Adult 1 Final

Which class of nutrients is the body's primary source of energy?

Carbohydrates

A patient with heart failure has BP 120/60 HR 64 R 18 T 97.6 coarse crackles bilaterally and 3 edemas toe the lower extremities': Diagnosis:

excess fluid volume

31. Which client does the nurse recognize as being at greatest risk for pressure ulcers Infant with skin excoriations in the diaper region Young adult with diabetes in skeletal traction Middle-aged adult with quadriplegia Older adult requiring use of assistive device for ambulation

3) Middle-aged adult with quadriplegia

7. The ability of nurses to base their practice on professional standards of ethical conduct and to participate in ethical decision making is known as which of the following? Ethical agency Attitudes Belief Value neutrality

1) Ethical agency

7. What is the primary goal that the nurse should establish for a patient with an open wound? The wound will remain free of infection throughout the healing process. Client completes antibiotic treatment as ordered. The wound will remain free of scar tissue at healing. Client increases caloric intake throughout the healing process.

1) The wound will remain free of infection throughout the healing process.

15. During which of the following developmental stages does a person tend to need the most hours of sleep? Toddler Adolescence Middle adulthood Older adulthood

1) Toddler

9. Three days ago a patient had cardiac surgery to bypass three occlusions of his coronary arteries. Veins for the bypass were harvested from his right leg. He informs the nurse that his leg is warm and tender in his right calf. The nurse notes a 3-cm periwound erythema and swelling at the distal end of the incision. Staples are intact along the incision, and there is no drainage. Vital signs are stable. The nurse would suspect that the patient has what kind of complication? Deep vein thrombosis Dehiscence of the wound Internal bleeding Infection at the incisional site

1) Deep vein thrombosis

11. What are patterns of waking behavior that appear during sleep are known as? Parasomnias Dyssomnias Insomnia Hypersomnia

1) Parasomnias

A patient complains of an impaired sense of smell. Which cranial nerve might have been affected? 1) Trigeminal 2) Glossopharyngeal 3) Olfactory 4) Vagus

Olfactory

To assure effectiveness, when should the nurse stop rubbing antiseptic hand solution over all surfaces of the hands? 1) When fingers feel sticky 2) After 5 to 10 seconds 3) When leaving the clients room 4) Once fingers and hands feel dry

Once fingers and hands feel dry

The muscle strength of a woman weighing 132 pounds who is able to lift 72 pounds would be recorded as which of the following? 1.83 Moderate 0.55 18.3%

0.55

4. A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it? Partial-thickness wound Penetrating wound Superficial wound Full-thickness wound

1) Partial-thickness wound

____ 3. Which of the following factors has the greatest positive effect on sleep quality? Sleeping hours in synchrony with the persons circadian rhythm Sleeping in a quiet environment Spending additional time in stage IV of the sleep cycle Napping on and off during the daytime

1) Sleeping hours in synchrony with the persons circadian rhythm

Surgeries are commonly classified by which of the following? Choose all that apply. 1) Acuity 2) Level of urgency 3) Length of surgery 4) Organ involved

1) Acuity 2) Level of urgency

A patient had a colon resection for removal of a cancerous tumor. Postoperatively, on the surgical floor which of the following activities would the nurse perform for the purpose of decreasing the risk of postoperative complications? Choose all that apply. Assist the patient to turn, breathe deeply, and cough every 2 hours. Teach the patient about the type of tumor removed. Assess the drainage from the surgical site. Monitor vital signs on a regular basis.

1) Assist the patient to turn, breathe deeply, and cough every 2 hours 3) Assess the drainage from the surgical site. 4) Monitor vital signs on a regular basis.

2. The nurses obligations in ethical decisions include which of the following? Choose all that apply. Be a patient advocate. Involve institutional ethics committees. Improve ones own ethical decision making. Respect patient confidentiality.

1) Be a patient advocate. 2) Involve institutional ethics committees. 3) Improve ones own ethical decision making. 4) Respect patient confidentiality.

. Which of the following are characteristics of an effective nurse manager? Choose all that apply. Clinical expertise Business sense Masters degree Leadership skills

1) Clinical expertise 2) Business sense 4) Leadership skills

The nurse is implementing a wellness program based on data gathered from a group of low-income seniors living in a housing project. He is using the Wheels of Wellness as a model for his planned interventions. Which of the following interventions would be appropriate based on this model? Choose all that apply. Creating a weekly discussion group focused on contemporary news Facilitating a relationship between local pastors and residents of subsidized housing Coordinating a senior tutorial program for local children at the housing center Establishing an on-site healthcare clinic operating one day per week

1) Creating a weekly discussion group focused on contemporary news 2) Facilitating a relationship between local pastors and residents of subsidized housing 3) Coordinating a senior tutorial program for local children at the housing center 4) Establishing an on-site healthcare clinic operating one day per week

3. An experienced nurse serves as a mentor to a new graduate. Which of the following are responsibilities of the person being mentored? Choose all that apply. Demonstrates an ability to move toward independence Has the ability to encourage excellence in others Seeks feedback and uses it to modify behaviors Demonstrates flexibility and an ability to change

1) Demonstrates an ability to move toward independence 3) Seeks feedback and uses it to modify behaviors 4) Demonstrates flexibility and an ability to change

The nurse is caring for a patient who had abdominal surgery 3 days ago and will be discharged home later today. The nurse will know that teaching is effective if the patient does which of the following? Choose all that apply. 1) Describes clinical findings associated with infection 2) Performs the dressing change as prescribed 3) Demonstrates freedom from surgical incision pain 4) Completes the regimen of prescribed antibiotics

1) Describes clinical findings associated with infection 2) Performs the dressing change as prescribed 4) Completes the regimen of prescribed antibiotics

11. A registered nurse administers the wrong medication to a patient. She does not notify anyone of the error and documents that the correct medication was administered. The nurse was reported to the state board of nursing. Which of the following actions can the state board of nursing take against the nurse in this situation? Disciplinary action against the nurses license to practice Criminal misdemeanor charges against the nurse Medical malpractice lawsuit against the nurse Employment release from the institution

1) Disciplinary action against the nurses license to practice

Health promotion programs assist a person to advance toward optimal health. Which of the following activities might such programs include? Choose all that apply. Disseminating information Changing lifestyle and behavior Prescribing medications to treat underlying disorders Environmental control programs

1) Disseminating information 2) Changing lifestyle and behavior 4) Environmental control programs

Goals for Healthy People 2020 include which of the following? Choose all that apply. Eliminate health disparities among various groups. Decrease the cost of healthcare related to tobacco use. Increase the quality and years of healthy life. Decrease the number of inpatient days annually.

1) Eliminate health disparities among various groups. 3) Increase the quality and years of healthy life.

4. You are caring for a patient with renal failure. His morning laboratory results reveal an abnormal potassium level of 6.8. This value is more elevated than on the previous day, when the level was within normal limits. You page the patients physician, but he does not return your call right away. You become busy with another patient and forget to notify the physician again and fail to mention the critical laboratory value to the oncoming nurse during shift report. Which of the following does this scenario illustrate? Choose all that apply. Failure to implement a plan of care Failure to evaluate Malpractice Failure to assess and diagnose

1) Failure to implement a plan of care 2) Failure to evaluate 4) Failure to assess and diagnose

According to Penders health promotion model, which variables must be considered when planning a health promotion program for a client? Choose all that apply. Individual characteristics and experiences Levels of prevention Behavioral outcomes Behavior-specific cognitions and affect

1) Individual characteristics and experiences 3) Behavioral outcomes 4) Behavior-specific cognitions and affect

The preoperative nurse is preparing a patient for surgery. Identify the interventions the nurse will perform. Choose all that apply. Inform the family to wait in the surgical waiting room. Prepare the surgical suite for the operation. Remove the patients dentures and contact lenses. Assist the patient to complete a living will.

1) Inform the family to wait in the surgical waiting room. 3) Remove the patients dentures and contact lenses.

3. What do negligence and malpractice have in common? Choose all that apply. Negligence and malpractice are unintentional torts. Negligence and malpractice are felonies. Malpractice is the professional form of negligence. Negligence and malpractice involve the intent to do harm to a patient.

1) Negligence and malpractice are unintentional torts. 3) Malpractice is the professional form of negligence.

2. Which of the following terms refers to the ethical questions that arise out of nursing practice? Nursing ethics Bioethics Ethical dilemma Moral distress

1) Nursing ethics

The nurse working in an ambulatory care program asks questions about the clients locus of control as a part of his assessment because of which of the following? Choose all that apply. People who feel in charge of their own health are the easiest to motivate toward change. People who feel powerless about preventing illness are least likely to engage in health promotion activities. People who respond to direction from respected authorities often prefer a health promotion program that is supervised by a health provider. People who feel in charge of their own health are less motivated by health promotion activities.

1) People who feel in charge of their own health are the easiest to motivate toward change. 2) People who feel powerless about preventing illness are least likely to engage in health promotion activities. 3) People who respond to direction from respected authorities often prefer a health promotion program that is supervised by a health provider.

1. Which of the following is an example of whistle-blowing? Choose all that apply. Reporting fraudulent billing practices Reporting patients health status against the patients wishes Reporting unsafe work practices Reporting a coworker for working under the influence of drug

1) Reporting fraudulent billing practices 3) Reporting unsafe work practices 4) Reporting a coworker for working under the influence of drugs

Which of the following actions demonstrate how nurses promote health? Role modeling Educating patients and families Counseling Providing support

1) Role modeling 2) Educating patients and families 3) Counseling 4) Providing support

1. Which of the following are examples of invasion of privacy by nurses? Choose all that apply. Searching a patients belongings without permission Reviewing the plan for patient care in the lunchroom Discussing healthcare issues for an unconscious patient with his power of attorney Releasing patient health information to local newspaper reporters

1) Searching a patients belongings without permission 2) Reviewing the plan for patient care in the lunchroom 4) Releasing patient health information to local newspaper reporters

2. Which of the following activities are involved when delegating tasks to other members of the nursing team? Choose all that apply. Supervising patient care that is given Determining the skill mix of unit personnel Assessing the needs of the clients involved Deciding which tasks to assign to a team member

1) Supervising patient care that is given 2) Determining the skill mix of unit personnel 3) Assessing the needs of the clients involved 4) Deciding which tasks to assign to a team member

Which of the following members of the operative team use sterile technique during the surgical procedure? Choose all that apply. 1) Surgeon 2) Anesthetist 3) Scrub nurse 4) Registered nurse first assistant

1) Surgeon 3) Scrub nurse 4) Registered nurse first assistant

A young adult woman is scheduled for a bilateral breast reduction under general anesthesia. She is normally healthy and takes no daily medications. Identify the preoperative screening tests appropriate for this patient. Choose all that apply. Urinalysis EKG Creatinine clearance CBC

1) Urinalysis 4) CBC

A patient returns from surgery with a nasogastric tube and intermittent gastric suction to provide abdominal decompression. Which of the following are correct nursing activities for managing the equipment and drainage? Choose all that apply. Wear nonsterile procedure gloves when emptying the drainage container. When irrigating the nasogastric tube, use sterile water. Wear sterile gloves when irrigating the nasogastric tube. Apply water-soluble lubricant if the patients lips are dry.

