FUNDAMENTALS OF NURSING PRACTICE QUESTIONS

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all that apply. A. Warm the enema solution prior to installation. B. Position the client on the left side with the right leg flexed forward. C. Lubricate the rectal tube or nozzle. D. Slowly insert the rectal tube about 2 inches. E. Hang the enema container 24 inches above the clients anus.

A, B, and C Enemas are rectal injections of fluid intended to cleanse or stimulate the emptying of the bowel. Enemas can be administered by a medical professional or self-administered at home. Enemas may also be prescribed to flush out the colon before certain diagnostic tests or surgeries. The bowel needs to be empty before these procedures to reduce infection risk and prevent stool from getting in the way. Option A: The nurse should warm the enema solution because cold fluid can cause abdominal cramping and hot fluid can injure the intestinal mucosa. Cleansing enemas are water-based and meant to be held in the rectum for a short time to flush the colon. Once injected, they're retained for a few minutes until the body rids itself of the fluid, along with loose matter and impacted stool in the bowel. Option B: Option B allows a downward flow of solution by gravity along the natural anatomical curve of the sigmoid colon. Some advocates claim that enemas can support weight loss, remove toxins and heavy metals from the body, and improve the skin, immunity, blood pressure, and energy levels. Option C: Lubrication prevents trauma or irritation to the rectal mucosa. The least irritating of all options, water or saline — salt water that mimics the body's sodium concentration — are used primarily for their ability to expand the colon and mechanically promote defecation. Option D: This is an appropriate length of insertion for a child. For an adult client, the nurse should insert a tube 3 to 4 inches. Research shows that enemas used in preparation for medical procedures significantly disrupt gut bacteria, though the effect appears to be temporary. However, enemas that are split and administered in two doses seem to have fewer effects on the microbiome. Option E: The height of the fluid container affects the speed of installation. The maximum recommended height is 18 inches. Hanging the container higher than that could cause rapid installation and possibly painful distention of the colon.

Which nursing diagnosis is/are most applicable to a client with fecal incontinence? Select all that apply. A. Bowel incontinence B. Risk for deficient fluid volume C. Disturbed body image D. Social isolation E. Risk for impaired skin integrity

A, C, D, and E Option A: This is the most appropriate. The client is unable to decide when stool evacuation will occur. Patients with fecal incontinence have an unintentional loss of liquid or solid stool. In true anal incontinence, there is loss of control of the anal sphincter which leads to the untimely release of feces. Option B: Risk for deficient fluid volume is more appropriate for a client with diarrhea. Avoid perianal skin soiling with regular cleaning, zinc oxide application, incontinence pads. Avoid food which can provoke diarrhea (high lactose/ fructose diet). Option C: The client's thoughts about self may be altered if unable to control stool evacuation. To maintain fecal continence, there is a complex interplay of several organ systems and nerves. As the fecal mass presents to the rectum, this causes distension. The sensation of rectal distension is transmitted by the parasympathetic nerves (S2-S4), which induces relaxation of the rectoanal inhibitory reflex and contraction of the rectoanal contractile reflex. The rectal lining has a rich supply of nerve endings that can sample if the mass is liquid or solid. It is believed that abnormal sampling and lowered anorectal sensation most likely contribute to fecal incontinence in many individuals. Option D: The prognosis for most patients with fecal incontinence is guarded. Short term outcomes after sphincteroplasty vary from 30-60%. Satisfactory results are seen in less than 50% of patients in the long term. The quality of life is poor and mental anguish is common. Option E: Increased tissue contact with fecal material may result in impairment. Fecal incontinence is a complex issue that is not easy to manage. The vast number of methods used to manage the condition is an indication that no method works reliably. Patients with fecal incontinence have enormous mental anguish, depression, and anxiety.

A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1 ml. How many milliliters should the nurse administer? A. 0.5 ml B. 0.75 ml C. 1 ml D. 2 ml

A. 0.5 ml There are 3 primary methods for calculation of medication dosages; Dimensional Analysis, Ratio Proportion, and Formula or Desired Over Have Method. Desired Over Have or Formula Method uses a formula or equation to solve for an unknown quantity (x) much like ratio proportion. Option B: Drug calculations require the use of conversion factors, for example, when converting from pounds to kilograms or liters to milliliters. Simplistic in design, this method allows clinicians to work with various units of measurement, converting factors to find the answer. These methods are useful in checking the accuracy of the other methods of calculation, thus acting as a double or triple check. Option C: The Ratio and Proportion Method has been around for years and is one of the oldest methods utilized in drug calculations (as cited in Boyer, 2002)[Lindow, 2004]. Addition principals is a problem-solving technique that has no bearing on this relationship, only multiplication, and division are used to navigate through a ratio and proportion problem, not adding. Option D: High-risk medications such as heparin and insulin often require a second check on dosage amounts by more than one provider before the administration of the drug. Follow institutional policies and recommendations on the double-checking of dose calculations by another licensed provider.

