Test 2 Intro to NUR Units 5-8

Question 3 of 5 Gliddens 48 Which of the following concepts would a nurse consider to have the strongest links to technology and informatics? Select all that apply. A Clinical judgment B Ethics C Leadership D Professionalism E Safety

A B C E

Question 7 of 14 CH 15 EVOLVE CRITICAL THINKING Which of the following describes a nurse's application of a specific knowledge base during critical thinking? Select all that apply. A. Initiative in reading current evidence from the literature B. Application of nursing theory C. Reviewing policy and procedure manual D. Considering holistic view of patient needs E. Previous time caring for a specific group of patients

A B D

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Question 11 of 14 The nurse is transferring a patient to a long-term, skilled care facility and has just given a telephone report to a registered nurse (RN) who works at that facility and who will be receiving the patient. In documenting this call, the nurse begins by writing the date and time the report was given and the name of the RN taking the report. Which of the following pieces of information does the nurse include in the documentation of this telephone call? Select all that apply. A. The patient's name, age, and admitting diagnoses B. The discussion of any allergies to food and medications that the patient has C. That the nurse receiving the report was advised that the patient is "needy" and "on the call light all the time" D. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol E. Description of any unresolved problems and current interventions in place

A B D E

CH 30 EVOLVE VITAL SIGNS Question 4 of 14 Which of the following patients are at most risk for tachypnea? Select all that apply. A. Patient just admitted with four rib fractures B. Woman who is 9 months' pregnant C. Adult who has consumed alcoholic beverages D. Adolescent waking from sleep E. Three-pack-per-day smoker with pneumonia

A B E

Question 1 of 14 CH 20 EVOLVE - EVALUATION Purposes of the Nursing Outcomes Classification (NOC) include which of the following? Select all that apply. A To identify and label nurse-sensitive patient outcomes B. To test the classification in clinical settings C. To establish health care reimbursement guidelines D. To identify nursing interventions for linked nursing diagnoses E. To define measurement procedures for outcomes

A B E

MODULE 6 LESSON 2 Question 1 1 pts What abnormal characteristics should be reported after obtaining a urine sample? (Select all that apply.) A. Presence of sediment B. Cloudiness of urine C. Light amber color D. Slight musty odor E. Yellow color F. Blood-tinged

A B F

Ch 24 Evolve Communication 13. Which strategies should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a skilled nursing facility? (Select all that apply.) A. Collaboration between staff members from sending and receiving departments B. Requiring that the patient visit the facility before a transfer is arranged C. Using a standardized transfer policy and transfer tool D. Arranging all patient transfers during the same time each day E. Relying on family members to share information with the new facility

A C

MODULE 16 EXAM SPECIMEN COLLECTION Question 3 1 pts What are some interventions the nurse can do to help minimize embarrassment for the patient during specimen collection? (Select all that apply.) A. Provide privacy. B. Provide written instructions only. C. Allow the patient to perform as much of the sample collection as appropriate. D. Perform the specimen collection for the patient so you don't have to discuss it. E. Have family members assist in the collection process.

A C

Question 7 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE When is an application of a warm compress to an ankle muscle sprain indicated? Select all that apply. A. To relieve edema B. To reduce shivering C. To improve blood flow to an injured part D. To protect bony prominences from pressure ulcers E. To immobilize area

A C

Ch 24 Evolve Communication 1. When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? A. Check for needed adaptive equipment. B. Exaggerate lip movements to help the patient lip read. C. Give the patient time to respond to questions. D. Keep communication short and to the point. E. Communicate only through written information.

A C D

Question 3 of 14 CH 20 EVOLVE - EVALUATION Which of the following statements correctly describes the evaluation process? Select all that apply. A. Evaluation is an ongoing process. B. Evaluation usually reveals obvious changes in patients. C. Evaluation involves making clinical decisions. D. Evaluation requires the use of assessment skills. E. Evaluation is only done when a patient's condition changes.

A C D

Question 6 of 14 CH 20 EVOLVE - EVALUATION A nurse in a community health clinic has been caring for a young teenager with asthma for several months. The nurse's goal of care for this patient is to achieve self-management of asthma medications. Identify appropriate evaluative indicators for self-management for this patient. Select all that apply. A. Quality of life B. Patient satisfaction C. Use of clinic services D. Adherence to use of inhaler E. Description of side effects of medications

A C D

Question 7 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE A nurse working on a surgery floor is assigned five patients and has a patient care technician assisting her. Which of the following shows the nurse's understanding and ability to safely delegate to the patient care tech? Select all that apply. A. The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test. B. Determining what is the patient care technician's current workload. C. The nurse chooses to delegate the measurement of a stable patient's vital signs and not the assessment of the patient arriving from a diagnostic test. D. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure. E. The nurse confers with another registered nurse about organizing priorities.

A C D

Question 8 of 15 CH 16 EVOLVE NURSING ASSESSMT When a nurse conducts an assessment, data about a patient often comes from which of the following sources? Select all that apply. A. An observation of how a patient turns and moves in bed B. The unit policy and procedure manual C. The care recommendations of a physical therapist D. The results of a diagnostic x-ray film E. Your experiences in caring for other patients with similar problems

A C D

module 19 wound care lesson 1 Question 3 1 pts Which of the following may indicate internal hemorrhage? (Select all that apply.) A. Distention or swelling of the affected body part. B. An elevated white blood cell count. C. A decreased blood pressure and increased pulse. D. A change in the type and amount of drainage from a surgical drain. E. Purulent drainage and tenderness at wound site.

A C D

MODULE 19 EXAM Question 7 1 pts The nurse is teaching the nursing assistive personnel (NAP) in a nursing home about daily routine measures to reduce the incidence of pressure injuries within the agency. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Turning patients at least every 2 hours. B. Rubbing reddened bony prominences. C. Use of pillow bridging when needed. D. Positioning patient in the 30-degree lateral position. E. Using a turn sheet to reposition patients. F. Decreasing patients' fluid intake to decrease incidence of incontinence.

A C D E

MODULE 19 WOUND CARE LESSON 2 Question 2 1 pts Identify contributing factors to pressure injury formation. (Select all that apply.) A. Malnutrition. B. Middle age. C. Decreased sensory perception/mobility. D. Anemia. E. Excessive sweating.

A C D E

CH 20 EVALUATION BOOK Q NOT IN EVOLVE From the following list of indicators, determine which indicators are GOALS A. will achieve pain relief B. ambulates 10 feet down the hallway C will remain free of infection D will be afebrile E reports pain severity reduced from a 6 to a 4 on scale of 0 to 10 F will gain improved mobility

A C D F

MODULE 6 LESSON 2 Question 2 1 pts Which of the following are normal characteristics of urine? (Select all that apply.) A. pH 4.6 to 8 B. Red blood cell count greater than 2 C. Specific gravity 1.010 to 1.025 D. Protein absent E. Casts present F. White blood cells 0 to 4

A C D F

Ch 24 Evolve Communication 4. Motivational interviewing (MI) is a technique that applies understanding a patient's values and goals in helping the patient make behavior changes. What are other benefits of using MI techniques? (Select all that apply.) A. Gaining an understanding of patient's motivations B. Focusing on opportunities to avoid poor health choices C. Recognizing patient's strengths and supporting their efforts D. Providing assessment data that can be shared with families to promote change E. Identifying differences in patient's health goals and current behaviors

A C E

MODULE 6 LESSON 1 Question 1 1 pts Which of the following are reasons for performing lab tests? (Select all that apply.) A. Aids in diagnosis of health care problems B. Meets requirements of third party payers (i.e., insurance companies) C. Provides information about the stage of a disease process D. Reduces the need for medication therapy E. Measures a patient's response to therapy

A C E

Question 11 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE Which of the following are measures to reduce tissue damage from shear? Select all that apply. A. Use a transfer device, e.g. transfer board B. Have head of bed elevated when transferring patient C. Have head of bed flat when re positioning patients D. Raise head of bed 60 degrees when patient positioned supine E. Raise head of bed 30 degrees when patient positioned supine

A C E

Question 6 of 14 CH 17 EVOLVE NURSING DIAGNOSIS The use of standard formal nursing diagnostic statements serves several purposes in nursing practice, including which of the following? Select all that apply. A. Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs B. Allows physicians and allied health staff to communicate with nurses how they provide care among themselves C. Helps nurses focus on the scope of nursing practice D. Creates practice guidelines for collaborative health care activities E. Builds and expands nursing knowledge

A C E

MODULE 19 EXAM Question 4 1 pts Identify the functions of dressings. (Select all that apply.) A. Maintaining a moist environment. B. Preventing shear. C. Control of bleeding and drainage. D. Removing surface bacteria. E. Protection from outside contaminants and further tissue injury. F. Increased patient comfort.

A C E F

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Question 3 of 14 The nurse is supervising a beginning nursing student and allowing the student to complete documentation of care under direct observation. Which of the following actions are not appropriate and would require intervention? The nursing student: A Documents a medication given by another nursing student. B Includes the date and time of the entry into the medical record. C Enters assessment data into the electronic medical record using the computer mounted on the wall in the patient's room. D Leaves a slip of paper with her user name and password in the patient's room. E Starts to enter "Docusate sodium 100 mg ordered at 08:00 held. Patient declined to take dose stating, "I had several loose stools yesterday, and I'm afraid if I take this dose the problem will get worse," as a narrative comment.

A D

MODULE 6 LESSON 3 Question 3 1 pts The nurse is collecting supplies to perform a Gastroccult test. The nurse sees both Gastroccult and Hemoccult test slides. Which of the following indicates correct understanding by the nurse of the differences between Gastroccult and Hemoccult testing? (Select all that apply.) A. Gastroccult testing tests pH and occult blood. B. There is no difference; they are the same test. C. Hemoccult testing takes longer because it is sent to the lab. D. Hemoccult testing tests only for occult blood. E. Gastroccult results are unaffected by diet or medicine.

A D

Question 12 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? Select all that apply. A. Notify the surgeon B. Allow the area to be exposed to air until all drainage has stopped C. Place several cold packs over the area, protecting the skin around the wound D. Cover the area with sterile, saline-soaked towels and immediately. E. Cover the area with sterile gauze and apply an abdominal binder

A D

Question 13 of 15 CH 16 EVOLVE NURSING ASSESSMT A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment findings when she rounds on the patient? Select all that apply. A. The nurse asks the patient to rate his pain on a scale of 0 to 10. B. The nurse asks the patient what caused his fall. C. The nurse asks the patient if he has had pain in his back in the past. D. The nurse assesses the patient's lower-limb strength. E. The nurse asks the patient what pain medication is most effective in managing his pain.

A D

Question 1 of 5 GLIDDENS CH 27 TISSUE INTEGRITY To help decrease the threat of melanoma in a blonde-haired, fair-skinned patient at risk, which recommendations should the nurse provide? Select all that apply. A. Wear sunglasses. B. Drink plenty of water. C. Eat plenty of foods high in vitamin K. D. Apply sunscreen 30 minutes prior to exposure. E. Consume fish oil and vitamin E.

A D E

Question 5 of 14 CH 17 EVOLVE NURSING DIAGNOSIS In which of the following examples are nurses making diagnostic errors? Select all that apply. A. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data B. The nurse who measures joint range of motion after the patient reports pain in the left elbow C. The nurse who considers conflicting cues in deciding which diagnostic label to choose D. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping E. The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia.

A D E

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Question 12 of 14 The nurse is working the evening shift at a hospital that uses military time for documentation. The nurse administered morphine 2 mg intravenously (IV) for pain at 3:45 PM, changed the dressing over the patient's abdominal incision at 5:34 PM, and administered Ancef 1 g IV at 8:00 PM. Using correct military time, which of the following is the correct label of documentation for each task with the time that it was completed? A 15 45, 17 34, 20 00 B 3 45, 17 34, 20 00 C 15 45, 5 34, 8 00 D 3 45, 5 34, 8 00

A

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Question 9 of 14 A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? A "CPOE reduces transcription errors." B "CPOE reduces the time needed for health care providers to write orders." C "CPOE eliminates verbal and telephone orders from health care providers." D "CPOE reduces the time nurses use to communicate with health care providers."

A

CH 30 EVOLVE VITAL SIGNS Question 2 of 14 The licensed practice nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first? A. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% B. 54-year-old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72 C. 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84 D. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62

A

CH 31 EVOLVE HEALTH ASSESSMENT Question 1 of 14 The nurse is teaching a patient how to perform a testicular self-examination. Which statement made by the patient indicates a need for further teaching? A "I'll recognize abnormal lumps because they are very painful." B "I'll start performing testicular self-examination monthly after I turn 15." C "I'll perform the self-examination in front of a mirror." D "I'll gently roll the testicle between my fingers."

A

CH 31 EVOLVE HEALTH ASSESSMENT Question 14 of 14 The nurse is assessing the cranial nerves. Match the cranial nerve with its related function. VI Adducens A Lateral movement of the eyeballs B Downward, inward eye movements C Position of the tongue D Motor innervation to the muscles of the jaw E Sensation of the pharynx

A

CH 31 EVOLVE HEALTH ASSESSMENT Question 5 of 14 The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? A Appearance and behavior B Measurement of vital signs C Observing specific body systems D Conducting a detailed health history

A

MODULE 16 EXAM SPECIMEN COLLECTION Question 2 1 pts Which of the following tests requires sterile gloves? A. Obtaining a wound culture B. Obtaining a midstream urine specimen C. Performing a Gastroccult test D. Performing a Hemoccult test on stool

A

MODULE 19 EXAM Question 11 1 pts Why does a wound bed need to stay moist? A. To support healing by enabling granulation tissue to grow. B. To prevent excessive fluid loss from the body. C. To determine if the area has reactive hyperemia. D. To decrease patient discomfort.

A

MODULE 19 EXAM Question 13 1 pts The nurse may use clean gloves for changing the dressing on which of the following? A. Chronic pressure injury. B. Surgical wound. C. Sterile gloves should always be used for dressing changes performed by nurses. D. Sterile gloves should always be used for dressing changes performed in the hospital setting.

A

MODULE 19 EXAM Question 15 1 pts When is a surgical wound at greatest risk for hemorrhage? A. During the first 24 to 48 hours after surgery. B. Two to three days after surgery. C. Four to five days after surgery. D. Five to seven days after surgery.

A

MODULE 19 WOUND CARE LESSON 3 Because a patient has a Penrose drain, the nurse inspects the patient's skin and changes the dressing by placing a drainage sponge around the drain. What is the rationale for doing this? A. Because drainage can be irritating to the skin and may cause skin breakdown. B. Because a Penrose drain has to be frequently compressed to create a constant low-pressure suction. C. To prevent the tubing from migrating into the wound. D. To advance the tube as the wound heals.

A

MODULE 19 WOUND CARE LESSON 3 Question 3 1 pts When should wound drainage be cultured? A. When there is a change in color, amount, or odor of drainage. B. If the patient complains of pain. C. When the drain is removed. D. If the nurse empties the drainage evacuator without applying sterile gloves.

A

MODULE 6 LESSON 2 Question 5 1 pts The nurse has instructed a patient on the procedure for obtaining a midstream urine specimen. The patient asks, "Why does the urine sample need to be collected in this manner?" The nurse's best response is: A. "The initial stream flushes out microorganisms that accumulate at the opening of the urinary tract." B. "It is performed this way in order to verify fresh urine is obtained for testing, increasing accuracy." C. "This method will prevent you from developing urinary incontinence by strengthening perineal muscles." D. "By catching the middle of the urine stream, it provides time to ensure the bladder is completely empty."

A

MODULE 6 LESSON 4 Question 2 1 pts The nurse is instructing the NAP how to perform a Hemoccult test. Which statement, if made by the NAP, indicates further teaching is necessary and would require correction? A. "When preparing the Hemoccult slide, I should moisten the windows of the testing slide before applying the fecal sample." B. "Blue discoloration indicates the presence of blood in the stool." C. "I should wear nonsterile clean gloves during stool testing." D. "The stool sample is applied to each of the two little boxes on the inside of the Hemoccult slide."

A

MODULE 6 LESSON 4 Question 3 1 pts The nurse is going to perform a Hematest on a fecal sample. Which of the following would be an incorrect action if made by the nurse? A. The Hematest tablets are placed on the guaiac paper and the stool sample is placed on top of the Hematest tablet. B. The Hematest tablets are protected from light and moisture. C. The nurse delegates testing the stool for blood using a Hematest to NAP. D. Water applied to the Hematest tablets flows onto the guaiac paper.

