Adult 1 Test 2
Which intervention would be part of the plan of care for a patient who has new vision loss? a. Allow the patient to express feelings of grief and anger. b. Have the UAP perform all self-care activities for the patient. c. Address any family present first when discussing care concerns. d. Speak loudly and clearly, addressing the patient with each contact.
a. Allow the patient to express feelings of grief and anger. Relatively easy - LOSS - Stages of Grief... answer A Note.. b NOT.. we need to keep our patient's independence, c - never - we never will address family first (we address the patient first), and d - well, patient has vision loss, not hearing loss.. so why speak loudly?
What should be included in the discharge teaching for the patient who had cataract surgery (select all that apply)? a. Eye discomfort is often relieved with mild analgesics. b. A decline in visual acuity is common for the first week. c. Stay on bed rest and limit activity for the first few days. d. Notify the provider if an increase in redness or drainage occurs. e. Following activity restrictions is essential to reduce intraocular pressure.
a. Eye discomfort is often relieved with mild analgesics. d. Notify the provider if an increase in redness or drainage occurs. e. Following activity restrictions is essential to reduce intraocular pressure.
After admitting a postoperative patient to the clinical unit, which assessment data require the most immediate attention? a. O2 saturation of 85% b. Respiratory rate of 13/min c. Temperature of 100.4°F (38°C) d. Blood pressure of 90/60 mm Hg
a. O2 saturation of 85% Although I am going to give you the normal values, a is standing out!! (again.. airway breathing circulation).. I would not be as worried about b, I will not be worried about c (we often get a temperature increase due to inflammation after surgery), and d, yes could be correct, although I would like to see in the scenario what is his baseline.. so back to question.. MOST IMMEDIATE ATTENTION.. thus ABC.. confirming A as the correct answer.
Which patient behaviors would the nurse promote for healthy eyes (select all that apply)? a. Protective sunglasses when bicycling b. Taking part in a smoking cessation program c. Supplementing diet intake of vitamin C and beta-carotene d. Washing hands thoroughly before putting in or taking out contact lenses e. A woman avoiding pregnancy for 4 weeks after receiving MMR immunization
a. Protective sunglasses when bicycling b. Taking part in a smoking cessation program c. Supplementing diet intake of vitamin C and beta-carotene d. Washing hands thoroughly before putting in or taking out contact lenses Ok, we did not discuss in detail.. a) yes, always a good option to protect eyes, b) yes, because we know it may increase risk of retinopathy, c - yes (remember your mother.. "eat your carrots - beta-carotene, d - yes alwys.. e - MMR (measles, mump rubella vaccination) - is does not GIVE rubella, it prevents it. And, rubella during pregnancy may cause blindness in the child; also, MMR is not live vaccine.. so you do not get the live virus!
The nurse is caring for a patient undergoing surgery for a knee replacement. What is critical to the patient's safety during the procedure (select all that apply)? a. Universal protocol is followed. b. The ACP is an anesthesiologist. c. The patient has adequate health insurance. d. The patient's family is in the surgery waiting area. e. The patient's allergies are conveyed to the surgical team.
a. Universal protocol is followed. e. The patient's allergies are conveyed to the surgical team. Universal protocol - don't get confused with Standard precautions.. universal protocol = refer to procedures to keep patient from WRONG SITE SURGERY and safety.. b.. don't care - if they don't give abbreviation unlikely it is important. Rule out b (they will write out abbreviation), c - not your role or problem! d - important but not CRITICAL TO SAFETY (look at question), e - allergies conveyed
A 17-yr-old patient with a leg fracture who is scheduled for surgery is an emancipated minor. She has a statement from the court for verification. Which intervention is most appropriate? a. Witness the permit after the surgeon obtains consent. b. Call a parent or legal guardian to sign the permit since the patient is under 18. c. Notify the hospital attorney that an emancipated minor is consenting for surgery. d. Obtain verbal consent since written consent is not necessary for emancipated minors.
