prep u im missing

The nurse has an order to obtain a 24-hour urine specimen from a client. Which instruction would be accurate for collection of the specimen?

"Discard your first urine and begin the collection after that." Explanation: The nurse would give the instructions to the client that the first urine would be discarded and collections of urine begin after that point. The urine is then collected for 24 hours and may need to be placed on ice or refrigerated. When the 24 hours is completed, the client would need to be asked to void, and the specimen collection is completed.

A client with end-stage chronic obstructive pulmonary disease (COPD) has reached the end of the 6-month period for hospice services and the family caregiver states, "I don't know what we will do if they cut off our hospice services." What is the best response by the hospice nurse?

"I will contact the health care provider to extend services since your family member meets the criteria."

An 83-year-old client who wears glasses is scheduled for surgery. Which action should the nurse take to assure the client remains oriented? Allow the client to wear glasses until after anesthetic is administered. or Allow the client to wear glasses until just before anesthetic is administered.

Allow the client to wear glasses until just before anesthetic is administered. Explanation: If an adult client is visually impaired, the nurse should allow the client to leave the glasses on until just before an anesthetic is administered. Doing so maintains visual orientation and helps to decrease fear and increase confidence. If a client is having a regional or local anesthetic, operating room personnel may allow the client to wear glasses or contact lenses during the procedure. The nurse should note any visual impairment on the chart so that operating room personnel are aware of this deficit. Glasses should not be given to the family unless the client has requested that action and there is no need for the client to leave glasses at home.

In report, the nurse is told that her patient has respiratory alkalosis. Which of the following could be potential causes of this condition? Select all that apply. A. Hyperventilation B. COPD C. Hypoventilation D. Anxiety E. Sepsis

Answer: A, D, E Respiratory alkalosis is caused when the patient loses too much CO2 by rapid breathing, such as with hyperventilation, anxiety, or sepsis. This would result in an ABG with high pH (>7.45) and low CO2 (<35). Hypoventilation and COPD would result in respiratory acidosis. Textbook: pg 1574 table 40-6 has a super helpful chart with the risk factors, assessments, and interventions for all the acid-base disturbances

A nurse is obtaining a urine specimen from a 28 y/o female. Which of the following is the priority for the nurse? A. Delay if patient is menstruating B. Obtain 3 mL C. Obtain 10 mL D. Send off to lab immediately

Answer: C- obtain 10 mL Rationale: When obtaining a urine culture, 3 mL is adequate. When obtaining a urine specimen, 10 mL is required. If the patient is on her period, it is appropriate to move forward with testing a specimen as long as the lab is aware. Once the specimen is ready, it is important to send off immediately so there is no time for bacteria to grow. See page 1353 for more info.

Which of the following are nursing actions that are performed in the preoperative phase? Select all that apply. A. Skin preparation B. Teaching deep breathing exercises C. Obtaining a list of the patient's current medications D. Assessing vital signs every 15 minutes E. Airway/oxygen therapy/pulse oximetry

Answers: B and C You must always teach any post-op exercises during the preoperative phase. Obtaining the client's medication history in the preoperative phase is vital so that any risk factors from taking those medications could be identified. You would perform skin preparation in the intraoperative phase. Frequently assessing vital signs would come in the postoperative phase, as well as performing respiratory assessments such as airway, oxygen therapy, and pulse oximetry. Textbook pg. 951

What accurately describes a practice guideline that the nurse should follow when inserting an indwelling catheter? Use the largest appropriate-sized catheter in order to prevent leakage. or Avoid irrigation unless needed to relieve an obstruction.

Avoid irrigation unless needed to relieve an obstruction. Irrigation should be avoided to prevent infection unless there is an obstruction. A closed system should be maintained using sterile technique. The smallest appropriate-sized catheter should be used.

The nurse is monitoring the patient who is 24 hours post-opt from surgery. Which finding requires intervention? A. BP 100/80 B. 24-hour urine output of 300 ml C. Pain rating of 4 on 1-10 scale D. Temperature of 99.3' F

B, The nurse needs to watch the patient's urinary output closely. Urinary output within a 24-hour period should be at least 30 ml/hr. In this case, the patient is only urinating 12.5 ml/hr.

A patient who has bone cancer is most likely experiencing which of the following types of pain? A. Cutaneous B. Somatic C. Visceral D. Referred

B. Somatic. Rationale: Somatic pain is defined as nociceptive, or physiologic pain. It can be found in bone, skin, joint, or muscle. Pg 1235

A nurse is performing digital removal of stool on a patient with a fecal impaction. During the procedure, the patient tells the nurse she is feeling dizzy and nauseated, and then vomits. What should be the nurse's next action? a. Reassure the patient that this is a normal reaction to the procedure. b. Stop the procedure, prepare to administer CPR, and notify the primary care provider. c. Stop the procedure, assess vital signs, and notify the primary care provider. d. Stop the procedure, wait 5 minutes, and then resume the procedure.

C is the right answer. If a patient reports dizziness or lightheadedness and has nausea and vomiting during digital stool removal, the nurse should stop the procedure, assess vital signs, and notify the health care provider as the vagus nerve could have been stimulated.

A patient has been experiencing nausea and vomiting for the past 3 days. The patient is admitted to the ED with poor skin turgor, pale mucous membranes, and says they feel lightheaded. Which type of IV solution would be appropriate to administer? A. 5% Nacl B. 0.33% Nacl C. Lactated ringers D. 0.45% normal saline

C. lactated ringers The patient is presenting with clinical manifestations of dehydration, therefore an isotonic solution should be used. The other options are hypertonic or hypotonic solutions. Pg. 1558 of the fluid and electrolytes chapter has information about IV fluid and tonicity

Which of the following is not an age-related change found in the older adult population? A. Diminished cough reflex B. Reduced bladder capacity C. Decreased gastric pH D. Increased vascular rigidity

C. pH increases with age. (pg. 945)

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

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

A nurse caring for patients in a skilled nursing facility performs risk assessments on the patients for foot and nail problems. Which patients would be at a higher risk? Select all that apply. a.A patient who is taking antibiotics for chronic bronchitis b.A patient diagnosed with type II diabetes. c.A patient who is obese. d.A patient who has a nervous habit of biting his nails. e.A patient diagnosed with prostate cancer f.A patient whose job involves frequent handwashing

b, c, d, f. Variables known to cause nail and foot problems include deficient self-care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity.

You are monitoring a patient who is recovering from abdominal surgery. You notice the patients BP is 98/55, HR is 113, and respirations are 23 per minute. You look at the wound dressing and you notice it has a large amount of sangeonous drainage. What should you do next? A. Request an order for a blood transfusion B. Call the provider and report the vital signs C. Change the dressing and give the patient fluids D. Apply pressure to the dressing and call for help

The answer is D. This patient is obviously demonstrating signs of bleeding so the priority should be to apply pressure and add more gauze to reinforce the dressing. You would also need to call for help because this is a medical emergency. Refer to pg. 955

A nurse teaches deep breathing exercises to a preoperative client. Which action should the nurse perform? Instruct the client to breathe in through the nose as deeply as possible and hold the breath for 10 seconds. or Instruct the client to exhale gently and completely before inhaling.

Instruct the client to exhale gently and completely before inhaling. The nurse should assist the client to sit up and place the palms of both hands along the lower anterior rib cage. The client should then exhale gently and completely inhale through the nose as deeply as possible, holding the breath for 3 seconds.

A client comes to the postoperative area and reports chest pain and palpitations. What priority intervention(s) will the nurse perform? Select all that apply. Obtain vital signs, especially heart rate and blood pressure Give pain medication as prescribed Ask the client to rate pain on a scale from zero to ten Review prior medical history

Obtain vital signs, especially heart rate and blood pressure Give pain medication as prescribed Ask the client to rate pain on a scale from zero to ten

A nurse caring for clients in a PACU assesses a client who is displaying signs and symptoms of shock. What is the priority nursing intervention for this client? Do not administer any further medication. or Place the client in a flat position with legs elevated 45 degrees.

Place the client in a flat position with legs elevated 45 degrees. Placing the client in a flat position with the legs elevated 45 degrees uses gravity to help direct blood to the vital organs. Removing extra coverings would cause the client's temperature to drop further during the blood loss occurring during shock. Medications will likely be ordered to help treat the shock. Prone position would be contraindicated.

A nurse is providing education to a client having same-day surgery. Which statement would be accurate regarding this type of surgery?

Some major surgeries can be done as same-day surgery.

A patient reports he hasn't had a bowel movement or passed gas since surgery. On assessment, you note the abdomen is distended and no bowel sounds are noted in the four quadrants. You notify the MD. What non-invasive nursing interventions can you perform without a MD order? A. Insert a nasogastric attached to intermittent suction B. Administer IV fluids C. Encourage ambulation, maintain NPO status, and monitor intake & output D. Encourage at least 3000 ml of fluids per day

The answer is C. This patient is most likely experiencing a paralytic ileus which is failure for the bowels to move its contents. The only correct non-invasive option is to encourage ambulation, maintain NPO status, and monitor intake & output. Inserting a NG tube or administering IV fluids is invasive and requires a MD order. Patients with potential paralytic ileus are to be NPO (nothing by mouth) so encouraging fluid intake is incorrect.

