Practice Test Exam 3

Which is an outcome for a patient diagnosed with osteoporosis? [47] 1. Maintain serum level of calcium 2. Maintain independence with ADLs 3. Reduce supplemental sources of vitamin D 4. Reverse bone loss through dietary manipulation

2

Which is the correct gait when a patient is ascending stairs on crutches? [38] 1. A modified two-point gait. The affected leg is advanced between the crutches to the stairs. 2. A modified three-point gait. The unaffected leg is advanced between the crutches to the stairs. 3. A swing-through gait. 4. A modified four-point gait. Both legs advance between the crutches to the stairs.

2

When grading muscle strength, the nurse records a score of 3, which indicates: [L62] 1. no detection of muscular contraction 2. a barely detectable flicker of contraction 3. active movement against full resistance without fatigue 4. active movement against gravity but not against resistance`

4

A patient with tendonitis asks what the tendon does. The nurse's response is based on the knowledge that tendons: [L62] 1. connect bone to muscle 2. provide strength to the muscle 3. lubricate joints with synovial fluid 4. relieve friction between moving parts

1

A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? [26] 1. "CPOE reduces transcription errors." 2. "CPOE reduces the time necessary for health care providers to write orders." 3. "Health are providers can write orders from any computer that has Internet access." 4. "CPOE reduces the time nurses use to communicate with health care providers."

1

A normal assessment finding of the musculoskeletal system is: [L62] 1. no deformity or crepitation 2. muscle and bone strength of 4 3. ulnar deviation and subluxation 4. angulation of bone toward midline

1

A nurse plans to provide education to the parents of school-aged children and includes which of the following results of children being less physically active outside of school? [38] 1. An increase in obesity 2. An increase in heart disease 3. Higher computer literacy 4. Improved school attendance and grades

1

A patient is discharged after an exacerbation of COPD. She states, "I'm afraid to go to pulmonary rehabilitation." What is your best response? [38] 1. Pulmonary rehab provides a safe environment for monitoring your progress. 2. You have to participate or you will be back in the hospital. 3. Tell me more about your concerns with going to pulmonary rehab. 4. The staff at our pulmonary rehab facility are professionals and will not cause you any harm.

1

A patient recovering from bilateral knee replacement surgery is prescribed partial weight bearing. You reinforce crutch walking knowing that which of the follow crutch gaits is most appropriate for this patient? [38] 1. two-point gait 2. three-point gait 3. four-point gait 4. swing-through gait

1

A patient with a fracture of the pelvis should be monitored for: [L63] 1. changes in urine output 2. petechiae on the abdomen 3. a palpable lump in the buttock 4. sudden increase in blood pressure

1

An 85-year-old patient is assessed to have a score of 16 on the Braden scale. Based on this information, how should the nurse plan for this patient's care? [L12] 1. Implement a Q2H turning schedule with skin assessment 2. Place DuoDerm on the patient's sacrum to prevent breakdown 3. Elevate head of bed to 90 degrees when the patient is supine 4. Continue with weekly skin assessments with no special precautions

1

During the postoperative period, the nurse instructs the patient with an above-the-knee amputation that the residual limb should not be routinely elevated because this position promotes: [L63] 1. hip flexion contractures 2. skin irritation and breakdown 3. clot formation at the incision site 4. increased risk of wound dehiscence

1

Name the three important dimensions to consistently measure to determine wound healing. [48] 1. Width, length, and depth 2. Width, depth, and diagonal dimension 3. Length, circumference and depth 4. Length, width, circumference

1

The increased risk for falls in the older adult is most likely due to: [L62] 1. Changes in balance 2. Decrease in bone mass 3. Loss of ligament elasticity 4. erosion of articular cartilage

1

The nurse explains to a patient with a fracture of the distal shaft of the humerus who is returning for a 4-week checkup that healing is indicated by: [L63] 1. formation of callus 2. complete bony union 3. hematoma at fracture site 4. presence of granulation tissue

1

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. The nurse would recommend which of the following menus? [47] 1. Cream of broccoli soup with whole wheat crackers and tapioca for dessert. 2. Hamburger on a soft roll with a side salad and an apple for dessert. 3. Low-fat turkey chili with sour cream and fresh pears for dessert. 4. Chick salad on toast with tomato and lettuce and honey bun for dessert.

