Fundamentals Final Exam Practice review

A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for laboratory testing. Which techniques for urine collection are performed correctly? Select all that apply. a. The nurse catheterizes a patient to collect a sterile urine sample for routine urinalysis. b. The nurse collects a clean-catch urine specimen in the morning from a patient and stores it at room temperature until an afternoon pick-up. c. The nurse collects a sterile urine specimen from the collection receptacle of a patient's indwelling catheter. d. The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture. e. The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma. f. The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient.

1. d, e, f. A urine culture requires about 3 mL of urine, whereas routine urinalysis requires at least 10 mL of urine. The preferred method of collecting a urine specimen from a urinary diversion is to catheterize the stoma. For a 24-hour urine specimen, the nurse should discard the first voiding, then collect all urine voided for the next 24 hours. A sterile urine specimen is not required for a routine urinalysis. Urine chemistry is altered after urine stands at room temperature for a long period of time. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. Chapter 36

Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult patient. Which information is least important for the evaluation process? a. The incontinence pattern b. State of physical mobility c. Medications being taken d. Age of the patient

15. d. Incontinence is not a natural consequence of the aging process. All the other factors are necessary information for the plan of care. Chapter 36

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply. a. Serous drainage is composed of the clear portion of the blood and serous membranes. b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood. c. Bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. d. Purulent drainage is composed of white blood cells, dead tissue, and bacteria. e. Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. f. Serosanguineous drainage can be dark yellow or green depending on the causative organism.

a, b, c, d. Serous drainage is composed primarily of the clear, serous portion of the blood and serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged. Chapter 31

A nurse cares for patients in a chiropractic office. What patient education might this nurse perform? Select all that apply. a. Applying heat or ice to an extremity b. Explaining the use of electrical stimulation c. Teaching a patient relaxation techniques d. Teaching a patient about a prescription e. Explaining an invasive procedure to a patient f. Teaching about dietary supplements

a, b, c, f. Chiropractors may combine the use of spinal adjustments and other manual therapies with several other treatments and approaches including heat and ice, electrical stimulation, relaxation techniques, rehabilitative and general exercise, counseling about weight and diet, and using dietary supplements. Chiropractors do not prescribe medication or perform invasive procedures. Chapter 27

A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply. a. A patient who has uncontrolled hypothyroidism b. A patient with coronary artery disease c. A patient who has gastroesophageal reflux (GERD) d. A patient who is HIV positive e. A patient who is taking corticosteroids for arthritis f. A patient with a urinary tract infection

a, b, c. A patient who has uncontrolled hypothyroidism tends to have a decreased amount of NREM sleep, especially stages II and IV. The pain associated with coronary artery disease and myocardial infarction is more likely with REM sleep, and a patient who has gastroesophageal reflux (GERD) may awaken at night with heartburn pain. Being HIV positive, taking corticosteroids, and having a urinary tract infection does not usually change sleep patterns. Chapter 33

A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply. a. It promotes the patient's sense of well-being. b. It prevents deterioration of the oral cavity. c. It contributes to decreased incidence of aspiration pneumonia. d. It eliminates the need for flossing. e. It decreases oropharyngeal secretions. f. It compensates for an inadequate diet.

a, b, c. Adequate oral hygiene is essential for promoting the patient's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyn- geal secretions, decreasing the incidence of aspiration pneu- monia and other systemic diseases (AACN, 2006; AACN, 2010). Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition. Chapter 30

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. a. Closely assess the patient before, during, and after the procedure. b. Hyperoxygenate the patient before and after suctioning. c. Limit the application of suction to 20 to 30 seconds. d. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. e. Use an appropriate suction pressure (80-150 mm Hg). f. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.

a, b, d, e. Close assessment of the patient before, during, and after the procedure is necessary to limit negative effects. Risks include hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. The nurse should also take the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80-150 mm Hg) will help prevent atelectasis related to the use of high negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis (Roman, 2005). Chapter 38

A nurse is caring for a patient who has fluid imbalance related to the development of ascites. Which imbalances would the nurse monitor for in this patient? Select all that apply. a. Extracellular fluid volume deficit b. Protein deficit c. Metabolic alkalosis d. Sodium deficit e. Plasma-to-interstitial fluid shift f. Metabolic acidosis

a, b, d, e. Patients with fluid loss due to ascites are at risk for extracellular fluid volume deficit, protein deficit, sodium deficit, and plasma-interstitial fluid shift. Chapter 39

A nurse is preparing medications for patients in the ICU. The nurse is aware that there are patient variables that may affect the absorption of these medications. Which statements accurately describe these variables? Select all that apply. a. Patients in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed. b. Some people experience the same response with a placebo as with the active drug used in studies. c. People with liver disease metabolize drugs more quickly than people with normal liver functioning. d. A patient who receives a pain medication in a noisy environment may not receive full benefit from the medication's effects. e. Oral medications should not be given with food as the food may delay the absorption of the medications. f. Circadian rhythms and cycles may influence drug action.

a, b, d, f. Nurses need to know about medications that may produce varied responses in patients from different ethnic groups. The patient's expectations of the medication may affect the response to the medication, for example, when a placebo is given and a patient has a therapeutic effect. The patient's environment may also influence the patient's response to medications, for example, sensory deprivation and overload may affect drug responses. Circadian rhythms and cycles may also influence drug action. The liver is the primary organ for drug breakdown, thus pathologic condi- tions that involve the liver may slow metabolism and alter the dosage of the drug needed to reach a therapeutic level. The presence of food in the stomach can delay the absorption of orally administered medications. Alternately, some medica- tions should be given with food to prevent gastric irritation, and the nurse should consider this when establishing a patient's medication schedule. Other medications may have enhanced absorption if taken with certain foods. Chapter 28

A nurse formulates the following diagnosis for an elderly patient who is having trouble getting to sleep at night: Disturbed Sleep Pattern: Initiation of Sleep. Which of the following nursing interventions would the nurse perform related to this diagnosis? Select all that apply. a. Arrange for assessment for depression and treatment. b. Discourage napping during the day. c. Decrease fluids during the evening. d. Administer diuretics in the morning. e. Encourage patient to engage in some type of physical activity. f. Assess medication for side effects of sleep pattern disturbances.

a, b, e, f. For patients who are having trouble initiating sleep, the nurse should arrange for assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects. Limiting fluids and administering diuretics in the morning are appropriate interventions for Disturbed Sleep Pattern: Maintaining Sleep. Chapter 33

A certified nurse midwife is teaching a pregnant woman techniques to reduce the pain of childbirth. Which stress reduction activities would be most effective? Select all that apply. a. Progressive muscle relaxation b. Meditation c. Anticipatory socialization d. Biofeedback e. Rhythmic breathing f. Guided imagery

a, b, e, f. Relaxation techniques are useful in many situations, including childbirth, and consist of rhythmic breathing and progressive muscle relaxation. Meditation and guided imagery could also be used to distract a patient from the pain of childbirth. Anticipatory socialization helps to prepare people for roles they don't have yet but aspire to, such as parenthood. Biofeedback is a method of gaining mental control of the autonomic nervous system and thus regulating body responses, such as blood pressure, heart rate, and headaches. Chapter 41

A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply. a. Daily mental activities b. Daily physical activities c. Morning and evening body temperature d. Daily measurement of fluid intake and output e. Presence of anxiety or worries affecting sleep f. Morning and evening blood pressure readings

a, b, e. A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is not usually kept in a sleep diary. Chapter 33

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply. a. Use standard precautions or transmission-based precautions when indicated. b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. c. Clean the wound in full or half circles beginning on the outside and working toward the center. d. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. e. Clean to at least one inch beyond the end of the new dressing if one is being applied. f. Clean to at least three inches beyond the wound if a new dressing is not being applied.

a, b, e. The correct procedure for cleaning a wound with unapproximated edges is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleans- ing agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least one inch beyond the end of the new dressing, and (6) clean to at least two inches beyond the wound margins if a dressing is not being applied. Chapter 31

A nurse mentor is teaching a new nurse about the underlying beliefs of CAT vs. allopathic therapies. Which statements by the new nurse indicate that teaching was effective? Select all that apply. a. "CAT proponents believe the mind, body, and spirit are integrated and together influence health and illness." b. "CAT proponents believe that health is a balance of body systems: mental, social and spiritual, as well as physical." c. "Allopathy proponents believe that the main cause of ill- ness is an imbalance or disharmony in the body systems." d. "Curing according to CAT proponents seeks to destroy the invading organism or repair the affected part." e. "The emphasis is on disease for allopathic proponents and drugs, surgery, and radiation are key tools for curing." f. "According to CAT proponents, health is the absence of disease."

a, b, e. With CAT, mind, body, and spirit are integrated and together influence health and illness, and illness is a manifes- tation of imbalance or disharmony. Allopathic beliefs include: the main causes of illness are considered to be pathogens (bacteria or viruses) or biochemical imbalances, curing seeks to destroy the invading organism or repair the affected part, and emphasis is on disease and high technology. Drugs, sur- gery, and radiation are among the key tools for dealing with medical problems. According to allopathic beliefs, health is the absence of disease. Chapter 27

A nurse is evaluating patients to determine their need for total parenteral nutrition (TPN). Which patients would be the best candidates for this type of nutritional support? Select all that apply. a. A patient with irritable bowel syndrome who has intractable diarrhea b. A patient with celiac disease not absorbing nutrients from the GI tract c. A patient who is underweight and needs short-term nutritional support d. A patient who is comatose and needs long-term nutritional support e. A patient who has anorexia and refuses to take foods via the oral route f. A patient with burns who has not been able to eat adequately for 5 days

a, b, f. Assessment criteria used to determine the need for TPN include an inability to achieve or maintain enteral access; motility disorders; intractable diarrhea; impaired absorption of nutrients from the GI tract (patient with celiac disease) and when oral intake has been or is expected to be inadequate over a 7- to 14-day period (Worthington & Gilbert, 2012; A.S.P.E.N., 2002). TPN promotes tissue healing and is a good choice for a patient with burns who has an inadequate diet. Oral intake is the best method of feeding; the second best method is via the enteral route. For short-term use (less than 4 weeks), a nasogastric or nasointestinal route is usually selected. A gastrostomy (enteral feeding) is the preferred route to deliver enteral nutrition in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Patients who refuse to take food should not be force fed nutrients against their will. Chapter 35

A nurse working in a hospital includes abdominal assessment as part of patient assessment. In which patients would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes? Select all that apply. a. A patient diagnosed with peritonitis b. A patient who is on prolonged bedrest c. A patient who has diarrhea d. A patient who has gastroenteritis e. A patient who has an early bowel obstruction f. A patient who has paralytic ileus caused by surgery

a, b, f. Decreased or absent bowel sounds—evidenced only after listening for 5 minutes (Jensen, 2011)—signify the absence of bowel motility, commonly associated with peritonitis, paralytic ileus, and/or prolonged immobility. Hyperactive bowel sounds indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction. Chapter 37

A nurse caring for older adults in a long-term care facility knows that several physical changes occur in the aging adult. Which characteristics best describe these changes? Select all that apply. a. Fatty tissue is redistributed. b. The skin is drier and wrinkles appear. c. Cardiac output increases. d. Muscle mass increases. e. Hormone production increases. f. Visual and hearing acuity diminishes.

a, b, f. Physical changes occurring with aging include these: fatty tissue is redistributed, the skin is drier and wrinkles appear, and visual and hearing acuity diminishes. Cardiac output decreases, muscle mass decreases, and hormone production decreases, causing menopause or andropause. Chapter 19

The three types of responses to pain are physiologic, behavioral, and affective. Which are examples of behavioral responses to pain? Select all that apply. a. A patient cradles a wrist that was injured in a car accident. b. A child is moaning and crying due to a stomachache. c. A patient's pulse is increased following a myocardial infarction. d. A patient in pain strikes out at a nurse who attempts to bathe him. e. A patient who has chronic cancer pain is depressed and withdrawn. f. A child pulls

a, b, f. Protecting or guarding a painful area, moaning and crying, and moving away from painful stimuli are behavioral responses. Examples of a physiologic or involuntary response would be increased blood pressure or dilation of the pupils. Affective responses, such as anger, withdrawal, and depression, are psychological in nature. Chapter 34

In addition to standard precautions, the nurse would initi- ate droplet precautions for which patients? Select all that apply. a. A patient diagnosed with rubella b. A patient diagnosed with diptheria c. A patient diagnosed with varicella d. A patient diagnosed with tuberculosis e. A patient diagnosed with MRSA f. An infant diagnosed with adenovirus infection

a, b, f. Rubella, diphtheria, and adenovirus infection are illnesses transmitted by large-particle droplets and require droplet precautions in addition to standard precautions. Air- borne precautions are used for patients who have infections spread through the air with small particles, for example, tuberculosis, varicella, and rubeola. Contact precautions are used for patients who are infected or colonized by a multidrug-resistant organism (MDRO), such as MRSA. Chapter 23

A nurse is assessing a 49-year-old male patient who complains of migraines that have become "unbearable." The patient tells the nurse, "I just got laid off from my job last week and I have two kids in college. I don't know how I'm going to pay for it all." Which physiologic effects of stress would be expected findings in this patient? Select all that apply. a. Changes in appetite b. Changes in elimination patterns c. Decreased pulse and respirations d. Use of ineffective coping mechanisms e. Withdrawal f. Attention-seeking behaviors

a, b. Physiologic effects of stress include changes in appetite and elimination patterns as well as increased pulse and respirations. Using ineffective coping mechanisms, becoming withdrawn and isolated, and exhibiting attention-seeking behaviors are psychological effects of stress. Chapter 41

A scrub nurse is assisting a surgeon with a kidney transplant. What are the patient responsibilities of this surgical team member? Select all that apply. a. Maintaining sterile technique b. Draping and handling instruments and supplies c. Identifying and assessing the patient on admission d. Integrating case management e. Preparing the skin at the surgical site f. Providing exposure of the operative area

a, b. The scrub nurse is a member of the sterile team who maintains sterile technique while draping and handling instru- ments and supplies. Two duties of the circulating nurse are to identify and assess the patient on admission to the operating room and prepare the skin at the surgical site. The RNFA actively assists the surgeon by providing exposure of the operative area. The APRN coordinates care activities, collab- orates with physicians and nurses in all phases of periopera- tive and postanesthesia care, and integrates case management, critical paths, and research into care of the surgical patient. Chapter 29

The rectal temperature, a core temperature, is considered to be one of the most accurate routes. In which cases would taking a rectal temperature be contraindicated? Select all that apply. a. A newborn who has hypothermia b. A child who has pneumonia c. An older patient who is post myocardial infarction (heart attack) d. A teenager who has leukemia e. A patient receiving erythropoietin to replace red blood cells f. An adult patient who is newly diagnosed with pancreatitis

a, c, d, e. The rectal site should not be used in newborns, children with diarrhea, and in patients who have undergone rectal surgery. The insertion of the thermometer can slow the heart rate by stimulating the vagus nerve, thus patients post-MI should not have a rectal temperature taken. Assessing a rectal temperature is also contraindicated in patients who are neutropenic (have low white blood cell counts, such as in leukemia), in patients who have certain neurologic disorders, and in patients with low platelet counts. Chapter 24

A nurse is caring for an older patient with type II diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. a. "Try to drink at least six to eight glasses of water each day." b. "Try to limit your fluid intake to one quart of water daily." c. "Limit sugar, salt, and alcohol in your diet." d. "Report side effects of medications you are taking, especially diarrhea." e. "Temporarily increase foods containing caffeine for their diuretic effect." f. "Weigh yourself daily and report any changes in your weight."

a, c, d, f. Generally, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics. Chapter 39

A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol- based handrub to decontaminate the hands? Select all that apply. a. The nurse is providing a bed bath for a patient. b. The nurse has visibly soiled hands after changing the bedding of a patient. c. The nurse removes gloves when patient care is completed. d. The nurse is inserting a urinary catheter for a female patient. e. The nurse is assisting with a surgical placement of a cardiac stent. f. The nurse removes old magazines from a patient's table.

a, c, d, f. It is recommended to use an alcohol-based handrub in the following situations: before direct contact with patients; after direct contact with patient skin; after contact with body fluids if hands are not visibly soiled; after remov- ing gloves; before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement; before donning sterile gloves prior to an invasive procedure; if moving from a contaminated body site to a clean body site; and after contact with objects contami- nated by the patient. Chapter 23

The student nurse learns that illnesses are classified as either acute or chronic. Which are examples of chronic illnesses? Select all that apply. a. Diabetes mellitus b. Bronchial pneumonia c. Rheumatoid arthritis d. Cystic fibrosis e. Fractured hip f. Otitis media

a, c, d. Diabetes, arthritis, and cystic fibrosis are chronic diseases because they are permanent changes caused by irreversible alterations in normal anatomy and physiology, and they require patient education along with a long period of care or support. Pneumonia, fractures, and otitis media are acute illnesses because they have a rapid onset of symptoms that last a relatively short time. Chapter 3

A nurse working with adolescents in a juvenile detention center teaches parents about behaviors that place adolescents at high risk for injury. Which statements accurately describe these risks? Select all that apply. a. Each year, underage drinking claims the lives of approximately 5,000 individuals under the age of 21. b. Approximately one in three high school students reported using some type of tobacco product. c. The CDC (2012i) lists motor vehicle accidents as the number-one cause of death for adolescents. d. Marijuana use among teenagers has been on the increase and the abuse of prescription medication and OTC drugs has remained at a high level. e. Homicide rates for adolescents are high, and youths aged 10-19 years committed almost 500 suicides using firearms. f. As many as 30% of children are bullied during their school years and cyber bullying is even more damaging to children.

a, c, d. Each year, underage drinking claims the lives of approximately 5,000 people under the age of 21. The CDC (2012j) lists motor vehicle accidents as the number one cause of death for adolescents. Marijuana use among teenagers has been on the increase and the abuse of prescription medication and OTC drugs has remained at a high level. Approximately one in five (20%) high school students reported using some type of tobacco product. Homicide rates for youths using firearms are higher than any other age group and the most recent statistics indicate that youths aged 10-19 years com- mitted almost 1,500 suicides using firearms (Kagler, Annest, Kresnow & Mercy, 2011). According to the American Acad- emy of Child & Adolescent Psychiatry, as many as 50% of children are bullied during their school years and some experts believe that cyber bullying is more dangerous and damaging to children than bullying that occurs in the schoolyard. Chapter 26

A nurse witnesses a street robbery and is assessing a 26-yearold female patient who is the victim. The patient has minor scrapes and bruises and tells the nurse, "I've never been so scared in my life." What other symptoms would the nurse expect to find related to the fight-or-flight response to stress? Select all that apply. a. Increased heart rate b. Decreased muscle strength c. Increased mental alertness d. Increased blood glucose levels e. Decreased cardiac output f. Decreased peristalsis

a, c, d. The sympathetic nervous system functions under stress to bring about the fight-or-flight response by increasing the heart rate, increasing muscle strength, increasing cardiac output, increasing blood glucose levels, and increasing mental alertness. Increased peristalsis is brought on by the parasympathetic nervous system under normal conditions and at rest. Chapter 41

A nurse is performing patient care for a severely ill patient who has cancer. Which nursing interventions are likely to assist a severely ill patient with cancer to maintain a positive sense of self? Select all that apply. a. The nurse makes a point to address the patient by name upon entering the room. b. The nurse avoids fatiguing the patient by performing all procedures in silence. c. The nurse performs care in a manner that respects the patient's privacy and sensibilities. d. The nurse offers the patient a simple explanation before moving her in any way. e. The nurse ignores negative feelings from the patient since they are part of the grieving process. f. The nurse avoids conversing with the patient about her life, family, and occupation.

a, c, d. When assisting the patient to maintain a positive sense of self, the nurse should address the patient by name when entering the room; perform care in a manner that respects the patient's privacy; offer a simple explanation before moving the patient's body in any way; acknowledge the patient's status, role, and individuality; and converse with the patient about the patient's life experiences. Chapter 40

A nurse caring for a patient with chronic obstructive pulmonary disease (COPD) knows that hypoxia may occur in patients with respiratory problems. What are signs of this serious condition? Select all answers that apply. a. Dyspnea b. Hypotension c. Small pulse pressure d. Decreased respiratory rate e. Pallor f. Increased pulse rate

a, c, e, f. If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis. Chapter 38

A nurse is caring for a patient who has a nasogastric tube in place for gastric decompression. Which nursing actions are appropriate when irrigating a nasogastric tube connected to suction? Select all that apply. a. Draw up 30 mL of saline solution into the syringe. b. Unclamp the suction tubing near the connection site to instill solution. c. Place the tip of the syringe in the tube to gently insert saline solution. d. Place syringe in the blue air vent of a Salem sump or double-lumen tube. e. After instilling irrigant, hold the end of the NG tube over an irrigation tray. f. Observe for return flow of NG drainage into an available container.

a, c, e, f. The nurse irrigating a nasogastric tube connected to suction should draw up 30 mL of saline solution (or amount indicated in the order or policy) into the syringe, clamp the suction tubing near the connection site to protect the patient from leakage of NG drainage, place the tip of the syringe in the tube to gently insert the saline solution, then place the syringe in the drainage port, not in the blue air vent of a Salem sump or double-lumen tube (the blue air vent acts to decrease pressure built up in the stomach when the Salem sump is attached to suction). After instilling irrigant, hold the end of the NG tube over an irrigation tray or emesis basin, and observe for return flow of NG drainage into an available container. Chapter 37

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply. a. Hemostasis occurs immediately after the initial injury. b. A liquid called exudate is formed during the proliferation phase c. White blood cells move to the wound in the inflammatory phase. d. Granulation tissue forms in the inflammatory phase. e. During the inflammatory phase, the patient has generalized body response. f. A scar forms during the proliferation phase.

a, c, e. Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking out of plasma and blood components into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bac- teria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar. Chapter 31

A nurse is teaching an adolescent patient how to use a meter- dosed inhaler to control his asthma. What are appropriate guidelines for this procedure? Select all that apply. a. Remove the mouthpiece cover and shake the inhaler well. b. Take shallow breaths when breathing through the spacer. c. Depress the canister releasing one puff into the spacer and inhale slowly and deeply. d. After inhaling, exhale quickly through pursed lips. e. Wait 1 to 5 minutes as prescribed before administering the next puff. f. Gargle and rinse with salt water after using the MDI.

a, c, e. The correct procedure for using a meter-dosed inhaler is: remove the mouthpiece cover and shake the inhaler well; breathe normally through the spacer; depress the canister releasing one puff into the spacer and inhale slowly and deeply; after inhaling, hold breath for 5 to 10 seconds, or as long as possible, and then exhale slowly through pursed lips; wait 1 to 5 minutes as prescribed before administering the next puff; and gargle and rinse with tap water after using the MDI. Chapter 28

