Fundamentals

You are a nurse preparing to give a subcutaneous Lovenox injection. Oliver, an 82-year-old patient with a recent history of pulmonary embolism. Oliver is 6 feet tall and weighs 235lbs. Place the steps for administering the injection in the correct order. -Hold syringe between the thumb and forefinger of dominant hand like a dart, with palm down. -Choose an injection site on the abdomen -Assit patient to lie in supine, relaxing abdomen -Cleanse site with antiseptic swab -Pinch skin with nondominant hand and insert needle quickly at 45 degree angle -While holding antiseptic swab between third and fourth finger of dominant hand, remove needle cap from syringe

1. Choose an injection site on the abdomen 2. assist patient to lie supine, relaxing abdomen 3. Cleanse site with an antiseptic swab 4. While holding antiseptic swab between third and fourth finger of dominant hand, remove needle cap from syringe 5. Hold syringe between thumb and forefinger of dominant hand like a dart, with palm down 6. Pinch skin with nondominant hand and insert needle quickly at 45 degree angle

Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. Attach drainage tubing Lubricate catheter When urine appears, advance another 2.5-5cm Inflate balloon catheter Insert and advance catheter Gently pull catheter until resistance is felt Drape patient with sterile square and fenestrated drapes Cleanse urethral meatus with an antiseptic solution Prepare sterile field and supplies

1. Prepare sterile field and supplies 2. Drape patient with a sterile square and fenestrated drape 3. Lubricate catheter 4. Cleanse urethral meatus with an antiseptic solution 5. Insert and advance catheter 6. When urine appears, advance catheter 2.5-5cm 7. Inflate catheter balloon 8. Gently pull catheter until resistance is felt 9. Attach drainage tubing

The nurse is contacting the health care provider about a patient's sleep problem. Place the steps of SBAR in the correct order. A. I'm calling to ask if you would order a hypnotic such as zolpidem to use on a PRN basis B. Mrs. Dodd 46-years-old, was admitted 3 days ago following a motor vehicle accident. She is in balanced skeletal traction for a fractured left femur. She is having difficulty falling asleep. C. Dr. Smithson, this is Pam, the nurse caring for Mrs. Dodd. I'm calling because Mrs. Dodd is having difficulty sleeping D. Mrs. Dodd is taking her pain medication every 4 hrs as ordered and rates her pain a 2 out of 10. Last night she was still awake at 0100. She states that she is comfortable but just can't fall asleep. Her vital signs are BP 124/76, P 78, R 12 and T 37.1C

4. I'm calling to ask if you would order a hypnotic such as zolpidem to use on a PRN basis 2. Mrs. Dodd 46-years-old, was admitted 3 days ago following a motor vehicle accident. She is in balanced skeletal traction for a fractured left femur. She is having difficulty falling asleep. 1. Dr. Smithson, this is Pam, the nurse caring for Mrs. Dodd. I'm calling because Mrs. Dodd is having difficulty sleeping 3. Mrs. Dodd is taking her pain medication every 4 hrs as ordered and rates her pain a 2 out of 10. Last night she was still awake at 0100. She states that she is comfortable but just can't fall asleep. Her vital signs are BP 124/76, P 78, R 12 and T 37.1C

An adult male patient with asthma is taking albuterol through a pressurized metered-dose inhaler that contains a total of 64puffs The dose is 2 puffs every 6hrs. How many day will the pMDI last? A. 8 days B. 7 days C. 9 days D. 6 days

A. 8 days

Sharon is concerned that she will not have enough time to complete her clinical assignment. What actions indicate that Sharon is using time management skills to complete her assignment? Select all that apply. A. Delegating appropriate tasks to the nursing tech B. Making a to-do list for her assignments C. Talking to a fellow student about a class that they both are taking D. Setting Priorities and determining the best time to do the tasks

A. Delegating appropriate tasks to the nursing tech B. Making a to-do list for her assignments D. Setting Priorities and determining the best time to do the tasks

When withdrawing medication from a vial it is important to remember these key points: Select all that apply. A. Draw the amount of air into the syringe that is equivalent to the volume of medication to be aspirated from the vial and carefully inject that into the vial. B. Keep the tip of the needle below the fluid level when withdrawing fluid from the vial C. Hold syringe at eye level at 90-degree angle to ensure correct volume and absence of air bubbles D. While holding the vial in your non-dominant hand, withdraw the medication into the syringe with your dominant hand

A. Draw the amount of air into the syringe that is equivalent to the volume of medication to be aspirated from the vial and carefully inject that into the vial. B. Keep the tip of the needle below the fluid level when withdrawing fluid from the vial C. Hold syringe at eye level at 90-degree angle to ensure correct volume and absence of air bubbles

Which of the following are possible outcomes with clear family communication. Select all that apply. A. Family goals B. Decision making C. Methods of discipline D. Improved education E. Impaired coping

A. Family goals B. Decision making C. Methods of discipline

After reviewing his chart and laboratory work, what fluid and electrolyte imbalances would Jamie determine? Select all that apply. A. Fluid volume deficit B. Hypokalemia C. Hypermagnesemia D. Hyperkalemia E. Hypomagnesemia

A. Fluid volume deficit B. Hypokalemia E. Hypomagnesemia

After receiving an IM injection in the deltoid, a patient states, " My rm really hurts. It's burning and tingling where I got my injection. What should the nurse do next? Select all that apply. A. Notify the patient's health care provider of assessment findings B. Document assessment findings and related interventions in the patient's medical record C. Administer an oral medication for pain D. Assess the injection site E. This is a normal finding so nothing needs to be done

A. Notify the patient's health care provider of assessment findings B. Document assessment findings and related interventions in the patient's medical record D. Assess the injection site

Mae wants to find out about Christy's sleep problems. What assessments should she include when discussing this with Christy? Select all that apply. A. Physical environment B. Food and drink C. Daily routine D. Emotional stress E. Usual sleep patterns F. Exercise and activity

A. Physical environment B. Food and drink C. Daily routine D. Emotional stress E. Usual sleep patterns F. Exercise and activity

Jared finds that Mr. Clark does have a distended bladder and wants to help Mr. Clark urinate. What interventions would be helpful? Select all that apply. A. Provide privacy B.Provide adequate fluid intake C. Place a urinal for Mr. Clark D. Turn on the water

A. Provide privacy B. Provide adequate fluid intake C. Place a urinal for Mr. Clark D. Turn on the water

At the end of the shift, the registered nurse assigned to Mr. Brown asls Cody if he would give the hand-off report to the nurse coming on who is assigned to Mr. Brown. Which of the following statements are true regarding had-off reports? Select all that apply. A. Provides for the continuity and individualized care of the patient B. Includes up-to-date information and recent changes about the patient C. Must be given face to face between the nurses D. Must include an opportunity for the receiver to ask questions of the person giving the report

A. Provides for the continuity and individualized care of the patient B. Includes up-to-date information and recent changes about the patient D. Must include an opportunity for the receiver to ask questions of the person giving the report

When planning care for a dying patient, which interventions promote the patient's dignity? Select all that apply. A. Providing respect B. Viewing patients as a whole C. Showing interest D. Being present E. Using a preferred name

A. Providing respect B. Viewing patients as a whole C. Showing interest D. Being present E. Using a preferred name

A patient needs to learn to use a cane. Which domain is required for learning this skill? A. Psychomotor domain B. Affective domain C. Cognitive domain D. Attentional domain

A. Psychomotor domain

Lana is developing Mrs. Watson's care plan. She wants to add more interventions and not just deliver pain medication. What are some other nursing actions that would be helpful to Mrs. Watson? Select all that apply. A. Relaxation techniques B. Distractions such as music C. Cold or heat applications D. Massage

A. Relaxation techniques B. Distractions such as music C. Cold or heat applications D. Massage

Heather assesses that Abby is very stressed about getting back to work as soon as possible and becomes tense and agitated when talking about it. What type of CAM treatment is the best treatment for Abby? A. Relaxation therapy B. Biofeedback C. Acupuncture D. Gingko bilboa

