Found 2

The nurse is assessing the characteristics of a patient's pain. Match the characteristic to the question a nurse will ask to determine that specific characteristic. a. Could you rate your pain on a scale of 0 to 10? b. How often does it recur? c. Could you point to the area of pain? d. Do certain activities worsen the pain? e. What does the pain feel like? 1. Timing 2. Location 3. Severity 4. Quality 5. Aggravating factors

1.B 2.C 3.A 4.D 5.E

A nurse is using focused charting referred to as DAR. Match the chart entry to the correct letter of the acronym. a. Applied oxygen, stayed with patient, and instructed to slow breathing. b. Patient states, ―feel better,‖ respirations 16 with O2 saturations 96%. c. Patient states, ―can't catch my breath and chest hurts.‖ Confused. 1. D 2. A 3. R

1.C 2.A 3.B

The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its description. a. Absorbs drainage through the use of exudate absorbers in the dressing b. Very soothing to the patient and do not adhere to the wound bed c. Barrier to external fluids/bacteria but allows wound to ―breathe‖ d. Manufactured from seaweed and comes in sheet and rope form e. Oldest and most common absorbent dressing 1. Gauze 2. Transparent 3. Hydrocolloid 4. Hydrogel 5. Calcium alginate

1.E 2.C 3.A 4.B 5.D

A patient at risk for skin impairment is able to sit up in a chair. How long should the nurse schedule the patient to sit in the chair? a. 2 hours or less at any one time b. For a total of least than 3 hours daily c. No longer than 30 minutes out of every hour d. Until the patient expresses being uncomfortable

a. 2 hours or less at any one time

In which order will the nurse use the nursing process steps during the clinical decision-making process? 1. Evaluating goals 2. Assessing patient needs 3. Planning priorities of care 4. Determining nursing diagnoses 5. Implementing nursing interventions a. 2, 4, 3, 5, 1 b. 4, 3, 2, 1, 5 c. 1, 2, 4, 5, 3 d. 5, 1, 2, 3, 4

a. 2, 4, 3, 5, 1

A nurse is teaching the staff about the general adaptation syndrome. In which order will the nurse list the stages, beginning with the first stage? 1. Resistance 2. Exhaustion 3. Alarm a. 3, 1, 2 b. 3, 2, 1 c. 1, 3, 2 d. 1, 2, 3

a. 3, 1, 2

A nurse is using the research process. Place in order the sequence that the nurse will follow. 1. Analyze results. 2. Conduct the study. 3. Identify clinical problem. 4. Develop research question. 5. Determine how study will be conducted. a. 3, 4, 5, 2, 1 b. 4, 3, 5, 2, 1 c. 3, 5, 4, 2, 1 d. 4, 5, 3, 2, 1

a. 3, 4, 5, 2, 1

As prescribed, the nurse leaves the pressure ulcer open to air and does not apply a dressing. Which stage of ulcer did the nurse appropriately treat? a. A Stage I b. A Stage II c. A Stage III d. A Stage IV

a. A Stage I

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing? a. A minimum data set b. An admission assessment and acuity level c. A focused assessment/specific body system d. An intake assessment form and auditing phase

a. A minimum data set

A nurse is caring for a group of patients. Which patient will the nurse see first to best manage patient needs? a. A patient who received morphine and has a pulse of 62 beats/min, respirations 10 breaths/min, and blood pressure 110/60 mm Hg. b. A patient lying very still in bed who reports no pain but is pale with warm, dry skin. c. A patient with severe pain who is nauseated and feels like he or she is about to vomit. d. A patient writhing and moaning from abdominal pain after abdominal surgery.

a. A patient who received morphine and has a pulse of 62 beats/min, respirations 10 breaths/min, and blood pressure 110/60 mm Hg.

A nurse writes the following PICOT question: How do patients with breast cancer rate their quality of life? How should the nurse evaluate this question? a. A true PICOT question regardless of the number of elements b. A true PICOT question because the intervention comes before the control c. Not a true PICOT question because the comparison comes after the intervention d. Not a true PICOT question because the time is not designated

a. A true PICOT question regardless of the number of elements

A nurse exchanges information with the oncoming nurse about a patient's care. Which action did the nurse complete? a. A verbal report b. An electronic record entry c. A referral d. An acuity rating

a. A verbal report

The nurse is caring for a group of patients. Which task may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Administer a back massage to a patient with pain. b. Assessment of pain for a patient reporting abdominal pain. c. Administer patient-controlled analgesia for a postoperative patient. d. Assessment of vital signs in a patient receiving epidural analgesia.

a. Administer a back massage to a patient with pain.

The nurse is caring for a patient at risk for skin impairment. Which initial action should the nurse take to decrease this risk? a. After cleansing thoroughly dry the skin. b. Request a therapeutic bed and mattress. c. Pad the bed with absorbent pads. d. Use products that retain moisture

a. After cleansing thoroughly dry the skin.

A nurse has collected several research findings for evidence-based practice. Which article will be the best for the nurse to use? a. An article that uses randomized controlled trials (RCT). b. An article that is an opinion of expert committees. c. An article that uses qualitative research. d. An article that is peer-reviewed.

a. An article that uses randomized controlled trials (RCT).

The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take initially? a. Call the health care provider; a blockage is present in the tubing. b. Chart the results on the intake and output flow sheet. c. Do nothing, as long as the evacuator is compressed. d. Remove the drain; a drain is no longer needed

a. Call the health care provider; a blockage is present in the tubing.

A nurse is assessing a patient with prolonged stress. Which conditions will the nurse monitor for in this patient? (Select all that apply.) a. Cancer b. Diabetes c. Infections d. Allostasis e. Low blood pressure

a. Cancer b. Diabetes c. Infections

Which action can the nurse take legally when charting on a patient's record? a. Charts in a legible manner. b. States the patient is belligerent. c. Writes entry for another nurse. d. Uses correction fluid to correct error

a. Charts in a legible manner.

A nurse is describing the purposes of a health care record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all that apply.) a. Communication b. Legal documentation c. Reimbursement d. Nursing process e. Research f. Education

a. Communication b. Legal documentation c. Reimbursement e. Research f. Education

Upon entering the room of a patient with a healing Stage III pressure ulcer, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What action should the nurse give priority to? a. Completing a head-to-toe assessment, including current treatment, vital signs, and laboratory results b. Notifying the health care provider by utilizing Situation, Background, Assessment, and Recommendation (SBAR) c. Consulting the wound care nurse about the change in status and the potential for infection d. Conferring with the charge nurse about the change in status and the potential for infection

a. Completing a head-to-toe assessment, including current treatment, vital signs, and laboratory results

A nursing instructor needs to evaluate students' abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor's needs? a. Concept mapping b. Reflective journaling c. Lecture and discussion d. Reading assignment with a written summary

a. Concept mapping

The nurse uses a PICOT question to develop an evidence-based change in protocol for a certain nursing procedure. However, to make these changes throughout the entire institution would require more evidence than is available at this time. What is the nurse's best option? a. Conduct a pilot study to investigate findings. b. Drop the idea of making the change at this time. c. Insist that management hire the needed staff to facilitate the change. d. Seek employment in another institution that may have the staff needed.

a. Conduct a pilot study to investigate findings.

The nurse is caring for a patient who will have a large abdominal bandage secured with an abdominal binder. Which actions will the nurse take before applying the bandage and binder? (Select all that apply.) a. Cover exposed wounds. b. Mark the sites of all abrasions. c. Assess the condition of current dressings. d. Inspect the skin for abrasions and edema. e. Cleanse the area with hydrogen peroxide. f. Assess the skin at underlying areas for circulatory impairment.

a. Cover exposed wounds. c. Assess the condition of current dressings. d. Inspect the skin for abrasions and edema. f. Assess the skin at underlying areas for circulatory impairment.

Which adverse effects will the nurse expect in a teenage patient who is using topical tretinoin? (Select all that apply.) a. Crusted skin b. Itching c. Altered skin pigmentation d. Rosacea e. Red and edematous blisters

a. Crusted skin c. Altered skin pigmentation e. Red and edematous blisters

A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development? a. Decreased level of consciousness b. Adequate dietary intake c. Shortness of breath d. Muscular pain

a. Decreased level of consciousness

A patient in a motor vehicle accident states, ―I did not run the red light,‖ despite very clear evidence on the street surveillance tape. Which defense mechanism is the patient using? a. Denial b. Conversion c. Dissociation d. Compensation

a. Denial

A nurse is auditing and monitoring patients' health records. Which action is the nurse taking? a. Determining the degree to which standards of care are met by reviewing patients' health records b. Realizing that care not documented in patients' health records still qualifies as care provided c. Basing reimbursement upon the diagnosis-related groups documented in patients' records d. Comparing data in patients' records to determine whether a new treatment had better outcomes than the standard treatment

a. Determining the degree to which standards of care are met by reviewing patients' health records

A nurse uses evidence-based practice (EBP) to provide nursing care. What is the best rationale for the nurse's behavior? a. EBP is a guide for nurses in making clinical decisions. b. EBP is based on the latest textbook information. c. EBP is easily attained at the bedside. d. EBP is always right for all situations.

a. EBP is a guide for nurses in making clinical decisions.

