Exam 2 Safety

A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient?

risk for injury: check on patient every 15 minutes

which potential problem with dysphagia has the greatest influence on the plan of care? A.) anorexia B.) aspiration C.) self care deficit D.) inadequate intake

B

A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure related accident?

surgical asepsis

A homeless adult presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8 degrees F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately?

temperature

The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient's health care needs?

the electricity was turned off 3 days ago

The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint?

the patient continues to remove the nasogastric tube

The nurse is trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working?

the patient folds three washcloths over and over

When making rounds the nurse observes a purple wristband on a patient's wrist. How will the nurse interpret this finding?

the patient has do not resuscitate preferences

During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?

the patient takes a hypnotic

The nurse has placed a yellow armband on a 70 year old patient. Which observation by the nurse will indicate the patient has an understanding of this action?

the patient wears the red nonslip footwear

The nurse is assessing a patient for lead poisoning. Which patient is the nurse most likely assessing?

toddler

A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals?

uses medication bar coding when administering medications

A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens?

wash hands

The nurse is conducting an admission interview with a patient. Which outcome identified by the nurse indicates that therapeutic communication is effective? 1. Verbal and nonverbal communication is congruent 2. Interaction is conducted in a professional manner 3. Common understanding is achieved 4. Thoughts can be put into words

3

The nurse is monitoring for the four categories of risk that have been identified in the healthcare environment. Which examples will alert the nurse that these safety risks are occurring?

wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning properly

The nurse is teaching a group of older adults at an assisted living facility about age related physiological changes affecting safety. Which question would be most important for the nurse to ask this group?

"are you able to hear the tornado sirens in your area?"

The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1 year old grandchild. Which comment by the grandparent will cause the nurse to intervene?

"if my grandchild eats a plant, I should provide syrup of ipecac"

A nurse concludes that a patient's elevated temperature, pulse, and respirations are significant. What step of the Nursing Process is being used when the nurse comes to this conclusion? 1. Analysis 2. Evaluation 3. Assessment 4. Implementation

1

A patient verbally communicates with the nurse while exhibiting nonverbal behavior. How should the nurse confirm the meaning of the nonverbal behavior? 1. Look for similarity in meaning between the patient's verbal and nonverbal behavior 2. Ask family members to help interpret the patient's behavior 3. Validate inferences by asking the patient direct questions 4. Recognize that what a patient says is most important

1

Melena

Black, tarry stools

A nurse is assessing a patient who has been admitted to the hospital. Which is the most important information that indicates whether the patient is at risk for serious injury? A.) weakness experienced during prior admission B.) medication that increases intestinal motility C.) two recent falls that occurred at home D.) the need for corrective eyeglasses

C

A nurse educator is teaching a group of newly hired nursing assistants. Which hospitalized patient should be taught is the greatest risk for injury? A.) school aged child B.) comatose teenager C.) postmenopausal woman D.) confused middle aged man

D

Arterial problems

Lower extremity pale and cool with decreased pulse

Venous problems

Lower extremity swollen and warm with normal pulse

Jugular Vein distension

Neck visible when sitting

Lordosis

Swayback

The nurse is discussing about threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic?

"smoking even at parties is not good for my body"

A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up?

"when it is cold outside in the winter, I will use a nonvented furnace"

A nurse evaluates a patient's response to a nursing intervention. To which aspect of the nursing process is this evaluation most directly related? 1. Goal 2. Problem 3. Etiology 4. Implementation

1

A nurse is planning a teaching plan for an older adult. Which common factor among older adult patients must be considered by the nurse? 1. Learning may require more energy 2. Intelligence decreases as people age 3. Older adults rely more on visual rather than auditory learning 4. Older adult patients are more resistant to change that accompanies new learning

1

A nurse is providing health teaching for a patient with a comprehension deficit. Which is the best intervention by the nurse that will support this patient's learning? 1. Establishing a structured environment 2. Asking that unclear words be repeated 3. Speaking directly in front of the patient 4. Making a referral for a hearing evaluation