A

MODULE 6 LESSON 5 Question 2 1 pts The patient looks apprehensively at the nurse who is going to obtain a wound culture. The patient asks, "Why do you have a needle?" What is the best response by the nurse? A. "I will use a syringe without a needle to obtain some drainage from your wound. The needle will only be attached to inject the drainage into a special tube for culture." B. "In order to get an accurate specimen from deep within the wound bed, a needle is required; however, there is little sensation at this level so it will only feel like a tickle rather than be painful." C. "The needle is sterile and keeps air from entering the specimen while it is being obtained. This way the drainage can be analyzed to determine the type and number of pathogenic organisms." D. "There's no need to worry, this is a routine procedure. I can give you some pain medicine and return in 30 minutes to obtain the culture."

A

MODULE 6 LESSON 5 Question 6 1 pts The nurse obtained an aerobic wound culture. Which of the following is the most accurate documentation of the procedure? A. 1920 Patient premedicated for pain with one tablet Oxycodone. Wound of right heel 4 cm in diameter by 2 cm depth, edges reddened. Yellow purulent drainage noted. Old exudate removed with antiseptic swab. Aerobic culture obtained from wound bed and sent to lab; will notify health care provider of results when available. Patient states area is tender when touched, otherwise pain is a "2" on 0-to-10 pain scale. Patient remains afebrile. Wound cleansed with normal saline, loosely packed with 4-by-4 moistened with normal saline and covered with dry 4-by-4. Held in place with stockinet. B. 1705 Patient states pain is "2" on 0-to-10 pain scale; refuses pain medication at this time. Temperature 99.5 °F; health care provider notified. Orders received to obtain aerobic wound culture. Dressing of right heel changed according to health care provider's orders. Aerobic culture obtained from site of drainage and sent to lab. Patient repositioned for comfort. Call light within reach. C. 2010 Patient complaining of wound pain. States is a constant ache, occasionally feels like it is "burning." States pain is a "6" on 0-to-10 pain scale. Oxycodone 1 tab given PO per request. Dressing removed from wound. Purulent yellow drainage noted on dressing and in wound bed. Area cleaned and sterile gloves applied; aerobic culture obtained; sent immediately to lab. Wound packed with sterile 4-by-4 moistened with normal saline and covered with dry 4-by-4 gauze. Paper tape applied. Patient repositioned for comfort. States pain is now a "5" on 0-to-10 pain scale and that wound feels better after dressing is changed. D. 1930 Clean gloves applied. Dressing removed and discarded from patient's left heel. No foul odor noted. Aerobic wound culture obtained per order. New dressing applied using sterile technique. Patient tolerated well. Call light in reach.

A

MODULE 6 LESSON 6 Question 3 1 pts The nurse informs the patient that the patient's fasting blood glucose reading was 86. The patient asks what this means. Which of the following is an accurate response by the nurse? A. "Your blood sugar is within normal range, I will document the finding." B. "Your blood sugar is too high. I will see if there is an order for insulin." C. "Your blood sugar is too low. I will bring you a snack of orange juice." D. "I will have to contact your health care provider for further orders."

A

Question 1 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE What is the removal of devitalized tissue from a wound called? Debridement Pressure reduction Negative pressure wound therapy Sanitization

A

Question 10 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE A nurse reviews all possible consequences before helping a patient ambulate such as how the patient ambulated last time; how mobile the patient was before admission to the health care facility; or any current clinical factors affecting the patient's ability to stand, remain balanced, or walk. Which of the following is an example of a nurse's review of this situation? A. Critical thinking B. Managing an adverse event C. Exercising self-discipline D. Time management

A

Question 10 of 14 CH 20 EVOLVE - EVALUATION A nurse has been caring for a patient over the last 10 hours. The patient's plan of care includes the nursing diagnosis of Nausea related to effects of postoperative anesthesia. The nurse has been asking the patient to rate his nausea over the last several hours after administering antiemetics and using comfort measures such as oral hygiene. The nurse reviews the patient's responses over the past 10 hours and notes how the patient's self-report of nausea has changed. This review an example of: A. Comparing outcome criteria with actual response. B. Gathering outcome criteria. C. Evaluating the patient's actual response. D. Reprioritizing interventions.

A

Question 12 of 14 CH 17 EVOLVE NURSING DIAGNOSIS A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. What are the steps for making a nursing diagnosis in the correct order, beginning with the first step?1. Considers context of patient's health problem and selects a related factor 2. Reviews assessment data, noting objective and subjective clinical information 3. Clusters clinical cues that form a pattern 4. Chooses diagnostic label A. 2, 3, 4, 1 B. 3, 2, 4, 1 C. 2, 3, 1, 4 D. 1, 4, 3, 2

A

Question 2 of 14 CH 20 EVOLVE - EVALUATION Which of the following does a nurse perform when discontinuing a plan of care for a patient? A. Confirms with the patient that expected outcomes and goals have been met B. Talks with the patient about reprioritizing interventions in the plan of care C. Changes the frequency of interventions provided D. Reassesses how goals were met

A

Question 2 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE Match the pressure ulcer categories/stages with the correct definition: Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. A . Category/Stage I B . Category/Stage II C . Category/Stage III D . Category/Stage IV

A

Question 2 of 5 Gliddens 40 A nursing instructor assigns their clinical group the task of writing a journal depicting the student's clinical day. What is the most likely rationale for this assignment? A Journaling allows reflection, an important critical thinking skill. B Journaling gives you time to review what happened in your clinical. C Journaling is a way to organize your thoughts about your experiences. D Journaling teaches open-mindedness, a critical thinking disposition.

A

Question 3 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE Before consulting with a physician about a female patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill? A. Cognitive B. Interpersonal C. Psychomotor D. Consultative

A

Question 5 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE Match the category of direct care on the left with the specific direct care activity on the right. Discussing a patient's options in choosing palliative care A. Counseling B. Lifesaving measure C. Physical care technique D. Activity of daily living

A

Question 5 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE What is the correct sequence of steps when performing a wound irrigation? 1. Use slow continuous pressure to irrigate wound. 2. Attach angio catheter to syringe 3. Fill syringe with irrigation fluid 4. Place water proof bag near bed 5. Position angio catheter over wound A. 4, 3, 2, 5, 1 B. 3, 4, 2, 1, 5 C. 4, 2, 3, 5, 1 D. 2, 3, 4, 5, 1

A

Question 5 of 15 CH 18 EVOLVE PLANNING NURSING CARE An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. Goals Outcomes Patient will ambulate independently in 3 days. A. Patient walks 20 feet using a walker in 24 hours B. Patient identifies barriers to remove in the home within 1 week C. Patient increases calorie intake to 2500 daily D. Patient expresses fewer nonverbal signs of discomfort within 24 hrs.

A

Question 5 of 5 GLIDDENS CH 24 INFLAMMATION A patient admitted to an acute care floor has rubor of an area of injury on the left lower extremity. The nurse understands that this redness is caused by A. vasodilation. B. extravasation. C. neutrophils. D. exudate.

A

Question 5 of 6 GLIDDENS 10 THERMOREGULATION A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for what manifestations of hypothermia? A Stupor B Erythema C Increased anxiety D Rapid respirations

A

Question 6 of 14 CH 15 EVOLVE CRITICAL THINKING A nurse just started working at a well-baby clinic. One of her recent experiences was to help a mother learn the steps of breastfeeding. During the first clinic visit the mother had difficulty positioning the baby during feeding. After the visit the nurse considers what affected the inability of the mother to breastfeed, including the mother's obesity and inexperience. The nurse's review of the situation is called: A. Reflection. B. Perseverance. C. Intuition. D. Problem solving.

A

Question 8 of 15 CH 18 EVOLVE PLANNING NURSING CARE A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient's activity tolerance a patient-centered effort? A. Engage the patient in setting mutual outcomes for distance he is able to walk B. Confirm with the patient's health care provider about ambulation goals C. Have physical therapy assist with ambulation D. Refer to medical record regarding nature of patient's physical problem

A

Question 9 of 14 CH 20 EVOLVE - EVALUATION A patient has been febrile and coughing thick secretions; adventitious lung sounds indicate rales in the left lower lobe of the lungs. The nurse decides to perform nasotracheal suction because the patient is not coughing. The nurse inspects the mucus that is suctioned, which is minimal. The nurse again auscultates for lung sounds. Auscultation and mucus inspection are examples of: A. Evaluative measures. B. Expected outcomes. C. Reassessments. D. Reflection.

A

The nurse clusters the patient's objectives an subjective signs and symptoms primarily to: A . Identify the nursing diagnosis B. Correlate data with the medical diagnosis C. Validate the subjective complaints D. Work with "risk for" diagnoses

A

The nurse teaches Alexander to apply a dressing over the sacral area. Which type of dressing is most likely to be used over the stage 1 pressure ulcer? The nurse teaches Alexander to apply a A. Transparent film dressing. B. Aherent film dressing. C. Gauze dressing. D. Hydrogel covered with a foam dressing.

A

UNIT 5 POWER POINT QUESTION The nurse is assigned to a patient who was admitted for a blood clot in the right leg. Which assessment technique should the nurse perform initially? A. Inspect the right leg B. Lightly palpate the right leg C. Deeply palpate edematous areas D. Palpate all pulses in the right leg

A

UNIT 6 POWER POINT QUESTION Helping relationships serve as the foundation of clinical nursing practice. Contracts for a therapeutic helping relationship are formed during the : A orientation stage B working stage C termination stage D preinteraction stage

A

UNIT 6 POWER POINT QUESTION Information regarding a patient's health status may not be released to non-health care team members because: A legal and ethical obligations require health care providers to keep information strictly confidential B regulations require health care institutions to document evidence of physical and emotional well-being C reimbursement issues related to patient care and procedures may be of concern D fragmentation of nursing and medical care procedures may be identified

A

UNIT 7 Power Point MC Nurse-initiated interventions are: A determined by state Nurse Practice Acts B supervised by the entire health care team C made in concert with the plan of care initiated by the physician D developed after interventions for the recent medical diagnoses are evaluated

A

UNIT 7 Power Point MC The nurse clusters the patient's objective and subjective signs and symptoms primarily to: A identify the nursing diagnosis B correlate data with the medical diagnosis C validate the subjective complaints D work with "risk for" diagnoses

A

UNIT 8 POWER POINT QUESTION The nurse is taking care of a patient who has a stage I pressure ulcer on the sacrum. What is most important for the nurse to do when delegating care of the patient to a nursing assistant? A . Instruct the nursing assistant to turn the patient every 2 hours B . Ask the nursing assistant to massage the patient's sacrum C. Review how to assess the patient's sacrum with the nursing assistant. D . Inform the nursing assistant of the patient's pressure ulcer

A

UNIT 8 POWER POINT QUESTION The nursing assistant asks you the difference between a wound that heals by primary versus secondary intention. You will reply that a wound heals by primary intention when the skin edges: A. Are well-approximated B. Migrate across the incision C . Appear slightly pink D. Slightly overlap each other

A

UNIT 8 POWER POINT QUESTION What is the first step when packing a wound? A . Assess its size, shape, and depth B. Prepare a sterile field C . Select gauze packing material D . Irrigate the wound

A

UNIT 8 POWER POINT QUESTION While reading the patient's medical record, the nurse notes that the physician has identified the presence of eschar on the left heel. What description best defines this finding? A . A black scabbed-like area on the left heel B . A bruised area on the left heel C . A stage III pressure iulcer on the left heel D. A stage IV pressure ulcer on the left heel

A

Upon learning that Alexander has a pressure-reducing gel chair cushion for his wheelchair, which action should the nurse take? A. Encourage him to continue to use this device in his wheelchair at all times. B. Recommend that he replace the gel pad with a donut-shaped foam cushion. C. Advise him to avoid the use of any form of pressure cushion on his wheelchair. D. Teach him that regular use of skin moisturizer is more important than cushion use.

A

What is the purpose of WET TO DRY dressing? A. Mechanically debride the tissue. B. Facilitate tissue healing. C. Decrease risk of infection. D. Preserve granulation tissue.

A

Which goal will the nurse include in Alexander's plan of care? A. Client's skin will remain intact. B. Client's motor function will be restored. C. Client teaching will be provided. D. Impaired skin integrity will not occur.

A

Which intervention is important to reduce the effect of the diarrhea on Alexander's skin? A. Apply a moisture-repellent ointment to intact skin areas. B. Rinse ulcerated areas with an alcohol-based irrigating solution. C. Position a plastic-lined pad under the buttocks. D. Apply moist heat to the area following exposure to feces.

A

module 19 wound care lesson 1 Question 2 1 pts Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms. A. True B. False

A

module 19 wound care lesson 1 Question 5 1 pts When teaching a patient about wound healing, what should the nurse tell the patient? A. Inadequate nutrition delays wound healing and increases risk of infection. B. Chronic wounds heal more efficiently in a dry, open environment, so leave them open to air when possible. C. Long-term steroid therapy diminishes the inflammatory response and speeds wound healing. D. Fat tissue heals more readily because there is less vascularization.

A

module 19 wound care lesson 1 Question 7 1 pts The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates correct understanding of wound dehiscence? A. The nurse should be alert for an increase in serosanguineous drainage from the wound. B. Wound dehiscence is most likely to occur during the first 24 to 48 hours after surgery. C. The nurse should administer cough suppressant to prevent wound dehiscence. D. The condition is an emergency that requires surgical repair.

A

Question 2 of 5 GLIDDENS CH 27 TISSUE INTEGRITY The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which of the following steps should the nurse include in the teaching plan? Select all that apply. A. Cleansing the wound B. Managing pain C. Applying a dry sterile dressing D. Using cold water in the bath

A B

Question 3 of 5 GLIDDENS CH 27 TISSUE INTEGRITY The nurse would explain to a patient that effective treatments for atopic pruritus include which treatments? Select all that apply. A. Oral steroids B. Topical steroids C. Oral antihistamines D. Topical antihistamines E. Topical petroleum ointment

A B

MODULE 19 WOUND CARE LESSON 4 Question 4 1 pts A patient with a wound vacuum-assisted closure (wound V.A.C.) continues to complain of pain. What measures may be taken? (Select all that apply.) A. Switch to the white polyvinyl alcohol (PVA) soft foam. B. Decrease the pressure setting. C. Administer pain medication. D. Switch to the black polyurethane (PU) foam. E. Keep the suction in the "off" position.

A B C

MODULE 6 LESSON 3 Question 8 1 pts A patient just vomited and the nurse is going to test the emesis for occult blood. Which of the following may increase the likelihood of a positive Gastroccult test result? (Select all that apply.) The patient: A. takes an iron preparation. B. ten year history of steroid use. C. is on a long-term nonsteroidal anti-inflammatory drug regimen. D. consumes carbohydrates. E. complains of nausea.

A B C

MODULE 6 LESSON 4 Question 5 1 pts The patient had a positive Hemoccult test. Which of the following could affect the test result? (Select all that apply.) A. Povidone-iodine B. Ascorbic acid (vitamin C) C. Diet high in poultry and fish D. Antibiotics E. Diets rich in carbohydrates

A B C

Question 10 of 15 CH 16 EVOLVE NURSING ASSESSMT Which of the following examples are steps of nursing assessment? Select all that apply. A. Collection of information from patient's family members B. Recognition that further observations are needed to clarify information C. Comparison of data with another source to determine data accuracy D. Complete documentation of observational information E. Determining which medications to administer based on a patient's assessment data

A B C

Question 12 of 15 CH 18 EVOLVE PLANNING NURSING CARE A nurse begins the night shift being assigned to five patients. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient's room, a nurse stops her in the hallway to ask about another patient. Which factors in this nurse's unit environment will affect her ability to set priorities? Select all that apply. A. Policy for conducting hourly rounds B. Staffing level C. Interruption by staff nurse colleague D. RN's years of experience E. Competency of patient care technician

A B C

Question 4 of 14 CH 15 EVOLVE CRITICAL THINKING A nurse on a busy medicine unit is assigned to four patients. It is 10 am. Two patients have medications due and one of those has a specimen of urine to be collected. One patient is having complications from surgery and is being prepared to return to the operating room. The fourth patient requires instructions about activity restrictions before going home this afternoon. Which of the following should the nurse use in making clinical decisions appropriate for the patient group? Select all that apply. A. Consider availability of assistive personnel to obtain the specimen B. Combine activities to resolve more than one patient problem C. Analyze the diagnoses/problems and decide which are most urgent based on patients' needs D. Plan a family conference for tomorrow to make decisions about resources the patient will need to go home E. Identify the nursing diagnoses for the patient going home

A B C

MODULE 16 EXAM SPECIMEN COLLECTION Question 5 1 pts What question(s) may you want to ask the patient before obtaining a stool specimen for occult blood testing? (Select all that apply.) A. What color are your stools? B. What medications are you taking? C. Do you take any iron or vitamin supplements? D. Have you ever had any gastrointestinal surgeries or disorders? E. Have you been running a fever? F. Did you remember to remain fasting for the test? G. Have you had any recent changes in your patterns of urination?