A client with Alzheimer's is unable to follow instructions for using their inhaled bronchodilator. Which medication delivery system would be most appropriate for this patient? A. Metered dose inhaler without spacer B. Dry powder inhaler C. Nebulizer D. incentive spirometer

The correct answer would be C. This is because a nebulizer goes onto the face and the client passively inhales the entire dose. A dry powder inhaler and metered dose inhaler require the user to keep their mouth around the port, which could be hard if there is an inability to understand or follow instructions. An incentive spirometer would be used to practice deep breathing and help expand the lungs. Ch 39 pages 1506-1508

The nurse-anesthetist is monitoring the client during surgery. He notices a ventricular dysrhythmia and unstable blood pressure. He notifies the surgeon. The operative team suspects:

The symptoms of malignant hyperthermia are masseter muscle rigidity, ventricular dysrhythmia, tachypnea, cyanosis, skin mottling, and unstable blood pressure.

When assessing pain in a child, the nurse needs to be aware of what considerations? a.Immature neurologic development results in reduced sensation of pain b.Inadequate or inconsistent relief of pain is widespread c.Reliable assessment tools are currently unavailable d.Narcotic analgesic use should be avoided

b. Health care personnel are only now becoming aware of pain relief as a priority for children in pain. The evidence supports the fact that children do indeed feel pain and reliable assessment tools are available specifically for use with children. Opioid analgesics may be safely used with children as long as they are carefully monitored.

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply. a.Serous drainage is composed of the clear portion of the blood and serous membranes. b.Sanguineous drainage is composed of a large number of red blood cells and looks like blood. c.Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. d.Purulent drainage is composed of white blood cells, dead tissue, and bacteria. e.Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. f.Serosanguineous drainage can be dark yellow or green depending on the causative organism.

a, b, c, d. Serous drainage is composed primarily of the clear, serous portion of the blood and serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.

A nurse is preparing a family for a terminal weaning of a loved one. Which nursing actions would facilitate this process? Select all that apply. a.Participate in the decision-making process by offering the family information about the advantages and disadvantages of continued ventilatory support. b.Explain to the family what will happen at each phase of the weaning and offer support. c.Check the orders for sedation and analgesia, making sure that the anticipated death is comfortable and dignified. d.Tell the family that death will occur almost immediately after the patient is removed from the ventilator. e.Tell the family that the decision for terminal weaning of a patient must be made by the primary care provider. f.Set up mandatory counseling sessions for the patient and family to assist them in making this end-of-life decision

a, b, c. A nurse's role in terminal weaning is to participate in the decision-making process by offering helpful information about the benefits and burdens of continued ventilation and a description of what to expect if terminal weaning is initiated. Supporting the patient's family and managing sedation and analgesia are critical nursing responsibilities. In some cases, competent patients decide that they wish their ventilatory support ended; more often, the surrogate decision makers for an incompetent patient determine that continued ventilatory support is futile. Because there are no guarantees how any patient will respond once removed from a ventilator, and because it is possible for the patient to breathe on his or her own and live for hours, days, and, rarely, even weeks, the family should not be told that death will occur immediately. Counseling sessions may be arranged if requested but are not mandatory to make this decision.

A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply. a.It promotes the patient's sense of well-being. b.It prevents deterioration of the oral cavity. c.It contributes to decreased incidence of aspiration pneumonia. d.It eliminates the need for flossing. e.It decreases oropharyngeal secretions. f.It helps to compensate for an inadequate diet.

a, b, c. Adequate oral hygiene is essential for promoting the patient's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of aspiration pneumonia and other systemic diseases. Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition.

A nurse midwife is assisting a patient who is firmly committed to natural childbirth to deliver a full-term baby. A cesarean delivery becomes necessary when the fetus displays signs of distress. Inconsolable, the patient cries and calls herself a failure as a mother. The nurse notes that the patient is experiencing what type of loss? Select all that apply. a.Actual b.Perceived c.Psychological d.Anticipatory e.Physical f.Maturational

a, b, c. The losses experienced by the woman are actual, perceived, and psychological. Actual loss can be recognized by others as well as by the person sustaining the loss; perceived loss is experienced by the person but is intangible to others; and psychological loss is a loss that is felt mentally as opposed to physically. Anticipatory loss occurs when one grieves prior to the actual loss; physical loss is loss that is tangible and perceived by others; and maturational loss is experienced as a result of natural developmental processes.

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. a.Closely assess the patient before, during, and after the procedure. b. Hyper-oxygenate the patient before and after suctioning. c.Limit the application of suction to 20 to 30 seconds. d.Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. e.Use an appropriate suction pressure (80 to 150 mm Hg). f.Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.

a, b, d, e. Close assessment of the patient before, during, and after the procedure is necessary to limit negative effects. Risks include hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. The nurse should also take the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80 to 150 mm Hg) will help prevent atelectasis related to the use of high negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis.

A nurse is providing foot care for patients in a long-term care facility. Which actions are recommended guidelines for this procedure? Select all that apply. a.Bathe the feet thoroughly in a mild soap and tepid water solution. b.Soak the feet in warm water and bath oil. c.Dry feet thoroughly, including the area between the toes. d.Use an alcohol rub if the feet are dry. e.Use an antifungal foot powder if necessary to prevent fungal infections. f.Cut the toenails at the lateral corners when trimming the nail.

a, c, e. The following are recommended guidelines for foot care: bathe the feet thoroughly in a mild soap and tepid water solution; dry feet thoroughly, including the area between the toes; and use an antifungal foot powder if necessary to prevent fungal infections. The nurse should avoid soaking the feet, use moisturizer if the feet are dry, and avoid digging into or cutting the toenails at the lateral corners when trimming the nails.

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

a, b, d, f. Nurses need to know about medications that may produce varied responses in patients from different ethnic groups. The patient's expectations of the medication may affect the response to the medication, for example, when a placebo is given and a patient has a therapeutic effect. The patient's environment may also influence the patient's response to medications, for example, sensory deprivation and overload may affect drug responses. Circadian rhythms and cycles may also influence drug action. The liver is the primary organ for drug breakdown, thus pathologic conditions that involve the liver may slow metabolism and alter the dosage of the drug needed to reach a therapeutic level. The presence of food in the stomach can delay the absorption of orally administered medications. Alternately, some medications should be given with food to prevent gastric irritation, and the nurse should consider this when establishing a patient's medication schedule. Other medications may have enhanced absorption if taken with certain foods.

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply. a.Use standard precautions or transmission-based precautions when indicated. b.Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. c.Clean the wound in full or half circles beginning on the outside and working toward the center. d.Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. e.Clean to at least 1 in beyond the end of the new dressing if one is being applied. f.Clean to at least 3 in beyond the wound if a new dressing is not being applied.

a, b, e. The correct procedure for cleaning a wound with unapproximated edges is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least 1 in beyond the end of the new dressing, and (6) clean to at least 2 in beyond the wound margins if a dressing is not being applied.

A nurse is evaluating patients to determine their need for parenteral nutrition (PN). Which patients would be the best candidates for this type of nutritional support? Select all that apply. a.A patient with irritable bowel syndrome who has intractable diarrhea b.A patient with celiac disease not absorbing nutrients from the GI tract c.A patient who is underweight and needs short-term nutritional support d.A patient who is comatose and needs long-term nutritional support e.A patient who has anorexia and refuses to take foods via the oral route f.A patient with burns who has not been able to eat adequately for 5 days

a, b, f. Assessment criteria used to determine the need for PN include an inability to achieve or maintain enteral access; motility disorders; intractable diarrhea; impaired absorption of nutrients from the GI tract; and when oral intake has been or is expected to be inadequate over a 7- to 14-day period (McClave et al., 2016; Worthington & Gilbert, 2012). PN promotes tissue healing and is a good choice for a patient with burns who has an inadequate diet. Oral intake is the best method of feeding; the second best method is via the enteral route. For short-term use (less than 4 weeks), a nasogastric or nasointestinal route is usually selected. A gastrostomy (enteral feeding) is the preferred route to deliver enteral nutrition in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Patients who refuse to take food should not be force fed nutrients against their will.

A nurse working in a hospital includes abdominal assessment as part of patient assessment. In which patients would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes? Select all that apply. a.A patient diagnosed with peritonitis b.A patient who is on prolonged bedrest c.A patient who has diarrhea d.A patient who has gastroenteritis e.A patient who has an early bowel obstruction f.A patient who has paralytic ileus caused by surgery

a, b, f. Decreased or absent bowel sounds—evidenced only after listening for 5 minutes (Hogan-Quigley, Palm, & Bickley, 2017)—signify the absence of bowel motility, commonly associated with peritonitis, paralytic ileus, and/or prolonged immobility. Hyperactive bowel sounds indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction.

The three types of responses to pain are physiologic, behavioral, and affective. Which are examples of behavioral responses to pain? Select all that apply. a.A patient cradles a wrist that was injured in a car accident b.A child is moaning and crying due to a stomachache c.A patient's pulse is increased following a myocardial infarction d.A patient in pain strikes out at a nurse who attempts to provide a bath e.A patient who has chronic cancer pain is depressed and withdrawn f.A child pulls away from a nurse trying to give an injection

a, b, f. Protecting or guarding a painful area, moaning and crying, and moving away from painful stimuli are behavioral responses. Examples of a physiologic or involuntary response would be increased blood pressure or dilation of the pupils. Affective responses, such as anger, withdrawal, and depression, are psychological in nature.