A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. the next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? a. Explore other options for pain relief. b. Discuss the surgical procedure and reason for the pain. c. Explain to the patient that nothing else has been ordered. d. Offer to notify the health care provider after morning rounds are completed.

a. Explore other options for pain relief.

Which nursing observation will indicate the patient is at risk for pressure ulcer formation? a. Fecal incontinence b. Ate two thirds of breakfast c. A raised red rash on the right shin d. Capillary refill is less than 2 seconds

a. Fecal incontinence

A 55-year-old obese patient was diagnosed with candidiasis in the skin folds under her breasts. When the nurse sees her at a follow-up visit 2 months later, she complains that it has returned. She said she applied the medicine for 1 week and stopped because the itching stopped and the cream was messy. Which statement is true regarding fungal infections of the skin? a. Fungal infections often require prolonged therapy. b. The patient has a new infection now. c. The patient needs to apply a dressing if the cream is too messy. d. This infection will probably never be cured.

a. Fungal infections often require prolonged therapy.

A nurse is caring for a patient with chronic pain from arthritis. Which action is best for the nurse to take? a. Give pain medications around the clock. b. Administer pain medication before any activity. c. Give pain medication after the pain is a 7/10 on the pain scale. d. Administer pain medication only when nonpharmacological measures have failed.

a. Give pain medications around the clock.

Before conducting any study with human subjects, the nurse researcher must obtain informed consent. What must the nurse researcher ensure to obtain informed consent? (Select all that apply.) a. Gives complete information about the purpose. b. Allows free choice to participate or withdraw. c. Understands how confidentiality is maintained. d. Identifies risks and benefits of participation. e. Ensures that subjects complete the study.

a. Gives complete information about the purpose. b. Allows free choice to participate or withdraw. c. Understands how confidentiality is maintained. d. Identifies risks and benefits of participation.

The nurse is caring for a patient with a wound healing by full-thickness repair. Which phases will the nurse monitor for in this patient? (Select all that apply.) a. Hemostasis b. Maturation c. Inflammatory d. Proliferative e. Reproduction f. Reestablishment of epidermal layer

a. Hemostasis b. Maturation c. Inflammatory d. Proliferative

A nurse is completing an Outcome and Assessment Information Set (OASIS) data set on a patient. The nurse works in which area of patient care? a. Home health b. Intensive care unit c. Skilled nursing facility d. Long-term care facility

a. Home health

A nurse is teaching the staff about health care reimbursement. Which information should the nurse include in the teaching session? a. Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care. b. A clinical information system must be installed by 2014 to obtain health care reimbursement. c. A ―near miss‖ helps determine reimbursement issues for health care. d. HIPAA is the basis for establishing reimbursement for health care.

a. Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care.

A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step for the nurse to take? a. Inspect the wound for bleeding. b. Irrigate the wound to remove foreign bodies. c. Measure and document the size of the wound. d. Determine when the patient last had a tetanus antitoxin injection.

a. Inspect the wound for bleeding.

The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients? a. Meaning of pain b. Neurological factors c. Competency of the surgeon d. Postoperative support personnel

a. Meaning of pain

A nurse is reviewing literature for an evidence-based practice study. Which study should the nurse use for the most reliable level of evidence that uses statistics to show effectiveness? a. Meta-analysis b. Systematic review c. Single random controlled trial d. Control trial without randomization

a. Meta-analysis

A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen tablets every 6 hours to control pain. Which part of the patient's social history is the nurse most concerned about? a. Patient drinks 1 to 2 glasses of wine every night. b. Patient smokes 2 packs of cigarettes a day. c. Patient occasionally uses marijuana. d. Patient takes antianxiety medications.

a. Patient drinks 1 to 2 glasses of wine every night.

The nurse is administering ibuprofen to an older patient. Which assessment data causes the nurse to hold the medication? (Select all that apply.) a. Patient states allergy to aspirin. b. Patient states joint pain is 2/10 and intermittent. c. Patient reports past medical history of gastric ulcer. d. Patient reports last bowel movement was 4 days ago. e. Patient experiences respiratory depression after administration of an opioid medication.

a. Patient states allergy to aspirin. c. Patient reports past medical history of gastric ulcer.

A nurse is trying to decrease the rate of falls on the unit. After reviewing the literature, a strategy is implemented on the unit. After 3 months, the nurse finds that the falls have decreased. Which process did the nurse institute? a. Performance improvement b. Peer-reviewed project c. Generalizability study d. Qualitative research

a. Performance improvement

The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.) a. Place moist sterile gauze over the site. b. Gently place the organs back. c. Contact the surgical team. d. Offer a glass of water. e. Monitor for shock.

a. Place moist sterile gauze over the site. c. Contact the surgical team. e. Monitor for shock.

The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority? a. Pressure points b. Breath sounds c. Bowel sounds d. Pulse points

a. Pressure points

The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first? a. Provide analgesic medications as ordered. b. Avoid accidentally removing the drain. c. Don sterile gloves. d. Gather supplies.

a. Provide analgesic medications as ordered.

A nurse is implementing an evidence-based practice project regarding infection rates. After reviewing research literature, which other evidence should the nurse review? a. Quality improvement data b. Inductive reasoning data c. Informed consent data d. Biased data

a. Quality improvement data

The nurse is preparing to conduct research that will allow precise measurement of a phenomenon. Which methods will provide the nurse with the right kind of data? (Select all that apply.) a. Surveys b. Phenomenology c. Grounded theory d. Evaluation research e. Nonexperimental research

a. Surveys d. Evaluation research e. Nonexperimental research

Which findings will alert the nurse that stress is present when making a clinical decision? (Select all that apply.) a. Tense muscles b. Reactive responses c. Trouble concentrating d. Feeling very tired e. Managed emotions

a. Tense muscles b. Reactive responses c. Trouble concentrating d. Feeling very tired

A nurse is helping parents who have a child diagnosed with attention-deficit/hyperactivity disorder. Which strategy will the nurse share with the parents to reduce stress regarding homework assignments? a. Time-management skills b. Speech articulation skills c. Routine preventative health visits d. Assertiveness training for the family

a. Time-management skills

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient? a. Upon admission b. Right before discharge c. After the congestion is treated d. When the primary care provider writes the order

a. Upon admission

The nurse is caring for a 4-year-old child who is demonstrating signs of pain. Which technique will the nurse use to best assess pain in this child? a. Use the FACES scale. b. Check to see what previous nurses have charted. c. Ask the parents if they think their child is in pain. d. Have the child rate the level of pain on a 0 to 10 pain scale

a. Use the FACES scale.

A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement? a. Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order. b. Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, ―felt better.‖ Finally, patient had no complaints. c. Breathing without difficulty. Sitting up in bed watching TV. Had a good day. d. Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours.

a. Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order.