1) Wear nonsterile procedure gloves when emptying the drainage container. 4) Apply water-soluble lubricant if the patients lips are dry.

12. Pressure ulcers are directly caused by which of the following conditions at the site? Compromised blood flow Edema Shearing forces Inadequate venous return

1) Compromised blood flow

____ 8. You are preparing the nursing care plan for a middle-aged patient admitted to the intensive care unit for an acute myocardial infarction (heart attack). His symptoms include tachycardia, palpitations, anxiety, jugular vein distention, and fatigue. Which of the following nursing diagnoses is most appropriate? Decreased Cardiac Output Impaired Tissue Perfusion Impaired Cardiac Contractility Impaired Activity Tolerance

1) Decreased Cardiac Output

10. Which of the following describes the difference between dehiscence and evisceration? With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent. Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue. Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.

1) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.

Identify the type of surgery a terminally ill patient will undergo if the purpose is removal of tissue to relieve pain. 1) Procurement 2) Ablative 3) Palliative 4) Diagnostic

Palliative

16. A patient had a CVA (stroke) 2 days ago, resulting in decreased mobility to her left side. During the assessment, the nurse discovers a stage I pressure area on the patients left heel. What is the initial treatment for this pressure ulcer? Antibiotic treatment for 2 weeks Normal saline irrigation of the ulcer daily Dbridement to the left heel Elevation of the left heel off the bed

4) Elevation of the left heel off the bed

A nurse is performing CPR on an infant. How many compressions:

100

3. What is the primary difference between acute and chronic wounds? Chronic wounds: Are full-thickness wounds, but acute wounds are superficial. Result from pressure, but acute wounds result from surgery. Are usually infected, whereas acute wounds are contaminated. Exceed the typical healing time, but acute wounds heal readily.

4) Exceed the typical healing time, but acute wounds heal readily.

24. The nurse gathers the following data: BP = 150/94; neck veins distended; P = 104; pulse bounding; respiratory rate = 20; T = 37C (98.6F). What disorder should the nurse suspect? Hypovolemia Hypercalcemia Hyperkalemia Hypervolemia

4) Hypervolemia

Identify the desired effects of general anesthesia. Choose all that apply. Reduction of risk Analgesia Amnesia Muscle relaxation

2) Analgesia 3) Amnesia 4) Muscle relaxation

5. A 45-year-old patient is ventilator dependent after a high cervical neck injury. He is alert and oriented and, after giving it much thought, has decided that he wants to be removed from the ventilator. The nurse believes the patient intends suicide, but supports his final decision. When the ventilator is removed, the nurse remains with the patient to support him. The nurses action demonstrates respect for what moral principle? Nonmaleficence Autonomy Beneficence Fidelity

2) Autonomy

4. Upon initial assessment of a 75-year-old patient, you identify bruises and scratches on the patients arms, legs, and trunk in various stages of healing. You notify your supervisor when you suspect the patient may be a victim of physical abuse. You are complying with which of the following state laws? Good Samaritan Law Mandatory Reporting Law Nurse Practice Act Nursing Standards of Practice

2) Mandatory Reporting Law

12. Nursing codes are: Legally binding. Not legally binding. Legally binding in some circumstances. Not admissible in court.

2) Not legally binding.

13. An alert, oriented, and competent frail older adult man has been told that he is dying, and has asked to have a DNAR order put on his chart. The patients family does not agree with his decision and asks the healthcare team to ignore the request. After a great deal of discussion among the physician, nurse, and family, they are no closer to resolution of the conflict. The nurse asks the hospital chaplain to come and help the family and the team understand each others opposing views. Which step of the MORAL model does this illustrate? Massage the dilemma Outline the options Resolve the dilemma Look back and evaluate

2) OOutline the options

The World Health Organizations definition of health includes which of the following? Choose all that apply. Absence of disease Physical well-being Mental well-being Social well-being

2) Physical well-being 3) Mental well-being 4) Social well-being

8. Identify the third step in the MORAL decision-making model. Reassess the dilemma Resolve the dilemma Review the problem Recall the history of the problem

2) Resolve the dilemma

Which of the following are potential complications of anesthesia? Choose all that apply. 1)Hypothermia 2) Respiratory depression 3)Cardiovascular compromise 4)Aspiration

2) Respiratory depression 3) Cardiovascular compromise 4) Aspiration

7. In which of the following circumstances might the nurse defer obtaining informed consent for care and treatment of a patient? The patient is confused and cannot understand or sign the consent form. The patient is brought to the emergency department in cardiac arrest; no family is present. The surgeon requests that the patient be sent to the surgical suite before you get the consent form signed. An unconscious patient is admitted to your unit; he is alone.

2) The patient is brought to the emergency department in cardiac arrest; no family is present.

6. Which of the following consequentialist theories takes the position that the value of an action is determined by its usefulness? Ethics of care Utilitarianism Deontology Categorical imperative

2) Utilitarianism

26. A patient had abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following? Steri-Strips Abdominal binder T-binder Paper tape

2) Abdominal binder

17. Chronic stress may lead directly to cardiovascular disease because of the repeated release of which of the following? Histamine Catecholamines Cortisol Protease

2) Catecholamines

30. What is a common characteristic of aging skin? Increased permeability to moisture Diminished sweat gland activity Reduced oxygen-free radicals Overproduction of elastin

2) Diminished sweat gland activity

17. Which laboratory results on a clients health record should alert the nurse to a potential problem? Na+ = 137 mEq/l K+ = 5.2 mEq/l Ca2+ = 9.2 mg/dl Mg2+ = 1.8 mg/dl

2) K+ = 5.2 mEq/l

10. What is the purpose of using a sleep diary? Identify sleeprest patterns over a 1-year period. Note the trend in sleepwakefulness patterns over a 2-week period. Note typical sleep habits and most common daily routines. Examine the patterns of sleep during the night and naps during the day.

2) Note the trend in sleepwakefulness patterns over a 2-week period.

6. The nurse is admitting to the medical-surgical unit an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure. The patient is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take? Review and implement the primary care providers prescriptions for treatments. Perform a quick physical examination of breathing, circulation, and oxygenation. Gather a thorough medical history, including current symptoms, from the family Administer oxygen to the patient through a nasal cannula.

2) Perform a quick physical examination of breathing, circulation, and oxygenation.

____ 21. When using sterile technique to perform tracheostomy care of a new tracheostomy, which of the following is correct? You will need a single pair of sterile gloves. Place the patient in semi-Fowlers position, if possible Clean the stoma under the faceplate with hydrogen peroxide. Cut a slit in sterile 4 x 4 gauze halfway through to make a dressing.

2) Place the patient in semi-Fowlers position, if possible

5. A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is: Primary intention healing. Secondary intention healing. Tertiary intention healing. Approximation healing.

2) Secondary intention healing.

8. While assessing a new wound, the nurse notes red, watery drainage. What type of drainage will the nurse document this as? Sanguineous Serosanguineous Serous Purosanguineous

2) Serosanguineous

9. When making rounds on the night shift, the nurse observes her patient to be in deep sleep. His muscles are very relaxed. When he arouses as the nurse changes the IV tubing, he is confused. What stage of sleep was the patient most likely experiencing? Stage V Stage IV Stage III REM

2) Stage IV

10. The nurse is a member of the ethics committee. An alert, oriented, and competent 87-year-old man has asked to have a DNAR order put on his chart. The patients family does not agree with his decision and requests the ethics committee to intervene on their behalf. The ethics committee would most likely use which model in this patients case? Social justice Patient benefit Autonomy DNAR determination

3) Autonomy

23. The nurse examines the electrocardiogram (ECG) tracing of a client and notes tall T waves. What electrolyte imbalance should the nurse suspect? Hypokalemia Hypophosphotemia Hyperkalemia Hypercalcemia

3) Hyperkalemia

1. A pregnant 15-year-old girl presents to the emergency department (ED) of the local private hospital. She has been transported by her mother and appears to be in active labor. The girl is crying uncontrollably and says she is scared and experiencing painful contractions. Her mother states, We dont have any money or insurance, but this hospital is closer than the public hospital, and she needs help now. What is the first step that the ED staff should take? Arrange for an ambulance to transport her to the nearest public hospital. Explain to the girl and her mother that the hospital only accepts patients who can pay the hospital bill. Examine her to determine if her condition is stable or if she requires immediate medical attention. Inform her mother that she will need to transport her daughter to the nearest public hospital.

3) Examine her to determine if her condition is stable or if she requires immediate medical attention.

2. While you are admitting an adult patient, he asks you whether he should create an advance directive. To provide him adequate information to make an informed decision, you should tell the patient which of the following? Choose all that apply. If he is unable to communicate, his family may make changes to his advance directive. Once he signs an advance directive, no further care will be provided to him. He may change his advance directive by telling his physician or by making changes in writing. An advance directive will ensure he gets as much or as little care as he wishes.

3) He may change his advance directive by telling his physician or by making changes in writing. 4) An advance directive will ensure he gets as much or as little care as he wishes.