1

What is removal of devitalized tissue from a wound called? [48] 1. Debridement 2. Pressure reduction 3. Negative pressure wound therapy 4. Sanitization

1

Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain? 1. Stage I 2. Stage II 3. Stage III 4. Stage IV

1

You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: [26] 1. Documented medication given by another nursing student. 2. Included the date and time of all entries in the chart. 3. Stood with his back against the wall while documenting on the computer. 4. Signed all documentation electronically.

1

Which action(s) are appropriate for the nurse to implement when a patient experiences orthostatic hypotension? (Select all that apply.) [38] 1. Call for assistance 2. Allow patient to sit down 3. Take the patient's blood pressure and pulse 4. Continue to ambulate the patient to build endurance 5. If the patient begins to faint, allow him to slide against the nurse's leg to the floor

1, 2, 3, 5

While performing passive range of motion for a patient, the nurse puts the ankle joint through the movements of: (Select all that apply.) [L62] 1. flexion and extension 2. inversion and eversion 3. pronation and supination 4. flexion, extension, abduction and adduction 5. pronation, supination, rotation, circumduction

1,2

Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.) [47] 1. Patient's weight 2. Patient's level of cooperation 3. Patient's ability to assist 4. Presence of medical equipment 5. 24-hour calorie intake

1,2,3,4

Which of the following activities does the nurse delegate to NAP in regard to crutch walking? (Select all that apply.) [38] 1. Notify the nurse if patient reports pain before, during, or after exercise. 2. Notify nurse of patient complaints of increased fatigue, dizziness, light-headedness when obtaining vital signs before and/or after exercise 3. Notify nurse of vital sign values 4. Evaluate the patient's ability to use crutches properly 5. Prepare the patient for exercise by assisting in dressing and putting on shoes

1,2,3,5

You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.) [26] 1. The patient's name, age, and admitting diagnosis 2. Allergies to food and medications 3. Your evaluation that the patient is "needy" 4. How much the patient ate for breakfast 5. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol

1,2,5

When is an application of a warm compress indicated? (Select all that apply.) [48] 1. To relieve edema 2. For a patient who is shivering 3. To improve blood flow to an injured part 4. To protect bony prominences from pressure ulcers

1,3

Select statements that apply to the proper use of a cane. (Select all that apply.) [38] 1. For maximum support when walking, the patient places the can forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs. The weaker leg is moved forward to the can so body weight is divided between the can and the stronger leg. 2. A person's cane length is equal to the distance between the elbow and the floor. 3. Canes provide less support than a walker and are less stable. 4. The patient needs to learn that two points of support such as both feet or one foot and the cane need to be present at all times.

1,3,4

A nurse caring for a patient on a ventilator electronically documents the head of the bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system? [26] 1. Electronic health record 2. Clinical documentation 3. Clinical decision support system 4. Computerized physician order entry

3

Match the correct entry with the appropriate SOAP category. [26] 1. S 2. O 3. A 4. P a. Repositioned patient on right side. Encouraged patient to use PCA device. b. "The pain increases every time I try to turn on my left side." c. Acute pain related to tissue injury from surgical incision. d. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.

1b, 2d, 3c, 4a

A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: [26] 1. Uses SBAR (Situation, Background, Assessment, Recommendation) as a format when providing the report. 2. Gives a newly ordered medication before entering the order in the patient's medical record. 3. Reads the orders back to the health care provider after receiving them and verifies their accuracy. 4. Asks the preceptor to listen in on the phone conversation.