A trauma survivor is requesting sleep medication because of ―bad dreams.‖ The nurse is concerned that the patient may be experiencing posttraumatic stress disorder (PTSD). Which question is a priority for the nurse to ask the patient? a. ―Are you reliving your trauma?‖ b. ―Are you having chest pain?‖ c. ―Can you describe your phobias?‖ d. ―Can you tell me when you wake up?‖

a. ―Are you reliving your trauma?‖

A nurse is planning care for an older-adult patient who is experiencing pain. Which statement made by the nurse indicates the supervising nurse needs to follow up? a. ―As adults age, their ability to perceive pain decreases.‖ b. ―Older patients may have low serum albumin in their blood, causing toxic effects of analgesic drugs.‖ c. ―Patients who have dementia probably experience pain, and their pain is not always well controlled.‖ d. ―It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication.

a. ―As adults age, their ability to perceive pain decreases.‖

The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.) a. ―Can you easily change your position?‖ b. ―Do you have sensitivity to heat or cold?‖ c. ―How often do you need to use the toilet?‖ d. ―What medications do you take?‖ e. ―Is movement painful?‖ f. ―Have you ever fallen?‖

a. ―Can you easily change your position?‖ b. ―Do you have sensitivity to heat or cold?‖ c. ―How often do you need to use the toilet?‖ e. ―Is movement painful?‖

A nurse teaches the patient about the gate control theory. Which statement made by a patient reflects a correct understanding about the relationship between the gate control theory of pain and the use of meditation to relieve pain? a. ―Meditation controls pain by blocking pain impulses from coming through the gate.‖ b. ―Meditation alters the chemical composition of pain neuroregulators, which closes the gate.‖ c. ―Meditation will help me sleep through the pain because it opens the gate.‖ d. ―Meditation stops the occurrence of pain stimuli.‖

a. ―Meditation controls pain by blocking pain impulses from coming through the gate.‖

The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates effective teaching? a. ―You cannot use a pain scale to compare the pain of my patient with the pain of your patient.‖ b. ―When patients say they don't need pain medication, they aren't in pain.‖ c. ―A patient's behavior is more reliable than the patient's report of pain.‖ d. ―Pain assessment scales determine the quality of a patient's pain.‖

a. ―You cannot use a pain scale to compare the pain of my patient with the pain of your patient.‖

A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with a prescription for hydrocodone. Which important patient education should the nurse provide? a. ―You need to drink plenty of fluids and eat a diet high in fiber.‖ b. ―Narcotics can be addictive, so do not take them unless you are in severe pain.‖ c. ―Be sure to eat a meal high in fat before taking the medication, to avoid a stomach ulcer.‖ d. ―As your pain severity lessens, you will begin to give yourself once-daily intramuscular injections.‖

a. ―You need to drink plenty of fluids and eat a diet high in fiber.‖

A female patient will be starting therapy with oral isotretinoin as part of treatment for severe acne, and the nurse is providing teaching. Which teaching point will the nurse include in her teaching plan about isotretinoin? a. ―You will have to use two contraceptive methods while on this drug.‖ b. ―You must avoid sexual activity while on this drug.‖ c. ―You will have to avoid pregnancy for 2 weeks after taking this drug.‖ d. ―If you are taking an oral contraceptive, you may take this drug.‖

a. ―You will have to use two contraceptive methods while on this drug.‖

The nurse performing a moist-to-dry dressing has prepared the supplies, solution, and removed the old dressing. In which order will the nurse implement the following steps, starting with the first one? 1. Apply sterile gloves. 2. Cover and secure topper dressing. 3. Assess wound and surrounding skin. 4. Moisten gauze with prescribed solution. 5. Gently wring out excess solution and unfold. 6. Loosely pack until all wound surfaces are in contact with gauze. a. 4, 3, 1, 5, 6, 2 b. 1, 3, 4, 5, 6, 2 c. 4, 1, 3, 5, 6, 2 d. 1, 4, 3, 5, 6, 2

b. 1, 3, 4, 5, 6, 2

While caring for a hospitalized older-adult female post hip surgery, the nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. Which action should the nurse take? a. Postpone catheter insertion until the next shift. b. Adapt the positioning technique to the situation. c. Notify the health care provider for a urologist consult. d. Follow textbook procedure with contraindicated position.

b. Adapt the positioning technique to the situation.

A 57-year-old woman being treated for end-stage breast cancer has been using a transdermal opioid analgesic as part of the management of pain. Lately, she has been experiencing breakthrough pain. The nurse expects this type of pain to be managed by which of these interventions? a. Administering NSAIDs b. Administering an immediate-release opioid c. Changing the opioid route to the rectal route d. Making no changes to the current therapy

b. Administering an immediate-release opioid

The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient? a. Low-air-loss b. Air-fluidized c. Lateral rotation d. Standard mattress

b. Air-fluidized

The nurse is caring for a patient and is focusing on modifiable factors that contribute to pain. Which areas does the nurse focus on with this patient? a. Age and gender b. Anxiety and fear c. Culture and ethnicity d. Previous pain experiences and cognitive abilities

b. Anxiety and fear

When caring for a group of patients, which task can the nurse delegate to the nursing assistive personnel (AP)? a. Assessing a surgical patient for risk of pressure ulcers b. Applying a gauze bandage to secure a nonsterile dressing c. Treating a pressure ulcer on the buttocks of a medical patient d. Implementing negative pressure wound therapy on a stable patient

b. Applying a gauze bandage to secure a nonsterile dressing

A patient has recently had surgery. Which action is best for the nurse to take to assess this patient's pain? a. Assess the patient's body language. b. Ask the patient to rate the level of pain. c. Observe the cardiac monitor for increased heart rate. d. Have the patient describe the effect of pain on the ability to cope.

b. Ask the patient to rate the level of pain.

A nurse is pulled from the surgical unit to work on the oncology unit. Which action by the nurse displays humility and responsibility? a. Refusing the assignment b. Asking for an orientation to the unit c. Admitting lack of knowledge and going home d. Assuming that patient care will be the same as on the other units

b. Asking for an orientation to the unit

Which action by a novice nurse will cause the preceptor to provide follow up instructions? a. Documents descriptively. b. Charts consecutively on every other line. c. Ends each entry with signature and title. d. Uses quotations to note patients' exact words.

b. Charts consecutively on every other line.

A patient was diagnosed with pancreatic cancer last month, and has complained of a dull ache in the abdomen for the past 4 months. This pain has been gradually increasing, and the pain relievers taken at home are no longer effective. What type of pain is the patient experiencing? a. Acute pain b. Chronic pain c. Somatic pain d. Neuropathic pain

b. Chronic pain

A patient is being discharged home. Which information should the nurse include? a. Acuity level b. Community resources c. Standardized care plan d. Signature for verbal order

b. Community resources

The nurse researcher is preparing to publish the findings and is preparing to add the limitations to the manuscript. Which area of the manuscript will the nurse researcher add this information? a. Abstract b. Conclusion c. Study design d. Clinical implications

b. Conclusion

In conducting a research study, the nurse researcher guarantees the subject no information will be reported in any manner that will identify the subject and only the research team will have access to the information. Which concept is the nurse researcher fulfilling? a. Bias b. Confidentiality c. Informed consent d. The research process

b. Confidentiality

The opioid Vicodin (acetaminophen/hydrocodone) is prescribed for a patient who has had surgery. The nurse informs the patient that which common adverse effects can occur with this medication? (Select all that apply.) a. Diarrhea b. Constipation c. Lightheadedness d. Nervousness e. Urinary retention f. Itching

b. Constipation c. Lightheadedness e. Urinary retention f. Itching

A patient is having difficulty reaching the water fountain while holding on to crutches. the nurse suggests that the patient place the crutches against the wall while stabilizing him or herself with two hands on the water fountain. Which critical thinking attitude did the nurse use in this situation? a. Humility b. Creativity c. Risk taking d. Confidence

b. Creativity

A nurse has instructed the patient regarding the proper use of crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the ―I‖ in PIE charting? a. Patient went up and down stairs b. Demonstrated use of crutches c. Used crutches with no difficulties d. Deficient knowledge related to never using crutches

b. Demonstrated use of crutches

A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse access? a. Electronic medical record b. Electronic health record c. Electronic charting record d. Electronic problem record

b. Electronic health record

The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient? a. Partial thickness wound repair b. Full thickness wound repair c. Primary intention d. Tertiary intention

b. Full thickness wound repair

The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.) a. Vision b. Hyperemia c. Induration d. Blanching e. Temperature of skin

b. Hyperemia c. Induration d. Blanching e. Temperature of skin

The nurse documents the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient? a. Imbalanced nutrition: less than body requirements b. Impaired peripheral tissue perfusion c. Risk for infection d. Acute pain

b. Impaired peripheral tissue perfusion

A nurse is developing a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.) a. Bypass the firewall. b. Implement an automatic sign-off. c. Create a password with just letters. d. Use a programmed speed-dial key when faxing. e. Impose disciplinary actions for inappropriate access. f. Shred papers containing personal health information (PHI).

b. Implement an automatic sign-off. d. Use a programmed speed-dial key when faxing. e. Impose disciplinary actions for inappropriate access. f. Shred papers containing personal health information (PHI).

The nurse is caring for an infant in the intensive care unit. Which information should the nurse consider when planning care for this patient? a. Infants cannot be assessed for pain. b. Infants respond behaviorally and physiologically to painful stimuli. c. Infants cannot tolerate analgesics owing to an underdeveloped metabolism. d. Infants have a decreased sensitivity to pain when compared with older children.

b. Infants respond behaviorally and physiologically to painful stimuli.

