Exam 3 CH 26 32 34/ATI 7, 14,

A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse check the clients MA R, and noted the last dose of pain medication with six hours ago. The prescription reads every four hours PRN for pain. The nurse administer the medication and checked with the client. 40 minutes later when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? A. Assessment B. Planning. C. Intervention. D. Evaluation.

A

A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse, should the nurse identify as appropriate for the planning step of the nursing process? A. "I will determine the most important client problem that we should address." B. "I will review the past medical history on the clients record to get more information." C. "I will carry out the new prescriptions from the provider." D. "I will ask the client if their nausea has resolved."

A

By the second postoperative day, the client has not achieved satisfactory pain relief. Based on the evaluation which of the following action, should the nurse take according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain, relief B. Wait to see whether the pain lessons during the next 24 hours. C. Change the plan of care to provide different pain, relief interventions. D. Teach the client about the pain of care for managing the pain.

A

A patient has a blood pressure reading of 130/90 mm Hg during a clinic visit. What recommendation for follow-up will the nurse make? A.Follow-up measurements of blood pressure B. Immediate treatment by a health care provider C. No action, because the nurse considers this reading is due to anxiety D. Change in dietary intake

A A single blood pressure reading that is mildly elevated is not significant, but the measurement should be monitored over time to determine if hypertension exists. The nurse will recommend a follow-up visit with the health care provider for a recheck.

A nurse is caring for a group of patients on a cardiac unit. Which finding will prompt the nurse to assess the apical-radial pulse? A. Bounding radial pulse B. Immediately postoperative C. Rapid, irregular pulse D. Fluid volume deficit

A The nurse assesses the apical-radial pulse when dysrhythmia exists or is suspected, manifested by tachycardia or irregular pulse. The difference between the apical and radial pulse rates, called the pulse deficit, captures heart beats not reaching the peripheral arteries.

A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential to good patient outcomes, especially for those receiving mechanical ventilation. What are positive outcomes expected from this care? Select all that apply. A. Promoting the patient's sense of well-being B. Preventing deterioration of the oral cavity C. Contributing to decreased incidence of aspiration pneumonia D. Eliminating the need for flossing E. Decreasing oropharyngeal secretions F. Compensating for an inadequate diet

A B C Adequate oral hygiene is essential for promoting the patient's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene and use of chlorhexidine gluconate (CHG) in critical care areas, can limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of ventilator-associated pneumonia, aspiration pneumonia, and other systemic diseases. Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition.

A nurse manager is reviewing guidelines, prevent for preventing injury with staff members. Which of the following instructions should the nurse manager include? Select all that apply A. Request assistance when repositioning a client. B. Avoid twisting your spine or bending at the waist. C. Keep your knees slightly lower than your hips when sitting for long periods of time. D. You smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 to 3 hours to flex and stretch your joints and muscles.

A B D

During assessment of vital signs, a patient reports severe abdominal pain. Which pain-related changes in vital signs may be present? Select all that apply. A. Pulse rate of 102 B. Body temperature 98.8°F C. Blood pressure 154/86 D. Increased respiratory depth E. Respiratory rate of 24 F. Body temperature 100.8°F

A C E The pulse, blood pressure, and respiratory rate often increase when a person is experiencing pain; respiratory depth decreases. Pain does not affect body temperature.

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? Select all that apply. A. Respiratory rate is 22/MIN with even unlabored respirations. B. The clients partner states, "they said they hurt after walking about 10 minutes." C. The clients pain rating is 3 on a scale of 0 to 10. D. The client skin is pink, a warm and dry. E. The assistive personnel reports that the client walked with a limp

A D E

A nurse observes a nursing student is taking the blood pressure on a patient with a cuff that is too large for the patient's arm. What explanation does the nurse give to the student for why errors of measurement may result? A. "Using the wrong cuff will result in an incorrect reading." B. "This cuff will cause an elevation in diastolic blood pressure." C. "Using the wrong cuff will cause dangerous pressure on the arm." D. "An overly large cuff will cause an inaccurate low reading."