a. Witness the permit after the surgeon obtains consent. emancipated means she is living on her own and not any parent involvement - she is normally not allowed to sign for a procedure if <18.. but.. parents not in her life
The nurse's primary responsibility for the care of the patient undergoing surgery is a. developing an individualized plan of nursing care for the patient. b. carrying out specific tasks related to surgical policies and procedures. c. ensuring that the patient has been assessed for safe administration of anesthesia. d. performing a preoperative history and physical assessment to identify patient needs.
a. developing an individualized plan of nursing care for the patient. the purpose of "plan of care" is to address the needs of the patients.. b is not the nurse's role (think of TIMEOUT initiated by the SURGEON c is not the nurse's role d = I initially said d.. my reason was that is correct.. BUT yes, this is one of THOSE questions to recognize.. when HESI, NCLEX, Lewis think about nursing responsibility of care.. their answer is "INDIVIDUALIZED PLAN OF NURSING CARE"!
Common age-related changes in the auditory system include (select all that apply) a. drier cerumen. b. tinnitus in both ears. c. auditory nerve degeneration. d. atrophy of the tympanic membrane. e. greater ability to hear high-pitched sounds.
a. drier cerumen. b. tinnitus in both ears. c. auditory nerve degeneration. d. atrophy of the tympanic membrane. ok.. this we don't know.. and common questions in exams on how SENSORY functions (and MOTOR functions) change in older patients.. so you need to check these on internet and your textbook to answer (remember ALSO to go back to VISION content and check the VISION CHANGES for older patients
Care of the patient experiencing an acute attack of Ménière's disease includes (select all that apply) a. giving antiemetics as needed. b. implementing fall precautions. c. keeping the room dark and quiet. d. placing the patient on NPO status. e. ambulating in the hall independently.
a. giving antiemetics as needed. b. implementing fall precautions. c. keeping the room dark and quiet. THis is important.. the one detail disorder we looked at.. but see if we can work it out.. (if you know Meniere syndrome - tinnitus, vertigo, dizziness which often causes nausea.. so a yes, b yes c yes , d no e no.. check the answer to see if we correct, if not.. try to think WHY we not correct
The patient who has a conductive hearing loss a. hears better in a noisy environment. b. hears sound but does not understand speech. c. often speaks loudly because his or her own voice seems low. d. has clearer sound with a hearing aid if the loss is less than 30 dB.
a. hears better in a noisy environment ok.. we know it is usually the "external and middle ear" involved in conductive hearing loss - the other type of hearing loss is sensorineural hearing loss (more often internal ear).. the only one we can rule out with this knowledge is b - a person hearing sound, but does not understand speech, has usually a speech disorder, receptive aphasia.. problem Brocca's area (if you don't recall, check APHASIA and Brocca or Wernicke's area for speech - which lobe of the cerebrum (one is temporal lobe (w), one is parietal lobe (b).. try to figure the answer
In a patient who has a hemorrhage in the posterior cavity of the eye, the nurse knows that blood is accumulating a. in the aqueous humor. b. between the lens and retina. c. between the cornea and lens. d. in the space between the iris and lens.
a. in the aqueous humor. easy one.. just note the aqueous humor = intra occular pressure = posterior chamber/cavity of the eye
A 59-year-old man scheduled for a herniorrghaphy in 2 days reports that he takes ginko daily. What is the priority intervention? a. inform the surgeon, since the procedure may have to be rescheduled b. notify the anesthesia care provider, since this herb interferes with anesthetics c. ask the patient if he has noticed any side effects from taking this herbal supplement d. tell the patient to continue to take the herbal supplement up to the day before surgery
a. inform the surgeon, since the procedure may have to be rescheduled herniorrhaphy refers to the surgical repair of a hernia, in which a surgeon repairs the weakness in your abdominal wall - I don't know the herb - but looking at the operation.. most likely effect on blood.. ? blood thinner similar to warfarin
When positioning a patient in preparation for surgery, the nurse understands that injury to the patient can occur because of (select all that apply) a. loss of pain perception. b. incorrect musculoskeletal alignment. c. vasoconstriction of the peripheral vessels. d. hypovolemia contributing to decreased perfusion. e. inability to sense pressure over bony prominences.