2

A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur? [L12] 1. Tertiary intention 2. Secondary intention 3. Regeneration of cells 4. Remodeling of tissues

2

A nurse is caring for a patient with diabetes who is scheduled for amputation of his necrotic left great toe. The patient's WBC count is 15.0 x 10^6/uL, and he has coolness of the lower extremities, weighs 75 lbs more than his ideal body weight, and smokes two packs of cigarettes a day. Which priority nursing diagnosis address the primary factor affecting the patient's ability to heal? [L12] 1. Imbalanced nutrition: more than body requirements r/t high fat foods 2. Impaired tissue integrity r/t decreased blood flow s/t diabetes and smoking 3. Ineffective peripheral tissue perfusion r/t narrowed blood vessels s/t diabetes and smoking 4. Ineffective individual coping r/t indifference and denial of the long term effects of diabetes and smoking

2

A patient 1 day postop after abdominal surgery has incisional pain, 99.5 F temperature, slight erythema at the incision margins, and 30mL serosanguineous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make? [L12] 1. The abdominal incision shows signs of an infection 2. The patient is having a normal inflammatory response 3. The abdominal incision shows signs of impending dehiscence 4. The patient's physician needs to be notified about her condition

2

A patient asks for a copy of her medical record. The best response by the nurse is to: [26] 1. State that only her family may read the record. 2. Indicate that she has the right to read her record. 3. Tell her that she is not allowed to read her record. 4. Explain that only health care workers have access to her record.

2

A patient in the unit has a 103.7 F temperature. Which intervention would be most effective in restoring normal body temperature? [L12] 1. Using a cooling blanket while the patient is febrile 2. Administer antipyretics on an around-the-clock schedule 3. Provide increased fluids and have the UAP give sponge baths 4. Give the prescribed antibiotics and provide warm blankets for comfort

2

A patient is scheduled for an electromyogram (EMG). The nurse explains that this diagnostic test involves: [L62] 1. incision or puncture of the joint capsule 2. insertion of small needles into certain muscles 3. administration of radioisotopes before the procedure 4. placement of skin electrodes to record muscle activity

2

A patient of any age can develop a contracture of a joint when: [47] 1. The adductors muscles are weakened as a result of immobility 2. The muscle fibers become shortened because of disuse. 3. The calcium-to-phosphorus ratio becomes disrupted. 4. There is a deficiency in vitamin D.

2

A patient on bed rest for several days attempts to walk with assistance. He becomes dizzy and nauseated. His pulse rate jumps from 85 to 100 beats/min. These are most likely symptoms of which of the following? [38] 1. Rebound hypertension 2. Orthostatic hypotension 3. Dysfunctional proprioception 4. Central nervous system rebound hypertension

2

A patient with a right knee replacement is prescribed no weight bearing on the right leg. You reinforce crutch walking knowing that which of the follow crutch gaits is most appropriate for this patient? [38] 1. two-point gait 2. three-point gait 3. four-point gait 4. swing-through gait

2

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? [48] 1. Binder 2. Ice bag 3. Elastic bandage 4. Absorptive diaper

2

On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system? [26] 1. Information technology 2. Electronic health record 3. Personal health information 4. Administrative information system

2

The nurse assessing a patient with a chronic leg wound finds local signs of erythema and pain at the wound site. What would the nurse anticipate being ordered to assess the patient's systemic response? [L12] 1. Serum protein analysis 2. WBC count with differential 3. Punch biopsy of center of wound 4. Culture and sensitivity of the wound

2

The patient at greatest risk for developing multiple adverse effects of immobility is a: [47] 1. 1-year-old child with a hernia repair 2. 80-year-old woman who has suffered a hemorrhagic CVA 3. 51-year-old woman following a thyroidectomy 4. 38-year-old woman undergoing a hysterectomy

2

What does the Braden scale evaluate? [48] 1. Skin integrity at bony prominences, including any wounds 2. Risk factors that place the patient at risk for skin breakdown 3. The amount of repositioning that the patient can tolerate 4. The factors that place the patient at risk for poor healing.

