What action should the nurse include in the plan of care that is a common hygiene need of all older adults? A. Remove the bottom denture first. B. Assist with daily bathing. C. Apply a skin moisturizer. D. Use deodorant soap

c

1. What safety instruction addresses a major cause of accidental death among people from all developmental levels? A. Resist pressure to engage in high-risk activities. B. Rise slowly to a standing position. C. Wear a seatbelt when in a car. D. Cut all food into small pieces.

c

1. Which response by the nurse is most effective when attempting to reduce a patient's hostility about an event? A. "I am here to help you." B. "You need to calm down." C. "What can I do now to help address the situation?" D. "Do you think you can be objective at this time?"

c

It is important to plot the school-age child's height and weight on a standardized growth chart because: A. Growth spurts are very predictable. B. Boys and girls grow at the same times and rates. C. Individual children will grow according to their own curve. D. We want the child to be able to compare their height and weight to their classmates.

c

The nurse should begin the assessment of the toddler by: A. Doing the most painful sections first. B. Explaining that the assessment will not be painful. C. Engaging the toddler in games to develop rapport. D. Talking to the parent.

c

The patient is receiving external radiation to the neck for cancer of the larynx. The most likely side effect to be expected is: A. Dyspnea B. Diarrhea C. Sore throat D. Constipation

c

When performing a physical assessment for a patient with scoliosis, which physical characteristic should the nurse expect to find during the assessment? a. Nonprotruding, symmetric scapulae b. Exaggerated curvature of the thoracic vertebrae c. Lateral deviation of the spinous processes d. Shoulders and scapulae at a horizontal position

c

Which is the single most important factor to consider when communicating with children? A. presence of the child's parent B. child's physical condition C. child's developmental level D. child's nonverbal behaviors

c

1. A nurse is collecting equipment for several procedures that need to be performed. For which procedure should the nurse wear sterile gloves? Select all that apply. A. Collecting a urine specimen from a closed drainage system for a culture and sensitivity test B. Instilling solution into a nasogastric tube to reestablish patency of the catheter C. Suctioning the oropharynx to maintain airway patency D. Obtaining a specimen for blood glucose monitoring E. Changing a dressing on a central venous catheter F. Inserting a urinary catheter

c, e, f

1. A nurse identifies that a patient is experiencing a developmental crisis specifically associated with middle adulthood. Which assessment identified by the nurse supports this conclusion? A. Inability to postpone satisfaction B. Incapable of facing one's morality C. Problems maintaining peer relationships D. Difficulty achieving a sense of fulfillment

d

1. A nurse is caring for a man with terminal pancreatic cancer. The wife is upset because her husband is quiet and withdrawn and is always suggesting that she go to the cafeteria to get something to eat. Which response by the nurse is therapeutic? A. "Maybe he just wants to sleep, and it is his way of asking you to leave so it is quiet." B. "Would you like the dietary department to bring you something during meal times?" C. "Why don't you bring a bag lunch tomorrow so that he sees that you are not missing a meal?" D. "Try not to take it personally because people who are dying often interact minimally with loved ones."

d

1. A nurse is providing teaching to a patient who is taking an antibiotic for a bacterial infection. Which is important for the nurse to teach the patient to do to help prevent resistance to this antibiotic in the future? A. "Eat some food when taking the medication." B. "Assess yourself for signs of a superinfection." C. "Take the pills evenly spaced around the clock." D. "Complete the entire regimen of medication prescribed."

d

1. A patient with a perforated gastric ulcer is scheduled for surgery. The patient cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this patient? A. Obtain a court order for the surgery. B. Have the charge nurse sign the informed consent immediately. C. Send the patient to surgery without the consent form being signed. D. Obtain a telephone consent from a family member, following agency policy.

d

1. On review of the patient's record, the nurse notes that the admission was voluntary. Based on this information, the nurse anticipates which patient behavior? A. Fearfulness regarding treatment measures. B. Anger and aggressiveness directed toward others. C. An understanding of the pathology and symptoms of the diagnosis. D. A willingness to participate in the planning of the care and treatment plan.

d

1. The clinic nurse is preparing to discuss the concepts of Kohlberg's theory of moral development with a parent. What motivates good and bad actions for the child at the preconventional level? A. Peer pressure B. Social pressure C. Parent's behavior D. Punishment and reward

d

1. The nurse has administered approximately half of an enema solution to a preoperative patient when the patient complains of pain and cramping. Which nursing action is most appropriate at this time? A. Reassure the patient and continue the flow. B. Raise the enema bag so that the solution can be instilled quickly. C. Discontinue the enema and notify the health care provider (HCP). D. Clamp the tubing for 30 seconds and restart the flow at a slower rate.

d

1. The nurse is conducting preoperative teaching with a patient about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the patient? A. Inhale as rapidly as possible. B. Keep a loose seal between the lips and the mouthpiece. C. After maximum inspiration, hold the breath for 15 seconds and exhale. D. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

d

1. The nurse is inserting a nasogastric tube in an adult client. During the procedure, the patient begins to cough and has difficulty breathing. What is the most appropriate nursing action? A. Quickly insert the tube. B. Notify the health care provider immediately. C. Remove the tube and reinsert when the respiratory distress subsides. D. Pull back on the tube and wait until the respiratory distress subsides.

d

1. The nurse is teaching a patient with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the patient to avoid which position that could aggravate breathing? A. Sitting up and leaning on a table B. Standing and leaning against a wall C. Sitting up with the elbows resting on knees D. Lying in a supine position

d

1. The spouse of a patient who is dying tells the nurse, "Even though I want to visit, I can come only once a week because I have work and have a dog that I need to walk and feed." Which defense mechanism does the nurse identify the spouse using? A. Projection B. Sublimation C. Compensation D. Rationalization

d

1. Which statement by an adult child about the adult child's 90-year-old father indicates ageism? A. "My father was always egocentric, but it has gotten worse as he has gotten older." B. "My father's physical status has progressively declined these last few years." C. "I am so tired of him constantly talking about past experiences." D. "I would rather die than reach the useless age of my father."

d

The recommended order for introduction of solid foods is: A. Fruits & vegetables, rice cereal, eggs, meat B. Eggs, rice cereal, meat, fruit C. Meat, eggs, rice cereal D. Rice cereal, pureed fruits & vegetables, meat

d

1. A nurse is caring for a patient who experienced numerous panic attacks. Place the following nursing interventions in the order that they should be performed when caring for this patient. A. Identify which nursing interventions reduce the patient's anxiety level. 5 B. Maintain a nonjudgmental approach when caring for the patient. 2 C. Stay with the patient when the patient is having a panic attack. 4 D. Explore own feelings about people who have panic attacks. 1 E. Assess the patient's level of anxiety. 3

d, b, e, c, a