A nurse is providing foot care for patients in a long-term care facility. Which actions are recommended guidelines for this procedure? Select all that apply. a. Bathe the feet thoroughly in a mild soap and tepid water solution. b. Soak the feet in warm water and bath oil. c. Dry feet thoroughly, including the area between the toes. d. Use an alcohol rub if the feet are dry. e. Use an antifungal foot powder if necessary to prevent fungal infections. f. Cut the toenails at the lateral corners when trimming the nail.

a, c, e. The following are recommended guidelines for foot care: bathe the feet thoroughly in a mild soap and tepid water solution; dry feet thoroughly, including the area between the toes; and use an antifungal foot powder if necessary to prevent fungal infections. The nurse should avoid soaking the feet, use moisturizer if the feet are dry, and avoid digging into or cut- ting the toenails at the lateral corners when trimming the nails. Chapter 30

A nurse caring for patients in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse screen for urinary retention? Select all that apply. a. A 78-year-old male patient diagnosed with an enlarged prostate b. An 83-year-old female patient who is on bedrest c. A 75-year-old female patient who is diagnosed with vaginal prolapse d. An 89-year-old male patient who has dementia e. A 73-year-old female patient who is taking antihistamines to treat allergies f. A 90-year-old male patient who has difficulty walking to the bathroom

a, c, e. Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse. Being on bedrest, having dementia, and having difficulty walking to the bathroom may place patients at risk for urinary incontinence. Chapter 36

A responsibility of the nurse is the administration of preop- erative medications to patients. Which statements describe the action of these medications? Select all that apply. a. Diazepam is given to alleviate anxiety. b. Ranitidine is given to facilitate patient sedation. c. Atropine is given to decrease oral secretions. d. Morphine is given to depress respiratory function. e. Cimetidine is given to prevent laryngospasm. f. Fentanyl citrate-droperidol is given to facilitate a sense of calm.

a, c, f. Sedatives, such as diazepam (Valium), midazolam (Versed), or lorazepam (Ativan) are given to alleviate anxiety and decrease recall of events related to surgery. Anticholiner- gics, such as atropine and glycopyrrolate (Robinul) are given to decrease pulmonary and oral secretions and to prevent laryngospasm. Neuroleptanalgesic agents, such as fentanyl citrate-droperidol (Innovar) are given to cause a general state of calm and sleepiness. Histamine-2 receptor blockers, such as cimetidine (Tagamet) and ranitidine (Zantac) are given to decrease gastric acidity and volume. Narcotic analgesics, such as morphine, are given to facilitate patient sedation and relaxation and to decrease the amount of anesthetic agent needed. Chapter 29

A nurse is counseling parents attending a parent workshop on how to build self-esteem in their children. Which teaching points would the nurse include to help parents achieve this goal? Select all that apply. a. Teach the parents to reinforce their child's positive qualities. b. Teach the parents to overlook occasional negative behavior. c. Teach parents to ignore neutral behavior that is a matter of personal preference. d. Teach parents to listen and "fix things" for their children. e. Teach parents to describe the child's behavior and judge it. f. Teach parents to let their children practice skills and make it safe to fail.

a, c, f. The nurse should include the following teaching points for parents: (1) reinforce their child's positive qualities; (2) address negative qualities constructively; (3) ignore neutral behavior that is a matter of taste, preference, or personal style; (4) don't feel they have to "fix things" for their children; (5) describe the child's behavior in a nonjudgmental manner; and (6) let their child know what to expect, practice the necessary skills, be patient, and make it safe to fail. Chapter 40

A nurse is providing range-of-motion exercises for a 53-year- old female patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? Select all that apply. a. Stop performing the exercises. b. Decrease the number of repetitions performed. c. Re-evaluate the nursing plan of care. d. Move to the patient's other side to perform exercises. e. Encourage the patient to finish the exercises and then rest. f. Assess the patient for other symptoms.

a, c, f. When a patient complains of fatigue during range-of- motion exercises, the nurse should stop the activity, re-evalu- ate the nursing plan of care, and assess the patient for further symptoms. The exercises could then be scheduled for times of the day when the patient is feeling more rested, or spaced out at different times of the day. Chapter 32

A nurse is caring for a 56-year-old male patient diagnosed with bladder cancer who has a urinary diversion. Which actions would the nurse take when caring for this patient? Select all that apply a. Measure the patient's fluid intake and output. b. Keep the skin around the stoma moist. c. Empty the appliance frequently. d. Report any mucous in the urine to the primary care provider. e. Encourage the patient to look away when changing the appliance. f. Monitor the return of intestinal function and peristalsis.

a, c, f. When caring for a patient with a urinary diversion, the nurse should measure the patient's fluid intake and output to monitor fluid balance, change the appliance frequently, monitor the return of intestinal function and peristalsis, keep the skin around the stoma dry, watch for mucous in the urine as a normal finding, and encourage the patient to participate in care and look at the stoma. Chapter 36

Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply. a. Compare bilateral parts for symmetry. b. Proceed in a toe-to-head systematic manner. c. Use standard terminology to report and record findings. d. Do not allow data from the nursing history to direct the assessment. e. Document only skin abnormalities on the patient record. f. Perform the appropriate skin assessment when risk factors are identified.

a, c, f. When performing a skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminol- ogy to report and record findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, and allow data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, includ- ing appearance, texture, size, location or distribution, and characteristics of any findings. Chapter 30

During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? Select all that apply. a. Group decision making b. Group leadership c. Group power d. Group identity e. Group patterns of interaction f. Group cohesiveness

a, d, e, f. Solving problems involves group decision making; ascertaining that the staff completes a task on time and that all members agree the task is important is a characteristic of group identity; group patterns of interaction involve honest communication and member support; and cohesiveness occurs when members generally trust each other, have a high commitment to the group, and a high degree of cooperation. Group leadership occurs when groups use effective styles of leadership to meet goals; with group power, sources of power are recognized and used appropriately to accomplish group outcomes. Chapter 20

A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variations in normal vital signs, which patients would the nurse document as having a normal vital sign? Select all that apply. a. A 4-month old infant whose temperature is 38.1°C (100.5°F) b. A 3-year old whose blood pressure is 118/80 c. A 9-year old whose temperature is 39°C (102.2°F) d. An adolescent whose pulse rate is 70 bpm e. An adult whose respiratory rate is 20 bpm f. A 72-year old whose pulse rate is 42 bpm

a, d, e, f. The normal temperature range for infants is 37.1°C to 38.1°C (98.7°F-100.5°F). The normal pulse rate for an adolescent is 55 to 105. The normal respiratory rate for an adult is 12 to 20 bpm and the normal pulse for an older adult is 40 to 100 bpm. The normal blood pressure for a toddler is 89/46 and the normal temperature for a child is 36.8°C to 37.8°C (98.2°F-100°F; refer to Table 24-1, Age-Related Variations in Normal Vital Signs). Chapter 24

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. a. 5% dextrose in water (D5W) b. 0.9% NaCl (normal saline) c. Lactated Ringer's solution d. 0.33% NaCl (¹∕³-strength normal saline) e. 0.45% NaCl (½-strength normal saline) f. 10% dextrose in water (D10W)

a, d, e. 5% dextrose in water (D5W), 0.33% NaCl (¹∕³-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia. 0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. 10% dextrose in water (D10W) is used in peripheral parenteral nutrition (PPN). Chapter 39

One of the most common distinctions of pain is whether it is acute or chronic. Which examples describe chronic pain? Select all that apply. a. A patient is receiving chemotherapy for bladder cancer. b. An adolescent is admitted to the hospital for an appendectomy. c. A patient is experiencing a ruptured aneurysm. d. A patient who has fibromyalgia requests pain medication. e. A patient has back pain related to an accident that occurred last year. f. A patient is experiencing pain from second-degree burns.

a, d, e. Chronic pain is pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period. Examples are cancer pain, fibromyalgia pain, and back pain. Acute pain is generally rapid in onset and varies in intensity from mild to severe, as occurs with an emergency appendectomy, a ruptured aneurysm, and pain from burns. Chapter 34

A nurse is teaching a student nurse how to cleanse the perineal area of both male and female patients. What are accurate guidelines when performing this procedure? Select all that apply. a. For male and female patients, wash the groin area with a small amount of soap and water and rinse. b. For a female patient, spread the labia and move the wash- cloth from the anal area toward the pubic area. c. For male and female patients, always proceed from the most contaminated area to the least contaminated area. d. For male and female patients, use a clean portion of the washcloth for each stroke. e. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. f. In an uncircumcised male patient do not retract the fore- skin (prepuce) while washing the penis.

a, d, e. Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis. Chapter 30

A nurse who is administering medications to patients in an acute care setting studies the pharmacokinetics of the drugs being administered. Which statements accurately describe these mechanisms of action? Select all that apply. a. Distribution occurs after a drug has been absorbed into the bloodstream and is made available to body fluids and tissues. b. Metabolism is the process by which a drug is transferred from its site of entry into the body to the bloodstream. c. Absorption is the change of a drug from its original form to a new form, usually occurring in the liver. d. During first-pass effect, drugs move from the intestinal lumen to the liver by way of the portal vein instead of going into the system's circulation. e. The gastrointestinal tract, as well as sweat, salivary, and mammary glands, are routes of drug absorption. f. Excretion is the process of removing a drug, or its metabolites (products of metabolism), from the body.

a, d, f. Distribution occurs after a drug has been absorbed into the bloodstream and the drug is distributed throughout the body, becoming available to body fluids and body tissues. Some drugs move from the intestinal lumen to the liver by way of the portal vein and do not go directly into the systemic circulation following oral absorption. This is called the first- pass effect, or hepatic first pass. Excretion is the process of removing a drug or its metabolites (products of metabolism) from the body. Absorption is the process by which a drug is transferred from its site of entry into the body to the blood- stream. Metabolism, or biotransformation, is the change of a drug from its original form to a new form. The liver is the primary site for drug metabolism. The gastrointestinal tract, as well as sweat, salivary, and mammary glands, are routes of drug excretion. Chapter 28

A nurse is preparing an exercise program for a 65-year-old male patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply. a. Instruct the patient to avoid sudden position changes that may cause dizziness. b. Recommend that the patient restrict fluid until after exercising is finished. c. Instruct the patient to push a little further beyond fatigue each session. d. Instruct the patient to avoid exercising in very cold or very hot temperatures. e. Encourage the patient to modify exercise if weak or ill. f. Recommend that the patient consume a high-carb, low protein diet.

a, d. Teaching points for exercising for a patient with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures. The nurse should also instruct the patient to provide for adequate hydration, respect fatigue by not pushing to the point of exhaustion, and avoid exercise if weak or ill. Older adults should consume a high-protein, high-calcium, and vitamin D-enriched diet. Chapter 32

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

a, e, f. Washing the skin removes oil and debris, hair should be kept off the face and washed daily to keep oil from the hair off the face, and sunbathing should be avoided when using acne treatments. Liberal use of cosmetics and emollients can clog the pores. Squeezing blackheads is always discouraged because it may lead to infection. Chapter 30

A patient complains of severe abdominal pain. When assess- ing the vital signs, the nurse would not be surprised to find what assessments? Select all that apply. a. An increase in the pulse rate b. A decrease in body temperature c. A decrease in blood pressure d. An increase in respiratory depth e. An increase in respiratory rate f. An increase in body temperature

a, e. The pulse often increases when a person is experiencing pain. Pain does not affect body temperature and may increase (not decrease) blood pressure. Acute pain may increase res- piratory rate but decrease respiratory depth. Chapter 24

It is important to have the appropriate cuff size when taking the blood pressure. What error may result from a cuff that is too large or too small? a. An incorrect reading b. Injury to the patient c. Prolonged pressure on the arm d. Loss of Korotkoff sounds

a. A blood pressure cuff that is not the right size may cause an incorrect reading. Chapter 24

A nurse sees a patient walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. It is important that the nurse assess the patient for: a. Pain b. Anxiety c. Depression d. Fluid volume deficit

a. A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior. Chapter 20

A nurse is caring for an older male patient in a long-term care facility who has a spinal cord injury affecting his neurologic reflex arc. Based on this patient data, what would be a priority intervention for this patient? a. Monitoring food and drink temperatures to prevent burns b. Providing adequate pain relief measures to reduce stress c. Monitoring for depression related to social isolation d. Providing meals high in carbohydrates to promote healing

a. A patient with a damaged neurologic reflex arc would have a diminished pain reflex response, which would put the patient at risk for burns as the sensors in the skin would not detect the heat of the food or liquids. All patients should be provided adequate pain relief, but this is not the priority intervention in this patient. Monitoring for depression would be an intervention for this patient but is not related to the damaged neurologic reflex arc. A patient who is immobile should eat a balanced diet based on the ChooseMyPlate dietary guidelines. Chapter 41

A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient? a. Follow-up measurements of blood pressure b. Immediate treatment by a physician c. No action, because the nurse considers this reading is due to anxiety d. A change in dietary intake

a. A single blood pressure reading that is mildly elevated is not significant, but the measurement should be taken again over time to determine if hypertension is a problem. The nurse would recommend a return visit to the clinic for a recheck. Chapter 24

A patient had a surgical procedure that necessitated a thoracic incision. The nurse anticipates that he will have a higher risk for postoperative complications involving which body system? a. Respiratory system b. Circulatory system c. Digestive system d. Nervous system

a. A thoracic incision makes it more painful for the patient to take deep breaths or cough. Shallow respirations and ineffective coughing increase the risk for respiratory complications. Chapter 29

A nurse is assessing the following children. Which child would the nurse identify as having the greatest risk for choking and suffocating? a. A toddler playing with his 9-year-old brother's construction set b. A 4-year-old eating yogurt for lunch c. An infant covered with a small blanket and asleep in the crib d. A 3-year-old drinking a glass of juice

a. A young child may place small or loose parts in the mouth; a toy that is safe for a 9-year-old could kill a toddler. An infant sleeping in a crib without a pillow or large blanket and a 3-year-old and a 4-year-old drinking juice and eating yogurt are not particular safety risks. Chapter 26

A nurse is caring for a patient who has crippling rheumatoid arthritis. Which nursing intervention best represents the use of integrative care? a. The nurse administers Naproxen (Aleve) and uses guided imagery to take the patient's mind off the pain. b. The nurse prepares the patient's physician-approved herbal tea and uses meditation to relax the patient prior to bed. c. The nurse administers Naproxen (Aleve) and performs prescribed range-of-motion exercises. d. The nurse arranges for acupuncture for the patient and designs a menu high in Omega-3 fatty acids.

a. Adding guided imagery (CAT) to the administration of pain medications (allopathy) is an example of integrative care. A person who uses integrative care uses some combination of allopathic medicine and CAT. Chapter 27

A nurse is caring for a postpartum patient who has stitches in the perineum from an episotomy (surgically planned incision to prevent vaginal tears). Which medication would the nurse most likely administer to this patient? a. A stool softener (Colace) b. An osmotic laxative (Miralax) c. A bulk-forming laxative (Metamucil) d. An emollient laxative (mineral oil)

a. Although all the choices are laxatives that would soften the stool and make it easier to expel, a stool softener, such as Colace, is the one recommended for a patient who must avoid straining. In this case, it would help to prevent disturbing the stitches in the perineum. Chapter 37

A nurse teaches problem solving to a college student who is in a crisis situation. What statement best illustrates the student's understanding of the process? a. "I need to identify the problem first." b. "Listing alternatives is the initial step." c. "I will list alternatives after I develop the plan." d. "I do not need to evaluate the outcome of my plan."

a. Although identifying the problem may be difficult, a solution to a crisis situation is impossible until the problem is identified. Chapter 41

A nurse caring for patients with bowel alterations formulates a nursing diagnosis for a patient with a new ileostomy. Which diagnosis is most appropriate? a. Disturbed Body Image b. Constipation c. Delayed Growth and Development d. Excess Fluid Volume

a. An ileostomy may cause disturbed body image due to the invasive nature of the procedure and the presence of the stoma. Constipation does not normally occur with an ileostomy because the drainage is liquid. Growth and development are not generally affected by the formation of an ileostomy. Excess fluid volume is unlikely to occur because the drainage is liquid and probably continual. Chapter 37

A patient has been in the United States only 3 months and has recently suffered the loss of her husband and job. She states that nothing feels familiar . . . "I don't know who I am supposed to be here" and she misses home (Nicaragua) terribly.

a. An unfamiliar culture, coupled with traumatic life events and loss of husband and job, result in this patient's total loss of her sense of self: "I don't know who I am supposed to be here." Her very sense of identity is at stake, not merely her body image, self-esteem, or role performance. Chapter 40

A 72-year-old woman who is scheduled for a hip replacement is taking several medications on a regular basis. Which drug category might create a surgical risk for this patient? a. Anticoagulants b. Antacids c. Laxatives d. Sedatives

a. Anticoagulant drug therapy would increase the risk for hemorrhage during surgery. Chapter 29

A nurse is caring for an 80-year-old female patient who is living in a long-term care facility. To help this patient adapt to her present circumstances, the nurse is using reminiscence as therapy. Which question would encourage reminiscence? a. "Tell me about how you celebrated Christmas when you were young." b. "Tell me how you plan to spend your time this weekend." c. "Did you enjoy the choral group that performed here yesterday? d. "Why don't you want to talk about your feelings?"

a. Asking questions about events in the past can encourage the older adult to relive and restructure life experiences. Chapter 19

A nurse practicing in a physician's office assesses self- concept in patients during the patient interview. Which patient is least likely to develop problems related to selfconcept? a. A 55-year-old woman television news reporter undergoing a hysterectomy (removal of uterus) b. A young clergyperson whose vocal cords are paralyzed after a motorbike accident c. A 32-year-old accountant who survives a massive heart attack d. A 23-year-old model who just learned that she has breast cancer

a. Based simply on the facts given, the 55-year-old news reporter would be least likely to experience body image or role performance disturbance because she is beyond her childbearing years, and the hysterectomy should not impair her ability to report the news. The young clergyperson's inability to preach (b), the 32-year-old's massive myocardial infarction (c), and the model's breast resection (d) have much greater potential to result in self-concept problems. Chapter 40

The physician has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure? a. The male urethra is more vulnerable to injury during insertion. b. In the hospital, a clean technique is used for catheter insertion. c. The catheter is inserted 2″ to 3″ into the meatus. d. Since it uses a closed system, the risk for urinary tract infection is absent.

a. Because of its length, the male urethra is more prone to injury and requires that the catheter be inserted 6″ to 8″. This procedure requires surgical asepsis to prevent introducing bacteria into the urinary tract. The presence of an indwelling catheter places the patient at risk for a UTI. Chapter 36

A patient's spinal cord was severed, and he is paralyzed from the waist down. When obtaining data about this patient, which component of the sensory experience would be most important for the nurse to assess? a. Transmission of tactile stimuli b. Adequate stimulation in the environment c. Reception of visual and auditory stimuli d. General orientation and ability to follow commands

a. Below-the-waist paralysis makes the transmission of tactile stimuli a problem. Although the other options may be assessed, they are indirectly related to his paralysis and of lesser importance at this time. Chapter 43

A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. Which information is accurate and should be included in the teach- ing plan? a. Booster seats should be used for children until they are 4′9′′ tall and weigh between 80 and 100 pounds. b. Most U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. c. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a front-facing safety seat. d. Children older than 6 years may be restrained using a car seat belt in the back seat.

a. Booster seats should be used for children until they are 4′9′′ tall and weigh between 80 and 100 pounds. All 50 U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a rear-facing safety seat. Many children older than 6 years should still be in a booster seat. Chapter 26

A nurse manager who works in a hospital setting is research- ing the use of energy healing to use as an integrative care practice. Which patient would be the best candidate for this type of CAT? a. A patient who is anxious about residual pain from cervical spinal surgery b. A patient who is experiencing abdominal discomfort c. A patient who has chronic pain from diabetes d. A patient who has frequent cluster headaches

a. Energy healing is focused on pain that lingers after an injury heals, as well as pain complicated by trauma, anxiety, or depression. Nutritional and herbal remedies treat all chronic pain, but especially abdominal discomfort, headaches, and inflammatory conditions, such as rheumatoid arthritis. Chapter 27

A patient who is febrile may lose body heat through perspira- tion. The nurse recognizes that this is an example of what mechanism of heat loss? a. Evaporation b. Convection c. Radiation d. Conduction

a. Evaporation is the conversion of a liquid to a vapor as occurs when body fluid in the form of perspiration is vapor- ized from the skin. With convection, the heat is disseminated by motion between areas of unequal density, for example, the action of a fan blowing cool air over the body. An example of radiation (diffusion of heat by electromagnetic waves) is the body giving off heat from uncovered areas. In conduction, the heat is transferred to another object during direct contact, for example, body heat melting an ice pack. Chapter 24

A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output? a. Decreased and highly concentrated b. Decreased and highly dilute c. Increased and concentrated d. Increased and dilute

a. Fever and diaphoresis cause the kidneys to conserve body fluids. Thus, the urine is concentrated and decreased in amount. Chapter 36

A nurse follows accepted guidelines for a healthy lifestyle. How can this promote health in others? a. By being a role model for healthy behaviors b. By not requiring sick days from work c. By never exposing others to any type of illness d. By spending less money on food

a. Good personal health enables the nurse to serve as a role model for patients and families. Chapter 3

A nurse is administering an oral medication to a patient via a gastric tube. The nurse observes the medication enter the tube, and then the tube becomes clogged. What would be the appropriate initial action of the nurse in this situation? a. Attempt to dislodge the medication with a 10-mL syringe. b. Notify the primary care provider. c. Remove the tube and replace it with another tube. d. Flush the tube with 60 mL of water.

a. If medication becomes clogged in a gastric tube, the nurse should attach a 10-mL syringe on the end of the tube and pull back and lightly apply pressure to the plunger in a repetitive motion to attempt to dislodge the medication. If the medica- tion does not move through the tube, the nurse should notify the primary care provider, who may request the tube be replaced. Chapter 28

A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in elderly patients. Which action is recommended for these patients? a. Increase physical activities during the day. b. Encourage short periods of napping during the day. c. Increase fluids during the evening. d. Dispense diuretics during the afternoon hours.

a. In order to promote sleep in the elderly patient, the nurse should encourage daily physical activity such as walking or water aerobics, discourage napping during the day, decrease fluids at night, and dispense diuretics in the morning or early evening. Chapter 33

A nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurse's next action following this assessment? a. Use warm water and gentle pressure to remove the clog. b. Use a stylet to unclog the tubes. c. Administer cola to remove the clog. d. Replace the tube with a new one.

a. In order to remove a clog in a feeding tube, the nurse should try using warm water and gentle pressure to unclog it. A stylet should never be used to unclog a tube, and cola and meat tenderizers have not been shown effective in removing clogs. The nurse should first attempt to remove the clog, and if unsuccessful, the tube should be replaced. Chapter 35

