PN Exam Chap 20-22, 25-27

A nurse is assessing a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to gain more information about the client's rash? A. How old are you? B. Do you smoke cigarettes or drink alcohol? C. Are you allergic to any medications. foods, or pollen? D. What have you been using to treat the rash? E. Have you recently traveled outside the country? F. When did the rash start?

- Are you allergic to any medications. foods, or pollen? - What have you been using to treat the rash? - Have you recently traveled outside the country? - When did the rash start?

A nurse is caring for an adolescent girl who was admitted to the hospital's medical unit after attempting suicide by ingesting acetaminophen (Tylenol). The nurse should incorporate which interventions into the care plan for this girl? A. Limit care until the girl initiates a conversation B. Ask the girl's parents if they keep firearms in their home C. Ask the girl is she's currently having suicidal thoughts D. Assist the girl with bathing and grooming as needed E. Inspect the girls mouth after giving oral medications F. Assure the girl that anything she says will be held in strict confidence

- Ask the girl's parents if they keep firearms in their home - Ask the girl is she's currently having suicidal thoughts - Assist the girl with bathing and grooming as needed - Inspect the girls mouth after giving oral medications

Chuck, who is in the hospital, complains of abdominal pain that ranks 9 on a scale of 1 (no pain) to 10. Which interventions should the nurse implement? A. Assessing the client's bowel sounds B. Taking the clients blood pressure and apical pulse C. Obtaining a pulse oximeter reading D. Notifying the health care provider E. Determining the last time the client received pain medication F. Encouraging the client to turn, cough, and deep breathe

- Assessing the client's bowel sounds - Taking the clients blood pressure and apical pulse -Determining the last time the client received pain medication

While providing care to married client, the nurse notes multiple ecchymotic areas on her arms and trunk. The color of the ecchymotic areas ranges from blue to purple to yellow. When asked by the nurse respond?

- Document the clients statement and complete a body map indicating the size, color, shape, location, and type of injuries - Assist the client in developing a safety plan for times of increased violence - Provide the client with telephone numbers of local shelters and safe houses

A nurse is planning care for a client with HIV. She's being assisted by a LPN. Which statements by the LPN indicate her understanding of HIV transmission?

- I will wear a mask, gown, and gloves when splashing of bodily fluids is likely - I will wash my hands after client care

Which of the following are functions of dressings? A. Promote hemostasis B. Keep wound bed dry C. Wound debridement D. Prevent contamination E. Increase circulation

- Promote hemostasis - Wound debridement - Prevent contamination

A nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate? A. Understand that all cultures experience pain in the same way B. Consider the nonverbal cues, such as eye contact, may have different meanings in different cultures C. Respect the client's cultural beliefs D. Ask the client if he has cultural or religious requirements that should be considered in his care E. Explain the nurse's beliefs so that the client will understand the differences

- Respect the client's cultural beliefs - Consider the nonverbal cues, such as eye contact, may have different meanings in different cultures - Ask the client if he has cultural or religious requirements that should be considered in his care

A nurse is talking with a delusional client when the fire alarm sounds and a staff member closes the door to the client's room. The client becomes very agitated and declares, "The aliens have arrived!" Which actions are appropriate for the nurse to take? A. Leave the room, telling the client she'll return soon B. Tell the client that there's no danger and that everything's fine C. Tell the client the alarm is just a drill and he shouldn't be afraid D. Stay with the client and wait for an update about the situation E. Continue to speak with the client in a reassuring tone

- Stay with the client and wait for an update about the situation - Continue to speak with the client in a reassuring tone

Your patient will be using crutches for mobility. After educating the patient on how to adjust the crutches to fit correctly, you assess how well the patient understood the instructions. What findings demonstrate that the crutches were adjusted correctly by the patient? A. The hand grips of the crutches are even with the mid-forearm B. When the patient grips the hand grips of the crutches the elbow bends at about 30 degrees C. The patient has a 2-3 finger width distance between the axillae and crutch rest pad D. The patient places weight on the axillae rather than the hands while ambulating