In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply. a.A patient diagnosed with rubella b.A patient diagnosed with diphtheria c.A patient diagnosed with varicella d.A patient diagnosed with tuberculosis e.A patient diagnosed with MRSAAn infant diagnosed with adenovirus infection

a, b, f. Rubella, diphtheria, and adenovirus infection are illnesses transmitted by large-particle droplets and require droplet precautions in addition to standard precautions. Airborne precautions are used for patients who have infections spread through the air with small particles; for example, tuberculosis, varicella, and rubeola. Contact precautions are used for patients who are infected or colonized by a multidrug-resistant organism (MDRO), such as MRSA.

A scrub nurse is assisting a surgeon with a kidney transplant. What are the patient responsibilities of the scrub nurse? Select all that apply. a.Maintaining sterile technique b.Draping and handling instruments and supplies c.Identifying and assessing the patient on admission d.Integrating case management e.Preparing the skin at the surgical site f.Providing exposure of the operative area

a, b. The scrub nurse is a member of the sterile team who maintains sterile technique while draping and handling instruments and supplies. Two duties of the circulating nurse are to identify and assess the patient on admission to the OR and prepare the skin at the surgical site. The RNFA actively assists the surgeon by providing exposure of the operative area. The APRN coordinates care activities, collaborates with physicians and nurses in all phases of perioperative and postanesthesia care, and integrates case management, critical paths, and research into care of the surgical patient.

A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply. a.Providing a bed bath for a patient b.Visibly soiled hands after changing the bedding of a patient c.Removing gloves when patient care is completed d.Inserting a urinary catheter for a female patient e.Assisting with a surgical placement of a cardiac stent f.Removing old magazines from a patient's table

a, c, d, f. It is recommended to use an alcohol-based handrub in the following situations: before direct contact with patients; after direct contact with patient skin; after contact with body fluids if hands are not visibly soiled; after removing gloves; before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement; before donning sterile gloves prior to an invasive procedure; if moving from a contaminated body site to a clean body site; and after contact with objects contaminated by the patient. Keep in mind that handrubs are not appropriate for use with C. difficile infection.

A nurse is caring for a patient who has an NG tube in place for gastric decompression. Which nursing actions are appropriate when irrigating an NG tube connected to suction? Select all that apply. a.Draw up 30 mL of saline solution into the syringe b.Unclamp the suction tubing near the connection site to instill solution. c.Place the tip of the syringe in the tube to gently insert saline solution. d.Place the syringe in the blue air vent of a Salem sump or double-lumen tube. e.After instilling irrigant, hold the end of the NG tube over an irrigation tray. f.Observe for return flow of NG drainage into an available container.

a, c, e, f. The nurse irrigating an NG tube connected to suction should draw up 30 mL of saline solution (or the amount indicated in the order or policy) into the syringe, clamp the suction tubing near the connection site to protect the patient from leakage of NG drainage, place the tip of the syringe in the tube to gently insert the saline solution, then place the syringe in the drainage port, not in the blue air vent of a Salem sump or double-lumen tube (the blue air vent acts to decrease pressure built up in the stomach when the Salem sump is attached to suction). After instilling irrigant, hold the end of the NG tube over an irrigation tray or emesis basin, and observe for return flow of NG drainage into an available container.

A nurse is attempting to improve care on the pediatric ward of a hospital. Which nursing improvements might the nurse employ when following the recommendations of the Institute of Medicine's Committee on Quality of Health Care in America? Select all that apply. a.Basing patient care on continuous healing relationships b.Customizing care to reflect the competencies of the staff c.Using evidence-based decision making d.Having a charge nurse as the source of control e.Using safety as a system priority f.Recognizing the need for secrecy to protect patient privacy

a, c, e. Care should be based on continuous healing relationships and evidence-based decision making. Customization should be based on patient needs and values with the patient as the source of control. Safety should be used as a system priority, and the need for transparency should be recognized.

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply. a.Hemostasis occurs immediately after the initial injury. b.A liquid called exudate is formed during the proliferation phase. c.White blood cells move to the wound in the inflammatory phase. d.Granulation tissue forms in the inflammatory phase. e.During the inflammatory phase, the patient has generalized body response. f.A scar forms during the proliferation phase.

a, c, e. Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking of plasma and blood components out into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar.

A nurse is teaching a patient how to use a meter-dosed inhaler to control asthma. What are appropriate guidelines for this procedure? Select all that apply. a.Shake the inhaler well and remove the mouthpiece covers from the MDI and spacer. b.Take shallow breaths when breathing through the spacer. c.Depress the canister releasing one puff into the spacer and inhale slowly and deeply. d.After inhaling, exhale quickly through pursed lips. e.Wait 1 to 5 minutes as prescribed before administering the next puff. f.Gargle and rinse with salt water after using the MDI.

a, c, e. The correct procedure for using a meter-dosed inhaler is: Shake the inhaler well and remove the mouthpiece cover; breathe normally through the spacer; depress the canister releasing one puff into the spacer and inhale slowly and deeply; after inhaling, hold breath for 5 to 10 seconds, or as long as possible, and then exhale slowly through pursed lips; wait 1 to 5 minutes as prescribed before administering the next puff; and gargle and rinse with tap water after using the MDI.

After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding?a.Pouring warm water over the patient's fingers. b.Having the patient ignore the urge to void until her bladder is full. c.Using a warm bedpan when the patient feels the urge to void. d.Stroking the patient's leg or thigh.

b. Ignoring the urge to void makes urination even more difficult and should be avoided. The other activities are all recommended nursing activities to promote voiding.

A nurse caring for patients in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse screen for urinary retention? Select all that apply. a.A 78-year-old male patient diagnosed with an enlarged prostate b.An 83-year-old female patient who is on bedrest c.A 75-year-old female patient who is diagnosed with vaginal prolapse d.An 89-year-old male patient who has dementia e.A 73-year-old female patient who is taking antihistamines to treat allergies f.A 90-year-old male patient who has difficulty walking to the bathroom

a, c, e. Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse. Being on bedrest, having dementia, and having difficulty walking to the bathroom may place patients at risk for urinary incontinence.

A responsibility of the nurse is the administration of preoperative medications to patients. Which statements describe the action of these medications? Select all that apply. a.Diazepam is given to alleviate anxiety. b.Ranitidine is given to facilitate patient sedation. c.Atropine is given to decrease oral secretions. d.Morphine is given to depress respiratory function. e.Cimetidine is given to prevent laryngospasm. f.Fentanyl citrate-droperidol is given to facilitate a sense of calm.

a, c, f. Sedatives, such as diazepam, midazolam, or lorazepam, are given to alleviate anxiety and decrease recall of events related to surgery. Anticholinergics, such as atropine and glycopyrrolate are given to decrease pulmonary and oral secretions and to prevent laryngospasm. Neuroleptanalgesic agents, such as fentanyl citrate-droperidol are given to cause a general state of calm and sleepiness. Histamine-2 receptor blockers, such as cimetidine and ranitidine, are given to decrease gastric acidity and volume. Narcotic analgesics, such as morphine, are given to facilitate patient sedation and relaxation and to decrease the amount of anesthetic agent needed.

A nurse is caring for a patient diagnosed with bladder cancer who has a urinary diversion. Which actions would the nurse take when caring for this patient? Select all that apply. a.Measure the patient's fluid intake and output. b.Keep the skin around the stoma moist. c.Empty the appliance frequently. d.Report any mucus in the urine to the primary care provider. e.Encourage the patient to look away when changing the appliance. f.Monitor the return of intestinal function and peristalsis.

a, c, f. When caring for a patient with a urinary diversion, the nurse should measure the patient's fluid intake and output to monitor fluid balance, change the appliance frequently, monitor the return of intestinal function and peristalsis, keep the skin around the stoma dry, watch for mucus in the urine as a normal finding, and encourage the patient to participate in care and look at the stoma.

Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply. a.Compare bilateral parts for symmetry. b.Proceed in a toe-to-head systematic manner. c.Use standard terminology to report and record findings. d.Do not allow data from the nursing history to direct the assessment. e.Document only skin abnormalities on the patient record. f.Perform the appropriate skin assessment when risk factors are identified.

a, c, f. When performing a skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to report and record findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, and allow data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings.

A nurse is teaching a student nurse how to cleanse the perineal area of both male and female patients. What are accurate guidelines when performing this procedure? Select all that apply. a.For male and female patients, wash the groin area with a small amount of soap and water and rinse. b.For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area. c.For male and female patients, always proceed from the most contaminated area to the least contaminated area. d.For male and female patients, use a clean portion of the washcloth for each stroke. e.For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. f.In an uncircumcised male patient, do not retract the foreskin (prepuce) while washing the penis.

a, d, e. Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis.

A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply. a.The nurse carefully removes the bandages from a burn victim's arm. b.The nurse assesses a patient to check nutritional status. c.The nurse formulates a nursing diagnosis for a patient with epilepsy. d.The nurse turns a patient in bed every 2 hours to prevent pressure injuries. e.The nurse checks a patient's insurance coverage at the initial interview. f.The nurse checks for community resources for a patient with dementia.

a, d, f. During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step.

