Nursing 112 Final Exam

1. The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. Which nutrient will the nurse most likely increase after collaboration with dietitian? a. Fat b. Protein c. Vitamin E d. Carbohydrate

b. Protein Rationale: Protein needs are especially increased in supporting the activity of wound healing. The physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals of zinc and copper.

1. The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. The patient is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. Which level of preventive care is this patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion

b. Secondary prevention Rationale: Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention.

1. The nurse is caring for a patient in the emergency department with an injured elbow. Which type of joint will the nurse assess? a. Fibrous b. Synovial c. Synergistic d. Cartilaginous

b. Synovial Rationale: Synovial joints, or true joints, are freely moveable and the most mobile, numerous, and anatomically complex body joints.

1. A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check? a. Vitamin E b. Potassium c. Albumin d. Sodium

c. Albumin Rationale: Normal wound healing requires proper nutrition. Serum proteins are biochemical indicators of malnutrition, and serum albumin is probably the most frequently measured of these parameters. The best measurement of nutritional status is prealbumin b/c it reflects not only what the patient has ingested but also what the body has absorbed, digested, and metabolized.

1. When reviewing the allergy history of a patient, the nurse notes that the patient is allergic to penicillin. Based on this finding, the nurse would question an order for which class of antibiotics? a. Tetracyclines b. Sulfonamides c. Cephalosporins d. Quinolones

c. Cephalosporins Rationale: Decreased WBC counts are an indication of reduction of infection and are a therapeutic effect of antibiotic therapy.

1. A patient has a urinary tract infection. The nurse knows that which class of drugs is especially useful for such infections? a. Macrolides b. Carbapenems c. Sulfonamides d. Tetracyclines

c. Sulfonamides Rationale: These achieve very high concentrations in the kidneys, through which they are eliminated. Therefore, they are often used in the treatment of UTIs.

1. A nurse is preparing to perform a complete physical examination on a weak, older-adult patient with bilateral basilar pneumonia. Which position will the nurse use? a. Prone b. Sims c. Supine d. Lateral recumbent

c. Supine Rationale: Supine is the most normally relaxed position. If the patient becomes short of breath easily, raise the head of the bed. Supine would be easiest.

1. A nurse is using Watson's model to provide care to patients. Which carative factor will the nurse use? a. Maintaining belief b. Instilling faith-hope c. Maintaining ethics d. Instilling values

b. Instilling faith-hope Rationale: Watson has 10 carative factors, one of which is instilling faith-hope.

1. After performing foot care, the nurse checks the medical record and discovers that the patient has a foot disorder caused by a virus. Which condition did the nurse most likely observe? a. Corns b. A callus c. Plantar warts d. Athlete's foot

c. Plantar warts Rationale: Plantar warts appear on the sole of the foot and are caused by papillomavirus.

The healthcare provider orders a patient to be given 1 tablespoon (Tbsp) of milk of magnesium (MOM). How many milliliters (mL) would the nurse give?

30mL

1. The patient is diagnosed with athlete's foot (tinea pedis). The patient says that he is relieved because it is only athlete's foot, and it can be treated easily. Which information should the nurse consider when formulating a response to the patient? a. Contagious with frequent recurrences b. Helpful to air-dry feet after bathing c. Treated with salicylic acid d. Caused by lice

a. Contagious with frequent recurrences Rationale: Athlete's foot spreads to other body parts, especially the hands. It is contagious and frequently recurs.

1. The nurse is caring for a patient who is immobile. The nurse frequently checks the patient for impaired skin integrity. What is the rationale for the nurse's action? a. Inadequate blood flow leads to decreases tissue ischemia b. Patients with limited caloric intake develop thicker skin c. Pressure reduces circulation to affected tissue d. Verbalization of skin care needs is decreased

c. Pressure reduces circulation to affected tissue

A nurse is assessing body alignment. What is the nurse monitoring? a. The relationship of one body part to another while in different positions b. The coordinated efforts of the musculoskeletal and nervous systems c. The force that occurs in a direction to oppose movement d. The inability to move about freely

a. The relationship of one body part to another while in different positions Rationale: The terms alignment and posture are similar and refer to the positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Body alignment means that the individual's center of gravity is stable.

1. The nurse is caring for a patient with a stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient? a. Partial thickness wound repair b. Full thickness wound repair c. Primary intention d. Tertiary intention

b. Full thickness wound repair Rationale: Stage IV pressure ulcers are full thickness wounds that extend into the dermis and heal by scar formation b/c the deeper structures do not regenerate, hence the need for full thickness repair.