The nurse is reviewing a research article on a patient care topic. Which area should entice the nurse to read the article? a. Literature review b. Introduction c. Methods d. Results

b. Introduction

The nurse caring for a patient with a healing Stage III pressure ulcer notes that the wound is clean and granulating. Which health care provider's order will the nurse question? a. Use a low-air-loss therapy unit. b. Irrigate with Dakin's solution. c. Apply a hydrogel dressing. d. Consult a dietitian.

b. Irrigate with Dakin's solution.

A patient is receiving opioid medication through an epidural infusion. Which action will the nurse take to protect the patient's safety? a. Restrict fluid intake. b. Label the tubing that leads to the epidural catheter. c. Apply a gauze dressing to the epidural catheter insertion site. d. Ask the nursing assistive personnel to check on the patient at least once every 2 hours

b. Label the tubing that leads to the epidural catheter.

The nurse is reviewing herbal therapies. Which is a common use of the herb feverfew? a. Muscle aches b. Menstrual cramps c. Joint pain d. Incision pain after surgery

b. Menstrual cramps

The nurse is reviewing laboratory results for a patient and notes that the patient has positive results for nasal colonization by methicillin-resistant Staphylococcus aureus (MRSA). The nurse anticipates an order for which medication? a. Acyclovir b. Mupirocin c. Clindamycin d. Clotrimazole

b. Mupirocin

A nurse is reviewing care plans. Which finding, if identified in a plan of care, should the registered nurse revise? a. Patient's outcomes for learning b. Nurse's assumptions about hospital discharge c. Identification of several actual health problems d. Documentation of patient's ability to meet the goal

b. Nurse's assumptions about hospital discharge

The nurse is reviewing nursing research literature related to a potential practice problem on the nursing unit. What is the rationale for the nurse's action? (Select all that apply.) a. Nursing research ensures the nurse's promotion. b. Nursing research identifies new knowledge. c. Nursing research improves professional practice. d. Nursing research enhances effective use of resources. e. Nursing research leads to decreases in budget expenditures.

b. Nursing research identifies new knowledge. c. Nursing research improves professional practice. d. Nursing research enhances effective use of resources.

The patient appears anxious as the nurse is preparing to change their wound dressing. Which action should the nurse take? a. Distract the patient with the television. b. Offer to explain what they should expect. c. Suggest that the patient ―Close your eyes.‖ d. Wait until family is visiting to support the patient.

b. Offer to explain what they should expect.

A patient has been treated for lung cancer for 3 years. Over the past few months, the patient has noticed that the opioid analgesic is not helping as much as it had previously and more medication is needed for the same pain relief. The nurse is aware that this patient is experiencing which of these? a. Opioid addiction b. Opioid tolerance c. Opioid toxicity d. Opioid abstinence syndrome

b. Opioid tolerance

A patient is receiving gabapentin (Neurontin), an anticonvulsant, but has no history of seizures. The nurse expects that the patient is receiving this drug for which condition? a. Inflammation pain b. Pain associated with peripheral neuropathy c. Depression associated with chronic pain d. Prevention of seizures

b. Pain associated with peripheral neuropathy

A nurse is developing a care delivery outcomes research project. Which population will the nurse study? a. Nurses b. Patients c. Administrators d. Health care providers

b. Patients

A woman who was sexually assaulted a month ago presents to the emergency department with reports of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. Which medical problem will the nurse expect to see documented in the chart? a. General adaptation syndrome (GAS) b. Posttraumatic stress disorder (PTSD) c. Acute stress disorder d. Alarm reaction

b. Posttraumatic stress disorder (PTSD)

The nurse caring for an unconscious patient who was involved in an automobile accident 2 weeks ago will give priority to which element when planning care to decrease the development of a decubitus ulcer? a. Resistance b. Pressure c. Weight d. Stress

b. Pressure

The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse expect to be increased after collaboration with the dietitian? a. Fat b. Protein c. Vitamin E d. Carbohydrate

b. Protein

A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing? a. Muscular strength assessment b. Pulse oximetry assessment c. Sensation assessment d. Sleep assessment

b. Pulse oximetry assessment

Which action will the nurse take when taking a telephone order? a. Print out a copy of the order once entered into the electronic health record. b. Read back the order as written to the health care provider for verification. c. Ask that another registered nurse listen to the call over an extension line. d. Verify that the health care provider will write the order within 24 hours.

b. Read back the order as written to the health care provider for verification.

A nurse is discussing the advantages of a nursing clinical information system. Which advantage should the nurse describe? a. Varied clinical databases b. Reduced errors of omission c. Increased hospital costs d. More time to read charts

b. Reduced errors of omission

Which health care team member will the nurse consult when a patient has received a nursing diagnosis of Impaired skin integrity? a. Respiratory therapist b. Registered dietitian c. Case manager d. Chaplain

b. Registered dietitian

The nurse caring for a patient in the burn unit should expect what type of wound healing when planning care for this patient? a. Partial-thickness repair b. Secondary intention c. Tertiary intention d. Primary intention

b. Secondary intention

After a natural disaster occurred, an emergency worker referred a family for crisis intervention services. One family member refused to attend the services, stating, ―No way, I'm not crazy.‖ What is the nurse's best response? a. Many times, disasters can create mental health problems, so you really should participate with your family.‖ b. Seeking this kind of help does not mean that you have a mental illness; it is a short-term problem-solving technique.‖ c. Don't worry now. The psychiatrists are well trained to help.‖ d. This will help your family communicate better.‖

b. Seeking this kind of help does not mean that you have a mental illness; it is a short-term problem-solving technique.‖

A preadolescent patient is experiencing maturational stress. Which area will the nurse focus on when planning care? a. Identity issues b. Self-esteem issues c. Physical appearance d. Major changing life events

b. Self-esteem issues

The preoperative nurse is ready to perform a skin prep with povidone-iodine on a patient who is about to have abdominal surgery. Which allergies, if present, would be a contraindication to this prep solution? a. Peanuts b. Shellfish c. Adhesives d. Latex

b. Shellfish

The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? (Select all that apply.) a. The patient's expectations are not being met. b. Skin is intact with no redness or swelling. c. Non-blanchable erythema is absent. d. No injuries to the skin and tissues are evident. e. Granulation tissue is present.

b. Skin is intact with no redness or swelling. c. Non-blanchable erythema is absent. d. No injuries to the skin and tissues are evident. e. Granulation tissue is present.

A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. Which nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider? a. Reassures the patient that the provider will come to the emergency department soon. b. Softly plays music that the patient finds relaxing. c. Frequently reassesses the patient's pain scores. d. Teaches the patient how to do yoga.

b. Softly plays music that the patient finds relaxing.

A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. The patient describes the pain as throbbing. Which type of pain does the nurse document in this patient's medical record? a. Visceral pain b. Somatic pain c. Centrally generated pain d. Peripherally generated pain

b. Somatic pain

The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV

b. Stage II

Despite working in a highly stressful nursing unit and accepting additional shifts, a new nurse has a strategy to prevent burnout. Which strategy will be best for the nurse to use? a. Delegate complex nursing tasks to nursing assistive personnel. b. Strengthen friendships outside the workplace. c. Write for 10 minutes in a journal every day. d. Use progressive muscle relaxation.

b. Strengthen friendships outside the workplace.

Which action indicates a registered nurse is being responsible for making clinical decisions? a. Applies clear textbook solutions to patients' problems. b. Takes immediate action when a patient's condition worsens. c. Uses only traditional methods of providing care to patients. d. Formulates standardized care plans solely for groups of patients.

b. Takes immediate action when a patient's condition worsens.

The nurse is reviewing the medical record of a patient who is to receive wound care with topical silver sulfadiazine. Which finding, if noted, would be a potential contraindication? a. The patient has an open wound from a burn on her arm. b. The patient is allergic to sulfonamide drugs. c. The patient is allergic to shellfish. d. The patient's burn wound has been débrided.

b. The patient is allergic to sulfonamide drugs.

The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse's assessment? a. The patient needed a substantial dose of naloxone. b. The patient needs increasingly higher doses of opioid to control pain. c. The patient no longer experiences sedation from the usual dose of opioid. d. The patient asks for pain medication close to the time it is due around the clock.

b. The patient needs increasingly higher doses of opioid to control pain.