For which patient would a nurse expect the primary care provider to order colostomy irrigation? a.A patient with IBS b.A patient with a left-sided end colostomy in the sigmoid colon c.A patient with post-radiation damage to the bowel d.A patient with Crohn's disease

b. Irrigations are used to promote regular evacuation of distal colostomies. Colostomy irrigation may be indicated in patients who have a left-sided end colostomy in the descending or sigmoid colon, are mentally alert, have adequate vision, and have adequate manual dexterity needed to perform the procedure. Contraindications include IBS, peristomal hernia, post-radiation damage to the bowel, diverticulitis, and Crohn's disease (Kent et al., 2015).

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

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

The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. a."The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." b."It's hospital policy. I know it must be tiresome, but I will try to make this quick!" c."I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." d."We want to make sure that your responses to the medical exam are consistent and that all our data are accurate." e."We need to check your health status and see what kind of nursing care you may need." f."We need to see if you require a referral to a physician or other health care professional."

a, e, f. Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patient's health status, the ability to manage his or her own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient's strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the patient to a physician or other health care professional, if indicated. The fact that this is hospital policy is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs a nursing history and exam. The assessment is not performed to check the accuracy of the medical examination.

A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: (1) Disturbed Body Image (2) Ineffective Airway Clearance (3) Spiritual Distress (4) Impaired Social Interaction Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow's model? a.2, 4, 1, 3 b.3, 1, 4, 2 c.2, 4, 3, 1 d.3, 2, 4, 1

a. 2, 4, 1, 3. Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to Maslow's hierarchy: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5) self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-actualization need.

A nurse is assessing the following children. Which child would the nurse identify as having the greatest risk for choking and suffocating?A toddler playing with his 9-year-old brother's construction setA 4-year-old eating yogurt for lunchAn infant covered with a small blanket and asleep in the cribA 3-year-old drinking a glass of juice

a. A young child may place small or loose parts in the mouth; a toy that is safe for a 9-year-old could kill a toddler. An infant sleeping in a crib without a pillow or large blanket and a 3-year-old and a 4-year-old drinking juice and eating yogurt are not particular safety risks.

A nurse is assessing a patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: a.Clinical judgment b.Clinical reasoning c.Critical thinking d.Blended competencies

a. Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to the result or outcome of critical thinking or clinical reasoning—in this case, the recommendation to meet with a nutritionist. Clinical reasoning usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems). Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting. Blended competencies are the cognitive, technical, interpersonal, and ethical and legal skills combined with the willingness to use them creatively and critically when working with patients.

The health care provider has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure? a.The male urethra is more vulnerable to injury during insertion. b.In the hospital, a clean technique is used for catheter insertion. c.The catheter is inserted 2 to 3 in into the meatus. d.Since it uses a closed system, the risk for UTI is absent.

a. Because of its length, the male urethra is more prone to injury and requires that the catheter be inserted 6 to 8 in. This procedure requires surgical asepsis to prevent introducing bacteria into the urinary tract. The presence of an indwelling catheter places the patient at risk for a UTI.

A nurse is caring for an older adult who has constipation. Which laxative would be contraindicated for this patient? a.A saline osmotic laxative b.A bulk-forming laxative c.Methylcellulose d.A stool softener

a. Certain saline osmotic laxatives can lead to fluid and electrolyte imbalances and should not be used in older adults or those with kidney or cardiac disease.

Older adults often have reduced vital capacity as a result of normal physiologic changes. Which nursing intervention would be most important for the postoperative care of an older surgical patient specific to this change? a.Take and record vital signs every shift b.Turn, cough, and deep breathe every 4 hours c.Encourage increased intake of oral fluids d.Assess bowel sounds daily

b. Reduced vital capacity in older adults increases the risk for respiratory complications, including pneumonia and atelectasis. Having the patient turn, cough, and deep breathe every 4 hours maintains respiratory function and helps to prevent complications.

A nurse is removing rigid gas-permeable (RGP) contact lenses from the eyes of a patient who is unable to assist with removal. The nurse notices that one of the lenses is not centered over the cornea. What would be the nurse's first action in this procedure? a. Apply gentle pressure on the lower eyelid to center the lens prior to removing it. b. Move the eyelids toward one another to cause the lens to slide out between the eyelids. c. Do not attempt to remove the lens as it should only be removed by an eyecare specialist. d. Have the patient look forward, retract the lower lid, and move the lens down on the sclera.

a. If the lens is not centered over the cornea, the nurse should apply gentle pressure on the lower eyelid to center the lens, gently pull the outer corner of the eye toward the ear, position the hand below the lens to receive it, and ask the patient to blink. Moving the eyelids toward one another to cause the lens to slide out between the eyelids is a later step in the procedure. Having the patient look forward, retracting the lower lid and moving the lens down on the sclera occurs during removal of soft contact lenses. It is not necessary to call in an eyecare specialist unless there is damage to the eye.

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

a. If the patient is receiving tube feedings, the nurse should review information about the drugs to be administered. Absorption of some drugs, such as phenytoin, is affected by tube-feeding formulas. The nurse should discontinue a continuous tube feeding and leave the tube clamped for the required period of time before and after the medication has been given, according to the reference and facility protocol.

A nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurse's next action following this assessment? a.Use warm water or air and gentle pressure to remove the clog. b.Use a stylet to unclog the tubes. c.Administer cola to remove the clog. d.Replace the tube with a new one.

a. In order to remove a clog in a feeding tube, the nurse should try using warm water or air and gentle pressure to unclog it. A stylet should never be used to unclog a tube, and cola and meat tenderizers have not been shown effective in removing clogs. The nurse should first attempt to remove the clog, and if unsuccessful, the tube should be replaced.

When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." What would be the instructor's BEST response to this student's diagnosis? a."Was this diagnosis derived from a cluster of significant data or a single clue?" b."This early diagnosis will help us manage the problem before it becomes more acute." c."Have you determined if this is an actual or a possible diagnosis?" d."This condition is a medical problem that should not have a nursing diagnosis."

a. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. A data cluster is a grouping of patient data or cues that point to the existence of a patient health problem. There may be a reason for the lack of a bowel movement for 2 days, or it might be this person's normal pattern.

A school nurse notices that a student is losing weight and decides to perform a focused nutritional assessment to rule out an eating disorder. What is the nurse's best action? a.Perform the focused assessment as this is an independent nurse-initiated intervention. b.Request an order from Jill's physician since this is a physician-initiated intervention. c.Request an order from Jill's physician since this is a collaborative intervention. d.Request an order from the nutritionist since this is a collaborative intervention.

a. Performing a focused assessment is an independent nurse-initiated intervention; thus the nurse does not need an order from the physician or the nutritionist.

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

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

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

a. Receptors in the skin and superficial organs may be stimulated by mechanical, thermal, chemical, and electrical agents. Friction from bed linens causing pressure sores is a mechanical stimulant. Sunburn is a thermal stimulant. An acid burn is the result of a chemical stimulant. An electrical shock is an electrical stimulant

A hospice nurse is caring for a patient who is terminally ill and who is on a ventilator. After a restless night, the patient hands the nurse a note with the request: "Please help me end my suffering." Which response by a nurse would best reflect adherence to the position of the American Nurses Association (ANA) regarding assisted suicide?a.The nurse promises the patient that he or she will do everything possible to keep the patient comfortable but cannot administer an injection or overdose to cause the patient's death b.The nurse tells the patient that under no condition can he be removed from the ventilator because this is active euthanasia and is expressly forbidden by the Code for Nurses. c.After exhausting every intervention to keep a dying patient comfortable, the nurse says, "I think you are now at a point where I'm prepared to do what you've been asking me. Let's talk about when and how you want to die d."The nurse responds: "I'm personally opposed to assisted suicide, but I'll find you a colleague who can help you."

a. The ANA Code of Ethics states that the nurse "should provide interventions to relieve pain and other symptoms in the dying patient consistent with palliative care practice standards and may not act with the sole intent to end life" (2015, p. 3). Yet, nurses may be confronted by patients who seek assistance in ending their lives and must be prepared to respond to the request: "Nurse, please help me die...."

A nurse is using the SOAP format to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation? a.A patient problem list b.Narrative notes describing the patient's condition c.Overall trends in patient status d.Planned interventions and patient outcomes

a. The SOAP format (Subjective data, Objective data, Assessment, Plan) is used to organize entries in the progress notes of a POMR. When using the SOAP format, the problem list at the front of the chart alerts all caregivers to patient priorities. Narrative notes allow nurses to describe a condition, situation, or response in their own terms. Overall trends in patient status can be seen immediately when using CBE, not SOAP charting. Planned interventions and patient-expected outcomes are the focus of the case management model.

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan? a.Document the findings and continue to monitor the patient. b.Administer antipyretics, as prescribed. c.Increase the frequency of assessment to every hour and notify the patient's primary care provider. d.Increase the frequency of wound care and contact the primary care provider for an antibiotic prescription.

a. The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.

A patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition? a.Vitamin B malnutrition b.Obesity c.Dehydration d.Vitamin C deficiency

a. The need for B vitamins is increased in alcoholics because these nutrients are used to metabolize alcohol, thus depleting their supply. Alcohol abuse specifically affects the B vitamins. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI tract.