3. A patient tells you that chart entries made by the nurse from the previous day indicate he was uncooperative when asked to ambulate. He says this is not true and asks his record be corrected. You understand that, if what he says is accurate, he has the right to have the documentation error corrected based on which of the following regulations? Americans with Disabilities Act (ADA) Patient Self-Determination Act (PSDA) Health Insurance Portability and Accountability Act (HIPAA) Health Care Quality Improvement Act (HCQIA)

3) Health Insurance Portability and Accountability Act (HIPAA)

1. A 77-year-old woman with an inoperable brain tumor has been hospitalized for the past 5 days. Her daughter comes to visit her. The patient has asked that her daughter not be told her diagnosis. After visiting with her mother, the daughter asks to speak to the nurse. She says, My mother claims she has pneumonia, but I know she is not telling me the truth. The daughter asks the nurse to tell her what is truly wrong with her mother. The nurse should tell her that: Her mother has an inoperable brain tumor, but does not wish anyone to know. She needs to speak to the physician in charge of her mothers care. Her mother has requested that her case not be discussed with anyone, not even family. Her mother is very sick with a serious case of pneumonia that could lead to death.

3) Her mother has requested that her case not be discussed with anyone, not even family.

6. The charge nurse in a progressive care unit assigns the care of a patient receiving hemodialysis to a newly hired licensed practical nurse (LPN) without checking to see that the nurse has been determined competent to care for hemodialysis patients. The LPN is in orientation and, does not inform the charge nurse that she does not have experience with this type of patient. The actions of the charge nurse would be considered to be which of the following? Malpractice Incompetence Negligence Abandonment

3) Negligence

11. A 60-year-old patient with a treatable form of breast cancer has decided not to pursue radiation or chemotherapy. The nurse believes that the patient should be treated. She coerces her into receiving treatment by continuing to remind the patient about her responsibilities for raising her children. What type of behavior has the nurse displayed? Nonmaleficence Autonomy Paternalism Beneficence

3) Paternalism

10. A registered nurse forgot to put the side rails up for a confused patient. The patient fell out of bed and fractured his hip. The patient sues and wins a judgment (award) for $2 million. The nurse has an occurrence policy with double limit coverage of $3 million/$10 million that covered the time period when the incident occurred. The statement that best describes the nurses situation is that her insurance policy will: Not cover her. Pay $4 million. Pay $2 million. Pay 75% of the $2 million

3) Pay $2 million.

14. An alert, oriented, and competent frail older adult man has been told that he is dying, and has asked to have a DNAR order put on his chart. The patients family does not agree with his decision and asks the healthcare team to ignore the request. The healthcare team does not agree, and after several days the family takes the matter to court. The court sides with the family and orders the healthcare team to remove the DNAR order. This is an example of which of the following? An integrity-producing (good) compromise An ethically sound compromise Settlement of an issue by force An effort to keep peace on the unit

3) Settlement of an issue by force

Which of the following describes the Perioperative Nursing Data Set? Choose all that apply. 1) A standardized tool for assessing high-risk surgical patients 2) A standardized vocabulary encompassing all surgical patient outcomes 3) The first specialized nursing language recognized by the ANA 4) A standardized language designed to describe the care of perioperative patients

3) The first specialized nursing language recognized by the ANA 4) A standardized language designed to describe the care of perioperative patients

4. A 45-year-old patient is ventilator dependent after a high cervical neck injury. He is conscious and competent and has decided that he wants to be removed from the ventilator. His family and the multidisciplinary team agree. The nurse believes the patient intends suicide, and would prefer he choose differently, but says nothing. The nurse remains at the bedside holding the patients hand. In this instance the nurse is displaying which of the following? Value set Value system Value neutrality Value awareness

3) Value neutrality

____ 22. A physician has ordered 250 ml of 0.9% sodium chloride to be infused over 2 hours. A microdrip infusion set is being used. What is the drip rate that the nurse should monitor? 60 drops per minute 75 drops per minute 125 drops per minute 250 drops per minute

3) 125 drops per minute

20. What intervention would be most appropriate for a wound with a beefy red wound bed? Mechanical dbridement Autolytic dbridement Dressing to keep the wound moist and clean Removal of devitalized tissue and a sterile dressing

3) Dressing to keep the wound moist and clean

19. A 62-year-old man with emphysema says, My doctor wants me to quit smoking. Its too late now, though; I already have lung problems. Which of the following would be the best response to his statement? You should quit so your family does not get sick from exposure to secondhand smoke. You will need to use oxygen, but remember it is a fire hazard to smoke with oxygen in your home. Once you stop smoking, your body will begin to repair some of the damage to your lungs. You should ask your primary care provider for a prescription for a nicotine patch so that you can quit.

3) Once you stop smoking, your body will begin to repair some of the damage to your lungs.

14. Chest percussion and postural drainage would be an appropriate intervention for which of the following conditions? Congestive heart failure Pulmonary edema Pneumonia Pulmonary embolus

3) Pneumonia

5. Which of the following is the main difference between sleep and rest? In sleep, the body may respond to external stimuli. Short periods of sleep do not restore the body as much as do short periods of rest. Sleep is characterized by an altered level of consciousness. The metabolism slows less during sleep than during rest.

3) Sleep is characterized by an altered level of consciousness.

____ 20. The nurse assesses that her patients intravenous solution has infiltrated into the tissues. What action should she take first? Aspirate, then inject 0.5 mL normal saline. Restart the IV line in a different vein. Stop the infusion immediately. Notify the primary care provider.

3) Stop the infusion immediately.

6. When teaching a patient about the healing process of an open wound after surgery, which of the following points would the nurse make? The patient will need to take antibiotics until the wound is completely healed. Because the patients wound was left open, the wound will likely become infected. The patient will have more scar tissue formation than for a wound closed at surgery. The patient should expect to remain hospitalized until complete wound healing occurs.

3) The patient will have more scar tissue formation than for a wound closed at surgery.

18. For the client with a stage IV pressure ulcer, what would an applicable patient goal/outcome be? Client will maintain intact skin throughout hospitalization. Client will limit pressure to wound site throughout treatment course. Wound will close with no evidence of infection within 6 weeks. Wound will improve prior to discharge as evidenced by a decrease in drainage.

3) Wound will close with no evidence of infection within 6 weeks.

____ 7. You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patients respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern? Biots breathing Kussmauls respirations Sleep apnea Cheyne-Stokes respirations

4) Cheyne-Stokes respirations

9. You are caring for an alert, oriented 47-year-old patient who is recovering from abdominal surgery. The patient becomes angry and upset and says, Im leaving this hospital. Remove my IV and surgical drains or I will do it myself. In order to keep him from removing his lines and leaving the hospital, you apply bilateral wrist restraints until you can contact the physician for an order for patient restraint. This is an example of which of the following? Assault and battery A felony False imprisonment A quasi-intentional tort

4) A quasi-intentional tort

For the patient with no healthcare coverage who is seeking medical care, the emergency department staff members decide whether to provide care or transport to a public facility based on which law, enacted by Congress in 1986 and updated in 2003? Health Care Quality Improvement Act (HCQIA) Patient Self-Determination Act (PSDA) Newborns and Mothers Health Protection Act (NMHPA) Emergency Medical Treatment and Active Labor Act (EMTALA)

4) Emergency Medical Treatment and Active Labor Act (EMTALA)

9. A patient has asked the nurse to explain her laboratory results. The nurse informs the patient that he must first assist another patient to the bathroom and then he will explain the results. The nurse assists the other patient to the bathroom and then returns to explain the results to the patient. What moral principle has the nurse displayed? Nonmaleficence Autonomy Beneficence Fidelity

4) Fidelity

5. Nursing codes of ethics support which of the following? Patients can receive emergency treatment regardless of their ability to pay. Nurses will educate patients about advance directives. Nurses with HIV must disclose their condition to their employer. Patients have the right to dignity, privacy, and safety.

4) Patients have the right to dignity, privacy, and safety.

3. A belief about the worth of something that serves as a principle or a standard that influences decision making is called which of the following? Morals Attitudes Beliefs Values

4) Values

4. Which is a major factor regulating sleep? Electrical impulses transmitted to the cerebellum Level of sympathetic nervous system stimulation Amount of sleep a person has become accustomed Amount of light received through the eyes

4) Amount of light received through the eyes

16. Which of the following blood levels normally provides the primary stimulus for breathing? pH Oxygen Bicarbonate Carbon dioxide

4) Carbon dioxide

7. Which patient teaching would be most therapeutic for someone with sleep disturbance? Give yourself at least 60 minutes to fall asleep. Avoid eating carbohydrates before going to sleep. Catch up on sleep by napping or sleeping in when possible. Do not go to bed feeling upset about a conflict.

4) Do not go to bed feeling upset about a conflict.

19. A patient is receiving an IV infusion of lactated Ringers solution and 40 mEq of KCl at 100 ml/hr. When assessing the IV site, the nurse notes swelling, erythema, and warmth. There is a palpable cord along the vein, and the infusion is sluggish. The patient is complaining of pain at the site. The nurse would recognize these findings to be consistent with which of the following? Infiltration Extravasation Hematoma Phlebitis

4) Phlebitis

14. From what stage of sleep are people typically most difficult to arouse? NREM, alpha waves NREM, sleep spindles NREM, delta waves REM

4) REM

20. The nurse administers intravenous morphine sulfate to a patient for pain control. She will need to monitor her patient for which of the following adverse effects? Decreased heart rate Muscle weakness Decreased urine output Respiratory depression

4) Respiratory depression

18. A patients vital signs prior to a blood transfusion were: T = 97.6F (36.4C); P = 72; R = 22; and BP = 132/76. Twenty minutes after the transfusion was begun, the patient began complaining of feeling itchy and hot. The nurse discovered a rash on the patients trunk. Vital signs were: T = 100.8F (38.2C); P = 82; R = 24; BP = 146/88. Based on these findings, what is the priority intervention? Administer an antihistamine (antiallergenic) medication. Flush the blood tubing with D5W immediately. Prepare for emergency resuscitation. Stop the blood transfusion immediately.

4) Stop the blood transfusion immediately.

29. A patient has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound heals a little more he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing? Primary intention Regenerative healing Secondary intention Tertiary intention

4) Tertiary intention

22. The nurse would know care for a stage II pressure ulcer is achieving the desired goal when: The ulcer is completely healed with minimal scarring. The patient reports no pain at the site. A minimal amount of drainage is noted. The wound bed contains 100% granulated tissue.

4) The wound bed contains 100% granulated tissue.