A nurse observes some involuntary muscle jerking in a sleeping patient. The nurse determines that the patient is most likely in which stage of sleep? a. Stage I NREM sleep b. Stage II NREM sleep c. Stage IV NREM sleep d. REM sleep

a. Involuntary muscle jerking occurs in stage I NREM sleep. In the other stages, the muscles proceed from a relaxed state to large muscle immobility. Chapter 33

To promote sleep in a patient, a nurse suggests what intervention? a. Follow the usual bedtime routine if possible. b. Drink two or three glasses of water at bedtime. c. Have a large snack at bedtime. d. Take a sedative-hypnotic every night at bedtime.

a. Keeping the same bedtime schedule helps promote sleep. Drinking two or three glasses of water at bedtime will probably cause the patient to awaken during the night to void. A large snack may be uncomfortable right before bedtime; instead, a small protein and carbohydrate snack is recommended. Taking a sedative-hypnotic every night disturbs REM and NREM sleep, and sedatives also lose their effectiveness quickly. Chapter 33

A college student visits the school's health center with vague complaints of anxiety and fatigue. The student tells the nurse, "Exams are right around the corner and all I feel like doing is sleeping." The student's vital signs are within normal parameters. What would be an appropriate question to ask in response to these complaints? a. "Are you worried about failing your exams?" b. "Have you been staying up late studying?" c. "Are you using any recreational drugs?" d. "Do you have trouble managing your time?"

a. Mild anxiety is often handled without conscious thought through the use of coping mechanisms, such as sleeping, which are behaviors used to decrease stress and anxiety. Based on the complaints and normal vital signs, it would be best to explore the patient's level of stress and physiologic response to this stress. Chapter 41

Mr. Wright is recovering from abdominal surgery. When the nurse assists him to walk, she observes that he grimaces, moves stiffly, and becomes pale. She is aware that he has consistently refused his pain medication. What would be a priority nursing diagnosis for this patient? a. Acute Pain related to fear of taking prescribed postoperative medications b. Impaired Physical Mobility related to surgical procedure c. Anxiety related to outcome of surgery d. Risk for Infection related to surgical incision

a. Mr. Wright's immediate problem is his pain that is unrelieved because he refuses to take his pain medication for an unknown reason. The other nursing diagnoses are plausible, but not a priority in this situation. Chapter 34

When developing the plan of care for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain is most effectively relieved when analgesics are administered in what matter? a. On a PRN (as needed) basis b. Conservatively c. Around the clock (ATC) d. Intramuscularly

a. Mr. Wright's immediate problem is his pain that is unrelieved because he refuses to take his pain medication for an unknown reason. The other nursing diagnoses are plausible, but not a priority in this situation. Chapter 34

A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test? a. Have the patient follow a clear liquid diet 24 to 48 hours before the test. b. Have the patient take Dulcolax and ingest a gallon of bowel cleaner on day 1. c. Prepare the patient for the use of general anesthesia during the test. d. Explain that barium contrast mixture will be given to drink before the test.

a. Preparation for a colonoscopy includes a clear liquid diet 24 to 48 hours before the test along with a 2-day bowel prep of a strong cathartic and Dulcolax on day 1 and enema on day 2 of the test, or a 1-day bowel prep that consists of ingestion of a gallon of bowel cleanser in a short period of time. Conscious sedation, not general anesthesia, will be given for the colonoscopy. A chalky-tasting barium contrast mixture is given to drink before an upper gastrointestinal and smallbowel series of tests. Chapter 37

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

a. Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and move- ment should be documented but are not the primary focus of interventions related to injury prevention. Chapter 32

A nurse is caring for a patient who is taking phenazopyridine (Pyridium, a urinary tract analgesic). The patient questions the nurse: "My urine was bright orangish-red today; is there something wrong with me?" What would be the nurse's best response? a. "This is a normal finding when taking phenazopyridine." b. "This may be a sign of blood in the urine." c. "This may be the result of an injury to your bladder." d. "This is a sign that you are allergic to the medication and must stop it."

a. Pyridium is noted for turning the urine orange-red; the patient needs to be aware of this. Chapter 36

An elderly patient is confined to bedrest following cervical spine surgery to treat nerve pinching. The nurse is vigilant about turning the patient and assessing the patient regularly to prevent the formation of pressure ulcers. What type of agent is the stimulus for pressure ulcers? a. Mechanical b. Thermal c. Chemical d. Electrical

a. Receptors in the skin and superficial organs may be stimulated by mechanical, thermal, chemical, and electrical agents. Friction from bed linens causing pressure sores and pressure from a cast are mechanical stimulants. Sunburn is a thermal stimulant. An acid burn is the result of a chemical stimulant. The jolt from a lightening bolt is an electrical stimulant. Chapter 34

In a group home in which most patients have slight to moderate visual or hearing impairment and some are periodically confused, what would be a nurse's first priority in caring for sensory concerns? a. Maintaining safety and preventing sensory deterioration b. Insisting that every patient participate in as many self-care activities as possible c. Emphasizing and reinforcing individual patient strengths d. Encouraging reminiscence and life review in groups

a. Safety is a basic physiologic need that must be met before higher-level needs—such as love and belonging, self-esteem, and self-actualization—can be met. Chapter 43

When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate com- munication technique? a. Cliché b. Giving advice c. Being judgmental d. Changing the subject

a. Telling a patient that everything is going to be all right is a cliché. This statement gives false assurance and gives the patient the impression that the nurse is not interested in the patient's condition. Chapter 20

The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient? a. CRIES scale b. COMFORT scale c. FLACC scale d. FACES scale

a. The CRIES Pain Scale is a tool intended for use with neonates and infants from 0 to 6 months. The COMFORT Scale, used to assess pain and distress in critically ill pediatric patients, relies on six behavioral and two physiologic factors that determine the level of analgesia needed to adequately relieve pain in these children. The FLACC scale (F—Faces, L—Legs, A—Activity, C—Cry, C—Consolability) was designed for infants and children from age 2 months to 7 years who are unable to validate the presence or severity of pain. The FACES scale is used for children who can compare their pain to the faces depicted on the scale. Chapter 34

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan? a. Document the findings and continue to monitor the patient. b. Administer antipyretics, as ordered. c. Increase the frequency of assessment to every hour and notify the patient's primary care provider. d. Increase the frequency of wound care and contact the primary care provider for an antibiotic order.

a. The assessment findings are normal for this stage of heal- ing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocyto- sis, and generalized malaise. Chapter 31

A nurse is caring for a male patient who had a condom catheter applied following hip surgery. What action would be a priority when caring for this patient? a. Preventing the tubing from kinking to maintain free urinary drainage b. Not removing the catheter for any reason c. Fastening the condom tightly to prevent the possibility of leakage d. Maintaining bedrest at all times to prevent the catheter from slipping off

a. The catheter should be allowed to drain freely through tubing that is not kinked. It also should be removed daily to prevent skin excoriation and should not be fastened too tightly or restriction of blood vessels in the area is likely. Confining a patient to bedrest increases the risk for other hazards related to immobility. Chapter 36

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? a. Checking the amount of oxygen in the cylinder before using it b. Using a cylinder for a patient transfer that indicates available oxygen is 500 psi c. Placing the oxygen cylinder on the stretcher next to the patient d. Discontinuing oxygen flow by turning cylinder key counterclockwise until tight

a. The cylinder must always be checked before use to ensure that enough oxygen is available for the patient. It is unsafe to use a cylinder that reads 500 psi or less because not enough oxygen remains for a patient transfer. A cylinder that is not secured properly may result in injury to the patient. Oxygen flow is discontinued by turning the valve clockwise until it is tight. Chapter 38

Two nurses are taking an apical-radial pulse and note a dif- ference in pulse rate of 8 beats per minute. The nurse would document this difference as which of the following? a. Pulse deficit b. Pulse amplitude c. Ventricular rhythm d. Heart arrhythmia

a. The difference between the apical and radial pulse rate is called the pulse deficit. Chapter 24

A nurse is feeding a patient who states that she is feeling nauseated and can't eat what is being offered. What would be the most appropriate initial action of the nurse in this situation? a. Remove the tray from the room. b. Administer an antiemetic and encourage the patient to take small amounts. c. Explore with the patient why she does not want to eat her food. d. Offer high-calorie snacks such as pudding and ice cream.

a. The first action of the nurse when a patient has nausea is to remove the tray from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect. Chapter 35

The agent-host-environment model of health and illness is based on what concept? a. Risk factors b. Demographic variables c. Behaviors to promote health d. Stages of illness

a. The interaction of the agent, host, and environment creates risk factors that increase the probability of disease. Chapter 3

A 62-year-old male patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition? a. Vitamin B malnutrition b. Obesity c. Dehydration d. Vitamin C deficiency

a. The need for B vitamins is increased in alcoholics because these nutrients are used to metabolize alcohol, thus depleting their supply. Alcohol abuse specifically affects the B vitamins. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI tract. Chapter 35

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? a. Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. b. Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. c. Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. d. Discontinue the infusion immediately, apply warm, moist compresses to the site, and restart the IV at another site.

a. The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis. Chapter 39

A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's best response to the neighbor? a. "New mothers need support." b. "The lack of a father is difficult." c. "How are you today?" d. "It is a very sad situation."

a. The nurse must maintain confidentiality when providing care. The statement "New mothers need support" is a general statement that all new parents need help. The statement is not judgmental of the family's roles. Chapter 20

A nurse is administering a pain medication to a patient. In addition to checking his identification bracelet, the nurse correctly verifies his identity by: a. Asking the patient his name b. Reading the patient's name on the sign over the bed c. Asking the patient's roommate to verify his name d. Asking, "Are you Mr. Brown?"

a. The nurse should ask the patient to state his name. A sign over the patient's bed may not always be current. The room- mate is an unsafe source of information. The patient may not hear his name but may reply in the affirmative anyway (e.g., a person with a hearing deficit). Chapter 28

Which patient would a nurse assess as being at greatest risk for sensory deprivation? a. An older man confined to bed at home after a stroke b. An adolescent in an oncology unit working on homework supplied by friends c. A woman in labor d. A toddler in a playroom awaiting same-day surgery

a. The patient confined to bedrest at home is at risk for greatly reduced environmental stimuli. All of the other patients are in environments in which environmental stimuli are at least adequate. Chapter 43

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? a. Slow or stop the infusion; monitor vital signs, notify the physician, place the patient in upright position with feet dependent. b. Stop the transfusion immediately and keep the vein open with normal saline, notify the physician stat, administer antihistamine parenterally as needed. c. Stop the transfusion immediately and keep the vein open with normal saline, notify the physician, and treat symptoms. d. Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the physician, administer antibiotics stat.

a. The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction. Chapter 39

When a fire occurs in a patient's room, what would be the nurse's priority? a. Rescue the patient. b. Extinguish the fire. c. Sound the alarm. d. Run for help.

a. The patient's safety is always the priority. Sounding the alarm and extinguishing the fire are important after the patient is safe. Calling for help, if possible, rather than running for assistance, allows you to remain with your patient and is more appropriate. Chapter 26

A nurse is counseling a husband and wife who have decided that the wife will get a job so that the husband can go to pharmacy school, as he has wanted to do for some time. Their three teenagers, who were involved in the decision, are also getting jobs to buy their own clothes. The husband plans to work 12 to 16 hours weekly and states, "I was always an A student, but I may have to settle for Bs now because I don't want to neglect my family, and I need to work a few hours so that my wife won't have to work overtime." How would the nurse document the husband's self-expectations? a. Realistic and positively motivating his development b. Unrealistic and negatively motivating his development c. Unrealistic but positively motivating his development d. Realistic but negatively motivating his development

a. The patient's self-expectations are realistic, given his multiple commitments, and seem to be positively motivating his development. Chapter 40

A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient? a. Support weight on stronger leg and cane and advance weaker foot forward. b. Hold the cane in the same hand of the leg with the most severe deficit. c. Stand with as much weight distributed on the cane as possible. d. Do not use the cane to rise from a sitting position, as this is unsafe.

a. The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position. Chapter 32

A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action would the nurse perform next? a. Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants. b. Percuss all quadrants of the abdomen in a systematic clockwise manner to identify masses, fluid, or air in the abdomen. c. Lightly palpate over the abdominal quadrants; first checking for any areas of pain or discomfort. d. Deeply palpate over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses.

a. The sequence for abdominal assessment proceeds from inspection, auscultation, percussion, and then palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility. Percussion and deep palpation are usually performed by advanced practice professionals. Chapter 37

A nurse caring for a patient who is hospitalized following a double mastectomy is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship? a. Determining the progress made in achieving established goals b. Clarifying when the patient should take medications c. Reporting the progress made in teaching to the staff d. Including all family members in the teaching session

a. The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning coor- dinates with the termination phase of a helping relationship. The nurse should determine the progress made in achieving the goals related to the patient's care. Chapter 20

A nurse is feeding an elderly patient who has dementia. Which intervention should the nurse perform to facilitate this process? a. Stroke the underside of the patient's chin to promote swallowing. b. Serve meals in different places and at different times. c. Offer a whole tray of various foods to choose from. d. Avoid between-meal snacks to ensure hunger at mealtime.

a. To feed a patient with dementia, the nurse should stroke the underside of the patient's chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide between-meal snacks that are easy to consume using the hands. Chapter 35

A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended? a. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. b. Draw the shape of the wound and describe how deep it appears in centimeters. c. Gently insert a sterile applicator into the wound and move it in a clockwise direction. d. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker.

a. To measure the depth of a wound, the nurse should perform hand hygiene and put on gloves; moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down; mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point cor- responding to the wound's margin; and remove the swab and measure the depth with a ruler. Chapter 31

A nurse is inserting an oropharyngeal airway for a patient who vomits when it is inserted. Which action would be the first that should be taken by the nurse related to this occurrence? a. Quickly position the patient on his or her side. b. Put on disposable gloves and remove the oral airway. c. Check that the airway is the appropriate size for the patient. d. Put on sterile gloves and suction the airway.

a. When a patient vomits upon insertion of an oropharyngeal airway, the nurse should immediately position the patient on his or her side to prevent aspiration, remove the oral airway, and suction the mouth if needed. Chapter 38

A nurse is caring for a newly placed gastrostomy tube of a postoperative patient. Which nursing action is performed correctly? a. The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site. b. The nurse wets a washcloth and washes the area around the tube with soap and water. c. The nurse adjusts the external disk every 3 hours to avoid crusting around the tube. d. The nurse tapes a gauze dressing over the site after cleansing it.

a. When caring for a new gastrostomy tube, the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage. The nurse would not use a washcloth with soap and water on a new gastrostomy tube, but may use this method if the site is healed. Also, once the sutures are removed, the nurse should rotate the external bumper 90 degrees once a day. The nurse should leave the site open to air unless there is drainage. If there is drainage, one thickness of precut gauze should be placed under the external bumper and changed as needed to keep the area dry. Chapter 35

A nurse is using the SOAP format of documentation to docu- ment care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation? a. A patient problem list b. Notes describing the patient's condition c. Overall trends in patient status d. Planned interventions and patient outcomes

a. When using the SOAP format, the problem list at the front of the chart alerts all caregivers to patient priorities. Narra- tive notes allow nurses to describe a condition, situation, or response in their own terms. Abnormal status can be seen immediately when using charting by exception, and planned interventions and patient expected outcomes are the focus of the case management model. Chapter 16

According to the Health Insurance Portability and Account- ability Act of 1996, if a health institution wants to release a patient's health information (PHI) for purposes other than treatment, payment, and routine health care operations, the patient must be asked to sign an authorization. The nurse is aware that there are exceptions to this requirement. In which of the following cases is an authorization form not needed? Select all that apply. a. News media are preparing a report on the condition of a public figure. b. Data are needed for the tracking and notification of disease outbreaks. c. Protected health information is needed by a coroner. d. Child abuse and neglect are suspected. e. Protected health information is needed to facilitate organ donation. f. The sister of a patient with Alzheimer's wants to help provide care.

b, c, d, e. Authorization is not required for tracking disease outbreaks, providing PHI to a coroner, reporting incidents of child abuse, or facilitating organ donations. Under no cir- cumstance can a nurse provide information to a news reporter without the patient's express authorization. An authorization form is still needed to provide PHI for a patient who has Alzheimer's disease. Chapter 16

Despite a national focus on health promotion, nurses working with patients in inner-city clinics continue to see disparities in health care for vulnerable populations. Which patients would be considered vulnerable populations? Select all that apply. a. A White male diagnosed with HIV b. An African American teenager who is 6 months pregnant c. A Hispanic male who has type II diabetes d. A low-income family living in rural America e. A middle-class teacher living in a large city f. A White baby who was born with cerebral palsy

b, c, d, f. National trends in the prevention of health disparities are focused on vulnerable populations, such as racial and ethnic minorities, those living in poverty, women, children, older adults, rural and inner-city residents, and people with disabilities and special health care needs. Chapter 3

A nurse is developing a plan of care for an 86-year-old woman who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure ulcer development for this patient? Select all that apply. a. The patient takes time to think about her responses to questions. b. The patient's age of 86 years. c. Patient reports inability to control urine. d. A scheduled hip arthroplasty e. Lab findings include BUN 12 (elderly normal 8-23 mg/dL) and creatinine 0.9 (adult female normal 0.61-1 mg/dL). f. Patient reports increased pain in right hip when repositioning in bed or chair.

b, c, d, f. Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure ulcer development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with move- ment, contributing to immobility; and increased pain in the hip may contribute to increased immobility. All these factors are related to an increased risk for pressure ulcer develop- ment. Apathy, confusion, and/or altered mental status are risk factors for pressure ulcer development. Dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure ulcer development. Chapter 31

A nurse caring for patients in a skilled nursing facility performs risk assessments on the patients for foot and nail problems. Which patients would be at a higher risk? Select all that apply. a. A patient who is taking antibiotics for chronic bronchitis b. A patient diagnosed with type II diabetes c. A patient who is obese d. A patient who has a nervous habit of biting his nails e. A patient diagnosed with prostate cancer f. A patient whose job involves frequent hand washing

b, c, d, f. Variables known to cause nail and foot problems include deficient self-care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity. Chapter 30

A nurse is caring for a 16-year-old male patient who has been hospitalized for an acute asthma exacerbation. Which testing methods might the nurse use to measure the patient's oxygen saturation? Select all that apply. a. Thoracentesis b. Spirometry c. Pulse oximetry d. Peak expiratory flow rate e. Diffusion capacity f. Maximal respiratory pressure

b, c, d. Spirometers are used to monitor the health status of patients with respiratory disorders, such as asthma. Pulse oximetry is used to obtain baseline information about the patient's oxygen saturation level and is also performed for patients with asthma, along with PEFR to monitor airflow. These three tests may be administered by the nurse. Diffusion capacity estimates the patient's ability to absorb alveolar gases and determines if a gas exchange problem exists. Maximal respiratory pressures help evaluate neuromuscular causes of respiratory dysfunction. Both tests are usually performed by a respiratory therapist. The physician or other advanced practice professional can perform a thoracentesis at the bedside with the nurse assisting, or in the radiology department. Chapter 38

The nurse instructor is teaching student nurses about the factors that may affect a patient's blood pressure. Which state- ments accurately describe these factors? Select all that apply. a. Blood pressure decreases with age. b. Blood pressure is usually lowest on arising in the morning. c. Women usually have lower blood pressure than men until menopause. d. Blood pressure decreases after eating food. e. Blood pressure tends to be lower in the prone or supine position. f. Increased blood pressure is more prevalent in African Americans.

b, c, e, f. Blood pressure increases with age due to a decreased elasticity of the arteries, increasing peripheral resistance. Blood pressure is usually lowest on arising in the morning. Women usually have lower blood pressure than men until menopause occurs. Blood pressure increases after eating food. Blood pressure tends to be lower in the prone or supine position. Increased blood pressure is more prevalent and severe in Afri- can American men and women. Chapter 24

A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply. a. A patient who is taking iron supplements for anemia b. A patient with Parkinson disease who is taking dopamine c. An elderly patient taking diuretics for congestive heart failure d. A patient who is taking antibiotics for an ear infection e. A patient who is prescribed antidepressants f. A patient who is taking low-dose aspirin prophylactically

b, c, e. Drugs that decrease REM sleep include barbiturates, amphetamines, and antidepressants. Diuretics, antiparkinsonian drugs, some antidepressants and antihypertensives, steroids, decongestants, caffeine, and asthma medications are seen as additional common causes of sleep problems. Chapter 33

A nurse is assisting a postoperative patient with condition- ing exercises to prepare for ambulation. The nurse correctly instructs the patient to do which actions? Select all that apply. a. Do full-body pushups in bed six to eight times daily. b. Breathe in and out smoothly during quadriceps drills. c. Place the bed in the lowest position or use a footstool for dangling. d. Dangle on the side of the bed for 30 to 60 minutes. e. Allow the nurse to bathe the patient completely to prevent fatigue. f. Perform quadriceps 2 to 3 times per hour, 4 to 6 times a day.

b, c, f. Breathing in and out smoothly during quadriceps drills maximizes lung inflation. The patient should perform quadri- ceps 2 to 3 times per hour, 4 to 6 times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for 30 to 60 minutes is unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling. The nurse should also encourage the patient to be as independent as possible to prepare for return to normal ambulation and ADLs. Chapter 32

A nurse instructor is teaching a class of student nurses about the nature of pain. Which statements accurately describe this phenomenon? Select all that apply. a. Pain is whatever the physician treating the pain says it is. b. Pain exists whenever the person experiencing it says it exists. c. Pain is an emotional and sensory reaction to tissue damage. d. Pain is a simple, universal, and easy-to-describe phenomenon. e. Pain that occurs without a known cause is psychological in nature. f. Pain is classified by duration, location, source, transmission, and etiology.

b, c, f. Margo McCaffery (1979, p. 11) offers the classic definition of pain that is probably of greatest benefit to nurses and their patients: "Pain is whatever the experiencing person says it is, existing whenever he (or she) says it does." The International Association for the Study of Pain (IASP) further defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage (IASP, 1994). Pain is an elusive and complex phenomenon, and despite its universality, its exact nature remains a mystery. Pain is present whenever a person says it is, even when no specific cause of the pain can be found. Pain may be classified according to its duration, its location or source, its mode of transmission, or its etiology. Chapter 34

Health promotion activities may occur on a primary, secondary, or tertiary level. Which activities are considered tertiary health promotion? Select all that apply. a. A nurse runs an immunization clinic in the inner city. b. A nurse teaches a patient with an amputation how to care for the residual limb. c. A nurse provides range-of-motion exercises for a paralyzed patient. d. A nurse teaches parents of toddlers how to childproof their homes. e. A school nurse provides screening for scoliosis for the students. f. A nurse teaches new parents how to choose and use an infant car seat.