A. Relaxation therapy

During the visit, Dorothy say to Sarah, "I know that Ann wants to quit the chemotherapy, but I don't want everyone to quit caring for her." What information could Sarah provide that would help Dorothy? Select all that apply. A. Sarah should explain that although the disease itself would not be treated, palliative care is a good option B. Sarah should tell Dorothy all of Ann's symptoms could still be managed which will improve her quality of life C. Sarah can explain that hospice care could be helpful to Ann D. Sarah can explain that quitting is not an option and that she will encourage Ann to fight until the very end

A. Sarah should explain that although the disease itself would not be treated, palliative care is a good option B. Sarah should tell Dorothy all of Ann's symptoms could still be managed which will improve her quality of life C. Sarah can explain that hospice care could be helpful to Ann

The nurse is caring for a patient with pneumonia who has severe malnutrition. The nurse recognizes that, because of the nutritional status, the patient is at increased risk for: Select all that apply. A. Sepsis B. Mental status changes (irritable, confusion, or inattentive) C. Heart disease D. Cardiac arrhythmias

A. Sepsis B. Mental status changes D. Cardiac arrhythmias

When preparing to administer a subcutaneous injection to a patient, what considerations should the nurse make when choosing an injection site? A. Skin lesions B. Site rotation to avoid lipohypertrophy C. Large underlying muscles or nerves D. Bony prominences E. Freckling of skin

A. Skin lesions B. Site rotation to avoid lipohypertrophy C. Large underlying muscles or nerves D. Bony prominences

Mr. Baker's nurse asks Lori to apply Thromboembolic Device TED hose and a sequential compression device SCD on him. What is the purpose of each device? A. To prevent thrombus and emboli B. To promote respirations C. To promote pain relief D. All of the above

A. To prevent thrombus and emboli

What statement made by a 2-year-old patient's mother indicates that she understands how to administer her son's eardrops? A. To straighten his ear canal, I need to pull the outside of his ear down and back B. After I'm done giving him his eardrops, I need to make sure that my son remains sitting straight up for at least 10min C. I need to straighten his ear canal before administering the medication by pulling his ear upward and outward D. I need to put my son in a chair and make sure that he's sitting up with his head tilted back before I give him the eardrops.

A. To straighten his ear canal, I need to pull the outside part of his ear down and back

A patient has been on contact isolation for 4D because of a hospital-acquired infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Which are the correct nursing interventions to reduce sensory deprivation? Select all that apply. A. Turning on the lights and opening the room blinds B. Teaching how activities such as reading and using crossword puzzles provide stimulation C. Moving him to a room away from the nurses station D. Sitting down, speaking, touching, and listening to his feelings and perceptions

A. Turning on the lights and opening the room blinds B. Teaching how activities such as reading and using crossword puzzles provide stimulation D. Sitting down, speaking, touching, and listening to his feelings and perceptions

Mrs. Watson tells Lana that she is worried about getting addicted to the morphine because she has heard that can happen. How should Lana respond? A. Don't worry. The cancer prevent you from becoming addicted B. It is okay, Because you have severe pain, the medication is necessary. There is little chance of addiction C. That is a valid worry. I wouldn't want to become addicted D. My cousin was addicted to pain killer when he had cancer

B. It is okay, Because you have severe pain, the medication is necessary. There is little chance of addiction

As part of Lori's assignment, she is observing Mr. Baker's surgery. She is to follow the circulating nurse. What will Lori learn is the role of the circulating nurse during the surgery? Select all that apply. A. Maintains a sterile field during the surgical procedure B. Review the perioperative assessment C. Assist with blood transfusions D. Documentation E. Establish and implement the intraoperative care plan F. Monitor operating room environment G. Assist with applying surgical drapes over the surgical field H. Anticipates and hands the surgeon intruments

B. Review the perioperative assessment C. Assist with blood transfusions D. Documentation E. Establish and implement the intraoperative care plan F. Monitoring operating room environment

Bethany is preparing Mrs. Wilson's morning medications. She reviews the rights of medication administration before starting. Her instructor asks her to name the six rights to medication administration. What are the six rights? A. Right direction B. Right dose C. Right route D. Right documentation E. Right medication F. Right patient G. Right doctor H. Right time

B. Right dose C. Right route D. Right documentation E. Right medication F. Right patient H. Right time

What does the braden scale evaluate? A. Skin integrity at bony prominences, including any wounds B. Risk Factors that place the patient at risk for skin breakdown C. The amount of repositioning that the patient can tolerate D. The factors that place the patient at risk for poor healing

B. Risk Factors that place the patient at risk for skin breakdown

A patient has just learned she has been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. You have cared for her for only 2hrs but have a good relationship with her. What might be the most appropriate intervention for support of her spiritual well-being at this time? A. Make a referral to a professional spiritual care advisor B. Sit down and talk with the patient; have her discuss her feeling and listen attentively C.Move the patient's bible from her bedside cabinet to the top of the over-bed table D. Ask the patient if she would like to learn more about the implications of having this type of tumor

B. Sit down and talk with the patient; have her discuss her feeling and listen attentively

Mrs. Wilson tells Bethany that even though she took a laxative, she still has not had a BM. Bethany reviews the PRN orders and sees an order for a glycerin suppository for constipation. What is the correct technique for Bethany to insert the suppository? A. Spread the cheeks of the buttocks, lubricate the rounded end of the suppository, and insert the suppository with the index finger past the internal anal sphincter and directly into the stool. B. Spread the cheeks of the buttocks, lubricate the rounded end of the suppository, and insert the suppository with the index finger past the internal anal sphincter and against the rectal wall C. Spread the cheeks of the buttocks, lubricate the rounded end of the suppository, and insert the suppository with the middle finger past the internal anal sphincter and against the rectal wall D. Spread the cheeks of the buttocks, lubricate the straight (blunt) end of the suppository, and insert the suppository with the index finger past the internal anal sphincter and against the rectal wall

B. Spread the cheeks of the buttocks, lubricate the rounded end of the suppository, and insert the suppository with the index finger past the internal anal sphincter and against the rectal wall

Joan is assessing Mr. Gordon's skin and notices that he has a 3cm blister and a shallow crater on his buttock. Mr. Gordon winces when Joan palpates the area. How should Joan stage this area. A. Stage I pressure injury B. Stage II pressure injury C. Stage III pressure injury D. Stage IV pressure injury

B. Stage II pressure injury

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? A. Recommend that she be evaluated for an overactive bladder (OAB) medication B. Start a scheduled toileting program C. Recommend that she be evaluated for an indwelling catheter D. Start a bladder re-training program

B. Start a scheduled toileting program

The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority intervention? A. Turn her on her side B. Stop feeding and assess her airway C. Put on oxygen at 2L nasal cannula D. Suction her mouth and throat

B. Stop feeding and assess her airway

________ is a closed-loop communication techniques used to evaluate patient understanding and retention of material? A. Role playing B. Teach back method C. Preparatory instruction D. Simulation

B. Teach back method

A patient has sever hyeprcalcemia. What is the priority nursing interventions? A. Fall prevention interventions B. Teaching regarding sodium restriction C. Encouraging increased fluid intake D. Explaining how to take daily weights

B. Teaching regarding sodium restriction

Joan assess Mr. Gordon using the braden scale and determines that his score is 12. What does this score indicate about Mr. Gordon's pressure injury risk? A. This indicates that he is at low risk for developing pressure injury B. This indicates that he is at high risk for developing pressure injury.

B. This indicates that he is at high risk for developing pressure injury.

Which of the following is the best nursing intervention when communicating with a patient who has expressive aphasia? A. Ask open-ended questions B. Use a dry-erase board or paper and pen for writing messages C. Speak to the patient as if he or she is a child D. Avoid the use of gestures and other nonverbal forms of communication

B. Use a dry-erase board or paper and pen for writing messages

Mr clark is unable to urinate 8 hours after surgery. Jared is now to catheterize Mr. Clark with a straight catheter. What is the most important principle for Jared to apply to the procedure A. Use clean technique B. Use sterile technique C. Use medical aseptic technique

B. Use sterile technique

When administering an IM injection, possible injection sites include: Select all that apply. A. Dorsogluteal muscle B. Ventrogluteal muscle C. Deltoid muscle D. Vastus lateralis muscle

B. Ventrogluteal muscle C. Deltoid muscle D. Vastus lateralis muscle

Which statement made by a mother being discharged to home with her newborn infant indicates that she understands the discharge teaching related to best sleep practice? A. I know the baby will not need to be fed until morning B. We'll place the baby on her back to sleep C. We will put the baby's stuffed animals in the crib to make her feel safe D. I'll give the baby a bottle to help her fall asleep.