13. A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as? Stage II pressure ulcer Stage III pressure ulcer Stage IV pressure ulcer Unstageable pressure ulcer

4) Unstageable pressure ulcer

8. The expected outcome (goal) for a patient with Disturbed Sleep Pattern is that she will: Limit exercise to 1 hour per day early in the day. Consume only one caffeinated beverage per day. Demonstrate effective guided imagery to aid relaxation. Verbalize that she is sleeping better and feels less fatigued.

4) Verbalize that she is sleeping better and feels less fatigued.

A nurse is teaching wellness to a womens group. The nurse should explain the importance of consuming at least how much fluid to promote healthy bowel function (assume these are 8-ounce glasses)? 1) 2 to 4 glasses a day 2) 4 to 6 glasses a day 3) 6 to 8 glasses a day 4)8 to 10 glasses a day

6 to 8 glasses a day(7-8)

Which documentation entry related to PRN medication administration is complete? 1) 6/5/11 0900 morphine 4 mg IV given in right antecubetal fossa for pain rated 8 on a 110 scale, J. Williams RN 2) 0600 famotidine 20 mg IV given in right hand, S. Abraham RN 3) 9/2/11 0900 levothyroxine 50 mcg PO given 4) 1/16/11 furosemide 40 mg PO given, J. Smith RN

6/5/11 0900 morphine 4 mg IV given in right antecubetal fossa for pain rated 8 on a 110 scale, J. Williams RN

Which of these statements made by a client whose BMI is 34 and is attempting to lose weight would indicate the need for further teaching:

: AN online food diary is unlikely to help me to improve my food intake

The nurse is teaching a female patient with stress incontinent how to performs PFME which of the following statements indicates that the patient understands:

: I will keep the contraction and relaxation times equal

The nurse knows that iron deficiency anemia is cause by low levels of iron in the body that can be improved by a diet high in iron: Diagnosis:

: Imbalance nutrition less than body requirements for iron r/t possible deficient recall of dietary needs

What is the most essential action to delegating the administration of IV to the LPN:

: review the states nurse practice act for LPN scope of practice

The enterostomal nurse is conducting a teaching session for patients with new colostomies. Today's topic is self-assessment and SS to repost what would this include:

: stoma is pale dusky or black

A patient has chronic confusion secondary to dementia. As a result, he is unable to sign an informed consent for surgery. In this situation: 1) An informed consent is not needed. 2) Two nurses may sign the informed consent for the patient. 3) The surgeon must sign the informed consent. 4) A family member will be asked to sign the informed consent.

A family member will be asked to sign the informed consent.

The nurse is administering a purified protein derivative test to a homeless client. Which of the following statements concerning PPD testing is true:

A positive reaction indicates that the client has been exposed to the disease

Which of the following is a nonverbal behavior that enhances communication? 1) Keeping a neutral expression on the face 2) Maintaining a distance of 6 to 12 inches 3) Sitting down to speak with the patient 4) Asking mostly open-ended questions

Sitting down to speak with the patient

The nurse identifies the nursing diagnosis Urinary Incontinence (Total) in an older adult patient admitted after a stroke. Urinary Incontinence places the patient at risk for which complication? 1) Skin breakdown 2) Urinary tract infection 3) Bowel incontinence 4) Renal calculi

Skin breakdown

An elderly female, adequate nourished was admitted to the skilled nursing facility 3 months ago Since then she has had a significant weight loss and become frail. Her appetite and activity level are reduced and she has lost interest in interacting with other patients. What would d the nurse suspect the reason:

Adult failure to thrive

The nurse receives a laboratory report that states her patients digoxin level is 1.2 ng/mL; therapeutic range for this drug is 0.5 to 2 ng/mL. Which action should the nurse take? 1) Notify the prescriber to reduce the dose. 2) Withhold the next dose of digoxin. 3) Administer the next dose as prescribed. 4) Notify the prescribing healthcare provider to increase the dose.

Administer the next dose as prescribed.

The nurse is assessing a male patient diagnosed with chronic heart failure 10 years ago. Which finding indicates poor perfusion to the tissues:

Absence of hair on lower legs and feet

A patient with a diabetic foot ulcer will need to perform dressing changes after discharge. When should the nurse schedule the teaching session(s)? 1) Within 10 minutes after his next dose of oral pain medication 2) After the patient wakes up from a restful nap 3) Before the surgeon dbrides the wound 4) Before the patient undergoes flow studies of his affected leg

After the patient wakes up from a restful nap

A patient is admitted to the hospital with tuberculosis. Which precautions must the nurse institute when caring for this patient?

Airborne transmission

Which individuals should receive annual lipid screening? All overweight children All adults 20 years and older Persons with total cholesterol greater than 150 mg/dL Persons with HDL less than 40 mg/dL

All overweight children

The nurse is preparing patient teaching for a patient diagnosed with peripheral edema secondary to right sided heart failure, what intervention will promote circulation and reduce edema:

Ambulation

A patient had surgery 6 hours ago. When the nurse enters the room to turn him, she notes that he is restless and grimacing. Considering the patients nonverbal communication, what action should the nurse take first? 1) Administer pain medication to the patient. 2) Turn and reposition the patient. 3) Assess to determine the cause of the grimacing. 4) Leave the patients room so he can rest quietly.

Assess to determine the cause of the grimacing.

An older adult patient who underwent bowel resection is recovering from surgery without complication. He ambulates in the hallway and requires little analgesia for pain. During the healthcare teams morning rounds, the surgeon informs the patient that the lesion removed was cancerous. Which factor will likely be the patients most significant obstacle for learning? 1) The patients baseline physical condition 2) A negative environmental influence 3) Anxiety associated with the new diagnosis 4) Reduced ability to understand the diagnosis

Anxiety associated with the new diagnosis

A patient is to have a sequential compression device (SCD) applied on the postoperative unit. The patient is wearing knee-high elastic (antiembolism) stockings. When applying the SCD, what should the nurse do? 1) Remove the antiembolism stockings and not replace them. 2) Replace the knee-high stockings with thigh-high stockings. 3) Notify the surgeon that the patient is wearing antiembolism stockings. 4) Apply the SCD over the knee-high antiembolism stockings.

Apply the SCD over the knee-high antiembolism stockings.

When the nurse is giving instruction for discharge he notices that the tv is on and he is eating a meal the best thing for the nurse to do to ensure that patients discharge detaching:

Arrange another time with the patient to review the discharge teaching

2. At a recent nurse staff meeting, the chief nursing officer (CNO) announced that all nursing staff would work 12-hour shifts on a daynight rotation schedule that would alternate every 6 weeks. The CNO announced that she made this decision as a means to solve discord between the day- and night-shift nurses. She explained that this plan will allow the staff to experience the work on each shift and to appreciate the various job responsibilities on each shift. What type of leadership is the CNO displaying? Management Laissez-faire Democratic Authoritarian

Authoritarian

What action is most important in limiting the nurses risk of back injuries? 1) Use good body mechanics at all times. 2) Work with another nurse or an aide when lifting and turning patients. 3) Avoid manual lifting by using assistive devices as often as possible. 4) Develop a lift team at the clinical site.

Avoid manual lifting by using assistive devices as often as possible.

Which instruction should the nurse be certain to include when providing discharge teaching for a patient who has a serious visual deficit? 1) Install blinking lights to alert an incoming phone call. 2) Have gas appliances inspected regularly to detect gas leaks. 3) Wear properly fitting shoes and socks. 4) Avoid using throw rugs on the floors.

Avoid using throw rugs on the floors.

To evaluate a patient's acid- base balance the PCP has prescribe diagnosis tests to measure pH PCO2 ND HCO3. THE NURSE realizes that the patient will:

have an arterial blood sample take

1. Theories that focus on what the leader does are called: Trait theories. Behavioral theories. Situational theories. Transformational theories.

Behavioral theories.

A patient who was prescribed furosemide (Lasix) is deficient in potassium. Which of the following is an appropriate goal for this patient? The patient will increase his consumption of: 1) Bananas, peaches, molasses, and potatoes. 2) Eggs, baking soda, and baking powder. 3) Wheat bran, chocolate, eggs, and sardines. 4) Egg yolks, nuts, and sardines.

Bananas, peaches, molasses, and potatoes.

11. A nurse observes a nursing assistant (NAP) fail to wash her hands before and after placing a patient on a bedpan. When giving negative feedback to the NAP, the nurse should: Be certain to offer constructive criticism about the task and do so in private. Ask the unit manager to be present to document responses of both parties. Call a meeting of all NAPs and stress hand washing to the entire group. Keep a record of the NAPs actions and save them for her annual formal review.

Be certain to offer constructive criticism about the task and do so in private.

9. The physical therapy department and the nursing department at a local rehabilitation hospital are in conflict over which department is responsible for transporting patients to and from therapy appointments. The members of the therapy department state they do not have sufficient time to come to the nursing unit to pick up the patients and that patients often are not ready to be transported. Nursing staff members state that they do not have the time to transport the patients from the unit and this leaves a shortage of nursing personnel on the floor. Managers from both departments have attempted to resolve the conflict with input from nursing and therapy staff members. All attempts at conflict resolution have failed. What is the next step the managers should take? Inform the nurses that they must take the patients to and from therapy. Inform the therapists that they must take the patients to and from therapy. Ask the hospital administrator to make an unbiased decision. Begin informal negotiation between the two departments.

Begin informal negotiation between the two departments.

A patient newly diagnosed with breast cancer tells the nurse, Im worried I wont survive to see my children grow up. Which response by the nurse best conveys concern and active listening? 1) There have been many advances in breast cancer treatment; hope for the best. 2) Breast cancer is a serious disease; I can understand why youre worried. 3) Youre strong and have youth on your side to fight the breast cancer. 4) Id be worried too; Ive seen a lot of patients die from breast cancer.

Breast cancer is a serious disease; I can understand why youre worried.

The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique? 1) Closing the patients door to limit room traffic while preparing the sterile field 2) Using clean procedure gloves to handle sterile equipment 3) Placing the nonsterile syringes containing flush solution on the sterile field 4) Remaining 6 inches away from the sterile field during the procedure

Closing the patients door to limit room traffic while preparing the sterile field

8. A 4-year-old child is brought to the emergency department by his mother. He has a large bruise in his left chest and multiple contusions on his face. His mother tells you her boyfriend intentionally pushed the child down the stairs in anger. The child appears to be in a great deal of pain. Which of the following four correct items should the nurse to do first? Notify the nursing supervisor of the suspected physical abuse. Complete a physical assessment of the child. Obtain an order for pain medication. Notify Child Protective Services of the suspected abuse.