b, c. Tertiary health promotion and disease prevention begins after an illness is diagnosed and treated to reduce disability and to help rehabilitate patients to a maximum level of functioning. These activities include providing ROM exercises and patient teaching for residual limb care. Providing immunizations and teaching parents how to childproof their homes and use an appropriate car seat are primary health promotion activities. Providing screenings is a secondary health promotion activity. Chapter 3

A nurse works for a physician who practices the naturopathic system of medicine. What is the focus of nursing actions based on this type of medical practice? Select all that apply. a. Treating the symptoms of the disease b. Providing patient education c. Focusing on treating individual body systems d. Making appropriate interventions to prevent illness e. Believing in the healing power of nature f. Encouraging patients to take responsibility for their own health.

b, d, e, f. Naturopathic medicine is not only a system of medicine, but also a way of life, with emphasis on client responsibility, client education, health maintenance, and disease prevention. Its principles include minimizing harm- ful side effects and avoiding suppression of symptoms, edu- cating patients and encouraging them to take responsibility for their own health, treating the whole person, prevent- ing illness, believing in the healing power of nature, and treating the cause of a disease or condition rather than its symptoms. Chapter 27

A nurse who is caring for older adults in a senior daycare center documents findings as related to which normal aging process? Select all that apply. a. A patient's increased skin elasticity causes wrinkles on the face and arms. b. Exposure to sun over the years causes a patient's skin to be pigmented. c. A patient's toenails have become thinner with a bluish tint to the nail beds. d. A patient experiences a hip fracture due to porous and brittle bones. e. Fragile blood vessels in the dermis allow for more easy bruising of a patient's forearm. f. Increased bladder capacity causes decreased voiding in an older patient.

b, d, e. Exposure to sun over the years can cause a patient's skin to be pigmented. Bone demineralization occurs with aging, causing bones to become porous and brittle, making fractures more common. The blood vessels in the dermis become more fragile, causing an increase in bruising and purpura. Wrinkling and sagging of skin occur with decreased skin elasticity. A patient's toenails may become thicker, with a yellowish tint to the nail beds. Bladder capacity decreases by 50%, making voiding more frequent; two or three times a night is usual. Chapter 19

A nurse who is assessing an older female patient in a longterm care facility notes that the patient is at risk for sensory deprivation related to severe rheumatoid arthritis limiting her activity. Which interventions would the nurse recommend based on this finding? Select all that apply. a. Use a lower tone when communicating with the patient. b. Provide interaction with children and pets. c. Decrease environmental noise. d. Ensure that the patient shares meals with other patients. e. Discourage the use of sedatives. f. Provide adequate lighting and clear pathways of clutter.

b, d, e. For a patient who has sensory deprivation, the nurse should provide interaction with children and pets, ensure that the patient shares meals with other patients, and discourage the use of sedatives. Using a lower tone of voice is appropriate for a patient who has a hearing deficit, decreasing environmental noise is an intervention for sensory overload, and providing adequate lighting and removing clutter is an intervention for a vision deficit. Chapter 43

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. a. Refrain from exercise. b. Reduce anxiety. c. Eat meals 1 to 2 hours prior to breathing treatments. d. Eat a high-protein/high-calorie diet. e. Maintain a high-Fowler's position when possible. f. Drink 2 to 3 pints of clear fluids daily.

b, d, e. When caring for patients with COPD, it is important to create an environment that is likely to reduce anxiety and ensure that they eat a high-protein/high-calorie diet. People with dyspnea and orthopnea are most comfortable in a high Fowler's position because accessory muscles can easily be used to promote respiration. Patients with COPD should pace physical activities and schedule frequent rest periods to conserve energy. Meals should be eaten 1 to 2 hours after breathing treatments and exercises, and drinking 2 to 3 quarts (1.9-2.9 L) of clear fluids daily is recommended. Chapter 38

The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply. a. A patient who is older than 60 years b. A patient who has already fallen twice c. A patient who is taking antibiotics d. A patient who experiences postural hypotension e. A patient who is experiencing nausea from chemotherapy f. A 70-year old patient who is transferred to long-term care

b, d, f. Risk factors for falls include age over 65 years, docu- mented history of falls, postural hypotension, and unfamiliar environment. A medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics is also a risk factor, not chemotherapy or antibiotics. Chapter 26

Following a fall that left an elderly male patient temporarily bedridden, the nurse is using the SPICES assessment tool to evaluate him for cascade iatrogenesis. Which are correct aspects of this tool? Select all that apply. a. S - Senility b. P - Problems with feeding c. I - Irritableness d. C - Confusion e. E - Edema of the legs f. S - Skin breakdown

b, d, f. The SPICES acronym is used to identify common problems in older adults and stands for: S - Sleep disorders P - Problems with eating or feeding I - Incontinence C - Confusion E - Evidence of falls S - Skin breakdown (Fulmer & Wallace, 2012). Chapter 19

A nurse assesses the stool of patients who are experiencing gastrointestinal problems. In which patients would diarrhea be a possible finding? Select all that apply. a. A patient who is taking narcotics for pain b. A patient who is taking laxatives c. A patient who is taking diuretics d. A patient who is dehydrated e. A patient who is taking amoxicillin for an infection f. A patient taking over-the-counter antacids

b, e, f. Diarrhea is a potential adverse effect of treatment with amoxicillin clavulanate (Augmentin), laxatives, or over-thecounter antacids. Narcotics, diuretics, and dehydration may lead to constipation. Chapter 37

A nurse assesses patients in a physician's office who are experiencing different levels of health and illness. Which statements best define the concepts of health and illness? Select all that apply. a. Health and illness are the same for all people. b. Health and illness are individually defined by each person. c. People with acute illnesses are actually healthy. d. People with chronic illnesses have poor health beliefs. e. Health is more than the absence of illness. f. Illness is the response of a person to a disease.

b, e, f. Each person defines health and illness individually, based on a number of factors. Health is more than just the absence of illness; it is an active process in which a person moves toward one's maximum potential. An illness is the response of the person to a disease. Chapter 3

A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. Which steps in this procedure are performed correctly? Select all that apply. a. The nurse removes all jewelry including a platinum wedding band. b. The nurse washes hands to one inch above the wrists. c. The nurse uses approximately two teaspoons of liquid soap. d. The nurse keeps hands higher than elbows when placing under faucet. e. The nurse uses friction motion when washing for at least 15 seconds. f. The nurse rinses thoroughly with water flowing toward fingertips.

b, e, f. Proper hand hygiene includes removing jewelry with the exception of a plain wedding band, wetting the hands and wrist area with the hands lower than the elbows, using about one teaspoon of liquid soap, using friction motion for at least 15 seconds, washing to one inch above the wrists with a fric- tion motion for at least 15 seconds, and rinsing thoroughly with water flowing toward fingertips. Chapter 23

A nurse has been asked to witness a patient signature on an informed consent form for surgery. For which of these patients would the document be valid? Select all that apply. a. A 92-year-old patient who is severely confused b. A 45-year-old patient who is oriented and alert c. A 10-year-old patient who is oriented and alert d. A 36-year-old patient who has had a narcotic premedication e. A 45-year-old mentally ill patient who has been ruled incompetent f. A 22-year old patient having an abortion against her partner's wishes

b, f. A consent form is not legal if the patient signing the form is confused, sedated, unconscious, or a minor. Chapter 29

A nurse is calculating the body mass index (BMI) of a 35-yearold male patient who is extremely obese. The patient's height is 5′6″ and his current weight is 325 pounds. What would the nurse document as his BMI? a. 50.5 b. 52.4 c. 54.5 d. 55.2

b. BMI= weight in pounds (325) / (height in inches)(66) x (height in inches)(66) x 703 BMI 52.4 Chapter 35

When planning care for a patient with chronic lung disease who is receiving oxygen through a nasal cannula, what does the nurse expect? a. The oxygen must be humidified. b. The rate will be no more than 2 to 3 L/min or less. c. Arterial blood gases will be drawn every 4 hours to assess flow rate. d. The rate will be 6 L/min or more.

b. A rate higher than 3 L/min may destroy the hypoxic drive that stimulates respirations in the medulla in a patient with chronic lung disease. Oxygen delivered at low rates does not necessarily have to be humidified, and arterial blood gases are not required at regular intervals to determine the flow rate. Chapter 38

A nurse assesses a patient's body temperature in the late afternoon as 37.2°C (99°F). What would be the nurse's best action related to this slight elevation in temperature? a. Assess the patient for infection. b. Record the temperature as a normal finding. c. Call the physician for an order for antipyretics. d. Decrease the room temperature.

b. A slight increase in body temperature in the late afternoon is the result of a normal circadian rhythm and does not need to be reported unless it becomes higher. This slight variation from normal does not necessarily mean an infection is present. A warm environment might cause an elevation in body temperature, but the most likely cause is normal circadian rhythm. Chapter 33

After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this ulcer would be classified as: a. Stage I b. Stage II c. Stage III d. Stage IV

b. A stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. Chapter 31

A 16-year-old patient has a nursing diagnosis of Body Image Disturbance related to severe acne. In planning nursing care, what is an appropriate goal for this nursing diagnosis? a. The patient will make above-B grades in all tests at school." b. The patient will demonstrate by diet control and skin care increased interest in control of acne. c. The patient reports that she feels more self-confidence in her music and art, which she enjoys. d. The patient expresses that she is very smart in school.

b. All of these patient goals may be appropriate for the patient but the only goal that directly addresses her body image disturbance is b. Chapter 40

A nurse assisting with a patient bed bath observes that an older female patient has dry skin. The patient states that her skin is always "itchy." Which nursing action would be the nurse's best response? a. Bathe the patient more frequently. b. Use an emollient on the dry skin. c. Massage the skin with alcohol. d. Discourage fluid intake.

b. An emollient soothes dry skin, whereas frequent bathing increases dryness, as does alcohol. Discouraging fluid intake leads to dehydration and, subsequently, dry skin. Chapter 30

A nurse is diagnosing an 11-year-old 6th grade student following a physical assessment. The nurse notes that the student's grades have dropped, she has difficulty completing her work on time, and she frequently rubs her eyes and squints. Her visual acuity on a Snellen's eye chart is 160/20. Which nursing diagnosis would be most appropriate? a. Deficient Knowledge related to visual impairment b. Ineffective Role Performance (Student) related to visual impairment c. Disturbed Body Image related to visual impairment d. Delayed Growth and Development related to visual impairment

b. An important role for an 11-year-old is that of student. Her impaired vision is clearly disturbing her role performance as a student, as evidenced by her lower grades. Although the other options may also represent accurate diagnoses for this patient, they do not flow from the data presented. Chapter 43

A nurse is inserting a nasogastric tube ordered for a patient to monitor bleeding in his GI tract. When the tube is being passed through the pharynx, the patient begins to cough and show signs of respiratory distress. What would be the priority action of the nurse upon this assessment? a. Keep the tube in place and notify the primary care provider immediately. b. Stop advancing the tube and pull it back into the nasal area. c. Ask the patient if he wants the nurse to stop the procedure. d. Call for help to perform CPR.

b. As the tube is passing through the pharynx and the patient begins to cough and show respiratory distress, the nurse should stop advancing the tube and pull it back into the nasal area. The nurse should also support the patient as he regains normal breathing ability and composure and have him try again if he feels able to. Chapter 35

A nurse is scheduling hygiene for patients on her unit. What is the most important consideration when planning a patient's personal hygiene? a. When the patient had his or her most recent bath b. The patient's usual hygiene practices and preferences c. Where the bathing fits in the nurse's schedule d. The time that is convenient for the patient care assistant

b. Bathing practices and cleansing habits and rituals vary widely. The patient's preferences should always be taken into consideration, unless there is a clear threat to health. The patient and nurse should work together to come to a mutu- ally agreeable time and method to accomplish the patient's personal hygiene. The availability of staff to assist may be important, but the patient's preferences are a higher priority. Chapter 30

A student nurse is learning to assess blood pressure. What does the blood pressure measure? a. Flow of blood through the circulation b. Force of blood against arterial walls c. Force of blood against venous walls d. Flow of blood through the heart

b. Blood pressure is the measurement of the force of blood against arterial walls. Chapter 24

A nurse caring for patients in a pediatrician's office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones? a. A 4-month-old infant who is unable to roll over b. A 6-month-old infant who is unable to hold his head up himself c. An 11-month-old infant who cannot walk unassisted d. An 18-month-old toddler who cannot jump

b. By 5 months, head control is usually achieved. An infant usually rolls over by 6 to 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump. Chapter 32

A nurse observes that a patient who has cataracts is sitting closer to the television than usual. The nurse would interpret that the etiologic basis of this sensory problem is an alteration in: a. Environmental stimuli b. Sensory reception c. Nerve impulse conduction d. Impulse translation

b. Cataracts are interfering with the patient's ability to receive visual stimuli: altered sensory reception. The nature of incoming stimuli, the conduction of nerve impulses, and the translation of incoming impulses in the brain are not a problem here. Chapter 43

A college freshman away from home for the first time says, "Why did I have to be born into a family of big bottoms and short fat legs! No one will ever ask me out for a date. Oh, why can't I have long thin legs like everyone else in my class? What a frump I am."

b. Clearly, this patient's concern is with body image. Chapter 40

A nurse working in a long-term care facility incorporates aromatherapy into her practice. For which patient would this nurse use the herb ginger? a. A patient who has insomnia b. A patient who has nausea c. A patient who has dementia d. A patient who has migraine headaches

b. Commonly used essential oils in a health care setting are ginger or peppermint for nausea and lavender or chamomile for insomnia. Chapter 27

A nurse is interviewing a patient who just received news that he has pancreatic cancer. The patient tells the nurse that getting cancer could never happen to him. Which defense mechanism is this patient demonstrating? a. Projection b. Denial c. Displacement d. Repression

b. Denial occurs when a person refuses to acknowledge the presence of a condition that is disturbing. Chapter 41

A school nurse is performing an assessment of a student who states: "I'm too tired to keep my head up in class." The student has a low-grade fever. The nurse would interpret these findings as indicating which stage of infection? a. Incubation period b. Prodromal stage c. Full stage of illness d. Convalescent period

b. During the prodromal stage, the person has vague signs and symptoms, such as fatigue and a low-grade fever. There are no obvious symptoms of infection during the incubation period, and they are more specific during the full stage of ill- ness, before disappearing by the convalescent period. Chapter 23

A nurse in the rehabilitation division states to her head nurse, Mr. Tyler, "I need the day off and you didn't give it to me!" The head nurse replies, "Well, I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of this exchange, what communication by the nurse would have been more effective? a. "Mr. Tyler, I placed a request to have August 8th off, but I'm working and I have a doctor's appointment." b. "Mr. Tyler, I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" c. "Mr. Tyler, I will need to call in on the 8th of August because I have a doctor's appointment." d. "Mr. Tyler, since you didn't give me the 8th of August off, will I need to find someone to work for me?"

b. Effective communication by the sender involves the imple- mentation of nonthreatening information by showing respect to the receiver. The nurse should identify the subject of the meeting and be sure it occurs at a mutually agreed upon time. Chapter 20

A patient is having dyspnea. What would the nurse do first? a. Remove pillows from under the head b. Elevate the head of the bed c. Elevate the foot of the bed d. Take the blood pressure

b. Elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm greater room for expansion and facilitating lung expansion. Chapter 24

A nurse is caring for an obese patient who has had surgery. The nurse monitors this patient for what postoperative complication? a. Hunger b. Impaired wound healing c. Hemorrhage d. Gas pains

b. Fatty tissue is less vascular and, therefore, less resistant to infection and more prone to delayed wound healing. Chapter 29

A 56-year-old male patient who has COPD is refusing to eat. Which intervention would be most helpful in stimulating his appetite? a. Administering pain medication after meals. b. Encouraging food from home when possible. c. Scheduling his respiratory therapy before each meal. d. Reinforcing the importance of his eating exactly what is delivered to him.

b. Food from home that the patient enjoys may stimulate him to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and telling the patient what he must eat is no guarantee that he will comply. Chapter 35

A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient's feet to prevent foot drop? a. Supination b. Dorsiflexion c. Hyperextension d. Abduction

b. For a patient who has footdrop, the nurse should support the feet in dorsiflexion, and use a footboard or high-top sneakers to further support the foot. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions would not be used to prevent foot drop. Chapter 32

A nurse is providing postural drainage for a patient with cystic fibrosis. In which position should the nurse place the patient to drain the right lobe of the lung? a. High Fowler's position b. Left side with pillow under chest wall c. Lying position/half on abdomen and half on side d. Trendelenberg position

b. For postural drainage, the nurse should place the patient lying on the left side with a pillow under the chest wall to drain the right lobe of the lung, use high Fowler's position to drain the apical sections of the upper lobes of the lungs, place the patient in a lying position, half on the abdomen and half on the side, right and left, to drain the posterior sections of the upper lobes of the lungs, and place the patient in the Trendelenburg position to drain the lower lobes of the lungs. Chapter 38

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document? a. 1 b. 2 c. 3 d. 4

b. Grade 2 phlebitis presents with pain at access site with erythema and/or edema. Grade 1 presents as erythema at access site with or without pain. Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3 with a palpable venous cord >1 inch and with purulent drainage. Chapter 39

A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? a. Explaining the mechanisms involved in transporting fluids to and from intracellular compartments b. Keeping fluids readily available for the patient c. Emphasizing the long-term outcome of increasing fluids when the patient returns home d. Planning to offer most daily fluids in the evening

b. Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day. Chapter 39

When assessing pain in a child, the nurse needs to be aware of what considerations? a. Immature neurologic development results in reduced sensation of pain. b. Inadequate or inconsistent relief of pain is widespread. c. Reliable assessment tools are currently unavailable. d. Narcotic analgesic use should be avoided.

b. Health care personnel are only now becoming aware of pain relief as a priority for children in pain. The evidence supports the fact that children do indeed feel pain and reliable assessment tools are available specifically for use with children. Opioid analgesics may be safely used with children as long as they are carefully monitored. Chapter 34

A nurse is irrigating the colostomy of a patient and is unable to get the irrigation solution to flow. What would be the nurse's next action in this situation? a. Assist the patient to a prone position on a waterproof pad and try again. b. Check the clamp on the tubing to make sure that the tubing is open. c. Quickly pull the cone from the stoma and check for bleeding. d. Remove the equipment and call the primary care provider.

b. If irrigation solution is not flowing, the nurse should first check the clamp on the tubing to make sure the tubing is open. Next, the nurse should gently manipulate the cone in the stoma and check for a blockage of stool. If there is a blockage, the nurse should remove the cone from the stoma, clean the area, and gently reinsert. Alternately, the nurse could assist the patient to a side-lying or sitting position in bed, place a waterproof pad under the irrigation sleeve, and place the drainage end of the sleeve in a bedpan. Chapter 37

After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding? a. Pouring warm water over the patient's fingers. b. Having the patient ignore the urge to void until her bladder is full. c. Using a warm bedpan when the patient feels the urge to void. d. Stroking the patient's leg or thigh.

b. Ignoring the urge to void makes urination even more difficult and should be avoided. The other activities are all recommended nursing activities to promote voiding. Chapter 36

A nurse is caring for an 82-year-old woman in a long-term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient? a. Improved renal blood supply to the kidneys b. Urinary stasis c. Decreased urinary calcium d. Acidic urine formation

b. In a nonerect patient, the kidneys and ureters are level. In this position, urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder, resulting in urinary stasis. Urinary stasis favors the growth of bacteria that may cause urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to increased levels of urinary calcium and alkaline urine, contributing to renal calculi and urinary tract infection, respectively. Chapter 32

A nurse teaches a patient at home to use clean technique when changing a wound dressing. This practice is considered: a. The nurse's preference b. Safe for the home setting c. Unethical behavior d. Grossly negligent

b. In the home setting, where the patient's environment is more controlled, medical asepsis is usually recommended, with the exception of self-injection. This is the appropriate procedure for the home and is neither unethical nor grossly negligent. Chapter 23

A patient tells the nurse she is having pain in her right lower leg. How does the nurse assess for the presence of thrombophlebitis? a. By palpating the skin over the tibia and fibula b. By documenting daily calf circumference measurements c. By recording vital signs obtained four times a day d. By noting difficulty with ambulation

b. Inflammation from thrombophlebitis increases the size of the affected extremity and can be assessed by measuring circumference on a regular basis. Chapter 29

At a follow-up visit, a patient recovering from a myocardial infarction tells the nurse: "I feel like my life is out of control ever since I had the heart attack. I would like to sign up for yoga, but I don't think I'm strong enough to hold poses for long." What would be the nurse's best response? a. "Right now you should concentrate on relaxing and taking your blood pressure medicine regularly, instead of worry- ing about doing yoga." b. "There is a slower-paced yoga called Kripaula that focuses on coming into balance and relaxation that you could look into." c. "Ashtanga yoga is a gentlepaced yoga that would help with your breathing and blood pressure." d. "Yoga is contraindicated for patients who have had a heart attack."

b. Kripaula, or "gentle yoga," focuses on relaxation and coming into balance. Ashtanga focuses on synchronizing breath with a fast-paced series of postures. The nurse should not discourage the use of yoga in patients who are healthy enough to participate. Yoga is not contraindicated in patients with controlled high blood pressure. Chapter 27

A nurse forms the following nursing diagnosis for a patient: Impaired Urinary Elimination related to maturational enuresis. Based on this diagnosis, for which patient is the nurse caring? a. An adult older than 65 years of age who is incontinent b. A child older than 4 years of age who has involuntary urination c. A 12-month-old child who has involuntary urination d. A patient with neurologic damage resulting in bladder dysfunction

b. Maturational enuresis is involuntary urination after an age when continence should be present. A 12-month-old child is not expected to be continent, and incontinence and neurologic damage are not maturational problems. Chapter 36

Based on Erikson's theory, middle adults who do not achieve their developmental tasks may be considered to be in stagna- tion. Which statement is one example of this finding? a. "I am helping my parents move into an assisted-living facility." b. "I spend all of my time going to the doctor to be sure I am not sick." c. "I have enough money to help my son and his wife when they need it." d. "I earned this gray hair and I like it!"

b. Middle adults who do not reach generativity tend to become overly concerned about their own physical and emotional health needs. Chapter 19

A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder? a. REM behavior disorder b. Narcolepsy c. Enuresis d. Sleep apnea

b. Narcolepsy is an uncontrollable desire to sleep; the person may fall asleep in the middle of a conversation. REM Behavior Disorder (RBD) is characterized by "acting out" dreams while asleep. Enuresis is urinating during sleep or bedwetting. Sleep apnea is a condition in which breathing ceases for a period of time between snoring. Chapter 33

A nurse is teaching a patient a relaxation technique. Which statement demonstrates the need for more teaching? a. "I must breathe in and out in rhythm." b. "I should take my pulse and expect it to be faster." c. "I can expect my muscles to feel less tense." d. "I will be more relaxed and less aware."

b. No matter what the technique, relaxation involves rhythmic breathing, a slower pulse, reduced muscle tension, and an altered state of consciousness. Chapter 41

