Fundamentals Exam 2

Which type of inhalers require less manual dexterity? 1 Dry powder inhalers 2 Mist spray metered-dose inhalers 3 Pressurized metered-dose inhalers 4 Breath-actuated metered-dose inhalers

1 Dry powder inhalers require less manual dexterity because the device is activated with the patient's breath so there is no need to coordinate puffs with inhalation. Mist spray metered-dose inhalers need hand-breath coordination. Pressurized metered-dose inhalers require an application of pressure to administer medication. Breath-actuated metered-dose inhalers release medication depending on the strength of the patient's breath on inspiration.

Which injection is most preferred for allergy skin testing? 1 Intradermal injection 2 Intravenous injection 3 Intramuscular injection 4 Subcutaneous injection

1 Intradermal injections are mostly preferred for skin testing. Intravenous injections are primarily used for fluid replacement in patients who are unable to take oral fluids. This includes supplying the electrolytes and nutrients. Intramuscular injections are preferred for medications such as hepatitis B and tetanus, diphtheria, and pertussis immunizations. For low-molecular-weight heparin, a subcutaneous injection is preferred.

What is the disadvantage of medication administration through intraocular disk? 1 Expensive 2 Slow absorption 3 Risk of introducing infection 4 Occurrence of serious systemic effects

1 Intraocular disk medications are usually expensive. Medications are absorbed slowly when administered topically on the skin. Administration of medication through the parenteral route may introduce infection. Some local agents used as inhalational sprays can cause serious systemic effects.

The nurse prepares to administer a solid form of oral medications. Which action made by the nurse indicates a need for correction? 1 Splitting the tablet in half when it is necessary to give half of a pill 2 Popping medications through the file into the cup when using a blister pack 3 Pouring the required tablet into a bottle cap 4 Placing the tablet into a cup without removing the wrapper while preparing unit dose tablets

1 Splitting tablets in half, even if they are prescored with a line down the middle, leads to medication errors. If a pill must be split within inpatient settings, the pharmacist splits the pill with a splitting device, repackages and labels it, and sends it to the nurse for administration. Nurses should not split pills. When using a blister pack, the nurse should pop medications through the foil or paper backing into a medication cup. To prepare tablets or capsules from a floor stock bottle, the nurse should pour the required amount into a bottle cap and transfer the medication to the medication cup without touching the medication with his or her fingers. To prepare unit-dose tablets or capsules, place the packaged tablet or capsule directly into the medicine cup without removing the wrapper.

Which route of drug administration is most economical and convenient? 1 Oral 2 Topical 3 Parenteral 4 Inhalational

1 The oral route of drug administration is convenient, comfortable, economical, and easy to administer. The topical route of administration is painless and primarily provides a local effect with limited side effects. Parenteral routes can be used when oral medications are contraindicated. This route has a more rapid absorption than topical or oral routes, but is expensive and not a convenient route for drug administration. Inhalational route provides rapid relief for local respiratory problems.

A patient has a bleeding tendency due to hemophilia. Which route of drug administration is appropriate for this patient? 1 Oral 2 Intradermal 3 Intramuscular 4 Subcutaneous

1 The route of administration appropriate for a patient with a bleeding tendency is the oral route, because it does not involve the use of needles. Any mode of administration that uses needles may increase the risk of bleeding. Therefore, intradermal, intramuscular, and subcutaneous routes should be avoided in this case to prevent bleeding.

While teaching a patient about metered dose inhalers, the nurse discusses the three-point position. What is the rationale for this nursing intervention? 1 To help the patient activate the canister 2 To direct the aerosol towards the airways 3 To ensure that fine particles are aerosolized 4 To distribute medication to the airways during inhalation

1 The three-point technique involves holding and having the thumb at the mouthpiece, with the index and middle fingers at the top. Holding the metered dose inhaler in this way will help the patient activate the canister effectively. Closing the mouth around the mouthpiece will help direct the aerosol towards the airways. A metered dose inhaler is shaken vigorously to ensure that fine particles are aerosolized. The patient is instructed to tilt his or her head back slightly to properly distribute medication to the airways during inhalation.

The registered nurse is teaching a nursing student about the role of the nurse in medication administration. Which statement if made by the nursing student indicates effective learning? 1 "I should assess the patient's ability to self-administer medications." 2 "I should delegate a part of the administration process to nursing assistive personnel." 3 "I should educate about medication administration and monitoring only to the family." 4 "I should instruct the patient about medications to be taken home on the day of discharge."

1 Unique nursing knowledge and skills are needed for medication administration. The role of a nurse in the medication administration is to assess the patient's ability to self-administer medications. The nurse should avoid delegating any part of medication administration to nursing assistive personnel. The nurse should educate the family and the patients about medication administration and monitoring. The instructions about medication to be taken home should begin as soon as possible to benefit the patient.

The registered nurse is teaching a nursing student how to administer eardrops to a 3-year-old patient with otitis media. Which action of the nursing student needs further correction? 1 Instilling the drops directly into the ear canal 2 Placing the cotton ball in the outermost part of the ear canal 3 Straightening the ear canal by pulling the auricle upward and outward 4 Instilling the drops holding the dropper 1 cm (½ inch) above the ear canal

1 While administering eardrops, instill prescribed drops above ear canal. The cotton ball should be placed in the outermost part of the ear canal, if needed after instilling the drops. The ear canal should be straightened by pulling the auricle upward and outward in children over 3 years of age and older adults. The prescribed eardrops should be instilled by holding a dropper 1 cm (½ inch) above the ear canal.

A patient is inhaling using a breath-activated metered-dose inhaler. Which action made by the patient indicates a need for correction? 1 Shaking the inhaler vigorously 2 Positioning the mouthpiece between the lips 3 Inhaling deeply and forcefully through the mouth 4 Holding the breath for 5 to 10 seconds during inhalation

1 While using a breath-activated metered-dose inhaler, the inhaler should not be shaken. The mouthpiece should be positioned between the lips for medication administration. The patient should inhale deeply and forcefully through the mouth to create an aerosol. The patient should hold his or her breath for 5 to 10 seconds during inhalation to ensure full medication administration.

The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse's next best course of action? 1 Ask the prescriber to change the order. 2 Crush the pill with a mortar and pestle. 3 Hide the capsule in a piece of solid food. 4 Open the capsule and sprinkle it over pudding.

1 Enteric-coated or sustained-release capsules should not be crushed or opened; the nurse should contact the prescriber to change the medication to a form that is liquid or can be crushed. The nurse should not hide the capsule in a piece of solid food, because it could put the patient at risk for choking

While preparing to administer oral medication, the charge nurse instructs the staff nurse to use a dysphagia screening tool. What is the rationale behind this instruction? 1 To assess the risk for aspiration 2 To assess the risk for allergic reaction 3 To assess the risk for food and drug interactions 4 To assess the risk for incorrect medication administration

1 Patients with dysphagia are at risk for aspirating oral medications. A dysphagia screening tool is used to assess the risk for aspiration. A patient's medical, medication, and dietary history are reviewed to assess the risk for allergic reactions and food-drug interactions. The medication administration record is checked to assess the risk for incorrect medication administration.

The primary health care provider prescribes pain medication to a patient with the notation "prn" in the prescription. What should the nurse interpret from the prescription? 1 The medication should be taken as needed. 2 The medication should be taken every hour. 3 The medication should be taken before meals. 4 The medication should be taken twice each day.

1 The notation "prn" in the prescription indicates that the medication can be taken as and when required, maintaining a specific time interval between doses. The notation "qh" indicates that the medication should be taken every hour. The notation "ac" indicates that the medication should be taken before meals. "bid" indicates that the medication should be taken twice a day.

The nurse is explaining to a patient about the side effects of a prescribed drug. Which terms describe side effects? Select all that apply. 1 Predictable 2 Often unavoidable 3 Occur after prolonged intake 4 Occur at usual therapeutic dose 5 Caused by defective drug excretion

1,2,4 Every drug has a desired therapeutic effect and certain other effects that are not desired. These effects of the drug are called side effects. These effects are usually predictable and often unavoidable due to the action of the drug on the organs other than the target organ. These side effects occur at the usual therapeutic dose, and dose adjustments may have little effect. Side effects are not due to prolonged intake or defective excretion of the drug. Prolonged intake and defective excretion of the drug may cause toxic effects due to drug accumulation.

Which interventions should the nurse follow while administering topical medications? Select all that apply. 1 Applying the topical medications with gloves and applicators 2 Applying each type of medication according to the directions of use 3 Using nonsterile techniques while applying medications for open wounds 4 Cleaning the skin thoroughly by washing the injured area gently with hot water 5 Documenting the location on the patient's body where the medication was placed

1,2,5 Many locally applied medications such as lotions, pastes, and ointments create systemic and local effects. Therefore, these medications should be applied with gloves and applicators. Different types of topical medication should be applied according to the directions to ensure proper penetration and absorption. Documenting the location on the patient's body where the medication was placed will help to prevent multiple dosing in the patient. The medications should be applied using sterile techniques in the case of open wounds. Before applying medications to the injured area, the skin should be thoroughly cleaned by washing the area gently with soap and water, and ensuring the soaking of the involved site.

What are the advantages of administering medications via volume-controlled infusions? Select all that apply. 1 Volume-controlled infusions reduce the risk of a rapid-dose infusion by an intravenous push. 2 Volume-controlled infusions involve diluting and infusing medications over longer time intervals. 3 Volume-controlled infusions provide increased patient mobility, safety, and comfort. 4 Volume-controlled infusions allow for cost savings because of the omission of continuous intravenous therapy. 5 Volume-controlled infusions allow for the administration of medications that are stable for a limited time in a solution.

1,2,5 Volume-controlled infusions reduce the risk of rapid-dose infusion by an intravenous push. This method involves medications being diluted and infused over longer time intervals. This method allows for administering medications that are stable for a limited time in a solution. Intermittent venous access allows for increased patient mobility and hospital cost savings because of the omission of continuous intravenous therapy.

The primary health care provider ordered the nurse to administer nasal drops to a patient with a sinus infection. Which nursing interventions would be beneficial for the patient? Select all that apply. 1 Holding dropper 1 cm (½ inch) above the nares 2 Instructing the patient to breathe through the mouth 3 Instilling the drops towards the side of the ethmoid bone 4 Tilting the patient's head forward for access to posterior pharynx 5 Tilting the patient's head back over the edge of the bed for access to the ethmoid bone

1,2,5 While administering nasal drops to a patient with a sinus infection, the nurse should hold the dropper 1 cm (½ inch) above the nares. The patient should be instructed to breathe through the mouth. The nurse should tilt the patient's head back over the edge of the bed for access to the ethmoid bone. The drops should be instilled towards the midline of the ethmoid bone. The patient's head should be tilted back for access to posterior pharynx.

The nurse has to administer a medication via intramuscular (IM) injection. Which are the various sites that can be used for an IM injection? Select all that apply. 1 Deltoid 2 Brachioradialis 3 Vastus lateralis 4 Ventrogluteal 5 Sternocleidomastoid

1,3,4 The three common sites for administering intramuscular (IM) injections are the deltoid, vastus lateralis, and ventrogluteal muscles. The deltoid site is easily accessible and is used for injecting small volumes. The vastus lateralis is a thick and well-developed muscle, located on the anterior lateral aspect of the thigh. The ventrogluteal muscle is the safest site for injection. It is deep and away from major nerves and blood vessels. The brachioradialis is a muscle of the arm and is not used for injecting medications. The sternocleidomastoid is a muscle of the neck and is not a favorable site for administering IM injections.

When is the administration of an oral medication contraindicated? Select all that apply. 1 When the patient is unconscious 2 When the patient is an older adult 3 When the patient has gastric suction 4 When the patient is a 5-year-old child 5 When the patient is awaiting surgery

1,3,5 Oral medication administration is contraindicated when a patient is unconscious, has gastric suction, or is awaiting surgery. Oral medication administration can be safely used for an older adult or a 5-year-old child.

The nurse is preparing an intravenous medication for an infant in the pediatric unit and is using a tuberculin syringe for precise medication measurement. The tuberculin syringe is calibrated in hundredths of a milliliter. What is the capacity of the syringe? Record your answer using a whole number. __ mL

1mL The capacity of the tuberculin syringe is 1 mL and is used to prepare small amounts of medications (e.g., intradermal or subcutaneous injections). IM 5ml SC/IM 3mL ID 1 mL insulin 50 units

he primary health care provider prescribes decongestant spray to a patient with sinusitis. Which action should the nurse perform immediately after administering the decongestant? 1 Observing the patient for side effects 2 Asking if the patient is experiencing any difficulty in breathing 3 Positioning the patient's head tilted slightly forward in the supine position 4 Comparing the name of the medication on the label with the medication administration record

2 Difficulty in breathing is the adverse effect of decongestants; therefore, it is important to ask a patient immediately if he or she has difficulty breathing after the administration of decongestants. After 15 to 30 minutes of decongestant administration, the nurse should observe the patient for any signs of side effects. Before the administration of nasal sprays, the patient is positioned in the supine position and the head is tilted forward. Before administering the medication, the name of the medication on the label is compared with the medication administration record.

Which statement is true regarding piggybacks? 1 A piggyback is battery-operated. 2 A piggyback is connected to a short tubing line. 3 A piggyback is commonly known as a saline lock. 4 A piggyback contains 10 to 20 mL of fluid.

2 A piggyback is connected to a short tubing line. A syringe pump is battery-operated and contains a very small amount of fluid. Intermittent venous access is commonly known as a saline lock. A piggyback contains between 25 and 250 mL of fluid.

After reading the prescription order of a patient, the nurse prepares to administer the medication in the patient's right ear. Which abbreviation in the prescription reflects the nurse's action? 1 AS 2 AD 3 OD 4 OS

2 AD in the prescription order indicates that the medication should be administered in the right ear. AS in the prescription order indicates that the medication should be administered in the left ear. OD indicates that the medication should be administered in the right eye. OS indicates that the medication should be administered in the left eye.

Which site is frequently recommended for administering heparin injections? 1 Thigh 2 Abdomen 3 Upper arm 4 Dorsal gluteal area

2 Heparin is administered subcutaneously at the abdominal site. This site has the best absorption. The thigh, upper arm, and dorsal gluteal areas are other sites for subcutaneous injection that are not widely recommended to administer heparin.

The nurse has applied a transparent fentanyl transdermal patch to a patient with pain. Which action of the nurse would be most appropriate for the patient? 1 Massaging over the patch to enhance absorption 2 Applying label to the patch to make it noticeable 3 Instructing the patient to avoid wetting the patch 4 Asking the patient about any medication history

2 In cases in which the patch or the dressing is clear or difficult to see, applying a noticeable label to the patch is the most appropriate intervention. This is to avoid inadvertently leaving the old transdermal patches in place, which may result in an overdose of the medication in the patient. Patients who use fentanyl transdermal patches for pain management can experience respiratory depression, coma, and death when the patches are not removed on time. Massaging should not be done on the patch after applying. Instructing the patient to avoid wetting the patch is not an appropriate action. Asking the patient about his or her medication history should be done before applying the patch.

Which statement is true regarding an inhaler containing rescue medication? 1 Rescue medication is long acting. 2 Rescue medication provides immediate relief. 3 The effects of rescue medication last for a longer period. 4 Rescue medication is used on a daily schedule.

2 Inhalers that contain rescue medications are used to provide immediate relief for acute respiratory distress. Rescue medications are short-acting. Maintenance medications last for a long period of time and are used on a daily schedule.

A diabetic patient has been switched from oral antidiabetic drugs to insulin. The nurse teaches the patient about self-administration of insulin. What is the route for insulin injection? 1 Intradermal 2 Subcutaneous 3 Intramuscular 4 Intravenous

2 Insulin is given as a subcutaneous injection for slower absorption. The intradermal route is used for skin tests. The intramuscular route is used for medications that need a faster absorption and are given in a volume that cannot be administered through subcutaneous route. The intravenous route is used for medications that are administered in a large volume.

Which topical medication contains alcohol? 1 Lotion 2 Liniment 3 Ointment 4 Transdermal disk

2 Liniment usually contains alcohol and is applied to the skin. Lotion is a semi-liquid suspension that usually protects, cools, or cleanses the skin. Ointment is a semisolid, externally applied preparation that usually contains one or more medications. Transdermal disks, or patches, are medications that are absorbed through the skin slowly over a long period. Lotions, ointments, and transdermal disks may not contain alcohol.

While caring for a patient taking herbal and nutritional supplements orally, a registered nurse teaches a nursing student about the interactions of a newly prescribed oral medication with the nutritional and herbal supplements the patient is already administering. How does this knowledge help the nursing student in providing effective care for the patient? 1 This knowledge helps to determine the dose of the drug to be administered 2 This knowledge helps to determine the best time for medication administration 3 This knowledge helps to determine the best route for medication administration 4 This knowledge helps to determine the dosage frequency of the drug to be administered

2 Many medications interact with nutritional and herbal supplements. Knowledge about these interactions helps to determine the best time to give oral medications. The health care provider determines the dose of the drug based on the patient's condition. Knowledge about these interactions may not help the nurse determine the dose of the drug. The route of drug administration and dosage frequency depends on the drug used and the patient's condition, which is determined by the health care provider.

After seeing a patient, the physician gives the nursing student a verbal order for a new medication. What should the nursing student do first? 1 Follow Institute for Safe Medication Practices (ISMP) guidelines for abbreviations. 2 Explain to the physician that the order should be given to a registered nurse. 3 Write down the order on the patient's order sheet and read it back to the physician. 4 Ensure that the six rights of medication administration are followed when giving the medication.

2 Nursing students cannot take orders from physicians. Thus, there is no need to refer to the ISMP for abbreviation guidelines, write down the order, and ensure the six rights of medication administration are followed in this instance.

The nurse cares for four patients in the medical unit. Which patient does the nurse suspect most likely needs parental administration of medication? 1 A child with anxiety 2 B unconscious adult 3 C bleeding tendency 4 D eye infection

2 Patient B is unconscious and is unable to take the medication orally. Therefore, the nurse has to administer the medication parentally in the patient B. Parental administration of the medication may increase anxiety in children. Therefore, the nurse should either calm patient A first and then begin parenteral injection or avoid this route altogether. Because patient C has bleeding tendencies, the parenteral route is considered to be too invasive. A patient with an eye infection can take medications orally, which is more comfortable and convenient.

A nursing student takes a patient's antibiotic to his room. The patient asks the nursing student what it is and why he should take it. How should the nursing student respond to the patient? 1 Explain that only the patient's physician can give this information. 2 Provide the name of the medication and a description of its desired effect. 3 State that information about medications is confidential and cannot be shared. 4 Tell the patient he has to speak with his assigned nurse about this.

2 Patients need to know information about their medications so they can take them correctly and safely. The nursing student can provide the name of the medication and a description of its desired effect. The student should not dismiss the patient's concerns by telling the patient that he should speak with the physician or assigned nurse.

While assessing a patient who is receiving intravenous therapy, the nurse notices circulatory fluid overload. What may be the reason for the patient's condition? 1 Overdose of the medication 2 Rapid infusion of the intravenous fluid 3 Flushing the intravenous port with saline solution 4 Incompatibility between the medication and the intravenous fluid

2 Rapid infusion of the intravenous fluid may cause circulatory overload in patients on intravenous therapy. Therefore, the nurse should verify the rate of administration with a medication reference or a pharmacist before giving them to ensure that intravenous infusions are safe over an appropriate amount of time. The patient is at a risk of medication overdose if the intravenous fluids are infused too rapidly. Flushing the intravenous port with the saline solution helps to maintain the patency of the intravenous line, but does not cause any adverse effects. The nurse should check the incompatibility of the medication with the fluid before starting the therapy.