Complete a physical assessment of the child.

The physician prescribes warfarin 5 mg orally at 1800 for a patient who underwent open reduction and internal fixation of his right hip. After administering the medication, the nurse realizes that she administered a 10 mg tablet instead of the prescribed 5 mg PO. Which of the following actions by the nurse is appropriate? 1) No action is necessary because an extra 5 mg of warfarin is not harmful. 2) Call the prescriber and ask her to change the order to 10 mg. 3) Document on the chart that the drug was given and indicate the drug was given in error. 4) Complete an incident report according to the facilitys policy.

Complete an incident report according to the facilitys policy.

10. The manager is conducting an informal negotiation between two staff members who have had ongoing difficulty working together peacefully. Most recently there was an argument about who would be scheduled for first lunch each day. At this stage of the informal negotiation, the manager is focusing on managing the emotions and setting the ground rules. Which stage does this demonstrate? Setting the stage Conducting the negotiation Making offers and counteroffers Agreeing on resolution of the conflict

Conducting the negotiation

A mother of a school-age child seeks healthcare because her child has had diarrhea after being ill with a viral infection. The patient states that after vomiting for 24 hours, his appetite has returned. Which recommendation should the nurse make to this mother? 1) Consume a diet consisting of bananas, white rice, applesauce, and toast. 2) Drink large quantities of water regularly to prevent dehydration. 3) Take loperamide [an antidiarrheal] as needed to control diarrhea. 4) Increase the consumption of raw fruits and vegetables.

Consume a diet consisting of bananas, white rice, applesauce, and toast.

The nurse is caring for a group of patient son the med sure the most important prevent falls:

identify those who are art risks for falls

The nurse must irrigate the ear of a 4-year-old child. How should the nurse pull the pinna to straighten the childs ear canal?

Down and back

A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2 days. His condition has stabilized, and his temperature has returned to normal. Which stage of infection is the patient most likely experiencing? 1) Incubation 2) Prodromal 3) Decline 4) Convalescence

Decline

Which teaching technique is best for teaching a nursing assistant how to perform finger-stick glucose testing? 1) Provide a manufacturers pamphlet with detailed instruction. 2) Explain the best technique for performing glucose testing. 3) Demonstrate the procedure; then ask for a return demonstration. 4) Suggest that the assistant watch a DVD showing the procedure.

Demonstrate the procedure; then ask for a return demonstration.

Health screening activities are designed to: Detect disease at an early stage. Determine treatment options. Assess lifestyle habits. Identify healthcare beliefs.

Detect disease at an early stage.

The nurse has just administered a SbQ insulin injection to her diabetic patient. What is the next immediate action:

Dispose of the needle/syringe uncapped into a disposable sharp

The nurse is assessing patient who is complaining of chest pain, clutching his chest, and is SOB which questions:

Does the pain radiate to your arm jaw or shoulder?

What position should the patient assume before the nurse inserts an indwelling urinary catheter? 1) Modified Trendelenburg 2) Prone 3) Dorsal recumbent 4) Semi-Fowlers

Dorsal recumbent

4. The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis. Which of the following responses indicates to the nurse that the medication is effective? The amount of sputum the patient expectorates decreases with each dose administered. Cough is completely suppressed, and she is able to sleep through the night. Dry, unproductive cough is reduced, but her voluntary coughing is more productive. Involuntary coughing produces large amounts of thick yellow sputum.

Dry, unproductive cough is reduced, but her voluntary coughing is more productive.

It is a busy day on the medical-surgical floor, and the nurse must teach a patient ready for discharge about his medications. How can the nurse most efficiently utilize her time and provide this education? 1) Write down instructions so the patient can read them at home. 2) Discuss the information while assisting the patient with his bath. 3) Educate the patient about his medications as each one is given. 4) Follow up with the patient after discharge with a phone call.

Educate the patient about his medications as each one is given.

8. An expert nurse feels confident in her role as a clinician on the unit. The nurse enjoys her work and feels in charge of her career. Which leadership state is she experiencing? Power-based authority Excellent management skills Empowerment in her role Followership skills

Empowerment in her role

The nurse suspects a 3-year-old child who is coughing vigorously has aspirated a small object. Which action should the nurse take first? 1) Encourage the child to continue coughing. 2) Deliver upward abdominal thrusts with a fisted hand. 3) Deliver five rapid back blows between the shoulder blades. 4) Perform a blind finger sweep of the childs mouth.

Encourage the child to continue coughing.

Prior to discharge, a patient with diabetes needs to learn how to check a finger-stick blood sugar before taking insulin. Which action will best help the patient remember proper technique? 1) Encouraging the patient to check the blood sugar each time the nurse gives insulin 2) Providing feedback after the patient takes his blood sugar for the first time 3) Verbally instructing the patient about how to obtain a finger-stick blood sugar 4) Offering a brochure that describes the technique for checking a blood sugar

Encouraging the patient to check the blood sugar each time the nurse gives insulin

The focus of nursing care in the intraoperative phase is to: 1) Prepare the patient for surgery. 2) Maintain the sterile field. 3) Ensure patient safety during the surgery. 4) Obtain a signed informed consent.

Ensure patient safety during the surgery.

After inserting a NG tube what would be the nurse's priority action:

Obtain an x-ray

A bowel prep until clear is prescribed for colonoscopy. The client experience diarrhea. What action is appropriate:

Explain that this is expected

The nurse to caring for a patient diagnosed with pneumonia teaching him or her how to cough and deep breath. The patient asks why is drinking fluids so important what is the best respond:

Fluids make secretions thin, making them easier to cough up

Which action should the nurse take immediately after administering a medication through a nasogastric tube? 1) Verify correct nasogastric tube placement in the stomach. 2) Auscultate the abdomen for presence of bowel sounds. 3) Immediately administer the next prescribed medication. 4) Flush the tube with water using a needleless syringe.

Flush the tube with water using a needleless syringe.

The nurse is providing nutrition counseling for a patient planning pregnancy. The nurse should emphasize the importance of consuming which nutrient to prevent neural tube defects? 1) Folic acid 2) Calcium 3) Protein 4) Vitamin D

Folic acid

A patient who underwent surgery 24 hours ago is prescribed a clear liquid diet. The patient asks for something to drink. Which item may the nurse provide for the patient? 1) Tea with cream 2) Orange juice 3) Gelatin 4) Skim milk

Gelatin

The patient tells the nurse, Im so nervous. I want to be knocked out for the surgery so that I dont know what is going on. When the nurse communicates with the surgeon and anesthetist, she tells them that the patient desires which type of anesthesia? 1) Conscious sedation 2) General anesthesia 3) Local anesthesia 4) Regional anesthesia

General anesthesia

6. The surgical unit is experiencing difficulty recruiting new RNs, although the hospital has an excellent reputation in the community and has no difficulty recruiting nurses for other units. A task force has been formed, consisting of one nurse from each shift on the unit, the unit manager, and the hospital nurse recruiter. The group has gathered data and identified the problem. What is the next step in this process? Generate possible solutions. Evaluate whether the problem has been resolved. Implement the solution changes. Evaluate suggested solutions.

Generate possible solutions.

The nurse is removing personal protective equipment (PPE). Which item should be removed first? 1) Gown 2) Gloves 3) Face shield 4) Hair covering

Gloves

Which intervention by the nurse helps to establish a trusting nurse patient relationship? 1) Avoiding topics that may provoke emotional responses from the patient 2) Listening to the patient while performing care activities 3) Performing care interventions quietly without explanation 4)Greeting the patient by name whenever entering the patients room

Greeting the patient by name whenever entering the patients room

The nurse admits beta adrenergic agent to a patient with CHF. What assessment findings would indication the drug was working:

HR changes from 92 to 76

What is the most frequent cause of the spread of infection among institutionalized patients? 1) Airborne microbes from other patients 2) Contact with contaminated equipment 3) Hands of healthcare workers 4) Exposure from family members

Hands of healthcare workers 1) Airborne microbes from other patients 2) Contact with contaminated equipment 3) Hands of healthcare workers 4) Exposure from family member

A mother of three young children is newly diagnosed with breast cancer. She is intensely committed to fighting the cancer. She believes she can control her cancer to some degree with a positive attitude and feelings of inner strength. Which of the following traits is she demonstrating that is linked to health and healing? Invincibility Hardiness Baseline strength Vulnerability

Hardiness

The nurse working in the ED is preparing heat therapy for one of the patients in the unit. Which one is it most likely to be?

Has lower back pain

7. A nurse with 2 years experience frequently appears stressed and has difficulty completing his work. He is clocking out 30 to 45 minutes late every day, even when his assignment load is light. The charge nurse describes his problem as running from one duty to the next and having no organization or daily routine. Which situation most likely describes this nurse? Has time management problems Has a heavy patient load Works at a hospital that is understaffed Is in a management position

Has time management problems

The nurse measures the urine output of a patient who requires a bedpan to void. Which action should the nurse take first? Put on gloves and: 1) Have the patient void directly into the bedpan. 2) Pour the urine into a graduated container. 3) Read the volume with the bedpan on a flat surface at eye level. 4) Observe color and clarity of the urine in the bedpan.

Have the patient void directly into the bedpan.

1. A client informs the nurse that he has quit smoking because his father died from lung cancer 3 months ago. Based on his motivation, smoking cessation should be recognized as an example of which of the following? Healthy living Health promotion Wellness behaviors Health protection

Health protection

The nurse is seeing a 20-year-old client with UTI at the women's health clinic. The client says to the nurse; It seems to me more women get uti than men why is this?

Hormone changes during pregnancy and pressure of the uterus on the bladder can make women more prone to UTIs

A patient is prescribed furosemide (Lasix), a loop diuretic, for treatment of congestive heart failure. The patient is at risk for which electrolyte imbalance associated with use of this drug? 1) Hypocalcemia 2) Hypokalemia 3) Hypomagnesemia 4) Hypophosphatemia

Hypokalemia

After instructing a mother about nutrition for a preschool-age child, which statement by the mother would indicate correct understanding of the topic? 1) I usually use dessert only as a reward for eating other foods. 2) I will hide vegetables in casseroles and stews to get my child to eat them. 3) I do not give my child snacks; they simply spoil his appetite for meals. 4) I know that lifelong food habits are developed during this stage of life.