A or I think this could also be D. (T check this lol) A blood pressure cuff that is too large will cause a falsely low reading; a cuff that is too small will cause a falsely high reading. The wrong size cuff will not injure the patient, but pressure may be felt on the arm from a too tight cuff.

A nurse is caring for a client who is receiving internal tube feeding due to dysphagia. Which of the following bad position should the nurse use for safe care of this client? A. Supine. B. Semi-Fowlers. C. Semi-prone. D. Trendelenburg

B

An RN in a long-term care facility supervises APs as they provide hygiene to older adults. What action by the AP will the nurse correct? A. When providing perineal care, washing the area from front to back B. Insisting the older adult must take a bath or shower each day C. Telling the patient to avoid soaking feet, helps the patient dry between the toes D. Covering areas not being bathed with a bath blanket

B Older adults tend to develop dry skin; bathing frequency will change accordingly. Soaking adults' feet is not recommended. It is appropriate to keep a patient warm with bath blankets and provide perineal care washing from front to back.

A nurse is caring for a 25-year-old patient who is unresponsive following a head injury. The patient has several piercings in the ears and nose that appear crusted and slightly inflamed. What is the most appropriate action to care for this patient's piercings? A. Avoiding removing or washing the piercings until the patient is responsive B. Rinsing the sites with warm water and remove crusts with a cotton swab C. Washing the sites with alcohol and apply an antibiotic ointment D. Removing the jewelry and allow the sites to heal over

B When providing care for piercings, the nurse performs hand hygiene, applies gloves, then cleanses the site of all crusts and debris by rinsing the site with warm water and removing the crusts with a cotton swab. The nurse should then apply a dab of liquid-medicated cleanser, per policy, to the area, turn the jewelry back and forth to work the cleanser around the opening, rinse well, remove gloves, and perform hand hygiene. The nurse should not use alcohol, peroxide, or ointments at the site and should avoid removing piercings unless it is absolutely necessary (e.g., when an MRI is ordered.)

A nurse is assessing the blood pressure of a patient with traumatic injuries using a Doppler device. Which information does the nurse expect to obtain? A. Amplitude of the brachial pulse B. Mean arterial blood pressure C. Estimation of the systolic blood pressure D. Apical-radial pulse rate

B A Doppler provides an estimation of the systolic blood pressure when the pulse is inaudible. Diastolic pressure cannot be calculated because oscillations of the pulse will be audible during the entire BP assessment; recall the nurse can auscultate a pulse with the Doppler. The pulse amplitude obtained with palpation, the mean arterial pressure reflects the average blood pressure during a cardiac cycle, and the apical-radial pulse is assessed to detect a pulse deficit, often present with a dysrhythmia.

A nurse is assessing the vital signs of a group of patients in the emergency department. Which patients require follow-up by the nurse? Select all that apply. A. Infant whose temperature is 100.5°F (38.1°C) B. Toddler whose blood pressure is 118/80 C. School-age child whose temperature is 102.2°F (39°C) D. Adolescent whose pulse rate is 70 beats/min E. Adult whose respiratory rate is 20 breaths/min F. Older adult whose pulse rate is 42 beats/min

B C The normal temperature range for infants is 98.7° to 100.5°F (37.1° to 38.1°C). The normal pulse rate for an adolescent is 55 to 105. The normal respiratory rate for an adult is 12 to 20 breaths/min and the normal pulse for an older adult is 40 to 100 beats/min. The normal blood pressure for a toddler is 89/46, and the normal temperature for a child is 98.2° to 100°F (36.8° to 37.8°C; refer to Table 26-1).

A nurse enters a room and finds a patient who is unable to catch their breath, has a respiratory rate of 28, and is using accessory muscles to breathe. What intervention will the nurse use to relieve dyspnea? A. Remove pillows from under the head B. Raise the head of the bed C. Elevate the foot of the bed D. Reassess the respiratory rate

B. Elevating the head of the bed facilitates lung expansion by allowing the abdominal contents to descend, which facilitates lung expansion and oxygenation. Elevated respiratory may occur due to distress or hypoxemia; assessing the respiratory rate does not resolve the problem of dyspnea.

