Nursing 102 exam 2

A nurse working in a long-term care facility uses proper patient care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures? A Carefully assessing the patient care environment B Using two nurses to lift a patient who cannot assist C Wearing a back belt to perform routine duties D Properly documenting the patient lift

a. Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and movement should be documented but are not the primary focus of interventions related to injury prevention.

A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient? Support weight on stronger leg and cane and advance weaker foot forward. A Hold the cane in the same hand of the leg with the most severe deficit. B Stand with as much weight distributed on the cane as possible. C Do not use the cane to rise from a sitting position, as this is unsafe.

a. The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position.

A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply. A. Do full-body pushups in bed six to eight times daily. B. Breathe in and out smoothly during quadriceps drills. C. Place the bed in the lowest position or use a footstool for dangling. D. Dangle on the side of the bed for 30 to 60 minutes. E. Allow the nurse to bathe the patient completely to prevent fatigue. F. Perform quadriceps two to three times per hour, four to six times a day.

b, c, f. Breathing in and out smoothly during quadriceps drills maximizes lung inflation. The patient should perform quadriceps two to three times per hour, four to six times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for 30 to 60 minutes is unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling. The nurse should also encourage the patient to be as independent as possible to prepare for return to normal ambulation and ADLs.

A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient's feet to prevent footdrop? A. Supination B. Dorsiflexion C. Hyperextension D. Abduction

b. For a patient who has footdrop, the nurse should support the feet in dorsiflexion and use a footboard or high-top sneakers to further support the foot. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions would not be used to prevent footdrop.

A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient? A Use the axillae to bear body weight. B Keep elbows close to the sides of the body. C When rising, extend the uninjured leg to prevent weight bearing. D To climb stairs, place weight on affected leg first.

b. The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg to prevent weight bearing when rising from a chair, and advance the unaffected leg first when climbing stairs.

A nurse is ambulating a patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient: A. Grasp the gait belt. B. Stay with the patient and call for help. C. Place feet wide apart with one foot in front. D. Gently slide patient down to the floor, protecting her head. E. Pull the weight of the patient backward against your body. F. Rock your pelvis out on the side of the patient.

c, f, a, e, d, b. If a patient being ambulated starts to fall, you should place your feet wide apart with one foot in front, rock your pelvis out on the side nearest the patient, grasp the gait belt, support the patient by pulling her weight backward against your body, gently slide her down your body toward the floor while protecting her head, and stay with the patient and call for help.

A nurse is caring for a patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? A. Dorsal recumbent position B. Lateral position C. Fowler's position D. Sims' position

c. Fowler's position promotes maximal breathing space in the thoracic cavity and is the position of choice when someone is having difficulty breathing. Lying flat on the back or side or Sims' position would not facilitate respiration and would be difficult for the patient to maintain.

A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient's knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action? Wait a few minutes and then continue the move to the chair. Call for assistance and continue the move with the help of another nurse. Lower the patient back to the side of the bed and pivot her back into bed. Have the patient sit down on the bed and dangle her feet before moving.

c. If a patient becomes faint and knees buckle when moving from bed to a chair, the nurse should not continue the move to the chair. The nurse should lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient's vital signs and for the presence of other symptoms. Another attempt should be made with the assistance of another staff member if vital signs are stable. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to a change in position, and avoid hypotension related to a sudden change in position

A nurse is caring for a patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side? A. Have the patient extend his arms outward and cross his legs on top of a pillow. B. Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side. C. Have the patient cross his arms on his chest and place a pillow between his knees. D. Place a cervical collar on the patient's neck and gently roll him to the other side of the bed.

c. The procedure for logrolling a patient is: (1) Have the patient cross the arms on the chest and place a pillow between the knees; (2) have two nurses stand on one side of the bed opposite the direction the patient will be turned with the third helper standing on the other side and if necessary, a fourth helper at the head of the bed to stabilize the neck; (3) fanfold or roll the drawsheet tightly against the patient and carefully slide the patient to the side of the bed toward the nurses; (4) have one helper move to the other side of the bed so that two nurses are on the side to which the patient is turning; (5) face the patient and have everyone move on a predetermined time, holding the drawsheet taut to support the body, and turn the patient as a unit toward the two nurses.

A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient correctly tells the aide not to place the patient in which position? A. Side-lying B. Fowler's C. Sims' D. Prone

d. The prone position is contraindicated in patients who have spinal problems because the pull of gravity on the trunk when the patient lies prone produces a marked lordosis or forward curvature of the lumbar spine.