A nurse is caring for a patient who is post-surgical following an IPAA. For which adverse effect would the nurse monitor in this patient?a.Incontinence b.Constipation c.Electrolyte imbalances d.Infection

a. The outcomes for this IPAA surgery are not always ideal, and many patients experience decreased quality of life due to frequent defecation and fecal seepage and incontinence.

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? a.Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. b.Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider stat, administer antihistamine parenterally as needed. c.Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider, and treat symptoms. d.Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the health care provider, administer antibiotics stat.

a. The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.

A nurse is feeding an older adult patient who has dementia. Which intervention should the nurse perform to facilitate this process?a.Stroke the underside of the patient's chin to promote swallowing. b.Serve meals in different places and at different times. c.Offer a whole tray of various foods to choose from. d.Avoid between-meal snacks to ensure hunger at mealtime.

a. To feed a patient with dementia, the nurse should stroke the underside of the patient's chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide between-meal snacks that are easy to consume using the hands.

When may a health institution release a PHI for purposes other than treatment, payment, and routine health care operations, without the patient's signed authorization? Select all that apply. a.News media are preparing a report on the condition of a patient who is a public figure. b.Data are needed for the tracking and notification of disease outbreaks. c.Protected health information is needed by a coroner. d.Child abuse and neglect are suspected. e.Protected health information is needed to facilitate organ donation. f.The sister of a patient with Alzheimer's disease wants to help provide care.

b, c, d, e. According to the HIPAA, a health institution is not required to obtain written patient authorization to release PHI for tracking disease outbreaks, infection control, statistics related to dangerous problems with drugs or medical equipment, investigation and prosecution of a crime, identification of victims of crimes or disaster, reporting incidents of child abuse, neglect or domestic violence, medical records released according to a valid subpoena, PHI needed by coroners, medical examiners, and funeral directors, PHI provided to law enforcement in the case of a death from a potential crime, or facilitating organ donations. Under no circumstance can a nurse provide information to a news reporter without the patient's express authorization. An authorization form is still needed to provide PHI for a patient who has Alzheimer's disease.

A nurse is planning care for a patient who was admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply. a.The nurse formulates nursing diagnoses.The nurse identifies expected patient outcomes. b.The nurse selects evidence-based nursing interventions. c.The nurse explains the nursing care plan to the patient. d.The nurse assesses the patient's mental status. e.The nurse evaluates the patient's outcome achievement.

b, c, d. During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to establish priorities, identify and write expected patient outcomes, select evidence-based nursing interventions, and communicate the nursing care plan. Although all these steps may overlap, formulating and validating nursing diagnoses occur most frequently during the diagnosing step of the nursing process. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process.

A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. Which steps in this procedure are performed correctly? Select all that apply. a.Removes all jewelry including a platinum wedding band b.Washes hands to 1 in above the wrists c.Uses approximately one teaspoon of liquid soap d.Keeps hands higher than elbows when placing under faucet e.Uses friction motion when washing for at least 20 seconds f.Rinses thoroughly with water flowing toward fingertips

b, c, e, f. Proper hand hygiene includes removing jewelry (with the exception of a plain wedding band), wetting the hands and wrist area with the hands lower than the elbows, using about one teaspoon of liquid soap, using friction motion for at least 20 seconds, washing to 1 in above the wrists with a friction motion for at least 20 seconds, and rinsing thoroughly with water flowing toward fingertips.

A nurse uses critical thinking skills to focus on the care plan of an older adult who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply. a.It functions independently of nursing standards, ethics, and state practice acts. b.It is based on the principles of the nursing process, problem solving, and the scientific method. b.It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. c.It is not designed to compensate for problems created by human nature, such as medication errors. d.It is constantly re-evaluating, self-correcting, and striving for improvement. e.It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care.

b, c, e. Critical thinking applied to clinical reasoning and judgment in nursing practice is guided by standards, policies and procedures, and ethics codes. It is based on principles of nursing process, problem solving, and the scientific method. It carefully identifies the key problems, issues, and risks involved, and is driven by patient, family, and community needs, as well as nurses' needs to give competent, efficient care. It also calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re-evaluating, self-correcting, and striving to improve (Alfaro-LeFevre, 2014).

A nurse instructor is teaching a class of student nurses about the nature of pain. Which statements accurately describe this phenomenon? Select all that apply. a.Pain is whatever the health care provider treating the pain says it is b.Pain exists whenever the person experiencing it says it exists c.Pain is an emotional and sensory reaction to tissue damage d.Pain is a simple, universal, and easy-to-describe phenomenon e.Pain that occurs without a known cause is psychological in nature f.Pain is classified by duration, location, source, transmission, and etiology

b, c, f. Margo McCaffery offers the classic definition of pain that is probably of greatest benefit to nurses and their patients, "Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does" (1968, p. 95). The International Association for the Study of Pain (IASP) further defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage (IASP, 2014b). Pain is an elusive and complex phenomenon, and despite its universality, its exact nature remains a mystery. Pain is present whenever a person says it is, even when no specific cause of the pain can be found. Pain may be classified according to its duration, its location or source, its mode of transmission, or its etiology.

A nurse is caring for a patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. a.Bronchial pneumonia b.Impaired gas exchange c.Ineffective airway clearance d.Potential complication: sepsis e.Infection related to pneumonia f.Risk for septic shock

b, c, f. Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential complication: sepsis" is a collaborative problem.

A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply. a.A nurse sits down with a patient and prioritizes existing diagnoses b.A nurse assesses a woman for postpartum depression during routine care. c.A nurse plans interventions for a patient who is diagnosed with epilepsy. d.A busy nurse takes time to speak to a patient who received bad news. e.A nurse reassesses a patient whose PRN pain medication is not working. f.A nurse coordinates the home care of a patient being discharged.

b, d, e. Informal planning is a link between identifying a patient's strength or problem and providing an appropriate nursing response. This occurs, for example, when a busy nurse first recognizes postpartum depression in a patient, takes time to assess a patient who received bad news about tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged.

A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? a.The nurse assures that the oxygen is flowing into the prongs b.The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. c.The nurse encourages the patient to breathe through the nose with the mouth closed. d.The nurse adjusts the flow rate to 6 L/min or more.

c. The nurse should encourage the patient to breathe through the nose with the mouth closed. The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should adjust the fit of the cannula so it is snug but not tight against the skin. The nurse should adjust the flow rate as ordered.

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. a.Refrain from exercise. b.Reduce anxiety. c.Eat meals 1 to 2 hours prior to breathing treatments. d.Eat a high-protein/high-calorie diet. e.Maintain a high-Fowler's position when possible. f.Drink 2 to 3 pints of clear fluids daily.

b, d, e. When caring for patients with COPD, it is important to create an environment that is likely to reduce anxiety and ensure that they eat a high-protein/high-calorie diet. People with dyspnea and orthopnea are most comfortable in a high-Fowler's position because accessory muscles can easily be used to promote respiration. Patients with COPD should pace physical activities and schedule frequent rest periods to conserve energy. Meals should be eaten 1 to 2 hours after breathing treatments and exercises, and drinking 2 to 3 quarts (1.9 to 2.9 L) of clear fluids daily is recommended.

The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply. A.A patient who is older than 50 B.A patient who has already fallen twice C.A patient who is taking antibiotics D.A patient who experiences postural hypotension E.A patient who is experiencing nausea from chemotherapy F.A 70-year-old patient who is transferred to long-term care

b, d, f. Risk factors for falls include age over 65 years, documented history of falls, postural hypotension, and unfamiliar environment. A medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics is also a risk factor, not chemotherapy or antibiotics.

Following a fall that left an older adult temporarily bedridden, the nurse is using the SPICES assessment tool to evaluate for cascade iatrogenesis. Which are correct aspects of this tool? Select all that apply. a.S—Senility b.P—Problems with feeding c.I—Irritability d.C—Confusion e.E—Edema of the legs f.S—Skin breakdown

b, d, f. The SPICES acronym is used to identify common problems in older adults and stands for:S—Sleep disordersP—Problems with eating or feedingI—IncontinenceC—ConfusionE—Evidence of fallsS—Skin breakdown

A registered nurse is writing a diagnosis for a patient who is in traction because of multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. a.The nurse uses the nursing interview to collect patient data. b.The nurse analyzes data collected in the nursing assessment. c.The nurse develops a care plan for the patient. d.The nurse points out the patient's strengths. e.The nurse assesses the patient's mental status. f.The nurse identifies community resources to help his family cope.

b, d, f. The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of the nursing process.

A nurse assesses the stool of patients who are experiencing gastrointestinal problems. In which patients would diarrhea be a possible finding? Select all that apply. a.A patient who is taking narcotics for pain b.A patient who is taking metformin for type 2 diabetes mellitus c.A patient who is taking diuretics d.A patient who is dehydrated e.A patient who is taking amoxicillin for an infection f.A patient taking over-the-counter antacids

b, e, f. Diarrhea is a potential adverse effect of treatment with amoxicillin clavulanate, metformin, or over-the-counter antacids. Narcotics, diuretics, and dehydration may lead to constipation.