A B C D

MODULE 19 EXAM Question 3 1 pts Which of the following lab results or measurements indicate a risk for impaired wound healing? (Select all that apply.) A. A BMI (body mass index) of 35 (elevated) B. Fasting blood glucose of 215 mg/dl (elevated) C. A serum albumin of 2.9 g/dl (decreased) D. A hemoglobin of 10.0 g per dL (decreased) E. A white blood cell count of 7000 per mm3 (normal)

A B C D

Question 5 of 5 GLIDDENS CH 27 TISSUE INTEGRITY The nurse in the skilled nursing facility is very busy and unable to answer the call bell lights. Which tasks related to skin care can the nurse delegate to the nursing assistant? Select all that apply. A. Applying over-the-counter lotions to skin that is not broken B. Assisting the client with frequent turning to prevent pressure ulcers C. Covering the client who complains of being cold with more blankets D. Placing a sterile gauze pad over broken skin to contain drainage E. Assessing a patient complaining of an itching rash

A B C D

MODULE 16 EXAM SPECIMEN COLLECTION Question 8 1 pts Which of the following may alter gastric analysis results? (Select all that apply.) A. Iron preparations B. Liquid antacids C. Aspirin D. Red meats E. Antihypertensive medications F. Anticoagulant medications

A B C D F

MODULE 19 EXAM Question 2 1 pts It is suspected that a patient is developing a wound infection. Which assessment data would support this conclusion? (Select all that apply.) A. Yellow-tinged drainage. B. Temperature 100.3° F (37.94° C). C. Increased complaints of pain at wound site. D. White blood cell count 13,000 mm3 (elevated). E. Wound edges pink to normal skin color. F. Foul odor noted from previous dressing.

A B C D F

Ch 24 Evolve Communication 11. A patient is evaluated in the emergency department after causing an automobile accident while being under the influence of alcohol. While assessing the patient, which statement would be the most therapeutic? A. "Why did you drive after you had been drinking?" B. "We have multiple patients to see tonight as a result of this accident." C. "Tell me what happened before, during, and after the automobile accident tonight." D. "It will be okay. No one was seriously hurt in the accident."

C

Ch 24 Evolve Communication 6. A patient who is Spanish-speaking does not appear to understand the nurse's information on wound care. Which action should the nurse take? A. Arrange for a Spanish-speaking social worker to explain the procedure B. Ask a fellow Spanish-speaking patient to help explain the procedure C. Use a professional interpreter to provide wound care education in Spanish D. Ask the patient to write down questions that he or she has for the nurse

C

Ch 24 Evolve Communication 9. A new nurse is experiencing lateral violence at work. Which steps could the nurse take to address this problem? A. Challenge the nurses in a public forum to embarrass them and change their behavior B. Talk with the department secretary and ask if this has been a problem for other nurses C. Talk with the preceptor or manager and ask for assistance in handling this issue D. Say nothing and hope things get better

C

MODULE 19 EXAM Question 12 1 pts A nurse is applying negative-pressure wound therapy (e.g., wound vacuum-assisted closure [V.A.C.]) independently for the first time. Assuming all other steps are performed correctly, which action, if made by the nurse, indicates that further instruction is needed in performing this procedure? A. With the V.A.C. unit off, the nurse applies clean gloves and disconnects the tubes to drain fluids into the canister. B. With dressing tube unclamped, the nurse instills 10 to 30 mL of normal saline into the tubing to soak the foam underneath. C. The nurse cuts the foam approximately one-half inch smaller than the size of the wound and gently places the foam in the wound, avoiding any tunneled and undermined areas. D. The nurse applies the tubing to the foam in the wound, applies a skin protectant to skin around the wound, and applies the transparent dressing, covering 3 to 5 cm (1.2 to 2 inches) of surrounding healthy tissue.

C

MODULE 19 EXAM Question 18 1 pts The nurse is instructing a patient on how to change a transparent dressing. Which statement, if made by the nurse, requires correction? A. "The old dressing may be removed while wearing clean gloves. Remove in direction of hair growth and toward the center. Remove disposable gloves pulling them inside out over the soiled dressing and dispose of properly." B. "You will need to apply new gloves after you open your supplies and before you clean the wound. Make sure the area around the wound is dry before applying a new transparent dressing." C. "You will want to remove your gloves to prevent the transparent dressing from sticking to them. Remove the paper backing of the transparent dressing and firmly stretch it over the wound to prevent wrinkling." D. "When the dressing change is completed, be sure to wash your hands. A transparent dressing is beneficial because it maintains a moist environment, which aids wound healing; allows you to examine the wound without having to remove the dressing; and conforms well to body contours."

C

MODULE 19 EXAM Question 9 1 pts A nurse is explaining how to perform a dressing change. Which of the following sequences for changing a surgical wound dressing (wound drain present) indicates that the nurse requires further education regarding this procedure? A. Dispose of gloves and soiled dressings in waterproof bag. Perform hand hygiene. Create a sterile field with individually wrapped sterile supplies on the over-bed table. Pour necessary prescribed solution into sterile basin. Apply sterile gloves. B. Cleanse wound. Use a separate swab for each cleansing stroke. Clean incision from top to bottom. Cleanse around drain by using a circular stroke starting near the drain and moving outward. C. Cleanse wound. Use a separate swab for each cleansing stroke. Cleanse around drain by using a circular stroke starting near the drain and moving outward. Clean incision in direction of bottom to top. D. Use sterile dry gauze to blot dry. Apply prescribed antiseptic ointment by using the same technique as for cleansing. Apply loose, woven gauze as contact layer. Place drain sponge (precut gauze) around drain. Apply additional layers of gauze as needed. Apply thicker woven pad (e.g., ABD or Surgipad).

C

MODULE 19 WOUND CARE LESSON 4 Question 8 1 pts How can the nurse determine that negative pressure is being achieved with a wound V.A.C.? A. The nurse can inquire about the patient's pain level. If there is a reported decrease in the level of pain, then the wound is constricting and negative pressure is being achieved. B. The nurse can ensure that there is no whistling noise at the wound site and that the wound V.A.C. has not triggered its alarm. C. The nurse can check for air leaks by listening with a stethoscope or by moving the hand around the edges of the wound while applying light pressure. D. The nurse can ensure that the foam is in contact with the entire wound base, margins, and tunneled and undermined areas.

C

MODULE 6 LESSON 2 Question 7 1 pts The NAP is obtaining a midstream urine specimen from a female patient. Which action, if made by the NAP, requires correction and indicates further instruction is needed? A. The NAP cleans the patient using a new swab each time. B. The NAP cleans the patient in a front to back motion. C. The NAP cleans the patient starting at the center and uses the same swab to clean the sides. D. The NAP cleans in a direction going from the least contaminated to most contaminated area.

C

MODULE 6 LESSON 3 Question 1 1 pts How many seconds after placing gastric contents on the pH paper should the results be read? A. 10 seconds B. 20 seconds C. 30 seconds D. 40 seconds

C

MODULE 6 LESSON 3 Question 5 1 pts Which of the following could alter gastric pH test results? A. Time of day B. Intermittent enteral feedings C. Prescribed omeprazole (Prilosec) D. Aspirin therapy

C

MODULE 6 LESSON 4 Question 1 1 pts The nurse is performing a Hemoccult test on stool of a patient with a low hemoglobin and hematocrit. Which one of the following steps would be inaccurate and would require correction? A. Perform hand hygiene, apply clean gloves. Use tip of wooden applicator to obtain small portion of feces. Apply this smear of stool on paper in first box. B. Obtain second fecal specimen from different area of stool and apply thin smear to second box of slide. C. Close slide cover, turn slide over, open cardboard flap and apply one drop of Hemoccult developing solution to each box. D. Read results after 30 to 60 seconds. Dispose of gloves and test slide. Perform hand hygiene.

C

MODULE 6 LESSON 5 Question 3 1 pts During change-of-shift report, the nurse is informed a wound culture needs to be obtained from one of the patients. Which of the following actions made by the nurse would be inaccurate and requires correction? A. Obtaining an aerobic culture from an open wound in an area of drainage. B. Obtaining an anaerobic culture by swabbing deeply into a draining body cavity. C. Delegating the procedure to nursing assistive personnel. D. Sending the culture to the lab in a biohazard bag.

C

MODULE 6 LESSON 5 Question 5 1 pts The nurse has informed the patient a wound culture is going to be obtained. The patient asks why the nurse cleans the wound before swabbing it, stating "Won't that keep any infection from showing up on the test?" Which response by the nurse indicates the correct rationale for cleaning the wound prior to obtaining the culture? A. "Cleaning the wound reduces the spread of infection." B. "Removing drainage minimizes discomfort during the procedure." C. "Removing skin flora prevents possible contamination of the specimen." D. "Cleaning the wound keeps the wound free of pathogenic microorganisms."

C

MODULE 6 LESSON 6 Question 4 1 pts The nurse confirms the diabetic patient has a fasting blood glucose reading of 76. Which statement, if made by the patient, indicates further teaching is needed? A. "Exercise is helping me to maintain a normal blood sugar level." B. "I think being careful with my carbohydrate intake is working." C. "That's really good, I can eat anything I want to today." D. "I shouldn't reuse lancets when monitoring my blood glucose."

C

Question 1 of 14 CH 17 EVOLVE NURSING DIAGNOSIS A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse's assessment reveals that the infant cries when breastfeeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the patient's nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best "related to" factor? A. Infant crying at breast B. Infant unable to latch on to breast correctly C. Mother's deficient knowledge D. Lack of infant weight gain

C

Question 13 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient? A. Knowing the source of the guideline B. Reviewing the evidence used to develop the guideline C. Individualizing how to apply the clinical guideline for a patient D. Explaining to a patient the purpose of the guideline

C

Question 14 of 15 CH 16 EVOLVE NURSING ASSESSMT A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems? A. "I can tell that your eating habits have led to your diabetes. Is that right?" B. "It's been difficult for people to find jobs. Is that why you work part time?" C. "You have four children; do you have any concerns about going home and caring for them?" D. "I wish patients understood how overeating affects their health."

C

Question 2 of 14 CH 15 EVOLVE CRITICAL THINKING By using known criteria in conducting an assessment such as reviewing with a patient the typical characteristics of pain, a nurse is demonstrating which critical thinking attitude? A. Curiosity B. Adequacy C. Discipline A. Thinking independently

C

Question 2 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE Match the pressure ulcer categories/stages with the correct definition: Full thickness skin loss, subcutaneous fat may be visible. May include undermining A . Category/Stage I B . Category/Stage II C . Category/Stage III D . Category/Stage IV

C

Question 2 of 6 GLIDDENS 10 THERMOREGULATION What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia? A Dyspnea B Precordial pain C Increased pulse rate D Elevated blood pressure

C

Question 3 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? A. Category/Stage II B. Category/Stage IV C. Unstageable D. Suspected deep tissue damage

C

Question 4 of 14 CH 17 EVOLVE NURSING DIAGNOSIS A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's room with the student to assess the patient's orientation, heart rate, skin turgor, and urine output for last 8 hours. The lead charge nurse suspects that the student has made which type of diagnostic error? A. Insufficient cluster of cues B. Disorganization C. Insufficient number of cues D. Evidence that another diagnosis is more likely

C

Question 4 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE What is the importance of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey? A. Measures a nurse's competency in interdisciplinary care B. Measures the number of adverse events in a hospital C. Measures quality of care within hospitals D. Measures referrals to a health care agency

C

Question 4 of 15 CH 16 EVOLVE NURSING ASSESSMT The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of: A. Cue. B. Reflection. C. Clinical inference. D. Probing.

C

Question 5 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE Match the category of direct care on the left with the specific direct care activity on the right. Using safe patient handling during positioning of a patient A. Counseling B. Lifesaving measure C. Physical care technique D. Activity of daily living

C

Question 5 of 15 CH 18 EVOLVE PLANNING NURSING CARE An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. Goals Outcomes Patient will achieve 5-lb weight gain in 1 month A. Patient walks 20 feet using a walker in 24 hours B. Patient identifies barriers to remove in the home within 1 week C. Patient increases calorie intake to 2500 daily D. Patient expresses fewer nonverbal signs of discomfort within 24 hrs.

C

Question 5 of 5 Gliddens 40 A nurse wishes to obtain data about a new patient's self-esteem. To gain the clearest picture, the nurse uses which assessment technique? A Completing an entire head-to-toe assessment first B Conducting a structured interview with direct questions C Interviewing the patient in an unstructured format D Disregard any nonverbal clues from the patient

C

Question 7 of 15 CH 16 EVOLVE NURSING ASSESSMT During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing? A. So you've had headaches periodically in the last week and sometimes they cause you to feel nauseated—correct? B. Have you taken anything for your headaches? C. Tell me what makes your headaches begin. D. Uh huh, tell me more.

C

Question 8 of 14 CH 15 EVOLVE CRITICAL THINKING An aspect of clinical decision making is knowing the patient. Which of the following is the most critical aspect of developing the ability to know the patient? A. Working in multiple health care settings B. Learning good communication skills C. Spending time establishing relationships with patients D. Relying on evidence in practice

C

Question 8 of 14 CH 20 EVOLVE - EVALUATION A nurse enters a patient's room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient's expectations of care. Which statement is appropriate for evaluating a patient's expectations of care? A. On a scale of 0 to 10 rate your level of nausea. B. The nurse weighs the patient. C. The nurse asks, "Did you believe that you received the information you needed to follow your diet?" D. The nurse states, "Tell me four different foods included in your diet."

C

Question 9 of 14 CH 15 EVOLVE CRITICAL THINKING Match the concepts for a critical thinker on the right with the application of the term on the left. Anticipate how a patient might respond to a treatment. A. Systematicity B. Truth seeking C. Analyticity D. Open-mindedness

C

To provide pressure relief at night, the nurse teaches Alexander to sleep in which position? A. Supine with the head of the bed elevated. B. Supine with a foam wedge between the knees. C. Thirty-degree lateral inclined position. D. Full side-lying position supported with pillows.

C

UNIT 8 POWER POINT QUESTION A patient is being discharged after abdominal surgery. The staples were removed on the third day after surgery and a gauze dressing was applied. The patient tells the nurse that as he was standing up he heard a pop come from his abdomen. Which assessment should the nurse do first? A . Fully assess neurologic status B . Auscultate the bowel sounds C . Inspect the surgical site D. Palpate the abdomen

C

Which areas are most important for the nurse to observe for additional pressure ulcers? A. Distal tips of the toes. B. Lower abdominal folds. C. Heels and ankles. D. Thighs and calves.

C

Which equipment will the nurse use to assess the length of the tract? A. Sterile gloves and lubricant. B. Sterile tape measure. C. Sterile cotton-tipped applicator. D. Sterile irrigation tray with syringe.

C

Which etiology identified by the nurse is accurate? A. Noncompliance with turning schedule. B. Poor nutritional intake. C. Impaired physical mobility. D. Impaired adjustment.

C

Your patient has met the expected outcomes to achieve the goal for improvement of ambulatory status. You would now: A. Modify the care plan B. Discontinue the care plan C. Create a new nursing diagnosis that states goals have been met D. Evaluate the implementation step of the nursing process

C

module 19 wound care lesson 1 Question 4 1 pts Which of the following patients has the least risk for developing a wound infection? A. An 80-year-old man who has a burn. B. A 17-year-old patient who has a metal fragment lodged in his thigh. C. A 30-year-old woman who had an episiotomy with childbirth. D. A patient receiving chemotherapy who has a surgical incision. E. A patient with peripheral vascular disease and an ulcer on the heel.