1. The patient is brought to the emergency department with possible injury to the left shoulder. Which area will the nurse assess to best determine joint mobility? a. The patient's gait b. The patient's range of motion c. The patient's ethnic influences d. The patient's fine-motor coordination

b. The patient's range of motion

1. A nurse is teaching about the transtheoretical model of change. In which order will the nurse place the progression of the stages from the beginning to end? i. Action ii. Preparation iii. Maintenance iv. Contemplation v. Precontemplation a. 5, 4, 2, 1, 3 b. 2, 5, 4, 3, 1 c. 4, 5, 3, 1, 2 d. 1, 5, 2, 3, 4

a. 5, 4, 2, 1, 3

1. A nurse is teaching a community group of school-aged parents about safety. The proper fitting of which safety item is most important for the nurse to include in the teaching session? a. A bicycle helmet b. Soccer shin guards c. Swimming goggles d. Baseball sliding shorts

a. A bicycle helmet Rationale:Head injuries are a major cause of death, with bicycle accidents being one of the major causes of such injuries. Proper fit of the helmet helps to decrease head injuries resulting from the bicycle accidents.

1. The nurse is starting an exercise program in a local community as a health promotion project. Which information will the nurse include in the teaching session? a. A cool-down period lasts about 5 to 10 minutes b. The purpose of weight training is to bulk up muscles c. Resistance training is appropriate for warm-up and cool-down periods d. Aerobic exercise should be done 3 to 5 times per week for about 20 minutes

a. A cool-down period lasts about 5 to 10 minutes

1. The nurse is caring for an older-adult patient with Alzheimer's disease who is ambulatory but requires total assistance with activities of daily living (ADLs). The nurse notices that the patient is edentulous. Which area should the nurse assess? a. Assess oral cavity b. Assess room for drafts c. Assess ankles for edema d. Assess for reduced sensations

a. Assess oral cavity

1. The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take to minimize the patient's risk for injury? a. Assess the patient b. Gather restraint supplies c. Try alternatives to restraints d. Call the health care provider for a restraint order

a. Assess the patient Rationale: When a patient becomes suddenly confused, the priority is to assess the patient, to identify the reason for change in behavior, and to try to eliminate the cause.

1. A nurse follows the "ethics of care" when working with patients. Which action will the nurse take? a. Becomes the patient's advocate based on the patient's wishes b. Makes decisions for the patient solely using analytical principles c. Uses only intellectual principles to determine what is best for the patient d. Ignores unequal family relationships since that is a personal matter for the family

a. Becomes the patient's advocate based on the patient's wishes Rationale: An ethic of care places the nurse as the patient's advocate, solving ethical dilemmas by attending to relationships and by giving priority to each patient's unique personhood.

1. A nurse attends a seminar on nursing theories for caring. Which information from the nurse indicates a correct understanding of these theories? a. Benner identifies caring as highly connected involving patient and nurse b. Swanson develops four caring processes to convey caring in nursing c. Watson's transcultural caring views inclusion of culture as caring d. Leininger's theory places care before cure and is transformative

a. Benner identifies caring as highly connected involving patient and nurse Rationale: Benner believes caring is highly connected involving each nurse-patient encounter.

1. In making rounds, the nurse meets a patient for the first time. The nurse asks the patient when they usually take their morning medications. What does knowing the patient allow the nurse to do? a. Choose the most appropriate time to give the medication b. Know what the information to put on the medication error report form c. Explain to the patient that the medication will not be given at the usual time d. Evaluate whether or not the patient is taking the medication correctly at home

a. Choose the most appropriate time to give the medication Rationale:"Knowing the patient" is at the core of the process nurses use to make clinical decisions. Knowing when the patient normally takes the medication will allow the nurse to keep the patient on as near normal a schedule as possible.

1. The nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency with peripheral neuropathy and urinary incontinence. On which areas does the nurse focus care? a. Decreased pain sensation and increased risk of skin impairment b. Decreased caloric intake and accelerated wound healing c. High risk for skin infection and low saliva pH level d. High risk for impaired venous return and dementia

a. Decreased pain sensation and increased risk of skin impairment Rationale: Patients with paralysis, circulatory insufficiency, or peripheral neuropathy (nerve damage) are unable to sense an injury to the skin (decreased pain sensation). The presence of urinary incontinence, circulatory insufficiency, and neuropathy can combine to result in breakdown, so the patient has an increased risk for skin impairment.