A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bed rest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement?a.Risk for Impaired Skin Integrity b.Related to prescribed bed rest c.As evidenced by d.As evidenced by reddened areas of skin on the heels and back

b. "Related to prescribed bed rest" is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "Risk for Impaired Skin Integrity" is the problem, and "as evidenced by reddened areas of skin on the heels and back" are the defining characteristics of the problem.

A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the FIRST nursing action that should be taken prior to performing this care? a.Administer pain medication. b.Reassess the patient. c.Prepare the equipment. d.Explain the procedure to the patient.

b. Before implementing any nursing action, the nurse should reassess the patient to determine whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and, if necessary, administer pain medications.

A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? Maslow's human needs Gordon's functional health patterns Human response patterns Body system model

b. Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document? a.1 b.2 c.3 d.4

b. Grade 2 phlebitis presents with pain at access site with erythema and/or edema. Grade 1 presents as erythema at access site with or without pain. Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3 with a palpable venous cord >1 in and with purulent drainage.

A patient requires 40 units of NPH insulin and 10 units of regular insulin daily subcutaneously. What is the correct sequence when mixing insulins? a.Inject air into the regular insulin vial and withdraw 10 units; then, using the same syringe, inject air into the NPH vial and withdraw 40 units of NPH insulin. b.Inject air into the NPH insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the regular insulin vial and withdraw 10 units; then, withdraw 40 units of NPH insulin. c.Inject air into the regular insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the NPH insulin vial and withdraw 40 units; then, withdraw 10 units of regular insulin. d.Inject air into the NPH insulin vial and withdraw 40 units; then, using the same syringe, inject air into the regular insulin vial and withdraw 10 units of regular insulin.

b. Regular or short-acting insulin (unmodified insulin) should never be contaminated with NPH or any insulin modified with added protein. Placing air in the NPH vial first without allowing the needle to contact the solution ensures that the regular insulin will not be contaminated.

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

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

A patient reports abdominal pain that is difficult to localize. The nurse documents this as which type of pain? a.Cutaneous b.Visceral c.Superficial d.Somatic

b. The patient's pain would be categorized as visceral pain, which is poorly localized and can originate in body organs in the abdomen. Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is an example of cutaneous pain. Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain.

A nurse is ordered to catheterize a patient following surgery. Which nursing guideline would the nurse follow? a.The nurse would use different equipment for catheterization of male versus female patients. b.The nurse should use the smallest appropriate indwelling urinary catheter. c.The nurse should always sterilize the equipment prior to insertion. d.The nurse should choose a 12F, 5-mL or 10-mL balloon, unless ordered otherwise.

b. The smallest appropriate indwelling urinary catheter should be selected to aid in prevention of CAUTIs in the adult hospitalized patient (ANA, 2014; SUNA, 2015a). The equipment used for catheterization is usually prepackaged in a sterile, disposable tray and is the same for both male and female patients. Most kits already contain a standard-sized catheter. Catheters are graded on the French (F) scale according to lumen size, with 12 to 16F gauge commonly used (Bardsley, 2015a). A 14F, 5-mL or 10-mL balloon is usually appropriate, unless ordered otherwise (ANA).

A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. What risk factor would be a priority concern for the nurse when caring for this patient? Imbalanced nutrition Impaired physical mobility Chronic pain Infection

d. The priority risk factor in this situation is the possibility of an infection developing in the open skin area. The other risk factors may be potential problems for this patient and may also require nursing interventions after the first diagnosis is addressed.

A school nurse is teaching parents about home safety and fires. What information would be accurate to include in the teaching plan? Select all that apply. A.Sixty percent of U.S. fire deaths occur in the home. B.Most fatal fires occur when people are cooking. C.Most people who die in fires die of smoke inhalation. D.Fire-related injury and death have declined due to the availability and use of smoke alarms. E.Fires are more likely to occur in homes without electricity or gas. F.Fires are less likely to spread if bedroom doors are kept open when sleeping.

c, d, e. Of all fire deaths in the United States, 80% occur in the home (Warmack, Wolf, & Frank, 2015). Most fatal home fires occur while people are sleeping, and most people who die in house fires die of smoke inhalation rather than burns. The widespread availability and use of home smoke alarms is considered the primary reason for the significant decline in fire-related injury and death. People with limited financial resources should be asked about how they heat their house because the electricity or gas may have been turned off and space or kerosene heaters, wood stoves, or a fireplace may be the sole source of heat. Bedroom doors should be kept closed when sleeping and monitors used to listen for children.

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply. a.A nurse administers 500 mg of ciprofloxacin to a patient with pneumonia. b.A nurse consults with a psychiatrist for a patient who abuses pain killers. c.A nurse checks the skin of bedridden patients for skin breakdown. d.A nurse orders a kosher meal for an orthodox Jewish patient. e.A nurse records the I&O of a patient as prescribed by his health care provider. f.A nurse prepares a patient for minor surgery according to facility protocol.

c, d, f. Nurse-initiated interventions, or independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing care plan, as well as any other actions that nurses initiate without the direction or supervision of another health care professional. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a health care provider. Consulting with a psychiatrist is a collaborative intervention.

A nurse is documenting patient data in the medical record of a patient admitted to the hospital with appendicitis. The health care provider has ordered 10-mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follow recommended guidelines? Select all that apply. a.6/12/20 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN b.6/12/20 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN c.6/12/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN d.6/12/20 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN e.6/12/20 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick, RN f.6/12/20 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick, RN

c, d, f. The nurse should enter information in a complete, accurate, concise, current, and factual manner and indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions. When charting, the nurse should avoid the use of stereotypes or derogatory terms as well as generalizations such as "patient's response to pain appears to be exaggerated" or "seems to be comfortable." The nurse should never document an intervention before carrying it out.

A nurse is preparing a patient for a cesarean section and teaches her the effects of the regional anesthesia she will be receiving. Which effects would the nurse expect? Select all that apply. a.Loss of consciousness b.Relaxation of skeletal muscles c.Reduction or loss of reflex action d.Localized loss of sensation e.Prolonged pain relief after other anesthesia wears off f.Infiltrates the underlying tissues in an operative area

c, d. A localized loss of sensation and possible loss of reflexes occur with a regional anesthetic. Loss of consciousness and relaxation of skeletal muscles occur with general anesthesia. Prolonged pain relief after other anesthesia wears off and infiltration of the underlying tissues in an operative area occur with topical anesthesia.

A nurse caring for adults in a provider's office researches aging theories to understand why some patients age more rapidly than others. Which statements describe the immunity theory of the aging process? Select all that apply. a.Chemical reactions in the body produce damage to the DNA. b.Free radicals have adverse effects on adjacent molecules. c.Decrease in size and function of the thymus results in more infections. d.There is much interest in the role of vitamin supplementation. e.Lifespan depends on a great extent to genetic factors. f.Organisms wear out from increased metabolic functioning.

c, d. The immunity theory of aging focuses on the functions of the immune system and states that the immune response declines steadily after younger adulthood as the thymus loses size and function, resulting in more infections. There is much interest in vitamin supplements (such as vitamin E) to improve immune function. The cross-linkage theory proposed that a chemical reaction produces damage to the DNA and cell death. The free radical theory states that free radicals—molecules with separated high-energy electrons—formed during cellular metabolism can have adverse effects on adjacent molecules. The genetic theory of aging holds that lifespan depends to a great extent on genetic factors. According to the wear-and-tear theory, organisms wear out from increased metabolic functioning, and cells become exhausted from continual energy depletion from adapting to stressors.

A nurse is preparing a brochure to teach patients how to prevent UTIs. Which teaching points would the nurse include? Select all that apply. a.Wear underwear with a synthetic crotch b.Take baths rather than showers c.Drink 8 to 10 8-oz glasses of water per day d.Drink a glass of water before and after intercourse and void afterward e.Dry the perineal area after urination or defecation from the front to the back f.Observe the urine for color, amount, odor, and frequency

c, e, f. It is recommended that a healthy adult drink 8 to 10 8-oz glasses of fluid daily, dry the perineal area after urination or defecation from the front to the back, and observe the urine for color, amount, odor, and frequency. It is also recommended to wear underwear with a cotton crotch, take showers rather than baths, and drink two glasses of water before and after sexual intercourse and void immediately after intercourse.

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

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

The nurse assesses the wound of a patient who was cut on the upper thigh with a chain saw. The nurse documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply. a.Enhanced healing due to the presence of sugars and proteins b.Delayed healing due to dead tissue present in the wound c.Decreased effectiveness of antibiotics against the bacteria d.Impaired skin integrity due to overhydration of the cells of the wound e.Delayed healing due to cells dehydrating and dying f.Decreased effectiveness of the patient's normal immune process

c, f. Wound biofilms are the result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Baranoski & Ayello, 2016; Hess, 2013). Necrosis (dead tissue) in the wound delays healing. Maceration or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment.