- When the patient grips the hand grips of the crutches the elbow bends at about 30 degrees - The patient has a 2-3 finger width distance between the axillae and crutch rest pad

In the emergency department, a client reveals to the nurse a lethal plan for committing suicide and agrees to a voluntary admission to the psychiatric unit. Which information will the nurse discuss with the client to answer the question. "How long do I have to stay here?" A. You may leave the hospital at any time unless you are suicidal B. Let's talk more after the health team has assessed you C. Once you've signed the papers, you have no say D. Because you could hurt yourself, you must be safe before being discharged E. You need a lawyer to help you make that decision F. There must be a court hearing before you leave the hospital

- You may leave the hospital at any time unless you are suicidal - Let's talk more after the health team has assessed you - Because you could hurt yourself, you must be safe before being discharged

Arrange the steps of the nursing process in the sequence in which they generally occur. - Assessment - Evaluation - Planning Outcomes - Planning Interventions - Diagnosis

1. Assessment 2.Diagnosis 3.Planning Outcomes 4.Planning Intervention 5.Evaluation

A client went to the emergency room with sudden onset on high fever and diaphoresis. Serum sodium was one of the laboratory test taken. Which of the following values would you expect to see?

148 mEq/L

A client with Congestive heart failure is about to take a dose of furosemide (Lasix). Which of the following potassium level, if noted in the client's record, should be reported before giving the due medication?

3.3 mEq/L

The potential need for amputation will most likely be discussed as part of the medical and surgical care for A. A 27-year-old with a comminuted fracture of the left femur from a car accident. B. A 64-year-old with gangrene of the left foot due to decreased circulation. C. A 71-year-old with arthritis in both knees. D. A 54-year-old with a newly developed diabetic foot ulcer.

A 64-year-old with gangrene of the left foot due to decreased circulation

Which of the following patients could successfully use a cane? A. A 59-year-old with a left below-the-knee amputation B. A 47-year-old with orders for non-weight-bearing on the left C. A 69-year-old recovering from a stroke with mild right-sided weakness D. A 70-year-old who cannot bear full weight on both legs

A 69-year-old recovering from a stroke with mild right-sided weakness

You are assigned 4 patients on your nursing unit. Which patient is at most risk for pressure ulcers? A. A 72 year old female weighing 82lbs with stress incontinence and dementia B. A 90 year old male with congestive heart failure who has 3+ pitting edema in lower extremities C. A 6 month old with the flu D. An ambulatory 88 year old with dementia who is admitted with shingles

A 72 year old female weighing 82lbs with stress incontinence and dementia

A nurse would inform which of the following patients that multiple loud clicks and knocks might be heard during their diagnostic test? A. An 84-year-old having an electrocardiogram (ECG) B. A 72-year-old having a magnetic resonance imaging test (MRI) C. A 55-year-old having a chest x-ray (CXR) D. A 48-year-old having a lumbar puncture

A 72-year-old having a magnetic resonance imaging test (MRI)

A doctor orders a complete blood cell count for a patient. The results include a breakdown of the total white blood cell count into percentages of five different types of white cells. The nurse identifies this as A. A left shift B. A right shift C. A differential D. Leukocytosis

A differential

When taking an inventory of items that a patient has brought to the hospital, a nurse should document the patients diamond and ruby wedding ring as A. A ring with rubies and diamonds. B. A gold colored ring with red stones and clear stones. C. A 24 karat gold wedding ring D. A 1 Karat diamond wedding ring.

A gold colored ring with red stones and clear stones

When performing a patients assessment, a nurse correctly recognizes that subjective data includes A. A patient's vital signs B. A patient's unsteady gait. C. A patient's foul-smelling wound D. A patient's complaint of discomfort

A patient's complaint of discomfort.