A nurse is scheduling hygiene for patients on the unit. What is the priority the nurse uses to guide planning for patient's personal hygiene? A. When the patient had their most recent bath B. The patient's usual hygiene practices and preferences C. Where the bathing fits in the nurse's schedule D. The time that is convenient for the AP

B. The patient's preferences, practices, and rituals should always be taken into consideration, unless there is a clear threat to health. The patient and nurse should work together to come to a mutually agreeable time and method to accomplish the patient's personal hygiene. The availability of staff to assist may be important, but the patient's preferences are a higher priority.

A nurse has assessed an older adult for orthostatic hypotension as shown in the electronic health record (EHR). What action will the nurse take? Exhibit: Electronic health record (EHR) Graphic sheet 8:00 AM BP lying 124/76 BP sitting 118/74 BP standing 98/58 A. Encourage the patient to rise from a sitting position quickly to improve blood flow B. Suggest that in the future the patient "dangle" for a few minutes before standing C. Return the patient to bed and place them in Fowler position D. Administer medication to increase blood pressure

B. Allowing the patient to "dangle" on the edge of the bed prior to rising may prevent orthostatic hypotension, by allowing time to adjust to the upright position. Arising and moving about slowly, especially after a period of bed rest, might also prevent orthostatic hypotension. If a patient becomes dizzy or faint, the nurse should return the patient to bed and place them in a supine position, which restores blood flow to the brain. A β-blocker is given to decrease blood pressure for a patient with hypertension; the nurse will question this prescription when hypotension is present.

A nurse assisting a patient with a bed bath observes the older adult has dry skin, which the patient states is "itchy." Which intervention is appropriate? A. Bathe the patient more frequently. B. Use an emollient on the dry skin. C. Explain that this is expected as people age. D. Limit the patient's fluid intake.

B. An emollient soothes dry skin, whereas frequent bathing increases dryness. Telling the patient this is normal with aging and does not help resolve the issue. Limiting fluid intake can promote dehydration and exacerbate dry skin.

A nurse is caring for a postoperative patient who experienced hypovolemic shock necessitating transfer to the ICU. The nurse manager reviews the medical record and suspects which situation contributed to the emergency? Exhibit: Electronic health record (EHR) Graphic sheet 2:00 PM T 99.2, P 88, RR 16, BP 106/54 2:15 PM T 99.6, P 94, RR 16, BP 100/52 2:30 PM T 99.4, P 110, RR 18, BP 96/50 2:45 PM T 99.2, P 120, RR 20, BP 84/48 A. Using an inappropriate format to document the vital signs B. Failing to report tachycardia and hypotension to the provider C. Not following the postoperative vital sign protocol D. Failing to reflect a pain assessment in the documentation

B. Pathologic hypotension, especially when associated with tachycardia, can result from vasodilation of the arterioles, failure of the heart to pump effectively, loss of blood (such as with a hemorrhage or shock), or poor oxygenation. The nurse reports such changes to the health care provider immediately and anticipates prescriptions to restore perfusion.

A nursing student is caring for a patient who has intravenous fluids infusing in the right arm. What action will the student take to correctly obtain the blood pressure? A. Take the blood pressure in the right arm B. Assess blood pressure using the left arm C. Use the smallest possible cuff D. Document an inability to take the blood pressure

B. The blood pressure should be taken in the arm opposite of the arm with intravenous access or infusion.

A nurse is instructing a client who has COPD about using the orthopedic position to relieve shortness of breath which of the following statements should the nurse make? A. "Lying on your back with our head and shoulder, supported by a pillow " B. "Have your head turned to the side while you lie on your stomach " C. "Have a table beside your bed so you can sit on the bedside and rest or arms on the table." D. "Lie on your side with your top arm resting on the bed in your way on your hip "

C

A nurse in a memory care unit is assisting a patient with dementia with bathing. Which nursing action will enhance patient comfort and prevent anxiety? A. Shifting the focus of the interaction to the "process of bathing" B. Washing the face and hair at the beginning of the bath C. Using music to soothe anxiety and agitation D. Avoiding towel baths or forms of bathing with which the patient is unfamiliar

C The nurse use music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the "task of bathing" to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. Wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider methods for bathing aside from showers and tub baths. Towel baths, washing under clothes, and bathing "body sections" one day at a time, as well as dry shampoo or "shower cap" shampoos, are additional options.

