chapter 30 sensation, perception, & cognition

Before the end of the shift, the nurse records the occurrences for each patient in the electronic medical record. Which statement below indicates that the nurse understands the main principle of accurate charting? a) "Charting communicates to members of the healthcare team the patient's care and responses during my shift." b) "Charting is important so that I may share with the healthcare team my opinions of what happened with the patient." c) "Charting allows the other nurses to understand the patient care provided during my shift." d) "Charting is important to comply with practice guidelines and institutional policies."

A Accurate charting is needed to clearly communicate the patient's care and responses to other members of the healthcare team, not just the other nurses. This statement reflects the nurse's understanding of this principle. The nurse's opinions are not to be placed in a chart because they are not factual. While charting is important to comply with standards of practice and institutional policy, it is not the main principle of accurate charting.

Which is not a professional value identified by the American Association of Colleges of Nursing (AACN)? a) Altruism b) Equality c) Education d) Honesty

A Altruism is identified as one of the values of nursing identified by the AACN. Equality, education, and honesty are not identified as values by the AACN; however, they have been frequently cited in nursing literature as being important to nursing.

Teratogenic drugs should be avoided in which patient population? a) Pregnant women b) Elderly c) Children d) Adolescents

A Drugs that are known to cause developmental defects are termed teratogenic. These drugs are contraindicated during pregnancy because of the likelihood of adverse effects in the embryo or fetus.

The nurse assesses assigned patients and determines which patient is at highest risk for altered skin integrity? a) Young adult in traction who has a low-protein diet and dehydration b) Elderly patient diagnosed with well-controlled type 2 diabetes c) Middle-aged adult with metabolic syndrome taking antihypertensives d) Adolescent in bed with influenza having periods of high fever and diaphoresis

A The young adult patient in traction has multiple risk factors including immobility, dehydration, and inadequate protein intake. Healthy skin depends on adequate protein levels to maintain the skin, repair minor defects, and preserve intravascular volume. Therefore, this patient is at greatest risk for altered skin integrity. An elderly patient with well-controlled diabetes has only one risk factor, and therefore is not at highest risk among the group of patients in the scenario. The middle-aged adult with metabolic syndrome, which involves obesity, hyperlipidemia, and hypertension, has compromised health, although not necessarily compromised skin integrity—unless the patient were immobile, which he is not. Although fever and skin moisture can compromise skin integrity, the adolescent's condition is likely transient.

The nurse manager performs a risk-benefit analysis to determine the minimum number of staff the unit will need over the Christmas and New Year's holiday to allow as many nurses to take time off as possible while maintaining the safety of the patients. What ethical problem-solving approach is this nurse manager using? a) Utilitarianism b) Deontology c) Categorical imperative d) Feminist ethics

A Use of a risk-benefit analysis to determine every alternative action for its potential outcomes is utilitarianism. This nurse is using utilitarianism when balancing fairness to the staff with safety of the patients. Deontology is based on rules and principles using the language of rights and duties, or right and wrong, which does not apply to this manager's approach. The categorical imperative states one should act only if the action is based on a principle that is universal, which does not apply to this situation. Feminist ethics is based on the belief that traditional ethical models provide a mostly masculine perspective and devalue women, which does not apply to this nurse manager's problem.

Which step should the nurse take first when performing otic irrigation in an adult? a) Warm the irrigation solution to room temperature. b) Position the patient so she is sitting with her head tilted away from the affected ear. c) Straighten the ear canal by pulling up and back on the pinna. d) Place the tip of the nozzle into the entrance of the ear canal.

A Warm the irrigation solution to room temperature. The nurse should warm the irrigation solution to room temperature first. Next, the nurse should assist the patient into a sitting position, with the head tilted away from the affected ear; straighten the ear canal by pulling up and back on the pinna; place the tip of the nozzle into the entrance of the ear canal; and direct the stream of irrigating solution gently along the top of the ear canal toward the back of the patient's head. Then continue irrigating until the canal is clean.

Which actions would the nurse take when emptying the patient's closed-wound drainage system? Select all that apply. a) Don sterile gloves and personal protective equipment. b) Inspect the drainage tube site and sutures. c) Check that tubing to drainage system is intact. d) Test the suction apparatus at prescribed pressure. e) Document the color, type, and amount of drainage.

A, B, C, D, E Emptying a closed-wound drainage system is not a sterile procedure; therefore, sterile gloves and personal protective equipment (e.g., mask, gown, goggles) would not be necessary. Clean gloves would protect the nurse from contamination and prevent the transmission of microbes with exposure to drainage. The nurse would inspect the appearance of the insertion site of the drain for signs of infection or skin irritation. The nurse would check the tubing to be sure it is tightly connected and there is no leakage. The nurse assesses the suction apparatus to ensure the system is working properly. Documentation of the amount and characteristics of the drainage (e.g., color, type, thickness, odor) would aid care providers in assessing the potential for development of wound infection.

Which of the following areas would the nurse include in a mental status assessment for an adult patient? Select all that apply. a) Behavior b) Judgment c) Knowledge d) Reflexes e) Appearance

A, B, C, E The mental status assessment includes assessment of behavior, appearance, response to stimuli, speech, memory, and judgment. Normal findings include an ability to express and explain realistic thoughts with clear speech, follow directions, listen, answer questions, and recall significant past events. Assessment of reflexes is associated with a complete and in-depth neurological assessment.

Which structure within the brain is responsible for consciousness and alertness? a) Reticular activating system b) Cerebellum c) Thalamus d) Hypothalamus

A. reticular activating system The reticular activating system, located in the brainstem, controls consciousness and alertness. The cerebellum maintains muscle tone, coordinates muscle movement, and controls balance. The thalamus is a relay system for sensory stimuli. The hypothalamus controls body temperature.

What is the function of the stratum corneum? a) Provides insulation for temperature regulation b) Provides strength and elasticity to the skin c) Protects the body against the entry of pathogens d) Continually produces new skin cells

The stratum corneum is the outermost layer of the epidermis and is composed of numerous thicknesses of dead cells. Functioning as a barrier to the environment, it restricts water loss, prevents entry of fluids into the body, and protects the body against the entry of pathogens and chemicals. The subcutaneous layer is composed of adipose and connective tissue that provide insulation, protection, and an energy reserve (adipose). The dermis is composed of irregular fibrous connective tissue that provides strength and elasticity to the skin. The stratum germinativum is the innermost layer of the skin that produces new cells, pushing older cells toward the skin surface

A client has a diagnosis of chronic pain. The physician has prescribed tramadol hydrochloride (Ultram) for the pain. The patient also receives therapeutic touch (TT) from a practitioner three times a week. In this situation, TT is considered to be which of the following? a) A complementary modality b) An alternative modality c) A placebo response d) Holistic healthcare

A A complementary modality is one that is used alongside traditional medical care. The patient receives prescription medication from a physician and also receives TT. An alternative modality is one that is used instead of traditional medical care. A placebo response is the client's expectation that a treatment will be effective. Holistic healthcare uses the concept of holism to focus on the relationships among all living things.

The health and well-being of a holistic nurse in relation to helping patients constitute an important part of the healing process. A method that would be helpful to nurses in fostering their own health and the health of their patients is: a) Role modeling healthy behaviors b) Avoiding discussions on personal behaviors c) Working and acting in isolation d) Setting goals for the patient

A A holistic nurse role models healthy behaviors for her patients. Practically speaking, a holistic nurse understands that unless her own health is balanced, it is difficult to sustain the energy necessary to be a constructive presence and an effective practitioner. Stress evokes negative physiological responses in the body, which could lead to illness. Working in isolation does not allow one to gain the perspectives and insights of others in a commonly shared experience.

Which term refers to the movement of a drug from the site of administration to the bloodstream? a) Absorption b) Distribution c) Metabolism d) Excretion

A Absorption refers to the movement of drug from the site of administration into the bloodstream. Distribution involves the transport of the drug in body fluids, such as blood, to the tissues and organs. Metabolism is the biotransformation of the drug into a more water-soluble form or into metabolites that can be excreted from the body. Excretion, or the removal of drugs from the body, takes place in the kidneys, liver and gastrointestinal tract, lungs, and exocrine glands.

An insulin-dependent diabetic patient tells the nurse that she has been giving herself injections in the same location in her right thigh for the past several months because it is easier. What is the nurse's best action? a) Provide patient teaching on rotating injection sites. b) Assess the patient for cumulative effects. c) Check the type of insulin the patient receives to ensure that it is compatible with the vastus lateralis site. d) Document the patient's comments, as the patient understands the treatment regimen.

A Administering medications in the same site over prolonged periods of time can cause fat deposits and skin lumps, which will interfere with absorption and thus hinder the effectiveness of the medication. Insulin is administered subcutaneously, not intramuscularly. The patient should be taught to rotate injection sites.

The nurse is facing a moral dilemma and applies the MORAL model to decision making. After writing down all the possible options to solve the problem, what will the nurse do next? a) Consider all the options and choose the best one. b) Implement the chosen option. c) Evaluate the effectiveness of the action. d) Consider the dilemma and whom it involves.

A After outlining the options, the next step is resolving the dilemma by choosing the best option. A choice cannot be implemented until an action is chosen. An action cannot be evaluated until an action is chosen and implemented. Considering the dilemma and determining who is involved must precede the step of writing down all possible options.

Your patient has a deep wound on the right hip, with tunneling at the 8 o'clock position extending 5 cm. The wound is draining large amounts of serosanguineous fluid and contains 100% red beefy tissue in the wound bed. Of the following, which would be an appropriate dressing choice? a) Alginate dressing b) Dry gauze dressing c) Hydrogel d) Hydrocolloid dressing

A Alginates are highly absorbent and are appropriate for wounds with moderate to large amounts of drainage. They are ideal for wounds with tunneling, as they will conform to fill the tunnel. Gauze and hydrocolloids have limited absorptive ability. Gauze could adhere to the wound bed and cause trauma when removed. A hydrogel would increase the drainage, with the potential of macerating surrounding skin.

A patient's arterial blood gas results are as follows: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80. An appropriate nursing diagnosis for the patient is which of the following? a) Impaired Gas Exchange b) Metabolic Acidosis c) Risk for Impaired Gas Exchange d) Risk for Acid-Base Imbalance

A An appropriate diagnosis is Impaired Gas Exchange. The arterial blood gas (ABG) results provide the defining characteristics for Impaired Gas Exchange. The ABG results demonstrate metabolic acidosis; however, this is not a nursing diagnosis. The patient has an actual problem; therefore, the "risk for" nursing diagnoses are incorrect. Additionally, there is no nursing diagnosis of Acid-Base Imbalance or Risk for Acid-Base Imbalance.

When applying heat or cold therapy to a wound, what should the nurse do? a) Leave the therapy on each area no longer than 15 minutes. b) Leave the therapy on each area no longer than 30 minutes. c) When using heat, ensure the temperature is at least 135°F (57.2°C) before applying it. d) When using cold, ensure the temperature is less than 32°F (0°C) before applying it.

A Apply heat or cold therapies intermittently, leaving them on for no more than 15 minutes at a time in an area. This helps prevent tissue injury and also makes the therapy more effective by preventing rebound phenomenon. Temperatures should be kept between 59°F and 113°F (15°C and 45°C), depending on the type of therapy chosen and what is comfortable to the patient. Temperatures colder or hotter than those recommended can damage tissue

The nurse on night shift is caring for a patient who is confused and gets out of bed frequently. The nurse pushes him into a chair and states, "Do not get out of this chair or I will tie you up and leave you alone for hours." The nurse's action is an example of: a) Assault and battery b) Libel c) False imprisonment d) Safe nursing practice

A Assault is putting the patient in fear of harm and battery is touching him without his permission or in a way that is forceful. Pushing the patient into the chair is considered battery; threatening to restrain him and leave him alone for hours is assault. False imprisonment is the restraint of a person without proper legal authorization. The patient was not restrained. This is not an example of safe nursing practice, which would require the nurse to initiate the hospital's fall precaution protocol. Restraints are applies as a last resort. Libel is a verbal or written type of character defamation.

Effective delegation is a vital part of the nurse's responsibilities. What factor should guide the nurse to correctly delegate a nursing task? a) The education and experience of the delegatee b) The job description of the delegatee c) The patient request for the delegatee d) The staffing levels on a unit

A Delegation is a vital component of nursing care; the nurse must know the educational level and experience of the person being delegated a task. This enables the nurse to accurately align the patient care needs with the patient assignments. Once the nurse knows this, patient care assignments can be given with consideration to patient requests and staffing levels on the unit. The delegatee's job description can provide insight into his scope of responsibilities, but the nurse must base delegation on the skill level and experience of the delegate.

After receiving diphenhydramine, a patient complains that his mouth is very dry. This is not uncommon for patients taking this medication. Which drug effect is this patient experiencing? a) Side effect b) Adverse reaction c) Toxic reaction d) Supportive effect

A Dry mouth is a side effect of diphenhydramine. Side effects are unintended, often predictable, physiological effects that are well tolerated by patients. Adverse reactions are harmful, unintended, usually unexpected reactions to a drug administered at a normal dosage. They are commonly more severe than are side effects. Toxic reactions are dangerous, damaging effects to an organ or tissue. Supportive effects are intended effects that support the integrity of body functions.

The nurse in a women's health clinic, educates patients about the benefits of probiotic therapy. Today, the nurse is working with a patient complaining of recurrent vaginal yeast infections. The patient's laboratory tests confirm Candida albicans. Which statement helps the nurse to determine that the patient needs more teaching regarding probiotic therapy? a) "If I eat yogurt, I will not get any more yeast infections." b) "I can eat yogurt and it will reduce my yeast infections." c) "Eating yogurt once a day will help to balance my natural body flora." d) "I can take probiotics once I read their labels to ensure the bacteria are live."

A Eating yogurt does not eliminate yeast infections permanently or completely take away the potential for them to occur. Eating a probiotic, such as yogurt, can reduce vaginal yeast infections if eaten on a regular basis by establishing and supporting healthy body flora. Probiotics are most helpful when the bacteria are live and of a sufficient number to reestablish healthy amounts of flora. The statement that probiotics will prevent future infections is false, so the patient requires teaching on this point.

30. The nurse must administer ear drops to an infant. How should she proceed? a) Pull the pinna down and back before instilling the drops. b) Pull the pinna upward and outward before instilling the drops. c) Instill the drops directly; no special positioning is necessary. d) Position the patient supine with the head of the bed elevated 30°.

A For a child younger than 3 years old, the nurse should pull the pinna down and back. For older children and adults, the nurse should pull the pinna upward and outward. Doing each straightens the ear canal for proper channeling of the medication. The patient should be assisted into a side-lying position with appropriate ear facing up before instillation.

The health clinic nurse is interviewing a new patient. The nurse asks questions about the patient's self-care and about his healthcare providers. Which statement is likely to yield the most information from the patient regarding the use of CAM? a) "Many people go to a medical provider and other healers, as well. Please tell me about the practitioners and healers you use." b) "Some people go to both medical and nonmedical providers for healthcare. Do you use both?" c) "Many people only go to a medical physician. Tell me about the practitioners you see for healthcare." d) "Some people go to different types of CAM healers. You don't use CAM, do you?"

A For therapeutic questioning, the nurse should use open-ended questions to yield the most information. The question ending in "Do you use both?" is a yes/no question that will likely elicit very little information. Although the option ending in "Tell me about the practitioners you see for healthcare," seems open ended, the negative use of "only" ("only go to a medical physician") implies that there is not another acceptable answer, thus decreasing the information the patient may share. "You don't use CAM, do you?" is a negative, closed question. It suggests that the patient should answer "No," and almost certainly will elicit a one-word answer.

14. An 82-year-old woman was brought to the emergency department by her granddaughter. She is a widow and lives alone, although her granddaughter checks on her daily. She has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6°F (37.6°C) orally; P = 110 beats/min, weak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/L BUN 29 mg/dL The nurse recognizes that the patient is displaying symptoms associated with which of the following? a) Hypovolemia b) Hypervolemia c) Hypernatremia d) Hyponatremia

A Hypovolemia may occur as a result of insufficient intake of fluid; bleeding; excessive loss through urine, skin, or the gastrointestinal tract; insensible losses; or loss of fluid into a third space. The first symptom of hypovolemia is thirst. Other symptoms are a rapid, weak pulse, a low blood pressure (although initially the blood pressure may rise), dry skin and mucous membranes, decreased skin turgor, and decreased urine output. Temperature increases because the body is less able to cool itself through perspiration. The person with fluid volume deficit usually has elevated BUN (blood urea nitrogen) and hematocrit levels. Hypervolemia involves excessive retention of sodium and water in the extracellular fluid, and the vital sign changes are opposite those of a patient with hypovolemia. Hypernatremia and hyponatremia are not applicable because the patient's sodium level is within normal range.

When a patient has metabolic acidosis, which body system influences the acid-base imbalance to produce the compensatory changes in the arterial blood gases? a) Respiratory system b) Renal system c) Vascular system d) Neurological system

A In a metabolic problem, the respiratory system compensates. In a respiratory problem, the renal system must compensate. The respiratory system compensates early in the disorder, but it may take up to 3 days for the renal system to compensate fully.

Laboratory test results indicate that warfarin anticoagulant therapy is suddenly ineffective in a patient who has been taking the drug for an extended period of time. The nurse suspects an interaction with herbal medications. What type of interaction does she suspect? a) Antagonistic drug interaction b) Synergistic drug interaction c) Idiosyncratic reaction d) Drug incompatibility

A In an antagonistic drug interaction, one drug interferes with the actions of another and decreases the resultant drug effect. In a synergistic drug interaction, there is an additive effect; that is, the effects of both drugs combined are greater than the individual effects. An idiosyncratic reaction is an unexpected, abnormal, or peculiar response to a medication. Drug incompatibilities occur when drugs are physically mixed together, causing a chemical deterioration of one or both drugs.