While checking on students who are caring for patients on an orthopedic unit, a nursing instructor would be most concerned if

A student assists a patient with a left hip replacement turn to the left side

A patient has returned to the room after total hip replacement surgery. A nurse identifies that the correct immobilization device to keep the patient from accidently moving the affected leg to or beyond the midline is a(n) A. Abductor pillow B. Immobilizer C. Splint D. Elastic bandage

Abductor Pillow

A patient who was involved in a motor vehicle accident is admitted to the hospital. The patient was thrown from the vehicle, and the nurse finds several areas where the patient's skin appears to have been scraped away, most likely as a result of hitting the pavement. These types of injuries are termed A. Lacerations B. Contusions C. Punctures D. Abrasions

Abrasions

A nurse should question an order for a heating pad for a client who has A. Active bleeding B. A reddened abscess C. An edematous lower leg D. Purulent wound drainage

Active bleeding

A male nurse performing an assessment should take extra care to ask permission before touching a patient who is

All of the above

A motor vehicle accident resulting in a comminuted fracture of the right fibula has left a patient's right leg shorter than the left. A nurse identifies that bone lengthening can be stimulated by using A. Plaster casting B. Skin traction C. An Ilizarov frame D. Internal fixators

An Ilizarov frame.

A patient who is one day postoperative is complaining of nausea and refusing to eat. Upon auscultation of the abdomen, the nurse finds that the patient's bowel sounds are hypoactive. This is most likely due to A. Peritonitis B. A bowel obstruction C. Anesthesia D. Paralytic Ileus

Anesthesia

A nurse performing an assessment would correctly identify that a patient has a greater chance of contracting health care facility acquired pneumonia if he has A. Difficulty swallowing B. An existing respiratory disease C. Poor oral hygiene D. Any of the above

Any of the above

The nurse charts that the patient is eupneic. This finding indicates that respirations A. Require the use of costal, sternal, and sub clavicular muscles. B. Are very shallow and at a rate between 8 and 12 per minute. C. Are between 20 and 24 per minute and that the patient is using his thoracic muscles. D. Are considered to be normal in depth and rate with use of the abdominal muscles.

Are considered to be normal in depth and rate with use of the abdominal muscles.

A nurse is observing as a medical student places a central line. The nurse notes that the medical student's tie is touching the sterile field. The best action by the nurse is to A. Refrain from saying anything because the sterile field may not really be contaminated B. Wait until the procedure is over to inform the medical student that his tie brushed the sterile field C. Ask the medical student to stop the procedure immediately D. Suggest that the medical student not touch that side of the field

Ask the medical student to stop the procedure immediately

During the admission procedure, a patient informs a nurse that he is a Sikh and must keep his head covered at all times. He normally wears a turban. The other patient in the double room he has been assigned to is recovering from detoxification and has had episodes where he's used racial slurs. In processing the patient's admission, which of the following should the nurse do? A. Make a note on the patient's record that a curtain should be kept drawn between the two patients at all times so the verbally abusive patient cannot see the new patient and make offensive remarks based on his appearance. B. Assume that the patient will be fine because Sikh men pride themselves on their strength. C. Inform the patient of the situation and ask if he is comfortable being in the same room with the abusive patient. D. Ask to have the patient assigned to a different room, without an abusive roommate.

Ask to have the patient assigned to a different room, without an abusive roommate.

Mrs. Bagapayo who had abdominal surgery 3 days earlier complains of sharp, throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to 10 (worst pain). Which intervention should the nurse implement first? A. Assessing the client to rule out possible complications secondary to surgery B. Checking the client's chart to determine when pain medication was last administered C. Explaining to the client that the pain should not be this severe 3 days postoperatively D. Obtaining an order for a stronger pain medication because the client's pain has increased

Assessing the client to rule out possible complications secondary to surgery

You're performing a head to toe assessment on a patient with abdominal pain. During inspection of the abdomen, you note the abdominal contour to be round and distended with no masses or lesions present. The patient reports that their last bowel movement was one hour ago, and the stool was loose. In addition, the patient states that the abdominal pain is located below the umbilicus and is sharp in quality. After inspection of the abdomen, you will:

Auscultate for bowel sounds by starting in the right lower quadrant

During a meal, a client with hepatitis B dislodges her I.V. line and bleeds on the surface of the over-the-bed table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with:

Bleach

Mr. Teban is a 73 year old patient diagnosed with pneumonia. Which data would be of greatest concern to the nurse when completing the nursing assessment of the patient? A. Alert and oriented to date, time, and place B. Buccal cyanosis and capillary refill greater than 3 seconds C. Clear breath sounds and nonproductive cough D. Hemoglobin concentration of 13g/7dl and leukocyte count 5,300/mm3

Buccal cyanosis and capillary refill greater than 3 seconds

In a postoperative assessment of a patient who has had a knee replacement surgery, the nurse notes that the patient is experiencing moderate knee pain and somewhat slurred speech. The nurse appropriately A. Checks the patient's chart to determine whether her slurred speech can be attributed to her postoperative medications and, if not, summons her doctor to determine whether she is having postoperative complications. B. Asks the doctor to adjust the patient's pain medications to relieve the pain and prevent any further slurring of speech. C. Asks the patient to let the nurse know if the pain or the slurred speech gets worse, then reassesses the patient's symptoms in 4 hours. D. Calls the patient's doctor immediately because she may be suffering a stroke because of a blood clot that traveled from her legs postoperatively.

Checks the patient's chart to determine whether her slurred speech can be attributed to her postoperative medications and, if not, summons her doctor to determine whether she is having postoperative complications.

QA nurse is conducting an admission assessment on a patient with a new diagnosis of AIDS. The nurse demonstrates a caring demeanor by A. Closing the door to the patient's room B. Asking the patient questions at the nurse's station C. Delivering nursing care as rapidly as possible to allow the patient more time alone D. Refraining from telling the patient why he or she needs to ask personal questions

Closing the door to the patient's room.

When conducting an admission assessment and taking an inventory of items that a patient has brought to the hospital, a nurse appropriately instructs the patient to send home with a family member her A. Dentures B. Eyeglasses C. Credit Cards D. Hearing Aids

Credit Cards

Nine days after abdominal surgery, a nurse notices a complete separation of the outer layers of the patient's wound. The nurse identifies this rare and extremely serious condition as A. Evisceration B. Sinus tract C. Phagocytosis D. Dehiscence

Dehiscence

A nurse notes as increase in serosanguineous drainage from a patients incision. The most appropriate action for the nurse is to A. Notify the physician of increasing amounts of clear drainage B. Draw a circle around the drainage and write the date, time, and initials on the dressing C. Change the dressing to decrease the patient's risk for infection D. Immediately call the laboratory and order a white blood cell (WBC) count

Draw a circle around the drainage and write the date, time, and initials on the dressing

A student nurse is observing surgery. During a surgical scrub, the student expects to see operating room personnel rinse their hands with their

Fingertips above their elbows

During a full body admission assessment, you note the patient has a stage III pressure ulcer. How would you document the appearance of the wound? A. Area is red and does not blanch. B. Full-thickness skin loss to dermis and subcutaneous tissues. C. Partial thickness of dermis with shallow open ulcer. D. Full thickness with bone and tendon visible.

Full-thickness skin loss to dermis and subcutaneous tissues

A telemetry monitor technician notifies a nurse that the patient in room 223 has a poor tracing. Which of the following actions should the nurse take first? A. Move the code cart closer to the patient's room. B. Go to the patient's room and check the patient's status. C. Instruct the technician to call a code. D. Report to the nursing station to view the tracing.

Go to the patient's room and check the patient's status.