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? a. Encourage foods and fluids with high sodium content. b. Administer oral K supplements as ordered. c. Caution the patient about eating foods high in potassium content. d. Discuss calcium-losing aspects of nicotine and alcohol use.

b. Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia. Chapter 39

Applying the gate control theory of pain, what would be an effective nursing intervention for a patient with lower back pain? a. Encouraging regular use of analgesics b. Applying a moist heating pad to the area at prescribed intervals c. Reviewing the pain experience with the patient d. Ambulating the patient after administering medication

b. Nursing measures such as applying warmth to the lower back stimulate the large nerve fibers to close the gate and block the pain. The other choices do not involve attempts to stimulate large nerve fibers that interfere with pain transmission as explained by the gate control theory. Chapter 34

Which action would be most important for a nurse to include in the plan of care for a patient who is 85 years old and has presbycusis? a. Obtaining large-print written material b. Speaking distinctly, using lower frequencies c. Decreasing tactile stimulation d. Initiating a safety program to prevent falls

b. Presbycusis is a normal loss of hearing as a result of the aging process. Speaking distinctly in lower frequencies is indicated. The other choices refer to interventions for other sensory problems. Chapter 43

The nurse uses the RYB wound classification system to assess the wound of a client who cut his arm on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound? a. Irrigate the wound. b. Provide gentle cleansing of the wound. c. Débride the wound. d. Change the dressing frequently.

b. Red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue. Wounds in this stage need protection with nursing interventions that include gentle cleansing, use of moist dressings, and changing of the dressing only when necessary, and/or based on product manufacturer's recommendations. To cleanse yellow wounds, nursing interventions include the use of wound cleansers and irrigating the wound. The eschar found in black wounds requires débridement (removal) before the wound can heal. Chapter 31

Older adults often have reduced vital capacity as a result of normal physiologic changes. Which nursing intervention would be most important for the postoperative care of an older surgical patient specific to this change? a. Take and record vital signs every shift. b. Turn, cough, and deep breathe every 4 hours. c. Encourage increased intake of oral fluids. d. Assess bowel sounds daily.

b. Reduced vital capacity in older adults increases the risk for respiratory complications, including pneumonia and atelec- tasis. Having the patient turn, cough, and deep breathe every 4 hours maintains respiratory function and helps to prevent complications. Chapter 29

A patient requires 40 units of NPH insulin and 10 units of regular insulin daily subcutaneously. What is the correct sequence when mixing insulins? a. Inject air into the regular insulin vial and withdraw 10 units; then, using the same syringe, inject air into the NPH vial and withdraw 40 units of NPH insulin. b. Inject air into the NPH insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the regular insulin vial and withdraw 10 units; then, with- draw 40 units of NPH insulin. c. Inject air into the regular insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the NPH insulin vial and withdraw 40 units; then, with- draw 10 units of regular insulin. d. Inject air into the NPH insulin vial and withdraw 40 units; then, using the same syringe, inject air into the regular insulin vial and withdraw 10 units of regular insulin.

b. Regular or short-acting insulin should never be contami- nated with NPH or any insulin modified with added protein. Placing air in the NPH vial first without allowing the needle to contact the solution ensures that the regular insulin will not be contaminated. Chapter 28

A nurse is caring for an 80-year-old patient who has become weak and fatigues easily. He is unable to wash his body and always asks the nurse to brush his teeth. Based on this information, what is an appropriate nursing diagnosis for this patient? a. Risk for Impaired Skin Integrity related to immobility b. Bathing/Hygiene Self-Care Deficit related to decreased strength and endurance c. Social Isolation related to lack of visitors d. Impaired Oral Mucous Membrane related to inability to brush his teeth

b. Risk for Impaired Skin Integrity, Social Isolation, and Impaired Oral Mucous Membrane may be appropriate nurs- ing diagnoses for this patient. However, not enough is known, based on the information given, to formulate these diagnoses. The priority at this time, based on the given information, is Bathing/Hygiene Self-Care Deficit. Chapter 30

When assessing a patient receiving a continuous opioid infusion, the nurse immediately notifies the physician when the patient has: a. A respiratory rate of 10/min with normal depth b. A sedation level of 4 c. Mild confusion d. Reported constipation

b. Sedation level is more indicative of respiratory depression because a drop in level usually precedes it. A sedation level of 4 calls for immediate action because the patient has minimal or no response to stimuli. A respiratory level of 10 with normal depth of breathing is usually not a cause for alarm. Mild confusion may be evident with the initial dose and then disappear; additional observation is necessary. Constipation should be reported to the physician, but is not the priority in this situation. Chapter 34

A patient has intravenous fluids infusing in the right arm. When taking a blood pressure on this patient, what would the nurse do in this situation? a. Take the blood pressure in the right arm b. Take the blood pressure in the left arm c. Use the smallest possible cuff d. Report inability to take the blood pressure

b. The blood pressure should be taken in the arm opposite the one with the infusion. Chapter 24

A nurse carefully assesses the acid-base balance of a patient who is unable to effectively control his carbonic acid supply. This is most likely a patient with damage to which of the following? a. Kidneys b. Lungs c. Adrenal glands d. Blood vessels

b. The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid hormones. The blood vessels act only as a transport system. Chapter 39

Ms. Hall has an order for hydromorphone (Dilaudid), 2 mg, intravenously, q 4 hours PRN pain. The nurse notes that according to Ms. Hall's chart, she is allergic to Dilaudid. The order for medication was signed by Dr. Long. What would be the correct procedure for the nurse to follow in this situation? a. Administer the medication; the doctor is responsible for medication administration. b. Call Dr. Long and ask that she change the medication. c. Ask the supervisor to administer the medication. d. Ask the pharmacist to provide a medication to take the place of Dilaudid.

b. The nurse is responsible for any medications he or she gives and must contact the doctor to inform her of the patient's allergy to the drug. The nurse should not give the medication and might speak with the supervisor only if uncomfortable with the physician's answer once she is notified. The nurse is legally unable to order a replacement medication, as is the pharmacist. Chapter 28

A nursing student is preparing to administer morning care to a patient. What is the most important question that the nurs- ing student should ask the patient about personal hygiene? a. "Would you prefer a bath or a shower?" b. "May I help you with a bed bath now or later this morning?" c. "I will be giving you your bath. Do you use soap or shower gel?" d. "I prefer a shower in the evening. When would you like your bath?"

b. The nurse should ask permission to assist the patient with a bath. This allows for consent to assist the patient with care that invades the patient's private zones. Chapter 20

The Joint Commission issues guidelines regarding the use of restraints. In which case is a restraint properly used? a. The nurse positions a patient in a supine position prior to applying wrist restraints. b. The nurse ensures that two fingers can be inserted between the restraint and patient's ankle. c. The nurse applies a cloth restraint to the left hand of a patient with an IV catheter in the right wrist. d. The nurse ties an elbow restraint to the raised side rail of a patient's bed.

b. The nurse should be able to place two fingers between the restraint and a patient's wrist or ankle. The patient should not be put in a supine position with restraints due to risk of aspiration. Due to the IV in the right wrist, alternative forms of restraints should be tried, such as a cloth mitt or an elbow restraint. Securing the restraint to a side rail may injure the patient when the side rail is lowered. Chapter 26

A friend of a nurse calls and asks if she is still working at Memorial Hospital. The nurse replies, "Yes." The friend tells the nurse that his girlfriend's father was just admitted as a patient and he wants the nurse to find out how he is. The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make? a. "You shouldn't be asking me to do this. I could be fined or even lose my job for disclosing this information." b. "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family mem- ber asks." c. "Because of the Health Insurance Portability and Account- ability Act, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble!" d. "Why do you think Sue isn't talking about her worries?"

b. The nurse should immediately clarify what he or she can and cannot do. Since the primary reason for refusing to help is linked to the responsibility to protect patient privacy and confidentiality, the nurse should not begin by mention- ing the real penalties linked to abuses of privacy. Finally, it is appropriate to ask about Sue and her worries, but this should be done after the nurse clarifies what he or she is able to do. Chapter 16

A nurse caring for patients in a busy hospital environment should implement which recommendation to promote sleep? a. Keep the room light dimmed during the day. b. Keep the room cool. c. Keep the door of the room open. d. Offer a sleep aid medication to patients on a regular basis.

b. The nurse should keep the room cool and provide earplugs and eye masks. The nurse should also maintain a brighter room environment during daylight hours and dim lights in the evening, and keep the door of the room closed. Sleep aid medications should only be offered as prescribed. Chapter 33

A nurse is documenting the care given to a 56-year-old patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation? a. Erase or use correcting fluid to completely delete the error. b. Draw a single line through the entry and rewrite it above or beside it. c. Use a permanent marker to block out the mistaken entry and rewrite it. d. Remove the page with the error and rewrite the data on that page correctly

b. The nurse should not use dittos, erasures, or correcting flu- ids. A single line should be drawn through an incorrect entry, and the words "mistaken entry" or "error in charting" should be printed above or beside the entry and signed. The entry should then be rewritten correctly. Chapter 16

A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the catheter to use? a. The age of the patient b. The size of the endotracheal tube c. The type of secretions to be suctioned d. The height and weight of the patient

b. The nurse would base the size of the suctioning catheter on the size of the endotracheal tube. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. Larger catheters can contribute to trauma and hypoxemia. Chapter 38

A nurse caring for a patient's hemodialysis access documents the following: "5/10/15 0930 Arteriovenous fistula patent in right upper arm. Area is warm to touch and edematous. Patient denies pain and tenderness. Positive bruit and thrill noted." Which documented finding would the nurse report to the primary care provider? a. Positive bruit noted. b. Area is warm to touch and edematous. c. Patient denies pain and tenderness. d. Positive thrill noted.

b. The nurse would report a site that is warm and edematous as this could be a sign of a site infection. The thrill and bruit are normal findings caused by arterial blood flowing into the vein. If these are not present, the access may be cutting off. No report of pain is a normal finding. Chapter 36

A 17-year-old has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient? a. Use the axillae to bear body weight. b. Keep elbows close to the sides of the body. c. When rising, extend the uninjured leg to prevent weight bearing. d. To climb stairs, place weight on affected leg first.

b. The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circula- tion, extend the injured leg to prevent weight bearing when rising from a chair, and advance the unaffected leg first when climbing stairs. Chapter 32

A nurse asks a 25-year-old patient to make a list of 20 words that describe him. After 15 minutes, the patient listed the following: 25 years old, male, named Joe; then declared he couldn't think of anything else. The nurse documents that the patient has demonstrated: a. Lack of self-esteem b. Deficient self-knowledge c. Unrealistic self-expectation d. Inability to evaluate himself

b. The patient's inability to list more than three items about himself indicates deficient self-knowledge. There are not enough data provided to determine whether he lacks selfesteem, has unrealistic self-expectations, or is unable to evaluate himself. Chapter 40

A patient complains of abdominal pain that is difficult to localize. The nurse documents this as which type of pain? a. Cutaneous b. Visceral c. Superficial d. Somatic

b. The patient's pain would be categorized as visceral pain, which is poorly localized and can originate in body organs in the abdomen. Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is an example of cutaneous pain. Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain. Chapter 34

A nurse is providing instruction to a patient regarding the procedure to change his colostomy bag. During the teach- ing session, he asks, "What type of foods should I avoid to prevent gas?" The patient's question allows for what type of communication? a. A closed-ended answer b. Information clarification c. The nurse to give advice d. Assertive behavior

b. The patient's question allows the nurse to clarify informa- tion that is new to the patient or that requires further explanation. Chapter 20

A nurse is using the Katz Index of Independence in Activi- ties of Daily Living to assess the mobility of an 80-year-old hospitalized female patient. During the patient interview the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index? a. 2 b. 4 c. 5 d. 6

b. The total score for this patient is 4. On the Katz Index of Independence in ADLs, one point is awarded for independ- ence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding. Chapter 32

A 70-year-old male is scheduled for surgery. He says to the nurse, "I am so frightened—what if I don't wake up?" What would be the nurse's best response? a. "You have a wonderful doctor." b. "Let's talk about how you are feeling." c. "Everyone wakes up from surgery!" d. "Don't worry, you will be just fine."

b. This answer allows the patient to talk about his feelings and fears, and is therapeutic. Chapter 29

A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when administering the patient's medications. What would be the priority action of the nurse following the exposure? a. Report the incident to the appropriate person and file an incident report. b. Wash the exposed area with warm water and soap. c. Consent to postexposure prophylaxis at appropriate time. d. Set up counseling sessions regarding safe practice to protect self.

b. When a needlestick injury occurs, the nurse should wash the exposed area immediately with warm water and soap, report the incident to the appropriate person and complete an incident injury report, consent to and await the results of blood tests, consent to postexposure prophylaxis, and attend counseling sessions regarding safe practice to protect self and others. Chapter 23

A nurse's neighbor tells the nurse, "I have a high temperature, feel awful, and I am not going to work." What stage of illness behavior is the neighbor exhibiting? a. Experiencing symptoms b. Assuming the sick role c. Assuming a dependent role d. Achieving recovery and rehabilitation

b. When people assume the sick role, they define themselves as ill, seek validation of this experience from others, and give up normal activities. In stage 1: experiencing symptoms, the first indication of an illness usually is recognizing one or more symptoms that are incompatible with one's personal definition of health. The stage of assuming a dependent role is characterized by the patient's decision to accept the diagnosis and follow the prescribed treatment plan. In the achieving recovery and rehabilitation role, the person gives up the dependent role and resumes normal activities and responsibilities. Chapter 3

A nurse is caring for a 25-year-old male patient who is coma- tose following a head injury. The patient has several piercings in his ears and nose. The piercing in his nose appears to be new and is crusted and slightly inflamed. Which action would be appropriate when caring for this patient's piercings? a. Do not remove or wash the piercings without permission from the patient. b. Rinse the sites with warm water and remove crusts with a cotton swab. c. Wash the sites with alcohol and apply an antibiotic ointment. d. Remove the jewelry and allow the sites to heal over.

b. When providing care for piercings, the nurse should perform hand hygiene and put on gloves, then cleanse the site of all crusts and debris by rinsing the site with warm water, removing the crusts with a cotton swab. The nurse should then apply a dab of liquid medicated cleanser to the area, turn the jewelry back and forth to work the cleanser around the opening, rinse well, remove gloves, and perform hand hygiene. The nurse should not use alcohol, peroxide, or ointments at the site or remove the piercings unless it is absolutely necessary (e.g., when an MRI is ordered.) Chapter 30

A physician orders a pain medication for a postoperative patient that is a PRN order. When would the nurse administer this medication? a. A single dose during the postoperative period b. Doses administered as needed for pain relief c. One dose administered immediately d. Doses routinely administered as a standing order

b. When the prescriber writes a PRN order ("as needed") for medication, the patient receives medication when it is requested or required. With a single or one-time order, the directive is carried out only once, at a time specified by the prescriber. A stat order is a single order carried out imme- diately. A standing order (or routine order) is carried out as specified until it is canceled by another order. Chapter 28

A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C. difficile infection. Which nursing action related to this activity promotes safe, effective patient care? a. The nurse puts on PPE after entering the patient room. b. The nurse works from "clean" areas to "dirty" areas during bath. c. The nurse personalizes the care by substituting glasses for goggles. d. The nurse removes PPE prior to leaving the patient room.

b. When using PPE, the nurse should work from "clean" areas to "dirty" ones, put on PPE before entering the patient room, always use goggles instead of personal glasses, and remove PPE in the doorway or anteroom. Chapter 23

An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? a. Tilt the patient's head forward. b. Hold the mask tightly over the patient's nose and mouth. c. Pull the patient's jaw backward. d. Compress the bag twice the normal respiratory rate for the patient.

b. With the patient's head tilted back, jaw pulled forward, and airway cleared, the mask is held tightly over the patient's nose and mouth. The bag also fits easily over tracheostomy and endotracheal tubes. The operator's other hand compresses the bag at a rate that approximates normal respiratory rate (e.g., 16-20 breaths/min in adults). Chapter 38

A patient who has a large abdominal wound suddenly calls out for help because she feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last. a. Notify the physician immediately of the situation. b. Cover the exposed tissue with sterile towels moistened with sterile NSS. c. Place the patient in the low Fowler's position.

c, b, a. Dehiscence and evisceration is a postoperative emer- gency that requires prompt surgical repair. The correct order of implementation by the nurse is to place the patient in the low Fowler's position, cover the exposed tissue with sterile towels moistened with sterile NSS, and notify the physician immediately of the situation. Chapter 31

A school nurse is teaching parents about home safety and fires. What information would be accurate to include in the teaching plan? Select all that apply. a. 60% of U.S. fire deaths occur in the home. b. Most fatal fires occur when people are cooking. c. Most people who die in fires die of smoke inhalation. d. Over 1/3 of fire deaths occur in a home without a smoke detector. e. Fires are more likely to occur in homes without electricity or gas. f. More fires occur in homes occupied by single parents.

c, d, e. Of all fire deaths in the United States, 85% occur in the home (CDC, 2011a). Most fatal home fires occur while people are sleeping, and most people who die in house fires die of smoke inhalation rather than burns. More than one-third of home fire deaths occur in a home without a smoke detector (CDC, 2011a). People with limited financial resources should be asked about how they heat their house because the electricity or gas may have been turned off and space or kerosene heaters, wood stoves, or a fireplace may be the sole source of heat. Being a single parent is not a risk factor for fire occurrences. Chapter 26

During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after she communicates the plan of care. What would be appropriate nurse responses in this situation? Select all that apply. a. Fill the silence with lighter conversation directed at the patient. b. Use the time to perform the care that is needed uninter- rupted. c. Discuss the silence with the patient to ascertain its mean- ing. d. Allow the patient time to think and explore inner thoughts. e. Determine if the patient's culture requires pauses between conversation. f. Arrange for a counselor to help the patient cope with emotional issues.

c, d, e. The nurse can use silence appropriately by taking the time to wait for the patient to initiate or to continue speak- ing. During periods of silence, the nurse should reflect on what has already been shared and observe the patient without having to concentrate simultaneously on the spoken word. In due time, the nurse might discuss the silence with the patient in order to understand its meaning. Also, the patient's culture may require longer pauses between verbal communication. Fear of silence sometimes leads to too much talking by the nurse, and excessive talking tends to place the focus on the nurse rather than on the patient. The nurse should not assume silence requires a consult with a counselor. Chapter 20

A nurse formulates the following diagnosis for an older female patient in a long-term care facility: Disturbed Sensory Perception: Chronic Sensory Deprivation related to the effects of aging. The patient walked out the door unobserved and was lost for several hours. Which interventions would be most effective for this patient? Select all that apply. a. Ignore when the patient is confused or go along to prevent embarrassment. b. Reduce the number and type of stimuli in the patient's room. c. Orient the patient to time, place, and person frequently. d. Provide daily contact with children, community people, and pets. e. Decrease background or loud noises in the environment. f. Provide a radio and television in the patient's room.

c, d, f. Even if well motivated, ignoring a patient's confusion to prevent embarrassment may be dangerous, as it was in this case in which the appropriate safety precautions were never implemented. Reducing the type of stimuli in the room and decreasing environmental noise is appropriate for a patient who is experiencing sensory overload. The other options are related to sensory deprivation and are appropriate for this patient. Chapter 43

A nurse is documenting patient data in the medical record of a patient admitted to the hospital with a diagnosis of appen- dicitis. The physician has ordered 10 mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follows recommended guidelines? Select all that apply. a. 6/12/15 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN b. 6/12/15 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN c. 6/12/15 0945 30 minutes following administration of mor- phine 10 mg IV patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN d. 6/12/15 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN e. 6/12/15 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick, RN f. 6/12/15 0945 Patient states she does not want pain medica- tion despite return of pain. After discussing situation, patient agrees to medication administration.

c, d, f. The nurse should enter information in a complete, accurate, concise, current, and factual manner and indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions. When charting, the nurse should avoid the use of stereotypes or derogatory terms as well as generalizations such as "seems comfortable today." The nurse should never document an intervention before carrying it out. Chapter 16

The nurse is administering a medication to a patient via a nasogastric tube. Which are accurate guidelines related to this procedure? Select all that apply. a. Crush the enteric-coated pill for mixing in a liquid. b. Flush open the tube with 60 mL of very warm water. c. Check for proper placement of the nasogastric tube. d. Give each medication separately and flush with water between each drug. e. Lower the head of the bed to prevent reflux. f. Adjust the amount of water used if patient's fluid intake is restricted.

c, d, f. The nurse should use the recommended procedure for checking tube placement prior to administering medications. The nurse should also give each medication separately and flush with water between each drug and adjust the amount of water used if fluids are restricted. Enteric-coated medications should not be crushed, the tube should be flushed with 15 to 30 mL of water, and the head of the bed should be elevated to prevent reflux. Chapter 28

A nurse is preparing a patient for a cesarean section and teaches her the effects of the regional anesthesia she will be receiving. Which effects would the nurse expect? Select all that apply. a. Loss of consciousness b. Relaxation of skeletal muscles c. Reduction or loss of reflex action d. Localized loss of sensation e. Prolonged pain relief after other anesthesia wears off f. Infiltrates the underlying tissues in an operative area

c, d. A localized loss of sensation and possible loss of reflexes occurs with a regional anesthetic. Loss of consciousness and relaxation of skeletal muscles occurs with general anesthesia. Prolonged pain relief after other anesthesia wears off and infiltration of the underlying tissues in an operative area occur with topical anesthesia. Chapter 29

A nurse caring for adults in a physician's office notes that some patients age more rapidly that other patients of the same age. The nurse researches aging theories that attempt to describe how and why aging occurs. Which statements apply to the immunity theory of aging? Select all that apply. a. Chemical reactions in the body produce damage to the DNA. b. Free radicals have adverse effects on adjacent molecules. c. Decrease in size and function of the thymus causes infections. d. There is much interest in the role of vitamin supplementation. e. Lifespan depends on a great extent to genetic factors. f. Organisms wear out from increased metabolic functioning.

c, d. The immunity theory of aging focuses on the func- tions of the immune system and states that the immune response declines steadily after younger adulthood as the thymus loses size and function, causing more infec- tions. There is much interest in vitamin supplements (such as vitamin E) to improve immune function. In the cross-linkage theory, cross-linkage is a chemical reac- tion that produces damage to the DNA and cell death. The free radical theory states that free radicals, formed during cellular metabolism, are molecules with separated high-energy electrons, which can have adverse effects on adjacent molecules. The genetic theory of aging holds that lifespan depends to a great extent on genetic fac- tors. According to the wear-and-tear theory, organisms wear out from increased metabolic functioning, and cells become exhausted from continual energy depletion from adapting to stressors (Eliopoulos, 2010). Chapter 19