2

Which group of patients is at most risk for severe injuries related to falls? [38] 1. Adolescents 2. Older adults 3. Toddlers 4. Young children

2

Which of the following best motivates a patient to participate in an exercise program? [38] 1. Giving a patient information on exercise 2. Providing information to the patient when the patient is ready to change behavior 3. Explaining the importance of exercise when a patient is diagnosed with a chronic disease such as diabetes 4. Following up with instructions after the health care provider tells a patient to begin an exercise program.

2

While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because: [26] 1. The nurse forgot to document on the pulmonary system. 2. The nurses were charting by exception. 3. The computer is not working correctly. 4. The physician does not have authorization to view the nursing assessment.

2

You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet? [26] 1. The new federal laws require that teaching sheets be emailed to patients after they are discharged. 2. You need to use words that patients can understand when writing the directions. 3. The form needs to be given to patients in a sealed envelope to protect their health information. 4. The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home.

2

A 65-year-old stroke patient with limited mobility has a purple area of suspected deep tissue injury on the left greater trochanter. Which nursing diagnoses is/are most appropriate? (Select all that apply.) [L12] 1. Acute pain r/t tissue damage and inflammation 2. Impaired skin integrity r/t immobility and decreased sensation 3. Impaired tissue integrity r/t inadequate circulation s/t pressure 4. Risk for infection r/t loss of tissue integrity and undernutrition s/t stroke

2,3

A home care nurse is preparing the home for a patient who is discharged to home following a left-sided stroke. The patient is cooperative and can ambulate with a quad-cane. Which of the following must be corrected or removed for the patient's safety? (Select all that apply.) [47] 1. The rubber mat in the walk in shower 2. The three-legged stool with wheels in the kitchen 3. The braided throw rugs in the entry hallway and between the bedroom and bathroom 4. The night-lights in the hallways, bedroom, and bathroom 5. The cordless phone next to the patient's bed

2,3

An older adult has limited mobility as a result of surgical repair of a fractured hip. During assessment you note that the patient cannot tolerate lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.) [47] 1. BP = 128/84 2. Respirations 26 per minute on room air 3. HR 114 4. Crackles heard on auscultation 5. Pain reported as 3 on 0-10 scale after medication

2,3,4

Immobilized patients are at risk for impaired skin integrity. Which of the following interventions would reduce this risk? (Select all that apply.) [47] 1. Repositioning patient every 1-2 hours while awake 2. Using an objective, valid scale to assess patient's risk for pressure ulcer development 3. Using a device to relieve pressure when patient is seated in chair 4. Teaching patient how to shift weight at regular intervals while sitting in a chair 5. A good rule is: the higher the risk for skin breakdown, the shorter the interval between position changes

2,3,4,5

A patient with osteoarthritis is scheduled for a total hip arthroplasty. The nurse explains that the purpose of this procedure is to: (Select all that apply.) [L63] 1. fuse the joint 2. replace the joint 3. prevent further damage 4. improve or maintain ROM 5. decrease the amount of destruction to the joint

2,4

Which of the following describes a hydrocolloid dressing? [48] 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface

4

A nursing assistive personnel asks for help to transfer a patient who weighs 125 lbs (56.8 kg) from the bed to the wheelchair. The patient is unable to assist. What is the nurse's best response? [38] 1. "As long as we use proper body mechanics, no one will get hurt." 2. "The patient only weighs 125 lbs. You don't need my assistance." 3. "Call the lift-team for additional assistance." 4. "The two of us can easily lift the patient."

3

A patient has her call bell on and looks frightened when you enter the room. She has been on bed rest for 3 days following a fractured femur. She says, "It hurts when I try to breathe, and I can't catch my breath." Your first action is to: [47] 1. Call the HCP to report this change in condition 2. Give the patient a paper bag to breathe into to reduce her anxiety. 3. Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen. 4. Explain that is is normal after such trauma and administer the ordered pain medication.