C

A patient is suffering from shortness of breath. The correct outcome statement would be written as: A. The patient will be comfortable by the morning B. The patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift C . Th patient will not complain of breathing problems within the next 8 hours D . The patient will have a respiratory rate of 14 to 18 breaths per minute

B

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Question 10 of 14 While reviewing the pulmonary assessment entered by a nurse in a patient's electronic medical record (EMR), a physician notices that the only information documented in that section is "WDL" (within defined limits). The physician also is not able to find a narrative description of the patient's respiratory status in the nurse's progress notes. What is the most likely reason for this? A. The nurse caring for the patient forgot to document on the pulmonary system. B. The EMR uses a charting-by-exception format. C. The computer shut down unexpectedly when the nurse was documenting the assessment. D. Because of HIPAA regulations, physicians are not authorized to view the nursing assessment.

B

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Question 14 of 14 A patient states, "I would like to see what is written in my medical record." What is the nurse's best response? A. "Only your family can read your medical record." B. "You have the right to read your record." C. "Patients are not allowed to read their records." D. "Only health care workers have access to patient records."

B

CH 31 EVOLVE HEALTH ASSESSMENT Question 13 of 14 While auscultating the adult patient's lungs, the nurse hears loud, bubbly sounds during inspiration that did not disappear after the patient coughed. Which finding should the nurse document from the lung assessment? A Rhonchi B Coarse crackles C Sibilant wheeze D Pleural friction rub

B

CH 31 EVOLVE HEALTH ASSESSMENT Question 14 of 14 The nurse is assessing the cranial nerves. Match the cranial nerve with its related function. IV Trochlear A Lateral movement of the eyeballs B Downward, inward eye movements C Position of the tongue D Motor innervation to the muscles of the jaw E Sensation of the pharynx

B

Ch 24 Evolve Communication 14. A nurse prepares to contact a patient's physician about a change in the patient's condition. Using SBAR (Situation, Background, Assessment, and Recommendation) communication, which of the following is the correct order? 1."She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on Levaquin at 5 pm yesterday. She complains of a poor appetite." 2. "The patient reported feeling very nauseated after her dose of Levaquin an hour ago." 3. "Would you like to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" 4. "The patient started complaining of nausea yesterday evening and has vomited several times during the night." A. 1, 3, 4, 2 B. 4, 1, 2, 3 C. 2, 1, 3, 4 D. 4, 2, 1, 3

B

Ch 24 Evolve Communication 5. A nurse is talking with a young-adult patient about the purpose of a new medication. The nurse says, "I want to be clear. Can you tell me in your words the purpose of this medicine?" This exchange is an example of which element of the transactional communication process? A. Message B. Obtaining feedback C. Channel D. Referent

B

MODULE 16 EXAM SPECIMEN COLLECTION Question 11 1 pts The nurse informs the patient that their fasting blood glucose reading was 151. The patient asks what this means. Which of the following is the best response by the nurse? A. "Your blood sugar is with normal range. I will document the finding." B. "Your blood sugar is too high. I will see if there is an order for insulin." C. "Your blood sugar is too low. I will bring you a snack containing carbohydrates." D. "You don't need to worry; I will contact your health care provider if necessary."

B

MODULE 19 EXAM Question 14 1 pts The nurse is reading electronic documentation from the emergency room on a patient who is to be admitted to the unit. The documentation states that the patient has a hematoma on the right knee. What does the nurse expect to see? A. A shallow wound with loss of the epidermis and partial loss of the dermis. B. A localized collection of blood underneath the tissues that often takes on a bluish discoloration. C. A deep wound extending into the dermis. D. An area of skin that has been scraped away.

B

MODULE 19 EXAM Question 16 1 pts The nurse inspects all wounds for signs of infection. When might a contaminated or traumatic wound show signs of infection? A. During the first 24 to 48 hours after injury. B. Two to three days after injury. C. Up to 5 days after injury. D. Five to seven days after injury.

B

MODULE 19 WOUND CARE LESSON 2 Question 4 1 pts The nurse is observing the patient's wife perform treatment of her husband's pressure injury. Which action, if made by the patient's wife, indicates that further instruction is needed? A. She premedicates the patient for pain before beginning the dressing change. B. She performs hand hygiene and removes the old dressing and begins to clean the injury with soap and water. C. While wearing gloves, she rinses the injury with normal saline, gently wiping around the wound base and surrounding skin with moistened gauze. D. She applies solution to the gauze and wrings out any excess. She unfolds the gauze and packs the wound with the moistened dressing. She covers the gently packed wound with dry 4 × 4-inch gauze pads and applies tape to secure the dressing. She removes her gloves and performs hand hygiene.

B

MODULE 19 WOUND CARE LESSON 2 Question 5 1 pts A family member calls the nurse to ask for advice regarding their mother who has developed a "bedsore" on her right heel. The family member describes the pressure injury as "a blister that has now popped and you can see redness." Based on this description, at what stage would the nurse classify this pressure injury? A Stage 1. B. Stage 2. C. Stage 3. D. Stage 4.

B

MODULE 19 WOUND CARE LESSON 3 Question 1 1 pts The patient asks the nurse what the purpose is for his Hemovac drain. What is the nurse's best response? A. "To reduce the need for frequent dressing changes." B. "To provide suction to remove and collect drainage from your wound to help it heal." C. "To accurately determinine fluid loss and whether your fluids need to be increased." D. "To prevent infection and crust formation at the wound site."

B

MODULE 19 WOUND CARE LESSON 3 Question 7 1 pts The patient complains "It feels like the drain is pulling on my surgical site." What is the nurse's best action? A. Secure the drain above the incision to the dressing with tape and a safety pin and instruct the patient to keep the drain above the insertion site when ambulating, sitting, and lying. B. Make sure there is slack in the tubing from the reservoir to the wound, allowing the patient movement and avoiding pulling at the insertion site. C. Instruct the patient that this is the normal sensation of having a drain. D. Have the patient lie down and advance the drain further into the patient until the sensation is relieved and drainage is noted in tubing; secure a new dressing over insertion site of drain.

B

MODULE 19 WOUND CARE LESSON 4 Question 5 1 pts During a sterile dressing change, when are the gloves changed? A. After the old dressing is removed and before creating a sterile field. B. After the old dressing is removed and before cleansing the wound. C. After the old dressing is removed, after cleansing the wound, and before applying a new dressing. D. It is unnecessary to change gloves for chronic wounds.

B

MODULE 6 LESSON 1 Question 2 1 pts The patient appears anxious about having a laboratory test. How should the nurse best respond? A. "Everyone is nervous about having laboratory tests performed. I will let you know the results as soon as I receive them." B. "What is it about the test that concerns you?" C. "There is nothing to worry about. This is routine." D. "Why are you anxious about having a laboratory test performed? I'm sure your doctor wouldn't order it unless necessary."

B

MODULE 6 LESSON 2 Question 3 1 pts The nurse has instructed the male patient on how to properly clean himself in preparation for obtaining a midstream urine specimen. Which statement made by the patient indicates correct understanding? A. "I should clean in a direction from the most contaminated area to the least contaminated area." B. "I should begin cleaning at the opening of my penis and go outward in a circular motion." C. "I should wash the area well with soap and water, and then I am ready to provide the specimen." D. "I should clean in a direction from front to back in the perineal area."

B

MODULE 6 LESSON 2 Question 4 1 pts The nurse is going to obtain a urine sample from a patient who has an indwelling urinary catheter for routine analysis. How much urine should the nurse obtain? A. At least 3 mL B. At least 20 mL C. At least 1 mL D. 90 to 120 mL

B

MODULE 6 LESSON 3 Question 7 1 pts The patient has been taking an over-the-counter acid reducer. What finding would be expected in the patient's gastric pH results? A. None, since this is a nonprescription medication. B. The pH would increase. C. A positive result for gastroccult testing. D. The pH would decrease.

B

MODULE 6 LESSON 4 Question 7 1 pts The patient is reading some literature on screening for colon cancer. The patient asks, "What is melena?" The nurse is correct to respond: A. "Noticeable bright red blood in the stool, typically from hemorrhoids." B. "Black tarry feces caused by the digestion of blood in the gastrointestinal tract." C. "Undigested fat which causes a white or clay-colored foul-smelling frothy stool." D. "Pain with defecation, usually due to the presence of polyps."

B

MODULE 6 LESSON 5 Question 1 1 pts The health care provider has written the following orders: 0.45% NaCl at 50 mL/hr, C & S (culture & sensitivity) of wound, Levofloxacin (an antibiotic) 500 mg IV q 24 h, Diet as tolerated. Which health care provider's order should receive highest priority? A. 0.45% NaCl @ 50 mL/hr B. C & S of wound C. Levofloxacin 500 mg IV D. Diet as tolerated E. It doesn't matter; just so that they are all completed

B

MODULE 6 LESSON 5 Question 4 1 pts A diabetic patient has a surgical incision that is not healing properly. The nurse notes purulent yellow drainage coming from an area of the incision that is poorly approximated. What type of wound culture would the nurse expect the health care provider to order? A. Anaerobic culture B. Aerobic culture C. Blood culture D. Tissue culture

B

Question 1 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE During the implementation step of the nursing process, a nurse reviews and revises a patient's plan of care. What is the correct order of steps for this?1. Modify care plan as needed. 2. Decide if the nursing interventions remain appropriate. 3. Reassess the patient. 4. Compare assessment findings to validate existing nursing diagnoses. A. 2, 1, 3, 4 B. 3, 4, 2, 1 C. 4, 3, 2, 1 D. 3, 4, 1, 2

B

Question 1 of 5 GLIDDENS CH 24 INFLAMMATION The nurse is completing an admission assessment of a new patient to the unit. The nurse notes a long, thin, fading scar on the patient's abdomen in the right lower quadrant. What is the best explanation for the scar's appearance? A. Optimal functioning of the inflammatory process after an injury B. Fibrous tissue replacing damaged tissue when injury is extensive C. The development of chronic inflammation D. A surgical incision

B

Question 10 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE What does the Braden Scale evaluate? A. Skin integrity at bony prominences, including any wounds B. Risk factors that place the patient at risk for skin breakdown C. The amount of repositioning that the patient can tolerate D. The factors that place the patient at risk for poor healing

B

Question 13 of 14 CH 15 EVOLVE CRITICAL THINKING Two patient deaths have occurred on a medical unit in the last month. The staff notices that everyone feels pressured and team members are getting into more arguments. As a nurse on the unit, what will best help you manage this stress? A. Keep a journal B. Participate in a unit meeting to discuss feelings about the patient deaths C. Ask the nurse manager to assign you to less difficult patients D. Review the policy and procedure manual on proper care of patients after death

B

Question 13 of 15 CH 18 EVOLVE PLANNING NURSING CARE A home health nurse visits a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over 2 weeks. The patient has had diabetes for 10 years. The ulcer has not been healing; it has drainage with a foul-smelling odor. As the nurse examines the patient, she learns that the patient is not following the ordered diabetic diet. Which of the following is considered a low-priority goal for this patient? A. Achieving wound healing of the foot ulcer B. Enhancing patient knowledge about the effects of diabetes C. Providing a dietitian consultation for diet retraining D. Improving patient adherence to diabetic diet

B

Question 14 of 14 CH 20 EVOLVE - EVALUATION A patient is being discharged after treatment for colitis (inflammation of the colon). The patient has had no episodes of diarrhea or abdominal pain for 24 hours. Following instruction, the patient identified correctly the need to follow a low-residue diet and the types of food to include if a bout of diarrhea develops at home. These behaviors are examples of: A. Evaluative measures. B. Expected outcomes. C. Reassessments. D. Standards of care.

B

Question 2 of 15 CH 16 EVOLVE NURSING ASSESSMT The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview? A. Orientation B. Working phase C. Data validation D. Termination

B

Question 4 of 14 CH 20 EVOLVE - EVALUATION A nurse caring for a patient with heart failure instructs the patient on foods to eat for a low-sodium diet. The nurse will perform which of the following evaluation measures to determine success of her instruction? A. Patient weight B. Asking patient to identify three low-sodium foods to eat for lunch C. A calorie count of food D. Patient description of how food selections are made

B

Question 4 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? A. Binder B. Ice bag C. Elastic bandage D. Absorptive dressing

B

Question 4 of 5 Gliddens 40 Which statement is included in the clinical reasoning communication category? A The mathematical calculation process by which a nurse verifies a medication dosage. B Relying heavily on analytic reasoning that requires systematically breaking a situation down into parts, examining alternatives, and weighing options. C Using experiential knowledge, the nurse begins to put everything together to make sense of it. D Clinical judgment is inherently complex and influenced by many factors related to the particular patient and caregiving situation.

B

Question 5 of 15 CH 18 EVOLVE PLANNING NURSING CAREAn 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. Goals Outcomes Patient will be injury free for 1 month A. Patient walks 20 feet using a walker in 24 hours B. Patient identifies barriers to remove in the home within 1 week C. Patient increases calorie intake to 2500 daily D. Patient expresses fewer nonverbal signs of discomfort within 24 hrs.

B

Question 6 of 6 GLIDDENS 10 THERMOREGULATION A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when observing the child's nurse perform which action? A Places a hypothermia blanket at the bedside B Adjusts the bed to the Trendelenburg position C Obtains electronic equipment for monitoring the vital signs D Secures a pump to administer the ordered intravenous fluids

B

Question 8 of 14 CH 17 EVOLVE NURSING DIAGNOSIS The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n): A. Risk nursing diagnosis. B. Problem-focused nursing diagnosis. C. Health promotion nursing diagnosis. D. Wellness nursing diagnosis.

B

Question 9 of 14 CH 15 EVOLVE CRITICAL THINKING Match the concepts for a critical thinker on the right with the application of the term on the left. Be objective in asking questions of a patient. A. Systematicity B. Truth seeking C. Analyticity D. Open-mindedness

B

Question 9 of 14 CH 17 EVOLVE NURSING DIAGNOSIS A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment and has had liquid stool and the skin is clean and intact; therefore she selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons? A. Incorrect clustering B. Wrong diagnostic label C. Condition is a collaborative problem. D. Premature closure of clusters

B

UNIT 5 POWER POINT QUESTION A newly admitted patient is complaining of itching and has a rash all over the body. Which intervention is most appropriate for the nurse to take initially? A. Inform the physician of the patient's complaints B. Inspect the patient and describe the rash C. Ask the patient to try not to scratch the areas D. Check the medication record for anti-itch medication

B

UNIT 5 POWER POINT QUESTION When conducting an abdominal assessment, which skill should the nurse use first? A. Auscultation B. Inspection C. Palpation D. Percussion

B

UNIT 6 POWER POINT QUESTION A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paperwork, the nurse needs to record: A an interpretation of patient behavior B objective data that are observed C lengthy entry using lay terminology D abbreviations familiar to the nurse

B

UNIT 6 POWER POINT QUESTION While admitting a patient, during the initial interview, a family member tells you, "My mom really means that she does not understand her medical diagnosis." This communication form used by the family member is: A focusing B clarifying C summarizing D paraphrasing

B

UNIT 7 Power Point MC A patient is admitted to the hospital with shortness of breath. As the nurse assesses this patient, the nurse is using the process of: A Evaluation B Data Collection C Problem Identification D Testing Hypothesis

B

UNIT 7 Power Point MC A patient is suffering from shortness of breath. The correct outcome statement could be written as: A The patient will be comfortable by the morning B The patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift C The patient will not complain of creating problems within the next 8 hours. D The patient will have a respiratory rate of 14 to 18 breaths per minute

B

UNIT 8 POWER POINT QUESTION On turning a patient in bed, the nurse notes a reddened area on the right hip. Further assessment reveals intact skin with blanching at the site. Which nursing intervention is most appropriate? A . Notify the physician B . Document the findings C . Apply a sterile dressing D . Document the presence of a stage I pressure ulcer

B

UNIT 8 POWER POINT QUESTION When assessing for wound infection, the signs of wound infection include all of the following except: A . Rise in temperature B. Bradypnea C . WBC count above 10,000/dl D . Restlesslessness and discomfort E. Purulent drainage F . Tenderness around the wound

B

module 19 wound care lesson 1 Question 1 1 pts A contaminated or traumatic wound may show signs of infection within 24 hours. A surgical wound infection usually develops postoperatively within 14 days. A. True B. False

B

module 19 wound care lesson 1 Question 8 1 pts The nurse reports that a patient has a wound on his abdomen that is healing by secondary intention. The nurse understands this means the patient: A. has a drain. B. Is at greater risk for infection. C. Is at greater risk for wound dehiscence. D. Is healing naturally.