While assessing a patient who experienced a mild allergic reaction, the nurse observes swelling and a clear, watery discharge from the nose. Upon nasal mucosal biopsy, the nurse finds inflammation of the mucous membranes. Which allergic reaction should the nurse suspect in the patient? 1 Rash 2 Rhinitis 3 Pruritus 4 Urticaria

2 Rhinitis is characterized by the inflammation of mucous membranes lining the nose. This inflammation causes swelling along with clear, watery discharge. Rashes are small, raised vesicles that are usually reddened and are distributed over the entire body. Pruritus is itching of the skin. It is accompanied with red rashes that are distributed over the entire body. The patient with urticaria shows raised, irregularly shaped skin eruptions of varying sizes and shapes. These eruptions have reddened margins and pale centers. Inflammation of the nasal mucous membranes is seen in a patient with urticaria.

Which term indicates the use of tampons that are treated with medication? 1 Ear instillation 2 Nasal instillation 3 Rectal instillation 4 Vaginal instillation

2 Tampons treated with medication are used for nasal instillation. Tampons are not indicated for rectal, ear, or vaginal instillation. Eardrops are used for ear instillation. Rectal suppositories are indicated for rectal instillation. Vaginal suppositories are indicated for vaginal instillation

What is the significance of the deltoid muscle site in parenteral administration? 1 The deltoid muscle site is used to administer heparin 2 The deltoid muscle site is used to administer hepatitis B vaccine 3 The deltoid muscle site is used to administer medications that have larger volumes 4 The deltoid muscle site is used to administer medications that are viscous and irritating

2 The deltoid muscle site is easily accessible and is used to administer small volumes of a medication. It is mainly used for giving immunizations such as hepatitis B and flu shots. Heparin is most likely to be administered via the subcutaneous route of administration. Medications that are more than 2 mL would be administered through the ventrogluteal muscle site. The ventrogluteal site is also preferred for medications that are viscous and irritating.

Which injection is given to a patient attending a tuberculin screening test? 1 Intrathecal 2 Intradermal 3 Intravenous 4 Subcutaneou

2 Tuberculin may be potent and a patient may have a severe anaphylactic reaction when tuberculin enters the circulation too rapidly. Therefore, tuberculin is administered through the intradermal route. An intrathecal injection is given to the spinal canal and is very painful. An intravenous injection may cause the patient to experience anaphylactic reactions. A subcutaneous injection may lead to unwanted reactions.

A patient reports severe vomiting, diarrhea, and abdominal cramps to the nurse. Which form of medication is contraindicated in the patient? 1 Lotion applied to the topical surface 2 Tablet administered through the oral route 3 Solution administered through an intravenous line 4 Transdermal medicine administered through the skin surface

2 Vomiting, diarrhea, and abdominal cramps are suggestive of the disturbed gastrointestinal tract. The oral route of drug administration is contraindicated in patients with gastrointestinal disturbance, because there will not be effective drug absorption. The astopial route, intravenous route, and transdermal route do not require gastrointestinal system for drug metabolism, so these routes of drug administration are safe for this patient.

Which nursing intervention is beneficial while administering a bitter medication to a child? 1 Reducing the dose of the medication 2 Offering the child a frozen juice bar 3 Replacing the medication with other medication 4 Mixing the medication in the child's favorite food

2 When a medication tastes bitter, the nurse should offer the child a frozen juice bar to numb the child's taste buds. Reducing the dose of the medication will not mask the bitter taste. The nurse is not authorized to replace a medication. The nurse should not mix a bitter medication into the child's food because the child may later refuse to eat the food.

A patient is on a corticosteroid inhaler. The nurse instructs the patient to rinse the mouth with salt water after inhalation. What is the rationale for this nursing intervention? 1 To prevent loss of powder 2 To prevent a fungal infection 3 To ensure full medication administration 4 To prevent medication from escaping through mout

2 While caring for a patient who is using a corticosteroid inhaler, the nurse should instruct the patient to rinse his or her mouth with salt water after inhalation to prevent fungal infections. The nurse should instruct the patient to exhale away from the inhaler before inhalation to prevent a loss of powder. The nurse should instruct the patient to hold his or her breath for 5 to 10 seconds to ensure full medication administration. The nurse should instruct the patient to position the mouthpiece between the lips to prevent medication from escaping through the mouth.

The nurse is administering prescribed medications to patients on the unit. When should the nurse compare the label of the medication container with the medication administration record (MAR)? Select all that apply. 1 Comparing the label with the medication administration record (MAR) is not required. 2 Before removing the container from the shelf 3 Twice daily regardless of administration to patients 4 At the patient's bedside before administering the medication 5 When the amount of medication ordered is removed from the container

2,3,4 The nurse is responsible to ensure that the right drug is administered to the right patient. Therefore, the nurse should compare the label of the medication container with the medication administration record (MAR) three times. The nurse should check the medication label before removing the container from the drawer or shelf and should verify the medication label again as the right amount of medication ordered is removed from the container. Finally, the nurse should check the medication label at the patient's bedside before administering the medication to the patient.

A primary health care provider prescribed a transparent fentanyl patch to manage a patient's pain. A new patch was applied without removing the old one. Which symptoms may be seen in the patient due to the delayed removal of the fentanyl patch? Select all that apply. 1 Pain 2 Coma 3 Death 4 Allergic reactions 5 Respiratory depression

2,3,5 Medication remains on the patch even after its recommended duration of use. When the old transdermal patch is inadvertently left in place while a new one is applied, it may result in an overdose of medication. The patient using fentanyl transdermal patches for pain management can experience coma, death, and respiratory depression when the patches are not removed in the recommended time. Pain and allergic reactions are not typical when the patches are not removed in the recommended time.

Which statements are true regarding the topical route of medication administration? Select all that apply. 1 It has more side effects. 2 It primarily provides local effect. 3 It is a painless route of administration. 4 Medications are absorbed through skin rapidly. 5 Patients with skin abrasions are at risk for systemic effect.

2,3,5 Topical medications are the medications that are applied locally, most often to intact skin. Medications applied to the skin and mucous membranes generally have local effects. This route of administration is usually painless. Patients with skin abrasions are at risk for rapid medication absorption and systemic effects. This route of administration has fewer side effects. The medications are absorbed through skin slowly compared to other routes.

Which is an example of the direct application of topical medications? Select all that apply. 1 Eardrops 2 Eyedrops 3 Nose drops 4 Swabbing the throat 5 Inserting medicated packing into the vagina

2,4 Administration of eyedrops and swabbing the throat are examples of direct application of topical medications. Administration of eardrops and nose drops are examples of instillation of fluids into a body cavity. Inserting medicated packing into the vagina is an example of insertion of medication into a body cavity.

The primary health care provider ordered the nurse to administer eardrops to a 5-year-old patient with an ear infection and a latex allergy. Which action of the nurse indicates a need for improvement? Select all that apply. 1 Removing the cotton ball after 15 minutes 2 Using latex gloves for cleaning the outer ear 3 Holding the dropper 1 cm (1/2 inch) above the ear canal 4 Straightening the ear canal by pulling the auricle down and backward 5 Asking the patient to remain in the side-lying position for 2 to 3 minutes

2,4, During the administration of eardrops in a 5-year-old patient with a latex allergy, the nurse should use latex-free gloves for cleaning the outer ear. For patients 3 years of age and older, the nurse should straighten the ear canal by pulling the auricle upward and outward. For patients of every age the nurse should remove the cotton ball after 15 minutes, hold the dropper 1 cm (1/2 inch) above the ear canal before administering eardrops, and help the patient to remain in the side-lying position for 2 to 3 minutes.

Which statement made by the nursing student regarding topical medications indicates ineffective learning? Select all that apply. 1 "Side effects with topical medications are limited." 2 "Anxiety following application is common." 3 "The effect of most topical medications is primarily local." 4 "Absorption occurs through the skin or mucous membranes." 5 "Topical absorption is more rapid than parenteral absorption

2,5 Medications administered through parenteral routes (subcutaneous, intramuscular, intravenous, and intradermal) may cause anxiety in patients, especially children. This is not the case with topical application, so this statement indicates ineffective learning. Parenteral routes have more rapid absorption than topical and oral routes, so this statement also indicates ineffective learning. Topical medications typically have limited side effects, primarily provide local effects, and are absorbed through skin or mucous membranes only.

The registered nurse is teaching a nursing student about preventing errors during medication administration. Which statements if made by the nursing student indicates effective learning? Select all that apply. 1 "I should document medications before administering." 2 "I should ensure that I am well rested when caring for patients." 3 "I should use one patient identifier while administering medications." 4 "I should read the label once carefully before administering medications." 5 "I should use automated medication dispensers (AMDs) to administer medications."

2,5 Nurses should be sure they have adequate rest while caring and administering medications to patients. When a nurse "works around" the technology, medication errors occur. Therefore, the nurse should use automated medication dispensers (AMDs) for medication administration. The nurse should document medications after administration. The nurse should use at least two patient identifiers while administering medications. The label should be read three times before administering the medication.

The nurse has been asked to administer a medication in the dose of 10 mg/kg for a pediatric patient weighing 44 lb. What dose should the nurse administer? Record your answer using a whole number. __________ mg

200mg First convert the patient's weight to kilograms. Because 2.2 lb equals 1 kg and the patient weighs 44 lb, the patient's weight is 20 kg. The formula is 44 lb/2.2 = 20 kg. Because the medication has to be administered at the dose of 10 mg/kg body weight, the dose of medication to be administered is 200 mg. 10mg x 44ib ________________ = 200mg kg x 2.2

While administering a rectal suppository in a patient, the nurse finds that anal sphincter is not relaxed. Which intervention of the nurse would help the patient relax the anal sphincter? 1 Performing the third accuracy check again 2 Applying gentle pressure on buttocks and holding them together 3 Instructing the patient to take slow, deep breaths through the mouth 4 Instructing the patient to remain in the side position for 5 minutes after administration

3 While administering a rectal suppository, asking a patient to take slow, deep breaths through the mouth will help in relaxing the anal sphincter. The third accuracy check is performed to confirm or ensure that the desired patient is being treated. Applying gentle pressure on buttocks and holding them together will be helpful in keeping the medication in place. Instructing the patient to remain in the side position for 5 minutes will help in preventing expulsion of the suppository.

A patient is transitioning from the hospital to the home environment and obtains a home care referral. Which is priority for the discharge nurse in relation to safe medication administration? 1 Set up the follow-up appointments with the physician for the patient. 2 Ensure that someone will provide housekeeping for the patient at home. 3 Ensure that the home care agency is aware of medication and health teaching needs. 4 Make sure the patient's family knows how to safely bathe the patient and provide mouth care.

3 A nursing responsibility is to collaborate with community resources when patients have home care needs or difficulty understanding their medications. Setting up follow-up appointments, ensuring that someone will provide housekeeping for the patient, and making sure the patient's family knows how to safely bathe the patient are not the priority for the discharge nurse in relation to medication administration.

The primary health care provider advises a patient to dissolve the prescribed drug in his mouth for a long time without swallowing. Which form of medication is prescribed for this patient? 1 Elixir 2 Capsule 3 Lozenge 4 Enteric-coated tablet

3 Flat, round tablets that dissolve in the mouth to release medication not meant for ingestion are referred to as lozenges. Elixir contains a clear fluid with water and alcohol that is often sweetened. Medication encapsulated in a gelatin to be swallowed is referred to as a capsule. Coated tablets that dissolve in the intestine are referred to as enteric-coated tablets.

Which type of volume-controlled infusion is commonly called a saline lock? 1 Piggyback 2 Syringe pump 3 Intermittent venous access 4 Volume-controlled administration set

3 Intermittent venous access is commonly called a saline lock. A piggyback is a small intravenous bag and its tubing is known as a microdrip system. Syringe pumps are battery-operated. Volume-controlled administration sets are small containers that attach just below the primary infusion bag.

The nurse finds a STAT order in the medication administration record of a patient. What action of the nurse is appropriate in this situation? 1 Administering the medication after 1 hour 2 Administering the medication when it is needed 3 Administering the medication only once and immediately 4 Administering the medication before the surgical procedure

3 STAT medications are given once and at the time the medication is ordered. Therefore, it requires administration immediately and only once. Medications that are not time-critical can be administered within 1 to 2 hours of the scheduled dose. Prn medications require administration as needed. STAT orders do not indicate administering the medication before the surgical procedure.

Which route of administration mainly uses medication in the form of aerosol sprays? 1 Oral 2 Buccal 3 Inhalational 4 Transdermal

3 The inhalational route of administration uses aerosol sprays, mists, or powders that penetrate lung airways. The oral route of administration generally uses medication in the form of solids and liquids. The buccal route of administration also uses medications in the form of solids and liquids. The transdermal route generally uses medication in the form of transdermal patches.

The nurse is administering medications to a 4-year-old patient. After the nurse explains which medications are being given, the mother states, "I don't remember my child having that medication before." Which action should the nurse take next? 1 Give the medications. 2 Identify the patient using two patient identifiers. 3 Withhold the medications and verify the medication orders. 4 Provide medication education to the mother to help her better understand her child's medications.

3 The nurse should not ignore patient or caregiver concerns and should always verify orders whenever a medication is questioned before administering it.

The nurse finds morphine sulfate 2 mg IV Q 4 hours prn in the prescription of a newly admitted patient in the hospital. Which action should the nurse perform based on this finding? 1 Administer morphine sulfate intravenously (IV) only once at specified time. 2 Administer morphine sulfate intravenously (IV) only once within 90 minutes. 3 Administer morphine sulfate intravenously (IV) when the patient requires it but not more than every 4 hours. 4 Administer morphine sulfate intravenously (IV) only once immediately when the patient's condition changes.

3 The term prn indicates that the medication is prescribed to the patient when it is required, and Q 4 hours means that the medication should not be administered more frequently than every 4 hours. The medication is given only once at a specific interval of time when the nurse finds the term single order or one-time order in the prescription. Medication administration at one time within the period of 90 minutes is considered to be a now order. Medications are administered immediately, one time, when the nurse finds the term STAT in the prescription.

The nurse in the palliative care unit is administering a higher-than-prescribed dose of opioid analgesic to a patient with terminal stage cancer to relieve pain. Which act or law should discipline the nurse? 1 Nurse Practice Act 2 Pure Food and Drug Act 3 Controlled Substance Act 4 Medication law of Food and Drug Administration

3 The use of opioid drugs is carefully controlled through federal and state guidelines. Violation of these guidelines is punishable under the controlled substance law. State Nurse Practice Acts (NPAs) define the scope of nurses' professional functions and responsibilities. The Pure Food and Drug Act is the first American law to regulate medications. The Food and Drug Administration is the current monitoring body for maintaining the standards of medication, through its medication law.

Which positions are most suitable for administering intramuscular medications in the ventrogluteal muscle site? Select all that apply. 1 Prone 2 Sitting 3 Supine 4 Lateral 5 Standing

3,4 In order to inject medication in the ventrogluteal muscle site, the patient is placed into the supine or the lateral position. The prone position is unsuitable for intramuscular injections at the ventrogluteal muscle site. The sitting position is appropriate for vastus lateralis intramuscular injections. The standing position is suitable for intramuscular injections at the deltoid muscle site.

Which steps followed by the nurse during intravenous medication administration would be beneficial to the patient? Select all that apply. 1 Increasing the flow rate of the medication for faster therapeutic effects 2 Checking whether the clamp on the air vent of the buretrol chamber is closed 3 Checking the flow rate on the primary infusion after administering the medication 4 Suggesting to the patient that discomfort is common during intravenous therapy 5 Reading the label at least three times before administering the medication

3,5 The nurse should check the flow rate on the primary infusion after administering the medication to ensure appropriate fluid balance in the patient. The nurse should read the labels at least three times and compare the medication administration record with label before administering the medication to prevent errors. A rapid administration of intravenous medication will cause medication overdose or infiltration at the intravenous site; this action does not produce faster therapeutic effects. The nurse should close the clamp and check that the clamp on the air vent of the buretrol chamber is open to prevent additional leakage of fluid into the buretrol. The nurse should encourage the patient to report symptoms of discomfort at the site immediately, because verbalizing pain helps the nurse detect infiltrations early.

A nurse explains the steps for administering a squeeze-and-breathe metered-dose inhaler (MDI) without a spacer to a patient. Arrange the steps explained by the nurse in order. 1. Sit up, take a deep breath, and exhale 2. Shake the inhaler vigorously five or six times 3. Insert the metered-dose inhaler canister into the holder 4. Remove the mouthpiece cover from the inhaler 5. Remove the metered-dose inhaler from the mouth and exhale through pursed lips 6. Tilt the head back slightly and inhale slowly and deeply through the mouth

3. Insert the metered-dose inhaler canister into the holder 4. Remove the mouthpiece cover from the inhaler 2. Shake the inhaler vigorously five or six times 1. Sit up, take a deep breath, and exhale 6. Tilt the head back slightly and inhale slowly and deeply through the mouth 5. Remove the metered-dose inhaler from the mouth and exhale through pursed lips First, insert the squeeze-and-breathe metered-dose inhaler (MDI) canister into the holder. Next, remove the mouthpiece cover from the inhaler. Then, shake the inhaler vigorously five or six times. Then, have the patient sit up, take a deep breath, and exhale. Next, tilt the patient's head back slightly and inhale slowly and deeply through the mouth. Then, remove the MDI from the mouth and exhale through pursed lips.

Which statement is true regarding parenteral medications? 1 Parenteral medications are medicated disks absorbed slowly through the skin. 2 Parenteral medications are dissolved in a sugar solution. 3 Parenteral medications are semi-liquid suspensions that usually protect, cool, or cleanse the skin. 4 Parenteral medications are sterile preparations that contain water with one or more dissolved compounds.

4 Parenteral medications are sterile preparations that contain water with one or more dissolved compounds. Transdermal medications are medicated disks that are slowly absorbed through the skin. Concentrated sugar solutions are medications dissolved in sugar solutions are referred to as syrup. Lotions are semi-liquid suspensions that usually protect, cool, or cleanse skin.

Which type of prescription order should the nurse carry out until the health care provider cancels the order? 1 Prn order 2 Now order 3 One-time order 4 Standing order

4 A routine medication order or standing order is a type of prescription order that should be carried out until the health care provider cancels it. A prn order signifies that the medication is to be administered whenever required by the patient. A now order indicates that the medication can be given within 90 minutes. A one-time order is a type of prescription order that is to be given once at a specified time.

A patient develops buccal irritation following the administration of a buccal medication for 3 days. Which nursing instruction would have prevented this irritation? 1 Chewing the medication 2 Swallowing the medication 3 Taking the medication with water 4 Alternating the cheeks with each dose

4 Buccal administration of medication may lead to buccal irritation by erosion of the mucous membrane. This may be very uncomfortable for the patient. Buccal irritation can be minimized by alternating the placement of the medication with each subsequent dose so that a single area is not affected. Buccal medications are not to be chewed, swallowed, or taken with any liquids, because the rate of absorption may be affected.

How do mist sprays cause a rapid relief of respiratory problems? 1 Because of a rapid absorption of medication through the mucous membrane 2 Because of a rapid absorption of medication through the gastrointestinal tract 3 Because of a rapid absorption of medication through the sublingual capillary network 4 Because of a rapid absorption of medication through the alveolar-capillary network

4 Inhalational medications administered through mist sprays penetrate lung airways. The alveolar-capillary network absorbs medications rapidly, thereby relieving respiratory problems. Medications are absorbed from the mucous membrane readily from aqueous solutions or suppositories. Orally administered drugs, such as tablets, capsules and some liquids, are generally absorbed from the gastrointestinal tract. Some oral medications, such as sublingual tablets, are rapidly absorbed from the sublingual capillary network.