An adult patient admitted with lower gastrointestinal bleeding is prescribed a unit of packed red blood cells. Which gauge needle should be inserted to administer this blood product? a) 18 gauge b) 22 gauge c) 24 gauge d) 26 gauge

A Large-gauge needles, 14 to 18 gauge, are used for blood products in adults because the bore is large enough to allow transfusion without cell damage (lysis). Smaller-gauge bores can cause clumping and breakage of the cell, thus leading to reduced effectiveness of the transfusion as well as contributing to fragmented by-product of red blood cell waste.

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? a) Partial-thickness wound b) Penetrating wound c) Superficial wound d) Full-thickness wound

A Partial-thickness wounds extend through the epidermis into the dermis. Superficial wounds involve only the epidermal layer of skin. Full-thickness wounds extend into the subcutaneous tissue and beyond. Penetrating is a descriptor sometimes added to indicate that the wound includes internal organs.

Pressure ulcers are directly caused by which of the following conditions at the site? a) Compromised blood flow b) Edema c) Shearing forces d) Inadequate venous return

A Pressure ulcers are caused by unrelieved pressure that compromises blood flow to an area, resulting in ischemia (inadequate blood supply) in the underlying tissue. Friction and shear are extrinsic factors affecting skin integrity, which increases the risk of a client developing a pressure ulcer but is not the direct cause. Inadequate arterial blood flow to an area as a result of pressure causes the development of a pressure ulcer. Edema leads to compromised skin and tissue integrity, which is more prone to pressure injury.

What is the most essential action by the nurse prior to delegating the administration of an intravenous (IV) medication to a licensed practical nurse (LPN)? a) Review the state's nurse practice act for LPN scope of practice. b) Review the unit policy and procedure for IV medication administration. c) Determine whether the LPN has previously performed this procedure. d) Demonstrate the procedure; then allow the LPN to administer the IV medication.

A The State Board of Nursing regulates the types and routes of medications that can be administered by the various levels of nurses. For example, LPNs in some states cannot administer IV medications, whereas other states require additional education and experience before LPNs can perform this action. The nurse must refer to her state's nurse practice act for the scope of practice. Once scope of practice is identified, the nurse can proceed with reviewing the unit policies and assessing the experience level of the LPN. If state regulations do not allow LPNs to administer IV medications, there is no reason for the nurse to proceed with the other actions.

Why is the information obtained from a swab culture of a wound limited? a) A positive culture does not necessarily indicate infection because chronic wounds are often colonized with bacteria. b) A negative culture may not indicate infection because chronic wounds are often colonized with bacteria. c) Most wound infections are viral, so the swab culture would not be indicative of a wound infection. d) A swab culture result does not include bacterial sensitivity information necessary to provide treatment.

A The information obtained from a swab culture is limited because a positive culture may not indicate infection. Chronic wounds are often colonized with bacteria, but this does not require antibiotic treatment. A needle aspiration of the wound would provide more definitive information about whether the wound is infected or not and can be performed by a registered nurse. However, the most accurate wound information is obtained by tissue biopsy performed by a specially trained provider.

Which documentation entry related to prn medication administration is complete? a) 6/5/14 0900 morphine 4 mg IV given in right antecubetal fossa for pain rated 8 on a 1-10 scale, J. Williams RN b) 0600 famotidine 20 mg IV given in right hand, S. Abraham RN c) 9/2/14 0900 levothyroxine 50 mcg PO given d) 1/16/14 furosemide 40 mg PO given, J. Smith RN

A The longest option, signed by J. Williams, is complete because it contains the date and time the medication was administered, the name of the medication, the route of administration and injection site, and the name of the nurse administering the medication. Because the medication administered was a prn order, the nurse also included the reason the medication was administered. Other options are incomplete.

When the nurse enters a patient's 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? a) Inform the patient that she will return when he is finished in the bathroom. b) Wait outside the bathroom door until the patient is ready for the dose. c) Withhold the dose until the next administration time later in the day. d) Document that the dose was omitted in the medication administration record.

A The nurse should inform the patient that she will return with the medication when he is finished in the bathroom. The nurse likely would not have time to stand outside the door and wait for the patient to finish in the bathroom. If the medication is left at the bedside for the patient, the nurse cannot be sure that the patient actually took the medication. Withholding the dose until the next administration time may compromise the patient's condition and is not appropriate nursing action. The drug should not be omitted; therefore, the nurse should not document a missed dose in the medication administration record.

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? a) Disciplinary action against the nurse's license to practice b) Criminal misdemeanor charges against the nurse c) Medical malpractice lawsuit against the nurse d) Employment release from the institution

A The state board of nursing is empowered to initiate disciplinary action against the nurse's license for professional misconduct. The board does not bring criminal charges or sentence the nurse to jail; that is the parameter of the state prosecutor and judge. A patient or the person harmed can bring medical malpractice lawsuits against the nurse.

The patient with a colostomy has been incorrectly applying his ostomy appliance. The continuous contact with liquid stool has caused a skin wound around the ostomy. The nurse assesses bleeding and purulent drainage that has extended into the dermis. How will the nurse classify and document this contaminated wound? a) Acute, full-thickness, open b) Chronic, partial-thickness, closed c) Acute, partial-thickness, closed d) Chronic, unstageable, open

A The wound is acute because it developed recently. The wound is full-thickness because it involves the dermis. The wound is open because it was bleeding, so the skin must be broken. The wound is contaminated because it is exposed to stool and appears to be infected.

The emergency department nurse cares for a 17-year-old adolescent who is diagnosed with cervical cancer secondary to human papillomavirus. The patient declines treatment, saying, "I don't want my parents to know I have been sexually active, and if they find out about the cancer, they'll figure out the rest of it." The nurse explains the risk of death if the cancer is not treated, but the patient continues to refuse therapy. What conflicting principles is this nurse facing as the result of this patient's choices? a) Autonomy versus nonmaleficence b) Autonomy versus veracity c) Fidelity versus justice d) Veracity versus beneficence

A This nurse has to choose between maintaining the confidentiality (one aspect of autonomy) of the patient's health information versus the harm that will come to the patient if confidentiality is maintained (i.e., nonmaleficence). This nurse has to choose between maintaining the confidentiality of the patient's health information (an aspect of autonomy); however, veracity is the duty to tell the truth and is not a component of this scenario. Fidelity relates to fulfilling one's obligations and maintaining one's commitments; justice is the obligation to be fair. Neither fidelity nor justice is well described by this scenario. Again, veracity is the duty to tell the truth, and does not apply here; beneficence is the concept of doing good, which is not in conflict in this scenario because the nurse has done everything possible to help this patient make an informed choice.

A patient develops urticaria and pruritus 5 days after beginning phenytoin for treatment of seizures. Which type of reaction is the patient most likely experiencing? a) Mild adverse reaction b) Dose-related adverse reaction c) Toxic reaction d) Anaphylactic reaction

A Urticaria and pruritus are considered minor adverse reactions. Dose-related adverse reactions are undesired effects that result from known pharmacological effects of the medication. Toxic reactions are dangerous, damaging effects to an organ or tissue. Anaphylactic reaction is a life-threatening allergic reaction that occurs during or immediately after administration.

Which of the following describes the difference between dehiscence and evisceration? a) 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. b) Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent. c) 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. d) Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.

A With dehiscence, there is a separation of one or more layers of wound tissue, whereas evisceration involves the protrusion of internal viscera from the incision site. Evisceration is an urgent complication usually requiring immediate surgical intervention.

What is the primary goal that the nurse should establish for a patient with an open wound? a) The wound will remain free of infection throughout the healing process. b) The client will complete antibiotic treatment as ordered. c) The wound will remain free of scar tissue at healing. d) The client will increase caloric intake throughout the healing process.

A Wounds healing by secondary intention are more prone to infection; therefore, the primary goal is to prevent infection. Antibiotics may not be necessary, and the nurse can expect the formation of scar tissue in this particular situation. There is no evidence presented that the patient needs to increase caloric intake.

Which essential oil might the nurse trained in aromatherapy use to uplift and stimulate a patient? a) Lavender b) Roman chamomile c) Rosemary d) Ylang-ylang

A Presbycusis, the loss of high-frequency tones, is an age-related change. Hyperopia is the ability to see distant objects well; it is not an age-related change. The ability to perceive touch and taste diminishes with age; it does not increase.

A patient diagnosed with macular degeneration asks the nurse to explain his condition. Which statement by the nurse best describes macular degeneration? a) "The portion of your eye called the macula, which is responsible for central vision, is damaged." b) "Your lens became cloudy, causing your blurred vision. This cloudiness will increase over time." c) "The pressure in the anterior cavity of your eye became elevated, shifting the position of your lens." d) "There's an irregular curvature of your cornea, causing your blurred vision."

A, "The portion of your eye called the macula, which is responsible for central vision, is damaged." Macular damage (degeneration) causes diminished central vision. Cataracts are caused by a cloudy lens and result in blurred vision. Glaucoma is pressure in the anterior cavity of the eye, which shifts the lens position. Astigmatism is irregular curvature of the cornea, resulting in blurred vision.

Which of the following are reasons for the popularity of biologically based therapies, such as dietary supplements and herbal products? Select all that apply. a) They are almost all readily available to consumers. b) They can be practiced as self-care measures. c) It is easy to know what dosage is being obtained from a product. d) Products on the market have been proved to be safe to use.

A, B Biologically based therapies use substances found in nature, such as food, herbs, vitamins, and scents used in aromatherapy. These therapies are readily available and are often practiced as self-care measures, so people who do not wish to see a practitioner may not need to do so. The U.S. Food and Drug Administration (FDA) regulates biologically based therapies and is developing guidelines for good manufacturing practices (GMPs). However, dosage and manufacturing processes are not standardized. The Federal Trade Commission monitors dietary supplements for truth in advertising. At present, it is difficult to know what dosage you are obtaining from a product, and safety cannot always be guaranteed.

The home health nurse is caring for a 75-year-old patient with severe arthritis of her hands and fingers. The patient states, "I can't use these childproof safety lock caps because I can't open them." What is the most appropriate response(s) by the nurse? Select all that apply. a) "I see this is difficult for you. Do you have any family members or friends who can help you?" b) "We can ask the pharmacist not to put childproof caps on your medications; you may need to sign a form." c) "You can transfer your medications to different containers that are easier for you to open." d) "All medications come in childproof containers, so there isn't much we can do about this."

A, B If a patient has difficulty opening containers and administering medications owing to pain or stiffness in the hands and fingers, family members and friends can be asked to help. Additionally, the nurse or patient can ask the pharmacy and the primary care provider not to put childproof safety lids on containers for easier handling. Older adults are allowed to sign a release with their pharmacy to be able to do this. Do not store a drug in a container that is different from the one it came in. The medication may lose its strength or the patient may take the wrong medication.

The nurse is preparing to administer a subcutaneous does of insulin to a patient with diabetes. Which two sites might the nurse use that would provide the best absorption of the injection? Select all that apply. a) Upper arm b) Abdomen c) Thigh d) Upper buttocks

A, B Subcutaneous injections are given into the subcutaneous tissue, the layer of fat located below the dermis and above the muscle tissue. Absorption is slower than through the intramuscular route because subcutaneous tissue does not have as rich a blood supple as does muscle. However, the speed of absorption varies with the subcutaneous site selected. Absorption is fastest in sites on the abdomen and arms; it is slower on the thigh and upper buttocks. Medication is absorbed more evenly from the abdomen than from the thighs and buttocks because it is affected less by activity.

Which of the following interventions are best for preventing sensory deficit for a resident in a long-term care facility? Select all that apply. a) Talk to the patient as you provide care. b) Incorporate touch when providing care. c) Turn on bright, fluorescent light for reading. d) Encourage waiting to drink water until after the meal. e) Offer spicy seasoning for the resident to use on food.

A, B Talking to the patient while providing care is not only important for personal and meaningful interaction, but also reduces social isolation and sensory deprivation. If the patient consents, you can stimulate the sense of touch by brushing his hair or giving a back rub, for example. However, use touch carefully, considering personal and cultural preferences, while observing the patient's reaction. Provide enough light, but avoid glare; use soft, diffuse lighting, not bright, fluorescent light. Teach clients to drink water between bites (not waiting until after the meal) to distinguish the taste of the food more readily. Seasonings, salt substitutes, spices, or lemon may improve the taste of foods and encourage the client's appetite. But avoid overseasoning food with excessively spicy food that overpowers the person's sense of taste.

What is/are the primary roles of the Food and Drug Administration (FDA)? Select all that apply. a) Regulate the testing, manufacture, and sale of all medications b) Monitor safety and effectiveness of medications available to consumers c) Manage the storage and handling of controlled substances d) Manage the sale and regulation of all herbal remedies

A, B The FDA of the U.S. Department of Health and Human Services regulates the testing, manufacturing, and sale of all medications. This agency also monitors the safety and effectiveness of medications available to consumers. This process helps to ensure that ineffective or unsafe drugs are not marketed or are recalled, if later found unsafe. However, many medicinal products are not regulated by the FDA. For example, herbal remedies and some naturopathic supplements are considered "food products" and are not regulated, even though they are advertised as having health benefits. The management of controlled substances is under the auspices of the Drug Enforcement Agency (DEA)

The nurse caring in the intensive care unit suspects that one of her patients is experiencing sensory overload. Which findings would increase her suspicion? Select all that apply. a) Disorientation b) Restlessness c) Hallucinations d) Depression e) Preoccupation with somatic complaints

A, B The patient with sensory overload might exhibit disorientation, confusion, restlessness, decreased attention span and ability to perform tasks, anxiety, muscle tension, and difficulty sleeping. Sensory deprivation also leads to irritability, confusion, reduced problem-solving, and impaired attention span; but unlike sensory overload, the person with sensory deficit experiences depression, preoccupation with somatic complaints, hallucinations, and delusions.

Sensory changes that occur with aging include which of the following? Select all that apply. a) Decreased number of nerve conduction fibers results in slower reflexes. b) The lens of eye becomes less flexible and less able to focus on near objects. c) Taste buds atrophy and decrease in number, causing decreased ability to perceive taste. d) Impaired regulation of body temperature causes an increased risk for seizures. e) The amount and waxiness of cerumen increases with aging

A, B, C A decreased number of nerve conduction fibers resulting in slower reflexes, less flexibility of the lens resulting in decreased ability to focus on near objects, and atrophy of taste buds resulting in decreased ability to taste are all sensory changes that occur with aging. Regulation of body temperature is not a sensory deficit. Cerumen is drier and more solid with aging, creating hearing loss.

Which of the following populations are considered high risk for sensory deprivation? Select all that apply, a) The homebound b) Those in prison c) Those who are depressed d) Those experiencing high anxiety e) Those feeling pain

A, B, C A nonstimulating, monotonous environment increases the risk for sensory deprivation, such as people who are in prison or who are homebound. Patients with depression are at risk for sensory deprivation, as they might be withdrawn from others and activities or less apt to interact within the usual context of their lives. Patients with anxiety often experience sensory overload. Pain lowers the threshold for processing sensory input, which increases the risk for sensory overload.

Herbs are used in a number of ways in CAM (complementary & alternative medicine). Why might a patient choose to use CAM for healing? Select all that apply. a) Aromatherapy b) Health maintenance c) Health promotion d) Infection prevention e) Avoidance of treatment side effects

A, B, C, D Herbal remedies have long been used to prevent or fight infection, promote and maintain health in a number of ways such as aromatherapy. As with pharmacological therapies, herbal remedies are not risk free and sometimes do have complications (e.g., allergic response).

The nurse's obligations in ethical decisions include which of the following? Select all that apply. a) Be a patient advocate. b) Involve institutional ethics committees. c) Improve one's own ethical decision making. d) Respect patient confidentiality.

A, B, C, D The nurse's obligations in ethical decisions include being a patient advocate, using and participating in institutional ethics committees, and improving ethical decision making. Confidentiality is a basic patient right. The nurse's role is to uphold that right.

Which of the following medical conditions has a direct effect on sensory function contributing to sensory deficits? Select all that apply. a) Diabetes b) Hypertension c) Multiple sclerosis d) Breast cancer e) Zinc deficiency

A, B, C, E Diseases that affect circulation may impair function of the sensory receptors and the brain, thereby altering perception and response. Some diseases affect specific sensory organs. Diabetic retinopathy is the leading cause of blindness among adults ages 20 to 74. Hypertension, too, can damage the retina of the eyes. Neurological disorders, such as multiple sclerosis, slow the transmission of nerve impulses. There is no indication that breast cancer leads to sensory deficits. Zinc deficiency can cause anosmia, which is reduced sense of smell.

The pediatric nurse educator is preparing a teaching plan for seizure prevention for parents of children with seizures. Which of the following can trigger seizures? Select all that apply. a) Fever b) Video games c) Sleep deprivation d) Food allergens e) Mood-altering substances

A, B, C, E The most common reason for seizures in a person with epilepsy is failure to take prescribed antiseizure medication. Other common triggers of seizures are illness and fever, sleep deprivation, stress, and ingestion of mood-altering substances. Additionally, high-contrast patterns and flashing or flickering lights (video games, strobe lights) can provoke seizure activity. Ingesting a food allergen invokes an immunological response with reactions related to anaphylaxis.

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

A, B, D Failure to implement a plan of care and failure to evaluate are two of the most common causes of nursing malpractice claims. The scenario represents a failure to follow standards of care, failure to communicate, and failure to document, which are in the category of failure to implement a plan of care. It also represents a failure to assess and report a significant change in the patient's condition, which is part of the category of failure to evaluate. The nurse did assess the potassium level and recognize that it was too high. The scenario does not provide enough information to determine malpractice. To establish malpractice, the four elements of duty, breach of duty, causation, and injury/damages have to be established. There is no information provided regarding whether the patient suffered an injury as the result of the nurse's breach of duty.

Which of the following beliefs is an essential component of holistic healthcare? Select all that apply. a) Illness occurs when there is a shift in an individual's balance. b) Regardless of the type of care received, ultimately all healing is self-healing. c) More healthcare resources should be focused on alternative healers. d) Illness can create an opportunity for personal and spiritual growth.