B

MODULE 16 EXAM SPECIMEN COLLECTION Question 4 1 pts Which of the following can be determined from Gastroccult testing? (Select all that apply.) A. The amount of bleeding in the stool B. The presence of blood in gastric contents C. The pH of the gastric contents D. Cancerous cells in the stool

B C

MODULE 19 WOUND CARE LESSON 4 Question 3 1 pts The nurse is observing the patient's wife perform the damp-to-dry dressing change. Which actions, if made by the patient's wife, indicate that further instruction is needed? (Select all that apply.) A. Premedicates for pain. B. Packs wound tightly. C. Leaves contact or primary dressing dripping moist. D. When removing the old dressing the wife leaves the dressing dry, even when it sticks slightly. E. Pulls tape in direction toward wound when removing previous dressing.

B C

MODULE 6 LESSON 3 Question 2 1 pts The nurse is verifying placement of a nasogastric tube. Which gastric pH result would indicate the tube is properly positioned? (Select all that apply.) A. 6.0 B. 2.0 C. 3.0 D. 5.0 E. 5.5

B C

Question 6 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions? Select all that apply. A. The application of the skin barrier is a dependent care measure. B. The call to the ostomy and wound care specialist is an indirect care measure. C. The cleansing of the skin is a direct care measure. D. The application of the skin barrier is an instrumental activity of daily living. E. Inspecting the skin in a direct care activity.

B C

Ch 24 Evolve Communication 2. Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply.) A. Improve the nurse's status with the health team members B. Reduce the risk of errors to the patient C. Provide optimum level of patient care D. Improve patient outcomes E. Prevent issu

B C D

MODULE 6 LESSON 3 Question 4 1 pts The nurse is reviewing the patient's medical record to determine if there are any factors present that can cause a false-positive result for occult blood testing. The nurse would be correct to identify which of the following? (Select all that apply.) A. Antacids (e.g., Amphojel, Maalox, Milk of Magnesia) B. Red meats, poultry, fish C. Iron supplement. D. Spinach, collard greens E. Anticoagulants (e.g., warfarin sodium, heparin)

B C D

Question 15 of 15 CH 18 EVOLVE PLANNING NURSING CARE Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnoses? Select all that apply. A. Numbered order of diagnosis on the basis of severity B. Notion of urgency for nursing action C. Symptom pattern recognition suggesting a problem D. Mutually agreed on priorities set with patient E. Time when a specific diagnosis was identified

B C D

CH 31 EVOLVE HEALTH ASSESSMENT Question 3 of 14 The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? Select all that apply. A Limit intake of cholesterol to less than 400 mg/day. B Talk with your health care provider about taking a daily low dose of aspirin. C Work with your health care provider to develop a regular exercise program. D Limit daily intake of fats to less than 25% to 35% of total calories. E Review strategies to encourage the patient to quit smoking.

B C D E

MODULE 19 WOUND CARE LESSON 2 Question 1 1 pts Which of the following are common sites for the development of pressure injuries? (Select all that apply.) A. Sternum. B. Heels. C. Sacrum. D. Lateral malleoli. E. Trochanters. F. Ischial tuberosities.

B C D E F

MODULE 6 LESSON 5 Question 8 1 pts A nurse is preparing to obtain an anaerobic wound culture. What supplies will the nurse require to carry out the procedure? (Select all that apply.) A. Culture tube with swab and ampule with medium B. Culture tube that contains carbon dioxide or nitrogen gas C. 5- to 10-mL syringe and 19-gauge needle D. Lab requisition, identification label, and biohazard bag E. Vacutainer F. Sterile specimen cup G. Clean gloves H. Sterile gloves I. Sterile dressing materials

B C D G H I

MODULE 6 LESSON 6 Question 1 1 pts The nurse observes the NAP obtain a patient's blood glucose measurement. Which of the following, if observed, would require correction by the nurse? (Select all that apply.) A. The NAP puts the unused strip in the meter and removes it, confirming code. B. The NAP milks the patient's finger before pressing the release button of the lancet device. C. The NAP cleans the central tip of the finger with an antiseptic swab and allows it to air dry. D. The NAP removes the cover on the tip of the lancet before cocking the lancet device. E. The NAP scrapes the drop of blood onto the test strip and waits for test result.

B C E

MODULE 19 WOUND CARE LESSON 2 Question 3 1 pts Identify prevention strategies for pressure injuries. (Select all that apply.) A. Reposition patient at least every 4 hours; use a documented schedule. B. When the patient is in the side-lying position in bed, use the 30-degree lateral position. C. Place patient on a pressure-reducing support surface. D. Maintain the head of the bed at 45 degrees. E. Massage reddened bony prominences. F. Oral supplements should be instituted if the patient is found to be undernourished.

B C F

MODULE 6 LESSON 5 Question 7 1 pts Which of the following are indications of a localized wound infection? (Select all that apply.) A. Fever B. Warmth at wound site C. Pain or tenderness at wound site D. Chills E. Excessive thirst F. Purulent drainage

B C F

MODULE 19 EXAM Question 5 1 pts Which of the following regarding removal of the old dressing on a surgical incision are accurate? (Select all that apply.) A. Tape should be pulled parallel to the skin in a direction away from the incision. B. If dressing is over a hairy area, remove tape in the direction of hair growth. C. While wearing clean gloves, remove the dressing layers all at one time and discard. D. Use caution to avoid tension on any drains that are present. E. Wear sterile gloves to remove old dressing.

B D

Question 13 of 14 CH 20 EVOLVE - EVALUATION A faculty member is reviewing a nursing student's plan of care, including the interventions the student provided for a patient with dementia. The student reviewed clinical guidelines on a professional website to identify interventions successful in reducing wandering in patients with dementia. The faculty member should evaluate which of the following? Select all that apply. A. Number of interventions B. Appropriateness of the intervention for the patient C. The prior use of interventions by other nursing staff D. Correct application of the intervention for the patient care setting E. The time it takes to provide interventions

B D

Question 14 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? Select all that apply. A. Collection of wound drainage B. Provides support to abdominal tissues when coughing or walking C. Reduction of abdominal swelling D. Reduction of stress on the abdominal incision E. Stimulation of peristalsis (return of bowel function) from direct pressure

B D

Question 2 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE A nurse is visiting a patient in the home and is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? Select all that apply. A. Reviewing the family caregiver's availability during medication administration times B. Making a judgment of the value of improved adherence for the patient C. Reviewing the number of medications and time each is to be taken D. Determining all consequences associated with the patient missing specific medicines E. Reviewing the therapeutic actions of the medications

B D

Question 9 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE A nurse is caring for a complicated patient 3 days in a row. The nurse attends an interdisciplinary conference to discuss the patient's plan of care. In which ways can the nurse develop trust with members of the conference team? Select all that apply. A. Is willing to challenge other members' ideas because the nurse disagrees with their rationale B. Shows competence in how to monitor patients' clinical status and inform the physician of critical changes C. Asks a more experienced nurse to attend the conference D. Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly E. During the meeting focus on similar problems the nurse has had in delivering care to other patients.

B D

CH 30 EVOLVE VITAL SIGNS Question 9 of 14 A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant reports his admitting vital signs to the nurse. Which measurements should the nurse reassess? Select all that apply. A. Right arm BP: 118/72 B. Radial pulse rate: 72 and irregular C. Temporal temperature: 37.4° C (99.3° F) D. Respiratory rate: 28 E. Oxygen saturation: 99%

B D E

Question 1 of 5 Gliddens 40 You are a new graduate nurse working with a nurse who has been out of school for 10 years. The seasoned nurse states, "I don't see the difference between this clinical reasoning and the nursing process." Which of the following statements would be an appropriate response? Select all that apply. A Clinical reasoning is limited to assessing, evaluating, and treating the nursing diagnosis. B Clinical reasoning involves reflecting on interventions and reevaluating the plan of care based on the results of reflection. C Clinical reasoning involves assessing, diagnosing, and planning and using interventions based on assessments. D Clinical reasoning is the thinking process by which a nurse reaches a clinical judgment. E Clinical reasoning is an iterative process of noticing, interpreting, and responding—reasoning in transition with a fine attunement to the patient and how the patient responds to the nurse's actions.

B D E

CH 20 EVALUATION BOOK Q NOT IN EVOLVE From the following list of indicators, determine which indicators are OUTCOMES A. will achieve pain relief B. ambulates 10 feet down the hallway C will remain free of infection D will be afebrile E reports pain severity reduced from a 6 to a 4 on scale of 0 to 10 F will gain improved mobility

B E

CH 30 EVOLVE VITAL SIGNS Question 10 of 14 The nursing assistive personnel (NAP) reports to you that the blood pressure (BP) of the patient in Question 11 is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? Select all that apply. A. Notify the health care provider immediately B. Repeat the measurements on both arms using a stethoscope C. Ask the patient if she has taken her blood pressure medications recently D. Obtain blood pressure measurements on lower extremities E. Verify that the correct cuff size was used during the measurements F. Review the patient's record for her baseline vital signs G. Compare right and left radial pulses for strength

B F

Question 2 of 15 CH 18 EVOLVE PLANNING NURSING CARE A nursing student is reporting during hand-off to the registered nurse (RN) assuming her patient's care. The student states, "Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr with D5 ½ NS infusing in right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. He still uses his cane without difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. If the nurse's goal for Mr. Roarke was to improve activity tolerance, which expected outcomes were shared in the hand-off? Select all that apply. A. IV site not tender B. Uses cane to walk C. Walked to end of hall D. No shortness of breath E. Slept better during night

C D

Question 4 of 5 GLIDDENS CH 27 TISSUE INTEGRITY A nurse is instructing a nursing assistant in how to prevent pressure ulcers in a frail elderly client. The nursing assistant indicates that she understands the instruction when she agrees to perform which actions? Select all that apply. A. Bathe and dry the skin vigorously to stimulate circulation. B. Keep the head of the bed elevated 30 degrees. C. Offer nutritional supplements and frequent snacks. D. Turn the patient at least every 2 hours. E. Maintain a cooler environment when bathing.

C D

Question 5 of 14 CH 15 EVOLVE CRITICAL THINKING A nurse changed a patient's surgical wound dressing the day before and now prepares for another dressing change. The nurse had difficulty removing the gauze from the wound bed yesterday, causing the patient discomfort. Today he gives the patient an analgesic 30 minutes before the dressing change. Then he adds some sterile saline to loosen the gauze for a few minutes before removing it. The patient reports that the procedure was much more comfortable. Which of the following describes the nurse's approach to the dressing change? Select all that apply. A. Clinical inference B. Basic critical thinking C. Complex critical thinking D. Experience E. Reflection

C D

Question 5 of 14 CH 20 EVOLVE - EVALUATION For the nursing diagnosis of Deficient Knowledge a nurse selects an outcome from the Nursing Outcome Classification (NOC) of patient knowledge of arthritis treatment. Which of the following are examples of an outcome indicator for this outcome? Select all that apply. A. Nurse provides four teaching sessions before discharge. B. Patient denies joint pain following heat application. C. Patient describes correct schedule for taking antiarthritic medications. D. Patient explains situations for using heat application on inflamed joints. E. Patient explains role family caregiver plays in applying heat to inflamed joint.

C D

CH 31 EVOLVE HEALTH ASSESSMENT Question 12 of 14 The faith community nurse is teaching the community center women's group about breast cancer risk factors. Which factors does the nurse include? Select all that apply. A First child at the age of 26 years B Menopause onset at the age of 49 years C Family history with BRCA1 inherited gene mutation D Age over 40 years E Onset of menses before the age of 12 F Recent use of oral contraceptives

C D E F

CH 31 EVOLVE HEALTH ASSESSMENT Question 6 of 14 A patient has undergone surgery for a femoral artery bypass. The surgeon's orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? Select all that apply. A Place the fingers behind and below the medial malleolus. B Have the patient slightly flex the knee with the foot resting on the bed. C Have the patient relax the foot while lying supine. D Palpate the groove lateral to the flexor tendon of the wrist. E Palpate along the top of the foot in a line with the groove between extensor tendons of great and first toes.

C E

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Match documentation with the appropriate SOAP category Acute pain related to tissue injury from surgical incision. A Subjective B Objective C Assessment D Plan

C

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Question 1 of 14 What is the appropriate way for a nurse to dispose of information printed out from a patient's electronic health record? A. Rip the papers up into small pieces and place the pieces into a standard trash can B. Place all papers in the flip-top binder designated for that patient that is located in the nurse's station on the patient care unit C. Place papers with patient information in a secure canister marked for shredding D. Burn documents with patient information in the steel sink located within the dirty supply room on the patient care unit

C

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Question 7 of 14 The nurse is caring for a patient with a nasogastric feeding tube who is receiving a continuous tube feeding at a rate of 45 mL per hour. The nurse enters the patient assessment data and information that the head of the patient's bed is elevated to 20 degrees. An alert appears on the computer screen warning that this patient is at a high risk for aspiration because the head of the bed is not elevated enough. This warning is known as which type of system? A Electronic health record B Clinical documentation C Clinical decision support system D Computerized physician order entry

C

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Question 8 of 14 The nurse is reviewing the Health Insurance Portability and Accountability Act (HIPAA) regulations with the patient during the admission process. The patient states, "I'm not familiar with these HIPAA regulations. How will they affect my care?" Which of the following is the best response? A HIPAA allows all hospital staff access to your medical record. B HIPAA limits the information that is documented in your medical record. C HIPAA provides you with greater protection of your personal health information. D HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

C

CH 30 EVOLVE VITAL SIGNS Question 13 of 14 Which patient is at highest risk for tachycardia? A. A healthy basketball player during warmup exercises B. A patient admitted with hypothermia C. A patient with a fever of 39.4° C (103° F) D. A 90-year-old male taking beta blockers

C

CH 30 EVOLVE VITAL SIGNS Question 14 of 14 A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a slow but regular radial pulse of 44. What is your priority intervention? A. Request that the nursing assistant repeat the pulse check B. Call for a stat electrocardiogram (ECG) C. Assess the patient's apical pulse and evidence of a pulse deficit D. Prepare to administer cardiac-stimulating medications

C

CH 30 EVOLVE VITAL SIGNS Question 5 of 14 A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7° C (101.6° F) (0400), 36.6° C (97.9° F) (0800), 36.9° C (98.4° F) (1200), 37.6° C (99.6° F) (1600), and 38.3° C (100.9° F) (2000). How would you describe this pattern of temperature measurements? A. Usual range of circadian rhythm measurements B. Sustained fever pattern C. Intermittent fever pattern D. Resolving fever pattern

C

CH 30 EVOLVE VITAL SIGNS Question 7 of 14 The nursing assistive personnel (NAP) informs you that the electronic blood pressure machine on the patient who has recently returned from surgery following removal of her gallbladder is flashing a blood pressure of 65/46 and alarming. What is the correct order for care activities? 1. Press the start button of the electronic blood pressure machine to obtain a new reading. 2. Obtain a manual blood pressure with a stethoscope. 3. Check the patient's pulse distal to the blood pressure cuff. 4. Assess the patient's mental status. 5. Remind the patient not to bend her arm with the blood pressure cuff. A. 5, 3, 1, 4, 2 B. 3, 2, 1, 4, 5 C. 4, 1, 3, 2, 5 D. 1, 2, 4, 3, 5 E. 2, 3, 1, 4, 5

C

CH 31 EVOLVE HEALTH ASSESSMENT Question 10 of 14 The nurse is observing the student nurse perform a respiratory assessment on a patient. Which action by the student nurse requires the nurse to intervene? A The student stands at a midline position behind the patient observing for position of the spine and scapula. B The student palpates the thoracic muscles for masses, pulsations, or abnormal movements. C The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds. D The student places the palm of the hand over the intercostal spaces and asks the patient to say "ninety-nine."

C

CH 31 EVOLVE HEALTH ASSESSMENT Question 11 of 14 During assessment of the skin, the nurse assesses a lesion on the arm of the patient. The lesion is irregularly shaped, elevated with edema, and about 3 cm. What type of lesion does the patient have? A Nodule B Macule C Wheal D Pustule

C

CH 31 EVOLVE HEALTH ASSESSMENT Question 9 of 14 The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up? A Auscultation of an apical heart rate of 76 B Absence of bowel sounds on abdominal assessment C Respiratory rate of 8 breaths/min D Palpation of dorsalis pedis pulses with strength of +2

C

After reviewing the results of the wound culture, which type of precautions should the nurse and staff use when caring for this client? A. Standard precautions. B. Droplet precautions. C. Airborne precautions. D. Contact precautions.