1

A patient has a urinary retention catheter. Which is most important when the nurse cares for this patient? 1. Ensuring that the catheter remains connected to the collection bag 2. Applying an antimicrobial agent to the urinary meatus 2 times a day 3. Wearing sterile gloves when accessing the specimen port 4. Increasing fluid intake to 3000 mL a day

1

The nurse is preparing a patient for a physical examination. What is most important for the nurse to do in this situation? 1. Identify the positions that may be contraindicated for the patient during the examination 2. Explore the patient's attitude toward health-care providers 3. Inquire about the other professionals caring for the patient 4. Ask when the patient last had a physical examination

1

Which is the first action the home care nurse should employ to prevent falls by an older adult living at home? 1. Conduct a comprehensive risk assessment 2. Encourage the patient to remove throw rugs in the home 3. Suggest installation of adequate lighting throughout the home 4. Discuss with the patient the expected changes of aging that place one at risk

1

A nurse holds a bottle with the label next to the palm of the hand when pouring a liquid medication. What is the rationale for this action? 1. Conceal the label from the curiosity of others 2. Prevent the soiling of the label by spilled liquid 3. Ensure the accuracy of the measurement of the dose 4. Guarantee the label is read before pouring the liquid

2

A nurse is assessing a patient's readiness to learn about smoking cessation. Which patient factor does the nurse consider is most important when determining if a teaching program is needed by the patient? 1. Previous experience 2. Perceived need 3. Expectations 4. Flexibility

2

A nurse is caring for two patients. One patient has reflex incontinence and the other has total incontinence. Which characteristic is common to both reflex incontinence and total incontinence? 1. Urination following an increase in intra-abdominal pressure 2. Loss of urine without awareness of bladder fullness 3. Retention of urine with overflow incontinence 4. Strong, sudden desire to void

2

A nurse is developing a therapeutic relationship with a patient with emotional needs. Which nursing interventions are essential during the working phase of the relationship? 1. Establish a formal or informal contract that addresses the patient's problems 2. Implement nursing interventions that are designed to achieve expected patient outcomes 3. Develop rapport and trust so the patient feels protected and an initial plan can be identified 4. Clearly identify the role of the nurse and establish the parameters of the professional relationship

2

A nurse is evaluating a patient's learning regarding nutrition. Which behavior reflects the highest level of learning in the cognitive domain? 1. Modifies favorite recipes by eliminating foods that have to be avoided 2. Evaluates the benefits associated with avoidance of certain foods 3. States why a mother's diet may affect breast-feeding 4. Identifies a list of foods to be avoided

2

A patient appears tearful and is quiet and withdrawn. The nurse says, "You seem very sad today." What interviewing approach did the nurse use? 1. Examining 2. Reflecting 3. Clarifying 4. Orienting

2

A patient is readmitted to the hospital because of complications resulting from nonadherence to the prescribed health-care regimen. What should the nurse do first? 1. Encourage healthy behaviors 2. Develop a trusting relationship 3. Use educational aids to reinforce teaching 4. Establish why the client is not following the regimen

2

A patient who has had a number of postoperative complications appears upset and agitated, yet withdrawn. What is the most appropriate statement by the nurse? 1. "You seem agitated. Tell me why you are upset." 2. "You've been having a pretty rough time of it since surgery." 3. "It's not uncommon to have complications after the kind of surgery that you had." 4. "I'm not sure that I know everything that has been happening. Tell me what has happened to you since surgery."