a. loss of pain perception. b. incorrect musculoskeletal alignment. d. hypovolemia contributing to decreased perfusion. e. inability to sense pressure over bony prominences. Although this is a question about intraoperative care, we also said SAFETY in the PREOPERATIVE period is EVERYONE's responsibility - and as the nurse caring postoperatively, we need to know what was going on.. a) Remember the 5 P's of neurovascular status.. No pain; b) question is about POSITIONING.. so makes sense, c = nonsense.. the issue is NOT vasoconstriction of the PERIPHERAL VESSELS (if it was vasoconstriction of the CENTRAL vessels, it would have been correct - remember, NCLEX in future will have SATA as minimum 1, but all options can be correct! d) hypovolemia leads to hypovolemic shock (look at question.. INJURY is anything that can be damaging - what the nurse does or what she is not doing! e is correct (remember the 5 P's of neurovascular status - thus, I also could nr. e as "parasthesia". 5 p's: pain, pulse, pallor, paresthesia, paralysis
Discharge criteria for patient being discharged from PACU after minimal invasive surgery (select all that apply) a. no nausea or vomiting. b. ability to drive self home. c. no respiratory depression. d. written discharge instructions understood. e. opioid pain medication given 45 minutes ago.
a. no nausea or vomiting. c. no respiratory depression. d. written discharge instructions understood. OK 5 is difficult - I don't know what a Phase II patient is, and I don't care.. not really important, so let's change this question more applicable for how we discussed Perioperative care.. and say.. "discharge criteria for patient to be discharged from PACU home after minimal invasive surgery.. then I will choose a, c, d and I am not sure about e.. why? well, if patient has so much patient to have to receive opioid, surely I want to make sure pain is under control.. but yes, is correct - so I am looking for a reason.. okay.. the question does not state whether a patient received opioid IV/IM or per mouth!!!! - so that is why it is important - I am not going to keep a patient, with all vitals stable and who had a pain relief tablet!
An overweight patient (BMI 28.1 kg/m2) is scheduled for a laparoscopic cholecystectomy at an outpatient surgery setting. The nurse knows that: a. surgery will involve multiple small incisions. b. This setting is not appropriate for this procedure. c. Surgery will involve removing a portion of the liver. d. The patient will need special preparation because of obesity.
a. surgery will involve multiple small incisions remember.. BMI (body mass index) of >25 = overweight, >30 obese and >35 morbid obese. So yes, that would be a problem like if this patient had a normal, open abdomen laparoscopy - issues like wound infection, risk of DVT due to immobilization and pulmonary edema. While this would be unsafe to do at an outpatient surgery for this patient, as a laparoscopy it is acceptable.. and a correct, b eliminate, c is nonsense and d is not correct - there are no special preparation
Always assess the patient with an eye problem for a. visual acuity. b. pupillary reactions. c. intraocular pressure. d. confrontation visual fields.
a. visual acuity ok this one had me puzzled.. so I said a and b (I ruled out c and d) and then I thought the right one b, but it is actually a.. so back to your question.. there is nothing there to say there is a potentially problem with pupil reactions - pupils usually problem with neurological patients
Which strategies would best aid the nurse communicate with a patient who has a hearing loss (select all that apply)? a. Overenunciate speech. b. Speak normally and slowly. c. Exaggerate facial expressions. d. Raise the voice to a higher pitch. e. Write out names or difficult words.
b. Speak normally and slowly. e. Write out names or difficult words.
What assessment technique should the nurse use to assess an adult patient's tympanic membrane? a. Have the patient tilt the head toward the nurse. b. Stabilize the otoscope with your fingers on the patient's cheek. c. Pull the auricle down and back to straighten the auditory canal. d. Use a speculum slightly larger than the size of the patient's ear canal.
b. Stabilize the otoscope with your fingers on the patient's cheek.