A home care nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure? A. Adding bath oil to the water to prevent dry skin B. Allowing the patient to lock the door to guarantee privacy C. Assisting the patient in and out of the tub to prevent falling D. Keeping the water temperature very warm because older adults chill easily

C Safe nursing practice requires that the nurse assists a patient with an unsteady gait in and out of the tub. Adding bath oil to the bath water poses a safety risk because it makes the patient and tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortably warm at 43° to 46°C. Older adults have an increased susceptibility to burns due to diminished sensitivity.

A nurse is about to bathe a female patient who has an IV in the forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. How will the nurse proceed? A. Quickly disconnecting the IV tubing closest to the patient and thread it through the gown sleeve B. Cutting the gown with scissors to allow arm movement C. Threading the bag and tubing through the gown sleeve, keeping the line intact D. Temporarily disconnecting the tubing from the IV container, threading it through the gown

C Threading the bag and tubing through the gown sleeve maintains a closed system and prevents contamination. No matter how quickly performed, any disconnection of IV tubing results in a breach of the sterile system, creating risk for infection. Cutting a gown is not an alternative except in an emergency.

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a providers prescription which of the following interventions should the charge nurse include. Select all that apply. A. Writing a prescription for morphine sulfate as needed for pain. B. Inserting a nasogastric tube to relieve gastric distention. c. Showing a client how to use progressive muscle relaxation. D. Performing a daily bath after the evening meal. E. Repositioning a client every two hours to reduce pressure injury risk.

C D E

A nurse participating in community blood pressure screening tells the patient their blood pressure is 120/80 mm Hg. When the patient asks what the numbers mean, what information does the nurse provide? A. Rhythmic distention of the arterial walls from increased pressure due to surges of blood with ventricular contraction B. Systolic pressure represents ventricular contraction causing high pressure on arterial walls; the bottom number or diastolic pressure reflects ventricular relaxation with a lower pressure on the arteries C. Normal blood pressure D. Difference between the pressure on arterial walls with ventricular contraction and relaxation

C. The systolic pressure, 120 mm Hg, occurs when ventricular contraction causes the highest pressure on arterial walls. The diastolic pressure, 80 mm Hg, correlates with the lowest pressure on arterial walls as the heart rests between beats. The difference between systolic and diastolic pressures is called the pulse pressure. The rhythmic distention of the arterial walls as ventricular contraction pumps blood to the body creates the pulse.

A nurse is caring for a client who is sitting in a chair and asked to return to bed which of the following actions is the nurses priority at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional staff to assist with the transfer. C. Use a transfer about an assisted client back to bed. D. Determine the clients ability to help with the transfer.

D

When assessing the skin, nurses use techniques to provide complete data and correct documentation. Which actions are appropriate during the skin assessment? Select all that apply. A. Comparing bilateral parts for symmetry B. Proceeding in a toe-to-head, systematic manner C. Using standard terminology to communicate and document findings D. Avoiding using data from the nursing history to direct the assessment E. Documenting only skin abnormalities on the health record F. When risk factors are identified, following up with a related skin assessment

a, b, c, f. During skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to communicate and document findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, using cues/data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings.

A nursing student asks an experienced nurse why they provide massage for their patients. Which of these would be reflected in the nurse's response? A. To help with pain management B. To provide comfort C. To communicate to patients through touch D. To energize patients, especially those with dementia E. To facilitate healing after back or spinal surgery F. To help increase circulation

a, b, c, f. The benefits of massage include general relaxation and increased circulation, pain relief, sleep promotion, and increased patient comfort and well-being. Massage also provides an opportunity for the nurse to communicate and connect with the patient through touch. Back massage is contraindicated if the patient has had back surgery or has fractured ribs.