A patient injured in a motor vehicle crash 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). Which assessment finding indicates effective pain management with the PCA? a. The patient is sleeping and is difficult to arouse. b. The patient rates pain at a level of 2 on a 0 to 10 scale. c. The patient has sufficient medication left in the PCA syringe. d. The patient presses the control button to deliver pain medication

b. The patient rates pain at a level of 2 on a 0 to 10 scale.

A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient's behavior? a. The surgery successfully cured the patient's pain. b. The patient's culture is possibly influencing the patient's experience of pain. c. The primary health care provider did not prescribe the correct amount of medication. d. The nurse is allowing personal beliefs about pain to influence pain management at this time

b. The patient's culture is possibly influencing the patient's experience of pain.

A patient had abdominal surgery this morning. The patient is groggy but complaining of severe pain around the incision. What is the most important assessment data to consider before the nurse administers a dose of morphine sulfate to the patient? a. The patient's pulse rate b. The patient's respiratory rate c. The appearance of the incision d. The date of the patient's last bowel movement

b. The patient's respiratory rate

The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. Which is the best method for repositioning the patient? a. Place the patient in a 30-degree supine position. b. Utilize a transfer device to lift the patient. c. Elevate the head of the bed 45 degrees. d. Slide the patient into the new position.

b. Utilize a transfer device to lift the patient.

A patient is considering taking oral aloe supplements and asks the nurse about potential problems with this therapy. Which statement by the nurse is correct? a. ―Aloe is not taken orally; it is only used topically to aid in wound healing.‖ b. ―Aloe is used by some to treat constipation; it may cause diarrhea.‖ c. ―This is a safe herbal supplement, with no known drug interactions.‖ d. ―This is a safe herbal supplement, with no known adverse effects.‖

b. ―Aloe is used by some to treat constipation; it may cause diarrhea.‖

A senior college student visits the college health clinic about a freshman student living on the same dormitory floor. The senior student reports that the freshman is crying and is not adjusting to college life. The clinic nurse recognizes this as a combination of situational and maturational stress factors. Which is the best response by the nurse? a. ―Let's call 9-1-1 because this freshman student is suicidal.‖ b. ―Give the freshman student this list of university and community resources.‖ c. ―I recommend that you help the freshman student start packing bags to go home.‖ d. ―You must make an appointment for the freshman student to obtain medications.‖

b. ―Give the freshman student this list of university and community resources.‖

A nurse is teaching a patient about patient-controlled analgesia (PCA). Which statement made by the patient indicates to the nurse that teaching is effective? a. ―I will only need to be on this pain medication.‖ b. ―I feel less anxiety about the possibility of overdosing.‖ c. ―I can receive the pain medication as frequently as I need to.‖ d. ―I need the nurse to notify me when it is time for another dose.‖

b. ―I feel less anxiety about the possibility of overdosing.‖

A female patient has been taking isotretinoin for 3 months. During a follow-up appointment, which statement by the patient would be of highest concern to the nurse? a. ―I am using two forms of contraception while on this drug.‖ b. ―I have been feeling rather down and lonely lately.‖ c. ―I wish I didn't have to be on this medication.‖ d. ―It's scary to know that this drug can cause birth defects.‖

b. ―I have been feeling rather down and lonely lately.‖

A nurse is caring for a patient diagnosed with chronic pain. Which statement by the nurse indicates an understanding of pain management? a. ―This patient says the pain is a 5 but is not acting like it. I am not going to give any pain medication.‖ b. ―I need to reassess the patient's pain 1 hour after administering oral pain medication.‖ c. ―It wasn't time for the patient's medication, so when it was requested, I gave a placebo.‖ d. ―The patient is sleeping, so I pushed the PCA button.‖

b. ―I need to reassess the patient's pain 1 hour after administering oral pain medication.‖

A teenage boy is taking tretinoin for acne. Which statement will the nurse include in the teaching plan? a. ―Avoid foods that are heavy in salt and oils.‖ b. ―This drug may cause increased redness of your skin.‖ c. ―Try using an abrasive cleanser to remove old skin layers.‖ d. ―Being out in the sunlight will help your skin heal.‖

b. ―This drug may cause increased redness of your skin.‖

The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate? a. ―Have you considered working with a physical therapist?‖ b. ―What activities, if any, has your pain prevented you from doing?‖ c. ―Would you please rate your pain on a scale from 0 to 10 for me? d. ―When does your pain medication typically take effect on your pain?‖

b. ―What activities, if any, has your pain prevented you from doing?‖

A patient has a prescription for topically applied 5% fluorouracil cream as part of treatment for basal cell carcinoma on her cheek. Which instructions will the nurse provide to the patient? (Select all that apply.) a. ―You must use gloves to apply this medication.‖ b. ―You can use clean fingertips to apply the cream, but be sure to wash your hands afterward.‖ c. ―You will need to stay out of the sun during therapy with this medication.‖ d. ―Apply this medication to the affected site once a day in the evening.‖ e. ―Apply this medication to the affected site twice daily.‖ f. ―You may have swelling, scaling, burning, and tenderness in the affected area.‖

b. ―You can use clean fingertips to apply the cream, but be sure to wash your hands afterward.‖ c. ―You will need to stay out of the sun during therapy with this medication.‖ e. ―Apply this medication to the affected site twice daily.‖ f. ―You may have swelling, scaling, burning, and tenderness in the affected area.‖

A child is being treated for head lice with spinosad. Which of these statements about treatment with spinosad is true? (Select all that apply.) a. ―You will need a prescription for a second product, malathion.‖ b. ―You will also need to decontaminate clothes and personal items.‖ c. ―Be sure to use a nit comb to remove nits from the hair shafts.‖ d. ―Try combing through the hair with mineral oil to loosen the lice from the hair shafts.‖ e. ―It is not necessary to comb the nits when using spinosad.‖

b. ―You will also need to decontaminate clothes and personal items.‖ e. ―It is not necessary to comb the nits when using spinosad.‖

A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document? a. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back. b. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN, read back. c. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back. d. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN

c. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.

The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient? a. 15 b. 17 c. 20 d. 23

c. 20

The nurse is preparing pain medications. To which patient does the nurse anticipate administering an opioid fentanyl patch? a. A 15-year-old adolescent with a fractured femur b. A 30-year-old adult with cellulitis c. A 50-year-old patient with prostate cancer d. An 80-year-old patient with a broken hip

c. A 50-year-old patient with prostate cancer

The nurse is assessing a patient for contraindications to drug therapy with acetaminophen (Tylenol). Which patient should not receive acetaminophen? a. A patient with a fever of 101°F (38.3°C) b. A patient who is complaining of a mild headache c. A patient with a history of liver disease d. A patient with a history of peptic ulcer disease

c. A patient with a history of liver disease

The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with a Stage IV pressure ulcer b. A patient with a Braden Scale score of 18 c. A patient with appendicitis using a heating pad d. A patient with an incision that is approximated

c. A patient with appendicitis using a heating pad

Which action should the nurse take to best develop critical thinking skills? a. Study 3 hours more each night. b. Attend all in-service opportunities. c. Actively participate in clinical experiences. d. Interview staff nurses about their nursing experiences.

c. Actively participate in clinical experiences.

A 78-year-old patient is in the recovery room after having a lengthy surgery on his hip. As he is gradually awakening, he requests pain medication. Within 10 minutes after receiving a dose of morphine sulfate, he is very lethargic and his respirations are shallow, with a rate of 7 breaths/minute. The nurse prepares for which priority action at this time? a. Assessment of the patient's pain level b. Immediate intubation and artificial ventilation c. Administration of naloxone (Narcan) d. Close observation of signs of opioid tolerance

c. Administration of naloxone (Narcan)

A young male patient is diagnosed with testicular cancer. Which action will the nurse take first? a. Provide information to the patient. b. Allow time for the patient's friends. c. Ask about the patient's priority needs. d. Find support for the family and patient.

c. Ask about the patient's priority needs.

A nurse receives an order from a health care provider to administer hydrocodone and acetaminophen to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurse's next best action? a. Give the medication to the patient immediately because the patient is experiencing severe pain. b. Ask the health care provider for a nonsteroidal antiinflammatory drug (NSAID) order. c. Ask the health care provider to verify the dosage and frequency of the medication. d. Give the medication in addition to playing soothing music for the patient.

c. Ask the health care provider to verify the dosage and frequency of the medication.