D

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Match documentation with the appropriate SOAP category Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device. A Subjective B Objective C Assessment D Plan

D

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Question 13 of 14 A manager is reviewing the nursing documentation entered by a staff nurse in a patient's electronic medical record and finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information? A "Avoid rushing when documenting an entry in the medical record." B "Use correction fluid to remove the entry." C "Draw a single line through the statement and initial it." D Enter only objective and factual information about a patient in the

D

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Question 2 of 14 As the nurse enters a patient's room, the nurse notices that the patient is anxious. The patient quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate way for the nurse to document this observation of the patient? A. "The patient has a defiant attitude and is demanding test results." B. "The patient appears to be upset with the nurse because he wants his test results immediately." C. "The patient is demanding and is complaining about the doctor." D. "The patient stated feelings of frustration from the lack of information received regarding test results."

D

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Question 5 of 14 Which of the following documentation entries is most accurate? A "Patient walked up and down hallway with assistance, tolerated well." B "Patient up, out of bed, walked down hallway and back to room, tolerated well." C "Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk." D "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise."

D

CH 30 EVOLVE VITAL SIGNS Question 11 of 14 A patient has been admitted for a cerebrovascular accident (stroke). She cannot move her right arm, and she has a right-sided facial droop. She is able to eat with her dentures in place and swallow safely. The nursing assistive personnel (NAP) reports to you that the patient will not keep the oral thermometer probe in her mouth. What direction do you provide to the NAP? A. Direct the NAP to hold the thermometer in place with her gloved hand B. Direct the NAP to switch the thermometer probe to the left sublingual pocket C. Direct the NAP to obtain a right tympanic temperature D. Direct the NAP to use a temporal artery thermometer from right to left

D

CH 30 EVOLVE VITAL SIGNS Question 8 of 14 A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 lbs. Her vital signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8° C (98.2° F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy? A. Temperature: 37° C (98.6° F) B. Radial pulse: 112 C. Respiratory rate: 24 D. Oxygen saturation: 96% E. Blood pressure: 134/78

D

CH 31 EVOLVE HEALTH ASSESSMENT Question 14 of 14 The nurse is assessing the cranial nerves. Match the cranial nerve with its related function. V Trigeminal A Lateral movement of the eyeballs B Downward, inward eye movements C Position of the tongue D Motor innervation to the muscles of the jaw E Sensation of the pharynx

D

CH 31 EVOLVE HEALTH ASSESSMENT Question 2 of 14 The nurse is performing an abdominal assessment on a patient. In what order does the nurse perform the steps? 1. Percussion 2. Inspection 3. Auscultation 4. Palpation A 4, 2, 3, 1 B 1, 2, 3, 4 C 3, 2, 4, 1 D 2, 3, 4, 1

D

CH 31 EVOLVE HEALTH ASSESSMENT Question 4 of 14 Which statement made by the patient indicates an understanding about teaching related to early detection of colorectal cancer? A "I'll make sure to schedule my colonoscopy annually after the age of 60." B "I'll make sure to have a computed tomography (CT) colonoscopy every 5 years." C "I'll make sure to have a flexible sigmoidoscopy every year once I turn 55." D "I'll make sure to have a fecal occult blood test annually once I turn 50."

D

In writing a care plan for a newly admitted patient, which outcome statement is written correctly? A . The patient will eat 80% of all meals B. The nursing assistant will set up the client for a bath every day C. The patient will have improved airway clearance by June 5 D. The patient will identify the need to increase dietary intake of fiber by June 5

D

MODULE 19 EXAM Question 17 1 pts A patient with lung cancer received radiation therapy to reduce the size of the tumor before a lobectomy (surgical removal of part of the lung). The patient is now being seen on home health services for packing of an abnormal passage between the patient's chest cavity and an opening on the patient's back. The nurse is aware the patient is at increased risk for: A. Edema. B. Hemorrhage. C. Nerve damage with decreased sensation. D. Fluid and electrolyte imbalance.

D

MODULE 19 EXAM Question 20 1 pts Which of the following may indicate an increased risk for wound dehiscence? A. It is within the first 24 to 48 hours after surgery. B. The patient holds a pillow over the abdomen whenever coughing. C. There is a small amount of serous drainage noted on the dressing. D. There is an increase in serosanguineous drainage from the wound.

D

MODULE 19 WOUND CARE LESSON 3 Question 4 1 pts The nurse is teaching a patient how to empty his Hemovac drain. Which action of the patient indicates that further instruction is needed? The patient: A. opens the plug on the port for emptying the drainage reservoir and drains the contents into the measuring container. B. presses downward until the bottom and top of the Hemovac are in contact to reestablish the vacuum. C. holds the surfaces of the Hemovac together with one hand, cleans the opening and plug with an alcohol swab with the other hand, and immediately replaces the plug. D. empties the Hemovac drain, replaces the plug, and records the amount of drainage.

D

MODULE 19 WOUND CARE LESSON 4 Question 7 1 pts A patient asks the nurse why the Montgomery ties are being used instead of regular tape. What is the nurse's best response? A. "Because Montgomery ties are nonallergenic." B. "Montgomery ties can be tied tighter, providing a more secure dressing and greater support of the wound." C. "Montgomery ties allow the wound to breathe." D. "Montgomery ties avoid frequent removal of tape, which is irritating to the skin during dressing changes."

D

MODULE 6 LESSON 1 Question 3 1 pts The nurse instructed the NAP on how to collect a urine specimen from a patient. Which of the following statements, if made by the NAP, indicates further instruction is needed? A. "I should wear clean gloves while handling the specimen and transport it in a biohazard bag." B. "I should get the specimen to the lab within 20 minutes or put it in the refrigerator." C. "I should ask the patient to state their name and check their patient identification number on their armband." D. "I only need to label the lid of the cup with the patient's name, date, and source of specimen."

D

MODULE 6 LESSON 3 Question 10 1 pts The nurse informs the patient the result of an occult blood test on gastric contents was negative. The patient asks what this means. The nurse's best response is: A. "A moderate amount of blood was "hidden" in the gastric contents." B. "You need to discuss your aspirin consumption with your health care provider." C. "You will need to be fasting so that we may repeat the test." D. "There was only a very small amount or no blood in the gastric secretions."

D

MODULE 6 LESSON 3 Question 6 1 pts Which step would be performed first in the sequence for obtaining a Gastroccult test from an NG tube? A. Apply two drops of commercial developer solution over sample and one drop between positive and negative performance monitors. B. Apply one drop of gastric sample to Gastroccult blood test slide. C. Observe specimen. If red blood or coffee-ground material is noted, report these findings immediately. D. Disconnect nasogastric tube from suction. Aspirate 5 to 10 mL with a catheter tip syringe.

D

MODULE 6 LESSON 3 Question 9 1 pts The nurse aspirates gastric contents and observes a "coffee ground appearance." What priority action should the nurse take? A. Restrict coffee from the patient's diet. B. Ask the patient what he recently consumed. C. Determine if the patient has ever had this before. D. Report the finding to the health care provider.

D

MODULE 6 LESSON 4 Question 6 1 pts The NAP reports that the Hemoccult test was positive. This means that: A. The patient has colon cancer. B. No further testing is required. C. Absence of gastrointestinal bleeding. D. The test result turned blue.

D

MOQuestion 6 1 pts The nurse has delegated the task of obtaining a midstream urine specimen to NAP. Which of the following responsibilities does NOT remain with the nurse who delegated the task? A. Understanding the results and reporting them to the health care provider B. Determining who is capable and knowledgeable to carry out the task with accuracy C. Ensuring the task was completed and performed accurately D. Instructing the patient on the procedure to gain cooperation

D

Question 10 of 14 CH 15 EVOLVE CRITICAL THINKING A nurse enters a 72-year-old patient's home and begins to observe her behaviors and examine her physical condition. The nurse learns that the patient lives alone and notices bruising on the patient's leg. When watching the patient walk, the nurse notes that she has an unsteady gait and leans to one side. The patient admits to having fallen in the past. The nurse identifies the patient as having the nursing diagnosis of Risk for Falls. This scenario is an example of: A. Inference. B. Basic critical thinking. C. Evaluation. D. Diagnostic reasoning.

D

Question 10 of 14 CH 17 EVOLVE NURSING DIAGNOSIS A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of: A. Collaborative data set. B. Diagnostic label. C. Related factors. D. Data cluster.

D

Question 10 of 15 CH 18 EVOLVE PLANNING NURSING CARE A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? A. Patient will be turned every 2 hours within 24 hours. B. Patient will have normal bowel function within 72 hours. C. Patient's skin integrity will remain intact through discharge. D. Erythema of skin will be mild to none within 48 hours.

D

Question 11 of 14 CH 20 EVOLVE - EVALUATION After caring for a young man newly diagnosed with diabetes, a nurse is reviewing what was completed in his plan of care following discharge. She considers how she related to the patient and whether she selected interventions best suited to his educational level. It was the nurse's first time caring for a new patient with diabetes. The nurse's behavior is an example of which of the following? A. Reflection-in-action B. Reassessment C. Reprioritizing D. Reflection-on-action

D

Question 12 of 15 CH 16 EVOLVE NURSING ASSESSMT A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask. 1. "You say you've lost weight. Tell me how much weight you've lost in the last month." 2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 3. "I have no further questions. Thank you for your patience." 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor—correct?" A. 4, 2, 1, 3, 5 B. 2, 4, 3, 1, 5 C. 4, 2, 5, 1, 3 D. 2, 4, 1, 5, 3

D

Question 13 of 14 CH 17 EVOLVE NURSING DIAGNOSIS A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement? A. Identifying the clinical sign instead of an etiology B. Identifying a diagnosis on the basis of prejudicial judgment C. Identifying the diagnostic study rather than a problem caused by the diagnostic study D. Identifying the medical diagnosis instead of the patient's response to the diagnosis.

D

Question 13 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE Which of the following describes a hydrocolloid dressing? A. A seaweed derivative that is highly absorptive B. Premoistened gauze placed over a granulating wound C. A debriding enzyme that is used to remove necrotic tissue D. A dressing that forms a gel that interacts with the wound surface

D

Question 14 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE A nurse collects equipment needed to administer an enema to a patient. Previously the nurse reviewed the procedure in the policy manual. The nurse raises the patient's bed and adjusts the room lighting to illuminate the work area. A patient care technician comes into the room to assist. Which aspect of organizing resources and care delivery did the nurse omit? A. Environment B. Personnel C. Equipment D. Patient

D

Question 2 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE Match the pressure ulcer categories/stages with the correct definition: Full thickness tissue loss, muscle and bone visible. May include undermining. A . Category/Stage I B . Category/Stage II C . Category/Stage III D . Category/Stage IV

D

Question 2 of 5 GLIDDENS CH 24 INFLAMMATION A patient comes to a clinic with a chief complaint of, "My left arm is red and swollen. It hurts badly enough that I couldn't go to work today." The physician orders computer-assisted tomography (CT) scanning of the left upper extremity. The nurse knows the patient understands the reason for the procedure when he states A. "I need to have this done because my arm is broken." B. "The doctor wants me to have this so that the pain will stop." C. "This will tell you what I did to my elbow because I really don't know what happened." D. "This test will help to better determine where the injury actually is and how severe it is."

D

Question 2 of 5 Gliddens 48 The specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice is known as which specialty? A Computer science B Health informatics C Health information technology D Nursing informatics

D

Question 3 of 14 CH 15 EVOLVE CRITICAL THINKING A nurse prepares to insert a Foley catheter. The procedure manual calls for the patient to lie in the dorsal recumbent position. The patient complains of having back pain when lying on her back. Despite this, the nurse positions the patient supine with knees flexed as the manual recommends and begins to insert the catheter. This is an example of: A. Accuracy. B. Reflection. C. Risk taking. D. Basic critical thinking.

D

Question 3 of 14 CH 17 EVOLVE NURSING DIAGNOSIS A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse reviews clusters of data that include the patient's report of frequent awakenings at night, reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the correct PES format? A. Disturbed Sleep Pattern evidenced by frequent awakening B. Disturbed Sleep Pattern related to family caregiving responsibilities C. Disturbed Sleep Pattern related to need to improve sleep habits D. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested

D

Question 3 of 15 CH 18 EVOLVE PLANNING NURSING CAREThe nurse writes an expected outcome statement in measurable terms. An example is: A. Patient will have normal stool evacuation. B. Patient will have fewer bowel movements. C. Patient will take stool softener every 4 hours. D. Patient will report stool soft and formed with each defecation.

D

Question 3 of 5 GLIDDENS CH 24 INFLAMMATION Which of the following patients is at higher risk for inflammatory reactions? A. 2-year-old girl with a healthy diet B. 38-year-old man who is obese C. 54-year-old woman in menopause D. 79-year-old man with diabetes

D

Question 4/ 6 GLIDDENS 10 THERMOREGULATIONThe nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates A increased respirations. B rapid pulse rate. C red, sweaty skin. D slow capillary refill.

D

Question 5 of 15 CH 16 EVOLVE NURSING ASSESSMT A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then asks the patient, "How do you see yourself now?" On the basis of Gordon's functional health patterns, which pattern does the nurse assess? A. Health perception-health management pattern B. Value-belief pattern C. Cognitive-perceptual pattern D. Self-perception-self-concept pattern

D

Question 5 of 15 CH 18 EVOLVE PLANNING NURSING CARE An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. Goals Outcomes Patient will achieve pain relief by discharge A. Patient walks 20 feet using a walker in 24 hours B. Patient identifies barriers to remove in the home within 1 week C. Patient increases calorie intake to 2500 daily D. Patient expresses fewer nonverbal signs of discomfort within 24 hrs.

D

Question 7 of 15 CH 18 EVOLVE PLANNING NURSING CARE A nursing student is reporting during hand-off to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 ½ NS. Which intervention is a dependent intervention? A. Reporting hand-off at change of shift B. Ambulating patient down hallway C. Sleep hygiene D. IV fluid administration

D

Question 8 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? A Necrotic tissue B. Wound drainage C. Wound circumference D. Cleansed wound

D

Question 9 of 14 CH 15 EVOLVE CRITICAL THINKING Match the concepts for a critical thinker on the right with the application of the term on the left. Be tolerant of the patient's views and beliefs A. Systematicity B. Truth seeking C. Analyticity D. Open-mindedness

D

UNIT 5 POWER POINT QUESTION A patient complains of thirst and headache and also appears emaciated. Upon initial examination you find that the skin does not return to normal shape. What does this finding indicate? A. Pallor B. Edema C. Erythema D. Poor skin turgor

D

UNIT 5 POWER POINT QUESTION The nurse is preparing to assess the neurologic status of an adult patient who had a hip fracture 5 days ago and was reported to have been confused the previous shift. Which statement will provide will provide the nurse with the most appropriate information? A. Can you tell me today's date? B. Do you know that you are in the hospital? C. When did you have hip surgery? D. Can you tell me where you are right now?