Which type of medication is often described as a "rescue" or "maintenance" medication? 1 Oral 2 Buccal 3 Parenteral 4 Inhalational

4 Inhaled medications are also often described as "rescue" or "maintenance" medications. Rescue medications are short acting and are taken to immediately relieve acute respiratory distress. Maintenance medications are used on a daily schedule to prevent acute respiratory distress.

The nurse accidentally gives a patient a medication at the wrong time. What is the nurse's first priority? 1 Complete an occurrence report. 2 Notify the healthcare provider. 3 Inform the charge nurse of the error. 4 Assess the patient for adverse effects.

4 Patient safety and assessing the patient are priorities when a medication error occurs. The first priority of the nurse is to assess and examine the patient's condition, and notify the healthcare provider of the incident as soon as possible. Once the patient is stable, report the incident to the appropriate person in the agency (e.g., manager or supervisor). The nurse is responsible for preparing and filing an occurrence or incident report as soon as possible after the error occurs.

A nurse is applying an ointment to a patient with skin encrustation. Which action of the nurse would be beneficial to increase the contact of medication with the tissue to be treated? 1 Applying gauze dressing over the medication 2 Applying a thick layer of medication on the affected area 3 Applying the medication by rubbing it gently into the skin 4 Applying the medication after cleaning the skin thoroughly

4 Skin encrustation harbors microorganisms and blocks the contact of medication with the tissue to be treated. Therefore, it is very important to clean the skin thoroughly by washing the area gently with soap and water to improve the contact of medication with the affected tissue. Applying the gauze dressing over the medication would help to prevent soiling clothes and wiping away the medication. However, it is not meant for improving the contact of medication with the affected tissue. Ointments should be spread evenly over the surface without applying an overly thick layer. Liniments should be applied by rubbing them gently into the skin. However, ointments should not be rubbed on the skin, because this can cause irritation.

Which route of administration is illustrated in the image? 1 Intradermal 2 Intraarterial 3 Intraosseous 4 Intramuscular

4 The image illustrates the ventrogluteal site, which is the most preferred and safest site for intramuscular injections. Intramuscular injections are usually given at an angle of 90 degrees. Intradermal administration includes injection of the medication directly into the dermis, just under the epidermis at an angle of 15 degrees. Intraarterial medications are administered directly into the arteries through infusions. Intraosseous administration involves the infusion of medication directly into bone marrow.

Which topical medication may lead to respiratory depression in the case of an overdose? 1 Lotion 2 Liniment 3 Ointment 4 Transdermal patch

4 The overuse of transdermal patches such as a fentanyl transdermal patch may lead to respiratory depression, coma, or even death. Lotion, liniment, and ointment do not cause serious adverse effects such as respiratory depression.

Which is the nurse's best response when asked about the advantage of parenteral medication administration? 1 "The parenteral route is easy to administer." 2 "The parenteral route rarely causes anxiety in patients." 3 "The parenteral route provides rapid relief for local respiratory problems." 4 "The parenteral route provides medication to patients with poor peripheral perfusion."

4 The parenteral route of administration aids patients who have poor peripheral perfusion. Parenteral administration may not be easy to administer; it requires a trained or skilled healthcare practitioner. Parenteral administration may cause anxiety in patients. The inhalational route of medication administration may provide rapid relief for local respiratory problems.

What is a disadvantage of the parenteral route of medication administration? 1 The parenteral route causes discoloration of the teeth. 2 The parenteral route can only be given to unconscious patients. 3 The parenteral route is contraindicated before some tests or surgery. 4 The parenteral route may place the patient at a higher risk of reactions.

4 The parenteral route of administration involves injecting the medication into the body tissues; this route places patients at a high risk of reactions. The oral route of medication administration may cause discoloration of the teeth. The parenteral route can be safely given to both unconscious and conscious patients, depending upon their medical condition. Before some tests or surgery, the oral route of medication administration is contraindicated.

Which topical medication preparation may involve more than one medication? 1 Paste 2 Lotion 3 Liniment 4 Ointment

4 The preparation of ointment may involve more than one medication. Paste is a thick ointment that is absorbed through the skin more slowly than ointment. Lotion is a semi-liquid suspension that usually protects, cools, or cleanses the skin. Liniment usually contains alcohol, oil, or soapy emollient applied to the skin.

The primary health care provider has ordered a time-critical scheduled medication for a patient. Which action of the nurse is appropriate in this situation? 1 Administering the medication immediately 2 Administering the medication within 1 hour of the scheduled time 3 Administering the medication within 2 hours of the scheduled time 4 Administering the medication within 30 minutes of the scheduled time

4 Time-critical scheduled medications should be given no later than 30 minutes before or after the scheduled dose. STAT medications are given once and at the time they are ordered. Medications that are not time-critical should be given within 1 to 2 hours of the scheduled dose.

Which form of topical medication is applied over a long period and should be removed before administering another dose? 1 Lotion 2 Liniment 3 Ointment 4 Transdermal patch

4 Transdermal patches are applied for a long period (such as 12 hours, 24 hours, or 7 days). They must be removed before administering another, because wearing two patches simultaneously may lead to life-threatening conditions. Lotions, liniments, and ointments are not applied for such a long period when compared with transdermal patches. Lotions, liniments, and ointments do not cause any life-threatening conditions; these medications have a local effect.

The nurse has to administer liquid medication that is available in a multidose bottle. Which intervention should the nurse follow while preparing to administer the medication? 1 Hold the bottle in the palm so that the label is facing up. 2 Make sure not to shake the bottle before administrating the medication. 3 Draw up a volume of less than 10 mL in parenteral syringe. 4 Place the cup at eye level on a firm surface and pour the medication.

4 While administering liquid medications, the nurse should place the medicine cup on a firm surface at eye level and pour the medication for dosing accuracy. The nurse should hold the bottle so that the label is against the palm to protect the integrity of the label. The nurse should shake the bottle before administration to mitigate any settling of contents. The nurse should draw a volume of less than 10 mL into an oral syringe, not a parenteral syringe.

Which route is considered a potential route of administration when oral medications are contraindicated? 1 Skin 2 Parenteral 3 Transdermal 4 Mucous membranes

4 Administration of medication through mucous membranes is considered as a potential route when oral medications are contraindicated. Medications are absorbed through the skin slowly; therefore, this is not considered a potential route of administration. The parenteral route can also be used when oral medications are contraindicated but this route has a lot of disadvantages such as risk of infection, pain, and tissue damage. The transdermal route is not considered when oral medications are contraindicated.

The prescription order of a patient who is scheduled for a surgery contains "on call." When should the nurse administer the medication? 1 When the surgeon orders 2 While the surgery is going on 3 Whenever the patient requires 4 When the surgical staff is coming to get the patient

4 The nurse should be aware of the right time of medication administration. "On call" on the prescription of a patient who is scheduled for a surgery indicates that the medication should be administered when the surgical staff is coming to get the patient for surgery. "On call" does not indicate that the medication is to be given when the surgeon orders it. "On call" also does not indicate that the medication is to be given during the surgery. Prn on the prescription indicates that the medication should be given whenever the patient requires.

Which materials are used to administer intravenous (IV) medication through piggybacks? Select all that apply. 1 Vial 2 Syringe 3 Buretrol 4 Short microdrip 5 Infusion tubing with blunt end

4,5 Short microdrip and infusion tubing with blunt end cannula attachments are used to administer intravenous medication by piggybacks. When administering intravenous medication by volume-controlled administration, a vial, syringe, and buretrol are used.

Which statement is true regarding enteral syringes? 1 Enteral syringes are a different color than parenteral syringes. 2 Needles attach to the enteral syringes and are easy to insert in any type of intravenous line. 3 The tips of the enteral syringes connect with parenteral medication administration system. 4 The syringe tip caps must be removed from the syringe before administration to prevent contamination.

The enteral syringes are often a different color than the parenteral syringes and must be labeled for oral or enteral use. Needles of the enteral syringes do not attach to the syringes and cannot be inserted into any type of intravenous line. The tips of the enteral syringes will not connect with the parenteral medication administration systems. The nurse must remove the tip cap of the syringe before administering the medication because there are chances of tracheal blockage due to aspiration of the cap, but this is not one to prevent contamination.

The healthcare provider instructs the nurse to inject 2 mg/kg of a medication to a pediatric patient. The weight of the patient is 33 lbs. How much of the medication should the nurse administer to the patient? Record your answer using a whole number. ___ mg

The nurse must convert the weight of the patient into kilograms; because 2.2 lbs is equivalent to 1 kg, 33 lbs is equivalent to 15 kg (33/2.2 = 15). The medication has to be administered in the dose of 2 mg/kg body weight; the amount of medication required for this patient is 2 x 15 = 30 mg.

The healthcare provider has instructed the nurse to administer 600 mg of amoxicillin to a pediatric patient. The bottle of the amoxicillin is labeled 400 mg/6 mL. How much of the medication should the nurse administer to this patient? Record your answer using a whole number. ___ mL

The patient requires 600 mg of amoxicillin. The volume of medication (V) appropriate to this amount of amoxicillin is calculated using the proportion method. 400 X V = 600 X 6, which means 400 V = 3600, and V = 3600/400 = 9. Therefore, 9 mL of the medication contains 600 mg of amoxicillin.

Which statement about medication names requires correction? 1 The trademark for generic names is indicated by the superscript "TM." 2 United States Adopted Names Council approves generic names of drugs. 3 The nonproprietary name of a medication is the generic name given to the drug. 4 The Institute for Safe Medication Practices publishes a list of medications that are frequently confused with another.

The trademark for generic names is indicated by the superscript "TM." Brand names of any drug are indicated by the trademark of superscript "TM." The United States Adopted Names Council approves the generic name of the drug released into the market as the first trade name. The nonproprietary name of a medication is the generic name given to the drug. The Institute for Safe Medication Practices publishes a list of medications that are frequently confused with another medications.

The nurse intends to use a medication that can give immediate relief to a patient. Which parameter of the drug should the nurse check to determine whether the drug can provide immediate relief to the patient? 1 Peak concentration 2 Onset of action 3 Plateau concentration 4 Duration of action

To provide immediate relief to the patient, a drug should have a faster onset of action. A drug with a slow onset of action may show a delayed effect. Peak concentration refers to the time taken to attain the highest effective concentration and does not provide information related to the onset of action. Plateau concentration is the plasma concentration attained and maintained after repeated fixed doses. Duration is the amount of time for which the drug produces its effect and does not provide information regarding onset of actio

A patient reports fatigue and an inability to lie flat. During an assessment, the nurse finds the patient has an increased blood pressure and an increased pulse rate. Further assessment reveals that the patient is dizzy, unable to concentrate, and has a decreased level of consciousness. Which condition does the nurse suspect? 1 Hypoxia 2 Hypoxemia 3 Hypovolemia 4 Hyperventilatio

The clinical signs and symptoms of hypoxia include an inability to concentrate, decreased level of consciousness, fatigue, and dizziness. Patients with hypoxia are unable to lie flat. Patients with hypoxia have an increased blood pressure and an increased pulse rate. Signs and symptoms of hypoxemia include central cyanosis of the tongue, soft palate, and conjunctiva. Shock and severe dehydration causes extracellular fluid loss and reduced circulating blood volume, also called hypovolemia. Severe anxiety, infection, drugs, or an acid-base imbalance causes hyperventilation.

Which is a high-flow oxygen-delivery device? 1 Venturi mask 2 Nasal cannula 3 Simple face mask 4 Oxygen-conserving cannula

1 A venturi mask is a high-flow delivery device. Nasal cannulas, simple face masks, and oxygen-conserving cannulas are low-flow delivery devices.

Which oral medication is available in liquid form? 1 Elixir 2 Tablet 3 Capsule 4 Lozenge

1 An elixir is a clear fluid containing water; this medication is available in liquid form and administered orally. Tablets, capsules, and lozenges are available in solid form.

The nurse observes weight gain, edema, hypertension, and distended neck veins in a patient who is on fluid replacement therapy. What could be the reason behind this condition in the patient? 1 The intravenous solution is infusing too fast. 2 The level of the fluid bag has been lowered 3 The intravenous sites of administration have been rotated. 4 The patient was placed in a high Fowler's position.

1 An infusion that is too rapid may cause an excessive infusion of intravenous fluids, which may cause circulatory fluid overload during fluid replacement therapy. Lowering the level of the fluid bag causes a decreased rate of infusion. Rotating the sites of the administration can minimize a patient's pain and discomfort; this action does not cause fluid overload. Placing the patient in high Fowler's position is not responsible for fluid overload.

Which complication would the nurse suspect if an endotracheal tube cuff is underinflated? 1 Aspiration 2 Impaired skin integrity 3 Impaired oxygenation 4 Necrosis of tracheal tissue

1 An underinflated cuff increases the patient's risk of aspiration. An inability to control secretions and pressure from airway devices may increase the risk of impaired skin integrity and infection. A buildup of secretions in the airways is responsible for impaired oxygenation. An overinflated cuff may result in ischemia or necrosis of the tracheal tissue.

While assessing a patient, the nurse notices bluish discoloration of the skin and mucous membrane. Which condition might the nurse suspect the patient is experiencing? 1 Hypoxia 2 Dehydration 3 Hyperlipidemia 4 Right-sided cardiac failure

1 Bluish discoloration of the skin and mucous membrane is cyanosis, which is a clinical manifestation of hypoxia, or reduced tissue oxygenation. Decreased skin turgor is a clinical manifestation of dehydration. Xanthelasma (yellow lipid lesions on the eyelids) is a clinical manifestation of hyperlipidemia. Distention of the veins of the neck is associated with right-sided heart failure.

While performing oropharyngeal suctioning, which intervention performed by the registered nurse helps move secretions from the lower to the upper airway and then into the mouth? 1 Encouraging the patient to cough 2 Lubricating the catheter before insertion 3 Keeping the oxygen mask near patient's face 4 Applying of suction pressure while introducing the catheter

1 Coughing moves secretions from lower to upper airways into the mouth. Therefore, the nurse should encourage the patient to cough. Lubricating the catheter may ease the insertion of the catheter, but does not move secretions. An oxygen mask should be kept near the patient's face, which allows access to the patient's mouth while having access to the oxygen-delivery system. Suction pressure is applied while introducing a catheter into the nasopharyngeal tissues, which increases the risk of damage to the mucosa.

Which is a clinical manifestation of hypoxia? 1 Cyanosis 2 Xanthelasma 3 Periorbital edema 4 Splinter hemorrhages

1 Cyanosis indicates decreased tissue oxygenation or hypoxia. Xanthelasma is an ophthalmic abnormality indicative of hyperlipidemia. Periorbital edema is a clinical manifestation of renal disease. Splinter hemorrhages is a clinical manifestation of bacterial endocarditis.

The nurse has been asked to administer a rectal suppository to a patient. In what position should the nurse place the patient? 1 Sims' position 2 Prone position 3 Lateral position 4 Doral recumbent

1 For rectal administration of a suppository, the patient should be placed in the Sims' position. Neither the patient nor the nurse would be comfortable if the patient were placed in the prone position, lateral position, or dorsal recumbent position.

What should the nurse do when a patient with a tracheostomy tube experiences the signs and symptoms of respiratory distress? 1 Perform manual ventilation 2 Remove the outer cannula of the endotracheal tube 3 Remove secretions around the stoma 4 Seek the assistance of the nursing assistive personne

1 If a patient with a tracheostomy tube has difficulty breathing, the nurse should manually ventilate the patient. The caregiver should not remove the patient's outer cannula without the permission of the health care provider. Removing secretions around the stoma helps to maintain asepsis. Nursing assistive personnel are not eligible to assist in endotracheal tube care.

The nurse is caring for a pregnant patient. The nurse understands that the body posture and alignment in a pregnant patient may change. Where does the center of gravity of a pregnant woman shift? 1 To the anterior 2 To the posterior 3 To the left lateral side 4 To the right lateral side

1 In pregnant women, changes in body posture and alignment occur due to weight gain and the growing fetus. The center of gravity of the body shifts to the anterior. Therefore, a pregnant woman leans backward and may report back pain. The center of gravity does not shift to the posterior or to any lateral sides; this might cause abnormal curvature of the spine.

The registered nurse is teaching a nursing student about the care for patients with artificial airways. Which statements should the nurse exclude from the teaching? 1 "Normal saline solution should be instilled into artificial airways." 2 "Artificial airways should be positioned in case of deviation." 3 "Suctioning should be performed through artificial airways." 4 "Sterile techniques should be used to maintain endotracheal and tracheal airways.

1 Instilling normal saline into artificial airways is no longer evidence-based clinical practice because there is no evidence that it helps to loosen secretions. Artificial airways should be positioned correctly in case of deviation to prevent airway damage. Suction through artificial airways helps to remove excess airway secretions. Sterile technique should be used to maintain endotracheal and tracheal airways to prevent health care-associated infections.

A registered nurse teaches a nursing student about intravenous medication administration. Which statement made by the nursing student needs correction? 1 "Intravenous medication is administered for testing skin conditions." 2 "Intravenous medication is administered when the medication highly alkaline." 3 "Intravenous medication is administered slowly to avoid severe adverse reactions." 4 "Intravenous medication is administered to maintain constant therapeutic blood levels."

1 Intravenous medications are administered to maintain constant therapeutic blood levels. Intradermal medications are administered for testing the skin. Intravenous medication is administrated when medications are highly alkaline because these medications may irritate the muscles. If intravenous medications are administered quickly, it may cause severe adverse reactions.

The nurse plans to provide education to the parents of school-age children. Which option does the nurse include to emphasize the results of children being less physically active outside of school? 1 An increase in obesity 2 An increase in heart disease 3 Higher computer literacy 4 Improved school attendance and grades

1 It is increasingly clear that many children today are less active, resulting in an increase in childhood obesity. Strategies for physical activity incorporated early into a child's daily routine may provide a foundation for a lifetime commitment to exercise and physical fitness. Research shows that exercise plays a role in secondary prevention or recurrence of heart disease for adult patients already diagnosed with coronary heart disease.

The registered nurse is teaching a nursing student about the interventions performed to prevent deep vein thrombosis in an immobilized patient. Which statement made by the nursing student indicates a need for correction? 1 "I will massage the legs." 2 "I will instruct the patient to avoid crossing the legs." 3 "I will assist the patient in performing range-of-motion exercises." 4 "I will position the patient without applying pressure on the posterior of knee."

1 Massaging the leg should be avoided in cases of deep vein thrombosis, because it may lead to dislodgement of the thrombus and result in severe complications. Crossing of the legs should be avoided to increase the blood circulation. Performing range-of-motion exercises reduce the risk of contractures and aid in preventing thrombi. Proper positioning without applying pressure on the posterior of knee reduces a patient's risk of thrombus formation, because compression of the leg veins is minimized.

An 82-year-old man tells the nurse that he is having difficulty hearing and that he has "too much earwax." Considering the patient's age, what question should the nurse ask? 1 "Have you ever experienced impacted earwax?" 2 "Do you have an upper respiratory infection?" 3 "Do you swim in a pool with chlorinated water?" 4 "Have you noted a change in the color of the earwax?"

1 Obstruction of the ear is most often caused by impacted cerumen. Older adults are more susceptible to cerumen impaction because hair in the ear becomes coarser with age and traps the wax. Upper respiratory problems, swimming in pools, and changes in the color of the earwax are not relevant questions.