Which patient scenario of a surgical patient in pain is most indicative of critical thinking? a. Administering pain-relief medication according to what was given last shift b. Offering pain-relief medication based on the health care provider's orders c. Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past d. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed

c. Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past

Which intervention should be included as the nurse cleanses a wound? a. Allow the solution to flow from the most contaminated to the least contaminated. b. Scrub vigorously when applying noncytotoxic solution to the skin. c. Cleanse in a direction from the least contaminated area. d. Utilize clean gauze and clean gloves to cleanse a site.

c. Cleanse in a direction from the least contaminated area.

Which action should the nurse take when using critical thinking to make clinical decisions? a. Makes decisions based on intuition. b. Accepts one established way to provide care. c. Considers what is important in any given situation. d. Reads and follows the heath care provider's orders.

c. Considers what is important in any given situation.

A patient is suffering from tendonitis of the knee. The nurse is reviewing the patient's medication administration record and recognizes that which adjuvant medication is most appropriate for this type of pain? a. Antidepressant b. Anticonvulsant c. Corticosteroid d. Local anesthesia

c. Corticosteroid

A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using? a. Clinical decision support system b. Nursing process design c. Critical pathway design d. Computerized provider order entry system

c. Critical pathway design

The nurse caring for an immobile patient wants to decrease the risk of the formation of pressure ulcers. Which action will the nurse take first? a. Offer favorite fluids. b. Turn the patient every 2 hours. c. Determine the patient's risk factors. d. Encourage increased quantities of carbohydrates and fats.

c. Determine the patient's risk factors.

A patient is to receive acetylcysteine as part of the treatment for an acetaminophen overdose. Which action by the nurse is appropriate when giving this medication? a. Giving the medication undiluted for full effect b. Avoiding the use of a straw when giving this medication c. Disguising the flavor with soda or flavored water d. Preparing to give this medication via a nebulizer

c. Disguising the flavor with soda or flavored water

A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do? a. Add this data to the problem list. b. Focus chart using the DAR format. c. Document the variance in the patient's record. d. Report a positive variance in the next interdisciplinary team meeting.

c. Document the variance in the patient's record.

In caring for patients, what must the nurse remember about evidence-based practice (EBP)? a. EBP is the only valid source of knowledge that should be used. b. EBP is secondary to traditional or convenient care knowledge. c. EBP is dependent on patient values and expectations. d. EBP is not shown to provide better patient outcomes.

c. EBP is dependent on patient values and expectations.

The nurse is caring for a patient who is experiencing a full thickness wound repair. Which type of tissue will the nurse expect to observe when the wound is healing? a. Eschar b. Slough c. Granulation d. Purulent drainage

c. Granulation

The wound care nurse is monitoring a patient with a Stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this ulcer in the patient's medical record? a. Stage I pressure ulcer b. Healing Stage II pressure ulcer c. Healing Stage III pressure ulcer d. Stage III pressure ulcer

c. Healing Stage III pressure ulcer

A 38-year-old man has come into the urgent care center with severe hip pain after falling from a ladder at work. He says he has taken several pain pills over the past few hours but cannot remember how many he has taken. He hands the nurse an empty bottle of acetaminophen (Tylenol). The nurse is aware that the most serious toxic effect of acute acetaminophen overdose is which condition? a. Tachycardia b. Central nervous system depression c. Hepatic necrosis d. Nephropathy

c. Hepatic necrosis

A patient will be discharged with a 1-week supply of an opioid analgesic for pain management after abdominal surgery. The nurse will include which information in the teaching plan? a. How to prevent dehydration due to diarrhea b. The importance of taking the drug only when the pain becomes severe c. How to prevent constipation d. The importance of taking the drug on an empty stomach

c. How to prevent constipation

A nurse is teaching the staff about informatics. Which information from the staff indicates the nurse needs to follow up? a. To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice. b. A nurse needs to know how to find, evaluate, and use information effectively. c. If a nurse has computer competency, the nurse is competent in informatics. d. Nursing informatics is a recognized specialty area of nursing practice.

c. If a nurse has computer competency, the nurse is competent in informatics.

The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis should the nurse add to the care plan? a. Readiness for enhanced nutrition b. Impaired physical mobility c. Impaired skin integrity d. Chronic pain

c. Impaired skin integrity

Which action demonstrates a nurse utilizing reflection to improve clinical decision making? a. Obtains data in an orderly fashion. b. Uses an objective approach in patient situations. c. Improves a plan of care while thinking back on interventions effectiveness. d. Provides evidence-based explanations and research for care of assigned patients.

c. Improves a plan of care while thinking back on interventions effectiveness.

The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. the nurse then auscultates an apical pulse and asks the patient whether there is any history of heart problems. the nurse is utilizing which critical thinking skill? a. Evaluation b. Explanation c. Interpretation d. Self-regulation

c. Interpretation

A nurse has provided care to a patient. Which entry should the nurse document in the patient's record? a. Status unchanged, doing well. b. Patient seems to be in pain and states, ―I feel uncomfortable.‖ c. Left knee incision 1 inch in length without redness, drainage, or edema. d. Patient is hard to care for and refuses all treatments and medications. Family is present.

c. Left knee incision 1 inch in length without redness, drainage, or edema.

In a natural disaster relief facility, the nurse observes that an older-adult male has a recovery plan, while a 25-year-old male is still overwhelmed by the disaster situation. A nurse is planning care for both patients. Which factors will the nurse consider about the different coping reactions? a. Restorative care factors b. Strong financial resource factors c. Maturational and situational factors d. Immaturity and intelligence factors

c. Maturational and situational factors

A nurse developed the following discharge summary sheet. Which critical information should the nurse add? TOPIC DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge a. Clinical decision support system b. Admission nursing history c. Mode of transportation d. SOAP notes

c. Mode of transportation

A nurse is teaching the staff about a nursing theory that views a person, family, or community developing a normal line of defense. Which theory is the nurse describing? a. Ego defense model b. Immunity model c. Neuman Systems Model d. Pender's Health Promotion Model

c. Neuman Systems Model

An adult male reports new-onset, seizure-like activity. An EEG and a neurology consultant's report rule out a seizure disorder. It is determined the patient is using conversion. Which action should the nurse take next? a. Suggest acupuncture. b. Confront the patient on malingering. c. Obtain history of any recent life stressors. d. Recommend a regular exercise program

c. Obtain history of any recent life stressors.

Which laboratory data will be important for the nurse to monitor when a patient develops a pressure ulcer? a. Vitamin E b. Potassium c. Prealbumin d. Sodium

c. Prealbumin

Which sociocultural finding in the history of a patient will alert the nurse to a possible developmental problem? a. Family relocation b. Childhood obesity c. Prolonged poverty d. Loss of stamina

c. Prolonged poverty

The nurse is trying to identify common general themes relative to the effectiveness of cardiac rehabilitation from patients who have had heart attacks and have gone through cardiac rehabilitation programs. The nurse conducts interviews and focus groups. Which type of research is the nurse conducting? a. Nonexperimental research b. Experimental research c. Qualitative research d. Evaluation research

c. Qualitative research

Which finding will alert the nurse to a potential wound dehiscence? a. Protrusion of visceral organs through a wound opening b. Chronic drainage of fluid through the incision site c. Report by patient that something has given way d. Drainage that is odorous and purulent

c. Report by patient that something has given way

The nurse is assessing a patient who has been admitted to the emergency department for a possible opioid overdose. Which assessment finding is characteristic of an opioid drug overdose? a. Dilated pupils b. Restlessness c. Respiration rate of 6 breaths/min d. Heart rate of 55 beats/min

c. Respiration rate of 6 breaths/min

A nurse is using thecritical thinking skill of evaluation. Which action will thenurse take? a. Examine themeaning of data. b. Support findings and conclusions. c. Review theeffectiveness of nursing actions. d. Search for links between thedata and thenurse's assumptions.

c. Review theeffectiveness of nursing actions.

A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene? a. Reading the patient's plan of care b. Reviewing the patient's medical record c. Sharing patient information with another student d. Documenting medication administered to the patient

c. Sharing patient information with another student

The nurse notes that a patient has a black pressure ulcer on the left hip. Which event will the nurse anticipate when planning care for this patient? a. Increased monitoring of the wound condition b. Documenting the wound's status daily c. Surgical debridement of the wound d. Increased drainage from wound

c. Surgical debridement of the wound

The nurse teaches stress-reduction and relaxation training to a health education group of patients after cardiac bypass surgery. Which level of intervention is the nurse using? a. Primary b. Secondary c. Tertiary d. Quad

c. Tertiary

A nurse is charting. Which event is critical for the nurse to document? a. The patient had a good day with no complaints. b. The family is demanding and argumentative. c. The patient received a pain medication. d. The family is poor and had to go on welfare.

c. The patient received a pain medication.