1. The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says, "I always bathe in the evening." Which action by the nurse is best? a. Defer the bath until the evening and pass on the information to the next shift b. Tell the patient that daily morning baths are the "normal" routine c. Explain the importance of maintaining morning hygiene practices d. Cancel hygiene for the day and attempt again in the morning

a. Defer the bath until the evening and pass on the information to the next shift Rationale: Allow the patient to follow normal hygiene practices. Patients have individual preferences and knowing those preferences promotes individualized care for the patient.

1. The nurse is reviewing the culture results of a patient with an infection, and notes that the culture indicates a gram-positive organism. Which generation of cephalosporin is most appropriate for this type of infection? a. First-generation b. Second-generation c. Third generation d. Fourth generation

a. First-generation Rationale:These provide excellent coverage against gram-positive bacteria but limited coverage against gram-negative bacteria.

1. The nurse is caring for a patient with impaired physical mobility. Which potential complications will the nurse monitor for in this patient? Select all that apply. a. Foot drop b. Somnolence c. Hypostatic pneumonia d. Impaired skin integrity e. Increase socialization

a. Foot drop c. Hypostatic pneumonia d. Impaired skin integrity

The nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking. Which health care model is the nurse following? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs

a. Health belief model Rationale:The health belief model addresses the relationship between a person's beliefs and behaviors.

1. Match the examples to the areas the nurse will promote connectedness for patient's spirituality needs. a. Intrapersonally b. Interpersonally Transpersonally

a. Intrapersonally - connection with oneself b. Interpersonally - connection with others and the environment c. Transpersonally - connection with the unseen, God, or a higher power

1. The nurse is caring for a patient with inner ear problems. Which goal is the priority? a. Maintain balance b. Maintain proprioception c. Maintain muscle strength d. Maintain body alignment

a. Maintain balance Rationale: Within the inner ear are the semicircular canals, three fluid-filled structures that help maintain balance.

1. A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess? a. Perception of functioning b. Socioeconomic factors c. Cultural background d. Family practices

a. Perception of functioning Rationale: Internal variables include a person's developmental stage, intellectual background, perception of functioning, and emotional and spiritual factors.

1. The nurse is completing an assessment of the patient's skin integrity. Which assessment is the priority? a. Pressure points b. Breath sounds c. Bowel sounds d. Pulse points

a. Pressure points Rationale: Observe pressure points such as bony prominences. The nurse continually assesses the skin for signs of ulcer development.

1. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first? a. Provide analgesic medications as ordered b. Avoid accidentally removing the drain c. Don sterile gloves d. Gather supplies

a. Provide analgesic medications as ordered Rationale: B/c removal of dressings is painful, if often helps to give an analgesic at least 30 minutes before exposing a wound and changing the dressing.

1. A nurse notices that a patient has a structural curvature of the spine associated with vertebral rotation. Which condition will the nurse most likely find documented in the patient's medical record? a. Scoliosis b. Arthritis c. Osteomalacia d. Osteogenesis

a. Scoliosis

1. The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver's license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next? a. Stand to the side of the patient's eye and observe the cornea b. Conclude that the glasses were lost during the accident c. Notify the ambulance personnel for missing glasses d. Ask the patient where the glasses are

a. Stand to the side of the patient's eye and observe the cornea Rationale: Determine if the patient wears contact lenses, especially in patients who are unresponsive. They can cause severe corneal injury when left in place too long.

1. A nurse is teaching a health promotion class about isotonic exercises. Which types of exercises will the nurse give as examples? a. Swimming, jogging, and bicycling b. Tightening or tensing of muscles without moving body parts c. Quadriceps set exercises and contraction of the gluteal muscles d. Push-ups, hip lifting, pushing feet against a footboard on the bed

a. Swimming, jogging, and bicycling Rationale: Examples of isotonic exercises are walking, swimming, dance aerobics, jogging, bicycling, and moving arms and legs with light resistance.

1. Which nursing observation will indicate the patient is at risk for pressure ulcer formation? a. The patient has fecal incontinence b. The patient ate 2/3 of breakfast c. The patient has a raised red rash on the right shin d. The patient's capillary refill is less than 2 seconds

a. The patient has fecal incontinence Rationale: The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence.

1. The nurse is dressed and is preparing to care for a patient in the perioperative area. The nurse has scrubbed hands and has donned a sterile gown and gloves. Which action will indicate a break in sterile technique? a. Touching clean protective eyewear b. Standing with hands above waist area c. Accepting sterile supplies from the surgeon d. Staying with the sterile table once it is open

a. Touching clean protective eyewear Rationale: Touching nonsterile (clean) protective eyewear once gowned and gloved with sterile gown and gloves would indicate a break in sterile technique. Sterile objects remain sterile only when touched by another sterile object.