A nurse is preparing a brochure to teach patients how to prevent urinary tract infections. Which teaching points would the nurse include? Select all that apply. a. Wear underwear with a synthetic crotch. b. Take baths rather than showers. c. Drink eight to ten 8-oz glasses of water per day. d. Drink a glass of water before and after intercourse and void afterwards. e. Limit caffeine-containing beverages. f. Drink 10 oz of cranberry or blueberry juice daily

c, e, f. It is recommended that a healthy adult drink eight to ten 8-oz glasses of fluid daily, limit caffeine because it is irritating to the bladder mucosa, and drink 10 oz of cranberry or blueberry juice daily to help prevent bacteriuria. It is also recommended to wear underwear with a cotton crotch, take showers rather than baths, and drink two glasses of water before and after sexual intercourse and void immediately after intercourse. Chapter 36

A nurse is assessing a 78-year-old male patient for kinesthetic and visceral disturbances. Which techniques would the nurse use for this assessment? Select all that apply. a. The nurse asks the patient if he is bored, and if so, why. b. The nurse asks the patient if anything interferes with the functioning of his senses. c. The nurse asks the patient if he noticed any changes in the way he perceives his body. d. The nurse asks the patient if he has found it difficult to communicate verbally. e. The nurse notes if the patient withdraws from being touched. f. The nurse notes if the patient seems unsure of his body parts and/or position.

c, e, f. To assess for kinesthetic and visceral disturbances, the nurse would assess for perceived body changes inside and out, and changes in body parts or position. Asking if the patient is bored assesses stimulation, asking if anything interferes with his senses assesses reception, and asking about difficulty communicating assesses for transmission- perception-reaction. Chapter 43

A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply. a. He is aware of his surroundings at this point. b. He is in delta sleep at this time. c. It would be most difficult to awaken him at this time. d. This is most likely an NREM stage. e. This stage constitutes around 20% to 25% of total sleep. f. The muscles are relaxed in this stage.

c, e. This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. Delta sleep is NREM stages III and IV sleep. In stage IV NREM sleep, the muscles are relaxed, whereas small muscle twitching may occur in REM sleep. Chapter 33

A nurse is ambulating a 48-year-old female patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to pro- tect the patient: a. Grasp the gait belt. b. Stay with the patient and call for help. c. Place feet wide apart with one foot in front. d. Gently slide patient down to the floor, protecting her head. e. Pull the weight of the patient backward against your body. f. Rock your pelvis out on the side of the patient.

c, f, a, e, d, b. If a patient being ambulated starts to fall, you should place your feet wide apart with one foot in front, rock your pelvis out on the side nearest the patient, grasp the gait belt, support the patient by pulling her weight backward against your body, gently slide her down your body toward the floor, protecting her head, and stay with the patient and call for help. Chapter 32

The nurse assesses the wound of a patient who cut himself on the upper thigh with a chain saw. The nurse then docu- ments the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply. a. Enhanced healing due to the presence of sugars and proteins b. Delayed healing due to dead tissue present in the wound c. Decreased effectiveness of antibiotics against the bacteria d. Impaired skin integrity due to overhydration of the cells of the wound e. Delayed healing due to cells dehydrating and dying f. Decreased effectiveness of the patient's normal immune process

c, f. Wound biofilms are the result of wound bacteria grow- ing in clumps, imbedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Beitz, 2012). Necrosis (dead tissue) in the wound delays healing. Macera- tion or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment. Chapter 31

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6 mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented? a. 1+ pitting edema b. 2+ pitting edema c. 3+ pitting edema d. 4+ pitting edema

c. 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. 1+ is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. 2+ is a 4-mm pit that lasts longer than 1+ with fairly normal contour. +4 is a deep pit (8 mm) that remains for a prolonged time after pressing with frank swelling. Chapter 39

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

c. A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis. The pH and bicarbonate would be elevated with metabolic alkalosis. Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis; increased PaCO2 in conjunction with an elevated pH indicates respiratory alkalosis. Chapter 39

A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient would the nurse report to the surgeon as possibly needing surgery to be postponed? a. A 19-year-old patient who is a vegan b. An elderly patient who takes daily nutritional drinks c. A 43-year-old patient who takes ginko bilboa and an aspirin daily d. An infant who is breast-feeding

c. A patient taking gingko biloba (an herbal), aspirin, and vitamin E (dietary supplement) may have to have surgery postponed due to an increased risk for excessive bleeding, because each of these substances have anticoagulant properties. Being a vegan should not affect surgery unless the patient has serious nutritional deficiencies. Drinking nutritional drinks and breastfeeding do not adversely affect the outcomes of surgery. Chapter 35

A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? a. The nurse carries the patients' soiled bed linens close to the body to prevent spreading microorganisms into the air. b. The nurse places soiled bed linens and hospital gowns on the floor when making the bed. c. The nurse moves the patient table away from the nurse's body when wiping it off after a meal. d. The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items.

c. According to the principles of medical asepsis, the nurse should move equipment away from the body when brush- ing, scrubbing, or dusting articles to prevent contaminated particles from settling on the hair, face, or uniform. The nurse should carry soiled items away from the body to prevent them from touching the clothing. The nurse should not put soiled items on the floor, as it is highly contaminated. The nurse should also clean the least soiled areas first and then move to the more soiled ones to prevent having the cleaner areas soiled by the dirtier areas. Chapter 23

A nurse is caring for a male patient with a severe hearing deficit who is able to read lips and use sign language. Which nursing intervention would be best to prevent sensory alterations for this patient? a. Turn the radio or television volume up very loud and close the door to his room. b. Prevent embarrassment and emotional discomfort as much as possible. c. Provide daily opportunity for him to participate in a social hour with six to eight people. d. Encourage daily participation in exercise and physical activity.

c. Although all the options listed are appropriate, providing daily opportunities for this patient to participate in a social hour builds on his strength of being able to lip-read and provides sufficient sensory stimulation to prevent sensory deprivation resulting from his hearing loss, thereby meeting his needs. Chapter 43

A nursing instructor teaching classes in gerontology to nurs- ing students discusses myths related to the aging of adults. Which statement is a myth about older adults? a. Most older adults live in their own homes. b. Healthy older adults enjoy sexual activity. c. Old age means mental deterioration. d. Older adults want to be attractive to others.

c. Although response time may be longer, intelligence does not normally decrease because of aging. Most older adults own their own homes, and although sexual activity may be less frequent, the ability to perform and enjoy sexual activity lasts well into the 90s in healthy older adults. Older adults want to be attractive to others. Chapter 19

A nurse formulated the following nursing diagnosis for an 8-month-old infant: Disturbed Sensory Perception: Sensory Deprivation related to inadequate parenting. Since that diagnosis was made, both parents have attended parenting classes. However, both parents work while the infant stays with her 86-year-old grandmother, who has reduced vision. The parents provide appropriate stimulation in the evening. At an evaluation conference at the age of 11 months, the infant lies on the floor sucking her thumb and rocking her body. Her facial expression is dull, and she vocalizes only in a low monotone ("uh-h-h"). Which statement accurately reflects evaluation about the child's sensory deprivation? a. The infant's parents lack motivation to provide necessary stimulation. b. The grandmother is unable to improve the infant's care. c. The infant's sensory deprivation is still severe. d. This is normal behavior for an 11-month-old infant.

c. Although the data show that the parents have been motivated to improve their parenting skills, it is clear from the data that the infant's sensory deprivation is still severe. The data suggest that the grandmother is not improving the infant's care, but there is nothing to suggest that she is unable to do so if shown how. Chapter 43

What is the leading cause of cognitive impairment in old age? a. Stroke b. Malnutrition c. Alzheimer disease d. Loss of cardiac reserve

c. Alzheimer disease is the most common degenerative neurologic illness and the most common cause of cognitive impairment. It is irreversible, progressing from deficits in memory and thinking skills to an inability to perform even the simplest of tasks. Chapter 19

A nurse caring for patients in a hospital setting uses anticipatory guidance to prepare them for painful procedures. Which instruction would the nurse provide in this type of stress management? a. The nurse teaches patients rhythmic breathing to perform prior to the procedure. b. The nurse tells patients to focus on a pleasant place, mentally place themselves in it, and breathe slowly in and out. c. The nurse teaches patients about the pain involved in the procedure and methods to cope with it. d. The nurse teaches patients to create and focus on a mental image during the procedure to become less responsive to the pain.

c. Anticipatory guidance focuses on psychologically preparing a person for an unfamiliar or painful event. When patients know what to expect, their anxiety is reduced, which occurs when teaching about the pain involved and related pain relief measures. Rhythmic breathing is a relaxation technique, focusing on a pleasant place and breathing slowly in and out is a meditation technique, and focusing on a mental image to reduce responses to stimuli is a guided imagery technique. Chapter 41

While discussing home safety with the nurse, a patient admits that she always smokes a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for this patient? a. Impaired Gas Exchange related to cigarette smoking b. Anxiety related to inability to stop smoking c. Risk for Suffocation related to unfamiliarity with fire prevention guidelines d. Deficient Knowledge related to lack of follow-through of recommendation to stop smoking

c. Because Mrs. Fuller is not aware that smoking in bed is extremely dangerous, she is at risk for suffocation from fire. The other three nursing diagnoses are correctly stated but are not a priority in this situation. Chapter 26

A nursing student is nervous and concerned about the work she is about to do at the clinical facility. To allay anxiety and be successful in her provision of care, it is most important for her to: a. Determine the established goals of the institution b. Be sure her verbal and nonverbal communication is congruent c. Engage in self-talk to plan her day and decrease her fear d. Speak with her fellow colleagues about how they feel

c. By engaging in self-talk, or intrapersonal communication, the nursing student can plan her day and enhance her clinical performance to decrease fear and anxiety. Chapter 20

A school nurse is teaching parents how to foster a healthy development of self in their children. Which statement made by one of the parents needs to be followed up with further teaching? a. "I love my child so much I 'hug him to death' every day." b. "I think children need challenges, don't you?" c. "My husband and I both grew up in very restrictive families. We want our children to be free to do whatever they want." d. "My husband and I have different ideas about discipline, but we're talking this out because we know it's important for Johnny that we be consistent."

c. Each option with the exception of c correctly addresses some aspect of fostering healthy development in children. Because children need effective structure and development, giving them total freedom to do as they please may actually hinder their development. Chapter 40

A nurse uses a whirlpool to relax a patient following intense physical therapy to restore movement in her legs. What is a potent pain-blocking neuromodulator, released through relaxation techniques? a. Prostaglandins b. Substance P c. Endorphins d. Serotonin

c. Endorphins are produced at neural synapses at various points along the CNS pathway. They are powerful painblocking chemicals that have prolonged analgesic effects and produce euphoria. It is thought that endorphins are released through pain relief measures, such as relaxation techniques. Prostaglandins, substance P, and serotonin (a hormone that can act to stimulate smooth muscles, inhibit gastric secretion, and produce vasoconstriction) are neurotransmitters or substances that either excite or inhibit target nerve cells. Chapter 34

A patient with COPD is unable to perform activities of daily living (ADLs) without becoming exhausted. Which nursing diagnosis best describes this alteration in oxygenation as the etiology? a. Decreased Cardiac Output related to difficulty breathing b. Impaired Gas Exchange related to use of bronchodilators c. Fatigue related to impaired oxygen transport system d. Ineffective Airway Clearance related to fatigue

c. Fatigue related to an impaired oxygen transport system is an example of a nursing diagnosis with alteration in oxygenation as the etiology or cause of other problems. Ineffective Airway Clearance, Decreased Cardiac Output and Impaired Gas Exchange are examples of nursing diagnoses indicating alterations in oxygenation as the problem. Chapter 38

A nurse is caring for a 73-year-old male patient who is hos- pitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? a. Dorsal recumbent position b. Lateral position c. Fowler's position d. Sims' position

c. Fowler's position promotes maximal breathing space in the thoracic cavity and is the position of choice when someone is having difficulty breathing. Lying flat on the back or side or Sims' position would not facilitate respiration and would be difficult for the patient to maintain. Chapter 32

A nurse has volunteered to give influenza immunizations at a local clinic. What level of care is the nurse demonstrating? a. Tertiary b. Secondary c. Primary d. Promotive

c. Giving influenza injections is an example of primary health promotion and illness prevention. Chapter 3

A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient's knees buckle and she tells the nurse she feels faint. What should the nurse do in this situation? a. Wait a few minutes and then continue the move to the chair. b. Call for assistance and continue the move with the help of another nurse. c. Lower the patient back to the side of the bed and pivot her back into bed. d. Have the patient sit down on the bed and dangle her feet before moving.

c. If a patient becomes faint and knees buckle when moving from bed to a chair, the nurse should not continue the move to the chair. The nurse should lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient's vital signs and for the presence of other symptoms. Another attempt should be made with the assistance of another staff member if vital signs are stable. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to a change in position, and avoid hypoten- sion related to a sudden change in position. Chapter 32

A nurse administers a dose of an oral medication for hyper- tension to a patient who immediately vomits after swallowing the pill. What would be the appropriate initial action of the nurse in this situation? a. Readminister the medication and notify the primary care provider. b. Readminister the pill in a liquid form if possible. c. Assess the vomit, looking for the pill. d. Notify the primary care provider.

c. If a patient vomits immediately after swallowing an oral pill, the nurse should assess the vomit for the pill or fragments of it. The nurse should then notify the primary care provider to see if another dosage should be administered. Chapter 28

A nurse is flushing a patient's implanted port after administering medications. The nurse observes that the port flushes, but does not have a blood return. What would be the nurse's next action based on these findings? a. Gently push down on the needle and flush it a second time. b. Stop flushing and remove the needle; notify the primary care provider. c. Ask the patient to perform a Valsalva maneuver; change the patient position. d. Close the clamp; wait 3 minutes, try flushing the port again.

c. If a port flushes but does not have a blood return, the nurse should ask the patient to perform a Valsalva maneuver, have the patient change position or place the affected arm over the head, or raise or lower the head of the bed. If these measures do not work, the nurse should remove the needle and reaccess the device with a new needle. Chapter 39

A nurse is finished with patient care. How would the nurse remove PPE when leaving the room? a. Remove gown, goggles, mask, gloves, and exit the room. b. Remove gloves, perform hand hygiene, then remove gown, mask, and goggles. c. Untie gown waiststrings, remove gloves, goggles, gown, mask; perform hand hygiene. d. Remove goggles, mask, gloves, gown, and perform hand hygiene

c. If an impervious gown has been tied in front of the body at the waist, the nurse should untie the waist strings before removing gloves. Gloves are always removed first because they are most likely to be contaminated, followed by the goggles, gown, and mask, and hands should be washed thoroughly after the equipment has been removed and before leaving the room. Chapter 23

A nurse is performing intermittent closed-catheter irrigation for a patient with an indwelling catheter. After attaching the syringe to the access port on the catheter, the nurse finds that the irrigant will not enter the catheter. What intervention would the nurse appropriately perform next? a. Apply pressure to the catheter to force the solution into the catheter. b. Disconnect and reconnect the drainage system quickly. c. Notify the primary care provider. d. Change the catheter.

c. If the irrigation solution will not enter the catheter, the nurse should not force the solution into the catheter; instead, the nurse should notify the primary care provider and prepare to change the catheter. Chapter 36

A nurse is administering a large-volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient complains of severe cramping. What would be the appropriate nursing intervention in this situation? a. Elevate the head of the bed 30 degrees and reposition the rectal tube. b. Place the patient in a supine position and modify the amount of solution. c. Lower the solution container and check the temperature and flow rate. d. Remove the rectal tube and notify the primary care provider.

c. If the patient complains of severe cramping with introduction of an enema solution, the nurse should lower the solution container and check the temperature and flow rate. If the solution is too cold or the flow rate too fast, severe cramping may occur. Chapter 37

A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appro- priate nursing action in this situation? a. Ask another nurse to hold the hand of the patient and continue setting up the field. b. Remove the instrument that was touched by the patient and continue setting up the sterile field. c. Discard the supplies and prepare a new sterile field with another person holding the patient's hand. d. No action is necessary since the patient has touched his or her own sterile field.

c. If the patient touches a sterile field, the nurse should dis- card the supplies and prepare a new sterile field. If the patient is confused, the nurse should have someone assist by holding the patient's hand and reinforcing what is happening. Chapter 23

A nurse is assisting a patient to empty and change an ostomy appliance. When the procedure is finished, the nurse notes that the stoma is protruding into the bag. What would be the nurse's first action in this situation? a. Reassure the patient that this is a normal finding with a new ostomy. b. Notify the primary care provider that the stoma is prolapsed. c. Have the patient rest for 30 minutes to see if the prolapse resolves. d. Remove the appliance and redo the procedure using a larger appliance.

c. If the stoma is protruding into the bag after changing the appliance on an ostomy, the nurse should have the patient rest for 30 minutes. If the stoma is not back to normal size within that time, notify the physician. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma. Chapter 37

A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the physician's order sheet. The nurse's best response is: a. "Thank you for taking care of this!" b. Get a second nurse to listen to the order, and after writing the order on the physician order sheet, have both nurses sign it. c. "I am sorry, but verbal orders can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly." d. Try calling another resident for the order or wait until the next shift.

c. In most agencies, the only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when the physician/nurse practitioner is present but finds it impossible, due to the emergency situation, to write the order. Chapter 16

The nurse assesses patients to determine their risk for health care-associated infections. Which hospitalized patient is most at risk for developing this type of infection? a. A 60-year-old patient who smokes two packs of cigarettes daily b. A 40-year-old patient who has a white blood cell count of 6,000/mm3 c. A 65-year-old patient who has an indwelling urinary catheter in place d. A 60-year-old patient who is a vegetarian and slightly underweight

c. Indwelling urinary catheters have been implicated in most health care-associated infections. Cigarette smoking, a normal white blood cell count, and a vegetarian diet have not been implicated as risk factors for HAIs. Chapter 23

A nurse is caring for an alert, ambulatory, older resident in a long-term care facility who voids frequently and has difficulty making it to the bathroom in time. Which nursing intervention would be most helpful for this patient? a. Teach the patient that incontinence is a normal occurrence with aging. b. Ask the patient's family to purchase incontinence pads for the patient. c. Teach the patient to perform Kegel exercises at regular intervals daily. d. Insert an indwelling catheter to prevent skin breakdown.

c. Kegel exercises may help a patient regain control of the micturition process. Incontinence is not a normal consequence of aging. Using absorbent products may remove motivation from the patient and caregiver to seek evaluation and treatment of the incontinence; they should be used only after careful evaluation by a health care provider. An indwelling catheter is the last choice of treatment. Chapter 36

A nurse is providing a lecture on CAT to a group of patients in a rehabilitation facility. Which teaching point should the nurse include? a. CAT is a safe intervention used to supplement traditional care. b. Many patients use CAT as outpatients, but do not wish to continue as inpatients. c. Many nurses are expanding their clinical practice by incorporating CAT to meet the demands of patients. d. Most complementary and alternative therapies are relatively new and their efficacy has not been established.

c. Many nurses are expanding their clinical practice by incor- porating CAT. Although CAT may seem totally safe, some therapies have led to harmful and at times lethal outcomes. Many patients use these types of therapies as outpatients and want to continue their use as inpatients. Although the use of most complementary and alternative therapies predates modern medicine, it was not until recently that nursing and medical schools began to teach about their use. Chapter 27

A nurse is guiding a patient in the practice of meditation. Which teaching point is most useful in helping the patient to achieve a state of calmness, physical relaxation, and psycho- logical balance? a. Teach the patient to always lie down in a comfortable posi- tion during meditation. b. Teach the patient to focus on multiple problems that the patient feels demand attention. c. Teach the patient to let distractions come and go naturally without judging them. d. Teach the patient to suppress distracting or wandering thoughts to maintain focus.

c. Meditators should have an open attitude by letting distrac- tions come and go naturally without judging them. They should also maintain a specific, comfortable posture lying down, sitting, standing, walking, etc.; focus attention on a mantra, object, or breathing; and not suppress distracting or wandering thoughts, instead they should gently bring attention back to focus. Chapter 27

A nurse is providing patient teaching regarding the use of negative-pressure wound therapy. Which explanation provides the most accurate information to the patient? a. The therapy is used to collect excess blood loss and prevent the formation of a scab. b. The therapy will prevent infection, ensuring that the wound heals with less scar tissue. c. The therapy provides a moist environment and stimulates blood flow to the wound. d. The therapy irrigates the wound to keep it free from debris and excess wound fluid.

c. Negative-pressure wound therapy (or topical negative pressure [TNP]) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment. The negative pressure results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or healing slowly. Chapter 31

Mr. James has an eye infection with a moderate amount of discharge. Which action would be most appropriate for the nurse to use when cleaning his eyes? a. Using hydrogen peroxide b. Wiping from the outer canthus to the inner canthus c. Positioning him on the same side as the eye to be cleansed d. Using only one cotton ball per eye

c. Positioning the patient on the same side as the involved eye discourages contamination of the other eye. Always cleanse from the inner canthus to the outer canthus to avoid forcing debris into the nasolacrimal duct. Water or normal saline should be used for cleansing the eye of any discharge, and one cotton ball should be used for each stroke. Chapter 30

An older patient with an unsteady gait requests a tub bath. Which action would be most appropriate? a. Add Alpha-Keri oil to the water to prevent dry skin. b. Allow the patient to lock the door to guarantee privacy. c. Assist the patient in and out of the tub to prevent falling. d. Keep the water temperature very warm because the patient chills easily.

c. Safe nursing practice requires that the nurse assist a patient with an unsteady gait in and out of the tub. Adding Alpha- Keri oil to the bath water is dangerous for this patient because it makes the tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortably warm at 43°C to 46°C. Older patients have an increased susceptibility to burns due to diminished sensitivity. Chapter 30

A medication order reads: "K-Dur, 20 mEq po b.i.d." When and how does the nurse correctly give this drug? a. Daily at bedtime by subcutaneous route b. Every other day by mouth c. Twice a day by the oral route d. Once a week by transdermal patch

c. The abbreviation "b.i.d." refers to twice-a-day administra- tion. po (by mouth) refers to administration by the oral route. Chapter 28

A nurse is assessing the developmental levels of patients in a pediatric office. Which individual would a nurse document as experiencing developmental stress? a. An infant who learns to turn over b. A school-aged child who learns how to add and subtract c. An adolescent who is a "loner" d. A young adult who has a variety of friends

c. The adolescent who is a loner is not meeting a major task (being a part of a peer group) for that level of growth and development. Chapter 41

A nurse is caring for a patient in the shock or alarm reaction phase of the GAS. Which response by the patient would be expected? a. Decreasing pulse b. Increasing sleepiness c. Increasing energy levels d. Decreasing respirations

c. The body perceives a threat and prepares to respond by increasing the activity of the autonomic nervous and endocrine systems. The initial or shock phase is characterized by increased energy levels, oxygen intake, cardiac output, blood pressure, and mental alertness. Chapter 41