2

During which of the five steps in the Nursing Process does the nurse determine whether outcomes of care are achieved? 1. Implementation 2. Evaluation 3. Planning 4. Analysis

2

How often should "docusate sodium (Colace) 100 mg b.i.d." be given? 1. Three times a day 2. Two times a day 3. Every other day 4. At bedtime

2

What clinical manifestation identified by the nurse most commonly is associated with excessive production of antidiuretic hormone (ADH)? 1. Diuresis 2. Oliguria 3. Retention 4. Incontinence

2

What is the best response by the nurse when the patient's husband says, "I just don't know what to say to my wife if she asks how I feel about her breast cancer." 1. "How do you feel about your wife's diagnosis?" 2. "This is a difficult topic. However, let's talk about it." 3. "Do you think you could be as supportive as you can possibly be?" 4. "Men don't always understand what women are going through. Ask her about how she feels."

2

What is the nurse doing when using the interviewing technique of active listening? 1. Identifying the patient's concerns and exploring them with why questions 2. Determining the content and feeling of the patient's message 3. Employing silence to encourage the patient to talk 4. Using nonverbal skills to display interest

2

What stage of an interview establishes the relationship between the nurse and the patient? 1. Working stage 2. Opening stage 3. Surrogate stage 4. Examining stage

2

Which ability of the nurse is most important to achieve effective therapeutic communication? 1. Sending a verbal message 2. Using interviewing skills 3. Being assertive when collecting data 4. Displaying sympathy when communicating

2

A nurse instructs a patient to inhale deeply and hold each breath for a second when using a hand-held nebulizer. The patient asks, "Why do I have to hold by breath?" The nurse responds, "This technique will: 1. Prolong treatment." 2. Limit hyperventilation." 3. Disperse the medication." 4. Prevent bronchial spasms."

3

A nurse is caring for a patient with a fever. Which is a well-designed goal for this patient? "The patient will: 1. have a lower temperature." 2. be taught how to take an accurate temperature." 3. maintain fluid intake sufficient to prevent dehydration." 4. be given aspirin every eight hours whenever necessary."

3

A patient is admitted to the emergency department because of hypertension and oliguria. For what additional clinical manifestation associated with this cluster of information should the nurse assess the patient? 1. Thirst 2. Retention 3. Weight gain 4. Urinary hesitancy

3

A school nurse is teaching a class of adolescents about avoiding smoking and includes role-playing as a creative learning activity. What is the primary reason for using role-playing? 1. Provides more fun than other methods 2. Eliminates the need for media equipment 3. Requires active participation by the learner 4. Gives the learner the opportunity to be another person

3

A home care nurse is helping a patient with short-term memory loss how to remember to take multiple drugs throughout the day. What should the nurse do when teaching this patient? 1. Suggest that the patient wear a watch with an alarm 2. Ask a family member to call the patient when medications are to be taken 3. Design a chart of the medications the patient takes each day during the week 4. Instruct the patient to put medications in a weekly organizational pill container

4

A nurse is collecting subjective data associated with a patient's anxiety. Which assessment method should be used to collect this information? 1. Observing 2. Inspecting 3. Auscultation 4. Interviewing

4

The nurse plans to foster a therapeutic relationship with a patient. What is most important for the nurse to do? 1. Work on establishing a friendship with the patient 2. Use humor to defuse emotionally charged topics of discussion 3. Sympathize with the patient when the patient shares sad feelings 4. Demonstrate respect when discussing emotionally charged topics

4

The patient states, "I can't believe that I couldn't even eat half my breakfast." Which statement by the nurse uses the interviewing skill of reflection? 1. "Let's talk about your inability to eat." 2. "What part of your breakfast were you able to eat?" 3. "How long have you been unable to eat most of your breakfast?" 4. "You seem surprised that you were unable to eat all your breakfast."

4

What is the primary reason why a nurse performs an admission assessment of a newly admitted patient? 1. Diagnose if the patient is at risk for falls 2. Ensure that the patient's skin is intact 3. Establish a therapeutic relationship 4. Identify important data

4

When the nurse considers the Nursing Process, the word "identify" is to "recognize" as the word "do" is to: 1. Plan 2. Analyze 3. Evaluate 4. Implement

4

The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat?