A, B, D Foundational beliefs of holistic care include the following: illness reflects a shift in balance, all healing is self-healing, and illness creates an opportunity for growth. Although holistic healthcare includes the use of alternative modalities, it does not emphasize the use of healthcare resources (money, time, etc.) for alternative healers.

Which of the following are examples of invasion of privacy by nurses? Select all that apply. a) Searching a patient's belongings without permission b) Reviewing the plan for patient care in the lunchroom c) Discussing healthcare issues for an unconscious patient with the person who holds his power of attorney d) Releasing patient health information to local newspaper reporters

A, B, D Invasion of privacy violates a person's right to be free from unwanted interference in her private affairs, such as occurs in discussing patient matters in a public setting; searching patients' private items without their permission; and releasing private information to the public. A durable power of attorney is a document empowering a person selected by the patient to make healthcare decisions in the event that the patient is unable to do so. It is permissible to discuss pertinent issues related to the welfare of the patient with the person holding a power of attorney.

The nurse is preparing to administer ophthalmic eye drops to her patient. What are the most appropriate actions for administering eye drops? Select all that apply. a) Place the patient in a high-Fowler's position. b) Administer the eye drops from the inner to the outer canthus of the eye. c) Position the eyedropper 1 to 2 inches above the eye. d) Apply the medication into the conjunctival sac.

A, B, D When administering ophthalmic medications, use a high-Fowler's position, work from the inner canthus to the outer canthus, and apply the medication into the conjunctival sac. Position the eyedropper about 1.5 to 2.0 cm ( to in.) above the eye; 1 to 2 inches is too high. Do not apply the medication to the cornea and do not allow the dropper to touch the eye.

Why is an accurate description of the location of a wound important? Select all that apply. a) Influences the rate of healing b) Determines the appropriate treatment choice c) Will affect the frequency of dressing changes d) Affects patient movement and mobility

A, B, D Wounds in highly vascular areas heal more rapidly than do wounds in less vascular regions. Wounds that can be stabilized also heal more readily than those in areas in which there is movement or pressure. Some wounds can be partially identified by their location. For instance, a venous stasis ulcer occurs in the lower extremities. Therefore, a wound located on an upper extremity would not be related to venous congestion. Wounds located on a plantar surface would impede the patient's mobility. Those in a location causing pain would also likely lead to restricted range of motion and movement (mobility). The frequency of dressing changes will be dependent on the type of wound and amount of drainage, but not necessarily the location.

For a patient with dementia, how might the nurse best improve orientation and clarity? Select all that apply. a) Place personal objects where the patient can see them. b) Introduce yourself each time you have contact with the patient. c) Encourage the patient to relax while the nurse gives the bath. d) Use short sentences with only a few words. e) Do not offer many choices when it comes to ADLs.

A, B, D, E Place personal objects, photos, and mementos in the immediate environment, and discuss them with the client. Introduce yourself and state the client's name each time you meet with him; wear a readable (large, plain type) nametag to reinforce your introduction. Also identify the day, date, and time as you interact. Encourage the patient to participate in familiar activities, such as bathing. To promote patient orientation for a patient with confusion (e.g., dementia), use simple communication and offer few choices with ADLs to prevent from overwhelming the patient. While you may sometimes find it necessary to bathe the patient, that intervention wouldn't be expected to improve orientation. Furthermore, encouraging the patient to relax would likely be ineffective in relaxing the patient, and might even elicit anger.

The home health nurse learns that an elderly patient isn't able to get to the grocery store. She doesn't have much food in her home, and eats and drinks little. Most of her time is spent sitting in her chair watching television, often not realizing that she has bladder leakage. Which nursing actions would she implement to reduce the risk of developing a pressure ulcer? Select all that apply. a) Help her to get out of the chair every 2 hours. b) Change her clothing frequently. c) Bath the patient using soap and water. d) Promote intake of green tea throughout the day. e) Encourage her to wear incontinence products.

A, B, E Immobility is a major cause of skin breakdown, especially when skin integrity is already compromised with poor nutritional status and poor hydration. Therefore, it is very important for the patient to get up out of the chair and move around periodically. The moisture from wet clothing is a source of skin breakdown. The nurse would not only need to help the woman put on dry undergarments but also implement a plan for incontinence care including using protective pads and absorption garments. Clean skin is important for optimizing skin integrity. However, soap can be drying to the skin, which could increase risk of alterations in skin integrity. Although this patient is at risk for dehydration and undernourishment, which compromises skin integrity, the nurse should educate the patient to drink noncaffeinated fluids, especially water. Caffeine can aggravate incontinence.

The nurse arrives at work to find the unit will be short staffed for the shift because a nurse called in sick at the last minute, leaving no time to find a replacement. What factors contribute to the dilemma faced by the nurse working this shift? Select all that apply. a) The nurse's multiple obligations and relationships b) Value conflicts and lack of clarity within the profession c) Autonomy versus escaping hard choices d) Higher pay versus cost effectiveness e) Caring versus the decreased time to spend with patients

A, B, E The nurse's multiple obligations influence this dilemma because the nurse may want to refuse to work short staffed because of safety issues, but wants to provide care for patients, and does not want to be fired for refusing to work under these conditions. The nurse's dilemma is partially owing to lack of clarity within the profession. Although the profession discusses the possibility of legal nurse-to-patient ratios, there is a lack of clarity about the best way to avoid short staffing. As well, there is a professional duty not to abandon patients. The nurse's dilemma is also focused on the realization that there will be inadequate time to care for patients adequately, or at least not as well as the nurse believes is her duty. Higher pay and cost-effectiveness are not about autonomy because the nurse is not giving up her autonomy by escaping hard choices and letting the provider choose her course of action. This shortage was not caused by reduction in staff to save money, but instead by a nurse calling in too late to provide adequate time to find a replacement.

What are the elements that the plaintiff must establish in a malpractice lawsuit? Select all that apply. a) Duty b) Breach of duty c) Intent to harm d) Assault e) Causation f) Injury

A, B, E, F For a malpractice suit to occur, duty, breach of duty, causation, and injury must be proved. Intent to harm and assault are types of crimes that are not part of the elements of malpractice suits.

Which of the following complementary and alternative modalities may be considered alternative medical systems? Select all that apply. a) Acupuncture b) Prayer c) Ayurveda d) Aromatherapy

A, C Acupuncture and ayurveda are considered alternative medical systems. Prayer is a mind-body intervention, and aromatherapy is a biologically based therapy.

The nurse is preparing to administer otic medications to her 35-year-old patient. What are the most appropriate actions by the nurse? Select all that apply. a) Pull the pinna up and back. b) Pull the pinna down and back. c) Place patient in side-lying position with appropriate ear up. d) Instruct the patient to remain on his side for at least 30 minutes.

A, C When administering otic medications, warm the solution to be instilled to body temperature, assist the patient to a side-lying position with the appropriate ear facing up, straighten the ear and pull the pinna up and back (adult patient), and instill the prescribed number of drops into the ear canal. Instruct the patient to remain on his side for 5 to 10 minutes after the procedure.

The new nurse is beginning her orientation on a medical-surgical unit. What is most important for the nurse to know regarding hospital policies concerning controlled substances? Select all that apply. a) Controlled substances are usually stored in a double-locked area. b) A count of all controlled substances is performed at specific times, usually monthly. c) The facility must keep a record of every dose of a controlled substance that is administered. d) Handling and storage of controlled substances is regulated by the U.S. Drug Enforcement Agency (DEA).

A, C, D Controlled substances must be stored, handled, disposed of, and administered according to regulations established by the U.S. Drug Enforcement Agency (DEA). Controlled substances must be stored in locked drawers with a second locked area. This process is known as double-locking. The facility must also keep a record of every dose administered. A count of all controlled substances is performed at specified times, usually at change of shift (not monthly).

The nurse understands that there are potential risks with herb use, just as there are risks with standard Western medications. These risks with herb use include which of the following? Select all that apply. a) Interaction with other medications b) Standardization of herbal preparations c) Lack of standardization of herbal preparations d) Lack of a formulary e) Reduced chance of toxicity

A, C, D Herbal therapies are not as regulated or standardized as Western medications. The major risks of herbal therapies are the lack of a formulary, the lack of standardization, the potential for interactions that are not identified, and the potential for toxicity as a result of dosages and interactions.

Through the use of the nursing process, holistic healthcare implemented by nurses includes which of the stated activities? Select all that apply. a) Health promotion b) Illness accentuation c) Health maintenance d) Education

A, C, D Holistic healthcare includes illness prevention, not accentuation, along with health education, health promotion, health maintenance, and restorative rehabilitative care.

What are some positive effects of pet therapy for residents in a long-term care facility? Select all that apply. a) Increases socialization b) Increases blood pressure c) Decreases pain d) Decreases loneliness e) Decreases insomnia

A, C, D Many facilities have resident pets or can arrange to have pets visit. Pet therapy can increase socialization, lower blood pressure, and decrease loneliness and perception of pain.

Which of the following is an example of whistleblowing? Select all that apply. a) Reporting fraudulent billing practices b) Reporting patient's health status against the patient's wishes c) Reporting unsafe work practices d) Reporting a coworker for working under the influence of drugs

A, C, D Reporting a patient's health status against the patient's wishes is a breach of patient confidentiality. Whistleblowing is identifying incompetent, unethical, or illegal situations or actions of others in the workplace and reporting to someone who may be in a position to rectify the situation. Fraudulent billing practices are illegal and unethical; unsafe work practices are unethical and illegal; and a coworker under the influence of drugs is a risk to patients, as well as acting in an illegal and unethical manner.

For an unconscious patient, which of the following interventions are necessary to provide for patient safety? Select all that apply. a) Talk to the patient as you provide care. b) Incorporate more touch in the plan of care. c) Give frequent eye care if blink reflex is absent. d) Keep the siderails up and bed in low position. e) Perform diligent oral care by irrigating with diluted mouthwash.

A, C, D Safety measures are a priority for unconscious clients. Keep the bed in low position when you are not at the bedside, and keep the siderails up. If the patient's blink reflex is absent or her eyes do not close totally, you may need to give frequent eye care to keep secretions from collecting along the lid margins. The eyes may be patched to prevent corneal drying, and lubricating eye drops may be ordered. It is important to talk to the patient because the sense of hearing may still be intact. This provides some stimulation and may help with reality orientation. Providing touch will also help prevent sensory deficit; however, it is not a safety measure. The unconscious patient would have a minimal or absent gag reflex and lack of swallowing; therefore, you would not squirt fluid in the mouth for oral care because it could cause the patient to aspirate.

Which of the following are examples of nonselective mechanical debridement methods? Select all that apply. a) Wet-to-dry dressings b) Sharp debridement c) Whirlpool d) Pulsed lavage

A, C, D Wet-to-dry dressings and hydrotherapy (e.g., whirlpool and pulsed lavage) are nonselective forms of debridement, which means that healthy tissue as well as devitalized tissue can be removed with their use. Sharp debridement is a selective form of debridement. With sharp debridement, only devitalized tissue is removed.

The nurse is caring for a patient who experienced a stroke leaving the left side of the body paralyzed. The patient says, "I can still bathe myself," but the nurse performs the bath to make certain the patient gets clean. What ethical principles is the nurse violating with this behavior? Select all that apply. a) Beneficence b) Fidelity c) Autonomy d) Veracity e) Nonmaleficence

A, C, E Beneficence is doing good, and performing care for the patient rather than encouraging the patient to do as much for himself as possible is not doing the patient any good. To do good for this patient, the nurse should encourage the patient to perform as much of the bath as possible so he will regain his strength. The nurse is limiting the patient's autonomy by not encouraging the patient to do as much self-care as possible and not respecting the patient's desire to try bathing by himself. Nonmaleficence is doing no harm and the nurse is harming this patient by encouraging dependence instead of autonomy. Fidelity is being loyal; this principle is not relevant to the scenario. Veracity means the nurse should be honest; this principle is not relevant to the scenario.

Which factors in a health history place a patient at risk for hearing loss? Select all that apply. a) Being an older adult b) Childhood chickenpox c) Frequent otitis media d) Diabetes mellitus e) Congenital rubella

A, C, E Having had frequent ear infections (otitis media) places a patient at risk for hearing loss because of scarring that may have occurred. Older adults experience a generalized decrease in the number of nerve conduction fibers and structural changes in the ear, which cause hearing loss. Sensorineural deafness, eye abnormalities, and congenital heart disease are the classic triad that occurs with congenital rubella. Chickenpox and diabetes mellitus do not place the patient at risk for hearing loss.

For a patient with hearing loss, it is essential to minimize the risk of further damage to the auditory nerve. Which of the following medications may need to be discontinued if the patient is taking them? Select all that apply. a) Furosemide, a diuretic b) Digoxin, a cardiotonic c) Famotidine, an antacid d) Aspirin, an analgesic e) Penicillin, an antibiotic

A, D Aspirin and furosemide may cause ototoxicity, leading to auditory nerve impairment. Digoxin, famotidine, or penicillin does not place the patient at risk for auditory nerve impairment.

The nurse educator in the local hospital is preparing a teaching plan for staff nurses on using medication abbreviations in nursing documentation. What is most important for the nurse to include in the teaching plan concerning acceptable abbreviations? Select all that apply. a) They are based on Joint Commission recommendations. b) They are commonly used by the pharmacy department. c) They are most commonly used by nurses. d) They are based on policies of the facility.

A, D The nurse should write out drug names and dosages in full. Abbreviations can be easily confused and many are not universally understood. However, you will see and use some abbreviations when administering and documenting medications. Always do so carefully because some may be similar and confusing. Consult The Joint Commission's official Do Not Use list and know the acceptable abbreviations used in your facility.

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

A,C Negligence and malpractice are unintentional torts—nurses can be negligent without intending to do harm. Negligence is simply the failure to use ordinary or reasonable care as dictated by the standards of practice and/or by what a reasonable and prudent nurse would do in the same or similar circumstances. Intent is not an element of negligence. When a nurse or other licensed professional healthcare provider is negligent and fails to exercise ordinary care, it is called malpractice. Malpractice is the professional form of negligence.

A patient tells the nurse that since taking a medication he has suffered from excessively dry mouth. Which of the following assessments would be needed to plan interventions for that symptom? a) Asking the patient whether foods taste different now b) Checking the patient's sense of smell c) Having the patient stand to check for balance d) Assessing for a history of seizures

A. Asking the patient whether foods taste different now Many medications cause xerostomia (dry mouth), and xerostomia is the most common cause of impaired taste. Impaired sense of smell also affects the sense of taste; however, there is no reason to assume impaired smell in this patient. Balance is related to the inner ear and to kinesthetic sense, not to taste and xerostomia. Xerostomia would be related to seizures only if a patient experienced dry mouth as an aura; this would be unusual. Even if this were the case, the information would allow the nurse to plan care for seizures, but not for the symptom of dry mouth.

Of the following, which is the best choice for performing wound irrigation? a) Water jet irrigation b) 35-mL syringe with a 19-gauge angiocatheter c) 5-mL syringe with a 23-gauge needle d) Bulb syringe

B A 35-mL syringe with a 19-gauge angiocatheter is the best choice for irrigation because it will deliver the irrigation solution at approximately 8 psi. The water jet irrigation unit and 5-mL syringe with a 23-gauge needle would deliver the solution above the recommended pressure range of 4 to 15 psi. A bulb syringe is not an appropriate choice because there is an increased risk of aspirating drainage from the wound.

Which laboratory result on a client's health record should alert the nurse to a potential problem? a) Na+ = 137 mEq/L b) K+ = 5.2 mEq/L c) Ca2+ = 9.2 mg/dL d) Mg2+ = 1.8 mg/dL

B A potassium level of 5.2 mEq/L indicates hyperkalemia. The other results are all within normal ranges.

The nurse is caring for a patient with severe, chronic headaches. According to a recent medical work-up, there "is no definitive physiological reason for these headaches." The nurse counsels the patient about alternative therapies for headaches, knowing that: a) Homeopathic medications eliminate migraine and other chronic headaches b) Acupuncture is more effective than medication in relieving chronic headaches c) Western medicine has no alternative treatment for severe, chronic headaches d) There is no palliative care for chronic headaches without physiological basis

B Acupuncture has been shown to more effectively relieve chronic headaches than medications. Homeopathic medicine is person specific and not disease/symptom specific—that is, it cannot be said that it affects headaches in a specific way. Western medicine does have other alternative treatments for severe and chronic headache management (e.g., biofeedback, botulinum toxin). There is palliative care for chronic headaches to manage the process rather than effecting a "cure."

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

B Aging skin tends to be drier. Sweat gland activity is diminished. The skin's connective tissue, collagen, and elastin are reduced, which means the skin loses firmness and so wrinkles. Skin aging also occurs with exposure to oxygen-free radicals that are waste products from chemical reactions in the body as well as with exposure to certain food and environmental sources. An infant's skin is thinner and more permeable to moisture in the environment.

A 4-year-old child is brought to the emergency department by his mother. He has a large bruise on 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 do first? a) Notify the nursing supervisor of the suspected physical abuse. b) Complete a physical assessment of the child. c) Obtain an order for pain medication. d) Notify Child Protective Services of the suspected abuse.

B Although the nurse must report to designated authorities (Child Protective Services) suspected physical abuse, the primary responsibility of the nurse in this situation is to evaluate the patient's physical condition and extent of his injuries for appropriate medical treatment to be provided. Pain medication should not be administered prior to a thorough physical assessment. The nurse should always notify the nursing supervisor if any outside agencies may need to be contacted.

Why might skin integrity and wound healing be compromised in the client who takes blood pressure medications? Antihypertensives: a) Can cause cellular toxicity b) Increase the risk of ischemia c) Delay wound healing d) Predispose to hematoma formation

B Blood pressure medications decrease the amount of pressure required to occlude blood flow to an area, creating a risk for ischemia. Chemotherapeutic agents delay wound healing because of their cellular toxicity. Anticoagulants can lead to extravasation of blood into subcutaneous tissue, predisposing to hematoma formation with minimal pressure or injury.