I know that lifelong food habits are developed during this stage of life.

After a physician discusses cancer treatment options with a patient, the patient asks the nurse which treatment he should choose. Which response by the nurse is best? 1) If I were you, Id choose chemotherapy. 2) You should choose radiation therapy. 3) Why dont you see what your wife thinks. 4) Ill give you some information about each option.

Ill give you some information about each option.

A patient comes to the emergency department complaining of severe, substernal chest pain. He is restless and anxious. Which statement by the nurse appropriately offers reassurance? 1) Ill give you some medication to help relieve the pain. 2) If you lie still and relax, youll be fine in a little while. 3) Everything is going to be okay. 4) Dont worry; were going to take good care of you

Ill give you some medication to help relieve the pain.

Which statement by the nurse indicates that the nurse patient relationship is entering the termination phase? 1) Ill be admitting you to our nursing unit as soon as I obtain your health history? 2) You seem upset today. Would you like to talk about whatever is bothering you? 3) Im leaving for the day. Is there anything I can do for you before I leave? 4) Hello. My name is Judith and Im your nurse today.

Im leaving for the day. Is there anything I can do for you before I leave?

A patient is on strict bed rest for 5 days. During this time he has not had a bowel movement; normally, he passes stools daily. He describes feeling bloated and uncomfortable. What information should the nurse give the patient when explaining constipation? 1) Immobility often causes constipation. 2) A stool softener daily will relieve the problem. 3) Use of a bedpan results in bloating and constipation. 4) A low-fiber diet will resolve the problem.

Immobility often causes constipation.

A patient is on strict bed rest for 5 days. During this time he has not had a bowel movement; normally, he passes stools daily. He describes feeling bloated and uncomfortable. A nursing diagnosis that would best address a patient who is on bed rest is Constipation related to: 1) Change in previous pattern. 2) Immobility. 3) Dietary intake. 4) Change in environment.

Immobility.

A patient who speaks little English is admitted to the hospital after experiencing severe abdominal pain. Which nursing diagnosis is preferred for this patient? 1) Impaired Communication 2) Readiness for Enhanced Communication 3) Impaired Verbal Communication 4) Sensory Alteration

Impaired Communication

A 2-year-old child is scheduled for a tonsillectomy. When determining the plan of care, the nurse should: 1) Include the parents or caregivers in the plan of care. 2) Explain to the child that she will have a sore throat after surgery. 3) Tell the child that she can have her favorite foods for the first 24 hours after surgery. 4) Prepare the child for discharge from the hospital as soon as she is alert.

Include the parents or caregivers in the plan of care.

A patient develops localized heat and erythema over an area on the lower leg. These findings are indicative of which secondary defense against infection? 1) Phagocytosis 2) Complement cascade 3) Inflammation 4) Immunity

Inflammation

When the nurse enters a patients room to administer a medication, he calls out from the bathroom telling her to leave his medication on the bedside table. He reassures her that he will take the medication as soon as he is finished. How should the nurse proceed? 1) Inform the patient that she will return when he is finished in the bathroom. 2) Wait outside the bathroom door until the patient is ready for the dose. 3) Withhold the dose until the next administration time later in the day. 4) Document that the dose was omitted in the medication administration record.

Inform the patient that she will return when he is finished in the bathroom.

A patient is admitted from a local skilled nursing facility to the outpatient surgery center for surgical dbridement of a stage IV sacral pressure ulcer. The perioperative nurse discovers that the patient does not have a signed consent form for the surgery on the chart or in the surgery center. The patient says that she has not talked to the surgeon and that she has many questions regarding her surgery. When informed of this, the surgeon tells the nurse to have the patient sign the informed consent form, and he will review it prior to the surgery. What should the nurse do? 1) Follow the surgeons orders, and ask the patient to sign the surgical consent form. 2) Inform the surgeon that she will have the patient sign after he discusses the surgery with the patient. 3) Ensure that the signed surgical consent is witnessed by two nurses, because the surgeon is not available. 4) Cancel the surgery and transfer the patient back to the long-term care facility.

Inform the surgeon that she will have the patient sign after he discusses the surgery with the patient.

A patient with pitted edema in the feet and ankles has excess volume in which fluid compartment?

Interstitial

A patient who just returned from the postanesthesia care unit is complaining of severe incision pain. Which drug contained in his medication administration record will offer him the fastest relief? 1) Liquid acetaminophen with codeine 2) Intravenous morphine sulfate 3) Intramuscular meperidine 4) Oral oxycodone tablets

Intravenous morphine sulfate

A patient is scheduled for abdominal surgery tomorrow. While gathering preoperative data, the nurse learns that the patient takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E 1,500 IU. The patient reports that he stopped taking the anticoagulant 4 days ago as instructed by the surgeon. He has continued to take the multivitamin and vitamin E. Based on the information given, the nurse telephones the surgeon because she: 1) Needs an order to restart the anticoagulant. 2) Is concerned about continued use of the multivitamin. 3) Is concerned about the vitamin E dosage. 4) Thinks the surgery should be delayed until further notice.

Is concerned about the vitamin E dosage.

Which collaborative interventions will help prevent paralytic ileus in a patient who underwent right hemicolectomy for colon cancer? 1) Administering morphine 4 mg intravenously every 2 hours for pain 2) Administering IV fluids at 125 ml/hr 3) Inserting an indwelling urinary catheter to monitor I&O 4) Keeping the patient NPO until bowel sounds return

Keeping the patient NPO until bowel sounds return

Which factor in a patients medical history is most likely to prolong the half-life of certain drugs? 1) Heart disease 2) Liver disease 3) Rheumatoid arthritis 4) Tobacco use

Liver disease

The nursing student is preparing to administer Lisinopril to her patient but does not know what Lisinopril is used for. What is the appropriate action:

Look up Lisinopril in a med reference text

An older patient with newly diagnosed osteoporosis asks the nurse to explain her health problem. Which of the following is the correct description of osteoporosis? 1) Loss of bone density that increases the risk of fracture 2) Degenerative joint disease that produces pain and decreased function 3) Chronic inflammatory joint disease that must be treated with steroids 4) Serious infection in the bone that must be treated with antibiotics

Loss of bone density that increases the risk of fracture

How can the nurse best provide teaching for a patient whose primary spoken language is not the same as hers? 1) Provide written materials in the patients primary language. 2) Make arrangements to teach using an interpreter. 3) Provide a demonstration and request a return demonstration. 4) Use visual teaching aids to convey information.

Make arrangements to teach using an interpreter.

The nurse administers sublingual nitroglycerine, a vasodilator, to a patient diagnosed with angina. When the patient's chest pain is not relived, the nurse prepares to give another tablet. What should she do first:

Measure the patients BP

The nurse caring for patient with recurrent abd pain of unknown origin addresses the patient t by name and puts her hand on her shoulder and offers reassuring words: you'll be okay. Try not to think about things too much:

Message provides false reassurance

The nurse received a prescription to obtain a urinalysis and microscopic analysis. When is the ideal time of the day for the nurse to collect:

Morning

Which of the following instructions is most important for the nurse to include when teaching a mother of a 3-year-old about protecting her child against accidental poisoning? 1) Store medications on countertops out of the childs reach. 2) Purchase medication in child-resistant containers 3) take medications in front of the child, and explain that they are for adults only. 4) Never leave the child unattended around medications or cleaning solutions.

Never leave the child unattended around medications or cleaning solutions.

When using the SBAR model to communicate with a physician, what information does the nurse offer first? 1) Statement of the problem and its probable cause 2) Nurses name, patients name, and reason for the communication 3) History of information related to and leading up to the reason for the communication 4) What the nurse thinks will correct the problem or what is needed from the physician

Nurses name, patients name, and reason for the communication

The nurse is inserting an indwelling urinary catheter for a female patient Upon insertion of the catheter the nurse accidentally touches the patient leg and bed sheet with the tip of the catheter:

Obtain a new catheter and reinsert it using sterile technique

While performing a physical assessment, the student nurse tells her instructor that she cannot palpate her patients bladder. Which statement by the instructor is best? You should: 1) Try to palpate it again; it takes practice but you will locate it. 2) Palpate the patients bladder only when it is distended by urine. 3) Document this abnormal finding on the patients chart. 4) Immediately notify the nurse assigned to your patient.

Palpate the patients bladder only when it is distended by urine.

The nurse assesses a patients abdomen 4 days after abdominal surgery and notes that bowel sounds are absent. This finding most likely suggest which postoperative complication? 1) Paralytic ileus 2) Small bowel obstruction 3) Diarrhea 4) Constipation

Paralytic ileus

A nurse is caring for a 25-year-old male quadriplegic patient. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility? 1) Active ROM 2) Turning the patient every 2 hours 3) Passive ROM 4) Administering glucosamine supplements

Passive ROM

5. Within the past month, there has been a change in the nursing documentation requirements at the hospital. The nurses have been trained in the new requirements and are documenting as requested, with the exception of one nurse. This nurse has been unable to attend any of the documentation in-service meetings and has been too busy to attend a private training session with the nurse manager. Meanwhile, she continues to use the old documentation process. What do the nurses actions illustrate? Unfreezing Active resistance Passive resistance Comfort zone

Passive resistance

Which is the most commonly reported incident in hospitals? 1) Equipment malfunction 2) Patient falls 3) Laboratory specimen errors 4) Treatment delays

Patient falls

Which outcome is appropriate for the patient who underwent urinary diversion surgery and creation of an ileal conduit for invasive bladder cancer? 1)Patient will resume his normal urination pattern by (target date). 2) Patient will perform urostomy self-care by (target date). 3) Patient will perform self-catheterization by (target date). 4) Patients urine will remain clear with sufficient volume.

Patient will perform urostomy self-care by (target date).