A nurse is using a concept map care plan to devise interventions for a patient with sickle cell anemia. What is the BEST description of the "concepts" that are being diagrammed in this plan? a.Protocols for treating the patient problem b.Standardized treatment guidelines c.The nurse's ideas about the patient problem and treatment d.Clinical pathways for the treatment of sickle cell anemia

c. A concept map care plan is a diagram of patient problems and interventions. The nurse's ideas about patient problems and treatments are the "concepts" that are diagrammed. These maps are used to organize patient data, analyze relationships in the data, and enable the nurse to take a holistic view of the patient's situation. Answers (a) and (b) are incomplete because the concepts being diagrammed may include protocols and standardized treatment guidelines but the patient problems are also diagrammed concepts. Clinical pathways are tools used in case management to communicate the standardized, interdisciplinary care plan for patients.

A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? a.A postoperative adult b.An adult with COPD c.A teenager with cystic fibrosis d.A child with pneumonia

c. Chest physiotherapy may help loosen and mobilize secretions, increasing mucus clearance. This is especially helpful for patients with large amounts of secretions or an ineffective cough, such as patients with cystic fibrosis. Chest physiotherapy has limited evidence for its effectiveness and is not recommended for use in numerous patient populations, including children with pneumonia, adults with COPD, and postoperative adults (Andrews et al., 2013; Lisy, 2014; Strickland et al., 2013).

A nurse is helping to prepare a calendar for an older adult patient with cognitive impairment. What is the leading cause of cognitive impairment in old age? a.Stroke b.Malnutrition c.AD d.Loss of cardiac reserve

c. Dementia, AD, depression, and delirium may occur and cause cognitive impairment. AD is the most common degenerative neurologic illness and the most common cause of cognitive impairment. It is irreversible, progressing from deficits in memory and thinking skills to an inability to perform even the simplest of tasks. The leading causes of death in adults aged 65 and older are heart disease, cancer, chronic respiratory disease, stroke, AD, and diabetes.

The nurse practices using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTIs is: a.Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice b.Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice c.Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice d.Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice.

A nurse is administering a large-volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient reports severe cramping. What nursing intervention would the nurse perform next based on this patient reaction? a.Elevate the head of the bed 30 degrees and reposition the rectal tube. b.Place the patient in a supine position and modify the amount of solution. c.Lower the solution container and check the temperature and flow rate. d.Remove the rectal tube and notify the primary care provider.

c. If the patient reports severe cramping with introduction of an enema solution, the nurse should lower the solution container and check the temperature and flow rate. If the solution is too cold or the flow rate too fast, severe cramping may occur. The head of the bed may be elevated 30 degrees for the patient's comfort if the patient needs to be placed on a bedpan in the supine position while receiving the enema.

A nurse is assisting a patient to empty and change an ostomy appliance. When the procedure is finished, the nurse notes that the stoma is protruding into the bag. What would be the nurse's first action in this situation? a.Reassure the patient that this is a normal finding with a new ostomy. b.Notify the primary care provider that the stoma is prolapsed. c.Have the patient rest for 30 minutes to see if the prolapse resolves. d.Remove the appliance and redo the procedure using a larger appliance.

c. If the stoma is protruding into the bag after changing the appliance on an ostomy, the nurse should have the patient rest for 30 minutes. If the stoma is not back to normal size within that time, notify the health care provider. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.

A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess? a.A pinched and drawn facial expression b.Deep, rapid respirations. c.Moist crackles heard upon auscultation d.Tachycardia

c. Moist crackles may indicate fluid volume excess. A person with a severe fluid volume deficit may have a pinched and drawn facial expression. Deep, rapid respirations may be a compensatory mechanism for metabolic acidosis or a primary disorder causing respiratory alkalosis. Tachycardia is usually the earliest sign of the decreased vascular volume associated with fluid volume deficit.

The nurse is helping a patient turn in bed and notices the patient's heels are red. The nurse places the patient on precautions for skin breakdown. This is an example of what type of planning? a.Initial planning b.Standardized planning c.Ongoing planning d.Discharge planning

c. Ongoing planning is problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared care plans that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning, the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors competently at home.

A premature infant with serious respiratory problems has been in the neonatal intensive care unit for the last 3 months. The infant's parents also have a 22-month-old son at home. The nurse's assessment data for the parents include chronic fatigue and decreased energy, guilt about neglecting the son at home, shortness of temper with one another, and apprehension about their continued ability to go on this way. What human response would be appropriate for the nurse to document? a.Grieving b.Ineffective Coping c.Caregiver Role Strain d.Powerlessness

c. The defining characteristics for the NANDA diagnosis Caregiver Role Strain fit the set of assessment data provided. The other diagnoses do not fit the assessment data.

A nurse is ordered to perform continuous irrigation for a patient with a long-term urinary catheter. What rationale would the nurse expect for this order? a.Irrigation of long-term urinary catheters is a routine order. b.Irrigation is recommended to prevent the introduction of pathogens into the bladder. c.A blood clot threatens to block the catheter. d.It is preferred to irrigate the catheter rather than increase fluid intake by the patient.

c. The flushing of a tube, canal, or area with solution is called irrigation. Natural irrigation of the catheter through increased fluid intake by the patient is preferred. It is preferable to avoid catheter irrigation unless necessary to relieve or prevent obstruction (Gould et al., 2009; SUNA, 2015a). However, intermittent irrigation is sometimes prescribed to restore or maintain the patency of the drainage system. Sediment or debris, as well as blood clots, might block the catheter, preventing the flow of urine out of the catheter.

A nurse is assisting a patient with dementia with bathing. Which guideline is recommended in this procedure? a.Shift the focus of the interaction to the "process of bathing." b.Wash the face and hair at the beginning of the bath. c.Consider using music to soothe anxiety and agitation. d.Do not perform towel baths or alternate forms of bathing with which the patient is unfamiliar.

c. The nurse should consider the use of music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the "task of bathing" to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. The nurse should wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider other methods for bathing. Showers and tub baths are not the only options in bathing. Towel baths, washing under clothes, and bathing "body sections" one day at a time are other possible options.

The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action? a.Inform the charge nurse. b.Inform the surgeon. c.Validate the finding. d.Document the finding.

c. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate; thus, all data should be validated before documentation if there are any doubts about accuracy.

A nurse discovers that a medication error occurred. What should be the nurse's first response? a.Record the error on the medication sheet. b.Notify the physician regarding course of action. c.Check the patient's condition to note any possible effect of the error. d.Complete an incident report, explaining how the mistake was made.

c. The nurse's first responsibility is the patient—careful observation is necessary to assess for any effect of the medication error. The other nursing actions are pertinent, but only after checking the patient's welfare.

A nurse is about to bathe a female patient who has an intravenous access in place in her forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What is the appropriate nursing action? a.Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeve. b.Cut the gown with scissors to allow arm movement. c.Thread the bag and tubing through the gown sleeve, keeping the line intact. d.Temporarily disconnect the tubing from the IV container, threading it through the gown.

c. Threading the bag and tubing through the gown sleeve keep the system intact. Opening an IV line, even temporarily, causes a break in a sterile system and introduces the potential for infection. Cutting a gown is not an alternative except in an emergency.

A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the new RN? a.Allow the UAPs to do the admission assessment and report the findings to the RN. b.Do his or her own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. c.Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. d.Contact his or her labor representative to report this practice to the state board of nursing.

c.The nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration.

A patient is visiting his primary care physician for a regular check-up and has complained of weakness. The nurse believes the patient is experiencing excess sodium levels. Which of the following would the nurse be expected to assess: select all that apply. a. the patient states"sometimes I think I see my son, but I know that's not possible. He passed away two years ago. b. serum sodium level of 165 mEq/L c. muscle twitching d. seizures e. red, swollen tongue f. moist mucous membranes

correct answer: a, b, e. A patient with hypernatremia would have a serum sodium level greater than 145 mEq/L. They also experience hallucinations. A patient that has low sodium levels would have muscle twitches and seizures. With excess sodium, dry and sticky mucous membranes is an expected assessment. Moist membranes are expected of a patient with balances sodium. (page 1568).

A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a patient who has been prescribed morphine via a patient-controlled analgesia pump (PCA) for pain related to pancreatic cancer. Place the following nursing statements related to this call in the correct ISBARR order. a."I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer." b."Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump." c."You want me to discontinue the PCA pump until you see him tonight at patient rounds." d."I am Rosa Clark, an RN working on the second floor of South Street Hospital." e."Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer." f."I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered."

d, a, e, b, f, c. The order for ISBARR is: Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read-back

A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for laboratory testing. Which techniques for urine collection are performed correctly? Select all that apply. a.The nurse catheterizes a patient to collect a sterile urine sample for routine urinalysis. b.The nurse collects a clean-catch urine specimen in the morning from a patient and stores it at room temperature until an afternoon pick-up. c.The nurse collects a sterile urine specimen from the collection receptacle of a patient's indwelling catheter. d.The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture. e.The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma. f.The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient.

d, e, f. A urine culture requires about 3 mL of urine, whereas routine urinalysis requires at least 10 mL of urine. The preferred method of collecting a urine specimen from a urinary diversion is to catheterize the stoma. For a 24-hour urine specimen, the nurse should discard the first voiding, then collect all urine voided for the next 24 hours. A sterile urine specimen is not required for a routine urinalysis. Urine chemistry is altered after urine stands at room temperature for a long period of time. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis.

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. a."I will be careful not to shake up the canister before using it." b."I will hold the canister upside down when using it." c."I will inhale the medication through my nose." d."I will continue to inhale when the cold propellant is in my throat." e."I will only inhale one spray with one breath." f."I will activate the device while continuing to inhale."

d, e, f. Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, and inhaling two sprays with one breath.