Which person is at the lowest risk for developing pulmonary disease? 1 A person who lives in a rural region 2 A person who smokes 3 A person who lives in a smoggy city 4 A person who works in a factory where asbestos is present

1 Of these people, the person living in a rural area is less exposed to pollution and is therefore at a lesser risk for developing pulmonary disease. Smoking, exposure to pollution and smog, and exposure to a health-hazardous substance like asbestos all increase the risk for pulmonary disease.

While positioning a patient in the supported supine position, the nurse places a pillow under the upper shoulders. What is the rationale behind this intervention? 1 Maintain correct alignment 2 Reduce external rotation of hip 3 Provide support for lumbar spine 4 Reduce internal rotation of shoulder

1 Placing of pillows under the shoulders while positioning a patient in the supine position maintains correct alignment and prevents flexion contractures of cervical vertebrae. Placing trochanter rolls to the lateral surface of the patient's thighs may reduce external rotation of the hip. Placing a small rolled towel under the lumbar area of the back provides support for the lumbar spine. Placing pillows under pronated forearms reduces internal rotation of the shoulder and prevents extension of the elbows.

How many nurses would be required to place a patient in the semi-prone position? 1 1 2 2 3 3 4 4

1 Positioning the patient in the Sims position or the semi-prone position would require only one nurse. Positioning the patient in the prone position would require two or three nurses. For logrolling the patient, the assistance of three or four nurses would be required.

The nurse goes to assess a new patient and finds the patient lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first? 1 Raise the head of the bed to 45 degrees. 2 Take the patient's oxygen saturation with a pulse oximeter. 3 Take the patient's blood pressure and respiratory rate. 4 Notify the health care provider of the patient's shortness of breath.

1 Raising the head of the bed brings the diaphragm down and allows for better chest expansion, thus improving ventilation. Taking the oxygen saturation, blood pressure, and respiratory rate should be included in the assessment, but raising the head of the bed should be the priority action. Depending on the situation, the nurse may need to notify the health care provider, but only after completing an in-depth assessment.

Which structure connects muscle to bone? 1 Tendon 2 Cartilage 3 Ligament 4 Syndesmosis

1 Tendons are white, fibrous bands of tissue that connect muscle to bone at the origin or insertion of the muscle. Cartilage acts as a shock absorber between articulating bones, whereas ligaments are the structures that connect bones and cartilage. Syndesmosis is a fibrous joint between the tibia and fibula.

Which route is used for the administration of regional analgesia for surgical procedures? 1 Epidural 2 Intrapleural 3 Intraosseous 4 Intraperitoneal

1 The epidural route involves the administration of medications in the epidural space. Regional analgesia for surgical procedures is administered through the epidural route by a nurse anesthetist or an anesthesiologist. Chemotherapeutic agents are administered through the intrapleural route. The intraosseous route is commonly used for infants and toddlers who have poor intravascular access. Chemotherapeutic agents, insulin, and antibiotics are administered through the intraperitoneal route.

What is the significance of the action depicted in the figure? 1 To maintain a patent airway 2 To prevent accidental extubation 3 To remove secretions from the stoma 4 To diminish the patient's need to cough

1 The image depicts reinsertion of the inner cannula. The inner cannula is replaced daily to prevent infection and maintain a patent airway. Maintaining the proper position of an endotracheal tube may help to prevent accidental extubation. Cleaning around the stoma helps to remove secretions from the stoma site. Endotracheal, tracheal, nasopharyngeal, or oropharyngeal suctioning helps to diminish the patient's need to cough.

A patient who has been resuscitated following a cardiac arrest needs to be administered adrenaline. Which route of administration is most appropriate? 1 Intravenous 2 Intradermal 3 Intramuscular 4 Subcutaneos

1 The intravenous route is used to administer adrenaline to patients with cardiac arrest. This route is often used in emergencies when a fast-acting medication needs to be delivered quickly. Injecting the medication through the intradermal route of administration is not beneficial because it may delay the action since the medication is injected under the epidermis. Subcutaneous injections involve a very slow medication absorption. The intramuscular route of administration has a faster absorption rate than the subcutaneous route, but this route may not be used in emergencies.

While inserting an endotracheal tube, the nurse instructs the patient to avoid coughing. What is the rationale behind this instruction? 1 To reduce anxiety 2 To prevent the need for more adhesive tape 3 To reduce the risk of accidental extubation 4 To reduce the transmission of microorganisms

1 The nurse instructs the patient to avoid coughing to reduce anxiety. Carefully removing the tape from the endotracheal tube and patient's face prevents adhesion of tape. Obtaining assistance from available staff to insert the endotracheal tube will reduce the risk for accidental extubation. Placing a towel across the patient's chest will reduce the risk of transmission of microorganisms.

Which action made by the nurse is depicted in the following figure? 1 Setting a piggyback 2 Setting a syringe pump 3 Setting an intermittent venous assess 4 Setting a volume-controlled administration set

1 The nurse is setting a piggyback in the depicted figure. The set contains a small bag that is placed higher than the primary infusion bag or bottle. A syringe pump is battery-operated and allows medication to be given in very small amounts of fluid. An intermittent venous access is an intravenous catheter capped off on the end with a small chamber covered by a rubber diaphragm. Volume-control administration sets are small containers that attach just below the primary infusion bags or bottles

Which nursing intervention is depicted in the image? 1 Supporting the joint 2 Assessing the intensity of pain 3 Assessing the resistance of the joint 4 Supporting the patient to sit in upright position

1 The nurse is supporting the joint by holding the adjacent distal and proximal areas. To assess the intensity of pain, pressure should be applied. However, as shown in the image, the nurse is just supporting the joint by holding the arm. The resistance of the joint is assessed by moving the joint, such as with flexion and extension. The patient should be supported to sit in an upright position by lifting the patient; lifting the patient by supporting the arm may cause joint dislocation

While assessing a patient who is on intravenous therapy, the nurse notices infiltration at the intravenous site. Which nursing intervention would best help the patient? 1 Stopping the intravenous infusion 2 Massaging the intravenous site gently 3 Reducing the intravenous infusion rate 4 Applying a cool compress to the intravenous site

1 The nurse should stop intravenous therapy immediately if infiltration occurs at the intravenous site. The nurse should remove the catheter and restart the infusion in another site. Massaging the site may cause pain and discomfort. The nurse should not reduce the infusion rate, but should stop the infusion and select a new site for continuation. Applying a cool compress to the site is not an appropriate intervention in this situation.

A patient has a leg fracture. Which statement made by the patient about crutch safety requires further teaching by the nurse? 1 "I should lean on the crutches to support my body weight." 2 "I should regularly inspect the structural intactness of the crutches." 3 "I should dry the crutch tips using paper towels if they become wet." 4 "I should immediately replace any worn crutch tips to prevent slipping."

1 The nurse teaches the patient about crutch safety in order to prevent further injuries. The patient should not lean on the crutches to support body weight because that may damage the crutches and also increase the risk of falling. Therefore, the patient's first statement requires correction by the nurse. The patient should regularly inspect the structure of the crutches because cracked crutches will increase the risk of falls. The patient should dry the crutch tips using a paper or cloth towel to decrease the risk of slipping. The patient should replace worn crutch tips with new ones to prevent slipping.

Which nursing action in tracheostomy care is illustrated in the image? 1 Applying the dressing 2 Reinserting the inner cannula 3 Replacing the tube ties 4 Adjusting the tube holder

1 The patient in the image has a tracheostomy. The nurse in the image is applying the tracheostomy dressing. The image does not illustrate the reinsertion of inner cannula, replacement of tube ties, or adjustment of the tube holder.

The registered nurse is teaching a patient about diaphragmatic breathing. Which statement if made by the patient indicates the need for further teaching? 1 "I should practice the exercise initially in the sitting position and then in the supine position." 2 "I should place one hand flat below the breastbone and another hand flat on the abdomen." 3 "I should inhale slowly, making the abdomen push out and moving the lower hand outward." 4 "I should practice these exercises often with the pursed-lip breathing technique."

1 The patient should practice the exercise initially in the supine position, because it is easier to perform when starting out than, and then switch to a sitting or standing position. The patient should place one hand flat below the breastbone and other hand flat on the abdomen. The patient should inhale slowly, making the abdomen push out and moving the lower hand outward. The patient should practice these exercises often with the pursed-lip breathing technique.

While caring for a patient who has a chest tube, the nurse places the patient in a high-Fowler's position. What is the reason behind this nursing action? 1 To promote draining of fluid 2 To evacuate air from the lungs 3 To prevent formation of blood clots 4 To prevent excessive negative intrapleural pressure

1 The patient who has a chest tube is positioned in a high-Fowler's position to promote draining of fluids from the chest in conditions such as hemothorax and emphysema. The patient is positioned in a semi-Fowler's position to evacuate air from the lungs in conditions such as pneumothorax. The tubing is adjusted to hang in a straight line from the top of the mattress to drainage chamber to prevent blood from accumulation. Stripping the tube should be avoided to prevent excessive negative intrapleural pressure.

On the first postoperative day, a patient who underwent a cholecystectomy complains of shortness of breath. The x-ray indicates that the patient has atelectasis. Which intervention could have prevented this complication? 1 Incentive spirometry 2 Early mobilization of the patient 3 Nebulization of the patient after surgery 4 Administration of oxygen to the patient

1 The patient's symptoms and signs indicate atelectasis. Patients who undergo abdominal surgery are at increased risk of atelectasis postoperatively. Incentive spirometry encourages these patients to practice deep breathing by providing visual feedback about inspiratory volume. This expands the alveoli and prevents lung collapse. Early mobilization of the patient does not prevent atelectasis but is important to prevent such complications as pneumonia and deep vein thrombosis (DVT). Nebulization or administration of oxygen will not prevent lung collapse.

Which statement is true regarding ventilation? 1 Ventilation is the process of moving gases into and out of the lungs. 2 The major expiratory muscle of respiration is the diaphragm. 3 Ventilation requires muscular irrespective of elastic properties of the lungs. 4 The diaphragm is innervated by the phrenic nerve that exits the spinal cord.

1 Ventilation is the process of moving gases into and out of the lungs. The diaphragm is the major muscle of inspiration, but not expiration. Ventilation requires both the muscular and elastic properties of the lungs. The diaphragm is innervated by the phrenic nerve, which exits the spinal cord at the fourth cervical vertebrae.

A 70-year-old diabetic patient is advised to do aerobic exercises. Which activity should the patient perform? 1 Walking 2 Yoga 3 Active range of motion 4 Resistance training

1 Walking is a type of aerobic exercise that would help to metabolize the excess sugar in the blood. Yoga is not a type of aerobic exercise. Active range of motion is one type of stretching and flexibility exercise. Resistance training is meant to increase the muscle strength and endurance.

A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104° F (40° C). Which physiological process explains why the child is at risk for developing dyspnea? 1 Fever increases metabolic demands, requiring increased oxygen need. 2 Blood glucose stores are depleted, and the cells do not have energy to use oxygen. 3 Carbon dioxide production increases as a result of hyperventilation. 4 Carbon dioxide production decreases as a result of hypoventilation.

1 When the body cannot meet the increased oxygenation need, the increased metabolic rate causes the breakdown of protein and wasting of respiratory muscles, increasing the work of breathing. Carbon dioxide production increases due to the increased metabolism stemming from the fever, not as a result of hyperventilation.

A patient was admitted after a motor-vehicle accident with multiple fractured ribs. During respiratory assessment, which signs and symptoms of secondary pneumothorax would the nurse expect to find? 1 Sharp pleuritic pain that worsens on inspiration 2 Crackles over lung bases of affected lung 3 Tracheal deviation toward the affected lung 4 Increased diaphragmatic excursion on side of rib fractures

1 When the lung collapses, the thoracic space fills with air on each inspiration, and the atmospheric air irritates the parietal pleura, causing pain.

Which device should the nurse use to prevent external rotation of the hips when the patient is in a supine position? 1 Trochanter roll 2 Positioning boots 3 Trapeze bars 4 Pillows

1 When the patient is in the supine position, the nurse should use a trochanter roll to prevent external rotation of the hips. When the hips are correctly aligned, the patella faces directly upward. The positioning boots help in preventing footdrop. Patients use trapeze bars to lift themselves during repositioning. Pillows may not be helpful in preventing the external rotation of the hips.

While caring for a patient who has a chest tube, the nurse finds continuous bubbling in a water-seal chamber. Which intervention would be beneficial for the patient? 1 Unclamping the chest tube 2 Obtaining a large-gauge needle 3 Obtaining a flutter (Heimlich) valve 4 Determining that the chest tube is not occlude

1 Continuous bubbling in a water-seal chamber is an unexpected outcome when experienced in patients with chest tubes. Unclamping the chest tube is beneficial for the patient. Obtaining a large-gauge needle or a flutter (Heimlich) valve and determining that chest tubes are not occluded would be beneficial should tension pneumothorax occur.

What are the clinical signs and symptoms of pruritus? 1 Itching of skin 2 Small raised vesicles over the body 3 Raised, irregularly shaped skin eruption 4 Inflammation of mucous membrane lining the nose

1 Skin itching is the primary sign of pruritus. Raised, irregularly shaped skin eruption is referred to as a rash. Raised, irregularly shaped skin eruption is referred to as urticaria. Inflammation of mucous membrane lining the nose is a condition associated with rhinitis

The nurse works in a geriatric unit. Which physiological changes affecting the metabolism of medication should the nurse be aware of in these patients? Select all that apply. 1 Reduced liver function 2 Reduced absorptive capacity 3 Reduced functioning of brain receptors 4 Shortening of half-life of drugs excreted through the kidneys 5 Reduced function of the immune system

1,2 In elderly patients, liver function is grossly reduced, which affects the metabolism of drugs and prolongs the half-life of drugs. The absorptive capacity of the intestines also declines in elderly patients. The brain receptors become more sensitive, and the patients are very much susceptible to psychoactive drugs. The kidney function diminishes and the half-life of drugs excreted through the kidney lengthens. The efficiency of the immune system decreases with age, but the immune system does not interact with the drug metabolism process.

Which urinary elimination changes are often observed as the period of immobility continues for a patient? Select all that apply. 1 Increased fluid intake 2 Increased urinary output 3 Increased risk of renal calculi 4 Increased urinary concentration 5 Increased risk for urinary tract infection

1,2,3 The urinary elimination changes that are often observed as the period of immobility continues are increased renal calculi, as immobilized patients may have hypercalcemia that causes calcium stones. As the immobility continues, the fluid intake decreases and the concentration of urine increases. As the concentration of urine increases, urinary tract infections also increase. As the period of immobility continues, fluid intake often diminishes and, therefore, urinary output also decreases.

What developmental and environmental factors significantly influence the activity and exercise regimen to be followed by a patient? Select all that apply. 1 Age 2 Ethnic origin 3 Work culture 4 Marital status 5 Number of children

1,2,3, A patient's age, cultural and ethnic origin, and work culture may have developmental and environmental effects on a patient's activity and exercise habits. The number of children a patient has and the patient's marital status are not developmental and environmental factors that might influence a patient's exercise regimen.

What are the symptoms of carpal tunnel syndrome? Select all that apply. 1 Tingling 2 Weakness 3 Numbness 4 Blurred vision 5 Reduced taste sensation

1,2,3, Carpal tunnel syndrome is a common use-related injury. Repetitive wrist or finger movements cause pressure on the median nerve, resulting in carpal tunnel syndrome. In this syndrome, alteration of tactile sensation occurs. A tingling sensation, weakness, and numbness are symptoms of carpal tunnel syndrome. Blurred vision and reduced taste sensation are not symptoms of carpal tunnel syndrome.

The nurse is caring for a patient who is at high risk of aspiration. Which preliminary assessments should the nurse perform to reduce the risk of aspiration while administering oral medications? Select all that apply. 1 Assess the ability to cough. 2 Assess the presence of intact gag reflex. 3 Assess the ability to swallow. 4 Assess the ability to clench teeth. 5 Assess the tongue movement.

1,2,3, To prevent aspiration while administering oral medications, the nurse should assess whether the patient is able to cough, has intact gag reflex, and has the ability to swallow. Presence of these reflexes reduces the chances of aspiration. The ability to clench the teeth and move the tongue is not protective against aspiration.

A diabetic patient is prescribed insulin. Which interventions should the nurse perform to teach the patient how to self-administer insulin? Select all that apply. 1 Check the visual acuity of the patient. 2 Instruct the patient about the appropriate storage of insulin. 3 Demonstrate rotation of insulin site injections. 4 Demonstrate the preparation of a single insulin preparation. 5 Instruct the patient not to titrate the insulin dose based on glucose monitoring.

1,2,3,4 Self-administration of insulin requires proper visual acuity to ensure drawing the appropriate amount of insulin. Insulin must be stored as directed by the manufacturer to maintain vitality. The site of insulin injection must be rotated to prevent local changes of the skin. The nurse should demonstrate the proper preparation of a single insulin preparation. Insulin doses may be adjusted based on home-based blood glucose estimation of capillary blood or per the health care provider's instructions.

Which group of patients is most at risk for severe injuries related to falls? 1 Adolescents 2 Older adults 3 Toddlers 4 Young children

2 Some older adults walk more slowly and are less coordinated. They also take smaller steps, keeping their feet closer together, which decreases the base of support. Thus, body balance is unstable, and they are at greater risk for falls and injuries.

The nurse is performing a routine physical examination of a patient and observes the patient's breathing patterns. Which factors might the nurse observe? Select all that apply. 1 Bradypnea is less than 12 breaths per minute. 2 Tachypnea is greater than 20 breaths per minute. 3 Apnea is the increased number of breaths per minute. 4 Apnea is the absence of respirations for some time. 5 Increased blood flow to the brain causes Cheyne-Stokes respiration.

1,2,4 At rest the breathing rate for normal adults is 12 to 20 regular breaths per minute. Bradypnea occurs when the respiratory rate decreases below 12 breaths per minute. Tachypnea occurs when the respiratory rate increases above 20 breaths per minute. Apnea is the absence of respiration for a period of time, when the patient will not have any breath sounds. An increase in the number of breaths per minute is called tachypnea. Cheyne-Stokes respiration is caused by decreased blood flow or injury to the brainstem and is characterized by periods of apnea followed by periods of deep breathing, then shallow breathing, followed by more apnea.

A patient wants to understand the mechanism of respiration. What should the nurse explain to the patient? Select all that apply. 1 Normal breathing is quiet with minimum or no effort. 2 Ventilation is the process of air moving in and out of lungs. 3 Normal breathing is noisy and requires all the chest muscles. 4 The diaphragm is an important muscle that helps in breathing. 5 Ventilation is the process of oxygenated blood flowing in the body.

1,2,4 Normal breathing is a quiet process, which requires minimum effort. Ventilation is the process of air moving in and out of lungs. The major muscles in breathing are the diaphragm and the intercostal muscles. Noisy breathing occurs in diseased conditions or in the presence of some obstruction. All chest muscles, such as pectorals and sternocleidomastoid, are used in labored breathing. Perfusion is a process by which the cardiovascular system delivers oxygen-rich blood to the tissues and returns deoxygenated blood to the lungs.

A patient presents to the clinic with knee pain. The patient is accompanied by his grandson, because the patient has some degree of visual impairment. The nurse decides to assess the patient's visual sphere. Which questions should the nurse include? Select all that apply. 1 "What problem do you have with your vision?" 2 "Do you use any device to correct your vision?" 3 "Do you use often ask people to repeat what they said?" 4 "Have you tried to correct your vision?" 5 "Have you ever felt a ringing in the ear?"