The patient tells the nurse in the preoperative setting that she has noticed she has a reaction when wearing rubber gloves. What is the most appropriate action? a. Notify the surgeon so that the surgery can be cancelled b. ask additional questions to assess for a possible latex-free supplies c. notify the OR staff at once so they can use latex-free supplies d. No action is needed because the patient's rubber sensitivity has no bearing on surgery
b. ask additional questions to assess for possible latex-free supplies We did not discuss this, however, it is also appropriate for working in units. The patient has a "latex allergy". Check this is about the patient (not about the nurse!)
A patient who normally takes 40 units of glargine insulin (long acting) at bedtime asks the nurse what to do about her dose the night before surgery. The best response would be to have her a. skip her insulin altogether the night before surgery. b. get instructions from her surgeon or HCP on any insulin adjustments. c. take her usual dose at bedtime and eat a light breakfast in the morning. d. eat a moderate meal before bedtime and then take half her usual insulin dose.
b. get instructions from her surgeon or HCP on any insulin adjustments. Insulin is one of the medications we will clarify with the physician.. so b is definitely.. you will NOT select a (it is NOT Nurse's call), patient is for surgery - you do not know what time.. thus cannot make the call to take breakfast and d is also not within your scope.. in this question, EASY. best answer b Meds to check with surgeon: diuretics (lasix, furosemide, aldactone, spironolactone), anticoagulants (warfarin, heparin, lovenox), insulin, corticosteroids, phenothiazines, beta-blockers, anti-thyroid or thyroid blocking meds
The nurse teaches a patient scheduled for an electronystagmography that the test involves a. measuring ear drum movement in response to pressure. b. recording eye movements associated with ear irrigation. c. placing an electrode on the eardrum and assessing for dizziness. d. wearing headphones and determining which sounds can be heard.
b. recording eye movements associated with ear irrigation.
Presbyopia occurs in older people because a. the eyeball elongates. b. the lens becomes inflexible. c. the corneal curvature becomes irregular. d. light rays are focusing in front of the retina.
b. the lens becomes inflexible ok I don't know.. but let's check presbyopia.... Farsightedness usually becomes noticeable in the early to mid-40s and worsens until around age 65. Symptoms include a need to hold reading material at arm's length to make letters clearer, blurred vision at normal reading distance, and eyestrain after reading. In rare cases, it may cause headaches. The condition can be corrected with nonprescription or prescription eyeglasses, contact lenses, and rarely surgery. So now that I know what presbyopia is.. I can rule out d, it is highly unlikely c.. this would cause one of the refractory eye problems, astigmatism (ok, I can't remember we talk in class about that.. let's see what it is? (Astigmatism is a common and generally treatable imperfection in the curvature of the eye that causes blurred distance and near vision. Astigmatism occurs when either the front surface of the eye (cornea) or the lens inside the eye has mismatched curves - so that rules out c, - now I know presbyopia causes like problems with reading (and we do know in older people.. cataracts, cloudy vision.. and cataracts associated with the LENS, it MUST be b! Got it?
A patient says she was diagnosed with astigmatism. When she asks what that is, what is the best explanation the nurse can give to the patient? a. "It happens because the lens of the eye is absent." b. "People with astigmatism have abnormally long eyeballs." c. "The cornea of the eye is uneven or irregular with astigmatism." d. "Astigmatism occurs because the eye muscles weaken with age."
c. "The cornea of the eye is uneven or irregular with astigmatism."
What are the priority interventions the nurse performs when admitting a patient to the PACU? a. Assess the surgical site, noting presence and character of drainage. b. Assess the amount of urine output and the presence of bladder distention. c. Assess for airway patency and quality of respirations and obtain vital signs. d. Review results of intraoperative laboratory values and medications received.
c. Assess for airway patency and quality of respirations and obtain vital signs. This is a good question to note - all these options are important, and actually correct.. but what are priority interventions - remember A, B, C (airway breathing circulation).. why without even looking at the other options, I will choose c
Ask patients using eyedrops to treat their glaucoma about a. use of corrective lenses. b. their usual sleep pattern. c. a history of heart or lung disease. d. sensitivity to opioids or depressants.
c. a history of heart or lung disease. a no (maybe with cataract) b) no relation to glaucoma c) don''t know d( sensitivity to potential Benadryl (pseudophedrine) in patients with a certain type of glaucoma.. so only answer could be c.. (ok.. the QUESTION does not make sense.. read it again!!! but let's hope our answer is correct..