The Code of Ethics for Nurses: a) Is legally binding b) Is not legally binding c) Is legally binding in some circumstances d) Cannot be used in legal cases

B Codes of ethics are open to public scrutiny. The ethical aspects of nursing work, just like the technical aspects, are subject to review by professional groups and licensure boards, which may use sanctions to punish code violations. The Code of Ethics for Nurses establishes standards of practice for nurses. Although nursing codes are not legally binding, they are often used in legal cases involving nurses (e.g., malpractice) to identify deviations from professional standards of practice.

The nurse is caring for a patient who after removal of a tumor had radiation therapy. The patient, without consulting his primary provider, added nutritional therapy and the use of acupuncture. The treatments chosen by the patient are examples of what type of treatments? a) Alternative modalities b) Complementary modalities c) Integrative healthcare d) Conventional biomedical therapies

B Complementary modalities (i.e., nutritional therapy and acupuncture) are used in conjunction with traditional medical care (the radiation treatments). Alternative modalities are used instead of conventional medical therapies. Integrative modalities are therapies that are proved to be effective and safe when combined with or integrated into conventional therapies. Conventional biomedical therapies include radiation therapy.

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

B Drugs administered by the sublingual (SL) route should be placed under the patient's tongue and allowed to dissolve. Drugs administered by the buccal route are placed in the cheek and allowed to dissolve. A subcutaneous injection is administered into the subcutaneous tissue. Placing the drug into the patient's mouth, giving him water, and instructing him to swallow the tablet describe oral administration.

The nurse enters a patient's room with a portable computer station to assess the patient. The nurse does not log out while assisting a patient to the bathroom. A visitor reads the patient's chart and begins to question the nurse about the patient information. This is an example of: a) Failure to educate the patient b) Failure to maintain patient confidentiality c) Negligence regarding the patient's care d) Failure to educate the visitor

B Even though it was an inadvertent act in this situation, failure to maintain patient confidentiality and privacy are applicable to patient records. By not closing the patient electronic medical record, the nurse made it available to someone not directly involved with the patient's care. Family and friends do not have the right to have access to the patient's chart by virtue of their relationship to the patient. Educating the patient or visitor or the lack to do so have nothing to do with this item. There was no negligence in care to the patient by the nurse in this situation.

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

B Informed consent is the necessary authorization by the patient for any and all types of care and must be written and signed by the patient or the person legally responsible for the patient for hospital admission and for invasive or specialized treatments or diagnostic procedures. Written consent is not necessary in an emergency if experts agree that there was an immediate threat to life or health. It is the physician responsible for the care of the patient who has the duty to obtain informed consent from the patient.

Identify the third step in the MORAL decision-making model. a) Reassess the dilemma. b) Resolve the dilemma. c) Review the problem. d) Recall the history of the problem.

B MORAL is an acronym for the following steps: M, Massage the dilemma; O, Outline the options; R, Resolve the dilemma; A, Act by applying the chosen option; L, Look back and evaluate.

Which factor in a patient's medical history is most likely to prolong the half-life of certain drugs? a) Heart disease b) Liver disease c) Rheumatoid arthritis d) Tobacco use

B Metabolism takes place largely in the liver. If there is a decrease in liver function (e.g., because of liver disease), the drug will be eliminated more slowly, prolonging the drug's half-life. Tobacco use can increase the elimination of some drugs, decreasing their effectiveness.

The nurse understands that CAM therapies are popular with many patients. What is the most important thing for the nurse to know regarding safe use of CAM therapies? CAM therapies a) Must be sensitive to the patient's culture b) Need to be tested to establish their effectiveness c) Should be determined by the patient d) Chosen by the patient can bypass testing

B Patients may use CAM therapies even if there is no accurate evidence on which to base their effectiveness or safety. Therefore, the nurse needs to look at empirical research to guide the nurse, patient, and healthcare provider in using these therapies. The other responses negate the importance of research data in the use of CAM, although they do suggest issues that can improve the effectiveness of any therapy (i.e., cultural sensitivity, the patient wants to use them).

The nurse in the emergency department 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 on the dressing? a) Serous b) Sanguineous c) Purosanguineous d) Purulent

B Sanguinous drainage contains blood, which would be expected from a wound with active bleeding. Serous drainage is clear, faintly yellow drainage. Serous drainage occurs when there is inflammation, such as with a burn injury. Purosanginous fluid contains pus, which occurs with infection. This patient has a wound from an acute injury. Although infection risk is high with gunshot wounds, infection generally takes 2 or more days to occur. Purulent drainage indicates infection. This wound is too recent to demonstrate infection.

While assessing a new wound, the nurse notes red, watery drainage. How should the nurse describe this type of drainage when documenting? a) Sanguineous b) Serosanguineous c) Serous d) Purosanguineous

B Serosanguineous drainage, a combination of bloody and serous drainage, is most commonly seen with new wounds. Serous drainage is straw colored, and sanguineous drainage is bloody. Purosanguineous drainage is pus that is red tinged.

Which expected outcome is best for a patient with a nursing diagnosis of Deficient Knowledge related to new drug treatment regimen? a) After an explanation and written materials, describes the expected actions and adverse reactions of his medication b) In 1 week after instructional session, describes the expected actions and adverse reactions of his medications c) Follows the treatment plan as prescribed d) Experiences no adverse effect from his prescribed treatment plan

B The best phrasing for the expected outcome is the one with a specific, measurable time frame (1 week) and details for how to resolve the patient's knowledge deficit. The other options provide no time line for achieving the goal and, therefore, are not measurable. Expected outcome statements must be measureable.

The nursing student is preparing to administer an intramuscular (IM) injection to her patient. She states to her instructor, "I'm going to administer this medication in my patient's buttocks at the dorsogluteal site." What is the most appropriate response by the instructor? a) "Okay. Explain the procedure to me and you are good to go." b) "This may not be the best site owing to proximity of the sciatic nerve." c) "I agree, this is a good site for thin patients such as this one." d) "Okay, but first be sure to locate the bony landmarks carefully."

B The dorsogluteal site consists of the gluteal muscles of the buttocks. Avoid using the dorsogluteal site for IM injections because its close proximity to the sciatic nerve and superior gluteal artery increases the risk of injection into a major blood vessel and damage to the sciatic nerve. Furthermore, the site is difficult to identify accurately in older adults or people with flabby skin. The instructor should advise the student that this is not the appropriate site and elicit another site from the student. Once this is identified, the student can proceed with patient identifiers.

The nurse believes that abortion is wrong, but applies the MORAL model and decides that caring for patients following an abortion is her ethical duty. When evaluating the effectiveness of the nurse's decision process, what finding would indicate the nurse made the best choice? a) The patient is discharged without experiencing complications from the procedure. b) The nurse believes quality care was delivered and feels satisfied with the decision. c) The nurse manager commends the nurse for providing excellent patient care. d) The patient thanks the nurse for being supportive during a difficult time.

B The fact that the nurse believes the right thing was done and has a sense of satisfaction with the decision is the important focus of an evaluation of a decision process. A positive patient outcome (i.e., discharge without complications) reflects good nursing care but is not a good criterion for evaluating an ethical decision process. No matter how carefully a process is applied, and no matter how well a moral decision is justified, you can never be certain of obtaining a good outcome for the patient because there are many variables other than moral variables that affect an outcome. The same is true for the quality of the nurse's patient care. The fact that the nurse thanks the nurse has no bearing on how well the decision process worked.

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 deep vein thrombosis. He also reports a sedentary lifestyle. How would the nurse classify this chronic wound? a) Pressure ulcer b) Venous stasis ulcer c) Diabetic foot ulcer d) Arterial ulcer

B The location of the ulcers and the history of past deep vein thrombosis would make venous stasis ulcers the most likely classification for these wounds. They occur usually between the inside ankle and the knee, not necessarily over a bony prominence, and are typically red in color, shiny, and taut, and may even feel warm or hot. Fluid drainage can be significant. A pressure ulcer is unlikely to develop on the medial side of the calf because it is neither a bony area nor one that is likely to be an area where there is pressure. There is no indication that this patient is diabetic and the wound is not on the foot. An arterial (ischemic) ulcer tends to be dry and pale, with little drainage. Arterial ulcers are usually very painful, especially at night.

A nurse is providing care to a patient who is a Jehovah's Witness. Against the patient's wishes, the physician ordered the nurse to give the patient two units of packed red blood cells. The nurse knows that the blood will save the patient's life, but also that it is against the patient's wishes; she is unsure what is the right thing for her to do. The nurse is experiencing a(n): a) Reflection encounter b) Ethical dilemma c) Moral outrage d) Moral distress

B The nurse is experiencing an ethical dilemma based on the conflict between the ethical principles of beneficence and autonomy. The nurse has not yet made a decision. This is not a situation of moral distress, in which the nurse would have made an acceptable moral decision, but was unable to implement it because of external constraints. The nurse does not perceive that others are acting immorally; thus, this is not moral outrage.

The nurse witnesses the patient's signature on a consent form to participate in her physician's research study. After the physician leaves the room, the patient tells the nurse she really doesn't want to participate but didn't have the heart to turn down the request because of fear that the physician would be upset. What should the nurse do to advocate for this patient? a) Tell the patient the physician will not be upset. b) Tell the physician why the patient agreed to participate. c) Explain the importance of the research study to the patient. d) Ask the patient what she would like you to do.

B The nurse should inform the physician of the patient's feelings and encourage the physician to talk with the patient to give her permission to change her mind. While the nurse can say the physician will not be upset, and it is likely to be true, it will not change how the patient feels nor provide her the opportunity to change her mind. Explaining the importance of the study would probably make the patient feel even more obligated to participate. The patient is likely to tell the nurse not to do anything, so the patient's needs would still go unmet.

An 87-year-old patient has just been diagnosed with cancer. Her durable power of attorney names her son as her surrogate decision maker. He arrives at the patient's bedside to discuss treatment options with her. The patient is alert and oriented. Her son tells you that he does not want her to receive any treatment (chemotherapy) because of the side effects and her age. The patient tells you that she wants to try the treatment. Which decision should be followed by the nurse? a) The patient's son's b) The patient's c) Both—initially the patient's; then the son's when the medication's side effects become severe d) Neither; this is a legal decision and should be made by a court of law

B The patient is alert and oriented and can make her own healthcare decisions. The son only has the authority to make healthcare decisions once his mother becomes incompetent and unable to process information to make decisions. This is not an issue for the court. The patient will decide if and when to discontinue treatment.

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? a) Ventrogluteal b) Vastus lateralis c) Deltoid d) Dorsogluteal

B The preferred site for IM injections for infants who are not yet walking is the vastus lateralis muscle because there are no major blood vessels or nerves in the area and the gluteal muscles have not been developed by walking. For children who are walking, the site of choice is the ventrogluteal muscle. The dorsogluteal site is not recommended for children or adults. The deltoid muscle can be used for small volumes in older children and adults.

After morning care, the nurse lowered the height of the IV container infusing via gravity flow, at the patient's request. What is the nurse's next best action? a) Calculate the new infusion rate. b) Readjust the infusion rate, as needed. c)Change the IV site and move it to the other arm. d) Instruct the client to call when the IV bag is empty.

B The rate of an IV infusing via gravity draining will be altered by raising or lowering the IV solution. Thus, if the IV pole is lowered, the rate will need to be verified and adjusted as needed. The drip rate is based on the administration set and prescribed rate and is not affected by the height of the IV solution. The IV site will need to be changed only when clinically indicated. The nurse should not rely on the patient, but should monitor the infusion amount.

An alert, oriented, and competent frail older adult man has been told that he is dying and has asked to have a DNAR (AND) prescription put on his chart. The patient's 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 other's opposing views. Which step of the MORAL model does this illustrate? a) M—Massage the dilemma b) O—Outline the options c) R—Resolve the dilemma d) L—Look back and evaluate

B This illustrates the Outlining the options step. In Massaging the dilemma, the team would already have identified and defined the issues in the dilemma, and considered the values and options of all the major players. At the Outlining the options step, someone should delineate all of the options to all parties, including those that are less realistic and conflicting. In that step, someone often asks a member of the ethics committee or the hospital chaplain to help the parties understand the opposing viewpoints. Resolving the dilemma is the step in which all the options are reviewed and basic ethical principles and frameworks are applied to arrive at a decision. Looking back to evaluate is done after a decision has been made and acted on. At that time, the entire process, including the consequences, are evaluated to determine how well they worked.

A man was involved in a motor vehicle accident yesterday. He is to be sedated for more than 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time? a) Risk for Infection related to subcutaneous injuries b) Risk for Impaired Skin Integrity related to immobility c) Impaired Tissue Integrity related to ventilator dependency d) Impaired Skin Integrity related to ventilator dependency

B This patient is at Risk for Impaired Skin Integrity because he is being kept in a sedated state. Thus, he is unable to turn himself to relieve pressure. There is no mention of subcutaneous injuries, ruling out Risk for Infection related to subcutaneous injuries. Impaired Tissue Integrity and Impaired Skin Integrity are also incorrect because there is no supporting evidence for these nursing diagnoses.

The primary care provider orders peak and trough levels for a patient who is receiving intravenous vancomycin every 12 hours. When should the nurse obtain a blood specimen to measure the trough? a) With the morning routine laboratory studies b) Approximately 30 minutes before the next dose c) Two hours after the next dose infuses d) While the drug is infusing

B Trough levels are typically obtained approximately 30 minutes before administering the next dose of the drug. Therefore, the trough cannot be collected with the morning routine laboratory studies. The vancomycin peak should be obtained 2 hours after the next dose infuses. Peak level must be measured when absorption is complete. This depends on all the factors that affect absorption. Trough levels would be inaccurate if the specimen is obtained while the drug infuses

Upon initial assessment of a 75-year-old patient, you identify bruises and scratches on the patient's 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? a) Good Samaritan Law b) Mandatory Reporting Law c) Nurse Practice Act d) Nursing Standards of Practice

B Under state mandatory reporting laws, nurses must report to designated authorities (e.g., Adult Protective Services) suspected physical, sexual, emotional, or verbal abuse or neglect by healthcare workers or family members. In general, nurses who fail to report suspected abuse or neglect may be held criminally or civilly liable.

The nurse records a patient's hourly urine output from an indwelling catheter as follows: 0700: 36 mL 0800: 45 mL 0900: 85 mL 1000: 62 mL 1100: 50 mL 1200: 48 mL 1300: 94 mL 1400: 78 mL 1500: 60 mL The nurse can conclude that the patient's urine output should be described as which of the following? a) Low b) Within normal limits c) High d) Inconclusive

B Urine accounts for the greatest amount of fluid loss. Normal urine output for an average-sized adult is approximately 1,500 mL in 24 hr. Urine output varies according to intake and activity but should remain at least 30 to 50 mL per hour. The patient's urine output is within the normal range. This patient has an indwelling catheter, which will result in continual flow of urine.

The nurse checks a patient's pupils using a penlight. Which receptors is the nurse stimulating? a) Chemoreceptors b) Photoreceptors c) Proprioceptors d) Mechanoreceptors

B Photoreceptors Photoreceptors located in the retina of the eyes detect visible light. Proprioceptors in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable an individual to sense the position of the body in space. Chemoreceptors are located in the taste buds and epithelium of the nasal cavity. They play a role in taste and smell. Thermoreceptors in the skin detect variations in temperature. Mechanoreceptors in the skin and hair follicles detect touch, pressure, and vibration.

Which actions can the nurse take to prevent sensory overload? Select all that apply. a) Leave the television on low volume to block out other noises. b) Minimize ambient light in the patient's room. c) Plan care to provide periods of sleep. d) Speak with a moderate tone of voice. e) Restrict caffeine intake during hospitalization.

B, C, D, E To prevent sensory overload, minimize unnecessary light, plan care to provide uninterrupted periods of sleep, and speak to the patient in a moderate tone of voice using a calm and confident manner. Television can be used to provide sensory stimuli, but not to prevent sensory overload. When used, it should not be left on indiscriminately. Medications and some substances that stimulate the CNS may also contribute to sensory overload, such as caffeine.

The nurse is caring for a patient diagnosed with a brain tumor who is about to undergo surgery to have the tumor removed. Before the surgery, the patient signs a document giving instructions to his family regarding the level and extent of life-prolonging treatments he desires. Which of the choices below describe this legal directive? Select all that apply. a) The document is a durable power of attorney for healthcare. b) The document is a living will. c) The family can make decisions that are consistent with the document if the patient is incompetent. d) The family is able to decide to prolong the patient's life, even if he does not want it. e) The family has guidance on the treatments the patient wants

B, C, E This is an example of a living will that directs the family members to have care given to the patient based on what the patient wants if the patient is unable to make these decisions. With this document, the family cannot choose to do something the patient did not request. As described in the item, this is not a power of attorney, giving someone else the right to make healthcare decisions for the patient should he become incapable of making those decisions.

Select the process(es) that occur(s) during the inflammatory phase of wound healing. Select all that apply. a) Granulation b) Hemostasis c) Epithelialization d) Inflammation

B, D During the inflammatory phase of wound healing, hemostasis and inflammation occur. After an injury, blood vessels constrict to limit blood loss, and platelets migrate to the site and aggregate to stop bleeding. Together, this results in hemostasis. Inflammation follows as a defense against infection at the wound site.

Under the American Nurses Association (ANA) Code of Ethics, the nurse has the professional responsibility to uphold ethical behavior. Choose the statements below that are accurate about the Code of Ethics. Select all that apply. a) ANA Code of Ethics is a law. b) Nurse actions are to be at the level expected by the profession. c) Nurses are not held accountable for their actions. d) Nurses are professionally bound to give correct information to the patient. e) Nurses do not need to collaborate to meet a patient's healthcare needs. f) ANA Code of Ethics will protect the nurse even if the law is broken.