The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which finding best indicates the effectiveness of guided imagery? a. The patient's facial expressions are stoic during the procedure. b. The patient rates pain during the dressing change as a 6 on a scale of 0 to 10. c. The patient's need for analgesic medication decreases during the dressing changes. d. The patient asks for pain medication during the dressing changes only once throughout the procedure.

c. The patient's need for analgesic medication decreases during the dressing changes.

A nurse is planning care for a patient that uses displacement as a defense mechanism. Which information should the nurse consider when planning interventions? a. This copes with stress directly. b. This evaluates an event for its personal meaning. c. This protects against feelings of worthlessness and anxiety. d. This triggers the stress control functions of the medulla oblongata.

c. This protects against feelings of worthlessness and anxiety.

A nurse wants to change a patient procedure. Which action will the nurse take to easily find research evidence to support this change? a. Read all the articles found on the Internet. b. Make a general search of the Internet. c. Use a PICOT format for the search. d. Start with a broad question.

c. Use a PICOT format for the search.

A nurse develops the following PICOT question: Do patients who listen to music achieve better control of their anxiety and pain after surgery when compared with patients who receive standard nursing care following surgery? Which information will the nurse use as the ―C‖? a. After surgery. b. Who listen to music? c. Who receive standard nursing care? d. Achieve better control of their anxiety and pain.

c. Who receive standard nursing care?

The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous with a drain is currently in place. Which statement by the patient indicates issues with self-concept? a. ―I am so weak and tired. I just want to feel better.‖ b. ―I been thinking I will be ready to go home early next week.‖ c. ―I really need a bath and linen change right; I feel so awful.‖ d. ―I am hoping there will be something good to eat for my dinner tonight.‖

c. ―I really need a bath and linen change right; I feel so awful.‖

A nurse is caring for a patient who is experiencing pain following abdominal surgery. Which information is important for the nurse to share with the patient when providing patient education about effective pain management? a. ―To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain.‖ b. ―You should take your medication after you walk to make sure you do not fall while you are walking.‖ c. ―We should work together to create a schedule to provide regular dosing of medication.‖ d. ―When you experience severe pain, you will need to take oral pain medications.‖

c. ―We should work together to create a schedule to provide regular dosing of medication.‖

A nurse is caring for a patient who recently had abdominal surgery and is experiencing severe pain. The patient's blood pressure is 110/60 mm Hg, and heart rate is 60 beats/min. Additionally, the patient does not appear to be in any physical distress. Which response by the nurse is most therapeutic? a. ―Your vitals do not show that you are having pain; can you describe your pain?‖ b. ―OK, I will go get you some narcotic pain relievers immediately.‖ c. ―What would you like to try to alleviate your pain?‖ d. ―You do not look like you are in pain.‖

c. ―What would you like to try to alleviate your pain?‖

The nurse has brought a patient the scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic? a. ―This medication will still be providing you relief at the time of your dressing change.‖ b. ―OK, swallow this pain pill, and I will return in a minute to change your dressing.‖ c. ―Would you like medication to be given for dressing changes in addition to your regularly scheduled medication?‖ d. ―Your medication is scheduled for this time, and I can't adjust the time for you. I'm sorry, but you must take your pill right now.‖

c. ―Would you like medication to be given for dressing changes in addition to your regularly scheduled medication?‖

Which entry will require follow-up by the nurse manager? 0800 Patient states, ―Fell out of bed.‖ Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, ―Did not pass out.‖ Assisted back to bed. Nurse call system within reach. Bed monitor on. —Jane More, RN 0810 Notified primary care provider of patient's status. New orders received. —Jane More, RN 0815 Portable x-ray of L hip taken in room. States, ―I feel fine.‖ —Jane More, RN 0830 Incident report completed and placed on chart. —Jane More, RN a. 0800 b. 0810 c. 0815 d. 0830

d. 0830

The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed? a. 12 b. 13 c. 20 d. 23

d. 23

The nurse is caring for a patient with chronic low back pain. The nurse wants to determine the best evidence-based practice regarding clinical guidelines for low back pain. What is the best database for the nurse to access? a. MEDLINE b. EMBASE c. PsycINFO d. Agency for Healthcare Research and Quality (AHRQ)

d. Agency for Healthcare Research and Quality (AHRQ)

A nurse is reviewing research studies for evidence-based practice. Which article should the nurse use for qualitative nursing research? a. An article about the number of falls after use of no side rails b. An article about infection rates after use of a new wound dressing c. An article about the percentage of new admissions on a new floor d. An article about emotional needs of dying patients and their families

d. An article about emotional needs of dying patients and their families

The nurse is caring for a postoperative patient recovering from a medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management? a. Monitor vital signs every 15 minutes. b. Check pulses in the right foot. c. Keep the leg dependent. d. Apply ice.

d. Apply ice.

A woman suffered a second-degree burn of the skin on her arm and hand while cooking breakfast. After examination in the urgent care center, silver sulfadiazine cream is ordered for the burned area. The nurse will apply the medication using which procedure? a. Gently patting a moderate amount over the burned area b. Massaging the cream completely into the wound c. Applying a thick layer over the burned area, and then leaving the area open d. Applying a thin layer with a sterile, gloved hand to clean and débrided areas

d. Applying a thin layer with a sterile, gloved hand to clean and débrided areas

The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority? a. Call the rapid response team. b. Start an intravenous (IV) line. c. Administer pain-relief medications. d. Ask the patient to rate and describe the pain.

d. Ask the patient to rate and describe the pain.

The nurse enters a room to find the patient sitting up in bed crying. How will the nurse display a critical thinking attitude in this situation? a. Provide privacy and check on the patient 30 minutes later. b. Set a box of tissues at the patient's bedside before leaving the room. c. Limit visitors while the patient is upset. d. Ask the patient what triggered the crying.

d. Ask the patient what triggered the crying.

A female teen diagnosed with celiac disease continues to eat food she knows will make her ill several hours after ingestion. While planning care, the nurse considers maturational and tertiary-level interventions. Which intervention will the nurse add to the care plan? a. Teach the teen about the food pyramid. b. Administer antidiarrheal medications with meals. c. Gently admonish the teen and her parents regarding the consistently poor diet choices. d. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends.

d. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends.

A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take? a. Use the same password all the time. b. Share password with only one other staff member. c. Print out and review computer nursing notes at home. d. Chart on the computer immediately after care is provided.

d. Chart on the computer immediately after care is provided.

A patient is admitted to the hospital for possible septicemia. He has a large pressure ulcer on his heel that is open and includes necrotic tissue. However, his prothrombin time/international normalized ratio (PT/INR) values are too high to permit surgical débridement at this time. The nurse expects that which wound-care product will be used to treat the wound? a. Cadexomer iodine b. Biafine topical emulsion c. Povidone-iodine d. Collagenase

d. Collagenase

After reviewing the literature, the evidence-based practice committee institutes a practice change that bedrails should be left in the down position and hourly nursing rounds should be conducted. The results indicate over a 40% reduction in falls. What is the committee's next step? a. Evaluate the changes in 1 month. b. Implement the changes as a pilot study. c. Wait a month before implementing the changes. d. Communicate to staff the results of this project.

d. Communicate to staff the results of this project.

A nurse identifies a clinical problem with pressure injuries. Which step should the nurse take next in the research process? a. Analyze results. b. Conduct the study. c. Determine method. d. Develop a hypothesis.

d. Develop a hypothesis.

An adult who was in a motor vehicle accident is brought into the emergency department by paramedics, who report the following in-transit vital signs: Oral temperature: 99.0F Pulse: 102 beats/min Respiratory rate: 26 breaths/min Blood pressure: 140/106 Which hormones should the nurse consider as the most likely causes of the abnormal vital signs? a. ADH and ACTH b. ACTH and epinephrine c. ADH and norepinephrine d. Epinephrine and norepinephrine

d. Epinephrine and norepinephrine

Which behaviors indicate the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.) a. Writes the patient's room number and date of birth on a paper for school. b. Prints/copies material from the patient's health record for a graded care plan. c. Reviews assigned patient's record and another unassigned patient's record. d. Gives a change-of-shift report to the oncoming nurse about the patient. e. Reads the progress notes of assigned patient's record. f. Discusses patient care with the hospital volunteer.

d. Gives a change-of-shift report to the oncoming nurse about the patient. e. Reads the progress notes of assigned patient's record.