About 3 weeks after being admitted to the hospital, a patient's wounds begin to fill in with a red and semitransparent material. The nurse identifies this as A. Granulation tissue B. Phagocytosis C. Hemostasis D. Keloids

Granulation tissue

A nurse supervising a CNA would correctly intervene upon hearing the CNA say A. Hi again, Mr. Jones. Are you feeling better today? Oh, really? Tell me what's wrong and I'll see what I can do B. Hello, Mr. Jones, my name is Andrea. The doctor says we need to move you to another unit today, so please let me know where you're keeping your personal belongings so we can send those along as well C. Hello, Mr. Jones. Please roll up your sleeve D. Hi, Mr. Jones. Ah, I see the Girl Scouts have come through today because you've got some cookies there, haven't you? Well, make sure to leave those alone till your kids come by to visit, okay?;Laughs We don't want the doctor getting mad about you going off your diet

Hello, Mr. Jones. Please roll up your sleeve

A nurse, preparing to auscultate breath sounds, correctly positions the patient in the most favorable position, which is A. Supine position B. Low Fowler position C. Semi Fowler position D. High Fowler position

High Fowler position

When educating a student nurse about hospital identification bands, a nurse appropriately recognizes that additional teaching is warranted when the student nurse states. A. The hospital identification band displays the patients name and birth date and the hospital identification number B.I have taken care of this patient before, so I will not need to check the patients identification band before administering medication C.I should instruct the patient to state his or her name and verify that it matches the name on the hospital identification band. D. I should ask the patient to state his or her date of birth and verify that it matches the date of birth listed on the hospital identification band.

I have taken care of this patient before, so I will not need to check the patients identification band before administering medication

A nurse is providing instructions for a patient who is to begin wearing a Holler monitor. Which of the following statements indicates further teaching is necessary? A. I should press this button if I feel any chest pain or pressure. B. I need to write down what I eat each day. C. I should make notes about the activities I'm doing while I wear the monitor. D. ill wear this for 2 days so the doctor can be sure to capture anything that may be going on.

I need to write down what I eat each day.

A nurse is assisting in the discharge of a patient who had a right hip replacement. Additional teaching is necessary if the patient states: A. I will need an extender to pick things up from the floor B. I should keep a wide stance when I walk with my walker C. I will have to bend way over to tie my shoes D. I have to keep this special pillow between my legs when I'm sleeping

I will have to bend way over to tie my shoes

When reassessing a patient's wound. a nurse notes redness and swelling, but no drainage. This indicative of a phase of healing called the A. Reconstruction phase B. Remodeling phase C. Inflammatory phase D. Maturation phase

Inflammatory phase

The nurse correctly assesses a patients abdomen by following the sequence of A. Inspection, palpation, and auscultation B. Palpation, inspection, and auscultation C. Palpation, auscultation, and inspection D. Inspection, auscultation, and palpation.

Inspection, auscultation, and palpation.

A nurse is caring for a patient scheduled for an electro cephalography. Which of the following actions taken by the nurse is best? A. Assess vital signs B. Determine whether the patient has an allergy to shellfish C. Identify what medications the patient is currently taking D. Instruct the patient to wash her hair

Instruct the patient to wash her hair

As a nurse manager of a medical surgical unit reviews the month's risk management data, she notices that a number of incident reports were completed because of 6pm medications were administered late. Dinner is served between 5:30 pm and 6pm. Staff take their dinner breaks between 5pm and 6:30 pm. Based on this information, which is the most appropriate action for the nurse manager to take? A. Terminate the nurses responsible for falling to administer medications on time B. Decide that the staff must postpone dinner breaks until at least 7pm C. Decide that the kitchen staff must change the time they deliver supper trays D. Investigate when medications are given, staff and client dinner times, the number of medications that must be given at 6pm (1800) and staff availability between 5pm (1700) and 6pm.