1,2,4,

What are the functions of the skeletal system? Select all that apply. 1 Provide support 2 Regulate calcium 3 Regulate posture 4 Contribute balance 5 Protect vital organs

1,2,5 The functions of the skeletal system include providing joint flexibility and support, regulating calcium, and protecting vital organs. The nervous system regulates movement and posture. Body alignment contributes to balance of the body.

A nurse is teaching a group of student nurses about the different types of medication orders seen in the acute care setting. Which statements made by the students indicate an understanding of the information? Select all that apply. 1 "A standing order is carried out until the health care provider cancels it by another order or until a prescribed number of days elapses." 2 ""Subjective and objective assessment findings are used to determine when to administer a prn medication." 3 "A single order prescription means that a medication is given only once, but the nurse can choose the time that it is given." 4 "A STAT order can be repeated as often as needed in an emergency situation, based on the patient's condition." 5 "A standing order must include a frequency of administration.

1,2,5 The students understand medication orders in acute care settings if they state that standing orders are carried out until the health care provider cancels them by another order or until a prescribed number of days elapses, subjective and objective assessment findings, along with nursing discretion and judgement are used to determine when to administer prn medications and standing orders have to include a frequency of administration. A single order prescription is given only once and at a time determined by the prescriber, not the nurse. STAT orders are given only once, and must be reordered for subsequent administration.

The nurse is teaching a patient about lifestyle practices to promote heart health. Which instructions should the nurse include in this teaching? Select all that apply. 1 Eat foods rich in fiber. 2 Eat foods rich in fats and proteins. 3 Have a daily calorie intake of 2000 calories. 4 Have a daily calorie intake of 3000 calories. 5 Exercise for at least 30-60 minutes every day.

1,3,5, It is proven that a diet rich in fiber has cardioprotective properties. A daily calorie intake of 2000 calories is sufficient for good heart health without excess calories. Exercising for 30-60 minutes daily will help promote circulation of the blood and a healthy heart. Diets high in fats and proteins will lead to cardiac disorders. A calorie intake of 3000 calories may lead to weight gain and obesity and have an adverse effect on the heart.

While caring for a patient who is on intravenous (IV) therapy, the nurse notes crackles on auscultation. What are the appropriate nursing interventions? Select all that apply. 1 Reducing the IV flow rate 2 Assessing whether the IV system is intact 3 Raising the head of the patient's bed 4 Starting a new IV line in another extremity 5 Elevating the patient's extremities

1,3 A patient on IV therapy may have circulatory overload if the IV solution is infused too rapidly or in an excessive amount. The nurse must reduce the IV flow rate and notify the primary health care provider for further guidance. The nurse must also raise the head of the patient's bed to make the extracellular volume excess subside. If there is any bleeding at the venipuncture site, the nurse must assess whether the IV system is intact. If there is any evidence of local infection or phlebitis near the IV site, the nurse must start a new IV line. If there is any evidence of infiltration near the IV site, the nurse must elevate the patient's extremity.

The nurse on night shift explains a patient's condition to the healthcare provider, who in turn provides the verbal order of medication over the phone. Which accurately describe the roles of nurse and health care provider in executing telephone orders? Select all that apply. 1 The nurse should read back the order. 2 The nurse should not sign the order. 3 The nurse has to enter the order in the computer. 4 The nurse should receive confirmation from the prescriber. 5 The prescriber should countersign within 48 hours.

1,3,4, In a hospital setting, whenever a verbal order is given, the nurse should read back the order to the prescriber to confirm it. The order should be entered in the computer. The nurse should receive confirmation of the order from the prescriber for validation. The nurse should enter the time and the prescriber's name and then sign the order, indicating that it was read back. The prescriber should countersign the order within 24 hours, not 48 hours.

A patient is admitted to the hospital with osteoporosis and lower back pain. The patient loses balance when trying to stand and walk. The patient has a nursing diagnosis of body imbalance. What instructions does the nurse give the patient? Select all that apply. 1 Instruct the patient to widen the base of support by separating the feet. 2 Instruct the patient to bring the knees closer together to maintain a broad base. 3 Instruct the patient to lower the center of gravity closer to the base of support. 4 Instruct the patient to keep the center of gravity away from the base of support. 5 Instruct the patient to maintain a vertical line from the center of gravity through the base of support.

1,3,5 To maintain body balance, the patient must attain a posture that requires the least muscular work and places the least strain on muscles, ligaments, and bones. To do this, the patient must first separate the feet to a comfortable distance to widen the base of support. Then the patient must try to increase balance by bringing the center of gravity closer to the base of support. The body posture is adjusted such that the vertical line from the center of gravity falls through the base of support to attain body balance. The knees should not be kept closer, because this could decrease the width of the base of support and impair balance. Increasing the distance between the center of gravity and the base of support would also impair the balance of the patient. Knees should be kept wide. Keeping the center of gravity away from the base of support will result in a loss of balance while standing or walking.

Contact lens wearers are subject to serious eye infections. What are causes of eye infections in these patients? Select all that apply. 1 The use of homemade saline 2 Wearing lenses while driving 3 Wearing lenses while swimming 4 The use of lenses with reduced visual acuity 5 Contamination of the lens' storage cases

1,3,5, The use of homemade saline, wearing lenses while swimming, and contamination of the lens' storage cases cause eye infections. Homemade saline creates a high risk of contamination and may cause an eye infection. The lens may absorb chemicals from the pool water while swimming, which may cause irritation or infection of the eye. Lenses that are stored in a contaminated case may become contaminated and cause an eye infection. Wearing lenses while driving and the use of lenses for strengthening reduced visual acuity do not cause an eye infection.

What are the risk factors for developing pathological fractures in patients with immobility? Select all that apply. 1 Decreased metabolism 2 Decreased urinary output 3 Decreased tissue catabolism 4 Decreased calcium regulation 5 Decreased urine concentration

1,4 Decreased metabolism and calcium regulation are the major risk factors for developing pathological fractures in patients with immobility. Decreased urinary output is a urinary elimination change seen in patients with immobility due to decreased intake of fluids. Decreased tissue catabolism is tissue breakdown due to muscle weakness and decreased muscle mass in patients with immobility. Decreased urinary concentration is a urinary elimination change seen in patients with immobility due to decreased fluid intake and output.

What parameters should the nurse monitor in a patient who has developed hypoxia due to severe anemia? Select all that apply. 1 Pulse rate 2 Blood urea 3 Serum bilirubin 4 Respiratory rate 5 Skin color change

1,4,5, Hypoxia presents as an increase in pulse rate and a rise in respiratory rate and depth of respiration. In late stages of hypoxia, the skin and mucous membrane may become bluish in color. Blood urea is a renal parameter, so it is less significant when monitoring a patient with hypoxia. Serum bilirubin indicates liver function, so it is less significant when monitoring a patient with hypoxia.

Which interventions should the nurse perform when administering medications to a patient through a nasogastric tube? Select all that apply. 1 Dissolve the different medications separately. 2 Draw all the medications together in a syringe. 3 Use a pigtail vent after connecting the syringe to the tube. 4 Flush the tube before and after administration of the medication. 5 Contact the health care provider if the patient resists the administration.

1,4,5, When administering medication through a nasogastric tube, all the medications should be dissolved separately in suitable solvents. The nasogastric tube should be flushed prior to drug administration and following administration of each drug to prevent blockage. If the nurse encounters resistance while administering the medication, the health care provider should be notified. Each medication should be separately dissolved and administered to prevent mixing of medications. The nurse should not use a pigtail vent after connecting the tube to the syringe, because it can cause air to escape into the digestive tract.

While the nurse is talking to a patient, the patient faints and starts to fall. Arrange the steps the nurse takes in the appropriate order to protect the patient from head injury. 1. Extend one leg and let the patient slide down against the leg. 2. Assume a wide base of support. 3. Gently lower the patient to the floor, protecting the head. 4. Put one foot in front of the other to support the patient's body weight.

1. Assume a wide base of support. Correct 2. Put one foot in front of the other to support the patient's body weight. Correct 3. Extend one leg and let the patient slide down against the leg. Correct 4. Gently lower the patient to the floor, protecting the head. When the nurse finds that a patient is having a fainting episode and is about to fall, it is important to protect the patient from head injury. The first step by the nurse should be to assume a wide base of support by having one foot in front of the other to support the patient's body weight. The nurse should then extend one leg and let the patient slide down against this leg. The final step is to gently lower the patient to the floor, protecting the head.

A patient who has hemiplegia is unable to dorsiflex and invert the feet. Which condition does the patient likely have? 1 Lordosis 2 Footdrop 3 Genu varum 4 Genu valgum

2 The inability to dorsiflex and invert the feet indicates that the patient has footdrop which is usually found in patients who are bedridden and immobile. The foot becomes permanently fixed in plantar flexion, making ambulation difficult. The patient is unable to lift the toes off the ground. Exaggeration of the anterior convex curve of the lumbar spine is called lordosis. One or both legs bent outward at the knee indicates genu varum. Legs curved inward so that the knees come together while walking is a sign of genu valgum.

What measure should a nurse least likely take to prevent self-injuries from lifting patients? 1 Take a position close to the patient 2 Bend at the knees and keep the feet close together 3 Encourage the patient to help as much as possible 4 Slide the patient closer using a pull sheet or slide board

2 The nurse needs to bend at the knees and keep the feet wide apart because a broad base of support increases stability and maintains the center of gravity. The nurse should take a position close to the patient to reduce the nurse's horizontal reach and back stress. Patients should be encouraged to help as much as possible. The nurse should slide the patient toward him or her because sliding requires less effort than lifting.

While performing airway suctioning, the nurse detects that the patient's blood pressure is low and finds that the patient has hypoxemia and arrhythmias. Which nursing action is most likely responsible for the patient's condition? 1 Rotating the catheter 2 Performing too frequent suctioning 3 Applying negative pressure during the withdrawal of the catheter 4 Maintaining pressure at 125 mm Hg while withdrawing the catheter

2 A patient is at risk for developing hypoxemia, hypotension, arrhythmias, and trauma to the mucosa of the lungs with too frequent suctioning. The rotation of the catheter enhances the removal of secretions that have adhered to the sides of the endotracheal tube. Applying negative pressure during the withdrawal of the catheter is a correct nursing action. While suctioning, negative pressures in between 100 and 150 mm Hg for adults should be applied during the withdrawal of the catheter.

Following surgery, a patient has become bedridden and has developed a thrombus in the left leg. The nurse instructs the patient, caregiver, and staff members to avoid massaging the affected area. What is the most likely reason for this instruction? 1 Massaging the area may be painful for the patient. 2 Massaging the area may dislodge the thrombus. 3 Massaging the area may cause skin breakdown. 4 Massaging the area may promote ulcer formation.

2 A patient who is immobile with limited movement of the lower limbs may develop deep vein thrombosis due to stagnation of blood. This thrombus may get dislodged if the affected calf muscles are massaged. A dislodged thrombus may block any blood vessel and lead to complications. Therefore, in the patient who has developed thrombosis, massage should be avoided. Massaging may not be painful and may not cause skin breakdown or an ulcer.

Which condition may cause decreased tissue oxygenation due to decreased oxygen-carrying capacity of the blood? 1 Obesity 2 Anemia 3 Pregnancy 4 Neuromuscular disease

2 Anemia decreases the oxygen-carrying capacity of blood by reducing the amount of available hemoglobin to transport oxygen. The other conditions cause decreased oxygenation for other reasons: Decreased oxygenation may result from reduced lung volumes in patients who are obese. Increased metabolic rate may result in decreased oxygenation in patients who are pregnant. Impaired ability to expand and contract the chest wall may result in decreased tissue oxygenation in patients who have neuromuscular diseases.

Which statement is true regarding chest tubes? 1 Chest tubes are routinely stripped to move clots. 2 Chest tubes are used in the treatment of pneumothorax. 3 Chest tube removal can be done without any patient preparation. 4 Chest tubes are catheters inserted through lungs to remove air from the pleural space.

2 Chest tubes are used in the treatment of pneumothorax and after chest surgery or trauma. Chest tubes are not routinely stripped to move clots. Chest tube removal requires patient preparation. Chest tubes are catheters inserted through the thorax, not the lungs, to remove air from the pleural space.

Which abnormality change in the fingertips iscaused by chronic hypoxemia? 1 Edema 2 Clubbing 3 Distention 4 Splinter hemorrhages

2 Clubbing in the fingertips is associated with chronic hypoxemia. Edema is associated with kidney disease. Distention is caused by right-sided heart failure. Splinter hemorrhages are caused by bacterial endocarditis.

The nurse assesses a patient's status after giving intravenous medication. Which nursing skill is involved in this situation? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

2 Evaluation is the skill involved when the nurse assesses a patient's status after giving an intravenous medication. Planning involves collecting the medication administration record as well as taking steps to avoid interruptions. Assessment involves checking the accuracy and completeness of each medication administration record with the primary health care provider's medication orders. Implementation involves performing hand hygiene, putting on gloves, explaining the procedures, and administering medications.

Which patient would most likely need teaching regarding dietary sodium restriction? 1 An 88-year-old scheduled for surgery for a fractured femur 2 A 65-year-old recently diagnosed with heart failure 3 A 50-year-old recently diagnosed with asthma and diabetes 4 A 20-year-old with vomiting and diarrhea from gastroenteritis

2 Heart failure commonly causes extracellular fluid volume (ECF) excess because diminished cardiac output reduces kidney perfusion and activates the renin-angiotensin-aldosterone system, causing the kidneys to retain Na + and water. Dietary sodium restriction is important with heart failure because Na + holds water in the extracellular fluid, making the ECF excess worse.

Which condition is associated with increased risk of footdrop? 1 Kyphosis 2 Hemiplegia 3 Osteoporosis 4 Disuse syndrome

2 In foot drop, the foot is permanently fixed in plantar flexion, resulting limited mobility. Patients with hemiplegia are at increased risk of developing footdrop. Kyphosis refers to increased convexity in curvature of the thoracic spine. Osteoporosis may result from decreased bone density. Disuse syndrome refers to impaired physical mobility.

While assessing a patient with impaired mobility, the nurse prioritizes which type of related complication? 1 Social isolation 2 Respiratory 3 Integumentary 4 Musculoskeletal

2 Lack of movement and exercise places patients at risk for respiratory complications. The metabolic changes seen in patients with impaired mobility are altered endocrine metabolism and calcium resorption. An ulcer is characterized by inflammation and usually forms over a bony prominence. It is seen due to integumentary changes in patients with impaired mobility. The musculoskeletal changes seen in patients with impaired mobility are temporary impairment and permanent disability. According to Maslow's hierarchy of needs, physiological complications take priority over social isolation. Respiratory complications take top priority to ensure the ABCs: Airway, Breathing, Circulation.

Which type of suctioning should be performed before pharyngeal suctioning? 1 Orotracheal suctioning 2 Nasotracheal suctioning 3 Oropharyngeal suctioning 4 Nasopharyngeal suctioning

2 Nasotracheal suctioning is performed before pharyngeal suctioning whenever possible because the mouth and pharynx contain more bacteria than the trachea. Orotracheal suctioning is necessary when a patient who has pulmonary secretions is unable to manage secretions by coughing and does not have an artificial airway. Oropharyngeal and nasopharyngeal suctioning is used when a patient is unable to clear secretions.

Which is a congenital defect? 1 Arthritis 2 Scoliosis 3 Osteoporosis 4 Osteomalacia

2 Scoliosis is a structural curvature of the spine associated with vertebral rotation; it is a congenital defect. Arthritis is an inflammatory joint disease that causes systemic signs of inflammation and destruction of the synovial membrane and articular cartilage. Osteoporosis is an aging disorder that results in the reduction of bone density or mass. Osteomalacia is an uncommon metabolic disease characterized by inadequate and delayed mineralization, resulting in compact and spongy bones.

Which patient is most likely to experience sensory deprivation? 1 A 79-year-old visually impaired resident of a nursing home who enjoys taking part in different hobbies and activities 2 A 14-year-old girl isolated in the hospital because of severe immune system suppression 3 A hearing-impaired 66-year-old woman who lives in an assisted-living facility 4 A 9-year-old boy who is deaf and uses sign language to communicate with his friends, family, and teachers

2 Patients isolated in a private room in a health care setting because of such conditions as severe immune system depression frequently experience sensory deprivation. Such individuals are at risk because of an unfamiliar and unresponsive environment, and they are unable to enjoy normal interactions with visitors.

A patient is admitted to the hospital for a scheduled cataract surgery. The patient has no major health history and the vital signs are stable. While assessing the patient, the nurse realizes that the patient has a progressive hearing disorder. How should the nurse document this condition? 1 Presbyopia 2 Presbycusis 3 Xerostomia 4 Glaucoma

2 Presbycusis is a common progressive hearing disorder in older adults. Presbyopia is a condition in which the patient has difficulty viewing nearby objects clearly. Xerostomia is a condition characterized by dry mouth. Glaucoma is a progressive increase in intraocular pressure.

The nurse is caring for a patient with acute respiratory distress syndrome. While positioning the patient, the nurse observes hyperextension of the lumbar spine. Which patient positioning would likely have caused this condition? 1 Sims' position 2 Prone position 3 Side-lying position 4 Supported Flower's position

2 Prone positioning is most suitable for patients with acute respiratory distress syndrome and acute lung injury. The potential trouble points with patients in the prone position include hyperextension of the lumbar spine and neck hyperextension. The trouble points of the Sims' position and the side-lying position are lateral flexion of the neck and lack of foot support. The trouble points of the supported Fowler's position are increased cervical flexion and pressure on the posterior aspects of the knee.

During preparation for practicing a mobility assessment, a student nurse encounters the term proprioception. Which phrase best explains the term proprioception? 1 Orientation to time, place, and person 2 Awareness of the position of the body and its parts 3 Perception of pressure over the palmar and plantar surfaces 4 Perception of abnormal thermal sensation on the skin

2 Proprioception is defined as the awareness of the position of the body and its parts. Proprioceptors present in the nerve endings of muscles, joints, and tendons monitor proprioception. It is required by the body to maintain proper posture. There is no special term used for orientation. When pressure is applied over the palmar and plantar surfaces, a touch sensation is perceived.

What is the name for the white, glistening, and fibrous bands of tissue that connect muscle to bone? 1 Joints 2 Tendons 3 Cartilage 4 Ligaments

2 Tendons are white, glistening, fibrous bands of tissue that connect muscles to bones. A joint is the connection between bones. Cartilage is nonvascular; it supports connective tissue that sustains weight and serves as a shock absorber between articulating bones. Ligaments are white, shiny, flexible bands of fibrous tissue that bind joints and connect bones with cartilage.

What is the advantage of the device that is illustrated in the image? 1 This device relieves upper airway obstruction. 2 This device encourages voluntary deep breathing. 3 This device supports cardiopulmonary gas exchange. 4 This device helps with maintaining adequate ventilation.

2 The image illustrates an incentive spirometer, which encourages voluntary deep breathing by providing visual feedback to the patients about inspiratory volume. An endotracheal tube helps to relieve upper airway obstruction, protects against aspiration, and clears secretion. Invasive mechanical ventilation is life-saving positive pressure ventilation because it supports cardiopulmonary gas exchange by increasing lung volume and reducing the work of breathing. Positioning helps with maintaining adequate ventilation.