A nurse is performing a psychological assessment of a 19-year-old male patient who has Down syndrome. The patient is mildly developmentally disabled with an intelligence quotient of 82. He told his nurse, "I'm a good helper. You see I can carry these trays because I'm so strong. But I'm not very smart, so I have just learned to help with the things I know how to do." The patient most likely has which of the following? a. Negative self-concept and low self-esteem b. Negative self-concept and high self-esteem c. Positive self-concept and fairly high self-esteem d. Positive self-concept and low self-esteem

c. The data point to the patient having a positive self-concept ("I'm a good helper") and fairly high self-esteem (realizes his strengths and limitations). The statement "But I'm not very smart" is accurate and is not an indication of a negative selfconcept. Chapter 40

A mother of a 10-year-old daughter tells the nurse: "I feel incompetent as a parent and don't know how to discipline my daughter." What should be the nurse's first intervention when counseling this patient? a. Recommend that she discipline her daughter more strictly and consistently b. Make a list of things her husband can do to give her more time and help her improve her parenting skills. c. Assist the mother to identify both what she believes is preventing her success and what she can do to improve. d. Explore with the mother what the daughter can do to improve her behavior and make the mother's role as a parent easier.

c. The first intervention priority with a mother who feels incompetent to parent a daughter is to assist the mother to identify what is preventing her from being an effective parent and then to explore solutions aimed at improving her parenting skills. The other interventions may prove helpful, but they do not directly address the mother's problem with her feelings of incompetence. a, c, f. The nurse should include the following teaching points for parents: (1) reinforce their child's positive qualities; (2) address negative qualities constructively; (3) ignore neutral behavior that is a matter of taste, preference, or personal style; (4) don't feel they have to "fix things" for their children; (5) describe the child's behavior in a nonjudgmental manner; and (6) let their child know what to expect, practice the necessary skills, be patient, and make it safe to fail. Chapter 40

A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indi- cates that the patient understands the explanation? a. "I can expect to have more discomfort in the area where the cold is applied." b. "I should expect more drainage from the incision after the ice has been in place." c. "I should see less swelling and redness with the cold treatment." d. "My incision may bleed more when the ice is first applied."

c. The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding. Chapter 31

A nurse asks a patient to close her eyes, state when she feels something, and describe the feeling. The nurse then brushes the patient's skin with a cotton ball, and touches the patient's skin with both sides of a safety pin. Which sense is the nurse assessing? a. Gustatory b. Olfactory c. Tactile d. Kinesthetic

c. The nurse is assessing for tactile (touch) disturbances by brushing the skin with a cotton ball and touching the skin with a safety pin. Gustatory disturbances involve taste, olfactory disturbances involve the sense of smell, and kinesthetic disturbances are related to body positioning. Chapter 43

A nurse is discussing with an older female patient the factors that affect sleep. What fact does the nurse teach her? a. Drinking a cup of regular tea at night induces sleep. b. Using alcohol moderately promotes a deep sleep. c. Aging decreases the amount of REM sleep a person experiences. d. Exercising decreases REM and NREM sleep.

c. The nurse would teach the patient that the amount of REM sleep decreases with age. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity increases both REM and NREM sleep. Chapter 33

A nurse discovers that she made a medication error. What should be the nurse's first response? a. Record the error on the medication sheet. b. Notify the physician regarding course of action. c. Check the patient's condition to note any possible effect of the error. d. Complete an incident report, explaining how the mistake was made.

c. The nurse's first responsibility is the patient—careful observation is necessary to assess for any effect of the medi- cation error. The other nursing actions are pertinent, but only after checking the patient's welfare. Chapter 28

A nurse is performing an assessment of a female patient who is 8 months pregnant. The woman states, "I worry all the time about being able to handle becoming a mother." Which nursing diagnosis would be most appropriate for this patient? a. Ineffective Coping related to the new parenting role b. Ineffective Denial related to ability to care for a newborn c. Anxiety related to change in role status d. Situational Low Self-Esteem related to fear of parenting

c. The nursing diagnosis of Anxiety indicates situational/ maturational crises or changes in role status. Ineffective coping refers to the inability to appraise stressors or use available resources. Ineffective denial is a conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety, and leads to detriment of health. Situational Low Self-Esteem diagnoses feelings of worthlessness related to the current situation the person is experiencing, not related to the fear of role changes. Chapter 41

A patient has a fecal impaction. The nurse correctly administers an oil-retention enema by: a. Administering a large volume of solution (500-1,000 mL) b. Mixing milk and molasses in equal parts for an enema c. Instructing the patient to retain the enema for at least 30 minutes d. Administering the enema while the patient is sitting on the toilet

c. The patient should be instructed to retain the enema solution for at least 30 minutes or as indicated in the manufacturer's instructions. The usual amount of solution administered with a retention enema is 150 to 200 mL for an adult. The milk and molasses mixture is a carminative enema that helps to expel flatus. The patient should be instructed to lie on the left side of the bed as dictated by patient condition and comfort. Chapter 37

Which clinic patient is most likely to have annual breast examinations and mammograms based on the physical human dimension? a. Jane, whose her best friend had a benign breast lump removed b. Sarah, who lives in a low-income neighborhood c. Tricia, who has a family history of breast cancer d. Nancy, whose family encourages regular physical examinations

c. The physical dimension includes genetic inheritance, age, developmental level, race, and gender. These components strongly influence the person's health status and health practices. A family history of breast cancer is a major risk factor. Chapter 3

A nurse is caring for a 26-year-old male patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side? a. Have the patient extend his arms outward and cross his legs on top of a pillow. b. Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side. c. Have the patient cross his arms on his chest and place a pillow between his knees. d. Place a cervical collar on the patient's neck and gently roll him to the other side of the bed.

c. The procedure for logrolling a patient is: (1) Have the patient cross the arms on the chest and place a pillow between the knees; (2) have two nurses stand on one side of the bed opposite the direction the patient will be turned with the third helper standing on the other side and if necessary, a fourth helper at the head of the bed to stabilize the neck; (3) fanfold or roll the drawsheet tightly against the patient and carefully slide the patient to the side of the bed toward the nurses; (4) have one helper move to the other side of the bed so that two nurses are on the side to which the patient is turning; (5) face the patient and have everyone move on a predetermined time, holding the draw- sheet taut to support the body, and turn the patient as a unit toward the two nurses. Chapter 32

A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? a. Instruct assistant to notify the primary care provider. b. Assess the patient's vital signs. c. Remove the tape, adjust the depth to ordered depth and reapply the tape. d. No action is required as depth will adjust automatically.

c. The tube depth should be maintained at the same level unless otherwise ordered by the physician. If the depth changes, the nurse should remove the tape, adjust the tube to ordered depth, and reapply the tape. Chapter 38

A 33-year-old businessperson is now in counseling attempting to deal with a long-repressed history of sexual abuse by her father. "I guess I should feel satisfied with what I've achieved in life, but I'm never content, and nothing I achieve makes me feel good about myself . . . I hate my father for making me feel like I'm no good. This is an awful way to live."

c. This patient's self-concept disturbance is mainly one of devaluing herself and thinking that she is no good. This is a self-esteem disturbance. Chapter 40

A perioperative nurse is preparing a patient for surgery for treatment of a ruptured spleen as the result of an automobile crash. The nurse knows that this type of surgery belongs in what category? a. Minor, diagnostic b. Minor, elective c. Major, emergency d. Major, palliative

c. This surgery would involve a major body organ, has the potential for postoperative complications, requires hospitali- zation, and must be done immediately to save the patient's life. Elective surgery is a procedure that is preplanned by essentially healthy people. Diagnostic surgery is performed to confirm a diagnosis. Palliative surgery is not curative, rather it is done to relieve or reduce the intensity of an illness. Chapter 29

A nurse is about to bathe a female patient who has an intravenous access in place in her forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What should the nurse do? a. Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeve. b. Cut the gown with scissors to allow arm movement. c. Thread the bag and tubing through the gown sleeve, keeping the line intact. d. Temporarily disconnect the tubing from the IV container, threading it through the gown.

c. Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an IV line, even temporar- ily, causes a break in a sterile system and introduces the potential for infection. Cutting a gown is not an alternative except in an emergency. Chapter 30

A nurse is performing digital removal of stool on a 74-year old female patient with a fecal impaction. During the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then she vomits. What should be the nurse's next action? a. Reassure the patient that this is a normal reaction to the procedure. b. Stop the procedure, prepare to administer CPR, and notify the physician. c. Stop the procedure, assess vital signs, and notify the physician. d. Stop the procedure, wait five minutes, and then resume the procedure.

c. When a patient complains of dizziness or lightheadedness and has nausea and vomiting during digital stool removal, the nurse should stop the procedure, assess heart rate and blood pressure, and notify the physician. The vagal nerve may have been stimulated. Chapter 37

A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. Which diagnosis would be most appropriate for this patient? a. Ineffective Coping: Multiple Stressors of New Job b. Sleep Deprivation: Difficulty Falling Asleep c. Disturbed Sleep Pattern: Altered Sleep-Wake Pattern d. Risk for Injury: Activity Intolerance/Sleep Deprivation

c. When assessment data point to a sleep problem that is amenable to nursing therapy, it receives the label Disturbed Sleep Pattern if the problem is time limited (such as changing shifts) or Sleep Deprivation if the problem is prolonged. The labels Ineffective Coping and Risk for Injury have not yet been determined. Chapter 33

A nurse is administering heparin subcutaneously to a patient. What is the correct technique for this procedure? a. Aspirate before giving and gently massage after the injection. b. Do not aspirate; massage the site for 1 minute. c. Do not aspirate before or massage after the injection. d. Massage the site of the injection; aspiration is not necessary but will do no harm.

c. When giving heparin subcutaneously, the nurse should not aspirate or massage, so as not to cause trauma or bleeding in the tissues. Chapter 28

A nurse is reconstituting powdered medication in a vial. Which action is a recommended step in this process? a. The nurse draws up the proper amount of powered medication into the syringe. b. The nurse inserts the needle through the rubber stopper of the diluent vial. c. The nurse gently agitates the powdered medication vial to mix the powder and diluent completely. d. The nurse draws up the prescribed amount of medication while holding the syringe horizontally at eye level.

c. When reconstituting powdered medication in a vial, the nurse should draw up the appropriate amount of diluent into the syringe, insert the needle through the center of the self- sealing stopper on the powdered medication vial, inject the diluent into the powdered medication vial, remove the needle from the vial and replace the cap, and gently agitate the vial to mix the powdered medication and diluent completely. The nurse should then draw up the prescribed amount of medica- tion while holding the syringe vertically and at eye level. Chapter 28

A patient, age 16, was in an automobile accident and received a wound across her nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate? a. Pain b. Impaired Skin Integrity c. Disturbed Body Image d. Disturbed Thought Processes

c. Wounds cause emotional as well as physical stress. Chapter 31

A nurse is documenting a blood pressure of 120/80 mm Hg. The nurse interprets the 120 to represent: a. The rhythmic distention of the arterial walls as a result of increased pressure due to surges of blood with ventricular contraction b. The lowest pressure present on arterial walls while the ventricles relax c. The highest pressure present on arterial walls while the ventricles contract d. The difference between the pressure on arterial walls with ventricular contraction and relaxation

c.Thesystolicpressureis120mmHg.Thediastolicpressureis 80 mm Hg, the lowest pressure present on arterial walls when the heart rests between beats. The difference between the systolic and diastolic pressures is called the pulse pressure. The rhythmic distention of the arterial walls as a result of increased pressure due to surges of blood with ventricular contraction is the pulse. Chapter 24

Prioritization: Place the following descriptions of the phases of Korotkoff sounds in order from Phase I to Phase V. a. Characterized by muffled or swishing sounds that may temporarily disappear; also known as the auscultatory gap b. Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery c. The last sound heard before a period of continuous silence, known as the second diastolic pressure d. Characterized by the first appearance of faint but clear tap ping sounds that gradually increase in intensity; known as the systolic pressure e. Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; considered to be the first diastolic pressure

d, a, b, e, c. Phase I is characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; the first tapping sound is the systolic pressure. Phase II is characterized by muffled or swishing sounds, which may temporarily disappear, especially in hypertensive people; the disappearance of the sound during the latter part of phase I and during phase II is called the auscultatory gap. Phase III is characterized by distinct, loud sounds as the blood flows rela- tively freely through an increasingly open artery. Phase IV is characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; in adults, the onset of this phase is considered to be the first diastolic pressure. Phase V is the last sound heard before a period of continuous silence; the pressure at which the last sound is heard is the second diastolic pressure. Chapter 24

A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a male patient who has been prescribed morphine via a patient- controlled analgesia pump (PCA) for pain related to pancre- atic cancer. Place the following nursing statements related to this call in the order in which they should be performed. a. "I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer." b. "Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump." c. "You want me to discontinue the PCA pump until you see him tonight at patient rounds." d. "I am Rosa Clark, an RN working on the second floor of South Street Hospital." e. "Mr. Sanchez was admitted two days ago following a diagnosis of pancreatic cancer." f. "I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered."

d, a, e, b, f, c. The order for ISBARR is: identity/introduction, situation, background, assessment, recommendation, and read-back. Chapter 16

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. a. "I will be careful not to shake up the canister before using it." b. "I will hold the canister upside-down when using it." c. "I will inhale the medication through my nose." d. "I will continue to inhale when the cold propellant is in my throat." e. "I will only inhale one spray with one breath." f. "I will activate the device while continuing to inhale."

d, e, f. Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, and inhaling two sprays with one breath. Chapter 38

A nurse prepares to assist a patient with her newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply. a. "When you inspect the stoma, it should be dark purple-blue." b. "The size of the stoma will stabilize within 2 weeks." c. "Keep the skin around the stoma site clean and moist." d. "The stool from an ileostomy is normally liquid." e. "You should eat dark green vegetables to control the odor of the stool." f. "You may have a tendency to develop food blockages."

d, e, f. Ileostomies normally have liquid, foul-smelling stool. The nurse should encourage the intake of dark green vegetables because they contain chlorophyll, which helps to deodorize the feces. Patients with ileostomies need to be aware they may experience a tendency to develop food blockages, especially when high-fiber foods are consumed. The stoma should be dark pink to red and moist. Stoma size usually stabilizes within 4 to 6 weeks, and the skin around the stoma site (peristomal area) should be kept clean and dry. Chapter 37

A nurse working the night shift at a hospital observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. a. REM sleep constitutes much of the sleep cycle of a preschool child. b. By the age of 8 years, most children no longer take naps. c. Sleep needs usually decrease when physical growth peaks. d. Many adolescents do not get enough sleep. e. Total sleep decreases in adults with a decrease in stage IV sleep. f. Sleep is less sound in older adults and stage IV sleep may be absent.

d, e, f. Many adolescents do not get enough sleep due to the stresses of school, activities, and part-time employment causing restless sleep. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks. Chapter 33

A nurse is helping an overweight female patient to devise a meal plan to lose 2 pounds per week. How many calories would the patient need to delete per day in order to accomplish this goal? a. 250 calories b. 500 calories c. 750 calories d. 1000 calories

d. 1 lb (0.45 kg) of body fat equals about 3,500 cal. Therefore, to gain or lose 1 lb (0.45 kg) in a week, daily calorie intake should be increased or decreased, respectively, by 500 cal (3,500 cal divided by 7 days = 500 cal/day). Similarly, a weight gain or loss of 2 lb (0.9 kg) per week would require an adjustment of 1,000 cal/day. Chapter 35

A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The physician ordered the following tests: (a) barium enema, (b) fecal occult blood test, (c) endoscopic studies, and (d) upper gastrointestinal series. Which is the correct order in which the tests would normally be performed? a. c, b, d, a b. d, c, a, b c. a, b, d, c d. b, a, d, c

d. A fecal occult blood test should be done first to detect gastrointestinal bleeding. Barium studies should be performed next to visualize gastrointestinal structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions. A barium enema and routine radiography should precede an upper gastrointestinal series because retained barium from an upper gastrointestinal series could take several days to pass through the gastrointestinal tract and cloud anatomic detail on the barium enema studies. Noninvasive procedures usually take precedence over invasive procedures, such as endoscopic studies, when sufficient diagnostic data can be obtained from them. Chapter 37

Which of the following nursing diagnoses would be most appropriate for a patient with a body mass index (BMI) of 18? a. Risk for Imbalanced Nutrition: More Than Body Requirements b. Imbalanced Nutrition: More Than Body Requirements c. Readiness for Enhanced Nutrition d. Imbalanced Nutrition: Less Than Body Requirements

d. A patient with a body mass index (BMI) of 18 is considered underweight, therefore a diagnosis of Imbalanced Nutrition: Less than Body Requirements is appropriate. The patient is not at risk for imbalanced nutrition because it is already a problem and certainly is not experiencing nutrition that is more than body requirements. Readiness for Enhanced Nutrition is appropriate when there is a healthy pattern of nutrient intake that is sufficient for meeting metabolic needs and can be strengthened and enhanced. Chapter 35

A nurse is changing the stoma appliance on a patient's ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia? a. The stoma is hard and dry. b. The stoma is a pale pink color. c. The stoma is swollen. d. The stoma is a purple-blue color.

d. A purple-blue stoma may reflect compromised circulation or ischemia. A pale stoma may indicate anemia. The stoma may be swollen at first, but that condition should subside with time. A normal stoma should be moist and dark pink to red in color. Chapter 36

While taking an adult patient's pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next? a. Check the pulse again in 2 hours. b. Check the blood pressure. c. Record the information. d. Report the rate to the primary care provider.

d. A rate of 140 beats/min in an adult is an abnormal pulse and should be reported to the primary care provider or the nurse in charge of the patient. Chapter 24

When completing a safety event report, the nurse should: a. Include suggestions on how to prevent the incident from recurring. b. Provide minimal information about the incident. c. Discuss the details with the patient before documenting them. d. Objectively describe the incident in detail.

d. A safety event report is a legal document, which must be as objective and complete as possible. It is not a collabora- tive effort with the patient, and any suggestions to prevent the occurrence from happening again should be discussed at a postincident conference. Chapter 26

A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response? a. "I'm sorry, but patients are not allowed to copy their medi- cal records." b. "I can make a copy of your record for you right now." c. "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules." d. "I will need to check with our records department to get you a copy."

d. According to HIPAA, patients have a right to see and copy their health record; update their health record; get a list of the disclosures a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations; request a restriction on certain uses or disclosures; and choose how to receive health information. The nurse should be aware of agency policies regarding the patient's right to access and copy records. Chapter 16

A nurse assesses an oral temperature for an adult patient. The patient's temperature is 37.5°C (99.5°F). What term would the nurse use to report this temperature? a. Febrile b. Hypothermia c. Hypertension d. Afebrile

d. Afebrile means without fever. This temperature is within the normal range for an adult. Fever (pyrexia) is an elevation of body temperature; a person with fever is said to be febrile. Hypothermia is a low body temperature and hyperthermia is a high body temperature. Chapter 24

An experienced nurse tells a younger nurse who is working in a retirement home that older adults are different and do not have the same desires, needs, and concerns as other age groups. The nurse also comments that most older adults have "outlived their usefulness." What is the term for this type of prejudice? a. Harassment b. Whistle blowing c. Racism d. Ageism

d. Ageism is a form of prejudice in which older adults are stereotyped by characteristics found in only a few members of their age group. Harassment occurs when a dominant per- son takes advantage of or overpowers a less dominant person (may involve sexual harassment or power struggles). Whistle blowing involves reporting illegal or unethical behavior in the workplace. Racism is prejudice against other races and ethnic groups. Chapter 19

A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastric tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placement of the tube? a. Auscultate the bowel sounds. b. Measure the gastric aspirate pH. c. Measure the amount of residual in the tube. d. Order radiographic examination of the tube.

d. Although a radiographic examination exposes the patient to radiation and is costly, it is still the most accurate method to check correct tube placement. Other methods that can be used are aspiration of gastric contents and measurement of the pH of the aspirate. The recommended method for checking placement, other than a radiograph, is measuring the pH of the aspirate. Visual assessment of aspirated gastric contents is also suggested as a tool to check placement. In addition, the length of the exposed tube is measured after insertion and documented. Tube length should be checked and compared with this initial measurement, in conjunction with the previous two methods for checking tube placement. The auscultatory method is considered inaccurate and unreliable. Measurement of residual amount does not confirm placement. Chapter 35

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? a. Using sterile dressing supplies b. Suggesting dietary supplements c. Applying antibiotic ointment d. Performing careful hand hygiene

d. Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important. Chapter 31

When discussing emergency preparedness with a group of first responders, what information would be important to include about preparation for a terrorist attack? a. Posttraumatic stress disorders can be expected in most survivors of a terrorist attack. b. The FDA has collaborated with drug companies to create stockpiles of emergency drugs. c. Even small doses of radiation result in bone marrow depression and cancer. d. Blast lung injury is a serious consequence following detonation of an explosive device.

d. Blast lung injury is a recognized consequence following exposure to an explosive device. The CDC is the federal agency that has collaborated with the pharmaceutical com- panies to stockpile drugs for an emergency. A high dose of radiation exposure can result in bone marrow depression and cancer. Most survivors of a terrorist event will experience stress and some (possibly one-third of survivors) may exhibit posttraumatic stress disorder. Chapter 26

When providing health promotion classes, a nurse uses concepts from models of health. What do both the health-illness continuum and the high-level wellness models demonstrate? a. Illness as a fixed point in time b. The importance of family c. Wellness as a passive state d. Health as a constantly changing state

d. Both these models view health as a dynamic (constantly changing state). Chapter 3

The nurse has opened the sterile supplies and put on two ster- ile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. The nurse must: a. Keep splashes on the sterile field to a minimum. b. Cover the nose and mouth with gloved hands if a sneeze is imminent. c. Use forceps soaked in a disinfectant. d. Consider the outer 1 inch of the sterile field as contaminated.

d. Considering the outer inch of a sterile field as contami- nated is a principle of surgical asepsis. Moisture such as from splashes contaminates the sterile field, and sneezing would contaminate the sterile gloves. Forceps soaked in disinfectant are not considered sterile. Chapter 23

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? a. Recording intake and output b. Testing skin turgor c. Reviewing the complete blood count d. Measuring weight daily

d. Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance. Chapter 39

A patient is in the late stages of AIDS, which is now affecting his brain as well other major organ systems. The patient confides to the nurse that he feels terribly alone because most of his friends are afraid to visit. The nurse determines that the least likely underlying etiology for his sensory problems would be: a. Stimulation b. Reception c. Transmission-perception-reaction d. Emotional responses

d. Emotional responses are an effect of sensory deprivation, and although they may be occurring with this patient, they are not the underlying etiology for his condition. This patient is receiving decreased environmental stimuli (a) (e.g., from his friends), is more than likely experiencing problems with reception because of major organ involvement (b), and his impaired brain function will impair impulse transmission- perception- reaction (c). Chapter 43