Investigate when medications are given, staff and client dinner times, the number of medications that must be given at 6pm (1800) and staff availability between 5pm (1700) and 6pm

As a nurse you are providing care to a 63 year old male who suffered a massive stroke. He has paralysis on upper and lower extremities. He has has a PEG tube with tubing feedings. The patient's daughter provides care to the patient. You notice the patient has a stage I pressure ulcer on the sacral area. What would you NOT include when educating the daughter on preventing further breakdown of the current pressure ulcer and how to prevent other ones from forming? A. Exercise the extremities actively and passively B. Turn and reposition the patient every 2 hours C. Keep the skin moist and layer the sacral area with extra sheet layers D. Use pillows to elevate bony prominences

Keep the skin moist and layer the sacral area with extra sheet layers

Ryan underwent an open reduction and internal fixation of the left hip. One day after the operation, the client is complaining of pain. Which data would cause the nurse to refrain from administering the pain medication and to notify the health care provider instead? A. Left hip dressing dry and intact B. Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute C. Left leg in functional anatomic position D. Left foot cold to touch; no palpable pedal pulse

Left foot cold to touch; no palpable pedal pulse

When assessing the integrity of a patient's skin, the nurse is A. Checking the elasticity of the skin B. Looking for cuts or breaks in the skin C. Assessing the color of the skin D. Determining whether the skin is moist or dry

Looking for cuts or breaks in the skin

At the staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell) to determine whether a patient is exhibiting signs of illness or injury. These signs of illness or injury are A. Subjective B. Measurable C. Reported by the patient D. Hidden

Measurable

While going down the stairs with crutches the patient will move the crutches down onto the step followed by? A. Moving the non injured leg down onto the step B. Moving the injured leg down onto the step C. Moving both legs down onto the step

Moving the injured leg down onto the step

A nurse is preparing to discharge a patient from telemetry to allow the patient to take a shower. Which of the following action should the nurse take? A. Instruct the patient to keep the telemetry patches in place. B. Inform the patient not to apply lotion or powder on her chest after the shower. C. Notify the monitor technician that telemetry will be turned off. D. Ask the patient if she has a history of falls in the bathroom.

Notify the monitor technician that telemetry will be turned off.

A nurse is unable to palpate a patient's left pedal pulse. The nurse will correctly first A. Notify the primary care physician that the patient's pedal pulse is not palpable B. Reassess the patient's left pedal pulse every 2 to 4 hours. C. Chart, Left pedal pulse nonpalpable, foot warm and dry D. Obtain a Doppler to further detect whether the pulse is present.

Obtain a Doppler to further detect whether the pulse is present

While assessing the feet of a 72 year old male patient with diabetes, the nurse noted that there were no cuts, cracks, or blisters. The patient stated, " I don't have as much feeling in my feet as I used to, " The nurse correctly understands that the patient is most likely suffering from

Paresthesia

A patients wound is showing signs of delayed healing. a nurse determines that the patients diet may be the culprit and instructs the patient to eat more

Protein

A student nurse is caring for a patient with a sprained ankle. An instructor says the acronym that should be used to help remember treatment for a sprain is

RICE

As a nurse enters the room of a patient who has had an amputation, the nurse notes that the patient is crying. The best response by the nurse is to A. Say, I'm here if you'd like to talk, while standing close to the patient's bed B. Say, I'll leave you alone for a little while, while leaving the room C. Ask; Is there someone you'd like me to call? While picking up the phone D. Say; Everyone feels this way at first, but it will get easier while patting the patient's shoulder

Say, I'm here if you'd like to talk, while standing close to the patient's bed.

The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient with chronic lung disease has a 30+ year history of tobacco use. The nurse used to smoke a pack of cigarettes a day at one time and worked very hard to quit smoking. She immediately thinks to herself, "I know I tend to feel negatively about people who use tobacco, especially when they have a serious lung condition; I figure if I can stop smoking, they should be able to. I must remember how physically and physiologically difficult that is, and they be very careful not to let be judgmental of this patient." This best illustrates A. Theoretical Knowledge B. Self-Knowledge C. Using reliable resources D. Use of the nursing process

Self- Knowledge

While preparing for a paracentesis, which of the following positions should a nurse assist the patient to assume? A. Prone B. Side lying with knees flexed C. Side lying with knees extended D. Semi-Fowler