A nurse is providing active-assistive range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient reports that they are "too tired to go on." What actions are appropriate at this time? Select all that apply. A. Stop performing the exercises. B. Decrease the number of repetitions performed. C. Reevaluate the plan of care. D. Move to the patient's other side to perform exercises. E. Encourage the patient to finish the exercises and then rest. F. Assess the patient for additional symptoms of intolerance.

a, c, f. When a patient reports fatigue during range-of-motion exercises, the nurse should stop the activity, reevaluate the plan of care, and assess the patient for further symptoms indicating the activity is not tolerated. The exercises can be rescheduled for times of the day when the patient is feeling more rested, or spaced out at different times of the day.

A nurse is teaching a nursing student how to perform perineal care for patients. What actions are appropriate when performing this procedure? Select all that apply. A. For male and female patients, wash the groin area with a small amount of soap and water and rinse. B. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area. C. For male and female patients, always proceed from the most contaminated area to the least contaminated area. D. For male and female patients, use a clean portion of the washcloth for each stroke. E. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. F. In an uncircumcised male patient, avoid retracting the foreskin (prepuce) while washing the penis.

a, d, e. Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis and return it to its original position when finished.

A nurse is developing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply. A. Teach the patient to avoid sudden position changes that may cause dizziness. B. Recommend that the patient restrict fluid intake until after exercise. C. Instruct the patient to push a little further beyond fatigue each session. D. Tell the patient to avoid exercising in very cold or very hot temperatures. E. Encourage the patient to modify exercise if weak or ill. F. Recommend that the patient consume a high-carb, low-protein diet.

a, d. Teaching points for exercising for a patient with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures. The nurse should also instruct the patient to remain adequately hydrated, respect fatigue as a sign of activity intolerance and not push to the point of exhaustion, and avoid exercise if weak or ill. Older adults should consume a high-protein, high-calcium, and vitamin D-enriched diet.

A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply. A. Wash the skin twice a day with a mild cleanser and warm water. B. Use cosmetics liberally to cover blackheads. C. Apply emollients on the area. D. Squeeze blackheads as they appear. E. Keep hair off the face and wash hair daily. F. Avoid tanning booth exposure and use sunscreen.

a, e, f. Washing the skin removes oil and debris, hair should be kept off the face and washed daily to keep oil from the hair off the face. Exposure to UV light should be avoided, especially when using acne treatments. Liberal use of cosmetics and emollients can clog the pores, worsening acne. Squeezing blackheads is discouraged because it may lead to infection.

A nurse working in a long-term care facility uses proper principles of ergonomics when moving and transferring patients to avoid back injury. Which action should be the focus of these preventive measures? A. Carefully assessing the patient care environment B. Using two nurses to lift a patient who cannot assist C. Wearing a back belt to perform routine duties D. Properly documenting the patient lift

a. Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and mobility should be documented but are not the primary focus of interventions related to injury prevention.

A nurse is instructing a patient recovering from a stroke on proper use of a cane. What information will the nurse include in the teaching plan? A. Support weight on the stronger leg and cane and advance weaker foot forward. B. Hold the cane in the same hand of the leg with the most severe deficit. C. Stand with as much weight distributed on the cane as possible. D. Avoid using the cane to rise from a sitting position, as this is unsafe.

a. The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position.

A nurse is caring for a patient with lower extremity paralysis. Which action will the nurse take to prevent external rotation of the hip and foot? A. Use a trochanter roll. B. Apply SCDs. C. Obtain a prescription for antiembolism stockings. D. Have the patient maintain low-Fowler's position. E. Have the patient cross their arms on their chest and place a pillow between their knees. F. Place a cervical collar on the patient's neck and gently roll them to the other side of the bed.

a. The trochanter roll is used to support the hips and legs to prevent external rotation. SCDs and antiembolism stockings are used to prevent DVT. Fowler's position allows for foot rotation and increases sacral pressure.