B, D The ANA Code of Ethics is not a law, but rather standards of professional responsibilities of the nurse using behavior that is ethical and expected by or acceptable to the profession. Under the Code of Ethics, nurses are bound to give correct information to patients. Collaboration is not forbidden in the Code. The Code of Ethics is not a law and won't protect the nurse who is in violation of them.

The nurse in the intensive care unit enters her patient's room and observes the patient is experiencing a seizure. What are the most appropriate interventions by the nurse? Select all that apply. a) Insert a padded tongue depressor in the patient's mouth. b) Turn the patient to his side. c) Restrain the patient to control his jerking movements. d) Loosen any restrictive clothing. e) Pad the siderails of the patient's bed.

B, D, E When a seizure is occurring, the nurse would turn the patient to his side to prevent aspiration and loosen any restrictive clothing; also pad the head, foot, and siderails of the bed and place oral suction at the bedside. Do not try to open the mouth and insert a tongue depressor. This action could result in injury to the patient or injury to the nurse (biting). Also do not attempt to restrain the patient, as this may result in muscle and joint injury.

A patient comes to the clinic complaining of a taste disturbance. Which medication that the patient is currently prescribed is most likely responsible for this disturbance? a) Furosemide, a diuretic b) Phenytoin, an anticonvulsant c) Glyburide, an antidiabetic d) Heparin, an anticoagulant

B,Phenytoin, an anticonvulsant Phenytoin is a medication that has a high incidence of associated taste disturbance. Furosemide, glyburide, and heparin are not implicated in taste disturbances

The 80-year-old patient on the medical-surgical unit says to the nurse, "My vision is blurry and I see halos around lights. The glare from the sun really bothers me." Upon assessment, the nurse notes a cloudy film over the lens of the eye. Based on the patient's complaints and the nurse's assessment, the nurse associates these findings with which of the following? a) Strabismus b) Cataracts c) Glaucoma d) Presbyopia

B. Cataracts A cataract is a cloudy film over the lens of the eye resulting in blurred vision, sensitivity to glare and bright light, halos around lights, fading or yellowing of colors, and image distortion. Tinnitus is ringing in the ear unrelated to vision. Presbyopia is a change in vision associated with aging in which a person is less able to accommodate to near objects. Glaucoma is a condition involving increasing pressure in the eye that can lead to loss of peripheral vision and even blindness, if not treated. Strabismus ("crossed-eyes") is the condition wherein one eye deviates from a fixed image

A patient has a stage II pressure ulcer on her right buttock. The ulcer is covered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound? a) Dry gauze dressing changed twice daily b) Nonadherent dressing with daily wound care c) Hydrocolloid dressing changed as needed d) Wet-to-dry dressings changed three times a day

C A hydrocolloid dressing would conform to this area and form a protective layer against friction and bacterial invasion. It would also promote autolytic debridement of the slough and absorb the exudate from the autolysis. Dry gauze and nonadherent dressing (e.g., Telfa) would cover the wound but would not aid in removing the slough. A wet-to-dry dressing is a form of mechanical debridement. It would aid in removing the slough but is nonselective; therefore, it could cause damage to healthy tissue as well.

What intervention would be most appropriate for a wound with a beefy red wound bed? a) Mechanical debridement b) Autolytic debridement c) Dressing to keep the wound moist and clean d) Removal of devitalized tissue and a sterile dressing

C A red wound indicates active healing, and the best treatment is gentle cleansing and a dressing that will ensure a clean, moist wound environment. Debridement is not necessary in this situation because there is no devitalized tissue present.

The nurse overhears a coworker say, "How can an overweight nurse teach proper nutrition? That nurse should practice what is taught." Which concept best describes what the coworker is expressing? a) Morals b) Ethics c) Values d) Compromise

C A value is a belief about the worth of something. This coworker is diminishing the worth of the overweight nurse through the statement made, which goes against nursing values of compassion and human dignity. Morals are something we learn that help us differentiate good from bad, right from wrong. Ethics is the study of a system of moral principles and standards; therefore, this coworker is not expressing ethics. A compromise is a solution in which parties with opposing positions all settle on a solution to a problem that is somewhere between what each party would ideally like to have. This nurse is simply stating her own position.

While applying a wet-to-dry dressing, how would the nurse explain to the patient how this procedure works for promoting healing? A wet-to-dry dressing is a: a) Method of submerging the wound in water, allowing it to soak before drying the wound bed b) Procedure that uses proteolytic agents to break down necrotic tissue in the wound bed c) Means of debriding the wound but also removing granulation tissue from the wound d) Form of debridement that uses an occlusive, moisture-retaining dressing to break down necrotic tissue

C A wet-to-dry dressing uses coarse gauze moistened with normal saline that is packed into the wound, allowed to dry, and then removed, perhaps several times a day. This form of nonselective debridement removes not only debris, but also granulation tissue from the wound. It is also quite painful. Hydrotherapy or whirlpool treatments are nonselective debridement wherein the wound is submerged in a whirlpool containing tepid water for a prescribed amount of time (usually 5 to 15 minutes). This form of debridement is reserved for wounds with a large amount of nonviable tissue, such as burns. Enzymatic debridement uses proteolytic agents to break down necrotic tissue without affecting viable tissue in the wound. To use an enzymatic product, clean the wound with normal saline, apply a thin layer of the cream, and cover with a moisture-retaining dressing. Autolysis breaks down necrotic tissue by using an occlusive, moisture-retaining dressing (e.g., transparent dressing) and the body's own enzymes and defense mechanisms. This process takes more time than the other techniques, but it is better tolerated.

A patient who is being discharged asks the nurse, "Can I take you out for dinner to show my appreciation for all that you have done for me? I really like you." The nurse's best response is which of the following? a) "Yes, that would be nice. It is really great to be appreciated." b) "No, and please do not ask again. You should have been told that already." c) "Thank you; however, I have to refuse, even though the thought is appreciated." d) "We will have to wait 3 days after you have been discharged to have a relationship."

C Accepting gifts from patients is a breach of professional boundaries: social contact. Nurses cannot accept gifts from patients in the form of dinners, money, social contact, and the like. The nurse should not enter into a relationship based on the patient's attempt to compensate her for performing her role responsibilities. Waiting 3 days would not change that. Telling the patient not to ask again, and that she should already know that, borders on rudeness. Although it reflects the understanding about gifts and professional boundaries, it is not an empathetic response and would not help build a trusting relationship.

Which of the following concepts refers to conflicts that arise between two or more ethical principles in patient care scenarios? a) Nursing ethics b) Bioethics c) Ethical dilemma d) Moral distress

C An ethical dilemma occurs when a choice must be made between two or more equally undesirable actions, and there is no clearly right or wrong option. Moral distress occurs when someone is unable to carry out his or her moral decision. Nursing ethics refers to ethical questions that arise out of nursing practice. Bioethics is a broader field that refers to the application of ethics to healthcare.

The nurse is caring for a patient, who recently emigrated from India. The patient states the reason for the visit is for a well-patient visit. While taking the patient's history, the nurse ascertains that the patient is using ayurvedic herbal remedies. Which statement below assists the nurse to determine whether the patient understands the pros and cons of these herbal remedies? a) "I can continue to order these herbal remedies from the shop in India where I have always purchased them." b) "I can order these herbal remedies from any Internet source selling them." c) "I should order these herbal remedies over the Internet from an FDA-approved site." d) "I have had no problems from taking these herbal remedies, so I can continue their use."

C Ayuvedic herbal remedies are frequently combined with metals that can be harmful to the patient. Purchasing them from an unregulated shop or Web site increases the chances of there being higher levels of toxic metals in the herbal mixtures. Therefore, the patient should purchase these herbal remedies only from an FDA-approved Web site source. Also, because the patient believes there is no problem with taking these unregulated remedies, the nurse must educate him about the potential issues with this.

Herbal products are very popular worldwide for prevention and treatment of illness. As a nurse you should: a) Advise patients to purchase herbal products from the least expensive source b) Inform patients that research conclusively states that herbs are safe c) Learn about herbal therapies and include them in questions when taking a patient's history d) Disregard patients' use of herbal products, as their use will not impact traditional medicine

C Because herbal products are readily available and widely used, you should learn about herbal products and include them in questions when taking a patient's history. The National Center for Complementary and Alternative Medicine (NCCAM) offers extensive material on herbal products for professionals and consumers. Advise patients to purchase herbs from a reliable source and seek advice from credentialed practitioners when incorporating herbs into their care.

When teaching a patient about the healing process of an open wound after surgery, which of the following points would the nurse make? a) The patient will need to take antibiotics until the wound is completely healed. b) Because the patient's wound was left open, the wound will likely become infected. c) The patient will have more scar tissue formation than there would be for a wound closed at surgery. d) The patient should expect to remain ho

C Because the wound edges are not approximated, more scar tissue will form. Although open wounds are more prone to infection, this is not an expected outcome, and antibiotics would not necessarily be needed. A patient with an open wound should not expect an extended hospital stay if wound care can be provided in the home or an outpatient setting.

A client wishes to avoid taking blood pressure medications. He is watching his diet and exercising. In addition, a CAM therapist has recommended an alternative therapy that will allow him to learn voluntary control over his blood pressure. What type of therapy is the therapist probably recommending? a) Homeopathy b) Naturopathy c) Biofeedback d) Hypnosis

C Biofeedback is a technique by which people learn voluntary control over typically involuntary activities. Homeopathy is based on an understanding of how the body heals itself and an acceptance that all symptoms represent the body's attempt to restore itself to health. Naturopathy is the belief that nature and each living being have the innate ability to establish, maintain, and restore health. Hypnosis is a trancelike state characterized by relaxed brain waves, hypersuggestibility, and heightened imagination. Hypnosis has been used to promote relaxation, weight loss, and smoking cessation and to suppress various symptoms.

The nurse mixes two medications together in one syringe and is preparing to administer them to her patient. On entering the patient's room, the nurse notices that the medication looks cloudy and there are some particles floating in the mixture. What is the most appropriate action by the nurse? a) Notify the pharmacist before proceeding. b) Check for medication compatibility. c) Discard the medications and syringe. d) Remix the medications in a different syringe.

C Drug incompatibilities occur when multiple drugs are mixed together, causing a chemical deterioration of one or more of the drugs. The result is an incompatible solution that should not be administered. You can usually recognize an incompatibility when the mixed solution takes on a changed appearance. If the contents of the syringe become discolored or there are particles in the solution, do not administer the medication. The nurse should always consult a medication resource and compatibility chart before mixing medications. Remixing the medications using a different syringe is inappropriate, as this will only elicit the same result.

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, "I'm leaving this hospital. Remove my IV and surgical drains or I will do it myself." 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? a) Assault and battery b) Felony c) False imprisonment d) Quasi-intentional tort

C False imprisonment involves an intentional or willful detention of a patient without consent or authority to do so. Restraining a patient without consent is another form of civil false imprisonment. Competent patients have a right to leave an institution, even if it is harmful to their health. Whenever possible, have the person sign a form stating that he is aware that he is leaving against medical advice

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 fails to 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? a) Malpractice b) Incompetence c) Negligence d) Abandonment

C Negligence is the failure to use ordinary or reasonable care or the failure to act in a reasonable and prudent (careful) manner. It is negligent to assign a nurse to care for a patient without verifying the nurse has training, experience, and clinical competence in caring for such patients

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? a) Nonmaleficence b) Autonomy c) Paternalism d) Beneficence

C Paternalistic behavior occurs when the nurse thinks she knows what is best for a competent patient and coerces the patient to act as she wishes rather than to act as the patient originally desired. Autonomy refers to a person's right to choose and his ability to act on that choice. Nonmaleficence is the twofold principle of doing no harm and preventing harm. Beneficence is the duty to do or promote good.

A patient with terminal cancer requires increasing doses of an opioid pain medication to obtain relief from pain. This patient is exhibiting signs of drug: a) Abuse b) Misuse c) Tolerance d) Dependence

C Patients in the terminal stages of cancer commonly exhibit drug tolerance, a decreasing response to repeated doses of a medication. Therefore, pain management must be carefully planned to promote patient comfort. Drug abuse is the inappropriate intake of a substance continually or periodically. Drug misuse is the nonspecific, indiscriminate, or improper use of drugs, including alcohol, over-the-counter preparations, and prescription drugs. Drug dependence occurs when a person relies on or needs a drug. Dependence leads to lifestyle changes that focus on obtaining and administering the drug.

The nursing student has registered for a class on pharmacokinetics. Which of the following reflects the student's accurate understanding of what he can expect to focus on in this class? a) The study of drug actions and their various side effects b) A classification system for organizing brand names and generic names of drugs c) The absorption, distribution, metabolism, and excretion of drugs d) The study of how medications achieve their effects at various sites in the body

C Pharmacokinetics refers to the absorption, distribution, metabolism, and exertion of a drug. These four processes determine the intensity and duration of a drug's action. Each drug has unique pharmacokinetics characteristics. Pharmacology is the science of drug effects. It deals with all drugs used in society, legal and illegal, prescription and nonprescription. Pharmacodynamics, another subconcept of pharmacology, is the study of how medications achieve their effects at various sites in the body, how specific drug molecules interact with target cells, and how biological responses occur.

The nurse is caring for a patient with a medical diagnosis of hypernatremia. The following prescriptions are written in the client's electronic health record. Which one should the nurse question? a) Administer an IV of D5W at 125 mL/hr. b) Strict I&O monitoring. c) Restrict oral intake to 900 mL every 24 hr. d) Monitor serum electrolytes every 4 hr.

C Restricting the oral intake of a patient with hypernatremia (Na+ greater than 145 mEq/L) would lead to further elevation in the serum sodium level. Infusing D5W IV fluid is appropriate, as this solution does not contain sodium. Hydrating the patient with D5W would reduce the serum sodium level. Strict I&O monitoring and laboratory evaluation of electrolytes every 4 hr would ensure that the patient is safely rehydrated.

The unit manager stops you in the hallway to discuss your inability to give safe patient care. The conversation is overheard by other nurses. The manager's comments are based on false information reported to her by a patient. This is an example of: a) Collaboration b) Assault and battery c) Slander d) Libel

C Slander is a spoken form of defamation of character. To establish slander, the comments regarding the person have to be false, communicated or overheard by a third party, and defame the nurse's character. This conversation should occur in a private location; thus, it is not collaboration. Libel is the written form of defamation of character. Assault and battery refers to placing the patient in fear of being harmed and following through with unwelcomed touching.

Which electrolyte is the primary regulator of fluid volume? a) Potassium b) Calcium c) Sodium d) Magnesium

C Sodium is the major action in the extracellular fluid (ECF). Its primary function is to regulate fluid volume. When sodium is reabsorbed in the kidney, water and potassium are also reabsorbed, thereby maintaining ECF volume. Potassium is a key electrolyte in cellular metabolism. Calcium is responsible for bone health and neuromuscular and cardiac functions. It is also an essential factor in blood clotting. Magnesium is a mineral used in more than 300 biochemical reactions in the body.

The charge nurse uses a whiteboard located at the nurse's station to write the nurses' patient assignments and the patients' diagnoses. This is a violation of which of the following? a) Americans with Disabilities Act (ADA) b) Patient Self-Determination Act (PSDA) c) Health Insurance Portability and Accountability Act (HIPAA) d) Health Emergency Medical Treatment and Active Labor Act (EMTALA)

C The Health Insurance Portability and Accountability Act (HIPAA) provides comprehensive protection for the privacy of protected health information (confidentiality of patient records). Writing the nurses' assignments with the corresponding patients and their diagnoses in a location where others may view it is a violation of HIPAA. Assignments should be kept in the nurses' conference room or a location that is not accessible to patients, their family members, or visitors.

On a patient's admission to the hospital, a nurse asks the patient whether he has a living will or durable power of attorney for healthcare. He states he does and provides a copy for the chart. The basis for the nurse's inquiry is which of the following? a) Code of Ethics for Nurses b) Patient Care Partnership c) Patient Self-Determination Act (PSDA) d) Health Insurance Portability and Accountability Act (HIPAA)

C The PSDA require healthcare facilities to provide patients with information on advance directives on admission. HIPAA protects a patient's medical information. The Code of Ethics for Nurses provides guidelines to nurses on acceptable and expected professional behaviors and practices. The Patient Care Partnership provides patients with their rights and what to expect during hospitalization.

The nurse is a member of the ethics committee. An alert, oriented, and competent 87-year-old man has asked to have a DNAR (AND) prescription put on his chart. The patient's 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 patient's case? a) Social justice b) Patient benefit c) Autonomy d) DNAR (AND) determination

C The autonomy model is useful when the patient is competent to decide. This model emphasizes patient autonomy and choice as the highest values. The patient benefit model assists in decision making for the incompetent patient by using substituted judgment. The social justice model focuses more on broad social issues involving the entire institution rather than on a single patient issue. There is no DNAR (AND) determination model.

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

C The client at greatest risk for pressure sores is the one with a lack of sensory perception at the site (e.g., quadriplegia). The infant with disruption to the skin from diaper rash is at risk for skin infection but not for a pressure sore. The young adult with diabetes is at increased risk for delayed wound healing but not likely for a pressure sore because he would shift weight in bed and respond to discomfort of pressure on a bony site. The older adult is normally at risk for pressure injury, but when mobile, even with an assistive device, the risk is minimal

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

C The goal for any wound is for healing to take place with no complications (such as infection). Intact skin throughout hospitalization is not realistic with a stage IV pressure ulcer. Limiting pressure to a wound site is incorrect because total pressure relief must be provided to the area. Improved wound drainage before discharge is not a realistic expectation for a stage IV pressure ulcer.