What is the leading cause of injury-related deaths in adults 65 and older?

falls Falls are the leading cause of injury-related deaths in adults 65 years and older. Motor vehicle accidents are the next leading cause after falls. Alcoholism and violence can occur but are not the leading cause of injury-related deaths for adults 65 years and older.

Reservoir

growth and multiplication of microorganisms is the natural habitat of the organism

Health care workers may be exposed to a common occupational injury such as:

inadvertent needlestick.

iatrogenic

infection that occurs as a result of a treatment or diagnostic procedure

Possible reservoirs that support organisms pathogenic to humans include

other people, animals, soil, food, water, milk, and inanimate objects.

Any microorganism capable of disrupting normal physiologic body processes is a:

pathogen

The portal of exit is

the point of escape for the organism from the reservoir

The activation of pain receptors is referred to as

transduction

Practicing Basic Principles of Medical Asepsis in Patient Care

*Carry soiled linens or other used articles/equipment so that they do not touch your clothing. *Do not place soiled bed linen or any other items on the floor, which is grossly contaminated. It increases contamination of both surfaces. *Clean the least soiled areas first and then the more soiled ones. This helps prevent having the cleaner areas soiled by the dirtier areas. *Use practices of personal grooming that help prevent spreading microorganisms. Examples include shampooing the hair regularly, keeping hair short or pinned up to limit the possibility of carrying microorganisms on hair shafts, keeping fingernails short and free of broken cuticles and ragged nail edges, and avoiding wearing rings with grooves and stones that may harbor microorganisms.

The nurse is caring for the following clients. Which client requires a negative air flow room?

81-year-old client with active tuberculosis and a productive cough The client who requires a negative air flow room (airborne precautions) is the client with active tuberculosis. Active tuberculosis always requires a negative air flow room; latent tuberculosis does not. Clostridium difficile requires contact precautions, not airborne; therefore, negative air flow is not necessary. Influenza requires droplet precautions, not negative air flow.

When the nurse assists a patient recovering from abdominal surgery to walk, the nurse observes that the patient grimaces, moves stiffly, and becomes pale. The nurse is aware that the patient has consistently refused pain medication. What would be a priority nursing diagnosis for this patient? A. Acute Pain related to fear of taking prescribed postoperative medications B. Impaired Physical Mobility related to surgical procedure C. Anxiety related to outcome of surgery D. Risk for Infection related to surgical incision

A

A nurse is monitoring patients in a hospital setting for acute and chronic pain. Which patients would most likely receive analgesics for chronic pain from the nurse? Select all that apply. A A patient is receiving chemotherapy for bladder cancer B An adolescent is admitted to the hospital for an appendectomy C A patient is experiencing a ruptured aneurysm D A patient who has fibromyalgia requests pain medication E A patient has back pain related to an accident that occurred last year F A patient is experiencing pain from second-degree burns

A, D, E Chronic pain is pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period. Examples are cancer pain, fibromyalgia pain, and back pain. Acute pain is generally rapid in onset and varies in intensity from mild to severe, as occurs with an emergency appendectomy, a ruptured aneurysm, and pain from burns.

A nurse who is administering medications to patients in an acute care setting studies the pharmacokinetics of the drugs being administered. Which statements accurately describe these mechanisms of action? Select all that apply. A. Distribution occurs after a drug has been absorbed into the bloodstream and is made available to body fluids and tissues. B. Metabolism is the process by which a drug is transferred from its site of entry into the body to the bloodstream. C. Absorption is the change of a drug from its original form to a new form, usually occurring in the liver. D. During first-pass effect, drugs move from the intestinal lumen to the liver by way of the portal vein instead of going into the system's circulation. E. The gastrointestinal tract, as well as sweat, salivary, and mammary glands, are routes of drug absorption. F. Excretion is the process of removing a drug, or its metabolites (products of metabolism), from the body.

A, D, F

A nurse is preparing medications for patients in the ICU. The nurse is aware that there are patient variables that may affect the absorption of these medications. Which statements accurately describe these variables? Select all that apply. A. Patients in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed. B. Some people experience the same response with a placebo as with the active drug used in studies. C. People with liver disease metabolize drugs more quickly than people with normal liver functioning. D. A patient who receives a pain medication in a noisy environment may not receive full benefit from the medication's effects. E. Oral medications should not be given with food as the food may delay the absorption of the medications. F. Circadian rhythms and cycles may influence drug action.