A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply. A. Do full-body pushups in bed six to eight times daily. B. Breathe in and out smoothly during quadricep-setting exercises. C. Place the bed in the lowest position or use a footstool for dangling. D. Dangle on the side of the bed for 30 to 60 minutes. E. Allow the nurse to bathe you completely to prevent fatigue. F. Perform quadriceps two to three times per hour, four to six times a day.

b, c, f. Breathing in and out smoothly during quadricep-setting exercises maximizes lung inflation. The patient should perform quadricep-setting exercises two to three times per hour, four to six times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for a few minutes is done to adjust to the upright position; dangling for 30 to 60 minutes is impractical for the nurse to supervise and may prove unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling. The nurse should also encourage the patient to be as independent as possible to prepare for return to normal ambulation and ADLs.

A nurse in a long-term care facility observes the AP providing foot care for patients. Which actions by the AP require the nurse to intervene? Select all that apply. A. Bathing the feet thoroughly in a mild soap and tepid water solution B. Soaking the resident's feet in warm water and bath oil C. Drying the feet and area between the toes thoroughly D. Applying an alcohol rub for odor and dryness to the feet E. Applying an antifungal foot powder F. Cutting the toenails at the lateral corners when trimming the nail

b, d, f. The nurse corrects the AP for soaking the feet or using alcohol and reminds them to use moisturizer if the feet are dry. Digging into or cutting the toenails at the lateral corners when trimming the nails requires correction; toenails should be trimmed straight across. Guidelines for foot care include bathing the feet thoroughly in a mild soap and tepid water solution; drying feet thoroughly, including the area between the toes; and applying an antifungal foot powder when requested.

A nurse caring for patients in a pediatric office assesses children's achievement of developmental milestones. Which patient finding requires follow-up with the pediatrician? A. 4-month-old infant who is unable to roll over B. 6-month-old infant who is unable to hold head up C. 11-month-old infant who cannot walk unassisted D. 18-month-old toddler who cannot jump

b. By 5 months, head control is usually achieved. An infant usually rolls over by 6 to 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump.

A nursing student asks the primary nurse why an immobile patient developed two urinary tract infections (UTIs) in the 6 months. How does the nurse best explain this patient's risk for UTI? A. Improved renal blood supply to the kidneys B. Urinary stasis C. Decreased urinary calcium D. Acidic urine formation

b. In a nonerect patient, the kidneys and ureters are level, limiting or delaying urinary drainage from the kidney pelvis to ureter and bladder. The resulting urinary stasis favors the growth of bacteria that can promote urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to bone demineralization, resulting in increased urinary calcium levels and alkaline urine, contributing to renal calculi and urinary tract infection, respectively.

A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient? A. Lean on the crutches using the axillae to bear body weight. B. Keep elbows close to the sides of the body. C. When rising, extend the uninjured leg to prevent weight bearing. D. To climb stairs, place weight on affected leg first.

b. The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg when rising to prevent weight bearing, and advance the unaffected leg first when climbing stairs.

A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess the mobility of a hospitalized patient. During the patient interview, the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index? A. 2 B. 4 C. 5 D. 6

b. The total score for this patient is 4. On the Katz Index of Independence in ADLs, one point is awarded for independence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding.

A nurse is caring for a patient who is on bedrest following a spinal injury. Which action is appropriate to prevent foot drop? A. Maintain the supine position with supination on the feet. B. Ask the family to bring in high-top sneakers to maintain foot dorsiflexion. C. Encourage hyperextension of the feet with adaptive devices or splints. D. Use pillows to keep the feet in the abducted position.

b. To prevent foot drop, the nurse should support the feet in dorsiflexion using a footboard and/or high-top sneakers for further support. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions do not prevent foot drop.

A nurse assists a patient with ambulation for the first time following a knee replacement. Shortly after beginning to walk, the patient tells the nurse that they are dizzy and feel like they might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient: A. Grasp the gait belt. B. Stay with the patient and call for help. C. Place feet wide apart with one foot in front. D. Gently slide the patient down to the floor, protecting their head. E. Pull the weight of the patient backward against your body. F. Rock your pelvis out on the side of the patient.

c, f, a, e, d, b. When a patient is being moved or ambulated and starts to fall, the nurse places their feet wide apart with one foot in front, rocks their pelvis out toward the side of the patient, grasps the gait belt, supports the patient by pulling the patient's weight backward against their body, gently slides the patient down their body toward the floor while protecting the patient's head, and remains with the patient while calling for help.