19. The nurse observes a new graduate nurse preparing to place an IV catheter in the patient's arm. The new graduate tells the patient, "You won't feel a thing" before inserting the needle under the skin. What ethical principle did the new graduate violate? a) Beneficence b) Nonmaleficence c) Veracity d) Confidentiality

C The graduate nurse was not honest with the patient, so the ethical principle of veracity was violated. The scenario does not describe the nurse performing the procedure incorrectly, so there is no reason to think that the graduate did not provide good care. There is no indication the patient was harmed, so the nurse did not violate nonmaleficence. There is no indication the new graduate shared any private, sensitive information about the patient with others; therefore, confidentiality was maintained.

The nurse admits an older adult patient to the long-term care facility. When assessing for pressure ulcer risk, what should the nurse do after conducting the first Braden scale assessment? a) Apply transparent film dressings to buttocks. b) Reassess using the Braden Q scale. c) Conduct another assessment in 3 days. d) Massage areas over the bony prominences.

C The initial Braden scale assessment should be repeated in 48 to 72 hours to establish an accurate baseline. Application of barrier products, such as transparent film dressing, prior to a thorough and accurate assessment of need is premature, and possibly unneeded. The Braden Q scale is used to assess pressure ulcer risk in children. Massaging the area over bony prominences could irritate the skin and lead to injury.

A woman is receiving physical therapy after surgery to repair a hip fracture. She tells the therapist before therapy begins that she expects therapy to be very painful. She rates her pain as 1 on a scale of 1 to 10 before therapy. Three minutes into the treatment session, the patient complains of excruciating pain rated as 10 and says she cannot tolerate exercise any longer. The therapist is concerned with the amount of pain, because severe pain is not expected during that form of exercise. The therapist considers the patient could be experiencing: a) Phantom limb pain b) Ineffective pain medication c) A nocebo effect d) A complication from the surgery

C The nocebo effect is a demonstration of the power of the mind to create bodily distress. The patient was expecting the treatment to be very painful, and this tends to increase the treatment discomfort. Phantom limb pain is sometimes experienced after an amputation but has nothing to do with surgery to repair a hip fracture. There is no evidence that the patient's pain medication is ineffective or that she is experiencing a complication from surgery.

A patient is having pain and has requested a dose of analgesic medication. The medication administration record indicates that he prescribed the narcotics hydromorphone (Dilaudid) intramuscularly and morphine sulfate intravenously. Where should the nurse first assess to determine which medication to administer? a) The patency of the IV site b) Which drug the patient prefers c) The patient's pain level d) Skin integrity of the dorsogluteal site

C The nurse should check the patient's pain level. If the pain is severe, the nurse should administer IV morphine to provide the patient immediate relief. The dorsogluteal site for IM injections should be avoided.

31. The nurse is teaching parents ways to give oral medication to their child. Which action would they implement to improve compliance? a) Crush time-release capsules to put in his favorite food. b) Give medication quickly before he knows what is happening. c) Allow the child to eat a frozen pop before receiving the medication. d) Mask the flavor of medication in a toddler cup with orange juice.

C The parent can give the child a frozen fruit bar or frozen flavored ice pop just before the medication. This helps to numb the taste buds to weaken the taste of the medication. To mask bad-tasting medicines, parents can crush pills or empty the contents of a capsule as long as it is not a time-release dose and mix with soft foods, such as applesauce, hot cereal, or pudding. This is helpful for patients who might aspirate liquids, as well. If the child is old enough to understand, warn him when a medication has an objectionable taste. Otherwise, his trust might be compromised if he is surprised with a bad taste. Do not use essential foods in the child's diet (e.g., milk or orange juice) to mask the taste of medications. The child may later refuse a food that he associates with the medicine.

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? a) Administer epinephrine IM. b) Give bolus dose of intravenous fluids. c) Stop the infusion of medication. d) Prepare for endotracheal intubation.

C The patient is experiencing an anaphylactic reaction (severe shortness of breath, wheezing, and severe hypotension), a life-threatening allergic reaction. Therefore, the nurse should immediately discontinue the medication. The first priority is to eliminate the cause of the problem. Next, the nurse should notify the physician, give IV fluids, and administer epinephrine, steroids, and diphenhydramine. Respiratory support ranging from oxygen administration to endotracheal intubation and mechanical ventilation may also be necessary.

A patient has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient? a) Transparent film dressing b) Sheet hydrogel c) Frequent turn schedule d) Enzymatic debridement

C The patient should be placed on a turn schedule to relieve the pressure. If pressure is not relieved, the wound will worsen. A stage I wound is not open, so a dressing is not warranted. Enzymatic debridement is used to remove slough or eschar in an open wound. A transparent film dressing would protect the area. However, the primary treatment is to relieve the source of pressure.

What is the recommended position for a patient who is experiencing an air embolus because of failure to prime the IV tubing? a) High-Fowler's b) Supine c) Trendelenburg, on the left side d) Prone, on the right side

C The patient should be put in the Trendelenburg position to prevent air from traveling through the right side of the heart into the pulmonary artery, which could create a blockage in ventricular outflow.

The nurse receives a laboratory report that states her patient's digoxin level is 1.2 mg/mL; therapeutic range for this drug is 0.5 to 2.0 mg/mL. Which action should the nurse take? a) Notify the prescriber to reduce the dose. b) Withhold the next dose of digoxin. c) Administer the next dose as prescribed. d) Notify the prescribing healthcare provider to increase the dose.

C Therapeutic range is a range whereby the medication is at a concentration to produce the desired effect. This patient's level is within the therapeutic range, so the nurse should administer the next dose as prescribed. The dose should not be increased or decreased because the prescribed dose is producing a level within the therapeutic range. The dose should not be withheld; this action could result in detrimental cardiac effects for the patient.

A patient receiving a unit of whole blood begins to complain of "feeling funny" and having chills. The nurse assesses that the patient has dyspnea, hypotension, and tachycardia. Which blood transfusion reaction should the nurse suspect? a) Febrile b) Circulatory overload c) Hemolytic d) Allergic

C These are the signs and symptoms of a hemolytic reaction, which includes fever, chills, dyspnea, tachycardia, chest pains, and hypotension. The blood should be stopped immediately, as this can be a fatal reaction. Fever, chills, and flushed skin are signs of a febrile reaction. A patient experiencing an allergic reaction will complain of flushing, wheezing, itching, and hives. A patient with fluid overload will have distended neck veins and difficulty breathing, and crackles can be auscultated.

An alert, oriented, and competent frail older adult man has been told that he is dying and has asked to have a DNAR (AND) prescription put on his chart. The patient's family does not agree with his decision and asks the healthcare team to ignore the request. The healthcare team does not comply with the family's wishes, 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 (AND) prescription. This is an example of which of the following? a) An integrity-producing (good) compromise b) An ethically sound compromise c) Settlement of an issue by force d) An effort to keep peace on the unit

C This is clearly an example of settling an issue by force, bringing in a more powerful entity (the court) to force the healthcare team to do what the family wants. It is not a compromise—of any sort—because neither party backed away from its original position, and the action that was taken was not agreed on by both parties. This was not an effort to keep peace. The family's effort was to settle the disagreement in their favor. If the healthcare team's goal had been to keep peace on the unit, they would have acceded to the family's wishes without the need for a court order.

The nurse faces a true ethical dilemma and uses several strategies for resolving the issue. What is the likely outcome? a) A satisfying solution will be found if the nurse logically applies more than one strategy for decision making. b) If the nurse involves other members of the healthcare team in the decision-making process, a compromise will be reached that satisfies everyone. c) The nurse will nevertheless probably not be comfortable with any course of action, regardless of the strategy, model, or type of reasoning used. d) A decision can be reached that is comfortable for the nurse if the nurse applies a decision model to the dilemma.

C True ethical dilemmas involve deciding between the better of two negative outcomes, so the nurse will probably not be comfortable with any course of action, regardless of the strategy, number of strategies, model, or type of reasoning used. Because of the nature of a dilemma, even with the involvement of other team members it is unlikely the decision will be fully satisfying to any one participant. Ethical decision-making models will help the nurse carefully consider several perspectives, guide reasoning, and explain reasons for final action; however, true ethical dilemmas require deciding between the lesser of two evils, so any conclusion is likely to be unsatisfying in some ways.

A patient has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6°F (37.6°C) orally; P = 110 beats/min, weak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/L BUN 29 mg/dL Which of the following is an appropriate nursing diagnosis for this patient? a) Impaired Gas Exchange related to ineffective breathing b) Excess Fluid Volume related to limited fluid output c) Deficient Fluid Volume related to abnormal fluid loss d) Electrolyte Imbalance related to decreased oral intake

C Vomiting has made this patient hypovolemic; therefore, she has deficient fluid volume. There is no information to indicate that she has respiratory problems or Impaired Gas Exchange. Her symptoms are not consistent with Excess Fluid Volume. Electrolyte Imbalance is not a nursing diagnosis.

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 don't 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? a) Arrange for an ambulance to transport her to the nearest public hospital. b) Explain to the girl and her mother that the hospital only accepts patients who can pay the hospital bill. c) Examine her to determine whether her condition is stable or whether she requires immediate medical attention. d) Inform her mother that she will need to transport her daughter to the nearest public hospital.

C When a client comes to the ED requesting examination or treatment for an emergency medical condition (including labor), the hospital must provide stabilizing treatment; the client cannot be transferred until she is stable.

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

C When a patient has difficulty taking liquid medications from a cup, the nurse should use a syringe without a needle to place the medication in the side of the patient's mouth. After placing the syringe between the gum and cheek, the nurse should push the plunger to administer the medication slowly. It is not necessary to ask the prescriber to change the order to the IV route; it is preferable to use the least invasive route. The nurse cannot administer a drug by another route without a prescription to do so. Dosing might not necessarily be the same in the oral versus the IM route; thus, a prescription is needed to change the route. Some drugs are not compatible with various food or liquid substances and should be taken on an empty stomach. Consult a pharmacist, prescriber, or drug formulary.

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? a) Encouraging family members to visit only during the day b) Applying wrist restraints during periods of agitation c) Playing soft, calming music during the evening d) Administering lorazepam (a tranquilizer)

C Playing soft, calming music during the evening Soft, calming music is sometimes helpful for patients with dementia. Encouraging a family member to sit with the patient might have a calming effect, but the option does not provide for that during the evening when the patient is symptomatic. Applying bilateral wrist restraints might further agitate the patient. Lorazepam will provide sedation but might cause further confusion.

5. Which nursing diagnosis has the highest priority for a patient with impaired tactile perception? a) Self-Care Deficit: Dressing and Grooming b) Impaired Adjustment c) Risk for Injury d) Activity Intolerance

C Risk for Injury The patient with impaired tactile perception is unable to perceive touch, pressure, heat, cold, or pain, placing him at risk for injury. Self-Care Deficit: Dressing and Grooming, Impaired Adjustment, and Activity Intolerance are also likely to be appropriate for this patient, but are not as high a priority as Risk for Injury. Risk for Injury is directly related to safety, which must always be a priority

Which intervention is appropriate for the patient with a nursing diagnosis of Disturbed Sensory Perception: Gustatory? a) Limit oral hygiene to one time a day. b) Teach the patient to combine foods in each bite. c) Assess for sores or open areas in the mouth. d) Instruct the patient to avoid salt substitutes.

C assess for sores or open areas in the mouth The nurse should assess for sores or open areas in the mouth and provide frequent oral hygiene. The nurse should also teach the patient to eat foods separately to allow the taste of food to be distinguishable. Seasonings, salt substitutes, spices, or lemon may improve the taste of foods, so the patient should not avoid them.

A patient complains of an impaired sense of smell. Which cranial nerve might have been affected? a) Trigeminal b) Glossopharyngeal c) Olfactory d) Vagus

C olfactory The olfactory nerve is responsible for the sense of smell. Damage to this nerve causes an impaired sense of smell. The trigeminal nerve transmits stimuli from the face and head. The glossopharyngeal nerve is responsible for taste. The vagus nerve is responsible for sensations of the throat, larynx, and thoracic and abdominal viscera.

Which of the following tasks may be delegated to a certified nursing assistant (CNA)? Select all that apply. a) Irrigating the ear of a child with impacted cerumen b) Administering eye drops for a patient in a coma c) Obtaining vital signs every 15 minutes after a seizure d) Padding the sides of a bed for seizure precautions e)Suctioning the patient's oropharynx after a seizure

C, D A CNA may obtain vital signs and suction the patient's oropharynx postseizure and may perform the tasks of setting up seizure precautions, which includes padding the side of the bed to prevent injury. A CNA may not perform ear irrigation or administer eye drops, as these interventions require knowledge, skills, and assessment of the professional nurse.

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? Select all that apply. a) If he is unable to communicate, his family may make changes to his advance directive. b) Once he signs an advance directive, no further care will be provided to him. c) He may change his advance directive by telling his physician or by making changes in writing. d) An advance directive will ensure he gets as much or as little care as he wishes.

C, D Advance directives include living wills and durable powers of attorney. A living will establishes the patient's wishes regarding future healthcare should he become unable to give instructions. A patient may specify actions in a living will that are not supported by family members, such as a desire for a "do not resuscitate" order, or for as much or as little care as he wishes. A person may change or revoke an advance directive at any time. Changes and written revocation should be signed and dated and shared with the patient's physician. Even without an official written change, orally expressed direction to the physician generally has priority over any statement made in an advance directive as long as the patient is able to decide for himself and can communicate his wishes.

An elderly client with a history of COPD is having difficulty sleeping and does not wish to see a medical practitioner. Which of the following strategies should the nurse discourage the client from using, or urge him to see a physician before beginning the therapy? The client has not used any of these therapies in the past. Select all that apply. a) Aromatherapy b) T'ai chi c) Yoga d) Melatonin

C, D Aromatherapy is known to be safe, and may be effective. Tai chi is safe for older adults, and may be effective for sleep. Yoga is possibly effective for sleep, but it is physically rigorous, so it has the potential to be harmful for older adults, who may have a variety of chronic conditions. The client should see a physician before beginning yoga. Melatonin is effective for certain sleep disorders, but it does interact with several prescription drugs. Therefore, the client should not take melatonin without consulting a physician.

What are two risk assessment tools used in the United States to evaluate a patient's risk for pressure ulcers? Select all that apply. a) Pressure Ulcer Healing Chart b) PUSH tool c) Braden scale d) Norton scale

C, D The Braden scale is a tool used to predict the risk of developing a pressure sore. Evaluation is based on six areas (indicators): sensory perception, moisture, activity, mobility, nutrition, and friction or shear. The Norton scale is another tool used to assess the risk for pressure ulcers based on the patient's physical condition, mental state, activity, mobility, and incontinence. These are the two most used risk assessment tools in the United States. Both of these tools are used to identify persons at high risk of pressure ulcer development. The PUSH tool provides a comprehensive means of reporting the progression of a pressure ulcer. Surface area, exudate, and type of wound tissue are scored and totaled. The Pressure Ulcer Healing Chart is part of the PUSH tool, which is used to monitor the progression of a pressure ulcer.

The nurse learns in report that the assigned patient has a stage III pressure ulcer. What type of tissue does the nurse expect to find in the wound? Select all that apply. a) Muscle b) Eschar c) Subcutaneous d) Dermis e) Fascia

C, D, E A stage III pressure ulcer is characterized by full-thickness, skin loss (epidermal and dermal layers) that may extend down to, but not through, underlying fascia. Muscle is not involved in stage III pressure ulcers, but would be involved in stage IV ulcers. A wound with eschar cannot be classified because it is impossible to determine the depth of the ulcer.

The patient at the clinic says to the nurse, "My doctor checked my eyes and told me my vision was 20 over 100 [20/100]. What does that mean?" What is the best response by the nurse? a) "This means that your eye pressure readings are quite high and may be indicative of glaucoma." b) "These are numbers associated with left and right eye readings for identifying macular degeneration." c) "This could be nearsightedness. Your vision for seeing objects up close is better than your vision for seeing things in the distance." d) "This could be that you are farsighted. Your vision for seeing objects in the distance is better than it is for seeing objects up close."

C. "This could be nearsightedness. Your vision for seeing objects up close is better than your vision for seeing things in the distance." Myopia, or nearsightedness, means that the person is able to see close objects well but not distant objects. For example, a person with 20/100 vision can see an object from 20 feet away that a person with normal sight could see from a distance of 100 feet. Hyperopia, or farsightedness, implies that the eye sees distant objects well. A person with hyperopia may have 20/10 vision—he can see an object form 20 feet that a normal eye can see from 10 feet. Glaucoma is a type of vision loss caused by increased pressure in the anterior cavity of the eyeball resulting in loss of peripheral vision. The fraction 20/100 is unrelated to glaucoma. Macular degeneration is the loss of central vision due to damage to the macula lutea, the central portion of the retina. This results in loss of central and near vision. The fraction 20/100 is unrelated to identifying macular degeneration.

How should the nurse dispose of a contaminated needle after administering an injection? a) Place the needle in a specially marked, puncture-proof container. b) Recap the needle, and carefully place it in the trashcan. c) Recap the needle, and place it in a puncture-proof container. d) Place the needle in a biohazard bag with other contaminated supplies.

D A To avoid needlestick injuries, the nurse should place the uncapped needle, pointing downward, directly into a specially marked, puncture-proof container. Recapping the needle should only be done when no other feasible alternative is available. When recapping is necessary, use an acceptable technique such as the one-handed scoop technique in which the nurse places the needle cap on a sterile surface and, using one hand, scoops up the cap with the needle. Placing the needle in an improper container (biohazard bag) that could be punctured by the contaminated needle places other staff members at risk.

Which of the following is the principal site for regulation of fluid and electrolyte balance? a) Cardiac system b) Vascular system c) Pulmonary system d) Renal system

D A balance of fluid and electrolytes is essential to maintain homeostasis. Excesses or deficits can lead to severe disorders. The kidneys are the principal regulator of fluid and electrolyte balance and are the primary source of fluid output. Specific hormones (e.g., ADH, aldosterone) cause the kidneys to regulate the body's fluid and electrolyte balance. The heart and vascular system are involved in fluid balance but not in electrolyte balance and not as dramatically in fluid balance as are the kidneys—that is, they do not actually regulate electrolytes. The pulmonary system plays a major role in regulation of acid-base balance.