Semi-Fowler

A patient with a plaster cast tells the nurse. "This thing itches like crazy, and it is making me nuts." The best response by the nurse is A. The cast itches because air is trapped between the cast and your skin B. Try to ignore that. The cast will be off in a few weeks C. Sometimes using a hair dryer on the cool setting to blow air down the cast can relieve itching D. Itching is a sign of infection. Let me take your temperature

Sometimes using a hair dryer on the cool setting to blow air down the cast can relieve itching

A nurse doing an assessment would correctly summon a physician immediately if he detected the breath sounds known as A. Rales B. Rhonchi C. Wheezes D. Stridor

Stridor

In explaining to a patient who is being dismissed from the hospital that he has a clean contaminated wound. The nurse states A. Although the wound is an incision, it was grossly contaminated during surgery, so it is important to notify your physician if the drainage increases B. Your incision seems to be developing a purulent drainage. Make sure that you notify your doctor if you notice that the drainage develops a foul smell C. Your drainage cultured a high number of microorganisms, but since we've seen no evidence of infection and you are taking an antibiotic, you probably don't need to worry about it D. Surgical wounds are exposed to normal flora that resides on the skin. It is important to observe it for signs of infection, such as drainage that turns yellow or green

Surgical wounds are exposed to normal flora that resides on the skin. It is important to observe it for signs of infection, such as drainage that turns yellow or green

Sterile technique is not necessary when A. Inserting a catheter into the bladder (hospital setting) B. Taking standard precautions C. Inserting an intravenous (IV) needle into the vein D. Injecting medications into subcutaneous tissue

Taking standard precautions

A nurse assessing a patient's oral health must assess which of the following as an immediate safety hazard? A. The color of the mucous membranes B. The ability to swallow C. The presence of ulcerations or lesions in the mouth D. The presence of bleeding in the mouth

The ability to swallow

An intervention by a nurse who is gathering gauze 4x4s, saline, and gloves for a dressing change would be required if A. Unopened sterile 4<180; 4s are already in the patient's room. B. The bottle of sterile saline was opened 3 days ago C. The glove packaging is dry D. The only available masks have eye protection shields

The bottle of sterile saline was opened 3 days ago

Mr.Lim who has chronic pain, loss of self esteem, no job, and bodily disfigurement from severe burns over the trunk and arms, is admitted to a pain center. Which evaluation criteria would indicate the client's successfully rehabilitation? A. The client remains free of the aftermath phase of the pain experience B. The client experiences decreased frequency of acute pain episodes C. The client continuous normal growth and development with intact support systems D. The client develops increased tolerance for severe pain in the future

The client continues normal growth and development with intact support systems

In response to a student nurse's question, the nurse correctly states

The first heart sound occurs when the mitral and tricuspid valves close.

The nurse takes additional time getting to know a patient admitted for surgery because A. The patient may not fully cooperate with the nurse otherwise. B. It is important that the nurse be prepared to answer any questions that the family may have about the patient. C. The nurse believes that a patient responds better if she and the patient are on a first-name basis. D. The nurse believes that establishing rapport with a patient leads to a trusting nurse-patient relationship.

The nurse believes that establishing rapport with a patient leads to a trusting nurse-patient relationship.

When a nurse is preparing a sterile field using a drape provided in a sterile pack, he or she would touch A. The anterior surface of the drape B. The outer 1-inch border of the drape C. The posterior aspect of the drape D. The top inner corners of the drape

The outer 1-inch border of the drape

Which demonstration by the patient below shows that the patient knows how to properly ambulate a cane?

The patient holds the cane on the strong side and moves the cane and weak side forward together, and then moves the strong side

The nurse is caring for a patient who has had knee replacement surgery 5 days ago. The patient's knee appears red and warm to the touch and patient is requesting increased pain medication. What complications should the nurse be concerned about?