1. The nurse is caring for a patient who has multiple ticks on lower legs and body. What should the nurse do to rid of the patient of ticks? a. Use blunt tweezers and pull upward with steady pressure b. Burn the ticks with a match or small lighter c. Allow the ticks to drop off by themselves d. Apply miconazole and cover with plastic

a. Use blunt tweezers and pull upward with steady pressure Rationale: Using blunt tweezers, grasp the tick as close to the head as possible and pull upward with even, steady pressure. Hold until the tick pulls out, usually for about 3 to 4 minutes. Save the tick in a plastic bag, and put it in the freezer if necessary to identify the type of tick b/c ticks transmit several diseases to people, they must be removed.

1. The patient's blood pressure is 140/60. Which value will the nurse record for the pulse pressure? a. 60 b. 80 c. 140 d. 200

b. 80 Rationale:The difference between the systolic and diastolic pressure is the pulse pressure (140 -60 = 80).

1. The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event? a. Lack of blood incompatibility with a blood transfusion b. A surgical sponge is left in the patient's incision c. Pulmonary embolism after lung surgery d. Stage II pressure ulcer

b. A surgical sponge is left in the patient's incision Rationale:The Centers for Medicare and Medicaid Services names select serious reportable event as Never Events (1.e., adverse events that should never occur in a health care setting). A surgical sponge left in a patient's incision is a Never Event.

1. The nurse is assessing a patient for possible lead poisoning. Which patient is the nurse most likely assessing? a. A teenager b. A toddler c. A young adult d. A adolescent

b. A toddler Rationale: The incidence of lead poisoning is highest in late infancy and toddlerhood. Children at this stage explore the environment and, b/c of their increased level of oral activity, put objects in their mouths.

1. A nurse is providing AM care to patients. Which action will the nurse take? a. Soaks feet of patient with peripheral vascular disease b. Applies CHG solution to wash perineum of patient with a stroke c. Cleanses eye from outer canthus to inner canthus of patient with diabetes d. Uses long, firm stroke to wash legs of patient with blood-clotting disorder

b. Applies CHG solution to wash perineum of patient with a stroke Rationale: CHG is safe to use on the perineum and external mucosa.

1. The nurse is caring for a group of patients. Which task can the nurse delegate to the nursing assistive personnel? a. Assessing a surgical patient for risk of pressure ulcers b. Applying an elastic bandage to a medical-surgical patient c. Treating a pressure ulcer on the buttocks of a medical patient d. Implementing negative pressure wound therapy on a stable patient

b. Applying an elastic bandage to a medical-surgical patient

1. The nurse is preparing to life and reposition a patient. Which action will the nurse take first? a. Position a drawsheet under the patient b. Assess weight to determine assistance needs c. Delegate the task to a nursing assistive personnel d. Attempt to manually lift the patient alone before asking for assistance

b. Assess weight to determine assistance needs

1. The patient requires temperatures to be taken every 2 hours. Which task will the nurse assign to an RN? a. Using appropriate route and device b. Assessing changes in body temperature c. Being aware of the usual values of the patient d. Obtaining temperature measurement at ordered frequency

b. Assessing changes in body temperature

1. A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel? a. Determining the level of comfort b. Changing the patient's position c. Identifying immobility hazards d. Assessing circulation

b. Changing the patient's position Rationale: The skill of moving and positioning patients in bed can be delegated to the NAP.

1. The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first? a. Maintain a narrow base of support b. Dangle the patient at the bedside c. Encourage isometric exercises d. Suggest a high-calcium diet

b. Dangle the patient at the bedside

1. The infection control nurse is reviewing data for the medical-surgical unit. The nurse notices an increase in post-op infections from Aspergillus. Which type of health care-associated infection will the nurse report? a. Vector b. Exogenous c. Endogenous d. Suprainfection

b. Exogenous Rationale: An exogenous infection comes from microorganisms found outside the individual such as Salmonella, Clostridium tetani, and Aspergillus.

The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2½ hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs

b. Holistic health model Rationale:The holistic health model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy.

1. The nurse collects the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient? a. Imbalanced nutrition: less than body requirements b. Ineffective peripheral tissue perfusion c. Risk for infection d. Acute pain

b. Ineffective peripheral tissue perfusion Rationale: The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has resulted in tissue damage.