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

D A healing wound contains granulating tissue. Although pain and drainage are indicators of inflammation, infection, bleeding, no pain or drainage at the wound site does not indicate proper healing is occurring. A wound can heal leaving a scar.

he parents of a 12-year-old boy refuse chemotherapy to treat the child's leukemia, saying they will not ruin what is left of his life with drugs that will make him feel sicker. Which solution to this ethical dilemma would demonstrate compromise, maintaining the integrity of all involved? a) Agreeing to allow the child to avoid chemotherapy b) Explaining to the parents that without chemotherapy the child will die. c) Obtaining a court order to require the parents to allow chemotherapy. d) Agreeing to administer the chemotherapy agent with the fewest side effects.

D Administering the chemotherapy agent with the fewest side effects demonstrates a compromise because the child receives treatment, but the parents' concerns about side effects are also considered. Allowing the child to avoid chemotherapy yields to the parents' concerns, but not the concerns of the healthcare team to do no harm to the child. Frightening the parents into agreeing with the healthcare team is coercion; a good compromise must be entered into freely. A court order is settling things by force and the parents lose their argument; a compromise cannot be obtained by force.

A client tells the nurse that he is having difficulty sleeping. He says, "I don't want to use sleeping pills, but I'm thinking about getting some melatonin." Which of the following is most important for the nurse to include in a response to the client? a) "Melatonin is an effective treatment for certain sleep disorders." b) "Melatonin appears to be a relatively safe sleep aid for most people." c) "You may experience some side effects, such as elevated blood pressure." d) "Before taking melatonin, you should consult your primary care provider."

D All of the statements are true about melatonin; however, side effects are rare. It is most important to consult the primary care provider because melatonin is known to interact with other medications, including prescription medications. Therefore, the client should talk with the provider about this possibility.

A patient is receiving healthcare focused on his illness and counteracting his symptoms. What type of healthcare is he receiving? a) Holistic b) Integrative c) Complementary d) Allopathic

D Allopathic care is conventional medical care focused on counteracting symptoms. Holistic healthcare uses the concept of holism to focus on the relationships among all living things. Integrative healthcare encompasses all traditional and alternative health practices used by a patient. Complementary healthcare is alternative care used in conjunction with traditional medical care.

The nurse is caring for a patient with an infected full-thickness wound with moderate drainage and no odor. What type of dressing will be most appropriate for the nurse to apply? a) Alginate b) Antimicrobial petroleum gauze c) Foam dressing d) Antimicrobial collagen dressings

D An antimicrobial collagen dressing promotes wound healing, is absorbent, and is treated with an antimicrobial to promote infection resolution. Although alginate dressings will absorb the drainage, they do not treat the infection. Petroleum gauze is not absorbent and would not be the best choice for a draining wound. Foam dressings are highly absorbent, but they will not treat the infected wound.

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? a) Stage II pressure ulcer b) Stage III pressure ulcer c) Stage IV pressure ulcer d) Unstageable pressure ulcer

D An eschar is a black, leathery covering made up of necrotic tissue. An ulcer covered in eschar cannot be classified using a staging method because it is impossible to determine the depth.

Confidentiality will be maintained by a nurse who believes in and values the ethical principle of: a) Fidelity b) Veracity c) Beneficence d) Autonomy

D Autonomy refers to a person's right to choose and his ability to act on that choice. An autonomous person has control over the collection, use, and access of his personal information. This information should not be shared without the patient's consent. Veracity means to tell the truth. Beneficence is the duty to do or promote good. Fidelity is the obligation to keep promises.

A patient has underlying cardiac disease and requires careful monitoring of his fluid balance. He also has a draining wound. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss? a) Draw a circle around the area of drainage on a dressing. b) Classify drainage as less or more than the previous drainage. c) Weigh the patient at the same time each day on the same scale. d) Weigh dressings before they are applied and after they are removed

D By weighing the dressing before it is applied and after it is removed, the nurse can accurately determine the amount of drainage. Weighing the patient daily would evaluate his overall fluid balance but is not sensitive to fluid loss through the wound. Marking a circle around the wound is useful for determining the extent of drainage seeping out of a wound but it does not provide information on how much fluid is draining.

A patient is admitted to the emergency department (ED) in respiratory distress. The results of his first arterial blood gases were pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80. The nurse evaluates the patient's treatment plan by examining repeat arterial blood gases (ABGs). The results are pH = 7.38; PCO2 = 32; HCO3 = 19 mEq/L. The nurse concludes which of the following? a) Respiratory acidosis; the treatment plan is ineffective. b) Metabolic alkalosis; the treatment plan is effective. c) Partial compensation; the treatment plan is ineffective. d) Complete compensation; the treatment plan is effective.

D Complete compensation has occurred as the PCO2 has returned the pH to the normal range. This change indicates that the treatment plan is effective. Partial compensation would be indicated by changes in the PCO2 but the pH would still be outside the normal range. The ABG is now complete compensation metabolic acidosis.

The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client a) Begins an aggressive exercise program b) Follows a diet plan of 1,200 calories per day c) Is fitted for deep-depth diabetic footwear d) Remains free of foot wounds

D Diabetic clients experiencing difficulty with blood sugar control are prone to the development of peripheral neuropathy, which results in decreased sensation in the feet and lower extremities. Decreased sensation in the feet places the client at increased risk for development of wounds or pressure ulcers in the feet. The nurse will know this plan of care is effective when the client's feet remain free of wounds. An aggressive exercise program would not be appropriate for a client with severely diminished sensation in the feet. Similarly, a 1,200-calorie diet would be inadequate for most clients. Being fitted for diabetic footwear is an intervention rather than a goal.

15. The nurse believes that abortion is murder of the unborn child. While at work, the nurse is assigned a woman with septicemia following an abortion. Which concept most specifically requires the nurse to provide high-quality care for this patient? a) Ethics b) Morals c) Bioethics d) Nursing ethics

D Ethics is a system of moral principles and standards that helps to decide conduct and actions, so although this applies to the situation, it is a more general guide and is not specific to this situation; there is a better answer choice. Morals are taught to us as children to guide behavior, such as learning that abortion is murder. However, this does not apply specifically to the nurse's care for this woman. Bioethics refers to the application of ethical principles to healthcare, but is not exactly the term we should use in this case - the nurse can provide high-quality care to someone who has a different set of morals from her own. Nursing ethics are a specific subset of bioethics that apply only to nurses, and is the specific concept upon which the nurse's behavior is based.

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 return to explain the results. After assisting the other patient to the bathroom, the nurse returns to explain the results to the patient. What ethical principle has the nurse displayed? a) Nonmaleficence b) Autonomy c) Beneficence d) Fidelity

D Fidelity is the obligation to keep promises. Autonomy refers to a person's right to choose and his ability to act on that choice. Nonmaleficence is the twofold principle of doing no harm and preventing harm. Beneficence is the duty to do or promote good.

The nurse working in the emergency department is preparing heat therapy for one of the patients in the unit. Which one is it most likely to be? a) Is actively bleeding b) Has swollen, tender insect bite c) Has just sprained her ankle d) Has lower back pain

D Heat therapy is used to relieve stiffness and discomfort commonly associated with musculoskeletal soreness. Heat causes dilation of the blood vessels and improves delivery of oxygen and nutrients to the tissues. It promotes relaxation and is used to aid in the healing process. Applying heat promotes vasodilation and reduces blood thickness (viscosity) and leaky capillaries, all of which would be harmful to the patient who is actively bleeding. It can lead to a drop in blood pressure. Heat should not be applied to a site with inflammation (insect bite or acute joint injury with swelling) because it can increase edema to the site. A good application for heat therapy is to promote comfort and relaxation to the patient experiencing back pain.

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

D In the Patient Bill of Rights, patients have the right to dignity, privacy, and safety. Although they are not laws, nursing codes of ethics specify ethical duties of the nurse to the patient as related to corresponding patient rights. Although patients do have a right to receive emergency medical care regardless of their ability to pay, this is not part of the nursing code of ethics. Likewise, a nurse's role is to educate patients about advance directives; this is a goal supported by nursing organizations but is not part of the code of ethics.

The nursing student is preparing to administer lisinopril to her patient but does not know what lisinopril is used for. What is the most appropriate action by the student to obtain the information? a) Consult the pharmacist. b) Ask the primary nurse. c) Ask her nursing instructor. d) Look up lisinopril in a medication reference text.

D Look it up! As a nurse, one is professionally, ethically, legally, and personally responsible for every dose of medication administered to a patient. Always use current information when researching a medication.

The nurse cares for a patient who is diagnosed with a sexually transmitted infection (STI). The patient is upset and asks the nurse not to share this information with anyone. The nurse explains to the patient that this must be reported to the local Health department based on which regulation? a) Americans with Disabilities Act (ADA) b) Whistleblower's law c) Good Samaritan Law d) Mandatory reporting

D Mandatory reporting is state law that requires health practitioners to report STIs to reduce the incidences of more people being infected/reinfected. The Good Samaritan Law is designed to protect from liability those people who assist in an emergency situation outside of the workplace. The Americans with Disabilities Act (ADA) protects those with disabilities from discrimination. Whistleblower's law protects those who report wrongdoing by corporations or others that have the potential to harm others.

Which of the following is the most appropriate goal for a patient with the nursing diagnosis of Deficient Fluid Volume? a) Electrolyte balance restored, as evidenced by improved levels of alertness and cognitive orientation. b) Electrolyte balance restored, as evidenced by sodium returning to normal range. c) Patient demonstrates effective coughing and deep-breathing techniques. d) Fluid balance restored, as evidenced by moist mucous membranes and urinating every 4 hours.

D Moist mucous membranes and urinating every 4 hours would demonstrate restoration of fluid balance. Electrolyte imbalance does not necessarily occur with Deficient Fluid Volume; if electrolyte imbalance were present, the nursing diagnosis would be different. There is no evidence that this patient has a respiratory problem, so coughing and deep breathing are irrelevant.

A patient with end-stage cancer is prescribed morphine sulfate to reduce pain. For which effect is this medication prescribed? a) Supportive b) Restorative c) Substitutive d) Palliative

D Morphine is prescribed for its palliative effects—to relieve pain, a symptom of cancer. Supportive effects support the integrity of body functions until other medications or treatments become effective. Restorative effects return the body to or maintain the body at optimal levels of health. Substitutive effects replace either body fluids or a chemical required by the body for improved functioning.

A patient is receiving an IV infusion of lactated Ringer's 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? a) Infiltration b) Extravasation c) Hematoma d) Phlebitis

D Phlebitis is an inflammation of the vein. It may be caused by the infusion of solutions that are irritating to the vein. Patients receiving IV solutions with potassium chloride are at a higher risk for phlebitis, as it is irritating to the vein. The symptom of a palpable cord along the vein distinguishes this as phlebitis. Infiltration presents as erythema, pain, and swelling. However, there is no palpable cord with inflammation. Extravasation is infiltration of a vesicant substance into the tissues. Differentiating symptoms include blanching and coolness of the surrounding skin; the formation of blisters and subsequent tissue sloughing and necrosis are later signs. A hematoma is a localized mass of blood outside the blood vessel. This is generally seen when a vein is nicked during an unsuccessful insertion of an IV line or when an IV line is discontinued without pressure applied over the site.

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 patient's left heel. What is the initial treatment for this pressure ulcer? a) Antibiotic treatment for 2 weeks b) Normal saline irrigation of the ulcer daily c) Debridement to the left heel d) Elevation of the left heel off the bed

D Pressure ulcers are caused by pressure to an area that restricts blood flow, causing ischemia to underlying tissue. The primary treatment is to relieve the pressure, thus improving blood flow. Elevating the patient's left heel off the bed would relieve pressure to this area. Antibiotics treat infection; a stage I pressure injury is not infected. Skin of a stage I pressure wound is intact but has nonblanchable redness; therefore, irrigation is not indicated for stage I pressure wounds. The area may be painful, firm, soft, or warmer or cooler as compared with adjacent tissue, but is not deep enough for debridement.

A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as? a) Stage I pressure ulcer, healing b) Stage II pressure ulcer, healing c) Stage III pressure ulcer, healing d) Stage IV pressure ulcer, healing

D Reverse staging is not done because, as the ulcer heals with granulation tissue and becomes shallower, the lost muscle, subcutaneous fat, and dermis are not replaced. Pressure ulcers maintain their original staging classification throughout the healing process but are accompanied by the modifier healing.

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? a) Primary intention b) Regenerative healing c) Secondary intention d) Tertiary intention

D Tertiary intention is used when a wound is clean-contaminated or "dirty" (potentially infected). Initially, the wound is allowed to heal by secondary intention, and when there is no evidence of edema, infection, or foreign matter, granulating tissue is brought together and the wound edges are sutured closed.

The American Nurses Association (ANA) believes nurses should not participate in active euthanasia (and assisted suicide) because such acts violate ____. a) the Patient Self-Determination Act b) civil laws c) the Good Samaritan laws d) the Code of Ethics for Nurse

D The ANA defines assisted suicide, a form of active euthanasia, as providing a patient the means to end his life, with full knowledge of the patient's intentions to do so. The ANA believes that participation in active euthanasia violates the Code of Ethics for Nurses and the ethical traditions of the profession.

An adult patient is fully able to detect and respond to pain and discomfort. He has no incontinence or mobility limitations. He is of normal weight and consumes a nutritious diet. The patient has no problem with rubbing, friction, or shear. What is the Braden score for this patient? a) 0 b) 15 c) 20 d) 23

D The Braden scale evaluates six major risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction and sheer. Each category is rated on a scale of 1 to 4, excluding the friction and shear, which is rated on a scale of 1 to 3. The final score reflects the patient's risk: the lower the score, the more likely the patient will develop a pressure ulcer. The patient receives four points for sensory perception, moisture, activity, mobility, and nutrition and three points for friction and shear, making a total of 23 points, which is a perfect score.

A nurse is being investigated for stealing narcotics from several patients. Which federal agency can become involved in the investigation of this incident? a) State Board of Nursing b) U.S. Food and Drug Administration c) U.S. Drug Compliance Department d) U.S. Drug Enforcement Agency

D The U.S. Drug Enforcement Agency (DEA) can investigate diversion and theft of controlled substances. The State Board of Nursing is not a federal agency and is only empowered to discipline a nurse's license. The U.S. Food and Drug Administration regulates the testing, sale, and manufacture of drugs.

Which statement describes the primary purpose of an incident report? a) This report is used by nurse managers to discipline the nurse for her errors. b) It is imperative that this report be kept in the patient's medical record in case of a lawsuit. c) A copy should be provided to the patient to promote open communication. d) This report is used by risk management to prevent the incident from reoccurring.

D The main function of an incident report is to prevent the incident from happening again. The report allows the nurse manager and risk management to evaluate the context in which the incident occurred and to identify appropriate strategies to prevent a reoccurrence. Although incident reports have been used to discipline nurses, this is not the current trend and is not their purpose. These reports are not a part of the patient record and therefore are not part of accurate patient charting. A copy should not be shared with the patient.

A patient has been taking herbal remedies to decrease blood pressure. The patient is convinced that this has reduced his blood pressure and he refuses to take a prescribed antihypertensive medication. The nurse checks his blood pressure reading during an office visit, with the following results: Left arm: 130/94, 140/86, and 160/90 mm Hg. With this information, what is the nurse's best response to the patient's refusal to take antihypertensive medications? a) "I see that you are correct; your blood pressure readings do not indicate hypertension." b) "Your blood pressure is elevated, so you will need to take a prescribed antihypertensive." c) "Your blood pressure is within normal limits and does not need anything for it." d) "Your blood pressure is elevated. It is important to discuss this with your doctor."

D The nurse identifies that these blood pressure readings are elevated and correctly suggests the discussion with the physician. The nurse is not the person to determine potential therapies for the patient. The nurse cannot tell the patient he is correct and does not have hypertension because his vital signs do not support that. The patient's blood pressure is not within normal limits.

A surgeon prescribes heparin 2,500 mEq IM q 12 hr. What is the nurse's best action? a) Administer the medication as prescribed. b) Clarify the medication dose with the surgeon. c) Administer the medication subcutaneously. d) Clarify the dose and route with the surgeon

D The nurse should contact the surgeon to clarify the dosage and route of administration. Heparin is measured in units and administered either subcutaneously or intravenously. The nurse should contact the provider who prescribed the medications.

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

D The nurse should flush the nasogastric tube with water using a needleless syringe after administering each medication. Some medications are less effective when given in combination with others. The nurse should verify nasogastric tube placement and auscultate the abdomen for bowel sounds before administering the medication.

A patient is given furosemide 40 mg orally at 0900. The duration of action for this drug is approximately 6 hours after oral administration. At which time in military hours should the nurse no longer expect to see the effects of this drug? a) 0930 b) 1000 c) 1100 d) 1500

D The nurse should no longer see the effects of furosemide at around 1500 hours (3:00 p.m.). The effects of oral furosemide should be seen 30 to 60 minutes after administration, which is 0900 (9:30 a.m. in this case). Peak effect (diuresis) should occur in 1 to 2 hours, which is 1000 hours (10:00 a.m.) to 1100 (11:00 a.m.) in the scenario.

A patient's vital signs prior to a blood transfusion were: T = 97.6°F (36.4°C); P = 72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg. Twenty minutes after the transfusion was begun, the patient began complaining of feeling "itchy and hot." The nurse discovered a rash on the patient's trunk. Vital signs were T = 100.8°F (38.2°C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the priority intervention? a) Administer an antihistamine (antiallergenic) medication. b) Flush the blood tubing with D5W immediately. c) Prepare for emergency resuscitation. d) Stop the blood transfusion immediately.