For which patient might the nurse use the diagnosis of Risk for Ineffective Renal Tissue Perfusion:

Patient with hypertension who is noncompliant with med administration

A patient had a hiatal hernia repair earlier today and is now in the postanesthesia care unit (PACU). The family asks the nurse why the patient is in the PACU rather than back in his room on the postsurgical unit. The nurse should inform the family that: 1) Patients who have had surgical complications are observed in the PACU until they are stable enough to return to the floor. 2) Patients recover from the effects of anesthesia in the PACU and then return to the postsurgical unit for further care. 3) The PACU is a holding area for patients awaiting a surgical unit bed or awaiting adequate staff to provide care on the postsurgical unit. 4) The nurse will ask the surgeon explain to them why the patient is not on the postsurgical unit, as is the usual procedure

Patients recover from the effects of anesthesia in the PACU and then return to the postsurgical unit for further care.

The nurse checks a patients pupils using a penlight. Which receptors is the nurse stimulating? 1) Chemoreceptors 2) Photoreceptors 3) Proprioceptors 4) Mechanoreceptors

Photoreceptors

The primary care provider prescribes nitroglycerin 1/150 g SL for a patient experiencing chest pain. How should the nurse administer the drug? 1) Place the drug in the cheek and allow it to dissolve. 2) Place the drug under the tongue and allow it to dissolve. 3) Inject the drug superficially into the subcutaneous tissue. 4) Give the pill and water to the patient for him to swallow the tablet.

Place the drug under the tongue and allow it to dissolve.

How should the nurse dispose of a contaminated needle after administering an injection? 1) Place the needle in a specially marked, puncture-proof container. 2) Recap the needle, and carefully place it in the trash can. 3) Recap the needle, and place it in a puncture-proof container. 4) Place the needle in a biohazard bag with other contaminated supplies.

Place the needle in a specially marked, puncture-proof container.

How should the nurse dispose of the breakfast tray of a patient who requires airborne isolation? 1) Place the tray in a specially marked trash can inside the patients room. 2) Place the tray in a special isolation bag held by a second healthcare worker at the patients door. 3) Return the tray with a note to dietary services so it can be cleaned and reused for the next meal. 4) Carry the tray to an isolation trash receptacle located in the dirty utility room and dispose of it there.v

Place the tray in a special isolation bag held by a second healthcare worker at the patients door.

The nurse is caring for a patient with dementia who becomes agitated every evening. Which intervention by the nurse is best for calming this patient? 1) Encouraging family members to visit only during the day 2) Applying wrist restraints during periods of agitation 3) Playing soft, calming music during the evening 4) Administering lorazepam (a tranquilizer)

Playing soft, calming music during the evening

The nurse is planning care for a 70-year-old patient newly admitted with a medical diagnosis of pneumonia, and a nursing diagnosis of ineffective airway clearance. Which is the nurse's priority intervention:

Position to optimize max ventilation

A patient is admitted for hip surgery. The patient usually takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E 1,500 IU. He stopped taking his anticoagulant 4 days ago as instructed by his surgeon, but has continued to take the multivitamin and vitamin E. An important collaborative problem or nursing diagnosis for this patient is which of the following? 1) Potential complication: anemia 2) Risk for infection related to inadequate anticoagulant dosage 3) Risk for noncompliance related to inability to follow instructions 4) Potential complication: increased bleeding

Potential complication: increased bleeding

Which laboratory test result most accurately reflects a patients nutritional status? 1) Albumin 2) Prealbumin 3) Transferrin 4) Hemoglobin

Prealbumin

3. A graduate nurse completed her nursing education 3 weeks ago and has just begun work at the local hospital. She is orienting to her new position with an experienced nurse, one who has been an RN for 15 years and an employee at the hospital for 7 years. She will provide guidance and practical teaching to the new graduate as she assumes a new position in the nursing unit. What role is the experienced RN assuming? Mentor Manager Preceptor Leader

Preceptor

Teratogenic drugs should be avoided in which patient population? 1) Pregnant women 2) Elderly 3) Children 4) Adolescents

Pregnant women

The focus of nursing activities in the preoperative phase is to: 1) Admit the patient to the surgical suite. 2) Prepare the patient mentally and physically for surgery. 3) Set up the sterile field in the operating room. 4) Perform the primary surgical scrub to the surgical site.

Prepare the patient mentally and physically for surgery.

Which action should the nurse take to assess a 2-year-old child for pinworms? 1) Press clear cellophane tape against the anal opening to obtain a specimen. 2) Collect a freshly passed stool from a diaper using a wooden spatula. 3) Place a smear of stool on a slide and add two drops of reagent. 4) Prepare the patient for a flat plate (x-ray) of the abdomen.

Press clear cellophane tape against the anal opening to obtain a specimen.

Which nutrient deficiency increases the risk for pressure ulcers? 1) Carbohydrate 2) Protein 3) Fat 4) Vitamin K

Protein

The nurse must administer eardrops to an infant. How should she proceed? 1) Pull the pinna down and back before instilling the drops. 2) Pull the pinna upward and outward before instilling the drops. 3) Instill the drops directly; no special positioning is necessary. 4) Position the patient supine with the head of the bed elevated 30.

Pull the pinna down and back before instilling the drops.

What would be the most appropriate goal for a frail, elderly patient with a nursing diagnosis of Risk for Injury after hip surgery? 1) Remain free from injury or falls throughout hospital stay. 2) Increase activity tolerance by discharge from hospital. 3) Demonstrate effective breathing when ambulating. 4) Increase mobility by discharge from hospital.

Remain free from injury or falls throughout hospital stay.

The nurse has stated to infuse tome first of 2 units of prbc on her patient: What is the best cation:

Remain with the patient for the first 15 mints of the infusion

While donning sterile gloves, the nurse notices the edges of the glove package are slightly yellow. The yellow area is over 1 inch away from the gloves and only appears to be on the outside of the glove package. What is the best action for the nurse to take at this point? 1) Continue using the gloves inside the package because the package is intact. 2) Remove gloves from sterile field and use a new pair of sterile gloves. 3) Throw all supplies away that were to be used and begin again. 4) Use the gloves and make sure the yellow edges of the package do not touch the client.

Remove gloves from sterile field and use a new pair of sterile gloves.

A nurse is teaching a group of mothers about first aid. Should poison come in contact with their childs clothing and skin, which action should the nurse instruct the mothers to take first? 1) Remove the contaminated clothing immediately. 2) Flood the contaminated area with lukewarm water. 3) Wash the contaminated area with soap and water and rinse. 4) Call the nearest poison control center immediately

Remove the contaminated clothing immediately.

What is the correct method for turning an adult patient who recently sustained a spinal cord injury? 1) Ask the patient to assist with the turn by holding the side rails of the bed. 2) Place a draw sheet under the patient to assist with turning. 3) Request help from another nurse to perform the logrolling technique. 4) Use a mechanical lift for safe turning and protecting the nurses back.

Request help from another nurse to perform the logrolling technique.

A patient who speaks only French was admitted to the hospital after a motor vehicle accident. Assuming that the nurse does not speak French, what is the best way to communicate with this patient? 1) Use sign language for communicating. 2) Ask a family member to serve as a translator. 3) Request the services of a hospital translator. 4) Speak in English, but speak very slowly.

Request the services of a hospital translator.

Which nutritional goal is appropriate for a patient newly diagnosed with hypertension? The patient will: 1) Limit his intake of protein. 2) Avoid foods containing gluten. 3) Restrict his use of sodium. 4) Limit his intake of potassium-rich foods.

Restrict his use of sodium.

Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis? 1) Risk for Falls 2) Risk for Ineffective Airway Clearance (choking) 3) Risk for Poisoning 4) Risk for Suffocation (drowning)

Risk for Falls

Which nursing diagnosis has the highest priority for a patient with impaired tactile perception? 1) Self-Care Deficit: Dressing and Grooming 2) Impaired Adjustment 3) Risk for Injury 4) Activity Intolerance

Risk for Injury

The school nurse at a local elementary school is performing physical fitness assessments on the third-grade children. When assessing students cardiorespiratory fitness, the most appropriate test is to have the students: Step up and down on a 12-inch bench. Perform the sit-and-reach test. Run a mile without stopping, if they can. Perform range-of-motion exercises.

Run a mile without stopping, if they can.

Which of the following is the most appropriate nursing goal for a 2-year-old who is to have a tonsillectomy? 1) Separation anxiety will be minimal. 2) The child will verbalize understanding of expected pain. 3) The child will tolerate a normal diet 24 hours after surgery. 4) The parent will indicate readiness to assume the childs care.

Separation anxiety will be minimal.

The nurse is caring for an elderly woman with dementia who is frightened in the hospital room. Empathy and compassion:

Shut the patient's door in the hall if there is noise or loud talking

The wife of an elderly patient begins crying after she is informed that he is has a terminal illness. Which intervention by the nurse is best? 1) Sit quietly with the patients wife and allow her to compose her thoughts. 2) Inform the wife that a chaplain is available if she would like to speak to him. 3) Remind the wife that her husband has lived a long and useful life. 4) Tell the wife there are always options and suggest she not give up hope.

Sit quietly with the patients wife and allow her to compose her thoughts.

A 15-year-old patient complains of left ankle pain after being tackled while playing football. He asks the nurse what tests he needs to have to determine if he has a strain or a fracture. How should the nurse reply? 1) You dont need an x-ray; I can tell by the way your ankle looks and feels whether you have a strain or fracture. 2) Sprains, strains, and fractures have similar symptoms at first; you will need an x-ray of the joint to be certain. 3) We will need to get a venous Doppler study to make sure that there is not a fracture. 4) An arterial Doppler will show whether the blood flow is interrupted, which is common for fractures but not for strains.

Sprains, strains, and fractures have similar symptoms at first; you will need an x-ray of the joint to be certain.

While receiving an intravenous dose of an antibiotic, levofloxacin, a patient develops severe shortness of breath, wheezing, and severe hypotension. Which action should the nurse take first? 1) Administer epinephrine IM. 2) Give bolus dose of intravenous fluids. 3) Stop the infusion of medication. 4) Prepare for endotracheal intubation.

Stop the infusion of medication.