D

UNIT 7 Power Point MC The following nursing diagnosis is found on the patient's record: Hip fracture r/t fall. In evaluating the written diagnosis, the nurse correctly concludes that the diagnosis: A is written appropriately B needs a modifier after the r/t statement C needs a modifier in the first part of the statement D is written inappropriately

D

UNIT 7 Power Point MC The nurse admits an elderly patient with the medical diagnosis of dehydration. In developing the nursing diagnoses, it is most important for the nurse to: A establish nursing diagnoses that are based on the medical diagnoses B forms on nursing diagnoses that affect fluid balance C gather data to support actual nursing diagnoses D include actual and risk for diagnoses

D

UNIT 7 Power Point MC The nursing process organizes your approach while delivering nursing care. To provide the best professional care to patients, nurses need to incorporate the nursing process and: A Decision making B Problem solving C Intellectual standards D Critical thinking

D

UNIT 8 POWER POINT QUESTION The assessment of a patient's wound indicates healing is occurring when: A . the center tissue is white B . bleeding has stopped C . there is no drainage from the wound D . pink granulation tissue is viable

D

UNIT 8 POWER POINT QUESTION Which method is correct when caring for a patient with an order for wet-to-dry dressing changes? A . Place dry gauze into the wound and remove it when it's wet B . Medicate the patient for pain after you change the dressing C . Complete this type of dressing change just once a day D . Place moist gauze into the wound and remove it when it's dry

D

UNIT 8 POWER POINT QUESTION Which nursing documentation is the most complete in its description of a wound? A . Wound appears to be healing well, dressing dry and intact B . Wound well approximated with minimal drainage C . Drainage size of quarter; wound pink; 4 x 4 applied D . Incisional edges approximated without erythema or exudate; two 4 x 4s applied

D

CH 31 EVOLVE HEALTH ASSESSMENT Question 14 of 14 The nurse is assessing the cranial nerves. Match the cranial nerve with its related function. X Vagus A Lateral movement of the eyeballs B Downward, inward eye movements C Position of the tongue D Motor innervation to the muscles of the jaw E Sensation of the pharynx

E

MODULE 16 EXAM SPECIMEN COLLECTION Question 6 1 pts Which of the following statements, if made by the patient regarding a midstream (clean-voided) urine specimen, indicate that further teaching is required? (Select all that apply.) A. Male patient: "I will clean myself by using the antiseptic towelette, starting at the center going outward in a circular motion." B. Female patient: "I will clean myself by using the cotton balls and antiseptic solution. I will cleanse moving from front to back using a fresh swab each time, repeating motion 3 times." C. "I should first start urinating into the toilet, then use the sterile specimen cup to collect about 3 to 4 ounces of urine, and finish urinating into the toilet." D. "I should avoid touching the inside of the specimen cup or lid." E. "I should wash myself with soap and water, and urinate into the specimen cup." F. "I should urinate 30 to 60 mL into a cup and then finish urinating in the toilet."

E F

CH 30 EVOLVE VITAL SIGNS Question 3 of 14 A 55-year-old female patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. Which sites do you instruct the nursing assistant to use for obtaining the patient's blood pressure and temperature? A. Right antecubital and tympanic membrane B. Right popliteal and rectal C. Left antecubital and oral D. Left popliteal and temporal artery

A

Ch 24 Evolve Communication 10. A nurse has been gathering physical assessment data on a patient and is now listening to the patient's concerns. The nurse sets a goal of care that incorporates the patient's desire to make treatment decisions. This is an example of the nurse engaged in which phase of the nurse-patient relationship? A. Working phase B. Preinteraction phase C. Termination phase D. Orientation phase

A

Ch 24 Evolve Communication 3. A new nurse complains to her preceptor that she has no time for therapeutic communication with her patients. Which of the following is the best strategy to help the nurse find more time for this communication? A. Include communication while performing tasks such as changing dressings and checking vital signs. B. Ask the patient if you can talk during the last few minutes of visiting hours. C. Ask Pastoral care to come back a little later in the day. D. Remind the nurse to complete all her tasks and then set up remaining time for communication.

A

MODULE 19 WOUND CARE LESSON 4 Question 9 1 pts Which of the following is a correct sequence for changing a gauze dressing? A. Remove old dressing, discard gloves and perform hand hygiene, create sterile field, apply sterile gloves, clean wound, blot dry, apply new dressing. B. Remove old dressing, discard gloves, apply new gloves, and apply new dressing. C. Remove old dressing, discard gloves, clean wound, apply loose woven gauze, and cover with thicker woven pad (e.g., ABD pad). D. Create sterile field, remove old dressing, discard gloves and perform hand hygiene, apply new gloves, clean wound, blot dry, apply new dressing.

A

Question 1 of 14 CH 15 EVOLVE CRITICAL THINKING Place the steps of the scientific method in their correct order with number 1 being the first step of the process. 1. Formulate a question or hypothesis. 2. Evaluate results of the study. 3. Collect data. 4. Identify the problem. 5. Test the question or hypothesis. A. 4, 3, 1, 5, 2 B. 3, 4, 1, 2, 5 C. 4, 3, 2, 1, 5 D. 3, 4, 1, 5, 2

A

Question 1 of 6 GLIDDENS 10 THERMOREGULATION A patient with hypothermia is brought to the emergency department. The nurse should explain which most likely treatment to the family members? A Core rewarming with warm fluids B Ambulation to increase metabolism C Frequent oral temperature assessment D Gastric tube feedings to increase fluids

A

Question 11 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following? A. Physical care technique B. Activity of daily living C. Indirect care measure D. Lifesaving measure

A

Question 11 of 15 CH 18 EVOLVE PLANNING NURSING CARE A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid remaining in the intravenous (IV) line, and the patient asking questions about whether his doctor is coming. Which of the following does the nurse perform first? A. Reconnect the drainage tubing B. Inspect the condition of the IV dressing C. Obtain the next IV fluid bag from the medication room D. Explain when the health care provider is likely to visit

A

Question 12 of 14 CH 15 EVOLVE CRITICAL THINKING A nurse is preparing medications for a patient. The nurse checks the name of the medication on the label with the name of the medication on the doctor's order. At the bedside the nurse checks the patient's name against the medication order as well. The nurse is following which critical thinking attitude: A. Responsible B. Complete C. Accurate D. Broad

A

Question 12 of 14 CH 20 EVOLVE - EVALUATION A nurse has been caring for a patient over 2 consecutive days. During that time the patient has had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks if the patient feels tenderness when the site is palpated. This is an example of which indicator reflecting the nurse's ability to perform evaluation: A. Examining results of clinical data B. Comparing achieved effects with outcomes C. Recognizing error D. Self-reflection

A

Question 4 of 5 Gliddens 48 Which are consequences for a staff nurse related to the use of health informatics? A Clinical decision support tools B Confidentiality of health data C Decreased cost of health care D Personal health record

A

Question 8 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE Which measures does a nurse follow when being asked to perform an unfamiliar procedure? Select all that apply. A. Checks scientific literature or policy and procedure B. Reassesses the patient's condition C. Collects all necessary equipment D. Delegates the procedure to a more experienced nurse E. Considers all possible consequences of the procedure

A B C E

Question 11 of 14 CH 15 EVOLVE CRITICAL THINKING In which of the following examples is a nurse applying critical thinking skills in practice? Select all that apply. A. The nurse thinks back about a personal experience before administering a medication subcutaneously. B. The nurse uses a pain-rating scale to measure a patient's pain. C. The nurse explains a procedure step by step for giving an enema to a patient care technician. D. The nurse gathers data on a patient with a mobility limitation to identify a nursing diagnosis. E. A nurse offers support to a colleague who has witnessed a stressful event.

A B D

Question 12 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE A nurse is conferring with another nurse about the care of a patient with a stage II pressure ulcer. The two decide to review the clinical practice guideline of the hospital for pressure ulcer management. The use of a standardized guideline achieves which of the following? Select all that apply. A. Makes it quicker and easier for nurses to intervene B. Sets a level of clinical excellence for practice C. Eliminates need to create an individualized care plan for the patient D. Delivers evidence-based interventions for stage II pressure ulcer E. Summarizes the various approaches used for the practice concern or problem

A B D

Question 3 of 15 CH 16 EVOLVE NURSING ASSESSMT The nurse enters the room of an 82-year-old patient for whom she has not cared previously. The nurse notices that the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult? Select all that apply. A. Listen attentively to the patient's story. B. Use gestures that reinforce your questions or comments. C. Stand back away from the bedside. D. Maintain direct eye contact. Ask questions quickly to reduce the patient's fatigue.

A B D

MODULE 6 LESSON 4 Question 4 1 pts The nurse wants to assess the patient for factors which may place the patient at risk for gastrointestinal bleeding. Which of the following would increase the patient's potential for having a positive Hemoccult test? (Select all that apply.) A. Anticoagulants (heparin, warfarin sodium) B. Long-term use of steroids C. A recent blood transfusion D. Long term use of nonsteroidal anti-inflammatory drugs (NSAIDs) E. Antidiabetic agents (oral hypoglycemics) F. Acetylsalicylic acid (aspirin)

A B D F

MODULE 19 EXAM Question 22 1 pts The nurse is caring for a patient with a Jackson-Pratt drain. Which of the following indicates correct understanding? (Select all that apply.) A. The nurse instructs the NAP to measure the drainage and record on the intake & output form every 8 to 12 hours and as needed for large drainage volume. B. The nurse expects the Jackson-Pratt drain to be used when there is a large amount of drainage (500 mL). C. The nurse ensures the drainage device appears deflated after it is emptied. D. The nurse pins the Jackson-Pratt drain above the wound. E. The nurse instructs the NAP to determine and report what type of drainage is present in the Jackson-Pratt drain.

A C

Question 11 of 14 CH 17 EVOLVE NURSING DIAGNOSIS Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. Select all that apply. A. Impaired Skin Integrity related to physical immobility B. Fatigue related to heart disease C. Nausea related to gastric distention D. Need for improved Oral Mucosa Integrity related to inflamed mucosa E. Risk for Infection related to surgery

A C

Question 2 of 14 CH 17 EVOLVE NURSING DIAGNOSIS A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: Select all that apply. A. Data collection. B. Data clustering. C. Data interpretation. D. Making a diagnostic statement. E. Goal setting.

A C

MODULE 19 EXAM Question 1 1 pts Which of the following is an example of healing by secondary intention? (Select all that apply.) A. A full-thickness pressure injury. B. A surgical incision. C. A dog bite. D. A burn. E. A skin tear.

A C D

MODULE 19 WOUND CARE LESSON 4 Question 1 1 pts Which of the following are functions of dressings? (Select all that apply.) A. To promote hemostasis. B. To keep the wound bed dry. C. Wound debridement. D. To prevent contamination. E. To increase circulation.

A C D

Question 6 of 15 CH 18 EVOLVE PLANNING NURSING CARE A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? Select all that apply. A. Assess condition of skin before making the call B. Rely on the nurse specialist to know the type of surgery the patient likely had C. Explain the patient's response emotionally to the repeated leaking of stool D. Describe the type of bag being used and how long it lasts before leaking E. Order extra colostomy bags currently being used

A C D

Question 14 of 14. CH 17 EVOLVE NURSING DIAGNOSIS A nurse is getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse's cultural competence in making an accurate diagnosis? Select all that apply. A. How is your diabetic diet affecting you and your family? B. You seem to not want to follow health guidelines. Can you explain why? C. What worries you the most about having diabetes? D. What do you expect from us when you do not take your insulin as instructed? E. What do you believe will help you control your blood sugar?

A C E

MODULE 19 WOUND CARE LESSON 4 Question 2 1 pts Which of the following patients would be expected to benefit from a damp-to-dry dressing? (Select all that apply.) A. A 24-year-old patient with an open and infected wound from a spider bite. B. A 7-year-old with abrasions on the knees. C. A 50-year-old with a postoperative knee-replacement incision. D. A 30-year-old after large cyst removal with necrotic tissue present in crater-type wound. E. A 19-year-old with a superficial laceration on the arm.

A D

Question 7 of 14 CH 20 EVOLVE - EVALUATION A nurse checks an intravenous (IV) solution container for clarity of the solution, noting that it is infusing into the patient's left arm. The IV solution of 9% NS is infusing freely at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site was changed as scheduled per standard of care. While in the room the nurse inspects the condition of the dressing and notes the date on the dressing label. In which ways did the nurse evaluate the condition of the IV site? Select all that apply. A. Checked the IV infusion rate B. Checked the type of IV solution C. Confirmed from nurses' notes the time of dressing change D. Inspected the condition of the IV dressing at the site E. Checked clarity of IV solution

A D

Question 11 of 15 CH 16 EVOLVE NURSING ASSESSMT A nurse gathers the following assessment data. Which of the following cues together form(s) a pattern suggesting a problem? Select all that apply. A. The skin around the wound is tender to touch. B. Fluid intake for 8 hours is 800 mL. C. Patient has a heart rate of 78 beats/min and regular. D. Patient has drainage from surgical wound. E. Body temperature is 38.3° C (101° F). F. Patient states, "I'm worried that I won't be able to return to work when I planned."

A D E

Question 14 of 15 CH 18 EVOLVE PLANNING NURSING CARE It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the patient and then begins to discuss the patient's plan of care to the day nurse using the standard checklist for reporting essential information. The patient has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off? Select all that apply. A. Using a standardized checklist for essential information B. Asking the wife to briefly leave the room C. Completing the hand-off without inviting questions D. Doing prework such as checking laboratory results before giving a report E. Including the wife in the hand-off discussion

A D E

Question 3 of 5 Gliddens 40 An interpretivist nurse is caring for a patient in the hospital setting. Which of the following factors will the interpretivist consider when caring for this patient? Select all that apply. A Context of care B The information from the chart C What the nurse personally brings to the caring encounter D Information from significant others and friends E The nurse's previous experiences, values, and emotions

A D E

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Match documentation with the appropriate SOAP category "The pain increases every time I try to turn on my left side." A Subjective B Objective C Assessment D Plan

A

MODULE 6 LESSON 2 Question 8 1 pts How much urine is needed to perform a urine culture? A. At least 3 mL B. At least 20 mL C. At least 1 mL D. 90 to 120 mL

A

Nurse-initiated interventions are: A. determined by state Nurse Practice Acts B. supervised by the entire health care team C. made in concert with the plan of care initiated by the physician D. developed after interventions for the recent medical diagnoses are evaluated.

A

Question 5 of 5 Gliddens 48 When discussing the purposes of nursing health care informatics with a nurse during orientation, a nurse educator would be concerned if the nurse orientee stated that which is a primary purpose of informatics? A Develop a data management system. B Improve disease tracking. C Improve a health provider's work flow. D Increase administrative efficiencies.

A

A patient is admitted to the hospital with shortness of breath. As the nurse assesses this patient, the nurse is using the process of: A . Evaluation B. Data collection C. Problem identification D. Testing hypotheses

B

Question 6 of 15 CH 16 EVOLVE NURSING ASSESSMT Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care? A. Probing B. Open-ended C. Problem-oriented D. Confirmation

B

CH 30 EVOLVE VITAL SIGNS Question 1 of 14 The nurse observes a nursing student taking a blood pressure (BP) on a patient. The nurse notes that the student very slowly deflates the cuff in an attempt to hear the sounds. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. Which of the following BP readings made by the student is most likely caused by an incorrect technique? A. 96/40 mm Hg B. 110/66 mm Hg C. 130/90 mm Hg D. 156/82 mm Hg

C

CH 31 EVOLVE HEALTH ASSESSMENT Question 14 of 14 The nurse is assessing the cranial nerves. Match the cranial nerve with its related function. XII Hypoglossal A Lateral movement of the eyeballs B Downward, inward eye movements C Position of the tongue D Motor innervation to the muscles of the jaw E Sensation of the pharynx

C

CH 31 EVOLVE HEALTH ASSESSMENT Question 7 of 14 How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast? A Supine with both arms overhead with palms upward B Sitting with hands clasped just above the umbilicus C Supine with the right arm abducted and hand under the head and neck D Lying on the right side, adducting the right arm on the side of the body

C

CH 31 EVOLVE HEALTH ASSESSMENT Question 8 of 14 The nurse plans to assess the patient's memory. Which task should the nurse ask the patient to perform? A "Tell me where you are." B "What can you tell me about your illness?" C "Repeat these numbers back to me: 7...5...8." D "What does this mean: 'A stitch in time saves nine?'"

C

MODULE 19 EXAM Question 8 1 pts How is the vacuum re-established after emptying a drain such as a Jackson-Pratt drain or Hemovac? A. By turning the suction on. B. By keeping the drain lower than the insertion site. C. By compressing the drain reservoir. D. By "milking" the tubing.

C

MODULE 19 WOUND CARE LESSON 3 Question 2 1 pts A patient is to go home with a Jackson-Pratt drain. Which of the following statements, if made by the patient, indicates further teaching is required? A. "I should empty the drain when it is one-half to two-thirds full." B. "I should keep a record of how much drainage I empty." C. "If drainage suddenly stops, it means the drain is ready to be removed." D. "The bulb of the drain should remain compressed."

C

MODULE 19 WOUND CARE LESSON 3 Question 6 1 pts Which of the following is inappropriate to delegate to nursing assistive personnel (NAP)? A. Emptying a closed drainage container. B. Measuring the amount of drainage. C. Assessment of wound drainage. D. Reporting the amount on the patient's intake and output record.

C

MODULE 6 LESSON 1 Question 4 1 pts A patient had blood drawn for coagulation studies. The result is critically high. What action should take place at this time? A. The laboratory technician should notify the health care provider of the result. B. The nurse should notify the health care provider whenever they arrive on the unit. C. The nurse should call the health care provider with the result. D. The laboratory technician should repeat the test for verification.