65 to 75 degrees F

A HCP orders a vest restraint for the patient. Which should the nurse do first when applying this restraint? A.) perform an inspection of the patients skin where the restraint is to be placed B.) ensure the back of the vest is positioned on the patient's back C.) permit 3 fingers to slide between the patient and the restraint D.) secure the restraint to the bed frame using a slipknot

A

A toaster is on fire in the pantry of a hospital unit. which should the nurse do first? A.) activate the fire alarm B.) unplug toaster from the wall C.) put out the fire w the extinguisher D.) evacuate the patients that are next to the room

A

a nurse is orienting a newly admitted patient to the hospital. which is the most important for the nurse to teach the patient how to do? A.) notify the nurse when help is needed B.) get out of bed to use the bathroom C.) raise and lower the head and foot of the bed D.) use the telephone to call family

A

which is the first action of the home care nurse should employ to prevent falls by an older adult living at home? A.) conduct a comprehensive risk assessment B.) encourage the patient to remove throw rugs C.) suggest installation of adequate lighting throughout the home D.) discuss aging changes

A

which nursing intervention enhances an older adult's sensory perception and thereby helps prevent injury when walking from the bed to the bathroom? A.) provide adequate lighting B.) raising the pitch of the voice C.) holding onto the patients arm D.) removing environmental hazards

A

which are appropriate goals for a patient who is at risk for falling? (select all that apply) A.) "the patient will be able to walk from a bed to a chair safely while hospitalized." B.) "the patient will be taught how to call for help to ambulate." C.) "the patient will be kept on bed rest when dizzy" D.) "the patient will be restrained when agitated" E.) "the patient will be free from trauma."

A and E

a nurse is preparing a bed to receive a newly admitted patient. which action is the most important? A.) placing the patient's name on the end of the bed B.) ensuring that the bed wheels are locked C.) positioning the call bell in reach D.) raising one side rail

B

which is the priority nursing intervention to prevent patient problems associated with latex gloves? A.) use non latex gloves B.) identify patients at risk C.) keep a latex safe supply cart available D.) administer allergy meds

B

Profuse smoke is coming out of the heating unit in the patient's room. Which should the nurse do first? A.) open the window B.) activate the alarm C.) move the patient out of the room D.) close the door to the patient's room

C

Which should the nurse do to best prevent the patient from falling? A.) provide a cane B.) keep walkways clear of obstacles C.) assist the patient with ambulation D.) encourage the patient to use walkway handrails

C

A nurse is caring for a confused patient. which should the nurse do to prevent this patient from falling? A.) encourage the patient to use bathroom rails B.) place the patient near the nurses station C.) reinforce how to use the call bell D.) maintain close supervision

D

A patient has dysphagia. which nursing action takes priority when feeding a patient? A.) ensuring that the dentures are in place B.) medicating for pain before providing meals C.) provide verbal cueing to swallow each bite D.) checking the mouth for emptying between each bite

D

A patient states that when turning on an electric radio a strong electrical shock was felt. Which should the nurse do first? A.) arrange for the maintenance department to examine the radio B.) disconnects the radio from the source of energy C.) check the patients skin for burns D.) take the patients apical pulse

D

Tinnitus

Ringing in the ears

Koilonychia

Spoon nails

An older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to perform skin checks to assess for signs of skin cancer? Select one: a. "Limit the time you spend in the sun." b. "Monitor for signs of infection." c. "Monitor spots for color change." d. "Use skin creams to prevent drying."

The correct answer is: "Monitor spots for color change."

A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment. Which statement made by the new graduate nurse requires the preceptor to intervene? Select one: a. "I will use the information from my assessment to figure out if your antihypertensive medication is working effectively." b. "Nursing assessment data are used only to provide information about the effectiveness of your medical care." c. "Nurses use data from their patient's physical assessment to determine a patient's educational needs." d. "Information gained from physical assessment helps nurses better understand their patients' emotional needs."

The correct answer is: "Nursing assessment data are used only to provide information about the effectiveness of your medical care."