A nurse on a medical-surgical unit notes a patient with pneumonia and is experiencing dyspnea. What action will the nurse take to improve the dyspnea? A. Encourage the patient to ambulate. B. Suggest the patient use music or television as distraction. C. Place the patient in Fowler's position. D. Tell the patient to take several deep breaths, then hold their breath for 5 seconds.

c. High-Fowler's position promotes maximal lung expansion and is the position of choice during episodes of dyspnea. Encouraging ambulation during distress will increase dyspnea. Distracting the patient is not addressing the underlying cause of dyspnea, which is activity. Holding the breath increases demands on the heart.

A nurse is assisting a patient who is 2 days postoperative from a cesarean section dangle in preparation for sitting in a chair. After assisting the patient to stand up, the patient's knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action? A. Supporting the patient as she stands, waiting a few moments, then continuing the move to the chair B. Calling for assistance and continuing the move with the assistance of another nurse C. Lowering the patient back to the side of the bed and pivoting her back into bed D. Having the patient sit down on the bed and dangle her feet before moving

c. If a patient becomes faint and their knees buckle when moving from bed to a chair or ambulating, the nurse should stop the activity, as the patient has demonstrated a clear risk for falling. The nurse should lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient's vital signs and for the presence of other symptoms. When vital signs are stable, another attempt can be made with the assistance of another staff. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to a change in position and prevent hypotension related to a sudden change from the supine position.

A nurse is getting a patient with right hemiparesis out of bed to the chair. What will the nurse say to the patient? A. "Stand on the weaker leg and pivot toward the chair." B. "I will call the lift team to carry you to the chair." C. "The chair is by your non-affected leg for smoother movement." D. "Avoid putting your hospital socks on, as that will restrict your feet moving."

c. When transferring a patient, the chair is placed on the unaffected or stronger side, rather than the weaker or affected side. Lifting and carrying a patient unless absolutely necessary poses an unnecessary risk for injury to patient and staff. Patients should wear proper shoes, sturdy slippers, or hospital-issued socks with grips to prevent sliding and/or falling.

Two nurses are repositioning a patient and pulling the patient up in bed. Which of these steps is most appropriate to prevent injury to the nurses? A. Telling the patient to cross their arms and legs B. Pulling the patient from underneath the axilla toward the top of the bed C. Avoiding using a draw sheet to lift or reposition the patient D. Ensuring the bed is at the level of the nurses' hips E. Facing the head of the bed and rocking in synchrony

d. The nurses should face the direction the patient will move and rock in synchrony prior to moving the patient in that direction. A lifting or repositioning sheet or device is used to decrease friction and facilitate movement. While the patient can cross their arms, they can also be instructed to press their feet into the mattress to assist movement. The bed should be at the level of the nurses' elbows.

A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient tells the AP not to place the patient in which position? A. Side-lying B. Fowler's C. Sims' D. Prone

d. While placing the patient in the prone position for 30 minutes two or three times daily helps prevent knee and hip flexion contractures, it is contraindicated in patients who have spinal problems. The pull of gravity on the trunk when the patient lies prone produces a marked lordosis or forward curvature of the lumbar spine.

A nurse is caring for a newborn with hypothermia. What action does the nurse take to prevent heat loss from convection? A. Wrapping the newborn in a blanket B. Placing the newborn on a warmed surface C. Reducing the temperature in the room D. Increasing the temperature in the room

A. Convection refers to heat disseminated by motion between areas of unequal density, for example, a fan blowing cool air over the body or an uncovered body. Placing the baby on a warmed surface would prevent heat loss via conduction. Reducing the temperature may decrease heat loss via perspiration (evaporation); increasing the temperature in the room may increase heat loss via evaporation.