D The nurse should suspect a transfusion reaction. When a transfusion reaction is suspected, the infusion should be stopped immediately. The blood bag and tubing must be sent to the laboratory for analysis. A new IV line of normal saline should be hung. Diphenhydramine (an antihistamine) may be ordered once the physician has been notified of the patient's condition. There is no information indicating that the patient is in danger of cardiovascular collapse or requires resuscitation.

The patient is struggling with a decision whether or not to receive experimental treatment. What is the nurse's role when caring for this patient? a) Provide recommendations for decision making. b) Teach the patient how to apply logic to the situation. c) Advocate for the patient with the primary healthcare provider. d) Listen to the patient's thoughts, ask questions, and provide support.

D The nurse's role while the patient is making a decision is to support the patient, listen to his thoughts, ask questions to help the patient think things through, and provide unbiased information. The nurse should not lead the patient to what the nurse thinks is best, but allow the patient to make his own decision (autonomy). Although the nurse may help the patient think through the decision, the nurse would not teach the patient how to make a decision because this could bias the patient toward the nurse's opinion (a subtle form of coercion). There is no need for the nurse to advocate for the patient until he makes a decision; this is not the nurse's role at this time.

The nurse would question a prescription for application of cold therapy to which patient? The patient with a: a) Wound oozing blood b) Sprained wrist c) Infected wound d) Pressure ulcer

D The patient with a pressure ulcer would not benefit from a cold application because it would slow blood supply and wound healing and increase risk of further tissue damage. A cold pack may be used for the patient with active bleeding because it causes vasoconstriction and would reduce bleeding. Cold therapy is appropriate for the patient with a sprain to reduce edema, inflammation, and pain. Application of cold slows bacterial growth, so this may be used for an infected wound that is warm to the touch and inflamed.

Before administering a medication, the nurse must verify the six rights of medication administration, which include: a) Right patient, right room, right drug, right route, right dose, and right time b) Right drug, right dose, right route, right time, right physician, and right documentation c) Right patient, right drug, right route, right time, right documentation, and right equipment d) Right patient, right drug, right dose, right route, right time, and right documentation

D The six rights of medication administration are the right patient, right drug, right dose, right route, right time, and right documentation.

Your patient has multiple open wounds that require treatment. When performing dressing changes, you should: a) Remove all of the soiled dressings before beginning wound treatment b) Cleanse wounds from most contaminated to least contaminated c) Treat wounds on the patient's side first, then the front and back of the patient d) Irrigate wounds from least contaminated to most contaminated

D To avoid the possibility of cross-contamination, the wound with the least amount of contamination should be treated first, progressing to the wound with the most contamination.

Which action should the nurse take to relax the vastus lateralis muscle before administering an intramuscular injection into the site? a) Apply a warm compress. b) Massage the site in a circular motion. c) Apply a soothing lotion. d) Have the client assume a sitting position.

D To relax the vastus lateralis for injection, the nurse should have the patient assume a sitting position or lie flat with his knee slightly flexed. Applying a warm compress, massaging the site, and applying soothing lotion are inappropriate interventions before administering an IM injection. After injection, massaging the site can enhance the absorption of medication into the muscle. Applying a warm compress increases circulation to the site, which can also enhance absorption. This action would be performed after the injection and not before.

The physician prescribes warfarin 5 mg orally at 1800 for a patient. 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? a) No action is necessary because an extra 5 mg of warfarin is not harmful. b) Call the prescriber and ask her to change the order to 10 mg. c) Document on the chart that the drug was given and indicate the drug was given in error. d) Complete an incident report according to the facility's policy.

D When a medication error is made, the nurse should first check the patient to assess for negative effects. If she is unfamiliar with the side effects of the medication, she should consult a drug reference, the licensed pharmacist at the institution, or the prescriber. Next, she should verify that she made an error and identify the type. Notify the nurse in charge and the physician. Follow any orders the physician prescribes. Document the drug, the dose, site, route, date, and time in the patient's healthcare record but do not document that the drug was given in error. Complete an incident report according to the facility's policy; submit the signed report to the nurse manager. Finally, critically review the error, and identify ways to improve your practice.

A mentally competent patient has an extremely low blood count and will likely die without a blood transfusion. The patient knows the risk, but continues to refuse the blood. Which action by the nurse is the most appropriate? a) Assume the patient is confused and give the blood anyway. b) Request a psychological evaluation to ensure that the patient understands the risk. c) Ask family members to intervene and make the patient consent to receiving blood. d) Follow the patient's wishes and do not administer a blood transfusion.

D You should follow the patient's wishes and do not administer a blood transfusion. There is no evidence of confusion; the patient is competent, is aware of the risk, and has given a valid refusal. The nurse should not assume that a patient is confused simply because of the choice a patient makes. A psychological evaluation is not needed simply because the patient refuses treatment that might result in his death. Family members cannot override a patient's decision. The nurse should respect the patient's decision.

Which intervention is helpful when caring for a patient with impaired vision? a) Suggest the patient use bright overhead lighting. b) Advise the patient to avoid wearing sunglasses when outdoors. c) Do not offer large-print books, as this may embarrass the patient. d) Place the patient's eyeglasses within easy reach.

D Place the patient's eyeglasses within easy reach. The nurse should place the patient's eyeglasses within easy reach and make sure that they are clean and in good repair. The patient should have sufficient light but avoid bright light, which might cause glare. The patient should be encouraged to wear sunglasses, visors, or hats with brims when outdoors. A magnifying lens or large-print books may be helpful.

The nurse administered the narcotic Demerol, 50 mg PO at 1400 to a patient with pain rated as 9 on a 0 to 10 scale. At 1430, the patient stated that the medication was not working and requested to have morphine IV, which the provider had prescribed for severe pain. What is the nurse's best evaluation of this situation? a) The patient needs to understand that it takes time for the medication to reduce pain. b) Administering Demerol PO was not the best nursing intervention in this situation. c) The provider should be notified if the patient's pain is not relieved in 2 hours. d) Demerol PO was the best intervention because morphine IV can cause drug addiction.

B Administering Demerol PO was not the best nursing intervention in this situation because the patient was in severe pain (9/10). The patient needed immediate pain relief, which would not occur with PO pain medication. The nurse should have been administered morphine IV. Waiting 2 hours to notify the physician does not provide patient comfort. The nurse should focus on pain relief and not worry about the patient becoming "addicted" to the morphine.

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? a) Steri-Strips b) Abdominal binder c) T-binder d) Paper tape

B An abdominal binder provides added support to an incision site and decreases the risk of wound dehiscence. A T-binder is used in the perineal area. Steri-Strips and paper tape would not be needed for an approximated incision that has intact staples or sutures.

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? a) Liquid acetaminophen with codeine b) Intravenous morphine sulfate c) Intramuscular meperidine d) Oral oxycodone tablets

B Drugs administered by the intravenous route are injected directly into the bloodstream and do not have to be absorbed into it. Therefore, they act more quickly than drugs administered by the oral or intramuscular routes.

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: a) Primary intention healing b) Secondary intention healing c) Tertiary intention healing d) Approximation healing

B Secondary intention healing occurs when a wound is left open, and it heals from the inner layer to the surface by filling in with beefy red granulation tissue. Primary intention healing occurs when a wound is surgically closed. Tertiary intention healing occurs when a wound that was previously left open to heal by secondary intention is closed by joining the margins of granulation tissue. Approximation is another word for the joining of wound edges

Which body organ is mostly responsible for medication excretion? a) Liver b) Kidney c) Lungs d) Exocrine glands

B The kidneys are the primary site of excretion. Adequate fluid intake facilitates renal excretion. If the patient has decreased renal function, the nurse should closely monitor for medication toxicity.

A surgeon refused a patient's request to restart a patient's total parenteral nutrition (giving nutrition through the intravenous route) because he believed that a greater good would be achieved by not using medical resources to prolong the life of a terminally ill patient when the resources could be used for other patients. Which ethical theory best explains the surgeon's rationale? a) Ethics of care b) Utilitarianism c) Deontology d) Categorical imperative

B Utilitarianism is a consequentialist theory that takes the position that the value of an action is determined by its usefulness. The surgeon believes that providing TPN to a terminally ill patient is useless, because it will not prevent her death, and furthermore that it does not achieve the "greater good." Other patients with a better prognosis would benefit from the TPN. An ethics of care is a nursing philosophy that directs attention to the specific situations of individual patients viewed within the context of their life narrative. Deontology considers an action to be right or wrong independent of its consequences. The surgeon is guided by the usefulness of the act, not one of duty. A categorical imperative is a principle, established by Immanuel Kant, that states that one should act only if the action is based on a principle that is universal.B Utilitarianism is a consequentialist theory that takes the position that the value of an action is determined by its usefulness. The surgeon believes that providing TPN to a terminally ill patient is useless, because it will not prevent her death, and furthermore that it does not achieve the "greater good." Other patients with a better prognosis would benefit from the TPN. An ethics of care is a nursing philosophy that directs attention to the specific situations of individual patients viewed within the context of their life narrative. Deontology considers an action to be right or wrong independent of its consequences. The surgeon is guided by the usefulness of the act, not one of duty. A categorical imperative is a principle, established by Immanuel Kant, that states that one should act only if the action is based on a principle that is universal.

Which groups of people choose CAM more often than do others? Select all that apply. a) Men b) Women c) People younger than 18 years of age and older than 70 years of age d) People older than 18 years of age and younger than 70 years of age e) Caucasians

B, D, E Caucasian women over 18 years of age and younger than 70 years of age are the main group that uses CAM. Although the other groups do use CAM, they do not use it as much as those groups.

The nurse has been teaching a parent about stimuli to develop her infant's auditory nervous system. Which behavior by a parent toward the child provides evidence that learning occurred? a) Cuddling b) Speaking c) Feeding d) Soothing

B. Speaking Exposure to voices, music, and ambient sound helps develop the infant's auditory nervous system. Cuddling, feeding, and soothing provide comfort and pleasure and teach the infant about his external environment.

After sustaining a stroke, the patient lacks attention to the right side of his body. Which nursing diagnosis best describes the patient's problem? a) Disturbed Sensory Perception b) Unilateral Neglect c)Risk for Peripheral Vascular Dysfunction d) Acute Confusion

B. Unilateral Neglect This patient lacks attention to the right side of his body after sustaining a stroke; therefore, the most appropriate nursing diagnosis is Unilateral Neglect. The patient may also have Disturbed Sensory Perception, Risk for Peripheral Vascular Dysfunction, and Acute Confusion, but they are not the most appropriate for the defined problem.

The patient experiences extensive third-degree burns. What type of healing does the nurse expect? Healing by: a) Primary intention b) Second intention c) Tertiary intention d) primary intention if no infection occurs

C A third-degree burn heals by tertiary intention. Skin grafts would be required to bring edges of granulation tissue together. Wound healing by primary intention occurs when there is minimal or no tissue loss, and edges are well approximated. With a third-degree burn the edges cannot approximate for primary intention healing. Even if no infection occurs, this wound will not heal by primary intention because of deep tissue loss.

A registered nurse forgot to put the siderails 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 nurse's situation is that her insurance policy will do which of the following? a) Not cover her b) Pay $4 million c) Pay $2 million d) Pay 75% of the $2 million

C An occurrence policy will cover those claims that occurred during the time the policy was in effect. The policy will pay up to $3 million per claim; because the amount awarded does not exceed this, the nurse is covered.

Which body organ is mostly responsible for the metabolism of medications? a) Kidney b) Skin c) Liver d) Large intestine

C Drug metabolism takes place mainly in the liver, but medications can also be detoxified in the kidneys, blood plasma, intestinal mucosa, and lungs. If liver function is impaired due to liver disease, medications will be eliminated more slowly, and toxic levels may accumulate.

The concept of holism focuses on which of the following? a) Relationship between nurse and patient b) Practice of spiritualism c) Relationships among all living things d) Totality of the body

C The concept of holism focuses on the relationships among all living things.

A client is admitted to the emergency department (ED) in respiratory distress. The results of his arterial blood gases are the following: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80. The nurse interprets the findings as which of the following? a) Respiratory acidosis with normal oxygen levels b) Respiratory alkalosis with hypoxia c) Metabolic acidosis with normal oxygen levels d) Metabolic alkalosis with hypoxia

C The pH is acidotic. The HCO3 of 19 mEq/L is low and has moved in the same direction as the pH, indicating a metabolic disorder. The PCO2 is within normal range with no signs of compensation. The PO2 level is normal.

The nurse must irrigate the ear of a 4-year-old child. How should the nurse pull the pinna to straighten the child's ear canal? a) Up and back b) Straight back c) Down and back d) Straight upward

C Down and Back The nurse should straighten the ear canal of a small child by pulling the pinna down and back. To straighten the ear canal of an adult, the nurse should pull the pinna up and outward.

The nurse is assessing an elderly male in the nursing home. What question will the nurse ask this patient to best assess his level of orientation? a) "Will you please repeat these three words for me: glasses, rocket, truck?" b) "Can you tell me the date of your retirement from your workplace?" c) "What is your name and today's date? Can you tell me where you are?" d) "What did you eat for breakfast this morning?"

C. "What is your name and today's date? Can you tell me where you are?" To assess level of orientation, the best question is to ask the patient for his name, date, and his current location. Asking the patient to repeat a sequence of words (e.g., glasses, rocket, truck) assesses recall and recent memory. Asking a patient for the date of retirement assesses long-term memory but does not reflect the patient's orientation status to the present time and situation. Asking a patient what he ate for breakfast assesses short-term memory only.

The home health nurse is developing a plan of care for her patient with a visual impairment. What is the priority nursing diagnosis for this patient? a) Self-Neglect b) Social Isolation c) Risk for Falls d) Risk for Imbalanced Nutrition: Less Than Body Requirements

C. Risk for Falls The priority nursing diagnosis for a patient with a visual impairment is Risk for Falls. The patient, owing to a visual impairment, may have deficits with feeding, dressing, and social interaction; however, the highest priority is promoting safety and reducing the patient's risk for falls.

Which process requires energy to maintain the unique composition of extracellular and intracellular compartments? a) Diffusion b) Osmosis c) Filtration d) Active transport

D Active transport occurs when molecules move across cell membranes from an area of low concentration to an area of high concentration. Active transport requires energy expenditure for the movement to occur against a concentration gradient. In the presence of ATP, the sodium-potassium pump actively moves sodium from the cell into the extracellular fluid. Active transport is vital for maintaining the unique composition of both the extracellular and intracellular compartments. Diffusion, osmosis, and filtration are passive processes.

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

D The length of time for healing is the determining factor when classifying a wound as acute or chronic. Acute wounds are expected to be of short duration. Wounds that exceed the anticipated length of recovery are classified as chronic wounds.

The nurse has started to infuse the first of two units of packed red blood cells (prbc) on her patient. What is the nurse's next best action? a) Delegate to the NAP to take vital signs every 15 minutes for 1 hour. b) Infuse the blood at a rate of 100 mL/hr so it will infuse in 4 hours. c) Infuse an IV solution of lactated Ringer's with the blood. d) Remain with the patient for the first 15 minutes of the infusion.

D The nurse's next best action is to stay with the patient and assess for a transfusion reaction, which is more likely with the first 50 mL of the blood. The nurse should not delegate the initial vital sign to the NAP. The only compatible IV solution that can infuse with blood is normal saline (0.9% NS).

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

D. Avoid using throw rugs on the floors. The nurse should instruct the visually impaired patient to avoid using throw rugs on the floors at home. She should instruct the patient with a hearing deficit to install blinking lights to alert him to an incoming phone call. She should instruct the patient with an olfactory deficit to have gas appliances inspected regularly to detect leaks. The patient with a tactile deficit should be instructed to use properly fitting shoes and socks

The nurse caring for a fussy newborn uses which of the following interventions to calm the baby and reduce sensory overload? a) Rubbing the baby's back b) Singing and rocking the baby c) Hanging a black and white mobile d) Swaddling the baby tightly

D. Swaddling the baby tightly In the first months of life until the autonomic nervous system matures, newborns are easily overstimulated by the loud noises, bright light, high-contrast objects (e.g., black and white mobile), and stroking sensitive areas (back and bottom of feet). Stroking the back or bottom of feet can be too much for the baby to handle. Newborns experience sensory overload, particularly when more than one sense is involved, such as singing (auditory) and rocking (kinesthetic).

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? a) Exophthalmos b) Anosomia c) Insomnia d) Xerostomia

D. Xerostomia The nurse should document excessively dry mouth as xerostomia. Exophthalmos is abnormal bulging of the eyeballs that commonly occurs with thyrotoxicosis. Anosomia is losing the sense of smell. Insomnia is inability to sleep.

A patient who sustained a head injury in a motor vehicle accident has damage to the temporal lobe. This injury places the patient at risk for which type of hearing loss? a) Otosclerosis b) Conduction deafness c) Presbycusis d) Central deafness

D.Central Deafness Central deafness results from damage to the auditory areas in the temporal lobes. Otosclerosis is hardening of the bones of the middle ear, especially the stapes. Conduction deafness results when one of the structures that transmits vibrations is affected. Presbycusis is a progressive sensorineural loss associated with aging.

The nurse receives a prescription to begin a morphine drip for a patient who is to be taken off the ventilator, and to increase the infusion rate as needed to maintain the patient's comfort. The nurse refuses to carry out the order because the morphine will depress respirations and the nurse believes this is equivalent to killing the patient. Which concept best describes what this nurse is demonstrating? a) Moral agency b) Morals c) Bioethics d) Clinical decision making

This nurse is demonstrating moral agency because the nurse perceives the difference between right and wrong, understands the abstract moral principle of right to die versus euthanasia, applies moral principles to decision making, decides and chooses freely that this action is not right for the nurse to perform, and acts according to choice. Morals reflect what the nurse was taught about right and wrong, but that is only one component of what this nurse is demonstrating. Bioethics is the application of ethics to healthcare, but this is only one component of what this nurse is demonstrating. Although the nurse is making a clinical decision, this is only one component of what this nurse is demonstrating