1. An adolescent tells the nurse that a health professional said the fibrous tissue that connects bone and cartilage was strained in a sporting accident. On which structure will the nurse focus an assessment? a. Tendon b. Ligament c. Synergistic muscle d. Antagonistic muscle

b. Ligament Rationale:Ligaments are white, shiny, and flexible bands of fibrous tissue that bind joints and connect bones and cartilage. Tendons are strong, flexible, and inelastic as they serve to connect muscle to bone.

1. The nurse is assessing an immobile patient for deep vein thrombosis (DVT). Which action will the nurse take? a. Remove elastic stockings every 4 hours b. Measure the calf circumference of both legs c. Lightly rub the lower leg for redness and tenderness d. Dorsiflex the foot while assessing for patient discomfort

b. Measure the calf circumference of both legs Rationale: Measure and record it daily as an assessment for DVT. Unilateral increases in calf circumference are an early indication of thrombosis.

A nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first? a. Anxiety b. Not eating c. Mental health d. Not seeing family members

b. Not eating Rationale:According to Maslow, in all cases an emergent physiological need takes precedence over a higher-level need. Nutrition is a physiological need and should be addressed first.

1. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer? a. Resistance b. Pressure c. Weight d. Stress

b. Pressure Rationale: Pressure is the main element that causes pressure ulcers. 3 pressure-related factors contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance.

1. The patient has a terminal diagnosis and is very near death. When the nurse assesses the patient and finds no pulse or blood pressure, the family begins sobbing and hugging each other. Some family members hold the patient's hand. The nurse is overwhelmed by the presence of grief and leaves the room. What is the nurse demonstrating? a. Caring touch b. Protective touch c. Therapeutic touch d. Task-oriented touch

b. Protective touch Rationale: It is the kind of touch that protects the nurse emotionally. A nurse withdraws or distances herself and himself from a patient when he or she is unable to tolerate suffering or needs to escape from a situation that is causing tension.

A nurse is using the World Health Organization definition of health to provide care. Which area will the nurse focus on while providing care? a. Focusing on helping patients be disease free b. Providing care that involves the whole person c. Assuring that care is strictly personal in nature d. Directing focus only on the pathological state

b. Providing care that involves the whole person Rationale:The World Health Organization (WHO) defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." Therefore, nurses' attitudes towards health and illness should consider the total person as well as the environment in which the person lives.

1. The medical-surgical acute care patient has received a nursing diagnosis of impaired skin integrity. Which health care team member will the nurse consult? a. Respiratory therapist b. Registered dietitian c. Case manager d. Chaplain

b. Registered dietitian Rationale: Refer patients with pressure ulcers to the dietitian for early intervention for nutritional problems. Adequate calories, protein, vitamins, and minerals promote wound healing for the impaired skin integrity.

1. A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient? a. Hypostatic pneumonia b. Renal stones c. Pressure ulcers d. Thrombus formation

b. Renal stones Rationale: Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters. Immobilized patients are at risk for calculi b/c they frequently have hypercalcemia.

1. Which action indicates a nurse is using caring touch with a patient? a. Insert a catheter b. Rubs a patient's back c. Prevents a patient from falling d. Administers an injection

b. Rubs a patient's back Rationale: It is the way a nurse holds a patient's hand, gives a back massage, or gently positions a patient.

1. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV

b. Stage II Rationale: The is a stage II pressure ulcer b/c it presents as partial-thickness skin loss involving epidermis and dermis. The ulcer presents clinically as an abrasion, blister, or shallow crater.

1. The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the temporary need for a restraint? a. The patient refuses to all for help to go to the bathroom b. The patient continues to remove the nasogastric tube c. The patient gets confused regarding the time at night d. The patient does not sleep and continues to ask for items

b. The patient continues to remove the nasogastric tube Rationale: Patients who are confused, disoriented, and wander or repeatedly fall or try to remove medical devices often require the temporary use of restraints to keep them safe. Restraints can be used to prevent interruption of therapy.

1. The nurse is completing a skin risk assessment using the Braden scale. The patient has slight sensory impairment, has skin that rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient? a. 15 b. 17 c. 20 d. 23

c. 20 Rationale: With use of the Braden scale, the total score is a 20. The patient receives 3 for slight sensory perception impairment, 4 for skin being rarely moist, 3 for walks occasionally, 3 for slightly limited mobility, 4 for intake of meals, and 4 for no problem with friction and shear.