A patient reports tinnitus and balance problems. The medication that may be responsible is a. digoxin. b. warfarin. c. furosemide. d. acetaminophen.
c. furosemide When you do this type of question, make sure you also learn your Pharma.. digoxin = digitalis, it is given usually patients with heart failure to increase contractions, patients usually experiencing eye problems - like halo.. warfarin - anticoagulant - may cause bleeding furosemide - not sure (induces temporary hearing loss, but rarely permanent deafness unless applied in severe acute or chronic renal failure or with other ototoxic drugs. - and d, yes, if taken for long time can cause hearing loss.. so potentially c+d.. I would go for c as it is known to have OTOTOXICITY!
IV induction for general anesthesia is the method of choice for most patients because a. the patient is not intubated. b. the agents are nonexplosive. c. induction is rapid and controlled. d. emergence is longer but with fewer complications.
c. induction is rapid and controlled. induction refers to the "method" leading to anesthesia - in this question it says why IV induction is the method of choice, why c is the correct answer.. don't spend too much time on understanding this question.. it is just I have seen it somewhere before!
Preoperative considerations for older adults include (select all that apply) a. using only large-print educational materials. b. speaking louder for patients with hearing aids. c. recognizing that sensory deficits may be present. d. providing warm blankets to prevent hypothermia. e. teaching important information early in the morning.
c. recognizing that sensory deficits may be present. d. providing warm blankets to prevent hypothermia. a - you cannot assume older adults need large-print educational materials, b - you cannot assume pt. with hearing aids cannot hear at all, c is possible (we know as we get older, our sensory (hearing, vision, taste, smell decrease), d is correct.. older patients tend to feel more cold than younger pt. and e - well for both older and younger pt. not a good time for health education!
In a patient with vertigo, the parts of the ear most likely involved are the (select all that apply) a. cochlea. b. ossicles. c. vestibule. d. semicircular canals. e. tympanic membrane.
c. vestibule. d. semicircular canals. Ok.. careful now.. cochlea - where the 8th cranial nerve is - HEARING, ossicles - in the middle ear.. transmit sounds; The inner ear is the cochlea and vestibule which are responsible for hearing and equilibrium, respectively. - vertigo is the feeling of 'room spinning around' - we say may cause dizziness.. and dizziness affects balance, Semicircular canals - we said is affecting balance, tympanic membrane - no, will affect HEARING when inflamed! so answer.. c + d
A patient is scheduled for surgery requiring general anesthesia at an ambulatory surgical center. The nurse asks him when he ate last. He replies that he had a light breakfast a couple of hours before coming to the surgery center. What should the nurse do first? a. Tell the patient to come back tomorrow, since he ate a meal. b. Have the patient void before giving any preoperative medications. c. Proceed with the preoperative checklist, including site identification. d. Notify the anesthesia care provider of when and what the patient last ate.
d. Notify the anesthesia care provider of when and what the patient last ate. Note the FIRST action.. let's rule out: a) eliminated b) yes it is correct - we don't want the patient to fall after giving preop meds c) this patient is just admitted - and yes, c will happen, but not immediately d) yes, so you will ask the patient "WHAT time the light breakfast was and what it was.. Again, a SATA I would have b and d.. Still not c.. why.. it is NOT the nurse's responsibility to do site identification - your choice?
When examining the patient's eyes, which finding would be of most concern to the nurse? a. Intraocular pressure of 16 mm/Hg b. Slightly yellowish cast of the sclera c. Outward turning of the lower lid margin d. Small, white nodule on the upper lid margin
d. Small, white nodule on the upper lid margin Ok.. a I don't have a clue, b = indicative of jaundice, c + d does not cause e MOST concern, I will select c!