3

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first? [48] 1. Allow the area to be exposed to air until all drainage has stopped 2. Place several cold packs over the area, protecting the skin around the wound 3. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration 4. Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly.

3

An 82-year-old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1 x 2 x 0.8cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? [L12] 1. Stage I 2. Stage II 3. Stage III 4. Stage IV

3

An indication of a neurovascular problem noted during assessment of the patient with a fracture is: [L63] 1. exaggeration of strength with movement 2. increased redness and heat below the injury 3. decreased sensation distal to the fracture site 4. purulent drainage at the site of an open fracture

3

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer? [48] 1. Stage II 2. Stage IV 3. Unstageable 4. Suspected deep tissue damage

3

The bone cells that function in the resorption of bone tissue are called: [L62] 1. osteoids 2. osteocytes 3. osteoclasts 4. osteoblasts

3

What is an appropriate way for a nurse to dispose of printed patient information? [26] 1. Rip several times and place in a standard trash can 2. Place in the patient's paper-based chart 3. Place in a secure canister marked for shredding 4. Burn the documents

3

Which description best fits that of serous drainage from a wound? [48] 1. Fresh bleeding 2. Thick and yellow 3. Clear, watery plasma 4. Beige to brown and foul smelling

3

Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher? [47] 1. The patient is 5 feet 6 inches and weights 120 pounds. 2. The patient speaks and understands English. 3. The patient received an injection of morphine 30 minutes ago for pain. 4. You feel comfortable handling a patient of his size and with his level of cooperation.

3

Which of the following is a principle of proper body mechanics when lifting or carrying objects? [38] 1. Keep the knees in a locked position 2. Bend at the waist to maintain a center of gravity 3. Maintain a wide base of support 4. Hold objects away from body for improved leverage

3

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? [48] 1. Collection of wound drainage 2. Reduction of abdominal swelling 3. Reduction of stress on the abdominal incision 4. Stimulation of peristalsis (return of bowel function) from direct pressure

3

Which one of the orders should a nurse question in the plan of care for a patient with stage III pressure ulcer? [L12] 1. Pack the ulcer with foam dressing 2. Turn and position the patient Q2H 3. Clean the ulcer every shift with Dakin's solution 4. Assess for pain and medicate before dressing change

3

Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence? [48] 1. Keeping buttocks exposed to air at all times 2. Using a large absorbent diaper, changing when saturated 3. Using an incontinence cleaner, followed by application of a mositure-barrier ointment 4. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel

3

While obtaining subjective assessment data related to the musculoskeletal system, it is particularly important to ask a patient about other medical problems such as: [L62] 1. hypertension 2. thyroid problems 3. diabetes mellitus 4. chronic bronchitis

3

You are reviewing HIPPA regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPPA regulations in the news lately. How will they affect my care?" Which of the following is the best response? [26] 1. HIPPA allows all hospital staff access to your medical record. 2. HIPPA limits the information that is documented in your medical record. 3. HIPPA provides you with greater control over your personal health care information. 4. HIPPA enables health care institutions to release all of your personal information to improve continuity of care.

3

A manager who is reviewing the nurses' notes in a patient's medical record find the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? [26] 1. Avoid rushing when charting an entry. 2. Use correction fluid to remove the entry. 3. Draw a single line through the statement and initial it. 4. Enter only objective and factual information about the patient.

4

A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements made by a woman in the audience reflects a need for further education? [47] 1. "I usually go swimming with my family at the YMCA 3 times a week." 2. "I need to ask my doctor if I should have a bone mineral density check this year." 3. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium I need in my diet." 4. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill."