B. We'll place the baby on her back to sleep

What is a critical step when inserting an indwelling catheter into a male patient? A. Slowly inflate the catheter balloon with sterile saline B. Secure the catheter drainage tubing to the bed sheets C. Advance Catheter to the bifurcation of the drainage and balloon ports D. Advance the catheter until urine flows, then insert 1/4 inch more.

C. Advance the catheter to the bifurcation of the drainage and balloon ports

Deanna is explaining to Mr. Mason that diabetes and COPD are examples of what type of illness? A. Acute B. Terminal C. Chronic

C. Chronic

What is the palliative care team's primary obligation for the patient with severe pain? A. Providing postmortem care B. Teaching about grief stages. C. Enhancing the patient's quality of life D. Supporting the family after death

C. Enhancing the patient's quality of life

After seeing a patient, the health care provider starts to give a nursing student a verbal order for a new medication. The nursing student first needs to: A. Ensure that the six rights of medication administration are followed when giving the medication B. Follow ISMP guidelines for safe medication abbreviations C. Explain to the health care provider that the order needs to be given to a registered nurse D. Write down the order on the patient's order sheet and read it back to the health care provider

C. Explain to the health care provider that the order needs to be given to a registered nurse

Maxwell is a senior nursing student completing his clinical rotation on the pediatric floor. He is currently caring for a 5-year-old patient named Peter who requires 2 eye drops in both eyes every 8 hrs. What is the best technique for Maxwell to administer these drops? A. Ask patient to lie supine, hold cotton ball or clean tissue in dominant hand on patient's cheekbone and gently press downward below lower lid with thumb or forefinger exposing conjunctival sac, have patient look at the ceiling while instilling medication from eyedropper that is approximately 1-2cm above the conjunctival sac, apply gentle pressure to patient's nasolacrimal duct for 60-90sec over each eye, have patient close eyes gently B. Apply clean gloves, ask patient to lie supine, hold cotton ball or clean tissue in non-dominant hand on patient's cheekbone and gently press downward below lower lid with thumb or forefinger exposing conjunctival sac, have patient look at the ceiling while instilling medication from eyedropper that is approximately 5-6cm above the conjunctival sac, apply gentle pressure to patient's nasolacrimal duct for 5-10sec over each eye, have patient close eyes gently C. Apply clean gloves, ask patient to lie supine, hold cotton ball or clean tissue in non-dominant hand on patient's cheekbone and gently press downward below lower lid with thumb or forefinger exposing conjunctival sac, have patient look at the ceiling while instilling medication from eyedropper that is approximately 1-2cm above the conjunctival sac, apply gentle pressure to patient's nasolacrimal duct for 60-90sec over each eye, have patient close eyes gently

C. Apply clean gloves, ask patient to lie supine, hold cotton ball or clean tissue in non-dominant hand on patient's cheekbone and gently press downward below lower lid with thumb or forefinger exposing conjunctival sac, have patient look at the ceiling while instilling medication from eyedropper that is approximately 1-2cm above the conjunctival sac, apply gentle pressure to patient's nasolacrimal duct for 60-90sec over each eye, have patient close eyes gently

As Deanna is talking to Mr. Mason, he tells her that he figures he will eventually get diabetes because his father and two brothers had type II diabetes. This is considered what type of risk factor? A. Age B. Environmental C. Genetic D. Lifestyle

C. Genetic

Cody wants to plan his morning. To which documentation form would Cody refer to find out activity orders, or what treatments Mr. Brown will be receiving today? A. Standardized care plan B. Flow sheet C. Kardex D. Admission history form

C. Kardex

What acid-base imbalance is Mr. Lewis experiencing? A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis

C. Metabolic alkalosis

Mrs. Wilson has a dose of NPH insulin ordered hs. She also has coverage for elevated blood sugar level. Her 2100 blood sugar level was 220mg/dL. The sliding-scale order reads as follows: A. Draw up 2 extra units of the NPH insulin and give the injection B. Give the patient the NPH insulin and do not give the regular insulin to avoid overdose C. Mix the regular and NPH insulin together and administer as one injection

C. Mix the regular and NPH insulin together and administer as one injection

Lori is developing Mr. Baker's care plan and adds the nursing diagnosis "potential for infection." Why would Mr. Baker be at high risk for developing infection? A. Mr. Baker's history of smoking B. Mr. Baker's history of hypertension C. Mr. Baker's history of type II diabetes

C. Mr. Baker's history of type II diabetes

The nurse evaluates which laboratory values to assess a patient's potential for wound healing? A. Lipids B. Fluid status C. Nitrogen balance D. Potassium

C. Nitrogen balance

A patient with progressive vision impairments had to surrender his driver's license 6M ago. He comes to the medical clinic for a routine checkup. He is accompanied by his son. His wife died 2 years ago, and he admits to feeling lonely much of the time. Which of the following interventions reduce loneliness? Select all that apply. A. Reassuring the patient that loneliness is a normal part of aging B. Maintaining distance while talking to avoid overstimulating the patient C. Sharing information about senior transportation services D. Providing information about local social groups in the patient's neighborhood E. Recommending that the patient consider making living arrangements that will put him closer to family or friends

C. Sharing information about senior transportation services D. Providing information about local social groups in the patient's neighborhood E. Recommending that the patient consider making living arrangements that will put him closer to family or friends

Sally is to remove the impaction from Mr. Miller. Sally knows that it is not good for Mr. Miller to strain for a bowel movement. Why could straining cause concern for Mr. Miller? A. Straining is normal and is of no concern B. Straining can lead to hemorrhoids C. Straining can cause complications for patients with cerebrovascular diseases

C. Straining can cause complications for patients with cerebrovascular diseases

Evaluation of spiritual care is necessary to determine if a patient's level of spiritual health has changed following intervention. If the use of rituals was part of a nurse's care plan, which of the following questions is most appropriate to evaluate it efficacy? A. Do you feel the need to forgive your wife over your loss? B. What can I do to help you feel more at peace? C. Were prayer or meditation helpful to you? D. Should we plan on having your family try to visit you more often in the hospital?

C. Were prayer or meditation helpful to you?

Two single fathers are active professionals and have teenage daughters. They also have busy social lives and date occasionally. Five years ago they decided to share a house and housing costs, living expenses, and child care responsibilities in order to save money. The children consider one another as their family. What type of family form does this represent? A. Diverse family relationship B. Blended family relationships C. Extended family relationship D. Alternative family relationship

D. Alternative family relationship

The nurse incorporates which priority nursing intervention into a plan of care to promote sleep for a hospitalized patient? A. Have patient follow hospital routines B. Turn television on low to late-night programming C. Give prescribed sleeping medications at dinner D. Avoid waking patient for nonessential tasks

D. Avoid waking patient for nonessential tasks

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? A. A local skin infection requiring antibiotics B. Sensitive skin that require special bed linen C. A stage III pressure ulcer needing the appropriate dressing D. Blanching hyperemia, indicating that attempt by the body to overcome the ischemic episode

D. Blanching hyperemia, indicating that attempt by the body to overcome the ischemic episode

Carla refuses to ambulate without an abdominal binder during her postpartum stay in the hospital. Of what belief is this a manifestation? A. Poor health habits B. Fear of bleeding C. Belief in hot and cold theory of illness D. Cultural belief that air would enter the uterus

D. Cultural belief that air would enter the uterus

The nurse would delegate which of the following to nursing assistive personnel? A. Hanging a new bag of enteral feeding B. Administering enteral feeding bolus after tube placement has been verified C. Repositioning and retaping a patient's nasogastric tube D. Documenting PO intake on a patient who is on a calorie count for 72hr

D. Documenting PO intake on a patient who is on a calorie count for 72hr

Which of the following most greatly affect a family's access to adequate health care., opportunity for education, and sound nutrition? A. Development B. Family function C. Family structure D. Economic stability

D. Economic stability

Because an older adult is at increased risk for respiratory complications after surgery, the nurse needs to: A. Withhold pain medication and ambulate the patient every two hours. B. Monitor fluid and electrolyte status every shift and vital signs with temperature every 4 hours C. Orient the patient to the surrounding environment frequently and ambulate him or her every 2 hours. D. Encourage the patient to turn, deep breathe and cough frequently and ensure adequate pain control.