1. A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition? a. Thermometer b. Elastic stockings c. Blood pressure cuff d. Sequential compression devices

c. Blood pressure cuff

1. A patient presents with heatstroke. The nurse uses cool pack, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss? a. Radiation b. Conduction c. Convection d. Evaporation

c. Convection Rationale: Convection is the transfer of heat away from the body by air movement.

1. The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate? a. Monitor the wound b. Document the wound c. Debride the wound d. Manage drainage from wound

c. Debride the wound Rationale: Debridement is the removal of nonviable necrotic (black) tissue. Removal is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base for healing. A wound will not move through the phases of healing if the wound is infected.

1. The nurse is caring for a patient who is immobile. The nurse wants to decrease the formation of pressure ulcers. Which action will the nurse take first? a. Offer favorite fluids b. Turn the patient every 2 hours c. Determine the patient's risk factors d. Encourage increased quantities of carbohydrates and fats

c. Determine the patient's risk factors

1. The patient has a colostomy but has not yet been able to look at it. The nurse teaches the patient how to care for the colostomy. The nurse sits with the patient, and together they form a plan on how to approach dealing with colostomy care. Which caring process is the nurse performing? a. Knowing b. Doing for c. Enabling d. Maintaining belief

c. Enabling Rationale: Enabling is facilitating another's passage through a life transition and unfamiliar events. Working with the patient to find alternate ways to perform the task is doing just that.

1. The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of tissue will the nurse expect to observe when the wound is healing? a. Eschar b. Slough c. Granulation d. Purulent drainage

c. Granulation Rationale: Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing.

1. The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the teaching session? a. Treatment is use of regular shampoo b. Products containing lindane are most effective c. Head lice may spread to furniture and other people d. Manual removal is not a realistic option as treatment

c. Head lice may spread to furniture and other people Rationlae: Head lice are difficult to remove and spread to furniture and other people if not treated.

1. The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the nurse document this ulcer in the patient's medical record? a. Stage I pressure ulcer b. Healing stage II pressure ulcer c. Healing stage III pressure ulcer d. Stage III pressure ulcer

c. Healing stage III pressure ulcer Rationale: When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled with the words "healing stage".

1. The nurse reviews the laboratory results for a patient and determines the viscosity of the blood is thick. Which laboratory result did the nurse check? a. Arterial blood gas b. Blood culture c. Hematocrit d. Potassium

c. Hematocrit Rationale: Hematocrit, or percentage of RBCs in the blood, determines blood viscosity.

1. The nurse is caring for a patient who cannot bear weight but needs to be transferred from the bed to a chair. The nurse decides to use a transportable hydraulic lift. What action indicates the nurse is aware of appropriate hydraulic lift use? a. Places a horseshoe-shaped base on the opposite side of the chair b. Removes straps before lowering the patient to the chair c. Hooks longer straps to the bottom of the sling d. Attaches short straps to the bottom of the sling

c. Hooks longer straps to the bottom of the sling Rationale: The nurse should attach the hooks on the strap to the holes in the sling. Short straps hook to top holes and longer straps hook to the bottom of the sling.

1. The nurse is caring for a patient with a stage IV pressure ulcer. Which nursing diagnosis does the nurse add to the care plan? a. Readiness for enhanced nutrition b. Impaired physical mobility c. Impaired skin integrity d. Chronic pain

c. Impaired skin integrity

1. The nurse is caring for a patient who has been sullen and quiet for the past 3 days. Suddenly, the patient says, "I'm really nervous about surgery tomorrow, but I'm more worried about how it will affect my family." What should the nurse do first? a. Assure the patient that everything will be all right b. Tell the patient that there is no need to worry c. Listen to the patient's concerns and fears d. Inform the patient a social worker is available

c. Listen to the patient's concerns and fears Rationale:Listening to the meaning of what a patient says help create a mutual relationship.

1. A nurse is following the no-lift policy when working to prevent personal injury from twisting. Which type of personal back injury is the nurse most likely trying to prevent? a. Thoracic b. Cervical c. Lumbar d. Sacral

c. Lumbar Rationale: The most common back injury for nurses is strain on the lumbar muscle group.

1. The nurse is caring for a patient with diabetes. Which task will the nurse assign to the nursing assistive personnel? a. Providing nail care b. Teaching foot care c. Making an occupied bed d. Determining aspiration risk

c. Making an occupied bed

A nurse is following the goals of Healthy People 2030 to provide care. Which action should the nurse take? a. Allowing people to continue current behaviors to reduce the stress of change b. Focusing only on health changes that will lead to better local communities c. Promoting a society in which all people live long, healthy lives d. Focusing on illness treatment to provide fast recuperation

c. Promoting a society in which all people live long, healthy lives Rationale: Healthy People sets objectives to help the U.S. increase its focus on health promotion and disease prevention (instead of illness care) and encourages cooperation among individuals, communities, and other public, private, and nonprofit organizations to improve health. The current publication, Healthy People 2030, promotes a society in which people live long, healthy lives.