Which nursing intervention is depicted in the image? 1 Inserting a Yankauer catheter 2 Attaching a catheter to a suctioning device 3 Suctioning saline by occluding the suction vent 4 Applying suction pressure while introducing the catheter into the nasopharyngeal tissues

2 The image signifies that the nurse is attaching a catheter to a suctioning device. A Yankauer catheter is inserted into the patient's mouth. The tip of the catheter is placed into sterile basin followed by suctioning a small amount of normal saline by occluding the suction vent. The application of suction pressure while introducing a catheter into nasopharyngeal tissues increases the risk of damage to mucosa.

The nurse is caring for a patient with an endotracheal tube. Which of the nurse's actions requires correction? 1 Holding the endotracheal tube firmly 2 Cleaning the oral airway with plain water 3 Keeping the endotracheal tube cuff inflated 4 Cleaning the face and neck with a soapy washcloth

2 The nurse should clean the oral airway with warm, soapy water, not plain water, to promote hygiene and reduce the transmission of microorganisms. The nurse should hold the endotracheal tube firmly at the patient's lips to maintain proper tube positioning and to prevent accidental extubation. The nurse should keep the endotracheal tube cuff inflated to reduce the risk for aspiration and accidental extubation. The nurse should clean the patient's face and neck with a soapy washcloth to prevent adhesive tape adherence.

While preparing intravenous medications, the nurse does not take phone calls or speak with others. What is the reason for this nursing action? 1 To treat medication toxicity 2 To prevent medication errors 3 To avoid the risk of adverse effects 4 To enhance time management and efficiency

2 The nurse should not take phone calls or speak with others while preparing IV medications to avoid interruptions that may result in medication errors. The nurse should keep an antidote close by while administering medications to treat medication toxicity. The nurse should double-check dosage calculations while preparing intravenous medications to avoid the risk of adverse effects. The nurse should collect appropriate equipment and check the medication administration record to enhance time management and efficiency.

Which patient is at greatest risk for developing multiple adverse effects of immobility? 1 1-year-old child with a hernia repair 2 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA) 3 51-year-old woman following a thyroidectomy 4 38-year-old woman undergoing a hysterectomy

2 The older the patient and the greater the period of immobility, which can be significant following a hemorrhagic stroke, the greater is the number of systems that can be affected by the immobility.

Which position is appropriate in a patient who has a chest tube drainage system, in order to drain fluid from the chest? 1 Supine 2 High-Fowler's 3 Semi-Fowler's 4 Trendelenburg's

2 The patient should be placed in the high-Fowler's position to drain fluids from the chest. The patient should not be placed in the supine position, because it may increase the risk of reduced lung volume. The semi-Fowler's position is appropriate to evacuate air in conditions such as pneumothorax. The patient should not be placed in the Trendelenburg's position, because it may increase the risk of reduced lung volume.

Which finding does the nurse anticipate while assessing a patient who has had limited mobility for the past month and is diagnosed with hemiplegia? 1 Increased peristalsis 2 Increased calcium resorption 3 Increased basal metabolic rate 4 Decreased intraluminal pressure

2 The patient with hemiplegia due to limited mobility is at risk of increased calcium resorption from the bones, resulting in hypercalcemia. Immobility may lead to loss of appetite and decreased (not increased) peristalsis. Immobilized patients often have a decreased (not increased) basal metabolic rate related to the immobility. Immobility may lead to impairment of gastrointestinal functioning, which may further lead to increased (not decreased) intraluminal pressure.

Following an assessment, the nurse finds that a patient has reduced tactile sensation. How does the nurse improve the patient's tactile sensation? 1 By avoiding rubbing the back of the patient 2 By providing touch therapy to the patient 3 By avoiding turning and repositioning 4 By recommending special wrist splints

2 Touch therapy is used to improve tactile sensation. It stimulates the existing function of the tactile receptors. A back rub is a way of increasing tactile contact. Turning and repositioning also improve the quality of tactile sensation. Special wrist splints are helpful in relieving nerve pressure. They are used for the patient who has numbness and tingling or pain in the hands. They are not useful for the patient with reduced tactile sensation.

The nurse is positioning a hemiplegic patient in the supine position. The nurse places a folded towel under the hip of the patient. What is the reason behind this intervention? 1 Maintain mobility 2 Control hip position 3 Maintain dorsiflexion 4 Decrease possibility of pain

2 While positioning a hemiplegic patient in the supine position, the nurse should place a folded towel under hip of the involved side to diminish the effect of spasticity in the entire leg by controlling the hip position. A folded towel does not maintain mobility, dorsiflexion nor decrease pain.

A 60-year-old female patient sustained a femur fracture due to a fall in the bathroom. The patient complains of severe pain. Which mineral supplement is likely to be added to the patient's prescription to manage osteoporosis? 1 Zinc 2 Calcium 3 Sodium 4 Iron

2 n osteoporosis the bones lack calcium due to demineralization. Therefore, calcium supplements are added to the prescription to improve bone strength. Zinc is useful in cellular metabolism but has no role in bone health. Sodium is important for cells to function but has no role in promoting bone health. Iron is needed for hemoglobin production. It does not help in managing osteoporosis related to bone changes.

Which environmental issue is a hindrance to activity and exercise? 1 Hormonal changes and increased osteoclastic activity with increasing age 2 Work sites reluctant in motivating employees for physical fitness regimens 3 A patient's decisions to change his or her behavior to include a daily exercise routine 4 A patient's knowledge, values, and beliefs about exercise in relation to health

2 Work sites reluctant in motivating employees for physical fitness regimens Activity and exercise promotion (or lack thereof) at work sites is an environmental factor that affects a patient's ability to exercise. Hormonal changes and increased osteoclastic activity with increasing age are developmental factors that affects activity and exercise. A patient's decision to change his or her behavior to include a daily exercise routine and the patient's knowledge, values, and beliefs about exercise in relation to health are behavioral factors that influence activity and exercise.

The home care nurse is preparing the home for a patient who is discharged to home following a left-sided stroke. The patient is cooperative and can ambulate with a cane. Which must be corrected or removed for the patient's safety? Select all that apply. 1 Rubber mat in the walk-in shower 2 Three-legged stool on wheels in the kitchen 3 Braided throw rugs in the entry hallway and between the bedroom and bathroom 4 Night-lights in the hallways, bedroom, and bathroom 5 Cordless phone next to the patient's be

2, 3 The three-legged stool on wheels and throw rugs are hazards that put the patient at risk for falls. The rubber mat in the shower, night-lights, and cordless phone are all safety measures that should be put in place to prevent fall or injury. By planning ahead and collaborating, the home care nurse can provide a safe home environment for the patient after discharge.

An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment the nurse notes that the patient cannot tolerate lying flat. Which assessment data support a possible pulmonary problem related to impaired mobility? Select all that apply. 1 B/P = 128/84 2 Respirations 26 per minute on room air 3 HR 114 4 Crackles heard on auscultation 5 Pain reported as 3 on scale of 0 to 10 after medication

2,3,4 Patients with reduced mobility are at risk for retained pulmonary secretions , and this risk increases in postoperative patients. As a result of retained secretions, the respiratory rate increases. The heart rate also increases because the heart is trying to improve oxygen levels. These symptoms are of concern for older adults because, if left untreated, further complications such as heart failure can occur.

While performing oropharyngeal suctioning, the nurse needs to assess the patient to determine the frequency of suctioning. Which aspects should the nurse consider? Select all that apply. 1 Hypertension 2 Visible secretions 3 Gurgling breath sounds 4 Rhonchi breath sounds 5 Increased breath sounds

2,3,4 The frequency of suctioning is indicated when visible secretions are present after other methods to remove airway secretions have failed. It is also indicated when rhonchi or gurgling breath sounds are audible on auscultation. Hypotension may indicate too-frequent suctioning. Diminished breath sounds, rather than increased breath sounds, indicate the frequency of suctioning.

A patient is being transferred from bed to stretcher. Which precautions should the nurse take to ensure patient safety during transfer? Select all that apply. 1 Release the brakes of the bed to allow movement. 2 Raise the bed to the level of the stretcher. 3 Cross the patient's arms on chest while transferring. 4 Involve multiple caregivers for safe transfer. 5 Unlock the stretcher's wheels once it is in place alongside the bed.

2,3,4, The bed should be raised to the level of the stretcher to allow the patient to slide from the bed to the stretcher. Keep the patient's arms crossed when transferring to prevent any injury to the arm. Three caregivers are needed to transfer a patient safely and are positioned specifically to minimize caregivers stretching. The bed brakes should be locked to prevent it from moving. Once the stretcher is placed alongside the bed, the wheels should be locked to prevent further movement.

TThe nurse visits an elderly patient who has sensory alterations due to aging. The patient has impaired vision, impaired proprioception, and impaired sense of touch. The nurse observes the patient's home environment for the presence of hazards that could increase the risk of injury to the patient. Which items might increase the patient's risk of injury and should be changed? Select all that apply. 1 Bathrooms with shower grab bars 2 Uneven, cracked walkways leading to the front or back door 3 Water faucets marked to designate hot and cold 4 Loose area rugs and runners placed over carpeting 5 Extension cords and phone cords in the main route of walking traffic communicating with these patients? Select all that apply. 1 Speak loudly when talking. 2 When not understood, repeat the conversation. 3 Ensure that the patients keep their eyeglasses clean. 4 Use written information to enhance or supplement spoken communication. 5 Keep the patient's hands free to allow communication through hand gestures.

2,4,5 Due to impaired proprioception, the patient may lose balance and fall if the walkways are uneven and cracked. The patient may slip over loose rugs and runners and fall. The patient has impaired vision and may trip on extension cords and phone cords. Bathrooms with shower grab bars decrease the risk of injury by supporting the patient. Water faucets marked to designate hot and cold help to prevent accidental burn injury, because the patient has an impaired sense of touch.

A patient with a history of a hearing deficit comes to the medical clinic for a routine checkup. His wife died 2 years ago, and he admits to feeling lonely much of the time. What are some interventions the nurse uses to reduce loneliness? Select all that apply. 1 Reassuring the patient that loneliness is a normal part of aging 2 Providing information about local social groups in the patient's neighborhood 3 Maintaining distance while talking to avoid overstimulating the patient 4 Recommending that the patient consider making living arrangements that will put him closer to family or friends 5 Introducing the idea of bringing a pet into the home

2,4,5 Loneliness is not a normal part of aging. Principles for reducing loneliness include providing information about local social groups and recommending alterations in living arrangements if physical isolation occurs. When appropriate, bringing a companion such as a pet into the home can help to reduce loneliness.

An elderly obese patient who has undergone total hip replacement surgery has been put on low-molecular-weight heparin (LMWH) enoxaparin. For which complications of subcutaneous injections should the nurse monitor? Select all that apply. 1 Phlebitis 2 Pain 3 Infiltration 4 Hypertrophy of the skin 5 Sterile abscess

2,4,5 Subcutaneous injections may be painful with irritating medication or if a large volume of medications is injected. Repeated injections at the same site may cause hypertrophy of the skin. The injected medication may collect at the site causing sterile abscess. Phlebitis is inflammation of the veins. Infiltration happens when the intravenous fluid or medication accidently enters extravascular space.

Which defining characteristics are consistent with fluid volume deficit? 1 A weight loss of 1 lb (0.5 kg) in 1 week, pale yellow urine 2 Engorged neck veins when upright, bradycardia 3 Dry mucous membranes, thready pulse, tachycardia 4 Bounding radial pulse, flat neck veins when supine

3 A deficit of fluid volume includes a deficit of extracellular fluid volume (ECF), hypernatremia, and clinical dehydration. ECF deficit is characterized by dry mucous membranes, thready pulse, and tachycardia, among other indicators. Weight loss of 1 lb (0.5 kg) in 1 week could indicate fat loss instead of fluid loss. ECF deficit causes dark yellow urine rather than pale yellow urine, which is normal.

While assessing a patient for joint mobility, the nurse notices that the patient is unable to dorsiflex the foot. Which condition does the nurse suspect in the patient? 1 Scoliosis 2 Torticollis 3 Joint contracture 4 Disuse osteoporosis

3 A patient with the type of joint contracture known as foot drop is permanently fixed in plantar flexion and is unable to dorsiflex the foot. Disuse osteoporosis refers to atrophy and decreased density of the bone tissue. Torticollis involves inclining the head to the affected side with the sternocleidomastoid muscle is contracted. Scoliosis refers to a lateral S- or C-shaped spinal column with vertebral rotation, and unequal heights of the hips and shoulders.

Which movement is assessed in the frontal plane when the nurse is observing the mobility of the joint? 1 Rotation 2 Extension 3 Adduction 4 Supination

3 Adduction, abduction, eversion, and inversion are the movements assessed in the frontal plane. Rotation is a movement assessed in the transverse plane. Extension is a movement in the sagittal plane. Supination is also the movement assessed in the transverse plane.

A patient reports having shortness of breath and fatigue on brisk walking for the past 2 weeks. The patient has also experienced menorrhagia for the past 2 months. The patient's blood reports show decreased hemoglobin and an increased red blood cell count. Which condition is the patient most likely experiencing? 1 Decreased surfactant in the lungs 2 Decreased lung compliance 3 Decreased oxygenation of blood 4 Decreased fraction of inspired oxygen concentration

3 An examination would likely indicate that the patient has anemia as a result of menorrhagia. In anemia, oxygenation decreases. Over a long period, the body responds by increasing the production of red blood cells, resulting in polycythemia. Surfactant is a chemical produced by the lungs that prevents alveolar collapse. It is highly unlikely the patient has decreased surfactant. Lung compliance is the ability of the lungs to expand and is affected by intraalveolar pressure. A decrease in the fraction of inspired oxygen concentration occurs in upper or lower airway obstruction.

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient? 1 Postural drainage 2 Chest percussion 3 Incentive spirometer 4 Suctioning

3 An incentive spirometer is used to encourage deep breathing to inflate alveoli and open pores of Kohn. Postural drainage, chest percussion, and suctioning are used to treat atelectasis and increased mucus production.

A registered nurse discusses physiological factors that affect oxygenation with a group of nursing students. Which statement if made by the nursing student is correct? 1 "The metabolic rate decreases normally in pregnancy, wound healing, and exercise." 2 "The physiological response to chronic hypoxia is an increase in white blood cell production." 3 "Carbon monoxide is the most common toxic inhalant; it decreases the oxygen-carrying capacity of the blood." 4 "The oxygen carrying capacity of the blood increases when there is a decline in inspired oxygen concentration."

3 Carbon monoxide (CO) is the most common toxic inhalant, decreasing the oxygen-carrying capacity of blood. The metabolic rate increases normally during pregnancy, wound healing, and exercise because the body is using energy or building tissue. The physiological response to chronic hypoxemia is the production of red blood cells, called polycythemia. When there is a decrease in inspired oxygen concentration, the oxygen-carrying capacity of the blood decreases.

What is cartilage? 1 Connection between bones 2 White fibrous bands of tissues that connect muscles to bones 3 Nonvascular supporting connective tissue located chiefly in joints 4 Shiny white flexible bands of fibrous tissues that bind joints together

3 Cartilage is nonvascular supporting connective tissue located chiefly in joints and the thorax, trachea, nose, and ear. Joints are the connections between bones. Tendons are the white, glistening fibrous bands of tissues that connect muscles to bones, and are strong, flexible, and inelastic. Ligaments are shiny white flexible bands of fibrous tissues that bind joints together, connect bones and cartilage, and aid joint flexibility and support.

A patient has had chronic diarrhea for 3 months and also suffers from repeated bouts of vomiting. The nurse is reviewing the patient's laboratory report. Which are likely findings in the laboratory report? 1 Serum K + levels are more than 5 mEq/L. 2 Total serum Ca 2+ is greater than 10.5 mg/dL. 3 Serum K + levels are less than 3.5 mEq/L. 4 Serum Mg 2+ levels are greater than 2.5 mEq/L.

3 Chronic diarrhea and vomiting can cause electrolyte imbalances in the body. Diarrhea and vomiting can result in the loss of electrolytes from the body, resulting in decreased potassium levels. Potassium, magnesium, and calcium levels may increase in the case of increased intake and absorption of these electrolytes.

A patient who is confined to bed has reduced tactile sensation. What is the major risk for this patient? 1 Aphasia 2 Hyperesthesia 3 Skin injury 4 Macular degeneration

3 Due to reduce tactile sensation the patient is unable to sense pressure on bony prominences or the need to change position. It increases the risk of skin breakdown. Aphasia is the inability to communicate. Hyperesthesia is exaggerated touch perception. Macular degeneration is characterized by changes in the macula of the eye and is not associated with reduced tactile sensation.

Which is a common debilitating contracture? 1 Disuse 2 Atrophy 3 Footdrop 4 Shortening of the muscle

3 Footdrop is a common and debilitating contracture in which the foot is permanently fixed in plantar flexion. Disuse, atrophy, and shortening of muscle fibers are the causes of joint contractures.

While caring for a patient undergoing suctioning, the nurse suddenly insists on stopping the process of suctioning. Which parameter observed by the nurse supports this intervention? 1 Pulse oximetry of 90% 2 Body temperature of 99° F 3 Heart rate of 40 bpm 4 Respiratory rate of 20 breaths per minute

3 If there is a change in heart rate of 20 bpm (either increase or decrease) or if the pulse oximetry falls below 90%, suctioning is stopped. A body temperature of 99° F is considered normal and is not associated with the process of suctioning. A normal respiratory rate is 18 breaths per minute. A slight increase in the respiratory rate may not interfere with the process of suctioning.

A patient is admitted with severe lobar pneumonia. Which assessment findings would indicate that the patient needs airway suctioning? 1 Coughing up thick sputum only occasionally 2 Coughing up thin, watery sputum easily after nebulization 3 Decreased independent ability to cough 4 Lung sounds clear only after coughing

3 Impaired ability to cough up mucus caused by weakness or very thick secretions indicates a need for suctioning when the patient has pneumonia. The other choices indicate that the patient has the ability to cough.

A registered nurse discusses piggyback medication with a group of nursing students. Which statement made by the nursing student needs correction? 1 "In a piggyback setup, the tubing is a microdrip system." 2 "In a piggyback setup, the small bag is higher than the primary infusion bag." 3 "In a piggyback setup, the mainline infuses when the piggybacked medication is infused." 4 "In a piggyback setup, a small intravenous bag is connected to a short tubing line that connects to the upper Y-port."

3 In a piggyback setup, the mainline does not infuse when the piggybacked medication is infused. In a piggyback setup, the tubing is a microdrip system. The piggyback contains a small bag that is higher than the primary infusion bag. A piggyback is a small intravenous bag connected to a short tubing line that connects to the upper Y-port of a primary infusion line.

Which statement is true regarding intermittent venous access? 1 Intermittent venous access requires constant monitoring of flow rates. 2 Intermittent venous accessreduces the risk of rapid-dose infusion by an intravenous push. 3 Intermittent venous access increases patient mobility, safety, and comfort. 4 Intermittent venous access allows medications to be given in very small amounts of fluid.

3 Intermittent venous access, also called a saline lock, is an intravenous catheter capped off on the end with a small chamber covered by a rubber diaphragm or a specially designed cap. It increases patient mobility, safety, and comfort. Intermittent venous access does not require constant monitoring of flow rates. Volume-controlled infusions reduce the risk of rapid-dose infusion by an intravenous push. Syringe pumps allow medications to be given in very small amounts of fluid.

Which risk is associated with suctioning when performed in an appropriate time interval on a patient who has a head injury? 1 Irregular heartbeat 2 Decreased blood pressure 3 Increased intracranial pressure 4 Abnormal decrease in oxygen concentration

3 Suctioning increases intracranial pressure even when provided in the appropriate time interval. Therefore, hyperventilation should be performed before suctioning to reduce the risk of intracranial pressure. Providing suctioning frequently increases the risk for irregular heartbeat, decreased blood pressure, and an abnormal decrease in oxygen concentration.