D. Encourage the patient to turn, deep breathe and cough frequently and ensure adequate pain control.

Mrs Brown asks Cody is she can look at her husband's medical record. On what legislation would Cody base his answer? A. State and federal EHR regulations B. State and federal EMR regulations C. HIPPA D. HIPAA

D. HIPAA

Heather assesses the medications that Abby is taking. Why would it be important to do this before recommending any herbal therapies? A. Herbal remedies enhance certain medications B. Herbal remedies can cause negative interactions between the drug and the herb C. It is not necessary to worry about the interactions between medication and herbal therapies D. Herbal remedies may interact with certain medications and cause negative interactions between the drug and the herb

D. Herbal remedies may interact with certain medications and cause negative interactions between the drug and the herb

A nurse is caring for a 78-year-old patient with chronic MS. The patient has severe fatigue, muscle weakness, severe muscle spasms, and difficulties with coordination and balance. Her disease will likely worsen. The nurse has gained the patient's trust and wants to assess her life satisfaction. Which of the following questions should the nurse ask? Select all that apply. A. How often are you able to attend your synagogue B. What does your husband do for you at home C. Looking back, what is your greatest accomplishment D. How has your illness affected the way you live your life spiritually at home

D. How has your illness affected the way you live your life spiritually at home

Which statement made by the parent of a school-age child requires follow-up by the nurse? A. We use quiet activities such as reading a book before bedtime B. I make sure that the room is dark and quiet at bedtime C. I offer my daughter a glass of warm milk before bedtime D. I encourage exercise about an hour before bedtime

D. I encourage evening exercise about an hour before bedtime

A student nurse is telling a faculty member that her patient talked about gaining spiritual comfort from being focused on her inner self, including her values and principles. The instructor explains that this is an example of: A. Faith B. Community C. Interpersonal connection D. Self-transcendence

D. Self-transcendence

What is the removal of devitalized tissue from a wound called? A. Debridement B. Pressure reduction C. Negative pressure wound therapy D. Sanitization

A. Debridement

Which patient is most likely to experience sensory overload? A. A visually impaired resident of a nursing home who enjoys taking part in different hobbies and activities B. A patient in the ICU whose pain in not well controlled C. A woman whose hearing aids were lost when she transferred to a long-term care facility D. A patient with a protective patch on her right eye following cataract surgery

B. A patient in the ICU whose pain is not well controlled

What assessment should Jared do first to determine whether Mr. Clark has a full bladder? A. Perform a bladder scan to measure the amount of urine in Mr. Clark's bladder B. Palpate the abdomen over the bladder and feel for distention C. Ask Mr. Clark how often he has been voiding in the last week

B. Palpate the abdomen over the bladder and feel for distention

Mrs. Lu complains of being short of breath. 3hrs after she was admitted to her room, Jim assesses her temperature, and it is 101.2F orally. Jim takes her other vital signs: BP 100/70, P 112, respirations 30. Her pulse ox in 88%. What nursing actions should Jim initiate to treat these changes in Mrs. Lu's condition? A. Jim should do a thorough respiratory assessment and contact the physician using SBAR B. Jim should do a thorough respiratory assessment and contact the physician using SBAR C. Jim should do a thorough respiratory assessment. He should place her in the fowler position, check that the oxygen is flowing through the nasal cannula, and encourage frequent coughing and deep breathing

C. Jim should do a thorough respiratory assessment. He should place her in the fowler position, check that the oxygen is flowing through the nasal cannula, and encourage frequent coughing and deep breathing

Jim decides to check with the primary nurse and see if he can start administering oxygen to Mrs. Lu. The nurse tells Jim that it would be good. What is the preferred method of oxygen administration for this patient? A. Simple face mask B. Venturi mask C. Nasal cannula

C. Nasal cannula

Which of the following describes a hydrocolloid dressing? A. A seaweed derivative that is highly absorptive B. Premoistened gauze over a granulating wound C. a debriding enzyme that is used to remove necrotic tissue D. A dressing that forms a gel that interacts with the wound surface

D. A dressing that forms a gel that interacts with the wound surface

Health care agencies often have assessment tools to use in clarifying patient values and assess spirituality. Using the FICA assessment tool, match the criteria on the left with the appropriate assessment question on the right. -Describe which activities give you comfort spiritually - tell me if you have a higher power or authority that helps you act on your beliefs -Your illness has kept you from attending church. Is that a problem for you? - To whom do you go for support in times of difficulty

A (interventions to address spiritual needs) -Describe which activities give you comfort spiritually Faith - tell me if you have a higher power or authority that helps you act on your beliefs Importance of spirituality -Your illness has kept you from attending church. Is that a problem for you? Community - To whom do you go for support in times of difficulty

Match the needle and syringe size to the type of injection: A. 1-3mL syringe and 1/8-5/8in needle B. Needle lenght corresponds to site of injection and age of patient C. 1mL syringe, 3/8-5/8in needle

A. 1-3mL syringe and 1/8-5/8in needle; subcutaneous B. Needle length corresponds to site of injection and age of patient; intramuscular C. 1mL syringe, 3/8-5/8in needle; intradermal

A nurse assess four patients. Which patient has greatest risk for hypermagnesemia? A. A 72-year-old with chronic alcoholism B. A 79-year-old with bone cancer C. A 41-year-old with hypernatremia D. A 46-year-old with respiratory acidosis

A. A 72-year-old patient with chronic alcoholism

Ellen knows that Mr. Scott's hypertension could be the result of which phase of general adaptation syndrome? A. Alarm reaction B. Resistance C. Recovery D. Exhaustion

A. Alarm reaction

Two weeks later, Ann returns to the clinic for a checkup. At her oncology appointment, she learned that the cancer had further metastasized and that her prognosis was poor Ann tells Sarah that she would like to live until her daughter has a baby in 6M. Sarah knows that this is which stage of the dying process? A. Bargaining B. Denial C. Acceptance D. Depression

A. Bargaining

What describes measurement of postvoid residual (PVR)? A. Bladder scan the patient immediately after voiding B. Catheterize the patient 30min after voiding C. Bladder scan the patient when he or she reports a strong urge to void D. Catheterize the patient with a 16Fr/10mL catheter

A. Bladder scan the patient immediately after voiding

Mr. Gordon has drainage coming from his surgical incision, and his dressing needs to be changed. What assessments of the incision should Joan perform while changing the dressing? Select all that apply. A. Characteristics of drainage (consistency, color, and amount) B. Intactness of the suture and closure of the wound C. Odor D. Presence of any redness or warmth

A. Characteristics of drainage (consistency, color, and amount) B. Intactness of the suture and closure of the wound C. Odor D. Presence of any redness or warmth

The patient's blood glucose level is 330 mg/dL. What is the priority nursing intervention? A. Check the medical record to see if there is a medications order for abnormal glucose levels B. Recheck by performing another blood glucose test C. Call the primary health care provider D. Monitor and recheck in 2 hrs

A. Check the medical record to see if there is a medication order for abnormal glucose levels

You are a nurse working in a care facility and passing medications to a patient who has had a stroke and takes oral medications. Which of the following steps is the THIRD check for accuracy in determining the patient is receiving the right medication? A. Comparing MAR with names of medication on medication labels and patient name at patient's bedside B. Selecting correct medications from the unit-dose drawer and stock medications and comparing name of medications on label with MAR C. Unlocking the medicine drawer on your cart D. Before going to the patient's room, comparing the patient's name and name of medications on label of prepared drugs with MAR

A. Comparing MAR with names of medication on medication labels and patient name at patient's bedside

As Sarah is starting the chemotherapy, Ann tells Sarah that she would have preferred not to go through all of this again but that her mother encouraged her to try more chemotherapy. What assessments would help Sarah in planning the care for Ann? Select all that apply. A. Coping Style B. Feelings about her cancer diagnosis C. Feelings about death and dying D. Family dynamics between her and her mother E. Culture and religion F. Support system