A,B,D,F

A nurse is caring for patients in a hospital setting. Which patient would the nurse place at risk for pain related to the mechanical activation of pain receptors? A. An older adult on bedrest following cervical spine surgery B. A patient with a severe sunburn being treated for dehydration C. An industrial worker who has burns caused by a caustic acid D. A patient experiencing cardiac disturbances from an electrical shock

A. An older adult on bedrest following cervical spine surgery

The nurse has discovered a fire in the care facility and is implementing the "RACE" acronym when responding to it. When implementing the "A" in this acronym, what should the nurse do?

Activate the fire alarm and notify the appropriate person. RACE stands for Rescue - Alarm - Contain - Extinguish. The "A" in the acronym RACE stands for "activate the fire alarm and notify the appropriate person."

A health care provider orders a pain medication for a postoperative patient that is a PRN order. When would the nurse administer this medication? A. A single dose during the postoperative period B. Doses administered as needed for pain relief C. One dose administered immediately D. Doses routinely administered as a standing

B

A nurse administers a dose of an oral medication for hypertension to a patient who immediately vomits after swallowing the pill. What would be the appropriate initial action of the nurse in this situation? A. Readminister the medication and notify the primary care provider. B. Readminister the pill in a liquid form if possible. C. Assess the vomit, looking for the pill. D. Notify the primary care provider.

C

A nurse is administering heparin subcutaneously to a patient. What is the correct technique for this procedure? A. Aspirate before giving and gently massage after the injection. B. Do not aspirate; massage the site for 1 minute. C. Do not aspirate before or massage after the injection. D. Massage the site of the injection; aspiration is not necessary but will do no harm.

C. Do not aspirate before or massage after the injection.

A nurse who gives subcutaneous and intramuscular injections to patients in a hospital setting attempts to reduce discomfort for the patients receiving the injections. Which technique is recommended? A. The nurse selects a needle of the largest gauge that is appropriate for the site and solution to be injected. B. The nurse injects the medication into contracted muscles to reduce pressure and discomfort at the site. C. The nurse uses the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track. D. The nurse applies vigorous pressure in a circular motion after the injection to distribute the medication to the intended site.

C. The nurse uses the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track

Included in the targeted infections are four categories that are responsible for a majority of HAIs in the acute care hospital setting (CDC, 2014b). These include:

Catheter-associated urinary tract infection (CAUTI) Surgical site infection (SSI) Central line-associated bloodstream infection (CLABSI) Ventilator-associated pneumonia (VAP)

The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. Which action by the nurse is appropriate? Keep splashes on the sterile field to a minimum Cover the nose and mouth with gloved hands if a sneeze is imminent Use forceps soaked in a disinfectant Consider the outer 1 in of the sterile field as contaminated

Consider the outer 1 in of the sterile field as contaminated

A patient is postoperative following an emergency cesarean section birth. The patient asks the nurse about the use of pain medications following surgery. What would be a correct response by the nurse? A. "It's not a good idea to ask for pain medication regularly as it can be addictive." B. "It is better to wait until the pain is severe before asking for pain medication." C. "It's natural to have to put up with pain after surgery and it will lessen in intensity in a few days." D. "Your doctor has prescribed pain medications for you, which you should request when you have pain."

D

A nurse is administering phenytoin via a gastric tube to a patient who is receiving tube feedings. What would be an appropriate action of the nurse in this situation? Discontinue the tube feeding and leave the tube clamped for required period of time before and after medication administration. Notify the primary care provider that medication cannot be given to the patient at this time via the gastric tube. Remove the tube in place and replace it with another tube prior to administering the medication. Flush the tube with 60 mL of water prior to administering the medication.

Discontinue the tube feeding and leave the tube clamped for required period of time before and after medication administration.

A nurse uses a whirlpool to relax a patient following intense physical therapy to restore movement in the patient's legs. What is a potent pain-blocking neuromodulator, released through relaxation techniques? Prostaglandins Substance P Endorphins Serotonin

Endorphins are produced at neural synapses at various points along the CNS pathway. They are powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria. It is thought that endorphins are released through pain relief measures, such as relaxation techniques. Prostaglandins, substance P, and serotonin (a hormone that can act to stimulate smooth muscles, inhibit gastric secretion, and produce vasoconstriction) are neurotransmitters or substances that either excite or inhibit target nerve cells.

The nurse is caring for a hospital client who was admitted for an exacerbation of congestive heart failure but who has just been diagnosed with Clostridium difficile-related diarrhea. How will the nurse categorize this development?

Health care-associated infection (HAI)

Over time, regular exercise leads to improved pulmonary functioning. Improvements in pulmonary function include:

Improved alveolar ventilation Decreased work of breathing Improved diaphragmatic excursion

typical primary exit routes

In humans, common portals of exit include the respiratory, gastrointestinal, and genitourinary tracts, as well as breaks in the skin. Blood and tissue can also be portals of exit for pathogens.