The nurse is assessing an adult patient's patellar reflex. Which finding will the nurse record as normal? Select one: a. 1+ b. 2+ c. 3+ d. 4+

The correct answer is: 2+

A nurse is assessing a patient's skin. Which patient is most at risk for impaired skin integrity? Select one: a. A patient who is afebrile b. A patient who is diaphoretic c. A patient with strong pedal pulses d. A patient with adequate skin turgor

The correct answer is: A patient who is diaphoretic

A nurse is performing a mental status examination and asks an adult patient what the statement "Don't cry over spilled milk" means. Which area is the nurse assessing? Select one: a. Long-term memory b. Abstract thinking c. Recent memory d. Knowledge

The correct answer is: Abstract thinking

The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take? Select one: a. Assess the patient. b. Gather restraint supplies. c. Try alternatives to restraint. d. Call the health care provider for a restraint order.

The correct answer is: Assess the patient.

During a routine physical examination of a 70-year-old patient, a blowing sound is auscultated over the carotid artery. Which assessment finding will the nurse report to the health care provider? Select one: a. Bruit b. Thrill c. Phlebitis d. Right-sided heart failure

The correct answer is: Bruit

A nurse is completing an assessment of the patient. Which principle is a priority? Select one: a. Foot care will always be important. b. Daily bathing will always be important. c. Hygiene needs will always be important. d. Critical thinking will always be important.

The correct answer is: Critical thinking will always be important.

While assessing the skin of an 82-year-old patient, a nurse discovers nonpainful, ruby red papules on the patient's trunk. What is the nurse's next action? Select one: a. Explain that the patient has basal cell carcinoma and should watch for spread. b. Document cherry angiomas as a normal older adult skin finding. c. Tell the patient that this is a benign squamous cell carcinoma. d. Record the presence of petechiae.

The correct answer is: Document cherry angiomas as a normal older adult skin finding.

On admission, a patient weighs 250 pounds. The weight is recorded as 256 pounds on the second inpatient day. Which condition will the nurse assess for in this patient? Select one: a. Anorexia b. Weight loss c. Fluid retention d. Increased nutritional intake

The correct answer is: Fluid retention

A male student comes to the college health clinic. He hesitantly describes that he found something wrong with his testis when taking a shower. Which assessment finding will alert the nurse to possible testicular cancer? Select one: a. Hard, pea-sized testicular lump b. Rubbery texture of testes c. Painful enlarged testis d. Prolonged diuretic use

The correct answer is: Hard, pea-sized testicular lump

A patient has fallen several times in the past week when attempting to get to the bathroom. The patient gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem? Select one: a. Limit fluid and caffeine intake before bed. b. Leave the bathroom light on to illuminate a pathway. c. Practice Kegel exercises to strengthen bladder muscles. d. Clear the path to the bathroom of all obstacles before bedtime.

The correct answer is: Limit fluid and caffeine intake before bed.

A nurse is assessing several patients. Which assessment findings will cause the nurse to follow up? (Select all that apply.) Select one or more: a. Orthopnea b. Nonpalpable lymph nodes c. Pleural friction rub present d. Crackles in lower lung lobes e. Grade 5 muscle function level f. A 160-degree angle between nail plate and nail

The correct answer is: Orthopnea, Pleural friction rub present, Crackles in lower lung lobes

A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel? Select one: a. Bag bath b. Sponge bath c. Partial bed bath d. Complete bed bath

The correct answer is: Partial bed bath

The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? (Select all that apply.) Select one or more: a. One family member has gone to lunch. b. Patient is placed in bilateral wrist restraints at 0815. c. Bilateral radial pulses present, 2+, hands warm to touch d. Straps with quick-release buckle attached to bed side rails e. Attempts to distract the patient with television are unsuccessful. f. Released from restraints, active range-of-motion exercises completed

The correct answer is: Patient is placed in bilateral wrist restraints at 0815., Bilateral radial pulses present, 2+, hands warm to touch, Attempts to distract the patient with television are unsuccessful., Released from restraints, active range-of-motion exercises completed

A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next? Select one: a. Remove the restraint. b. Place a blanket over the feet. c. Immediately do a complete head-to-toe neurologic assessment. d. Take the patient's blood pressure, pulse, temperature, and respiratory rate.