A. Coping Style B. Feelings about her cancer diagnosis C. Feelings about death and dying D. Family dynamics between her and her mother E. Culture and religion F. Support system

Marie goes to begin caring for Carla and finds that she has a roomful of visitors who are who are identified as her extended family. Marie knows that Carla needs rest. Marie tells the visitors that they must leave now so Carla can rest. This is showing what type of care? A. Culturally incongruent care B. Scientific approach to care C. Individualized patient care D. Family-centered care

A. Culturally incongruent care

Once Jared has finished with the catheterization procedure, he tells Mr. Clark to report any signs that may indicate a urinary tract infection. What signs should Jared tell Mr. Clark to report? Select all that apply. A. Frequency of urination B. Burning upon urination C. Cloudy urine D. Odor to urine E. Blood in urine

A. Frequency of urination B. Burning upon urination C. Cloudy urine D. Odor to urine E. Blood in urine

During a visit to a family clinic, a nurse teaches a mother about immunizations, car-seat use, and home safety for an infant and toddler. Which type of nursing interventions are these? A. Health promotion activities B. Acute care activities C. Restorative care activities D. Growth and development care activities

A. Health promotion activities

Marie knows that it is important when planning care to conduct a cultural assessment. Which of the following are important aspects for conducting a cultural assessment on Carla? Select all that apply. A. How does your culture view breastfeeding? B. How much do you want Juan to be involved in the care? C. What do you value from the health care providers here? D. What do you expect from me today in providing care?

A. How does your culture view breastfeeding? B. How much do you want Juan to be involved in the care? C. What do you value from the health care providers here? D. What do you expect from me today in providing care?

Mr. Miller's sister has come with him to the urgent care clinic and asks Sally what could have caused Mr. Miller to get so constipated. Sally should explain that constipation can be caused by which factors? Select all that apply. A. Ignoring the urge to defecate B. Low-fiber diet and low fluid intake C. Medications D. Depression or cognitive impairment E. Aging F. Lack of regular exercise G. Hemorrhoids

A. Ignoring the urge to defecate B. Low-fiber diet and low fluid intake C. Medications D. Depression or cognitive impairment E. Aging F. Lack of regular exercise G. Hemorrhoids

Michael goes into Mr. Miller's room and finds him on the floor. His granddaughter tells Michael she had just left the room for a minute, and he fell. What record will Michael need to fill out about what happened? A. Incident or occurrence report B. Living will C. Deposition D. Consent form

A. Incident or occurrence report

An x-ray is ordered for Mr. Miller, and it shows that he has a fractured hip. The orthpedic surgeon examines Mr. Miller and determines that he needs surgery for a hip pinning. He instructs Michael to have a consent form signed for surgery. Which of the following is true regarding the consent form? Select all that apply. A. It is the physician's responsibility to explain the procedure, risks, benefits, and alternatives to the patient and his granddaughter B. It is okay for Mr. Miller to sign the consent form. C. The granddaughter can sign the consent form if he has health care power of attorney D. It is okay to not have a consent form signed because Mr. Miller is confused

A. It is the physician's responsibility to explain the procedure, risks, benefits, and alternatives to the patient and his granddaughter C. The granddaughter can sign the consent form if he has health care power of attorney

What are the advantages of using Z-track method for IM injections? Select all that apply. A. It prevents leakage of medication into the subcutaneous tissue B. It seals medication into the muscle C. It is a quicker way to administer an IM injection D. It minimizes irritation E. It prevents leakage of medication into the intradermal tissue

A. It prevents leakage of medication into the subcutaneous tissue B. It seals the medication into the muscle D. It minimizes irritation

The nurse is taking a sleep history from a patient. Which statement made by the patient need further follow-up? A. It takes me about 45-60min to fall asleep B. I feel refreshed when I wake up in the morning C. I use soft music at night to help me relax D. I take the pain medication for my leg pain about 30min before I go to bed

A. It takes me about 45-60min to fall asleep

Jill wants to find out more about this question, so she goes to the library and uses which of the following as a database to find articles on the subject related to health care? A. MEDLINE B. Dewey Decimal System C. Google D. National Publisher's Clearinghouse

A. MEDLINE

Heather uses the following types of treatments for pain. Which one(s) is/are CAM treatments? Select all that apply. A. Massage therapy B. Tai Chi C. Guided imagery D. Chinese herbal therapy E. Narcotic administration

A. Massage therapy B. Tai Chi C. Guided imagery D. Chinese herbal therapy

Ellen knows that dealing with stress requires many different factors. What factors are important to assess n Mr Scott's situation that could help him cope and control his physiological symptoms of stress? Select all that apply. A. Mr. Scott's support systems B. How he has dealt with stress in the past C. Sociocultural factors D. Maturational factors

A. Mr. Scott's support systems B. How he has dealt with stress in the past C. Sociocultural factors D. Maturational factors

If the unit is doing a research study on effects of gum chewing on a patient who has had abdominal surgery and wants Mrs. Jones to participate in the study, which of the following would be true? A. Mrs. Jones would have to give informed consent B. Mrs. Jones would have to discuss with her family first C.No one could tell Mrs. Jones that she is in the study because it might skew the data. D. Mrs. Jones would have to participate if she wanted to be on that unit

A. Mrs. Jones would have to give informed consent

Later, while Jim is listening to Mrs. Lu's lung through the stethoscope, he hears a high-pitched musical sound. What does this indicate? A. Mrs. Lu is wheezing B. Mrs. Lu has a pleural friction rub C. Mrs. Lu has fine crackles D. Mrs. Lu has coarse crackles

A. Mrs. Lu is wheezing

Claudia asks Joan what she can do when she takes her father home to help prevent more pressure injuries. How should she answer? Select all that apply. A. Nutrition - increase protein intake and provide healthy meals B. Hydration - keep him hydrated with fluids C. Keep his skin clean and dry D. Keep excess pressure off points and inspect the skin often to report and changes E. Try not to reposition her father very often as this will cause him discomfort

A. Nutrition - increase protein intake and provide healthy meals B. Hydration - keep him hydrated with fluids C. Keep his skin clean and dry D. Keep excess pressure off points and inspect the skin often to report and changes

Cody is going to document in Mr. Brown's medical record. Which of the following is appropriate to document? A. Patient rates headache pain as a 6. Pain is in the L temporal area and does not get better with any positioning B. IV site looks good C. Voiding without difficulty D. Is pleasant to care for

A. Patient rates headache pain as a 6. Pain is in the L temporal area and does not get better with any positioning

Deanna know that Mr. Mason needs to quit smoking to improve his health .What factors should she take into consideration that could affect Mr. Mason's willingness to engage in health promotion activities? Select all that apply. A. Socioeconomic status B. Access to resources C. Other chronic illnesses D. Mental and physical health E. Cognitive status F. Encouragement by health care providers G. Age

A. Socioeconomic status B. Access to resources C. Other chronic illnesses D. Mental and physical health E. Cognitive status F. Encouragement by health care providers G. Age

The nurse is developing a plan for a patient who was diagnose with narcolepsy. Which interventions should the nurse include on the plan? Select all that apply. A. Take brief, 20min naps no more than twice a day B. Establish a regular exercise program C. Teach the patient about the side effects of Modafinil (Provigil), their newly prescribed medicine for narcolepsy D. Drink a glass of wine with dinner. E. Eat the large meal at lunch rather than dinner

A. Take brief, 20min naps no more than twice a day B. Establish a regular exercise program C. Teach the patient about the side effects fo Modafinil (Provigil), their newly prescribed medicine for narcolepsy

Martin is a 16-year-old male who was recently diagnosed with asthma. As the nurse working at a pulmonology clinic it is your responsibility to teach Martin how to use his newly prescribed metered dose inhaler. What steps will you teach Martin? Select all that apply. A. Tell Martin to place his lips on the mouthpiece and hold the inhaler in his dominant hand B. Assess Martin's understanding and knowledge of asthma and the purpose and action of the prescribed medication C. Instruct Martin to hold his full breath for 30sec D. Since Martin needs 2 puffs, instruct him to wait 20-30sec between inhalation E. Instruct Martin to depress the MDI once, spraying one puff into the spacer device, then inhale quickly so none of the medicine escapes F. Allow Martin time to manipulate the inhaler, canister and spacer then demonstrate how to put the MDI into the end of the spacer device G. Identify patient using 1 identifier and compare the identifier on Martin's MAR