4

A patient had a left-sided CVA 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The patient is receiving enteral feedings through a small-bore NG tube because of dysphagia. Which of the following symptoms requires the nurse to call the HCP immediately? [47] 1. Pale yellow urine 2. Unilateral neglect 3. Slight movement on the R side 4. Coffee ground-like aspirate from the feeding tube

4

A patient on week-long bed rest is now performing isometric exercises. Which nursing diagnosis best addresses the safety of this patient? [38] 1. Disturbed though process 2. Impaired skin integrity 3. Disturbed body image 4. Risk for activity intolerance

4

A patient with a stable, closed fracture of the humerus caused by trauma to the arm has a temporary splint with bulky padding applied with an elastic bandage. The nurse suspects compartment syndrome and notifies the physician when the patient experiences: [L63] 1. increasing edema of the limb 2. muscle spasms of the lower arm 3. rebounding pulse at the fracture site 4. pain when passively extending the fingers

4

A patient with comminuted fracture of the tibia is to have an open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when: [L63] 1. the patient is unable to tolerate prolonged immobilization 2. the patient cannot tolerate the surgery of a closed reduction 3. a temporary cast would be too unstable to provide normal mobility 4. adequate alignment cannot be obtained by other nonsurgical methods

4

A patient with left-sided weakness asks his nurse, "Why are you walking on my left side? I can hold on to you better with my right hand." What would be your best therapeutic response? [47] 1. "Walking on your left side lets me use my right hand to hold on to your arm. In case you fall, I can still hold you." 2. "Would you like me to walk on your right side so you feel more secure?" 3. "Either side is appropriate, but I prefer the left side. If you like, I can have another nurse walk with you who will hold you on the right side." 4. "By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint.

4

An older adult who was in a car accident and fracutred his femur has been immobilized for 5 days. Which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the first time? [47] 1. Chronic pain 2. Impaired skin integrity 3. Rick for ineffective cerebral tissue perfusion 4. Risk for activity intolerance

4

As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? [26] 1. The patient has a defiant attitude and is demanding his test results. 2. The patient appears to be upset with his nurse because he wants his test results immediately. 3. The patient is demanding and complains frequently about his doctor. 4. The patient stated that he felt frustrated by the lack of information he received regarding his test results.

4

In teaching a patient scheduled for a total ankle replacement, it is important to tell the patient that after surgery he should avoid: [L63] 1. lifting heavy objects 2. sleeping on the back 3. abduction exercises of the affected ankle 4. bearing weight on the affected leg for 6 weeks

4

The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to: [47] 1. Prevent varicose veins 2. Prevent muscular atrophy 3. Ensure joint mobility and prevent contractures 4. Promote venous return to the heart

4

The nurse suspects an ankle sprain when a patient at the urgent care center relates: [L63] 1. being hit by another soccer player during a game 2. having ankle pain after sprinting around the track 3. dropping a 10 lb weight on his lower leg at the health club 4. twisting his ankle while running bases during a baseball game

4

To prevent muscle atrophy, the nurse teaches the patient with a leg immobilized in traction to perform: (Select all that apply.) [L62] 1. flexion contractions 2. tetanic contractions 3. isotonic contractions 4. isometric contractions 5. extension contractions

4

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? 1. Necrotic tissue 2. Wound drainage 3. Drainage on the dressing 4. Wound after it has first been cleaned with normal saline

4

When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch? [48] 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A stage III pressure ulcer needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

4

Which of the following charting entries is most accurate? [26] 1. Patient walked up and down the hallway with assistance, tolerated well. 2. Patient up, out of bed, walked down the hallway and back to room, tolerated well. 3. Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk. 4. Patient worked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.

4

You are transferring a patient who weighs 320 lbs (145.5 kg) from his bed to a chair. The patient has an order for partial weight bearing as a result of bilateral reconstructive knee surgery. Which of the following is the best technique for the transfer? [38] 1. Use a transfer board 2. Obtain a stand assist device 3. Implement a three person carry 4. Use the ceiling mounted lift

4