The correct answer is: Remove the restraint.

The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient. Which action indicates the nursing assistant has understood the nurse's teaching? Select one: a. Bathing and drying the skin vigorously to stimulate circulation b. Keeping the head of the bed elevated 30 degrees c. Limiting intake of fluid and offer frequent snacks d. Turning the patient at least every 2 hours

The correct answer is: Turning the patient at least every 2 hours

A nurse is auscultating different areas on an adult patient. Which technique should the nurse use during an assessment? Select one: a. Uses the bell to listen for lung sounds b. Uses the diaphragm to listen for bruits c. Uses the diaphragm to listen for bowel sounds d. Uses the bell to listen for high-pitched murmurs

The correct answer is: Uses the diaphragm to listen for bowel sounds

A female patient is having difficulty voiding in a bedpan but states that her bladder feels full. To stimulate micturition, which nursing intervention should the nurse try first? Select one: a. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient's progress. b. Utilizing the power of suggestion by turning on the faucet and letting the water run. c. Obtaining an order for a Foley catheter. d. Administering diuretic medication.

The correct answer is: Utilizing the power of suggestion by turning on the faucet and letting the water run.

An 86-year-old woman's priority nursing diagnosis is Disturbed Sleep Pattern related to anxiety and lack of understanding of upcoming surgery. The nurse teaches the patient what to expect before, during, and after surgery. The nurse knows that the patient understands the procedures to expect after surgery when the patient: A. demonstrates how she will get out of bed following her surgery. B. states that she needs to ask her daughter to be at the hospital the day of her surgery. C. needs reinforcement of information regarding pain management and activity following surgery. D. calls her friends to tell them about the day of her surgery and how long she will be in the hospital.

a

Which nursing intervention enhances an older adult's sensory perception and thereby helps prevent injury when walking from the bed to the bathroom? A. Providing adequate lighting B. Raising the pitch of the voice C. Holding onto the patient's arm D. Removing environmental hazards

a

Which patient will the nurse see first?

a 56 year old patient with oxygen using an electric razor for grooming

The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event?

a surgical sponge is left in the patient's incision

The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take?

a, b, c, d a- close all doors b- note evacuation routes c- note oxygen shut-offs d- move bedridden patients in their bed

The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient?

a, b, c, d a- where did you fall? b- what time did the fall occur? c- what were you doing when you fell? d- what types of injuries occurred after the fall?

A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene?

a, c, d a- smoking in bed helps me relax and fall asleep c- we use the same space heater as my grandparents used d- we use the RACE method when using the fire extinguisher

The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. In which order will the nurse perform the steps, beginning with the first one?

a. 2, 1, 4, 3 2- remove the patient 1- pull the alarm 4- close doors and windows 3- use the fire extinguisher

A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?

applying the restraint

The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take?

assess the patient

A nurse is evaluating how well a client learned the information presented in an instructional session about following a heart healthy diet. The client states that she understands what to do now. Which of the following actions by the nurse should assist the nurse in evaluating the client's learning? A. Encourage the client to ask questions. B. Ask the client to explain how to select or prepare meals C. Encourage the client to fill out an evaluation form. D. Ask the client if she has resources for further instruction on this topic.