Which topical medication contains soapy emollient? 1 Paste 2 Lotion 3 Liniment 4 Ointment

3 Liniment usually contains soapy emollient. Paste is a form of thick ointment which may not contain soapy emollient. Lotion is a semi-liquid suspension which may not contain soapy emollient. Ointment is semi-solid which may not contain soapy emollient.

A primary health care provider prescribes maintenance medication to a patient with respiratory distress. What does the nurse teach the patient about maintenance medication? 1 Maintenance medication is short acting. 2 Maintenance medication provides immediate relief. 3 The effects of maintenance medication last for a long time. 4 A dose of maintenance medication is administered monthly.

3 Maintenance medications are inhaled; their effects lasts for long periods of time. Rescue medications are short acting and provide immediate relief. Maintenance medications are used on a daily basis to prevent acute respiratory distress.

The nurse asks a patient to say "ahh" while performing suctioning. What is the rationale behind this intervention? 1 To facilitate breathing 2 To elevate the bronchial passage 3 To assist in opening the glottis 4 To permit the flow of secretions into the mouth

3 Making sounds such as "ahh" assists in opening the glottis to permit passage of the catheter into the trachea. Making sounds such as "ahh" may not facilitate breathing. Turning the patient's head to the side elevates the bronchial passage on the opposite side. Continuous coughing may permit the flow of secretions into the mouth from the upper respiratory tract.

The nurse completes an assessment of a 67-year-old female patient who comes to the clinic for the first time. During the examination, the patient's temperature is 99.6° F (37.6° C), heart rate 80 beats/minute, respiratory rate 18 breaths/minute, and blood pressure 142/84 mm Hg. She is not attentive as the nurse asks questions. At one point, she shouts answers to questions about her diet. However, as the nurse speaks, the patient consistently smiles and nods in agreement. What is the nurse's assessment regarding this patient? 1 The patient has a visual deficit. 2 The patient is normal. 3 The patient has a hearing deficit. 4 The patient has sensory overlo

3 Patient behaviors indicating a hearing deficit include decreased attention span, increased volume of speech, and smiling and nodding in approval when someone speaks.

The nurse completes an assessment of a 67-year-old female patient who comes to the clinic for the first time. During the examination, the patient's temperature is 99.6° F (37.6° C), heart rate 80 beats/minute, respiratory rate 18 breaths/minute, and blood pressure 142/84 mm Hg. She is not attentive as the nurse asks questions. At one point, she shouts answers to questions about her diet. However, as the nurse speaks, the patient consistently smiles and nods in agreement. What is the nurse's assessment regarding this patient? 1 The patient has a visual deficit. 2 The patient is normal. 3 The patient has a hearing deficit. 4 The patient has sensory overload

3 Patient behaviors indicating a hearing deficit include decreased attention span, increased volume of speech, and smiling and nodding in approval when someone speaks.

Which type of oxygen mask is contraindicated for patients who have carbon dioxide retention? 1 Venturi mask 2 Nasal cannula 3 Simple face mask 4 Partial rebreather

3 Simple face masks are contraindicated in patients who have carbon dioxide retention because retention can be worsened. Venturi masks, nasal cannulas, and partial rebreathers will not cause further worsening of the retention, so they are not contraindicated.

Which treatment is provided for patients with lordosis? 1 Knee braces 2 Denis Browne splint 3 Spine-stretching exercises 4 Bracing with ankle-foot orthotic

3 Spine stretching exercises is a treatment provided for patients with lordosis. Knee braces are provided for patients with knock-knee. A Denis Browne splint is provided for patients with clubfoot. Bracing with ankle-foot orthotic is provided for patients with footdrop.

Which patient finding indicates the need for home oxygen therapy? 1 Heart rate 72 bpm 2 Respiratory rate 24 bpm 3 Arterial partial pressure 50 mm Hg 4 Serum carbon dioxide level 24 mEq/L

3 The indications for home oxygen therapy include an arterial partial pressure less than 55 mm Hg and partial oxygen saturation less than 88%. The normal heart rate is 60 to 80 bpm. Therefore, the rate of 72 bpm is a normal finding. A respiratory rate of 24 bpm is also a normal finding. The normal level of serum carbon dioxide is 23 to 30 mEq/L . Therefore, the level of 24 mEq/L is a normal finding and is not an indication for home oxygen therapy.

The nurse is reviewing the data of patients who have undergone surgery. Which patient would be at the highest risk of orthostatic hypotension based on the given data? 1 Patient A appendectomy 2 Patient B lobotomy 3 Patient C hip replacement 4 Patient D bypass surgery

3 The longer the duration of a patient's immobility, the higher the risk is for orthostatic hypotension. Therefore, the patient who underwent hip replacement and required bed rest for 90 days would be at the highest risk of orthostatic hypotension.

After administrating intravenous medication, the nurse flushes the injection port with normal saline. What is the rationale behind this intervention? 1 To reduce the risk of accidental needlesticks 2 To reduce the transmission of infection 3 To prevent the occlusion of the intravenous access devices 4 To prevent the transmission of microorganisms

3 The nurse flushes the injection port with normal saline to prevent the occlusion of the intravenous access devices. The nurse should dispose of uncapped needles and syringes in puncture-proof containers to reduce the risk of accidental needlesticks. The nurse should remove the saline flush syringe to reduce the transmission of infection. The nurse removes and disposes of used gloves to prevent transmission of microorganisms.

Which nursing intervention is done to prevent needlestick injuries after intravenous administration? 1 Bend the needle before disposal 2 Break the needle before disposal 3 Avoid recapping the used needles 4 Clean the needle with an antiseptic swab before dispo

3 The nurse should avoid recapping used needles and should dispose in puncture-proof and leak-proof containers to prevent accidental needlestick injuries. The nurse should not break or bend needles before disposal. The nurse should not clean used needles with an antiseptic swab because they are not used again and should be disposed.

Which aspect of positioning a patient in the supported Fowler's position has a goal of decreasing flexion of vertebrae? 1 Place a small pillow under thigh 2 Place the head on a small pillow 3 Place a small pillow at the lower back 4 Place a pillow to support arms and hands

3 The nurse should place a small pillow at lower back to decrease flexion of vertebrae. Placing a small pillow under the thigh prevents hyperextension of the knee. Placing the head on a small pillow prevents flexion contractures of cervical vertebrae. Placing a pillow to support the arms and hands prevents shoulder dislocation.

In what position should the nurse place the patient in to examine the apical segments of the lungs? 1 Prone 2 Supine 3 Fowler's (Sitting) 4 High-Fowler's

3 The nurse should place the patient in a Fowler's (sitting) position to examine the apical segments of the lungs. The prone position is used to examine the posterior segment of the lungs. The supine position is used to examine the anterior segment and posterior segment of the lung. The high-Fowler's position is used to examine the bilateral segment of the lungs.

Which nursing intervention is done to prevent accidental needlestick injuries? 1 Adjusting the regulator clamp infusion rate 2 Regulating the main infusion line to the desired rate 3 Using the needleless port of the main intravenous line after cleaning with an antiseptic swab 4 Hanging the piggyback medication bag above the level of the primary fluid bag

3 The nurse should use the needleless port of the main intravenous line after cleaning with an antiseptic swab to prevent accidental needlestick injuries. The nurse should adjust the regulator clamp infusion rate to maintain therapeutic blood levels. The nurse regulates the main infusion line to the desired rate to prevent interference with the mainline infusion rate. The nurse should hang the piggyback medication bag above the level of the primary fluid bag to prevent negative flow rate effects.

Which statement is true regarding oxygen concentrators? 1 They are expensive. 2 They have cylinders or tanks to refill. 3 They provide large sources of oxygen. 4 They are a good choice for patients who leave their homes frequently.

3 The oxygen concentrator provides a large source of oxygen. They are inexpensive. These devices do not contain cylinders or tanks to refill. This type of home oxygen storage system is beneficial for patients who do not leave their homes frequently.

A patient has reduced taste sensation and is finding food less appealing. What does the nurse instruct the patient? 1 Avoid smelling baked bread. 2 Avoid smelling cooked garlic. 3 Avoid blending or mixing foods. 4 Avoid eating food of different textures

3 The patient should avoid blending or mixing foods because doing that makes it difficult for the patient to identify tastes. Smelling baked bread, smelling cooked garlic, and eating foods of different textures heightens taste sensation. There is no need to avoid such activities.

The patient who has a severe left leg injury needs to avoid weight bearing on the affected leg. Which crutch gait is appropriate for the patient? 1 Two-point gait 2 Four-point gait 3 Three-point gait 4 Swing-through gait

3 The three-point gait is appropriate for this patient because in a three-point gait, the patient bears all of the weight on the unaffected foot. In a two-point gait, partial weight is placed on each foot. In a four-point gait, weight is placed on both the legs. In a swing-through gait, weight is placed on the supported legs, which have weight-supporting braces.

Which positioning aid decreases the shearing action from sliding across up and down in bed? 1 Thin pillow 2 Thick pillow 3 Trapeze bar 4 Trochanter roll

3 The trapeze bar decreases the shearing action from sliding across or up and down in bed. Thin and thick pillows are used for positioning patients. The trochanter roll prevents external rotation of the hips when a patient is in a supine position.

A patient is receiving an intravenous (IV) push medication. If the drug infiltrates into the outer tissues, what should the nurse do? 1 Continue to let the IV run. 2 Apply a warm compress to the infiltrated site. 3 Stop administration of the medication and follow agency policy. 4 Don't worry about this because vesicant filtration is not a problem.

3 When an intravenous (IV) medication infiltrates, stop giving the medication and follow agency policy. Vesicant infiltration can be a problem and is an unexpected outcome of IV therapy. Do not continue to let the IV run or apply a warm compress to the infiltrated site, but do treat IV site as indicated by agency policy.

Which is a principle of proper body mechanics when lifting or carrying objects? 1 Keep the knees in a locked position. 2 Bend at the waist to maintain a center of gravity. 3 Maintain a wide base of support. 4 Hold objects away from the body for improved leverage

3 Maintaining a wide base of support allows for proper body mechanics. Locking the knees or bending at the waist causes strain on the lower back. Holding objects close to the body helps use the center of gravity for leverage.

A patient develops sudden onset of bronchiolar constriction, edema of pharynx and larynx, and shortness of breath following administration of a medication. Which type of allergic reaction is the patient experiencing? 1 Rhinitis 2 Medication allergy 3 Anaphylactic reaction 4 Idiosyncratic reaction

3 The sudden onset of bronchiolar constriction, edema of pharynx and larynx, and shortness of breath indicate the severe form of allergic reaction called anaphylactic reaction. Rhinitis is a minor form of allergic reaction that manifests as sneezing, swelling, and clear nasal discharge. Medication allergy is a nonspecific term and encompasses rhinitis, rash, urticaria, and pruritus. Idiosyncratic reaction is the onset of an unpredictable response in a patient.

When caring for a patient undergoing intravenous therapy, the nurse observes redness and swelling around the intravenous (IV) catheter insertion site. A purulent drainage is also present. Which immediate actions should the nurse perform? Select all that apply. 1 Apply pressure to the dressing over the site. 2 Raise the head of the bed and administer oxygen. 3 Remove the catheter and preserve for culture. 4 Start a new intravenous (IV) line in another extremity. 5 Clean the site with alcohol and apply sterile dressing.

3,4,5 The assessment findings show a possibility of infection; therefore, the catheter should be removed and preserved for culture. Antibiotics can be prescribed based on the culture reports. Because there is redness and swelling at the site, a new intravenous line should be started in a different extremity. To avoid the spread of infection, the nurse should clean the site with alcohol and apply a sterile dressing. Applying pressure to the dressing over the site would be performed in case of bleeding from the site, not because of infection. Raising the head of the bed and administering oxygen should be considered in case of circulatory overload of intravenous solution.

Which strategies does the nurse keep in mind when communicating with a hearing-impaired patient? Select all that apply. 1 Speak loudly towards the patient's ear. 2 Avoid sitting at the same level as the patient. 3 Avoid eating or chewing while speaking. 4 Use a normal tone of voice and normal inflections of speech. 5 Use written information to enhance the spoken word.

3,4,5 The patient has a hearing impairment, so precaution should be taken while communicating with the patient. Eating or chewing while speaking may lead to misinterpretation of the message by the patient, because the patient tends to read facial expressions and interpret messages. Using a normal tone of voice and inflections of speech help the patient to hear and understand properly. Written information can be used to enhance the spoken word so that the patient can completely understand the message. The nurse should avoid speaking loudly towards the patient's ear, because higher pitched sound often impedes hearing by accentuating vowel sounds and concealing consonants. Sitting at the same level as the patient helps the patient to easily see the communicator, read lip movements, and read facial expressions.

The nurse is attending to patients with hearing impairments. What precautions should the nurse take while communicating with these patients? Select all that apply. 1 Speak loudly when talking. Incorrect2 When not understood, repeat the conversation. Correct3 Ensure that the patients keep their eyeglasses clean. Correct4 Use written information to enhance or supplement spoken communication. Correct5 Keep the patient's hands free to allow communication through hand gesture

3,4,5 f the speaker. If possible, information can be written down and shared with hearing-impaired patients. Patients with hearing impairment should be allowed to use their hands freely so that they can communicate with hand gestures or sign language. Loud sounds are usually higher-pitched and often impede hearing by accentuating vowel sounds and concealing consonants. If you need to raise your voice, speak in lower tones. When you are not understood, rephrase rather than repeat the conversation.

Which age-related changes in the older adult may result in decreased tissue oxygenation due to impaired chest expansion? Select all that apply. 1 Change in cough mechanism 2 Impairment of the immune system 3 Ossification of costal cartilage 4 Decreased intervertebral space 5 Diminished respiratory muscle strength

3,4,5, Ossification of costal cartilage, decreased intervertebral space, and diminished respiratory strength will all impair chest expansion, which leads to decreased tissue oxygenation. A change in the cough mechanism may lead to atelectasis, due to retained pulmonary secretions. An impaired immune system can cause respiratory infections but won't impair chest expansion.

A 3-year-old child has rickets. Which vitamin should be supplemented to the child's diet? 1 Vitamin A 2 Vitamin B 3 Vitamin C 4 Vitamin D

4 A deficiency of vitamin D causes rickets. Therefore, the child should receive vitamin D supplements. Deficiency of vitamin A causes night blindness. Lack of vitamin B causes neural tube defects. Vitamin C deficiency leads to scurvy.

The primary health care provider prescribes lorazepam (Ativan) 1 mg IV to a patient who is about to undergo an MRI scan. Which type of prescription order has been given by the primary health care provider? 1 Prn order 2 Now order 3 STAT order 4 Single order

4 A single order prescription necessitates the administration of medication at one specific time; administration of lorazepam, an anti-anxiety agent, before an MRI scan is an example of this prescription order. A prn order is prescribed when the drug should be administered to the patient as required; administration of morphine sulfate is an example of this prescription order. A now order prescription is given when the drug should be administered to the patient quickly, but not right away; administration of vancomycin is an example of this prescription order. A STAT order prescription is given when the drug should be administered to the patient immediately, as in an emergency situation; administration of a drug such as apresoline is an example of this prescription order.

Which positioning aid prevents external rotation of the hips when the patient is in the supine position? 1 Thin pillow 2 Thick pillow 3 Trapeze bar 4 Trochanter roll

4 A trochanter roll prevents external rotation of the hips when a patient is in the supine position. A thin pillow or thick pillow would not be helpful for preventing the external rotation of the hips, but may lead to increased flexion when the appropriate pillow size is not taken. The trapeze bar allows the patient to raise the upper extremities to raise the trunk off the bed, which helps in decreasing the shearing action from sliding across or up and down the bed.

Which statement is true regarding an oxygen mask? 1 It is easily tolerated. 2 It is inexpensive and disposable. 3 It is a simple, comfortable device used for precise oxygen delivery. 4 It is a device that fits snugly over the mouth and nose and is secured in place with a strap.

4 An oxygen mask is a device that fits snugly over the mouth and the nose and is secured in place with a strap. A nasal cannula is easily tolerated, inexpensive, and disposable. A nasal cannula is a simple, comfortable device used for precise oxygen delivery.

A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min. While in the supine position for a bath, the patient complains of shortness of breath. Which is the most appropriate first nursing action? 1 Increase the flow of oxygen. 2 Perform tracheal suctioning. 3 Report this to the healthcare provider. 4 Assist the patient to semi-Fowler's position.

4 Breathing is easier in semi-Fowler's position because it permits greater expansion of the chest cavity. If repositioning does not improve the situation, then oxygenation and contacting the health care provider might be appropriate. The patient would not benefit from tracheal suctioning.

Why is clamping a chest tube contraindicated while ambulating a patient? 1 It causes kyphosis. 2 It causes burning sensation. 3 It causes pulmonary infection. 4 It causes tension pneumothorax

4 Clamping a chest tube is contraindicated while ambulating a patient, because it results in tension pneumothorax. Kyphosis is a chest wall abnormality, and clamping a chest tube may not be contraindicated while ambulating a patient. While removing the chest tube, the patient may have a burning sensation, but this is not associated with clamping the chest tube. Clamping a chest tube while ambulating a patient may not prevent pulmonary infection.

A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder? 1 Alcoholism and hypertension 2 Obesity and diabetes 3 Stress-related illnesses 4 Cardiopulmonary disease and lung cancer

4 Effects of nicotine on blood vessels and lung tissue have been proven to increase pathological changes, leading to heart disease and lung cancer. Smoking causes hypertension but not alcoholism. Smoking does not directly lead to obesity, diabetes, or stress-related illnesses

The nurse puts elastic stockings on a patient following major abdominal surgery. Why are elastic stockings used after a surgical procedure? 1 To prevent varicose veins 2 To prevent muscular atrophy 3 To ensure joint mobility and prevent contractures 4 To promote venous return to the heart

4 Elastic stockings maintain external pressure on the lower extremities and assist in promoting venous return to the heart. This increase in venous return helps reduce the stasis of blood and in turn reduces the risk for deep vein thrombosis (DVT) formation in the lower extremities. The stockings are not used to prevent varicose veins, muscular atrophy, and contractures, or to promote joint mobility.

A patient uses a single unit dry powder inhaler twice daily. Each bottle contains 30 capsules. How many bottles are required for 2 months, if the patient uses one capsule for every dose? Record your answer using a whole number. ____

4 First multiply to determine the number of capsules needed for two months: 1 capsule x 2 times daily x 30 days x 2 months = 120 capsules per 2 months. Because each bottle contains 30 capsules, divide 120 by 30 to get 4 bottles.

Which health promotion intervention is important to teach parents and children to prevent hearing impairment? 1 Avoid activities in which there may be crowds. 2 Delay childhood immunizations until hearing can be verified. 3 Prophylactically administer antibiotics to reduce the incidence of infections. 4 Take precautions when involved in activities associated with high-intensity noises.

4 Good sensory function begins with prevention. Nurses need to routinely assess children for noise exposure and reinforce the use of protective devices to minimize hearing loss. There is no need to delay immunizations, prophylactically administer antibiotics, or avoid crowds, because these measures will not prevent or cause hearing impairment.