A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to a. notify the surgeon and expect obtaining blood work to evaluate renal function. b. perform a straight catheterization to measure the amount of urine in the bladder. c. continue to monitor the patient because this is a normal finding during this time period. d. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound.
d. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound. You probably learned in fundamentals.. normal Urinary Output is 30ml/hour - however, the actual correct way to look at it, is 0.5ml/kg/hour.. and you see they give the weight.. why.. they want you to use that.. so you expect this pt. to pass urine of 35mLhour and then for 8 hours thus you would expect at least - over 200mL (you make the calculation!! make sure to check.. I can give the "pounds, then expect you to convert to kg - that one conversion you need to do.. 1kg = 2.2 pounds! a. yes can be true.. b - no, although straight catheterization is an option for retention of urine (patient cannot pass urine, definitely not do to MEASURE urine) - for that they will do a bedside bladder scan; c = nonsense.. d is an option.. so now we have a and d as options.. back to question.. PRIORITY NURSING.. I would not choose A.. why.. not necessarily will call the surgeon after 8 hours, any physician will be good enough, and yes, labs will be done.. however, I need to know if the low output is due to retention, - the safest way is with a bladder scan.. at the same time, the fluid volume is important (it may be the patient is behind in fluids.. so d is an excellent option covering all the things I am wondering about less
A priority nursing intervention to aid a preoperative patient in coping with fear of postoperative pain would be to a. inform the patient that pain medication will be available. b. teach the patient to use guided imagery to help manage pain. c. describe the type of pain expected with the patient's particular surgery. d. explain the pain management plan, including the use of a pain rating scale.
d. explain the pain management plan, including the use of a pain rating scale. potentially a and d is correct (if it was a SATA, I would choose both) - I am ruling out b immediately! and c is not my role.. also, remember pain is about "what the patient says it is"! So we need to decide on what the BEST answer is.. now your choice?
Increased intraocular pressure may occur because of a. edema of the corneal stroma. b. dilation of the retinal arterioles. c. blockage of the lacrimal canals and ducts. d. increased aqueous humor production by the ciliary process.
d. increased aqueous humor production by the ciliary process. Intraocular pressure - posterior chamber.. a( incorrect - cornea) b (incorrect - retina) c) incorrect - lacrimal canals and ducts make tears!! d) yes, we know about the aqueous humor - glaucoma and increased intra-occular pressure..
A normal finding the nurse would expect when assessing hearing would be a. absent cone of light. b. bluish purple tympanic membrane. c. fluid level at hairline in the tympanum. d. midline tone heard equally in both ears.
d. midline tone heard equally in both ears. let's hope you remember Health assessment, a, b and c is not correct, must be d.. and yes (this is the WEBER test, we do it with the vibration fork on the head - the other test is the RHINE test (this is where we put the otoscope behind the ear at the mastoid process.. go back to your case study of your patient with Meniere syndrome!
A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to "throw up." A priority nursing intervention is to a. increase the rate of the IV fluids. b. give antiemetic medication as ordered. c. obtain vital signs, including O2 saturation. d. position patient in lateral recovery position.
d. position patient in lateral recovery position. Check https://www.firstaidforfree.com/what-is-the-recovery-position-in-first-aid/ explaining the lateral recovery position - it is aimed at PROTECTiNG ThE AIRWAY.. so again.. airway breathing circulation If a patient feels he wants to vomits, my priority is to prevent him/her from ASPIRATION (vomit lands in the lungs) - this is even more important with major abdominal surgery - I cannot get the patient sit upright and prevent aspiration! - so yes, b is definitely correct, I would not choose a (nothing in this scenario states patient lost fluids), c is correct but nothing telling me in scenario it is needed, so only option is "lateral recovery position" - even if you did not know the correct answer , you reached that answer by eliminating the others.