A. Tell Martin to place his lips on the mouthpiece and hold the inhaler in his dominant hand B. Assess Martin's understanding and knowledge of asthma and the purpose and action of the prescribed medication F. Allow Martin time to manipulate the inhaler, canister and spacer then demonstrate how to put the MDI into the end of the spacer device

Ellen gives Mr. Scott some strategies to help him cope with his stressors. Identify the strategies proven to help cope with stress. Select all that apply. A. Use of available support system B. Relaxation techniques C. Staying up all night binge watching television to forget about his problems. D. Regular exercise E. Healthy diet F. Guided imagery and visualization

A. Use of available support system B. Relaxation techniques D. Regular exercise E. Healthy diet F. Guided imagery and visualization

You are working in a health clinic on a college campus. You need to administer Medroxyprogesterone acetate IM to a female patient for birth control. You look up this medication in a reference manual and determine that it is viscous and injections can be painful. On the basis of the information, you plan which of the following when administering this medication? Select all that apply. A. Use the z-track method when administering the medication B. Administer the medication in the ventral gluteal site C. Inject the medication over 3min to reduce pain associated with the injection D. Use the deltoid site for medication administration E. Ask the patient questions about her major and which classes she is taking during the injection to provide distraction

A. Use the z-track method when administering the medication B. Administer the medication in the ventral gluteal site C. Inject the medication over 3min to reduce pain associated with the injection E. Ask the patient questions about her major and which classes she is taking during the injection to provide distraction

Lori is going over Mr. Baker's preoperative checklist. The informed consent has been signed by Mr. Baker. Lori know that it is the responsibility fo the ______ to tell the patient about the surgery, including risks, benefits, expected outcomes, and alternatives. A. Preoperative nurse B. Surgeon C. Anesthesiologist D. Circulating nurse

B Surgeon

You are assigned to care for the following patients on your surgical unit. On the basis of the information provided, which patient do you need to see first? A. A 75-year-old following hip replacement surgery who is complaining of moderate pain in the surgical site, with a HR of 92. B. A 57-year-old following hip replacement 6 hours earlier who is IV patient-controlled analgesia with a history of obstructive sleep apnea (pulse ox has been alarming a reading 85%) C. a 36-year-old following bladder neck suspension who is 30min late to receive her postop dose of antibiotic. D. A 48-year0old following total knee replacement who needs help positioning in bed.

B. A 57-year-old following hip replacement 6 hours earlier who is IV patient-controlled analgesia with a history of obstructive sleep apnea (pulse ox has been alarming a reading 85%)

Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? Select all that apply. A. Attach a 3mL syringe to inflate the port B. Allow the balloon to drain into the syringe by gravity C. Pull the catheter quickly D. Clamp the catheter before removal

B. Allow ballon to drain into the syringe by gravity

You are caring for a 65-year-old patient 2 days after surgery and helping him ambulate down the hallway. The surgeon ordered exercise as tolerated. Your assessment indicates that the patient's HR at baseline is 88. After walking approximately 30 yards down the hallway, his HR is 110. What is your next action? A. Stop exercise immediately and have him sit in a nearby chair B. Ask him how he feels; determine if there is any discomfort or SOB; and if not, continue exercise C. Tell him that he needs to walk further to reach a HR of 120 D. Have him walk slower, he has reached his maximum

B. Ask him how he feels; determine if there is any discomfort or SOB; and if not, continue exercise

Linda begins the initial assessment, and when she asks each question, Mr. Jones asks her to repeat it. Mrs. Jones tells Linda that he is not wearing his hearing aids today. What is the best approach for Linda so Mr. Jones can answer her questions? A. Ask Mrs. Jones all of the questions so Mr. Jones will not have to hear her. B. Ask the question directly to Mr. Jones while facing him, speaking slower and in a normal tone of voice C. Write down all of her questions and ask him to read the questions and then answer D. Ask the family to go home and get his hearing aids and postpone the procedure until the family returns

B. Ask questions directly to Mr. Jones while facing him, speaking slower in a normal tone of voice.

A pediatric nurse takes a medication to a 16-year-old male patient. The patient tells the nurse to take it away because he is not going to take it. What is the nurse's next action? A. Take the medication away and chart the patient's refusal B. Ask the patient's reason for refusal C. Consult with the patient's parents for advice D. Tell the patient that her health care provider knows what is best for her.

B. Ask the patient's reason for refusal

A last term nursing student is working a hectic morning shift. While passing medications, he/she accidentally give a patient the medication that were ordered for the patient's roommate. What is the first priority? A. Complete an occurrence report B. Assess the patient for adverse effects C. Inform the charge nurse of the error D. Notify the health care provider

B. Assess the patient for adverse effects

Mae learns that since summer, Macy has been going to bed when her 7-year-old sister goes to bed, and Macy does not take a nap during the day. Mae encourages Christy to establish a set bedtime for Macy and stick to it. Reading a stork before going to bed may help in the transition. Macy may like to sleep with a certain stuffed animal. A small night-light could also help Macy. Why are bedtime rituals important for toddlers? A. It is not necessary to establish bedtime rituals because toddlers will sleep when they are tired and will fight it regardless of any routine B. Bedtime rituals are important to toddlers and preschoolers to feel safe. They promote relaxation that will promote sleep. C. Bedtime rituals are important so that parents can easily get kids in bed and finally have time for themselves in the evening

B. Bedtime rituals are important to toddlers and preschoolers to feel safe. They promote relaxation that will promote sleep.

You are a new graduate nurse completing your orientation on a very busy ICU. You cannot read a health care provider's order for one of your patient's medications. You have heard from more experienced nurses that this is a health care provider that does not like to be called, and you know that another of the health care providers' patients is very unstable. What is the most appropriate net step for you to take? A. Refer to a medication manual before you give the medication B. Call the health care provider to clarify the order C. Use your best judgement and critical thinking and administer the dose you think the health care provider ordered D. Talk with your peer to help you interpret the order

B. Call the health care provider to clarify the order

The nurse on the unit where Jill is getting her clinical experience tells Jill that the unit is questioning whether a patient who has abdominal surgery will have less nausea if she chews gum. In this PICOT question, what represents the "I"? A. The surgical patient B. Chewing gum C. Having less nausea D. Postoperative abdominal surgery patients

B. Chewing gum

A patient newly diagnosed with prostate cancer is going home. The patient is avoiding discussion of his illness and postop orders. What is the nurse's best plan in teaching this patient? A. Teach the patient's spouse B. Convince the patient that learning about his health is necessary C. Focus on knowledge the patient will need in a few weeks D. Provide only the information that the patient needs to go home

B. Convince the patient that learning about his health is necessary

A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, " I think my hearing aid is broken. I can't hear anything." Which of the following teaching strategies does the nurse implement? Select all that apply. A. Demonstrate how to wash the earmold and microphone with hot water B. Demonstrate hearing aid battery replacement C. Discuss the importance of having wax buildup pin the ear canal removed D. Review method to check volume on hearing aid E. Recommend a chemical cleaner to remove difficult buildup

B. Demonstrate hearing aid battery replacement C. Discuss the importance of having wax buildup pin the ear canal removed D. Review method to check volume on hearing aid

Which sleep-hygiene actions at bedtime can the nurse delegate to the nursing assistant? Select all that apply. A. Giving a patient a cup of coffee B. Dimming the lights in the patient's room C. Turning on quiet music D. Monitoring for the effect of the sleeping medication that was given E. Giving the patient a backrub

B. Dimming the lights in the patient's room C. Turning on quiet music E. Giving the patient a backrub

The nurse is developing a plan of care for a patient experiencing obstructive sleep apnea. Which intervention is appropriate to include on the plan? A. Encourage patient to take an OTC sleep aid B. Elevate head of bed and assume a side or prone position C. Have patient limit fluid intake 2hrs before bedtime D. Instruct the patient to sleep in a supine position