Which nursing intervention, if performed before suctioning, minimizes hypoxemia after suctioning? 1 Lubricating the catheter 2 Applying suction during the insertion 3 Performing the suctioning too frequently 4 Hyperoxygenating the patient before suctioning

4 Hyperoxygenation before suctioning minimizes the risk of hypoxemia after suctioning. Lubricating the catheter permits easier insertion and reduces mucosal surface trauma. The nurse should never apply suction during the insertion; suction should be applied while withdrawing the catheter. The risk of developing hypoxemia, hypotension, arrhythmias, and possible trauma to the mucosa of the lungs is increased with too frequent suctioning.

A patient has been diagnosed with severe iron deficiency anemia. To determine the patient's oxygen status, the nurse should assess for which symptoms during physical assessment? 1 Increased breathlessness and increased activity tolerance 2 Decreased breathlessness and decreased activity tolerance 3 Increased activity tolerance and decreased breathlessness 4 Decreased activity tolerance and increased breathlessness

4 Hypoxia occurs because of decreased circulating blood volume, which leads to decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a feeling of shortness of breath.

The nurse is suctioning the tracheostomy in a patient. Which step in the nursing process is the nurse performing? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

4 Implementation involves executing the intubation and related activities. Therefore, suctioning the tracheostomy is considered part of the implementation stage of the nursing process. Planning would involve the health care team deciding the steps involved and surrounding the intubation. Assessment includes gathering data about the patient; these data may be what leads the health care team to decide to intubate the patient. Evaluation involves assessing the success of a procedure.

Which nursing action is most appropriate during suctioning? 1 Picking up the connecting tubing with the dominant hand 2 Applying a clean glove to the dominant hand for oropharyngeal suctioning 3 Applying a sterile glove to the nondominant hand for artificial airway suctioning 4 Picking up a suction catheter with the nondominant hand and not letting the catheter touch nonsterile surfaces

4 In oropharyngeal suctioning, the nurse should wear a clean glove on his or her dominant hand or on each hand. Connecting tubing is picked up with the nondominant hand. Sterile gloves are worn for artificial airway suctioning. The suction catheter is picked up with the dominant hand and the catheter should not be allowed to touch nonsterile surfaces.

A registered nurse evaluates the actions of a nursing student who is performing tracheal suctioning in a patient who has a history of respiratory distress. Which of the student's nursing actions indicates effective learning? 1 Applying the suction before the patient has coughed 2 Applying suction pressure while inserting the catheter 3 Continuing the press without allowing rests in between passes of the catheter 4 Maintaining the suction pressure between 120 and 150 mm Hg while withdrawing the catheter

4 In tracheal suctioning, once the catheter is inserted to the necessary distance, the suction pressure should be maintained in between 120 and 150 mm Hg while being withdrawn. Oropharyngeal and nasopharyngeal suctioning is used when the patient is able to cough effectively, but is unable to clear secretions by expectorating. Oropharyngeal and nasopharyngeal suctioning is applied after the patient has coughed. Suction pressure should not be applied while the catheter is being inserted. If the patient has respiratory distress, then the nurse should allow the patient to rest between the passes of the catheter.

A patient reports having shortness of breath for 2 months. The nurse asks the patient to rate the shortness of breath on a scale of 0 to 10 and state whether it is affecting daily activities. The nurse also asks about exposure to passive smoking and whether the patient feels comfortable when sleeping in a reclining chair. Which question asked by the nurse is about orthopnea? 1 Exposure of patient to passive smoking 2 Shortness of breath affecting daily activities 3 Rating the shortness of breath on a scale of 0 to 10 4 Feeling of comfort when sleeping in a reclining chair

4 Orthopnea occurs when the patient feels short of breath while sleeping, but comfortable when sleeping in a reclining chair. In a reclined position, the patient may also use multiple pillows to facilitate breathing. Orthopnea is quantified based on the number of pillows used. The question about exposure to passive smoking gives information about the predisposing factors to the complaints. The question about symptoms affecting daily activities indicates the severity of the symptoms. The question to rate dyspnea gives information about severity of the complaints.

An older adult who was in a car accident and fractured the femur has been immobilized for 5 days. Which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the first time? 1 Chronic pain 2 Impaired skin condition 3 Risk for ineffective cerebral tissue bloodflow 4 Risk for inability to tolerate activity

4 Patients on bed rest are at risk for inability to tolerate activity, which increases patients' risk for falling. The patient is in acute pain, not chronic pain. The patient could have some skin breakdown, but this is not relevant to getting the patient out of bed. The patient's cerebral tissue bloodflow is not an issue in this situation.

When communicating with a patient who has expressive aphasia, what is the highest priority for the nurse? 1 Asking open-ended questions 2 Understanding that the patient will be uncooperative 3 Coaching the patient to respond 4 Offering pictures or a communication board so the patient can point

4 Patients who have expressive aphasia understand questions but have difficulty expressing an answer. To promote interaction with the patient, offer pictures or a communication board so the patient can point to key words or images. Listen to the patient and wait for him or her to communicate. Use simple, short questions and facial gestures to give additional cues.

The nurse reviews discharge instructions with a patient who has osteoporosis. Which statement by the patient indicates that the patient understands the instructions? 1 "I will avoid intake of leafy green vegetables." 2 "I will avoid exercises, because they may cause bone fracture." 3 "I will reduce consumption of food containing calcium." 4 "I will stop smoking as soon as possible."

4 Patients with osteoporosis should make lifestyle changes to prevent the disease from becoming worse. Smoking poses a major risk for osteoporosis, but this risk can be drastically reduced if the patient stops smoking. Intake of leafy green vegetables is helpful for the patient who has osteoporosis and should not be avoided. Exercise is helpful in keeping the bones strong. The patient should increase intake of calcium to maintain bone health.

Medications undergo vigorous testing before they are made available to the public. Which regulatory agency is responsible for ensuring this process? 1 Medicare program 2 National Formulary 3 United States Pharmacopeia 4 Food and Drug Administration

4 The Food and Drug Administration ensures that all medications available in the market undergo vigorous testing to ensure their safety and efficacy. The Medicare program does not ensure testing of drugs. The United States Pharmacopeia and the National Formulary set standards for medication strength, quality, purity, packaging, safety, and dose form.

An elderly patient has undergone hip replacement surgery. On the second postoperative day, the nurse finds that the pedal pulses are absent and the lower extremities are cold to the touch. What should the nurse interpret from this finding? 1 It is an age-related effect. 2 The patient's hip joint has dislocated. 3 The room temperature is too cold. 4 The patient has venous thrombus formation

4 The absence of pedal pulses and abnormally cold extremities indicate that the patient has venous thrombus formation. Venous thrombus formation occurs because of stagnation or alteration in the blood flow as a result of immobility or injury to the vessel wall during surgery. The thrombus may block the blood supply to the extremities. The clinical manifestations in the patient are not age-related effects. Hip joint dislocation may not result in absence of pedal pulses. A cool room temperature may cause the extremities to become cold but may not lead to an absence of pedal pulses.

In which position would the nurse place a patient with a pneumothorax and chest tubes for optimal lung expansion? 1 High-Fowler's 2 Sitting 3 Supine 4 Semi-Fowler's

4 The chest tube is a catheter inserted into the thorax to remove air and fluids from the pleural space and to prevent them from reentering that space, or to reestablish normal intrapleural and intrapulmonic pressures. Researchers have shown that a semi-Fowler's position is optimal for promoting lung expansion and reduced abdominal pressure on the diaphragm. The sitting and high-Fowler's positions are similar and preferred when examining apical lung segments. The supine position is preferred to examine the right anterior upper lobe lung segment.

What is the function of this instrument? 1 Helps to clear respiratory secretions 2 Helps in administration of invasive mechanical ventilation 3 Encourages voluntary deep breathing by providing visual feedback 4 Prevents obstruction of the trachea by displacement of the tongue into the oropharynx

4 The image depicts an oral artificial airway. It prevents obstruction of the trachea by displacement of the tongue into the oropharynx. A suction catheter helps to clear respiratory secretions. Endotracheal tubes facilitate mechanical ventilation. Incentive spirometry is used to achieve optimal inhalation.

Which nursing action is depicted in the image? 1 Cleaning around the stoma 2 Reinserting the inner cannula 3 Removing the outer cannula 4 Replacing tracheostomy ties

4 The image depicts replacing tracheostomy ties to secure the endotracheal tube in place. Cleaning around the stoma removes secretions from the stoma site. The inner cannula should be cleaned to remove secretions and then reinserted. The outer cannula should not be removed unless it is so instructed by the health care pro

A nurse is about to withdraw medication from an ampule. Which nursing action reduces the patient's risk for an allergic drug response? 1 Checking the patient's name, medication name, and dosage 2 Assessing the patient's body build, muscle size, and weight 3 Reviewing the medication action, purpose, dose, and route 4 Assessing the patient's medical history and medication history

4 The nurse should assess the patient's medical history, medication history, and history of allergies to reduce the risk of an allergic drug response. The nurse should check the patient's name, medication name, and dosage to ensure that the patient receives the correct medication. Assessing the patient's body build, muscle size, and weight helps to determine the type and size ofthe syringe and needles for injection. The nurse should review all pertinent information regarding medication action, dose, purpose, and route of administration to administer the medication properly and to monitor the patient's response.

A registered nurse teaches a nursing student about instructions to be given to a patient on intravenous therapy at home. Which statement made by the nursing student indicates the need for further teaching? 1 "I should teach the patient and family how to recognize problems of intravenous therapy." 2 "I should carefully assess the patient's and family's ability to manage intravenous therapy at home." 3 "I should teach patients and their families how to maintain intravenous administration therapy equipment." 4 "I should begin giving instructions to the patient about intravenous therapy when the patient is at home."

4 The nurse should begin giving instructions about intravenous therapy when the patient is hospitalized. The nurse should teach the patient and family how to recognize problems of intravenous therapy. The nurse should carefully assess the patient's and family's ability to manage home intravenous therapy. The nurse should teach patients and family how to maintain intravenous administration therapy equipment.

A registered nurse teaches a nursing student about safety measures to be followed when using oxygen. Which statement if made by the nursing student indicates a need for further teaching? 1 "I should store oxygen cylinders by placing them upright." 2 "I should check the oxygen level of portable tanks before transporting." 3 "I should keep the oxygen-delivery system 5 ft away from any open flames." 4 "I should place an 'Oxygen In Use' sign on the patient's door and in the room."

4 The nurse should keep the oxygen-delivery system at least 10 ft away from any open flames to prevent fires. The nurse should store oxygen cylinders by placing them upright. The nurse should check the oxygen level of portable tanks before transporting. The nurse should place an "Oxygen in Use" sign on the patient's door and in the room.

The registered nurse is teaching a nursing student about the safety guidelines for nursing skills. Which statement by the nursing student indicates the need for further learning? 1 "I should raise the side rail on the opposite side of the bed from where I'm standing." 2 "I should evaluate the patient for correct body alignment." 3 "I should determine the type of assistance required for safe positioning." 4 "I should arrange the positioning equipment as close as possible to the patient's bed."

4 The positioning equipment should be arranged in such a way that it does not interfere with the positioning process; therefore, the equipment should not always be placed next to or too far away from the bed, but should be placed appropriately. The side rails on the side of the bed should be raised on the opposite side where the nurse stands to prevent the patient from falling out of the bed. The nurse should evaluate the patient for correct body alignment and pressure risks after repositioning. The nurse should determine the amount and type of assistance required for safe positioning, including any transfer equipment and the number of personnel to safely transfer the patient.

What event describes an impulse that is transmitted from the nervous system to the musculoskeletal system? 1 Isotonic contraction 2 Voluntary movement 3 Isometric contraction 4 Electrochemical activity

4 The transmission of an impulse from the nervous system to the musculoskeletal system is an electrochemical activity that requires a neurotransmitter to transfer signals. Isotonic contractions are related to muscles and not related to the nervous system. The transmission of impulses from the nervous system to the musculoskeletal system are automatic, not voluntary, movements. Isometric contractions are related to muscles and not related to the nervous system.

While performing nasotracheal suctioning, the health care provider refrains from applying suction while inserting the catheter. What is the rationale behind this action? 1 To prevent hypotension 2 To protect against hypoxemia 3 To enhance the removal of secretions 4 To avoid traumatizing the tracheal mucosa

4 Tracheal suctioning is performed through an artificial airway, such as an endotracheal or tracheostomy tube. While inserting a catheter, pressure on the suction should be avoided to prevent traumatizing the tracheal mucosa. Less frequent suctioning helps to prevent hypotension and protect against hypoxemia. Rotating the catheter helps to enhance the removal of secretions.

A patient with left-sided weakness asks the nurse, "Why are you walking on my left side? I can hold on to you better with my right hand." What would be the best therapeutic response? 1 "Walking on your left side lets me use my right hand to hold on to your arm. In case you start to fall, I can still hold you." 2 "Would you like me to walk on your right side so you feel more secure?" 3 "Either side is appropriate, but I prefer the left side. If you like, I can have another nurse walk with you who will hold you on the right side." 4 "By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint.

4 Walking on the affected (weak side) side and holding the patient around the waist or using a gait belt gives the nurse better control if the patient starts to fall. If the nurse were holding the patient's arm as the patient was falling, this might dislocate the shoulder.

After administering a medication, the nurse finds that a medication error has occurred. Which action by the nurse is most appropriate in this situation? 1 Preparing and filing an incident report 2 Reporting the incident to the manager 3 Reporting the incident to the supervisor 4 Assessing and examining the patient's condition

4 When a medication error occurs, the nurse should first assess and examine the patient's condition and report it to the primary health care provider. Preparing and filing an incident report is appropriate, but not the most appropriate. Reporting the incident to the manager and supervisor are also appropriate, but not the most appropriate interventions in this situation.

A patient had a left-sided cerebrovascular accident (CVA) 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The patient is receiving enteral feedings through a small-bore nasogastric (NG) tube because of dysphagia. Which symptom requires the nurse to call the healthcare provider immediately? 1 Pale yellow urine 2 Unilateral neglect 3 Slight movement noted on the right side 4 Coffee ground-like aspirate from the feeding tube

4 When patients are receiving medications such as heparin or enoxaparin, the nurse must assess for signs of bleeding. These include overt signs, such as bleeding from the gums, or covert signs, which can be detected by testing the stool or observing the patient's aspirate from nasogastric (NG) tubes for coffee ground-like matter. These are signs of bleeding in the gastrointestinal tract. Pale yellow urine is not cause for concern, because it may be diluted and pale due to the extra fluids the patient may be given. Unilateral neglect in a cerebrovascular accident (CVA) is common. Slight movement that was not there during the previous neurological check is important and should be documented, but it is not necessary to call the healthcare provider.

The nurse is assisting a patient in the supported supine position. Which nursing action should the nurse implement to reduce the rotation of the hip? 1 Placing pillows under the upper shoulders 2 Placing pillows under the pronated forearms 3 Placing small rolled towel under the lumbar area of back 4 Placing trochanter rolls parallel to the lateral surface of the thighs

4 While positioning the patient in the supine position, the nurse should place trochanter rolls or sandbags parallel to the lateral surface of the patient's thighs if the patient is immobile. Placing pillows under the upper shoulders, neck, or head helps in maintaining the correct body alignment and prevents flexion contractures of the cervical spine. The nurse places pillows under the pronated forearms and keeps the upper arms parallel to the patient's body to reduce the internal rotation of the shoulder and prevent extension of the elbows. Placing a small rolled towel under the lumbar area of the back provides support to the lumbar region.

Which oxygen delivery system is indicated for long-term oxygen use at home? 1 Oxymizer 2 Partial mask 3 Nasal cannula 4 Nonbreather mask

Oxymizer (oxygen-conserving cannulas) are indicated for long-term oxygen use at home. Partial masks, nasal cannulas, and nonrebreather masks are used for short peroids

Using the sliding scale for insulin prescribed by the healthcare provider, 2 units of insulin is required for a blood glucose level between 150 and 200 mg/dL. The nurse finds that a patient's blood glucose level is 175 mg/dL. How much insulin should the patient be given? Record your answer using a whole number. ___ units

The correction or sliding scale of insulin is based on the patient's blood sugar levels at a given point in time. The prescribed dose of insulin for a blood glucose level of 150 to 200 mg/dL is 2 units; because the patient's level falls in that range, the patient should be given 2 units

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which menus should the nurse recommend? 1 Cream of broccoli soup with whole wheat crackers and tapioca for dessert 2 Hamburger on soft roll with a side salad and an apple for dessert 3 Low-fat turkey chili with sour cream and fresh pears for dessert 4 Chicken salad on toast with tomato and lettuce and honey bun for dessert

The dairy and broccoli in the soup, the whole grain crackers, plus the tapioca are all great sources of calcium.

The nurse is performing inner cannula care for a patient with a tracheostomy. Which intervention provided by the nurse is incorrect? 1 Dropping the inner cannula into normal saline solution 2 Removing the inner cannula with the nondominant hand 3 Holding the inner cannula over a basin and rinsing it with water 4 Using a small brush to remove secretions inside the cannula

While holding the inner cannula over a basin, the nurse should rinse it with normal saline solution using the nondominant hand. The nurse should drop the inner cannula into normal saline solution. A small brush should be used to remove secretions inside and outside the cannula. The nurse should touch only the outer aspect of the tube and remove the inner cannula with the nondominant hand.

The patient has an order for 2 tablespoons of magnesium hydroxide. How much medication does the nurse give him or her? 1 2 mL 2 5 mL 3 16 mL 4 30 mL

1 tablespoon = 15 mL; 2 tablespoons = 30 mL.

Which topical dosage form may show systemic side effects? 1 Paste 2 Lotion 3 Liniment 4 Transdermal patch

4 Transdermal patches may show systemic side effects. Paste, lotion, and liniment may not show systemic side effects; these show local effects.

A patient is admitted to the emergency unit with hypertension. Which prescription order would the primary health care provider use in this situation? 1 STAT order 2 Now order 3 Single order 4 Standing order

1 A STAT order indicates that the single dose of medication should be given immediately and only once. When a patient with high blood pressure is admitted to an emergency unit, then a STAT order is used by the primary health care provider. A now order is used when the patient requires the medication within the next 90 minutes, but not immediately. A single order is used for preoperative medications or medications given before diagnostic examinations; these medications are given at once in a specified time. A standing order is an order that is carried out until the primary health care provider cancels it.

A registered nurse prepares to administer medications to four patients through the oral route. Which patient is instructed to dissolve the medication slowly in the mouth? 1 Patient A troche 2 Patient B caplet 3 Patient C capsule 4 Patient D tablet

1 A troche is a flat, round tablet that should be dissolved in the mouth for medication release. Therefore, a patient who is prescribed a troche form of medication should be instructed to dissolve the medication slowly in the mouth. A caplet is a solid dosage form of medication, which is available in coated form and meant to be swallowed whole. A capsule is a form of medication that is encased in a gelatin shell; this medication is meant to be swallowed whole. A tablet is a powdered medication compressed into a hard disk or cylinder; this medication is also meant to be swallowed whole.

While administering eardrops in a patient, the nurse straightens the ear canal by pulling the auricle down and back. What is the age group of the patient? 1 Adult 2 Toddler 3 Adolescent 4 Preschooler

2 Straightening the ear canal by pulling the auricle down and back is performed in toddlers, children younger than 3 years of age. Straightening the ear canal by pulling the auricle upward and outward is performed in children 3 years of age and older. Therefore, adults, adolescents, and preschoolers require pulling the auricle upward and outward.

Which parental route of administration uses the Z-track method? 1 Intravenous route 2 Intradermal route 3 Intramuscular route 4 Subcutaneous route

3 The Z-track method is recommended during intramuscular injection to minimize local skin irritation by sealing the medication in muscle tissue. The intravenous route, intradermal route, and subcutaneous routes do not use the Z-track metho