b

The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult? A. Formulate a nursing diagnosis of impaired gas exchange B. Record in the medical record the distance a client ambulate in the hall C. Write individualized nursing orders in the care plan D. Compare client responses to the desired outcomes for pain relief

b

Which of the following descriptors is most appropriate to use when stating the "problem" part of a nursing diagnosis? A. Grimacing B. Anxiety C. Oxygenation saturation 93% D. Output 500 mL in 8 hours

b

Which of the following interventions implemented by the nurse when caring for a patient who recently had a stroke indicates that the nurse is incorporating teaching with nursing care? A. The nurse speaks clearly and develops alternative communication methods as needed. B. The nurse describes the importance of changing positions while turning the patient onto the side. C. The nurse determines the patient's reading level and ensures that teaching materials are written at the appropriate level. D. The nurse assesses the patient's culture and ensures that food delivered by the kitchen is consistent with the patient's cultural preferences.

b

The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which information will the nurse include in the teaching session?

b, c, e b- walk to the mailbox in the summer c- encourage yearly eye examinations e- keep pathways clutter free

The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care?

b, c, e, f b- patient is placed on bilateral wrist restraints at 0815 c- bilateral radial pulses present, 2+, hands warm to touch e- attempts to distract the patient with television are unsuccessful f- released from restraints, active range-of-motion exercises completed

A patient requires restraints after alternatives are not successful. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for self care?

b, d, e b- healthcare provider writes the type and location of the restraint d- healthcare provider performs a face to face assessment prior to the order e- healthcare provider specifies the duration and circumstances under which the restraint will be used

An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient?

backs wheelchair into elevator, leading with large rear wheels first

The nurse is performing the "Timed Get Up and Go (TUG)" assessment. Which actions will the nurse take?

c, d, f c- instructs the patient to walk 10 feet as quickly and safely as possible d- observes for unsteadiness in patient's gait f- allows the patient a practice trial

A 68-year-old man needs to learn how to do self-catheterization. In teaching the patient about this, you need to: A. speak loudly and clearly. B. demonstrate the skill quickly and efficiently. C. expect the patient to understand the information the first time you present it. D. allow the patient time to express his feelings about catheterizing himself and ask questions.

d

A 68-year-old man was diagnosed with Alzheimer's disease 4 years ago. The patient's cognitive abilities have since deteriorated, and the patient is withdrawn and frustrated. Which nursing intervention would be most helpful when communicating with this patient with a cognitive disorder? A. Stand within 6 inches of the patient when providing direction. B. Speak in a low monotone voice when communicating with the patient. C. Ask only "yes" and "no" questions when talking to the patient. D. Break tasks into small steps, giving one instruction at a time.

d

The rehabilitation nurse wishes to make the following entry into a client's plan of care: "Client will reestablish a pattern of daily bowel movements without straining within two months." The nurse would write this statement under which section of the plan of care? A. Nursing diagnosis/problem list B. Nursing orders C. Short-term goals D. Long-term goals

d

While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment? A. Help client into the chair but more quickly B. Document client's vital signs taken just prior to moving the client C. Help client back to bed immediately D. Observe client's skin color and take another set of vital signs

d

The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. Which interventions should the nurse utilize for this patient and family?

d, e d- discuss with the family steps to take if the seizure does not discontinue e- instruct the family to reorient and reassure the patient after consciousness is regained

The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient's plan of care?

deficient knowledge

A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session?

disconnect items before cleaning

how often should restraints be removed, area massaged, and the joints moved through their full rom?

every 2 hours

The nurse is presenting an education session on safety for parents of adolescents. Which information will the nurse include in the teaching session?

increased aggressiveness and blood spots on the clothing may indicate substance abuse

A patient is admitted and is placed on full precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take?

keep the patient on fall risk until discharge

The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?

manage all patients using standard precautions

The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next?

notify the health care provider

A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls?

orthostatic hypotension

A home health nurse is assessing a family's home after the birth of an infant. A toddler also lives in the home. Which finding will cause the nurse to follow up?

plastic grocery bags are neatly stored under the counter

A nurse is teaching a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in this teaching session?

proper fit of a bicycle helmet

A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next?

remove the restraint

The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan?

risk for injury

Which activity will cause the nurse to monitor for equipment related accidents?

uses a patient controlled analgesic pump