C

The nursing process organizes your approach while delivering nursing care. To provide the best professional care to patients, nurses need to incorporate the nursing process and: A. Decision making B. Problem solving C. Intellectual standards D. Critical thinking

D

...draining a large amount of thick yellow-tan fluid with an unpleasant odor. Which documentation best describes the drainage from Alexander's wound? A. Infectious. B. Purulent. C. Serous. D. Sanguineous.

B

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Match documentation with the appropriate SOAP category Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation. A Subjective B Objective C Assessment D Plan

B

MODULE 19 WOUND CARE LESSON 4 Question 6 1 pts A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient? A. "If you are having difficulty with your dressing changes, we can see if the doctor will give you a referral to a home care agency." B. "Make sure that you have a margin of 1 to 1.5 inches (2.5 to 3.75 cm) around the wound, and that the skin is thoroughly dry before applying the dressing." C. "This type of dressing requires frequent changing because they do not stay in place." D. "You probably are applying it incorrectly, or perhaps you are just too anxious about having to perform the dressing change." E. "There are many options on the market. Why don't you try to use a non-adhesive-backed transparent dressing instead?"

B

Question 2 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE Match the pressure ulcer categories/stages with the correct definition: Partial thickness skin loss or intact blister with serosanginous fluid. A . Category/Stage I B . Category/Stage II C . Category/Stage III D . Category/Stage IV

B

Question 5 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE Match the category of direct care on the left with the specific direct care activity on the right. Protecting a violent patient from injury A. Counseling B. Lifesaving measure C. Physical care technique D. Activity of daily living

B

Ch 24 Evolve Communication 15. The nurse uses silence as a therapeutic communication technique. What is the purpose of the nurse's silence? (Select all that apply.) A. Prevent the nurse from saying the wrong thing B. Prompt the patient to talk when he or she is ready C. Allow the patient time to think and gain insight D. Allow time for the patient to drift off to sleep E. Determine if the patient would prefer to talk with another staff member

B C

Question 1 of 15 CH 18 EVOLVE PLANNING NURSING CARE A patient has the nursing diagnosis of Nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? Select all that apply. A. Providing mouth care every 4 hours B. Maintaining intravenous (IV) infusion at 100 mL/hr C. Administering prochlorperazine (Compazine) via rectal suppository D. Consulting with dietitian on initial foods to offer patient E. Controlling aversive odors or unpleasant visual stimulation that triggers nausea

B D

Question 7 of 14 CH 17 EVOLVE NURSING DIAGNOSIS Which of the following nursing diagnoses is stated correctly? Select all that apply. A. Fluid Volume Excess related to heart failure B. Sleep Deprivation related to sustained noisy environment C. Impaired Bed Mobility related to postcardiac catheterization D. Ineffective Protection related to inadequate nutrition E. Diarrhea related to frequent, small, watery stools.

B D

MODULE 16 EXAM SPECIMEN COLLECTION Question 1 1 pts Which of the following can be delegated to NAP? (Select all that apply.) A. Obtaining a wound culture B. Obtaining a midstream urine specimen C. Performing a Gastroccult test on a patient with an NG tube D. Performing a Hemoccult test on stool E. Performing a blood glucose measurement

B D E

CH 26 EVOLVE DOCUMENTATION & INFORMATICS Question 6 of 14 A preceptor observes a new graduate nurse discussing changes in a patient's condition with a physician over the phone. The new graduate nurse accepts telephone orders for a new medication and for some laboratory tests from the physician at the end of the conversation. During the conversation the new graduate writes the orders down on a piece of paper to enter them into the electronic medical record when a computer terminal is available. At this hospital new medication orders entered into the electronic medical record can be viewed immediately by hospital pharmacists, and hospital policy states that all new medications must be reviewed by a pharmacist before being administered to patients. Which of the following actions requires the preceptor to intervene? The new nurse: A Reads the orders back to the health care provider to verify accuracy of transcribing the orders after receiving them over the phone. B Documents the date and time of the phone conversation, the name of the physician, and the topics discussed in the electronic record. C Gives a newly ordered medication before entering the order in the patient's medical record. D Asks the preceptor to listen in on the phone conversation.

C

CH 30 EVOLVE VITAL SIGNS Question 6 of 14 As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. What is the best response? A. Nail polish attracts microorganisms and contaminates the finger sensor. B. Nail polish increases oxygen saturation. C. Nail polish interferes with sensor function. D. Nail polish creates excessive heat in sensor probe.

C

MODULE 16 EXAM SPECIMEN COLLECTION Question 10 1 pts The patient has been instructed on how to collect a midstream urine specimen. Thirty minutes later the NAP reports the patient is unable to produce a urine specimen. What would be the best action at this time? A. Catheterize the patient to obtain the urine specimen. B. Notify the health care provider. C. Encourage the patient to drink fluids and allow more time. D. Obtain a bladder scanner and scan the patient.

C

MODULE 16 EXAM SPECIMEN COLLECTION Question 7 1 pts Which of the following statements, if made by the nurse regarding obtaining a wound drainage specimen for culture, indicates that further instruction is needed? A. "I should explain to the patient the purpose of the test." B. "I should clean the wound of exudate and obtain the culture from fresh wound drainage." C. "After obtaining the culture, I should get the specimen to the lab within 1 hour." D. "Purulent drainage is an indication of infection."

C

MODULE 19 EXAM Question 19 1 pts The nurse is performing a dressing change on a patient who is postoperative from a laparotomy. The patient coughs and the nurse sees a few loops of intestine uncoiling from the wound. What is the nurse's best action at this time? A. Apply sterile gloves and push the intestines back into the wound. B. Instruct the patient to avoid looking at the wound. C. Apply sterile saline-soaked towels to the area. D. Assess the wound to determine the extent of evisceration.

C

Question 1 of 5 Gliddens 48 To address a goal of improving the health of populations, a nurse is most likely to use informatics in which domain? A Certified clinical information systems B Clinical health care informatics C Public health/population informatics D Translocational bioinformatics

C

Question 4 of 15 CH 18 EVOLVE PLANNING NURSING CARE A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The patient says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first? A Giving the enema on time B. Talking with the patient about her past experiences with illness C. Talking with the patient about her concerns and acknowledging her sense of unfairness D. Beginning instruction on postoperative procedures

C

Question 4 of 5 GLIDDENS CH 24 INFLAMMATION The nurse is reviewing the erythrocyte sedimentation rate (ESR) of a patient to determine which significant finding? A. Determines specific causes of inflammation B. Identifies the location of inflammation within the body C. Confirms the nonspecific presence of inflammation D. Indicates a diagnosis of systemic lupus

C

UNIT 8 POWER POINT QUESTION Which description best defines serous drainage? A . Fresh bleeding B. Thick and yellow C . Clear watery plasma D. Brown and foul smelling

C

module 19 wound care lesson 1 Question 9 1 pts A postoperative diabetic patient had an exploratory laparotomy (incision in the abdomen) 5 days ago. The patient's history indicates obesity with a body mass index (BMI) of 32 and smoking 1 pack/day. Based on this information, the nurse understands the patient should be observed for: A. Developing a blood clot. B. Developing a fistula. C. Wound dehiscence. D. Hemorrhage.

C

MODULE 19 EXAM Question 21 1 pts Which of the following patients is at greatest risk for developing a wound infection? A. A diabetic obese patient who smokes. B. An adolescent who takes steroids for asthma. C. An alcoholic. D. An elderly patient.

A

Question 1 of 15. CH 16 EVOLVE NURSING ASSESSMT A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing: A. Patient's level of function. B. Patient's willingness to perform self-care. C. Patient's level of consciousness. D. Patient's health management values.

A

Question 9 of 14 CH 15 EVOLVE CRITICAL THINKING Match the concepts for a critical thinker on the right with the application of the term on the left. Organize assessment on the basis of patient priorities. A. Systematicity B. Truth seeking C. Analyticity D. Open-mindedness

A

In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform? Select all that apply A. Apply light pressure to the area with the fingertips. B. Measure the diameter of the redness. C. Obtain a wound culture. D. Gently lift a fold of skin. E. Observe for wound approximation.

A B

Question 9 of 15 CH 18 EVOLVE PLANNING NURSING CARE Which of the following factors does a nurse consider for a patient with the nursing diagnosis of Disturbed Sleep Pattern related to noisy home environment in choosing an intervention for enhancing the patient's sleep? Select all that apply. A. The intervention should be directed at reducing noise. B. The intervention should be one shown to be effective in promoting sleep on the basis of research. C. The intervention should be one commonly used by the patient's sleep partner. D. The intervention should be one acceptable to the patient. E. The intervention should be one you used with other patients in the past.

A B D

CH 30 EVOLVE VITAL SIGNS Question 12 of 14 A healthy adult patient tells the nurse that he obtained his blood pressure in "one of those quick machines in the mall" and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/92? A. Cuff too small B. Arm positioned above heart level C. Slow inflation of the cuff by the machine D. Patient did not remove his long-sleeved shirt E. Insufficient time between measurements

A E

MODULE 6 LESSON 6 Question 2 1 pts The student nurse has attempted to obtain a patient's blood glucose measurement but is unable to obtain a drop of blood from the patient. What could be a possible explanation for this difficulty? (Select all that apply.) A. The student nurse did not remove the protective cover on the tip of the lancet. B. The student nurse took too long preparing the lancet device prior to puncture. C. The tip of the lancet device was held firmly against the skin of the chosen test site. D. The student nurse did not massage the skin or milk the finger prior to releasing the lancet device. E. The lancet device was not adjusted to a depth of insertion that could penetrate the patient's skin.

A E

UNIT 5 POWER POINT QUESTION A patient is admitted with pneumonia. The nurse auscultates the patient's chest and hears low-pitched, continuous sounds over the bronchi. What type of sound is the nurse hearing? A. Crackles B. Rhonchi C. Wheezes D. Pleural rub

B

UNIT 6 POWER POINT QUESTION A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of: A. PIE documentation. B. SOAP documentation. C. narrative charting. D. charting by exception.

C

UNIT 7 Power Point MC Your patient has met the expected outcomes to achieve the goal for improvement of ambulatory status. You would now: A Modify the care plan B Discontinue the care plan C Create a new nursing diagnosis that states goals have been met D Evaluate the implementation step of the nursing process

C

Question 14 of 14 CH 15 EVOLVE CRITICAL THINKING A nurse has seen many cancer patients struggle with pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping patients focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of: A. Creativity. B. Fairness. C. Clinical reasoning. D. Applying ethical criteria.

D

Question 3 of 6 GLIDDENS 10 THERMOREGULATION The nurse identifies which priority nursing invention for a patient with hyperthermia? A Initiating seizure precautions B Limiting oral intake C Providing a blanket D Removing excess clothing

D

Which irrigation technique is best? A. Pour the saline directly onto the wound from the bottle. B. Moisten a sterile gauze pad and pat the gauze over the wound. C. Irrigate as gently as possible using a 60-ml bulb syringe. D. Apply steady pressure using a 35 mL syringe and 19 gauge needle.

D

Ch 24 Evolve Communication 12. A nursing student is reviewing a process recording with the instructor. The student engaged the patient in a discussion about availability of family members to provide support at home once the patient is discharged. The student reviews with the instructor whether the comments used encouraged openness and allowed the patient to "tell his story." This is an example of which step of the nursing process? A. Planning B. Assessment C. Intervention D. Evaluation

D

Ch 24 Evolve Communication 8. A nurse is assigned to care for a patient for the first time and states, "I don't know a lot about your culture and want to learn how to better meet your health care needs." Which therapeutic communication technique did the nurse use in this situation? A. Validation B. Empathy C. Sarcasm D. Humility

D

MODULE 19 EXAM Question 10 1 pts A patient is to have frequent dressing changes. What should the nurse use to secure the dressing? A. Hypoallergenic tape. B. Paper tape. C. Adhesive tape. D. Montgomery ties.

D

Question 15 of 15 CH 16 EVOLVE NURSING ASSESSMT A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe? A. Review of systems approach A. Use of a structured database format C. Back channeling D. A problem-oriented approach

D

Question 5 of 14 CH 19 EVOLVE IMPLEMENTING NURSING CARE Match the category of direct care on the left with the specific direct care activity on the right. Assisting patient with oral care A. Counseling B. Lifesaving measure C. Physical care technique D. Activity of daily living

D

Question 6 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? A. A local skin infection requiring antibiotics B. Sensitive skin that requires special bed linen C. A stage III pressure ulcer needing the appropriate dressing D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

D

Question 9 of 15 CH 16 EVOLVE NURSING ASSESSMT A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? A. Value-belief pattern B. Cognitive-perceptual pattern C. Coping-stress-tolerance pattern D. Health perception-health management pattern

D

The following nursing diagnosis is found on the patient's record: Hip fracture r/t fall. In evaluating the written diagnosis, the nurse correctly concludes that the diagnosis: A. is written appropriately B. needs a modifier after the r/t statement C. needs a modifier in the first part of the statement D. is written innappropriately

D

The nurse admits an elderly patient with the medical diagnosis of dehydration. In developing the nursing diagnoses, it is most important for the nurse to: A. establish nursing diagnoses that are based on the medical diagnosis B. focus on nursing diagnoses that affect fluid balance C . gather data to support actual nursing diagnoses D. include actual and risk for diagnoses

D

The nurse prepares a written positioning schedule and places it in Alexander's room as a reminder for the unlicensed assistive personnel (UAP) assigned to help with Alexander's care. The charge nurse removes the schedule and states that it violates Alexander's privacy. What action should the nurse take? A. Provide verbal instructions about positioning to the UAP and document the instructions in the nurse's notes. B. Ask the charge nurse to assist with verbal communication to all of the staff involved in Alexander's care to ensure continuity of care. C. Advise the charge nurse that client confidentiality is secondary to continuity of care. D. Assure the charge nurse that written instructions in the client's room are effective and do not violate any client rights.

D

The sacral area has remained red for 2 hours and does not blanch when tested. Which is the best description for the nurse to document? A Excessive pallor. B. Unusual skin mottling. C. Dependent sacral rubor. D. Reactive hyperemia.

D

UNIT 6 POWER POINT QUESTION A patient that you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to: A exchange information among health care members B provide information about patients from one unit to another unit C ensure proper care for the patient D aid in the hospital's quality improvement program

D

UNIT 6 POWER POINT QUESTION You are invited to attend the weekly unit patient care conference. The staff discusses patient care issues. This type of communication is: A public B interpersonal C transpersonal D small group

D

UNIT 7 Power Point MC In writing a care plan for a newly admitted patient, which outcome statement is written correctly? A The patient will eat 80% of all meals B The nursing assistant will set up the client for a bath every day C The patient will have improved airway clearance by June 5 D The patient will identify the need to increase dietary intake of fiber by June 5

D

UNIT 8 POWER POINT QUESTION Which statement is correct in regard to the use of an abdominal binder? A . It replaces the need for underlying dressings B . It should be kept loose for patient comfort C . The patent should be sitting or standing when it is applied D. The patient must have adequate ventilatory capacity

D

What action should the nurse implement? A. Apply heat to reduce the inflammation that has occurred at these sites. B. Notify the healthcare provider (HCP) that the client is retaining excess fluid. C. Reassure the client that no pressure damage is present at these sites. D. Identify these areas as sites where pressure damage has occurred.

D

module 19 wound care lesson 1 Question 6 1 pts The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient's knee appears red and is very warm to the touch. The patient requests pain medication. Which of the following would be a correct explanation of what the nurse has assessed? A. These are expected findings for this postoperative period. B. The patient is becoming dependent on pain medication. C. The nurse should observe the patient more closely for wound dehiscence. D. The patient is demonstrating signs of a postoperative wound infection.

D

MODULE 16 EXAM SPECIMEN COLLECTION Question 9 1 pts The nurse is performing a Gastroccult test on nasogastric tube aspirate. Which of the following would be a "normal" finding of gastric contents? (Select all that apply.) A. pH of 3 B. Gastroccult positive C. pH of 5 D. Greenish color E. Brown "coffee-ground" appearance F. Gastroccult negative

A D F

Question 9 of 14 EVOLVE CH 48 SKIN INTEGRITY AND WOUND CARE Which skin care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? Select all that apply. A. Frequent position changes. B. Keeping the buttocks exposed to air at all times C. Using a large absorbent diaper, changing when saturated D. Using an incontinence cleaner E. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel F. Applying a moisture barrier ointment

A D F