A nurse wants to find the daily weights of a hospitalized patient. Which resource will the nurse consult? a. Database b. Progress notes c. Patient care summary d. Graphic record and flow sheet

d. Graphic record and flow sheet

A nurse is providing medication education to a patient who just started been prescribed ibuprofen. Which information will the nurse include in the teaching session? a. Ibuprofen helps to depress the central nervous system to decrease pain perception. b. Ibuprofen reduces anxiety, which will help you cope with your pain. c. Ibuprofen binds with opiate receptors to reduce your pain. d. Ibuprofen inhibits the development of inflammation.

d. Ibuprofen inhibits the development of inflammation.

A nurse who is caring for a patient with a pressure ulcer applies there commended dressing according to hospital policy. Which standard is the nurse following? a. Fairness b. Intellectual standards c. Independent reasoning d. Institutional practice guidelines

d. Institutional practice guidelines

Which is the best explanation for the nurse to provide when teaching the patient, the reason for the binder after an open abdominal aortic aneurysm repair? a. It reduces edema at the surgical site. b. It secures the dressing in place. c. It immobilizes the abdomen. d. It supports the abdomen.

d. It supports the abdomen.

A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene? a. Making an ethical clinical decision b. Making an informed clinical decision c. Making a clinical decision in the patient's best interest d. Making a clinical decision based on previous shift assessments

d. Making a clinical decision based on previous shift assessments

A child has been diagnosed with impetigo, a skin infection. The nurse anticipates that which drug will be used to treat this condition? a. Spinosad b. Nystatin c. Acyclovir d. Mupirocin

d. Mupirocin

Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly pigmented skin patient? a. Disposable measuring tape b. Cotton-tipped applicator c. Sterile gloves d. Natural light

d. Natural light

A 16-year-old field hockey player fell and twisted her ankle during a game. The nurse will expect to administer which type of analgesic? a. Synthetic opioid, such as meperidine b. Opium alkaloid, such as morphine sulfate c. Opioid antagonist, such as naloxone HCL d. Nonopioid analgesics, such as indomethacin

d. Nonopioid analgesics, such as indomethacin

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan? a. Partial-thickness repair b. Secondary intention c. Tertiary intention d. Primary intention

d. Primary intention

The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility? a. Explain the risks of immobility to the patient. b. Turn the patient every 3 hours while in bed. c. Encourage the patient to sit up in the chair. d. Provide analgesic medication as ordered.

d. Provide analgesic medication as ordered.

A nurse is caring for a patient experiencing stress and is in the evaluation stage of the critical thinking model. Which actions will the nurse take? a. Select nursing interventions and promote patient's adaptation to stress. b. Establish short- and long-term goals with the patient experiencing stress. c. Identify stress management interventions and achieve expected outcomes. d. Reassess patient's stress-related symptoms and compare with expected outcomes.

d. Reassess patient's stress-related symptoms and compare with expected outcomes.

A woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? a. Transcutaneous electrical nerve stimulation (TENS) b. Herbal supplements with analgesic effects c. Pudendal block (regional anesthesia) d. Relaxation and guided imagery

d. Relaxation and guided imagery

A nurse is preparing to document a patient who has reported chest pain. Which information provided by the patient is critical for the nurse to include? a. ―My family doesn't believe I'm in pain.‖ b. Pupils equal and reactive to light. c. Had poor results from the pain medication. d. Reports sharp pain of 8 on a scale of 1 to 10.

d. Reports sharp pain of 8 on a scale of 1 to 10.

A home health nurse is preparing for an initial home visit. Which information should be included in the patient's home care medical record? a. Nursing process form b. Step-by-step skills manual c. A list of possible procedures d. Reports to third-party payers

d. Reports to third-party payers

Which nursing observation will indicate the patient's wound healed by the process of secondary intention? a. Minimal loss of tissue function b. Permanent dark redness at site c. Minimal scar tissue d. Scarring that may be severe

d. Scarring that may be severe

After providing care, a nurse charts in the patient's record. Which entry will the nurse document? a. Appears restless when sitting in the chair. b. Drank adequate amounts of water. c. Apparently is asleep with eyes closed. d. Skin pale and cool.

d. Skin pale and cool.

A nurse is using a critical thinking model to provide care. Which component is first implemented when helping a nurse make clinical decisions? a. Attitude b. Experience c. Nursing process d. Specific knowledge base

d. Specific knowledge base

A patient asks about using minoxidil for hair thinning. Which statement about minoxidil is accurate? a. The product is applied once daily in the morning. b. Systemic absorption of topically applied minoxidil is rare. c. Results may be seen as soon as 2 weeks after beginning therapy. d. Systemic absorption may cause tachycardia, fluid retention, and weight gain

d. Systemic absorption may cause tachycardia, fluid retention, and weight gain

The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation related to the incision will indicate the patient is experiencing a complication of wound healing? a. Patient reporting, ―My incision is hurting.‖ b. Approximation of the incision edges has occurred. c. Patient asks, ―Why has my incision started to itch?‖ d. The incision appears both swollen and bluish in color.

d. The incision appears both swollen and bluish in color.

The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first? a. The patient who needs to be premedicated before walking. b. The patient who has a PCA running that needs the syringe replaced. c. The patient who needs to take a scheduled dose of maintenance pain medication. d. The patient who is experiencing 8/10 pain and has an immediate order for pain medication

d. The patient who is experiencing 8/10 pain and has an immediate order for pain medication

When a comatose patient develops a Stage II pressure ulcer, the nurse includes the nursing diagnosis of Risk for infection to the care plan. Which is the best goal for this patient? a. The patient will state what to look for with regard to an infection. b. The patient's family will demonstrate specific care of the wound site. c. The patient's family members will wash their hands when visiting the patient. d. The patient will remain free of odorous or purulent drainage from the wound.

d. The patient will remain free of odorous or purulent drainage from the wound.

The drug nalbuphine is an agonist-antagonist (partial agonist). The nurse understands that which is a characteristic of partial agonists? a. They have anti-inflammatory effects. b. They are given to reverse the effects of opiates. c. They have a higher potency than agonists. d. They have a lower dependency potential than agonists

d. They have a lower dependency potential than agonists

A nurse is using professional standards to influence clinical decisions. What is the rationale for the nurse's actions? a. Establishes minimal passing standards for testing. b. Utilizes evidence-based practice based on nurses' needs. c. Bypasses the patient's feelings to promote ethical standards. d. Uses critical thinking for the highest level of quality nursing care.

d. Uses critical thinking for the highest level of quality nursing care.

Which action by a nurse indicates application of thecritical thinking model to make thebest clinical decisions? a. Drawing on past clinical experiences to formulate standardized care plans b. Relying on recall of information from past lectures and textbooks c. Depending on thecharge nurse to determine priorities of care d. Using thenursing process

d. Using thenursing process

A nurse is assessing a patient who began experiencing severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, ―The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most.‖ Which type of pain does the nurse document the patient is having at this time? a. Superficial pain b. Idiopathic pain c. Chronic pain d. Visceral pain

d. Visceral pain

A nurse is teaching guided imagery to a prenatal class. Which technique did the nurse describe? a. Singing b. Massaging back c. Listening to music d. Visualizing peaceful settings

d. Visualizing peaceful settings

A patient diagnosed with type 2 diabetes 26 years ago is beginning to experience peripheral neuropathy in the feet and lower leg. The nurse is providing education to the patient to prevent injury to the feet by wearing shoes or slippers when walking. Which statement made by the nurse best explains the rationale for this instruction? a. ―Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet.‖ b. ―Shoes provide nonpharmacological pain relief to people with diabetes and peripheral neuropathy.‖ c. ―The neurological gates open when wearing shoes, which protects your feet.‖ d. ―If you step on something without shoes, you might not feel it; this could possibly cause injury to your foot.‖

d. ―If you step on something without shoes, you might not feel it; this could possibly cause injury to your foot.‖

A patient arrives at the urgent care center complaining of leg pain after a fall when rock climbing. The radiographs show no broken bones, but he has a large bruise on his thigh. The patient says he drives a truck and does not want to take anything strong because he needs to stay awake. Which statement by the nurse is most appropriate? a. ―It would be best for you not to take anything if you are planning to drive your truck.‖ b. ―We will discuss with your doctor about taking an opioid because that would work best for your pain.‖ c. ―You can take acetaminophen, also known as Tylenol, for pain, but no more than 1000 mg per day.‖ d. ―You can take acetaminophen, also known as Tylenol, for pain, but no more than 3000 mg/day

d. ―You can take acetaminophen, also known as Tylenol, for pain, but no more than 3000 mg/day