A nurse prepares to assist a patient with a newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply. a."When you inspect the stoma, it should be dark purple-blue." b."The size of the stoma will stabilize within 2 weeks." c."Keep the skin around the stoma site clean and moist." d."The stool from an ileostomy is normally liquid." e."You should eat dark-green vegetables to control the odor of the stool." f."You may have a tendency to develop food blockages."

d, e, f. Ileostomies normally have liquid, foul-smelling stool. The nurse should encourage the intake of dark-green vegetables because they contain chlorophyll, which helps to deodorize the feces. Patients with ileostomies need to be aware they may experience a tendency to develop food blockages, especially when high-fiber foods are consumed. The stoma should be dark pink to red and moist. Stoma size usually stabilizes within 4 to 6 weeks, and the skin around the stoma site (peristomal area) should be kept clean and dry.

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. a.5% dextrose in 0.9% b.NaCl0.9% NaCl (normal saline) c.Lactated Ringer's solution d.0.33% NaCl (⅓-strength normal saline) e.0.45% NaCl (½-strength normal saline) f.5% dextrose in Lactated Ringer's solution

d, e. 0.33% NaCl (⅓-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia. 5% dextrose in 0.9% NaCl is used to treat SIADH and can temporarily be used to treat hypovolemia if plasma expander is not available. 0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. 5% dextrose in Lactated Ringer's solution replaces electrolytes and shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume.

A nurse is assisting a client with the use of a urinal. The nurse recognizes that which statement about the use of a urinal is true? a. Both male and female clients commonly void into a urinal in the bathroom to facilitate measurement of urinary output b. If nocturnal incontinence is anticipated, a urinal can be placed between the legs while the client is asleep. c. Urinals must be replaced every 24 hours to reduce the risk of infection. d. Unless contraindicated, nurses should encourage clients to stand to use a urinal.

d. Rationale: A standing position facilitates bladder emptying and decreases the likelihood of spillage of urine. Although female urinals exist, they are more difficult to use and are not commonly used in health care facilities. Replacing urinals every 24 hours is not necessary. A urinal should not be left in place for extended periods of time, because pressure and irritation to the client's skin can result. Ch. 37: Urinary Elimination- Page 1357, 1388

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. What is an example of an affective outcome for this patient? a.Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge b.By 6/12/20, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. c.By 6/19/20, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3 to 2.5 in). d.By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

d. Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient's achievement of new skills; and (c) is an outcome describing a physical change in the patient.

A nurse is counseling a patient who refuses to look at or care for a new colostomy. The patient tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem?a.Collaborative problem b.Interdisciplinary problem c.Medical problem d.Nursing problem

d. Altered Health Maintenance is a nursing problem, because the diagnosis describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies.

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection?a.Using sterile dressing supplies b.Suggesting dietary supplements c.Applying antibiotic ointment d.Performing careful hand hygiene

d. Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important.

When discussing emergency preparedness with a group of first responders, what information would be important to include about preparation for a terrorist attack? A.Post traumatic stress disorders can be expected in most survivors of a terrorist attack. B.The FDA has collaborated with drug companies to create stockpiles of emergency drugs. C.Even small doses of radiation result in bone marrow depression and cancer. D.BLI is a serious consequence following detonation of an explosive device.

d. BLI is a recognized consequence following exposure to an explosive device. The CDC is the federal facility that has collaborated with the pharmaceutical companies to stockpile drugs for an emergency. A high dose of radiation exposure can result in bone marrow depression and cancer. Most survivors of a terrorist event will experience stress and some (possibly one third of survivors) may exhibit posttraumatic stress disorder.

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? a.Recording intake and output. b.Testing skin turgor. c.Reviewing the complete blood count. d.Measuring weight daily.

d. Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance.

A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correctly written as two-part nursing diagnoses? 1.Ineffective Coping related to inability to maintain marriage 2.Defensive Coping related to loss of job and economic security 3.Altered Thought Processes related to panic state 4.Decisional Conflict related to placement of parent in a long-term care facility a.(1) and (2) b.(3) and (4) c.(1), (2), and (3) d.(1), (2), (3), and (4)

d. Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause.

Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult. Which information is least important for the evaluation process? a.The incontinence pattern b.State of physical mobility c.Medications being taken d.Age of the patient

d. Incontinence is not a natural consequence of the aging process. All the other factors are necessary information for the care plan.

The family of a patient who has just died asks to be alone with the body and asks for supplies to wash the body. The nurse providing care knows that the mortician usually washes the body. Which response would be most appropriate? a.Inform the family that there is no need for them to wash the body since the mortician typically does this. b.Explain that hospital policy forbids their being alone with the deceased patient and that hospital supplies are to be used only by hospital personnel. c.Give the supplies to the family but maintain a watchful eye to make sure that nothing unusual happens. d.Provide the requested supplies, checking if this request is linked to their religious or cultural customs and asking if there is anything else you can do to help.

d. The family may want to wash the body for personal, religious, or cultural reasons and should be allowed to do so.

A nurse working in a pediatrician's office receives calls from parents whose children have ingested toxins. What would be the nurse's best response? A.Administer activated charcoal in tablet form and take child to the ED. B.Administer syrup of ipecac and take child to the ED. C.Bring the child in to the primary care provider for gastric lavage. D.Call the PCC immediately before attempting any home remedy.

d. The nurse should tell the parents to call the PCC immediately, before attempting any home remedy. Parents may be instructed to bring the child immediately to an emergency facility for treatment. Activated charcoal is considered the most effective agent for preventing absorption of the ingested toxin. It is not recommended for storage or use at home. Activated charcoal can be administered through a nasogastric tube in the ED for serious poisonings after the risks and benefits have been determined. Syrup of ipecac is no longer recommended because vomiting may be dangerous. A toxic substance may prove more hazardous coming up rather than when it was swallowed. Gastric lavage is no longer prescribed routinely for the treatment of ingestion of a toxic substance because it may propel the poison into the small intestine, where absorption will occur. The amount of toxin removed by gastric lavage is relatively small.

An older resident who is disoriented likes to wander the halls of his long-term care facility. Which action would be most appropriate for the nurse to use as an alternative to restraints? A.Sitting him in a geriatric chair near the nurses' station B.Using the sheets to secure him snugly in his bed C.Keeping the bed in the high position D.Identifying his door with his picture and a balloon

d. This allows the resident to be on the move and be more likely to find his room when he wants to return. The alternative would be to not allow him to wander. Many facilities use this kind of approach. Identifying his door with his picture and a balloon may work as an alternative to restraints. Using the geriatric chair and sheets are forms of physical restraint. Leaving the bed in the high position is a safety risk and would probably result in a fall.

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

d. To add a sterile solution to a sterile field, the nurse would open the solution container according to directions and place the cap on the table away from the field with the edges up. The nurse would then hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 in (10 to 15 cm).

A nurse is developing a care plan related to prevention of pressure injuries for residents in a long-term care facility. Which action accurately describes a priority intervention in preventing a patient from developing a pressure injury? a.Keeping the head of the bed elevated as often as possible b.Massaging over bony prominences c.Repositioning bed-bound patients every 4 hours d.Using a mild cleansing agent when cleansing the skin

d. To prevent pressure injuries, the nurse should cleanse the skin routinely and whenever any soiling occurs by using a mild cleansing agent with minimal friction, and avoiding hot water. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Bony prominences should not be massaged, and bed-bound patients should be repositioned every 2 hours.

A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient? a.Feed the patient solids first and then liquids last. b.Place the head of the bed at a 30-degree angle during feeding. c.Puree all foods to a liquid consistency. d.Provide a 30-minute rest period prior to mealtime.

d. When feeding a patient who has dysphagia, the nurse should provide a 30-minute rest period prior to mealtime to promote swallowing; alternate solids and liquids when feeding the patient; sit the patient upright or, if on bedrest, elevate the head of the bed at a 90-degree angle; and initiate a nutrition consult for diet modification and food size and/or consistency.

A nurse is looking for trends in a postoperative patient's vital signs. Which documents would the nurse consult first? a.Admission sheet b.Admission nursing assessment c.Flow sheet d.Graphic record

d. While one recording of vital signs should appear on the admission nursing assessment, the best place to find sequential recordings that show a pattern or trend is the graphic record. The admission sheet does not include vital sign documentation, and neither does the flow sheet. .

The nurse observes that a client frequently experiences urine loss when being transferred from a chair to the bed. Which type of incontinence does the nurse identify that the client is experiencing?

functional

A nurse is working with a group of clients in the preoperative area. Which client task would be the highest priority? obtaining a list of home medications from a client or raising the stretcher side rails when administering a sedative

raising the side rails when administering a sedative Although all of these are important to do, making sure of client safety with raising the side rails of the client's bed when administering a sedative is most important. Inserting the Foley catheter before surgery, obtaining a list of home medications, and measuring a blood glucose on a client could potentially prevent safety issues as well but are not as direct an intervention as raising the side rails of the bed to prevent a client fall.

The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. Which urine characteristics does the nurse anticipate?

strongly aromatic, dark amber The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine. The other characteristics are not associated with dehydration.