A patient complains that she passes urine whenever she sneezes or coughs. How should the nurse document this complaint in the patients healthcare record? 1) Transient incontinence 2) Overflow incontinence 3) Urge incontinence 4) Stress incontinence

Stress incontinence

A patient being admitted in hypertensive crisis informs the nurse that he stopped taking his blood pressure medication 3 weeks ago. Which response by the nurse is best? 1) Youre lucky you didnt have a stroke; you really need to take your medication. 2) Tell me more about your experience with your high blood pressure medication. 3) Why did you stop taking your high blood pressure medication? 4) Its very important to take your blood pressure medication

Tell me more about your experience with your high blood pressure medication.

A 55-year-old man suffered a myocardial infarction (heart attack) three months ago. During his hospitalization, he had stents inserted in two locations in the coronary arteries. He was also placed on a cholesterol-lowering agent and two antihypertensives. What type of care is he receiving? Primary prevention Secondary prevention Tertiary prevention Health promotion

Tertiary prevention

An 82-year-old patient is unsteady on her feet when transferring her position in the room. She reports feeling a little sore but has no complaints of weakness. What is the appropriate piece of equipment to use when helping her ambulate? 1) Mechanical lift 2) Transfer belt 3) Draw sheet 4) Transfer board

Transfer belt

1. The preoperative phase encompasses which period of time? 1) Entry to the operating suite until admission to postanesthesia care 2) Entry into the operating suite until discharge from the hospital 3) The decision to have surgery until admission to postanesthesia care 4) The decision to have surgery until entry to the operating suite

The decision to have surgery until entry to the operating suite

In the Leavell and Clark model of health protection, the chief distinction between the levels of prevention is: The point in the disease process at which they occur. Placement on the Wheels of Wellness. The level of activity required to achieve them. Placement in the Model of Change.

The point in the disease process at which they occur.

The student nurse asks the provider if she will prescribe an indwelling urinary catheter for a hospitalized patient who is incontinent. The provider explains that catheters should be utilized only when absolutely necessary because: 1) They are the leading cause of nosocomial infection. 2) They are too expensive for routine use. 3) They contain latex, increasing the risk for allergies. 4) Insertion is painful for most patients.

They are the leading cause of nosocomial infection.

The nurse is providing teaching for a weight loses group on the cardia dangers of obesity. Which statement if made by the nurse would be incorrect?

Tissue perfusion is diminished by obesity

The nurse caring for a frail, malnourished, immobile patient recognizes which of the following as the best treatment to protect the patients integument? 1) Offering the patient 6 small meals a day 2) Assisting the patient to sit in a chair 3 times a day 3) Turning the patient at least every 2 hours 4) Administering fluid boluses as directed by the healthcare provider

Turning the patient at least every 2 hours

4. What is the first stage of the complex process of change? Recognizing resistance Unfreezing Forming a comfort zone Actively resisting

Unfreezing

After sustaining a stroke, the patient lacks attention to the right side of his body. Which nursing diagnosis is best describes the patients problem? 1) Disturbed Sensory Perception 2) Unilateral Neglect 3) Risk for Peripheral Vascular Dysfunction 4) Acute Confusion

Unilateral Neglect

Which is one of the greatest concerns with heavy and chronic use of alcohol in teens and young adults? Liver damage Unintentional death Tobacco use Obesity

Unintentional death

A patient has difficulty taking liquid medications from a cup. How should the nurse administer the medications? 1) Request that the physician change the order to the IV route. 2) Administer the medication by the IM route. 3) Use a needleless syringe to place the medication in the side of the mouth. 4) Add the dose to a small amount of food or beverage to facilitate swallowing.

Use a needleless syringe to place the medication in the side of the mouth.

The nurse must administer hepatitis B immunoglobulin 0.5 mL intramuscularly to a 3-day-old infant born to an HB Ag-positive mother. Which injection site should the nurse choose to administer this injection? 1) Ventrogluteal 2) Vastus lateralis 3) Deltoid 4) Dorsogluteal

Vastus lateralis

The patient has shiny ulcerations on a red base over the medial calf of the right leg. There is quite a bit of fluid drainage. He takes anticoagulants because of recurrent DVT he also reports a sedentary lifestyle. How would the nurse classify this chronic wound?

Venous stasis ulcer

The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse should explain that ingestion of which substance may cause a false-negative fecal occult blood test? 1) Vitamin D 2) Iron 3) Vitamin C 4) Thiamine

Vitamin C

The nurse is assessing an elderly male in the nursing home. What question will the nurse ask this patient:

What is your name and todays day> Can you tell me where you are?

Which food provides the body with no usable glucose? 1) Wheat germ 2) Apple 3) White bread 4) White rice

Wheat germ

The nurse has a prescription to give a series of medications on an on call basis. The nurse realizes that these medications will be given: 1) In the postanesthesia recovery unit. 2) At the time specified in the order. 3) On the patients arrival in the surgery suite. 4) When the OR staff notify the nurse to do so.

When the OR staff notify the nurse to do so.

What is the best technique for obtaining a sterile urine specimen from an indwelling urinary catheter? 1) Use antiseptic wipes to cleanse the meatus prior to obtaining the sample. 2) Briefly disconnect the catheter from the drainage tube to obtain sample. 3) Withdraw urine through the port using a needleless access device. 4) Obtain the urine specimen directly from the collection bag.

Withdraw urine through the port using a needleless access device.

A patient complains to the nurse that since taking a medication he has suffered from excessively dry mouth. What term should the nurse use to document this complaint 1) Exophthalmos 2) Anosomia 3) Insomnia 4) Xerostomia

Xerostomia

A patient is diagnosed with an intestinal infection after traveling abroad. The nurse should encourage the intake of which food to promote healing? 1) Yogurt 2) Pasta 3) Oatmeal 4) Broccoli

Yogurt

. A patient with morbid obesity was enrolled in a weight loss program last month and has attended four weekly meetings. But now he believes he no longer needs to attend meetings because he has learned what to do. He informs the nurse facilitator about his decision to quit the program. What should the nurse tell him? By now you have successfully completed the steps of the change process. You should be able to successfully lose the rest of the weight on your own. Although you have learned some healthy habits, you will need at least another 6 weeks before you can quit the program and have success. You have done well in this program. However, it is important to continue in the program to learn how to maintain weight loss. Otherwise, you are likely to return to your previous lifestyle. You have entered the determination stage and are ready to make positive changes that you can keep for the rest of your life. If you need additional help, you can come back at a later time.

You have done well in this program. However, it is important to continue in the program to learn how to maintain weight loss. Otherwise, you are likely to return to your previous lifestyle.

Which statement by the nurse manager demonstrates an assertive approach? 1) You must assess and document pain status for every patient. 2) Why havent you been assessing and documenting pain for every patient? 3) Will you please assess and document pain status for every patient? 4) Explain why you havent been assessing and documenting pain for every patient.

You must assess and document pain status for every patient.

The nurse assess assigned patients and determines which is at highest risk for altered skin integrity

Young adult in traction who has a low protein diet and dehydration

The nurse is caring for patient after abd surgery and notice that his urine is blood tinged. She places a call the primary physician regarding the color of the using SBAR: R:

Your patient has blood tinged urine after surgery I suggest that we obtain a urinalysis for this patient

A 16-year-old was hospitalized 3 weeks ago. He has been confined to bed throughout his hospital stay because of a crushed pelvis. His parents tell the nurse, Our son is just staring off into space; he wont talk to us. We are worried because he has not even listened to his music CDs, watched television, or played his video games for 2 days. That is so unlike him. What is the best response the nurse can make? 1) I will inform his physician and see if we can get your son started on an antidepressant. 2) He is at a critical time in his life; adolescents are often moody, and being in the hospital with an injury will only make that worse. 3) Your son had a major injury, and his immobility can cause feelings of isolation and depression. 4) He is bored because he has been in the hospital for 3 weeks; Ill try to find some new activities for him.

Your son had a major injury, and his immobility can cause feelings of isolation and depression.

A patient who has a temperature of 101F (38.3C) most likely requires: 1) acetaminophen (Tylenol). 2) increased fluids. 3) bedrest. 4) tepid bath.

increased fluids.

The quality and risk nurse in the local hospital is performing hospital survey on sentinel events best description:

an unexpected event involving death or serious physical or psychological injury

While easting in the hospital cafe the nurse sees a visitor display choking what is the first action:

assess for ineffective breathing are you choking?

The nurse is invited to a childcare cent. I think one of the children swallowed poison what is the first action:

call 911 immediate

A patient infected with a virus but who does not have any outward sign of the disease is considered a: 1) Droplet transmission 2) Airborne transmission 3) Direct contact 4) Indirect contact

carrier

The nurse caring for several patients on the intermediate care unit considers which of the following patients to be most at risk for developing an infection:

central venous catheter

A patient's catheter bag is empty 2 hours after it was drained. The nurse first action is to

check for kinks or compression

For which patient could the nurse collect a sputum specimen without suction:

chronic bronchitis

The patient in the ICU has developed UTI related to the indwelling catheter what type of infection

nosocomial

An insulin dependent diabetic patient tells the nurse that she is giving her inject in the same spot best action:

provide teaching on rotating sites

A new farther begins to hyperventilate as his baby is about to be born he becomes light headed. The nurse instructs him to breath into a paper bag until his breathing slows. When he feels better he asks the nurse why using the paper bag helped:

rebreathe CO2 to correct respiratory alkalosis

Before administering a medication, the nurse must verify the rights of medication administration, which include: 1) right patient, right room, right drug, right route, right dose, and right time. 2) right drug, right dose, right route, right time, right physician, and right documentation. 3) right patient, right drug, right route, right time, right documentation, and right equipment. 4) right patient, right drug, right dose, right route, right time, and right documentation.

right patient, right drug, right dose, right route, right time, and right documentation.

The nurse in the ED admits a patient with a gunshot wound to the lower abdomen accompanied by heavy bleeding. What type of drainage does the nurse expect to see:

sanguineous

The nurse will teach the community based client that the most common cause of injury related to house fire is

smoke inhalation

The nursing student is assignment to care for patient who has just been diagnosed with advance stage cancer. That patient is very upset and crying I don't know with to do my patient just can't stop crying best respond:

sometimes just sitting with patient and remaining silent can be the best care

The nurse is performing a colostomy irrigation on a male client during the irrigation the client begins to complain of abdominal cramps what does the action the nurse needs to take

stop irrigation temporarily

Which procedure can the nurse safely delegate to the CNA

suctioning the laryngopharynx