The nurse educator is reviewing proper body mechanics during employee orientation, which of the following statement should the nurse identify as an indication that the attend the understands the teaching? Select all that apply. A. "My line of gravity should fall outside my base of support " B. "The lower my center of gravity the more stability I have." C. "To broaden my base of support I should spread my feet apart. " D. "When I left an object, Aisha hold it as close to my body as possible. " E. "When pulling an object, I should move my front foot forward. "

B C D

The nurse must assess a patient's blood pressure using a thigh cuff, due to presence of a right antecubital IV and a left arm dialysis access. Which of these arteries will the nurse use for auscultation? A. Brachial B. Carotid C. Popliteal D. Radial

C . When the patient's brachial artery is inaccessible and/or the use of the upper arm is contraindicated, blood pressure can be assessed using the popliteal artery of the leg. The blood pressure in that area, in both adults and children, is generally higher.

A charge nurse working on a medical-surgical unit stops the AP from taking rectal temperatures on patients with which problems? Select all that apply. A. Hypothermia B. Pneumonia C. Bradycardia D. Leukemia E. Thrombocytopenia F. Pancreatitis

C D E The rectal site should not be used in newborns, children with diarrhea, and in patients who have undergone rectal or vaginal surgery. Inserting a rectal thermometer can stimulate the vagus nerve causing or worsening bradycardia; this route may be contraindicated in certain cardiac patients. The rectal route is also contraindicated in patients who have neutropenia (low white blood cell counts, such as in leukemia or those receiving chemotherapy), thrombocytopenia (low platelet counts), and certain neurologic disorders.

While taking an adult patient's pulse, a nurse obtains a heart rate of 140 beats/min. What should the nurse do next? A. Reassess the pulse in 1 hour B. Measure the blood pressure C. Document the information, noting tachycardia D. Report the rate to the health care provider

D A pulse rate of 140 beats/min in an adult, tachycardia, is abnormally fast, and should be reported to the primary nurse or health care provider immediately. Tachycardia at rest often reflects an underlying issue and can lead to decreased tissue perfusion; additional assessments are needed.

A nurse receives information during shift report that a patient is afebrile. What action will the nurse take in response? A.Checking the MAR for prescribed antipyretic medication B. Reporting the finding to the primary care provider C. Taking the patient's temperature using a different method D. No action is necessary; this is a normal reading

D Afebrile means without fever, or a temperature is within the normal range. No additional actions are needed.

A nurse is performing oral care on a patient who has advanced dementia. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What action will the nurse take next? A. Recommend a consultation with an oral surgeon. B. Communicate the condition to the health care team. C. Gently scrape the oral cavity with a tongue depressor. D. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa.

D. If initial oral care results in continued dryness of the oral cavity with crusting, the nurse should increase frequency of oral hygiene, apply mouth moisturizer to oral mucosa, and monitor fluid intake and output to ensure adequate intake of fluid. It is not necessary to report this condition prior to providing the interventions mentioned above; however, mouth care and re-evaluation of the oral cavity is documented. The crusts should not be scraped with a tongue depressor.

A nurse is caring for a patient with an eye infection with a moderate amount of discharge. What is the most appropriate technique for the nurse to use when cleansing this patient's eyes? A. Using diluted hydrogen peroxide on a clean washcloth to wipe the eyes B. Wiping the eye from the outer canthus toward the inner canthus C. Positioning the patient on the opposite side of the eye to be cleansed D. Cleansing the eye using a different section of the cloth for each stroke until clean

D. The nurse applies gloves for the cleaning procedure, uses water or normal saline, and a clean washcloth or gauze to cleanse the eyes. After dampening a cleaning cloth with the solution of choice, the nurse wipes once while moving from the inner canthus to the outer canthus of the eye to reduce forcing debris into the area drained by the nasolacrimal duct. The nurse should turn the cleansing cloth and use a different section for each stroke until the eye is clean.

A charge nurse in a skilled nursing facility is working to reduce patients' foot and nail problems. The charge nurse reminds the nurses and APs to closely observe which of these patients at higher risk? Select all that apply. A. Patient taking antibiotics for chronic bronchitis B. Patient with type 2 diabetes C. Patient who has obesity D. Patient who frequently bites their nails E. Patient with prostate cancer F. Patient who frequently washes their hands

b, c, d, f. Variables known to cause nail and foot problems include deficient self-care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity. Antibiotic use and prostate cancer do not predispose to foot or nail problems.