1. Which instruction will the nurse provide to the nursing assistive personnel when providing foot care for a patient with diabetes? a. Do not place slippers on the patient's feet b. Trim the patient's toenails daily c. Report sores on the patient's toes d. Check the brachial artery

c. Report sores on the patient's toes Rationale: Report any changes that may indicate inflammation or injury to tissue. Do not allow the patient to go barefoot; injury can lead to amputations.

1. A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient's blood pressure? a. Smoking increases BP for up to 3 hours b. Caffeine increases BP for up to 15 minutes c. Smoking result in vasoconstriction, falsely elevating BP d. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement

c. Smoking result in vasoconstriction, falsely elevating BP Rationale: Vasoconstriction is the narrowing of blood vessels.

1. Which areas should the nurse assess to determine the effects of external variables on a patient's illness? Select all that apply. a. Patient's perception of the illness b. Patient's coping skills c. Socioeconomic status d. Cultural background e. Social support

c. Socioeconomic status d. Cultural background e. Social support Rationale: External variables include visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support.

1. The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection? a. Teaching the patient about fall prevention b. Teaching the patient to take a temperature c. Teaching the patient to select nutritious foods d. Teaching the patient about the effects of alcohol

c. Teaching the patient to select nutritious foods Rationale: A patient's nutritional health directly influences susceptibility to infection.

1. The nurse is monitoring for therapeutic results of antibiotic therapy in a patient with an infection. Which laboratory value would indicate therapeutic effectiveness of this therapy? a. Increased RBC count b. Increased hemoglobin level c. Decreased WBC count d. Decreased platelet count

c. Third generation Rationale: Decreased WBC counts are an indication of reduction of infection and are a therapeutic effect of antibiotic therapy.

1. When a patient is on aminoglycoside therapy, the nurse will monitor the patient for which indicators of potential toxicity? a. Fever b. WBC count of 8000 cells/mm^3 c. Tinnitus and dizziness d. Decreased blood urea nitrogen (BUN) levels

c. Tinnitus and dizziness Rationale:Dizziness, tinnitus, hearing loss, or a sense of fullness in the ear could indicate ototoxicity, a potentially serious toxicity in a patient.

1. The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene? a. "The number for poison control is 800-222-1222." b. "Never induce vomiting if my grandchild drinks bleach." c. "I should call 911 if my grandchild loses consciousness." d. "If my grandchild eats a plant, I should provide syrup of ipecac."

d. "If my grandchild eats a plant, I should provide syrup of ipecac." Rationale: The administration of ipecac syrup or induction of vomiting is no longer recommended for routine home treatment of poisoning. The nurse must intervene to provide additional teaching.

1. Having misplaced a stethoscope, a nurse borrows a colleague's stethoscope. The nurse next enters the patient's room and identifies self, washes hands with soap, and states the purpose of the visit. The nurse performs proper identification of the patient before auscultating the patient's lungs. Which critical health assessment step should the nurse have performed? a. Running warm water over stethoscope b. Draping stethoscope around the neck c. Rubbing stethoscope with betadine d. Cleaning stethoscope with alcohol

d. Cleaning stethoscope with alcohol Rationale: The stethoscope should be cleaned before use on each patient with isopropyl alcohol.

A nurse is providing passive range of motion for a patient with impaired mobility. Which technique will the nurse use for each movement? a. Each movement is repeated 5 times by the patient b. Each movement is performed until the patient reports pain c. Each movement is completed quickly and smoothly by the nurse d. Each movement is moved just to the point of resistance by the nurse

d. Each movement is moved just to the point of resistance by the nurse Rationale: Passive ROM exercises are performed by the nurse. Carry out movements slowly and smoothly, just to the point of resistance; ROM should not cause pain. Never force beyond capacity.

1. The nurse is caring for a school-aged child who has injured the right leg after a bicycle accident. Which signs and symptoms will the nurse assess for to determine if the child is experiencing a localized inflammatory response? a. Malaise, anorexia, enlarged lymph nodes, and increased WBCs b. Chest pain, shortness of breath, nausea, and vomiting c. Dizziness and disorientation to time, date, and place d. Edema, redness, tenderness, and loss of function

d. Edema, redness, tenderness, and loss of function Rationale: The body's cellular response to an injury is seen as inflammation. Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part.