Over time, regular exercise results in cardiovascular conditioning and produces the following benefits:

Increased efficiency of the heart Decreased heart rate and blood pressure Increased blood flow to all body parts Improved venous return Increased circulating fibrinolysin (substance that breaks up small clots)

The more a person exercises, the more strength the person has to exercise or work in the future. Regular exercise produces the following benefits:

Increased muscle efficiency (strength) and flexibility Increased coordination Reduced bone loss Increased efficiency of nerve impulse transmission

Other benefits of exercise on the metabolic processes include:

Increased triglyceride breakdown Increased gastric motility Increased production of body heat

An infection occurs as a result of a cyclic process, consisting of six components, as shown in Figure 24-1 (on page 597). These components are:

Infectious agent Reservoir Portal of exit Means of transmission Portals of entry Susceptible host

An organism's potential to produce disease in a person depends on a variety of factors

Number of organisms Virulence: of the organism, or its ability to cause disease Competence of the person's immune system Length and intimacy (extent) of the contact between the person and the microorganism

The most common injuries associated with exercise:

Orthopedic problems caused by irritation of bones, tendons, ligaments, and sometimes muscles

A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task? Place the bottle cap on the table with the edges down Hold the bottle inside the edge of the sterile field Hold the bottle with the label side opposite the palm of the hand Pour the solution from a height of 4 to 6 in (10 to 15 cm)

Pour the solution from a height of 4 to 6 in (10 to 15 cm)

A patient who is having a myocardial infarction reports pain that is situated in the neck. The nurse documents this as what type of pain?

Referred pain

While discussing home safety with the nurse, a patient admits that she always smokes a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for this patient? Impaired gas exchange related to cigarette smoking Anxiety related to inability to stop smoking Risk for suffocation related to unfamiliarity with fire prevention guidelines Deficient knowledge related to lack of follow-through of recommendation to stop smoking

Risk for suffocation related to unfamiliarity with fire prevention guidelines

A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? The nurse carries the patients' soiled bed linens close to the body to prevent spreading microorganisms into the air The nurse places soiled bed linens and hospital gowns on the floor when making the bed The nurse moves the patient table away from the nurse's body when wiping it off after a meal The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items

The nurse moves the patient table away from the nurse's body when wiping it off after a meal

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. How should the nurse best perform chest auscultation?

Use a stethoscope that remains in the client's room

Contact Precautions

Use these for patients who are infected or colonized by a multidrug-resistant organism (MDRO). Place the patient in a private room, if available. Wear PPE whenever you enter the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient's environment. Change gloves after having contact with infective material. Remove PPE before leaving the patient environment, and wash hands with an antimicrobial or waterless antiseptic agent. Limit movement of the patient out of the room. Avoid sharing patient-care equipment.

Airborne Precautions

Use these for patients who have infections that spread through the air such as tuberculosis, varicella (chicken pox), and rubeola (measles). Place patient in a private room that has monitored negative air pressure in relation to surrounding areas, 6 to 12 air changes per hour, and appropriate discharge of air outside, or monitored filtration if air is recirculated. Keep door closed and patient in room. Wear a respirator when entering room of patient with known or suspected tuberculosis. If patient has known or suspected rubeola (measles) or varicella (chicken pox), respiratory protection should be worn unless the person entering room is immune to these diseases. Transport patient out of room only when necessary and place a surgical mask on the patient if possible. Consult CDC guidelines for additional prevention strategies for tuberculosis.

Droplet Precautions

Use these for patients with an infection that is spread by large-particle droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. Use a private room, if available. Door may remain open. Wear PPE upon entry into the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient's environment. Transport patient out of room only when necessary and place a surgical mask on the patient if possible. Keep visitors 3 ft from the infected person.

A patient reports abdominal pain that is difficult to localize. The nurse documents this as which type of pain?

Visceral

A nurse is preparing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply. A. Instruct the patient to avoid sudden position changes that may cause dizziness. B. Recommend that the patient restrict fluid until after exercising is finished. C. Instruct the patient to push a little further beyond fatigue each session. D. Instruct the patient to avoid exercising in very cold or very hot temperatures. F. Encourage the patient to modify exercise if weak or ill. G. Recommend that the patient consume a high-carb, low-protein diet.

a, d. Teaching points for exercising for a patient with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures. The nurse should also instruct the patient to provide for adequate hydration, respect fatigue by not pushing to the point of exhaustion, and avoid exercise if weak or ill. Older adults should consume a high-protein, high-calcium, and vitamin D-enriched diet.