When describing safety issues and related mortality to a local senior citizens group, what would the nurse identify as the leading cause of hospital admissions for trauma in older adults? a. Fires b. Exposure to temperature extremes c. Intimate partner violence d. Falls

d. Falls among older adults are the most common cause of hospital admissions for trauma. Fires and temperature extremes are also significant hazard for older adults but are not the most common cause of trauma admissions. Intimate partner violence occurs more frequently in adults as opposed to older adults. Chapter 26

A nurse interviews a woman who was abused by her partner and is staying at a women's shelter with her three children. She tells the nurse, "I'm so worried that my husband will find me and try to make me go back home." Which data would the nurse most appropriately document? a. "Patient displays moderate anxiety related to her situation." b. "Patient manifests panic related to feelings of impending doom." c. "Patient describes severe anxiety related to her situation." d. "Patient expresses fear of her husband."

d. Fear is a response (feeling of dread) to a known threat. Anxiety, on the other hand, is a vague, uneasy feeling of discomfort or dread from an often unknown source. Panic causes a person to lose control and experience dread and terror, which can lead to exhaustion and death; that is not the case in this situation. Chapter 41

A nurse is teaching a patient with frequent constipation how to implement a bowel-training program. What is a recommended teaching point? a. Using a diet that is low in bulk b. Decreasing fluid intake to 1,000 mL c. Administering an enema once a day to stimulate peristalsis d. Allowing ample time for evacuation

d. For a bowel-training program to be effective, the patient must have ample time for evacuation (usually 20-30 minutes). Fluid intake is increased to 2,500 to 3,000 mL, food high in bulk is recommended as part of the program, and a daily enema is not administered in a bowel-training program. A cathartic suppository may be used 30 minutes before the patient's usual defecation time to stimulate peristalsis. Chapter 37

A nurse working in a busy emergency department is caring for a teenage patient who presents with a burning pain in his mouth, edema of the lips, vomiting, and hemoptysis. The teen admits that he was playing a dare game with friends and was forced to swallow a drain opener preparation. What would be the nurse's priority intervention? a. Induce vomiting and call the primary care provider. b. Perform stomach lavage and call the poison control center. c. Give activated charcoal orally and call the physician. d. Dilute the poison with milk and call the primary care provider.

d. For the ingestion of drain opener, the nurse should never induce vomiting; instead, the poison should be diluted with milk or water and the primary care provider should be called. For vitamin preparations, stomach lavage is used to remove undigested pills and for acetaminophen poisoning, activated charcoal may be used. Chapter 26

A nurse is caring for a postoperative patient who is expe- riencing pain. Which CAT involves active participation by the patient and is effective for pre- or postoperative pain control? a. Acupuncture b. Therapeutic touch c. Botanical supplements d. Guided imagery

d. Imagery involves using all five senses to imagine an event or body process unfolding according to a plan. A patient can be encouraged to "go to a favorite place." With the other modalities, the patient is more passive. Chapter 27

A sophomore in high school has missed a lot of school this year because of leukemia. He said he feels like he is falling behind in everything and misses "hanging out at the mall" with his friends most of all.

d. Important roles for this patient are being a student and a friend. His illness is preventing him from doing either of these well. This self-concept disturbance is basically one that concerns role performance. Chapter 40

While assessing a patient in the PACU, a nurse notes increased wound drainage, restlessness, a decreasing blood pressure, and an increase in the pulse rate. The nurse inter- prets these findings as most likely indicating: a. Thrombophlebitis b. Atelectasis c. Infection d. Hemorrhage

d. Increased wound drainage, restlessness, decreasing blood pressure, and increasing pulse rate are assessment findings that indicate hemorrhage. Manifestations of thrombophlebitis are pain and cramping in the calf or thigh of the involved extremity, redness and swelling in the affected area, elevated temperature, and an increase in the diameter of the involved extremity. Manifestations of atelectasis include decreased lung sounds over the affected area, dyspnea, cyanosis, crack- les, restlessness, and apprehension. Signs of infection include elevated white blood count and fever. Chapter 29

A nurse orients an older patient to the safety features in her hospital room. What is a priority component of this admission routine? a. Explain how to use the telephone. b. Introduce the patient to her roommate. c. Review the hospital policy on visiting hours. d. Explain how to operate the call bell.

d. Knowing how to use the call bell is a safety priority; knowing how to use the phone, meeting the roommate, and knowledge of visiting hours will not necessarily prevent an accidental injury. Chapter 26

A nurse is explaining the rationale for performing leg exer- cises after surgery. Which reason would the nurse include in the explanation? a. Promote respiratory function b. Maintain functional abilities c. Provide diversional activities d. Increase venous return

d. Leg exercises in the postoperative period increase venous return. As a result, the patient has a decreased risk for throm- bophlebitis and emboli. Chapter 29

A nurse asks the same patient in question 2 to list facts, traits, or qualities that he would like to be descriptive of himself. The patient quickly lists 25 traits, all of which are characteristic of a successful man. When asked if he knows anyone like this, he replies, "My father." This discrepancy between the patient's description of himself as he is and as he would like to be indicates: a. Negative self-concept b. Joe's modesty (lack of conceit) c. Body image disturbance d. Low self-esteem

d. Low self-esteem is characterized by great discrepancy between the ideal and real selves. There are no data given here that suggest that Joe has either a negative self-concept or a body image disturbance. The data do indicate something more serious than modesty. Chapter 40

A medication order reads: "Hydromorphone, 2 mg IV every 3 to 4 hours PRN pain." The prefilled cartridge is available with a label reading "Hydromorphone 2 mg/1 mL." The cartridge contains 1.2 mL of hydromorphone. Which nursing action is correct? a. Give all the medication in the cartridge because it expanded when it was mixed. b. Call the pharmacy and request the proper dose. c. Refuse to give the medication. d. Dispose of 0.2 mL correctly before administering the drug.

d. Many cartridges are overfilled, and some of the medica- tion needs to be discarded. Always check the volume needed to provide the correct dose with the volume in the syringe. Giving the excess medication in the cartridge may result in adverse effects for the patient. For this dose, it is not neces- sary to call the pharmacy or refuse to give the medication, provided the order is written correctly. Chapter 28

Which of the following nursing diagnoses would be appropri- ate for many middle adults? a. Risk for Imbalanced Nutrition: Less Than Body Requirements b. Delayed Growth and Development c. Self-Care Deficit d. Caregiver Role Strain

d. Many middle adults help care for aging parents and have concerns about their own health and ability to continue to care for an older family member. Caregivers often face 24-hour care responsibilities for extended periods of time, which creates physical and emotional problems for the caregiver. Chapter 19

A patient is postoperative following an emergency cesarean section birth. The patient asks the nurse about the use of pain medications following surgery. What would be a correct response by the nurse? a. "It's not a good idea to ask for pain medication regularly as it can be addictive." b. "It is better to wait until the pain gets unbearable before asking for pain medication." c. "It's natural to have to put up with pain after surgery and it will lessen in intensity in a few days." d. "Your doctor has ordered pain medications for you, which you should not be afraid to request any time you have pain."

d. Many pain medications are ordered on a PRN (as needed) basis. Therefore, nurses must be diligent to assess patients for pain and administer medications as needed. A patient should not be afraid to request these medications and should not wait until the pain is unbearable. Few people become addicted to the medications if used for a short period of time. Pain following surgery can be controlled and should not be considered a natural part of the experience that will lessen in time. Chapter 34

A nurse is responsible for preparing patients for surgery in an ambulatory care center. Which technique for reducing anxiety would be appropriate for these patients? a. Discouraging over-verbalization of fears and anxieties b. Focusing on the outcome as opposed to the details of the surgery c. Providing time alone for reflection on personal strengths and weaknesses d. Mutually determining expected outcomes of the plan of care

d. Nurses preparing patients for surgery should mutually determine expected outcomes of the care, as well as encourage verbalizations of feelings, perceptions, and fears. Explain all procedures including sensations likely to be experienced during the procedure, and stay with the patient to promote safety and reduce fear. Chapter 41

A nurse is explaining pain control methods to a patient undergoing a bowel resection. The patient is interested in the PCA pump and asks the nurse to explain how it works. What would be the nurse's correct response? a. "The pump allows the patient to be completely free of pain during the postoperative period." b. "The pump allows the patient to take unlimited amounts of medication as needed." c. "The pump allows the patient to choose the type of medication given postoperatively." d. "The pump allows the patient to self-administer limited doses of pain medication."

d. PCA infusion pumps allow patients to self-administer doses of pain-relieving medication within physician-prescribed time and dose limits. Patients activate the delivery of the medica- tion by pressing a button on a cord connected to the pump or a button directly on the pump. Chapter 29

A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication? a. Every three hours b. Every four hours c. Daily d. As needed

d. PRN means "as needed." Chapter 16

A nurse observes a marked inflammation of the gums, along with recession and bleeding of the gums, and documents this observation using which term? a. Glossitis b. Caries c. Cheilosis d. Periodontitis

d. Periodontitis is a marked inflammation of the gums, whereas caries refers to the presence of tooth decay. Cheilosis is ulceration of the lips, and glossitis is an inflammation of the tongue. Chapter 30

A visiting nurse is performing a family assessment of a young couple caring for their newborn who was diagnosed with cerebral palsy. The nurse notes that the mother's hair and clothing are unkempt, the house is untidy, and the mother states that she is "so busy with the baby that I don't have time to do anything else." What would be the priority intervention for this family? a. Arrange to have the infant removed from the home. b. Inform other members of the family of the situation. c. Increase the number of visits by the visiting nurse. d. Notify the care provider and recommend respite care for the mother.

d. Reactions of family members to home health care for long periods of time, called caregiver burden, include chronic fatigue, sleep disorders, and an increased incidence of stressrelated illnesses, such as hypertension and heart disease. The nurse should address the issue with the primary care provider and recommend a visit from a social worker and/or arrange for respite care for the family. Chapter 41

A female patient who is having a myocardial infarction complains of pain that is situated in her jaw. The nurse documents this as what type of pain? a. Transient pain b. Superficial pain c. Phantom pain d. Referred pain

d. Referred pain is perceived in an area distant from its point of origin, whereas transient pain is brief and passes quickly. Superficial pain originates in the skin or subcutaneous tissue. Phantom pain may occur in a person who has had a body part amputated, either surgically or traumatically. Chapter 34

A 76-year-old patient states, "I have been experiencing com- plications of diabetes." The nurse needs to direct the patient to gain more information. What is the most appropriate com- ment or question to elicit additional information? a. "Do you take two injections of insulin to decrease the complications?" b. "Most physicians recommend diet and exercise to regulate blood sugar." c. "Most complications of diabetes are related to neuropathy." d. "What specific complications have you experienced?"

d. Requesting specific information regarding complications of diabetes will elicit specific information to guide the nurse in further interview questions and specific assessment techniques. Chapter 20

A nurse working the night shift in a pediatric unit observes a 10-year-old male patient walking the hallway in a sleep state. The child is unaware of his environment and doesn't recall the incident in the morning. Which sleep disorder would the nurse expect? a. Bruxism b. Cataplexy c. Restless leg syndrome d. Somnambulism 9. A nurse is performing

d. Somnambulism (sleepwalking) may range from sitting up in bed to walking around the room or the house to walking outside the house. The sleepwalker is unaware of the environment. Bruxism is grinding of one's teeth and frequently is an indicator of stress. Cataplexy is a sudden loss of motor tone that may cause the person to fall asleep; it is usually experienced during a period of strong emotion. People with restless leg syndrome (RLS) cannot lie still and report unpleasant creeping, crawling, or tingling sensations in the legs. Chapter 33

The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which cat- egory of patients? a. Only patients with diagnosed infections b. Only patients with visible blood, body fluids, or sweat c. Only patients with nonintact skin d. All patients receiving care in hospitals

d. Standard precautions apply to all patients receiving care in hospitals, regardless of their diagnosis or possible infection status. These recommendations include blood; all body fluids, secretions, and excretions except sweat; nonintact skin; and mucous membranes. Chapter 23

What consideration should the nurse keep in mind regarding the use of side rails for a confused patient? a. They prevent confused patients from wandering. b. A history of a previous fall from a bed with raised side rails is insignificant. c. Alternative measures are ineffective to prevent wandering. d. A person of small stature is at increased risk for injury from entrapment.

d. Studies of restraint-related deaths have shown that people of small stature are more likely to slip through or between the side rails. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails. Creative use of alternative measures indicates respect for the patient's dignity and may in fact prevent more serious fall-related injuries. A history of falls from a bed with raised side rails carries a significant risk for a future serious incident. Chapter 26

During rounds, a charge nurse hears the patient care techni- cian yelling loudly to a patient regarding a transfer from the bed to chair. When entering the room, what is the nurse's best response? a. "You need to speak to the patient quietly. You are disturbing the patient." b. "Let me help you with your transfer technique." c. "When you are finished, be sure to apologize for your rough demeanor." d. "When your patient is safe and comfortable, meet me at the desk."

d. The charge nurse should direct the patient care techni- cian to determine the patient's safety. Then the nurse should address any concerns regarding the patient care technician's communication techniques privately. The nurse should direct the patient care technician on aspects of therapeutic commu- nication. Chapter 20

An unresponsive patient is wearing gas-permeable contact lenses. How would the nurse remove these lenses? a. Gently irrigate the eye with an irrigating solution from the inner canthus outward. b. Grasp the lens with a gentle pinching motion. c. Don sterile gloves before attempting the removal procedure. d. Ensure that the lens is centered on the cornea before gently manipulating the lids to release it.

d. The lens must be situated on the cornea, not the sclera, before removal. To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean, not sterile, gloves are used. Chapter 30

A nurse enters a patient's room and examines the patient's IV fluids and cardiac monitor. The patient states, "Well, I haven't seen you before. Who are you?" What is the nurse's best response? a. "I'm just the IV therapist checking your IV." b. "I've been transferred to this division and will be caring for you." c. "I'm sorry, my name is John Smith and I am your nurse." d. "My name is John Smith, I am your nurse and I'll be caring for you until 11 p.m."

d. The nurse should identify himself, be sure the patient knows what will be happening, and the time period he will be with his patient. Chapter 20

A nurse is caring for an obese 62-year-old patient with arthri- tis who has developed an open reddened area over his sacrum. What is a priority nursing diagnosis for this patient? a. Imbalanced Nutrition: More Than Body Requirements related to immobility b. Impaired Physical Mobility related to pain and discomfort c. Chronic Pain related to immobility d. Risk for Infection related to altered skin integrity

d. The priority diagnosis in this situation is the possibility of an infection developing in the open skin area. The others may be potential or probable diagnoses for this patient and may also require nursing interventions after the first diagnosis is addressed. Chapter 23

A 49-year-old who injured his spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilita- tion center. The nurse caring for him correctly tells the aide not to place him in which position? a. Side-lying b. Fowler's c. Sims' d. Prone

d. The prone position is contraindicated in patients who have spinal problems because the pull of gravity on the trunk when the patient lies prone produces a marked lordosis, or forward curvature of the lumbar spine. Chapter 32

A 36-year-old female who was divorced 5 years earlier enters the emergency department with severe burns and cuts on her face after an auto accident in a car driven by her fiancé of 3 months. Three weeks later, her fiancé has not yet contacted her. The patient states that he is very busy and she is too tired to have visitors anyway. The patient frequently lies with her eyes closed and head turned away. These data suggest that: a. There is no disturbance in self-concept. b. This patient has ego strength and high self-esteem but may have a disturbance of body image. c. The area of self-esteem has very low priority at this time and should be ignored until much later. d. It is probable that there are disturbances in self-esteem and body image.

d. The traumatic nature of this patient's injuries, her fiancé's failure to contact her, and her withdrawal response all point to potential problems with both body image and self-esteem. It is not true that self-esteem needs are of low priority. Chapter 40

A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admis- sion interview, the nurse should implement which commu- nication techniques to elicit the most information from the parents? a. The use of reflective questions b. The use of closed questions c. The use of assertive questions d. The use of clarifying questions

d. The use of the clarifying question or comment allows the nurse to gain an understanding of a patient's comment. When used properly, this technique can avert possible misconcep- tions that could lead to an inappropriate nursing diagnosis. The reflective question technique involves repeating what the person has said or describing the person's feelings. Open- ended questions encourage free verbalization and expression of what the parents believe to be true. Assertive behavior is the ability to stand up for oneself and others using open, hon- est, and direct communication. Chapter 20

A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which statement is the most therapeutic? a. The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill." b. The nurse places a hand on the patient's arm and states, "You feel so alone." c. The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." d. The nurse holds the patient's hand and asks, "What makes you feel so alone?"

d. The use of touch conveys acceptance, and the implemen- tation of an open-ended question allows the patient time to verbalize freely. Chapter 20

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? a. Reposition the extremity and raise the height of the IV pole. b. Apply pressure to the dressing on the IV. c. Pull the catheter out slightly and reinsert it. d. Put on gloves; remove the catheter; apply pressure with a sterile pad.

d. This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also apply pressure with a sterile gauze pad, secure the gauze with tape over the insertion site, and restart the IV in a new location. Chapter 39

An older resident who is disoriented likes to wander the halls of his long-term care facility. Which action would be most appropriate for the nurse to use as an alternative to restraints? a. Sitting him in a geriatric chair near the nurses' station b. Using the sheets to secure him snugly in his bed c. Keeping the bed in the high position d. Identifying his door with his picture and a balloon

d. This allows the resident to be on the move and be more likely to find his room when he wants to return. The alterna- tive would be to not allow him to wander. Many facilities use this kind of approach. Identifying his door with his picture and a balloon may work as an alternative to restraints. Using the geriatric chair and sheets are forms of physical restraint. Leaving the bed in the high position is a safety risk and would probably result in a fall. Chapter 26

A patient in an intensive care burn unit for 1 week is in pain much of the time and has his face and both arms heavily bandaged. His wife visits every evening for 15 minutes at 6, 7, and 8 pm. A heart monitor beeps for a patient on one side, and another patient moans frequently. Assessment would suggest that that the patient probably is experiencing: a. Sufficient sensory stimulation b. Deficient sensory stimulation c. Excessive sensory stimulation d. Both sensory deprivation and overload

d. This patient's bandages may result in deficient sensory stimulation (sensory deprivation), and the monitors and other sounds in the intensive care burn unit may cause a sensory overload. All other options are incomplete responses. Chapter 43

A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task? a. Place the bottle cap on the table with the edges down. b. Hold the bottle inside the edge of the sterile field. c. Hold the bottle with the label side opposite the palm of the hand. d. Pour the solution from a height of 4 to 6 inches (10 to 15 cm).

d. To add a sterile solution to a sterile field, the nurse would open the solution container according to directions and place the cap on the table away from the field with the edges up. The nurse would then hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 inches (10 to 15 cm). Chapter 23

A nurse is developing a plan of care related to preventionof pressure ulcers for residents in a long-term care facility. Which action would be a priority in preventing a patient from developing a pressure ulcer? a. Keeping the head of the bed elevated as often as possible b. Massaging over bony prominences c. Repositioning bed-bound patients every 4 hours d. Using a mild cleansing agent when cleansing the skin

d. To prevent pressure ulcers, the nurse should cleanse the skin routinely and whenever any soiling occurs by using a mild cleansing agent with minimal friction, and avoiding hot water. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Bony prominences should not be massaged, and bed-bound patients should be repositioned every 2 hours. Chapter 31

A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient's diet should not be advanced? a. The patient consumed 75% of the liquids on her breakfast tray. b. The patient tells you she is hungry. c. The patient's abdomen is soft, nondistended, with bowel sounds. d. The patient reports fullness and diarrhea after breakfast.

d. Tolerance of diet can be assessed by the following: absence of nausea, vomiting, and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50% to 75% of the food on the meal tray. Chapter 35

A pregnant woman is receiving an epidural analgesic prior to delivery. The nurse provides vigilant monitoring of this patient to prevent the occurrence of: a. Pruritus b. Urinary retention c. Vomiting d. Respiratory depression

d. Too much of an opioid drug given by way of an epidural catheter or a displaced catheter may result in the occurrence of respiratory depression. Pruritus, urinary retention, and vomiting may occur but are not life threatening. Chapter 34

A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? a. Notify the physician. b. Apply an occlusive dressing on the site. c. Assess the patient for signs of respiratory distress. d. Put on gloves and insert the chest tube in a bottle of sterile saline.

d. When a chest tube becomes separated from the drainage device, the nurse should first put on gloves, open a sterile bottle of normal saline or water, and insert the chest tube into the bottle without contaminating the chest tube. This creates a water seal until a new drainage unit can be attached. Then the nurse should assess vital signs and notify the physician. Chapter 38

An older female patient has a severe visual deficit related to glaucoma. Which nursing action would be appropriate when providing care for this patient? a. Assist the patient to ambulate by walking slightly behind the person and grasping the patient's arm. b. Concentrate on the sense of sight and limit diversions that involve other senses. c. Stay outside of the patient's field of vision when performing personal hygiene for the patient. d. Indicate to the patient when the conversation has ended and when the nurse is leaving the room.

d. When caring for a patient who has a visual deficit, the nurse should indicate when the conversation is over and when he or she is leaving the room, assist with ambulation by walking slightly ahead of the person and allowing her to grasp the nurse's arm, provide diversions using other senses, and stay in the person's field of vision if she has partial or reduced peripheral vision. Chapter 43

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? a. The patient vomits during suctioning. b. The secretions appear to be stomach contents. c. The catheter touches an unsterile surface. d. Epistaxis is noted with continued suctioning.

d. When epistaxis is noted with continued suctioning, the nurse should notify the physician and anticipate the need for a nasal trumpet. The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning Chapter 38

A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient? a. Feed the patient solids first and then liquids last. b. Place the head of the bed at a 30-degree angle during feeding. c. Puree all foods to a liquid consistency. d. Provide a thirty-minute rest period prior to mealtime.

d. When feeding a patient who has dysphagia, the nurse should provide a 30-minute rest period prior to mealtime to promote swallowing; alternate solids and liquids when feeding the patient; sit the patient upright or, if on bedrest, elevate the head of the bed at a 90-degree angle; and initiate a nutrition consult for diet modification and food size and/or consistency. Chapter 35

A nurse is looking for trends in a postoperative patient's vital signs. Which documents would the nurse consult first? a. Admission sheet b. Admission nursing assessment c. Activity flow sheet d. Graphic record

d. While one recording of vital signs should appear on the admission nursing assessment, the best place to find sequen- tial recordings that show a pattern or trend is the graphic record. The admission sheet does not include vital sign docu- mentation, and neither does the activity flow sheet. Chapter 16

A nurse is teaching a man scheduled to have same-day surgery. Which teaching method would be most effective in preoperative teaching for ambulatory surgery? a. Lecture b. Discussion c. Audiovisuals d. Written instructions

d. Written instructions are most effective in providing infor- mation for same-day surgery. Chapter 29