1. The nurse is administering a vancomycin (Vancocin) infusion. Which measure is appropriate for the nurse to implement in order to reduce complications that may occur with this drug's administration? a. Monitoring blood pressure for hypertension during the infusion b. Discontinuing the drug immediately if red man syndrome occurs c. Restricting fluids during vancomycin therapy d. Infusing the drug over at least 1 hour

d. Infusing the drug over at least 1 hour Rationale: This can reduce the occurrence of red man syndrome.

1. A nurse is performing passive range of motion and splinting on an at-risk patient. The absence of which finding will indicate goal achievement for the nurse's action? a. Atelectasis b. Renal calculi c. Pressure ulcers d. Joint contractures

d. Joint contractures Rationale: Goal achievement for passive ROM is prevention of joint contractures. Contractures develop in joints not moved periodically through their full ROM.

1. A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls? a. 55 years old b. 20/20 vision c. Urinary continence d. Orthostatic hypotension

d. Orthostatic hypotension Rationale: Numerous factors increase the risk of falls, including a history of falling, age 65 or over, reduced vision, orthostatic hypotension, lower extremity weakness, gait and balance problems, urinary incontinence, improper use of walking aids, and the effects of various medications.

1. The nurse is providing education about the importance of proper foot care to a patient who has diabetes mellitus. Which primary goal is the nurse trying to achieve? a. Prevention of plantar warts b. Prevention of foot fungus c. Prevention of neuropathy d. Prevention of amputation

d. Prevention of amputation Rationale: Foot ulceration is the most common single precursor to lower extremity amputations among persons with diabetes.

1. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan? a. Partial thickness repair b. Secondary intention c. Tertiary intention d. Primary intention

d. Primary intention Rationale: A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. The skin edges are approximated or closed, and the risk for infection is low.

1. The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility? a. Explain the risks of immobility to the patient b. Turn the patient every 3 hours while in bed c. Encourage the patient to sit up in the chair d. Provide analgesic medication as ordered

d. Provide analgesic medication as ordered Rationale: Maintaining adequate pain control and patient comfort increases the patient's willingness and ability to increase mobility, which in turn reduces pressure ulcer risks.

1. 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

d. Reassess the patient Rationale: Assessment is a continuous process that occurs each time the nurse interacts with a patient.

1. The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan? a. Impaired home maintenance b. Deficient knowledge c. Risk for poisoning d. Risk for injury

d. Risk for injury Rationale:The patient's behaviors support the nursing diagnosis of Risk for Injury. Injury could result if the patient falls out of bed or begins to bleed from a pulled line.

1. A nurse is assessing a patient's wound. Which nursing observation will indicates the wound healed by secondary intention? a. Minimal loss of tissue function b. Permanent dark redness at site c. Minimal scar tissue d. Scarring that may be severe

d. Scarring that may be severe Rationale: A wound healing by secondary intention takes longer than one healing by primary intention. The wound is left open until it becomes filled with scar tissue. If the scarring is severe, permanent loss of function often occurs.

A 79-year-old patient is receiving a quinolone as treatment for a complicated incision infection. The nurse will monitor for which adverse effect that is associated with these drugs? a. Neuralgia b. Double vision c. Hypotension d. Tendonitis and tendon rupture

d. Tendonitis and tendon rupture Rationale: A black box warning is required by the U.S. Food and Drug Administration for all quinolones b/c of the increased risk for tendonitis and tendon rupture with the use of the drugs. This effect is more common in elderly patients, patients with renal failure, and those receiving concurrent glucocorticoid therapy.

1. The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient's low heart rate? a. The patient has a fever b. The patient has possible hemorrhage or bleeding c. The patient has chronic obstructive pulmonary disease (COPD) d. The patient has calcium channel blockers or digitalis medication prescriptions

d. The patient has calcium channel blockers or digitalis medication prescriptions Rationale: Negative chronotropic drugs such as digitalis, beta-adrenergic agents, and calcium channel blockers can slow down pulse rate.

1. A nurse is caring for a patient who is experiencing some symptoms related to arthritis. The nurse is teaching the patient about this process. Which information will the nurse include in the teaching session? a. This will affect synovial fluid b. This will affect the body systemically c. This involves mostly non-weight-bearing joints d. This involves an increased risk for impaired weight bearing

d. This involves an increased risk for impaired weight bearing