B. Elevate head of bed and assume a side or prone position

A patient needs to learn how to monitor their blood glucose using a glucometer. Which of the following reflects that the patient is ready to learn? A. Describing difficulties a family member has had in taking insulin B. Expressing the importance of learning the skill correctly C. Being able to see and understand the markings on the syringe D. Having the dexterity needed to prepare and inject the medication

B. Expressing the importance of learning the skill correctly

One of the goals of Sharon's assignment is delegating to other on the nursing team. Which tasks are appropriate for Sharon to ask the nursing tech to do? Select all that apply. A. Getting Mr. Duncan some aspirin for his elevated temperature B. Getting Mrs. Thomas ready to go to her x-ray examination C. Getting two ice bags for Mr. Duncan D. Assessing Mrs. Thomas for her knowledge of the diabetic diet

B. Getting Mrs. Thomas ready to go to her x-ray examination C. Getting two ice bags for Mr. Duncan

Which nursing intervention decreases the risk for catheter-associated urinary tract infections? A. Cleansing the urinary meatus 3-4 times daily with antiseptic solution B. Hanging the urinary bag below the level of the bladder C. Emptying the drainage bag daily D. Irrigating the urinary catheter with sterile water

B. Hanging the urinary bag below the level of the bladder

Myrtle is a 78-year-old patient who lives alone. She fell and suffered a compound fracture of her right wrist. You are a new nurse coming on to your shift and will be caring for Myrtle, who is 12hrs postop. Myrtle has a history of CHF, cataracts and type II diabetes. You will need to administer furosemide 40mg PO, NPH insulin 20 units subcutaneous injection, CanC 2 drops in each eye, and hydromorphone 1.0mL IV push. Which of the medications is the most dangerous to administer to Myrtle? A. CanC 2 drops in each eye B. Hydromorphone 1.0mL IV push C. NPH insulin 20 units subcutaneous injection D. Furosemide 40mg PO

B. Hyrdomorphone 10.mL IV push

Which statement made by the patient indicates a need for further teaching on sleep hygiene? A. I'm going to go to bed every night at about the same time. B. I moved my computer to the bedroom so I could work before I go to sleep C. I set my alarm to get up at the same time every morning D. I'm going to do my exercises before I eat dinner

B. I moved my computer to the bedroom so I could work before I go to sleep

Mrs. Wilson has not had her influenza injection. Bethany is going to administer it to Mrs. Wilson It is going to be given intramuscularly. Which of the following actions is correct in administering an IM injection Select all that apply. A. Insert needle at a 45-degree angle B. Inject the medication C. Use at least 1-1/2 inch needle D. Cleanse the area with an alcohol prep E. Remove the needle from the patient and dispose of it properly. F. Insert the needle at a 90-degree angle G. Aspirate by pulling back on the plunger and observe for blood return

B. Inject the medication D. Cleanse the area with an alcohol prep E. Remove the needle from the patient and dispose of it properly. F. Insert the needle at a 90-degree angle G. Aspirate by pulling back on the plunger and observe for blood return

Michael is filling out the admission paperwork. He asks Jennifer if Mr. Miller has and advanced directive. Jennifer asks what that is. Which of the following is correct for Michael to answer? A. It is a document that allows the hospital to apply restraints if needed B. It documents the wishes of a person in the even that he or she is incapacitated or appoints someone to make those decisions on his or her behalf. C. It is a document that a family member signs for the patient if he or she is unable to sign. D. It is a form that a family member signs that states that the patient is not to be resuscitated.

B. It documents the wishes of a person in the even that he or she is incapacitated or appoints someone to make those decisions on his or her behalf.

Mr. Mason says to Deanna that he doesn't see any reason to quit smoking; he already has COPD, so it wouldn't do any good. According to the stages of behavior change model, how should Deanna respond? A. You are right, it isn't that important B. It is hard to quit smoking. What things are important to you now? What will be important to you over the next year? C. I am going to tell your daughter that you have to quit smoking D. Maybe someday you will decide to quit smoking. I hope you do before it is too late.

B. It is hard to quit smoking. What things are important to you now? What will be important to you over the next year?

Mr. Jones has macular degeneration, which causes his vision to be blurred. Linda is concerned about his safety while ambulating to the bathroom. What is the best way to accompany him to the bathroom before his surgery? A. Linda should walk behind Mr. Jones and direct him to go with her voice. She should walk at his pace. B. Linda should walk beside Mr. Jones and allow him to hold onto her arm. She should walk on his side and about one-half step in front of him. She should walk at his pace C. Linda should walk in front of Mr. Jones and ask him to follow her at a slow, steady pace.

B. Linda should walk beside Mr. Jones and allow him to hold onto her arm. She should walk on his side and about one-half step in front of him. She should walk at his pace

Which patient should Sharon determine as the priority and go to first? Why? A. Mrs. Thomas would be the priority patient because her son can only take her home in the morning B. Mr. Duncan would be the priority patient to assess because of his abnormal vital signs C. Mrs. Thomas would be the priority patient to check her blood sugar since she is diabetic D. Mr. Duncan would be the priority patient to assess his confusion

B. Mr. Duncan would be the priority patient to assess because of his abnormal vital signs

A nurse is performing an assessment on a patient admitted to the unit following treatment in the ED for severe bilateral eye trauma. During patient admission the nurse's priority interventions include which of the following? Select all that apply. A. Reinforcing eye safety at work and in activities that place the patient at risk for eye injury B. Placing necessary objects such as the call light and water in front of the patient to prevent falls caused by reaching C. Placing signage on the patient's room door and over the bed to alert health care providers about patient's visual status D. Conducting a home-safety assessment and identifying hazards in the patient's living environment E. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye

B. Placing necessary objects such as the call light and water in front of the patient to prevent falls caused by reaching C. Placing signage on the patient's room door and over the bed to alert health care providers about patient's visual status E. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye

Christy asks if there is anything that could be causing her husband to snore so loud. Before Mae can answer, she needs to gather more information. What could indicate Christy's husband may have sleep apnea? Select all that apply. A. Falling asleep at inopportune times B. Positive family history of sleep apnea C. Excessive daytime sleepiness D. Snoring accompanied by snorting

B. Positive family history of sleep apnea C. Excessive daytime sleepiness D. Snoring accompanied by snorting

A toddler is to receive a 2.5mL of an antibiotic by mouth. Which equipment in the most appropriate for medication administration for this child? A. a 3mL syringe B. An oral-dosing syringe C. D. Medication cup

B. an oral-dosing syringe

A health care provider ordered Enalapril (Vasotec) 2mg IV push for a patient with hypertension. The pharmacy has sent vials marked 1.25mg enalapril/mL. How many ml does the nurse administer? ____ mL A. 1.8 B. 16 C. 1.6 D. 18

C. 1.6mL

Kyle, a nursing student is caring for Mark, a 50-year-old who is being treated for multiple fractures after a motor vehicle accident. Mark's health care provider writes a new order for morphine sulfate liquid suspension 25mg STAT and then q4h as needed for pain. The unit-dose containers of liquid morphine sulfate on the patient care unit are labeled "10mg morphine sulfate/5mL." Using dimensional analysis, how much medication should Kyle administer? A. 15mL B. 2.5mL C. 12.5mL D. 10mL

C. 12.5mL

Bethany is getting Mrs. Wilson's medications together to take in to her before breakfast. The NSAID must be given with food. What should Bethany do about administering this medication to Mrs. Wilson? A. Do not administer the medication because it is not schedule at the same time as the others B. Give that medication with the other medications. It won't hurt as long as she eats soon C. Administer the medication after the meal has been served and ensure that mrs. Wilson is eating D. Administer the medication after the meal has been served and ensure that Mrs. Wilson is eating

C. Administer the medication after the meal has been served and ensure that mrs. Wilson is eating

Which statement made by a patient of a 2-month-old infant requires further education? A. I'll start feeding the baby cereal at 4M B. I'll continue to use formula for the baby until he is at least a year old C. I'm going to alternate formula with whole milk starting next month D. I'll make sure that I purchase iron-fortified formula

C. I'm going to alternate formula with whole milk starting next month

The primary nurse ask Jim to take Mrs. Lu and incentive spirometer and teach her what it is and how to use it properly. What should Jim include in his teaching plan? A. Jim should explain that an incentive spirometer is used to encourage deep breathing and prevent pulmonary complications after abdominal surgery. He should have her place her lips around the mouthpiece and exhale slowly with an even flow to elevate the balls and keep them floating as long as possible B. Jim should explain that an incentive spirometer is used to promote wound healing after lung surgery. He should have her place her lips around the mouthpiece and inhale to elevate the balls as quickly as possible. C. Jim should explain that an incentive spirometer is used to encourage deep breathing and prevent pulmonary complications after abdominal surgery. He should have her place her lips around the mouthpiece and inhale slowly with an even flow to elevate the balls and keep them floating as long as possible. He should tell her to do this frequently while she is awake.