The patient is demonstrating signs of a postoperative wound infection

A nursing instructor observes as a student collects and prepares sterile materials for a procedure. The instructor recognizes that further teaching is necessary when A. The student checks the expiration date on the pack B. The sterilization tape has dark hash marks C. The student chooses sterile gloves in the correct size D. The student uses a nightstand that is lower than the waist level

The student uses a nightstand that is lower than the waist level

Your patient is prescribed to use crutches for ambulation. The patient can bear partial weight and needs to be taught how to use the two point gait while using crutches. Which description below best describes this type of gait with crutches?

The two point gait where the patient moves both the right crutch (injured side) and left foot (non-injured side) forward together and then moves the left crutch (non-injured) and right foot (injured) forward together

A nursing instructor is evaluating elastic bandages applied to the ankle in a skills laboratory. The nursing instructor recognizes that additional teaching is needed because A. The wrap has a crisscross pattern across the top of the foot B. The wrap progresses down the limb at a 45-degree angle C. The wrap comes around the inner ankle and behind the leg D. The wrap comes around the outer ankle and then across the top of the foot to the instep

The wrap progresses down the limb at a 45-degree angle

A 15 year old football player is diagnosed with a bad sprain. A nurse recognizes that the injury involves A. Torn ligaments B. A fine crack in the anklebone C. Injury to a long bone D. Damage to cartilage tissue

Torn ligaments

A nurse requires supplies and equipment that have been prepared for surgical asepsis. The nurse intervenes when he or she realizes that the supplies were prepared using A. Ionizing radiation B. Ultrasound C. Autoclaving D. Chemical disinfection

Ultrasound

A nurse determines that the best way to clean a long incision that is sutured or stapled closed with approximately edges is to A. Use antiseptic swabs and clean from the inferior end of the incision to the superior end B. Use antiseptic swabs and clean around the wound in a circular manner C. Use sterile antiseptic swabs or cotton balls and forceps, and clean from the superior end of the incision to the inferior end D. Use one cotton ball to make a circular sweep and then dispose of the cotton ball

Use sterile antiseptic swabs or cotton balls and forceps, and clean from the superior end of the incision to the inferior end

Prevention of a wound infection requires diligent care from a nurse. The first and most important step for the nurse to take when emptying the patient's Jackson Pratt drain is to A. Don sterile gloves B. Wash his or her hands C. Wipe the drain spout with alcohol D. Assess the contents of the drain

Wash his or her hands

A student nurse is instructing a patient restricted to partial weight bearing on the safe use of crutches. A nurse intervenes when she hears the student say A. If the knee is flexed and the foot is held behind the crutches, it can affect your balance, causing you to fall backward B. Since you are able to bear partial weight on the affected limb, you should use a two-point gait C. Bearing weight on the axilla can cause compression of nerves and can lead to nerve damage affecting the arm and hand D. When walking upstairs on crutches, you should place the affected leg on the step, then move up the crutches and the unaffected leg

When walking upstairs on crutches, you should place the affected leg on the step, then move up the crutches and the unaffected leg

A patient's wound is healing by third intention. The nurse charts: A. Wound intact and draining a moderate amount of serosanguineous fluid B. Wound approximately 2?3? <180> 3?3?, granulation tissue visible, draining serous fluid C. Wound 4?3? in diameter, open with jagged edges, draining sanguineous fluid D. Wound 6?3? long with well-approximated edges, reddened around incision, no drainage

Wound approximately 2?3? <180> 3?3?, granulation tissue visible, draining serous fluid

A nurse is caring for a patient who asks, "The doctor said I have leucopenia. What does that mean? "Which of the following responses by he nurse is best? A. That means your white blood cell count is higher than normal B. You have a lot of white blood cells that are very immature, so your risk for infection is high C. It means your body is building new white blood cells to fight infection D. Your risk for infection is higher than normal because your body doesn't have many white blood cells

Your risk for infection is higher than normal because your body doesn't have many white blood cells