C. Jim should explain that an incentive spirometer is used to encourage deep breathing and prevent pulmonary complications after abdominal surgery. He should have her place her lips around the mouthpiece and inhale slowly with an even flow to elevate the balls and keep them floating as long as possible. He should tell her to do this frequently while she is awake.

Lana goes in to meet Mrs. Watson, and Mrs. Watson is holding her abdomen and is restless. She is pale. Lana asks Mrs. Watson to rate her pain on a scale of 1 to 10 being the worst pain you could have. Mrs. Watson tells Lana that it is a 9. Lana checks the PCA pump and notices that Mrs. Watson has not been pushing the button for medication delivery. What should Lana do to alleviate the pain? A. Lana should ask Mrs. Watson's daughter if s she understands how to use the PCA pump, since Mrs. Watson is in so much pain B. Lana should ask Mrs. Watson if she understands how to use the PCA pump. She should review the use of the pump with Mrs. Watson, including daughter in teaching to make sure that Mrs. Watson does not push "the button" too many time and overdose on pain medication. C. Lana should ask Mrs. Watson if she understands how to use the PCA pump. She should then review the use of the pump with Mrs. Watson. She will want to include the daughter in the teaching since she is going to be staying with Mrs. Watson

C. Lana should ask Mrs. Watson if she understands how to use the PCA pump. She should then review the use of the pump with Mrs. Watson. She will want to include the daughter in the teaching since she is going to be staying with Mrs. Watson

The nurse sees the nursing assistive personnel perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention? A. Ambulating patient with enteral feedings still infusing B. Fastening tube to the gown with new tape C. Placing patient supine while giving a bath

C. Placing patient supine while giving a bath

A nurse admits a 72-year-old patient with a medical history of hypertension, heart failure, and depression to a general medical patient care unit. The nurse reviews the patient's medication orders and notes that the patient has three health care providers who have ordered a total of 13 medications. What is the most appropriate action for the nurse to take next? A. Provide medication education to the patient to help with adherence to the medical plan B. Set up a medication schedule for the patient that is least disruptive to the expected treatment schedule in the hospital C. Review the list of medication with the health care providers to ensure that the patient needs all 13 medications. D. Give the medications after identifying the patient using 2 identifiers.

C. Review the list of medication with the health care providers to ensure that the patient needs all 13 medications.

Which patients are at high risk for nutritional deficits? Select all that apply. A. The 65-year-old patient with gallbladder disease whose electrolyte, albumin, and protein levels are normal B. The divorced computer programmer who eats precooked food from the local restaurant C. The middle-age female with celiac disease who does not follow her gluten-free diet D. The 45-year-old patient with type II diabetes who monitors her carbohydrate intake and exercises regularly E. The 25-year-old patient with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements

C. The middle-age female with celiac disease who does not follow her gluten-free diet E. The 25-year-old patient with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements

The nurse is planning to teach a patient the importance of smoking cessation. When is the best time for teaching to occur? Select all that apply. A. When the patient is being transported for a procedure to make conversation B. When there are visitors in the room C. When the patient states that he or she is symptom free D. Just before lunch, when the patient is most awake and alert E. When the patient is talking about current stressors in his or her life

C. When the patient states that he or she is symptom free D. Just before lunch, when the patient is most awake and alert

After surgery Mr. Baker is taken to the PACU, the endotracheal tube is removed, and Mr. Baker responds to his name. During the time in the PACU, Lori monitors respiratory status closely due to what factors? A. Anesthesia can have a depressing effect on respirations B. Mr. Baker has a history of smoking C. Mr Baker has an abdominal incision D. All of the above

D. All of the above

A nurse is conducting discharge teaching for a patient with diminished tactile sensation. Which of the following statements by the patient indicates that additional teaching is needed? A. I am at risk for injury from temperature extremes B. I may be able to dress more easily with zippers or pullover sweaters C. A home care nurse may help me figure out how to be more independent D. I have a right-sided partial paralysis and reduced sensation; so I should dress the left side of my body first

D. I have a right-sided partial paralysis and reduced sensation; so I should dress the left side of my body first

Mr. Miller is also to have a tap water enema to promote bowel evacuation. After gettin her equipment ready, Sally should position Mr. Miller in what position on the table? A. Right side-lying position with his left knee flexed B. Right side-lying position with his right knee flexed C. Left side-lying with his right knee flexed D. Left side-lying position with his left knee flexed

D. Left side-lying position with his left knee flexed

After a patient has been given preoperative sedative, which safety precaution do you take? A. Obtain informed consent immediately after sedative administration B. Raise the side rails and keep the bed or stretcher in the high position C. Determine if patient has any allergies to latex D. Reinforce to patient to remain in bed or on the stretcher

D. Reinforce to patient to remain in bed or on the stretcher

A patient is hyperventilating from acute pain and hypoxia. Interventions to manage his pain and oxygenation will decrease his risk of which acid-base imbalance? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

D. Respiratory alkalosis

A nursing student is administering ampicillin PO. The expiration date on the medication wrapper was yesterday. What it the appropriate action for the nursing student to take next? A. Administer the medication since medications are good for 30D after their expiration date B. Call the health care provider after discussing this situation with the charge nurse C. Ask the nursing professor for advice D. Return the medication to the pharmacy and get another tablet

D. Return the medication to the pharmacy and get another tablet

A patient with numbness and tingling in the left arm, SOB, and chest pain is having an emergency cardiac catheterization. Which teaching approach does the nurse use in this situation? A. Participating approach B. Selling approach C. Entrusting approach D. Telling approach

D. Telling approach

A nursing student is administering medications to a patient through a gastric tube. Which of the following actions taken by the nursing student requires the nursing instructor to intervene? A. The nursing students places all the patient's medication in different medicine cups B. The nursing student flushes the tub with 30mL of water between each medication C. The nursing student evaluates each medication and holds the tube feeding before administering a medication that needs to be administered on an empty stomach. D. The nursing student crushes a Nifedipine extended-release tablet and mixes it with water before administering it.

D. The nursing student crushes a Nifedipine extended-release tablet and mixes it with water before administering it.

George is a 14-year-old boy who has come to your clinic today for a flu shot. He is afraid of injections. Which of the following techniques can the nurse use that will decrease George's discomfort? A. Ask George to think about why the flu shot is important B. Tell George that it is silly for him to be afraid and that flu shots do not hurt C. Use a large gauge needle D. Use a small gauge needle

D. Use a small gauge needle

The nurse is caring for a patient with glaucoma. When developing a discharge plan, which priority intervention enables the patient to function safely with existing deficits and continue a normal lifestyle? A. Encourage the patient to rearrange their home furnishings regularly to keep active. B. Suggest to the patient that he or she consider either moving to a smaller home or long-term care facility. C. Say nothing because it is the most appropriate that the patient identify personal interventions to compensate for a sensory alteration D. Work closely with the patient and family to identify in-home medications to create a comfortable and accessible environment

D. Work closely with the patient and family to identify in-home medications to create a comfortable and accessible environment

Match the pressure ulcer categories/stages with the correct definition - partial-thickness skin loss or intact blister with serosanguinous fluid - full thickness tissue loss; muscle and bone visible. May include undermining -Full-thickness skin loss; subcutaneous fat may be visible. May include undermining -Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present

Stage I - Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present Stage II - partial-thickness skin loss or intact blister with serosanguinous fluid Stage III - Full-thickness skin loss; subcutaneous fat may be visible. May include undermining Stage IV - full thickness tissue loss; muscle and bone visible. May include undermining