1800 ml is equal to how many liters? A. 1.8 B. 18000 C. 180 D. 2800

A. 1.8 Move three decimal points backward. Option B: 18000 liters is equal to 18,000,000 ml. Option C: 180 liters is equal to 180,000 ml. Option D: 2800 liters is equal to 280,000 ml.

The physician's order reads "Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal saline solution in 60 minutes." What is the flow rate if the drop factor is 10 gtt = 1 ml? A. 25 gtt/minute B. 37 gtt/minute C. 50 gtt/minute D. 60 gtt/minute

A. 25 gtt/minute When you have an order for an IV infusion, it is the nurse's responsibility to make sure the fluid will infuse at the prescribed rate. IV fluids may be infused by gravity using a manual roller clamp or dial-a-flow, or infused using an infusion pump. Regardless of the method, it is important to know how to calculate the correct IV flow rate. Option B: When calculating the flow rate, determine which IV tubing you will be using, microdrip or macrodrip, so you can use the proper drop factor in your calculations. The drop factor is the number of drops in one mL of solution, and is printed on the IV tubing package. Option C: Macrodrip and microdrip refers to the diameter of the needle where the drop enters the drip chamber. Macrodrip tubing delivers 10 to 20 gtts/mL and is used to infuse large volumes or to infuse fluids quickly. Microdrip tubing delivers 60 gtts/mL and is used for small or very precise amounts of fluid, as with neonates or pediatric patients. Option D: If you simply need to figure out the mL per hour to infuse, take the total volume in mL, divided by the total time in hours, to equal the mL per hour.

The nurse inspects a client's pupil size and determines that it's 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as: A. Anisocoria B. Ataxia C. Cataract D. Diplopia

A. Anisocoria Unequal pupils are called anisocoria. Anisocoria, or unequal pupil sizes, is a common condition. The varied causes have implications ranging from life-threatening to completely benign, and a clinically guided history and examination is the first step in establishing a diagnosis. Option B: Ataxia is uncoordinated actions of involuntary muscle use. Ataxia is a degenerative disease of the nervous system. Many symptoms of Ataxia mimic those of being drunk, such as slurred speech, stumbling, falling, and incoordination. These symptoms are caused by damage to the cerebellum, the part of the brain that is responsible for coordinating movement. Option C: A cataract is an opacity of the eye's lens. A cataract is a clouding of the normally clear lens of the eye. For people who have cataracts, seeing through cloudy lenses is a bit like looking through a frosty or fogged-up window. Clouded vision caused by cataracts can make it more difficult to read, drive a car (especially at night) or see the expression on a friend's face. Option D: Diplopia is double vision. Diplopia is the perception of 2 images of a single object. Diplopia may be monocular or binocular. Monocular diplopia is present when only one eye is open. Binocular diplopia disappears when either eye is closed.

Critical thinking and the nursing process have which of the following in common? Both: A. Are important to use in nursing practice. B. Use an ordered series of steps. C. Are patient-specific processes. D. Were developed specifically for nursing.

A. Are important to use in nursing practice. Nurses make many decisions: some require using the nursing process, whereas others are not client related but require critical thinking. Neither is linear. Critical thinking applies to any discipline. n 1958, Ida Jean Orlando started the nursing process that still guides nursing care today. Defined as a systematic approach to care using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing intuition. Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care. Option B: The nursing process has specific steps; critical thinking does not. The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. Option C: The utilization of the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition. Option D: Critical thinking skills will play a vital role as we develop plans of care for these patient populations with multiple comorbidities and embrace this challenging healthcare arena. Thus, the trend towards concept-based curriculum changes will assist us in the navigation of these uncharted waters.

A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to: A. Assess the client's airway. B. Provide pain relief. C. Encourage deep breathing and coughing. D. Splint the chest wall with a pillow.

A. Assess the client's airway. The first priority is to evaluate airway patency before assessing for signs of obstruction, sternal retraction, stridor, or wheezing. Airway management is always the nurse's first priority. Blunt trauma, on the whole, is a more common cause of traumatic injuries and can be equally life-threatening. It is important to know the mechanism as management may be different. Most blunt trauma is managed non-operatively, whereas penetrating chest trauma often requires operative intervention. Pain management and splinting are important for the client's comfort but would come after airway assessment. Option B: Pain control greatly affects mortality and morbidity in patients with chest trauma. Pain leads to splints which worsen or prevent healing. In many cases, it can lead to pneumonia. Early analgesia should be considered to decrease splinting. In the acute setting, push doses of short-acting narcotics should be used. Option C: Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries. Minor injuries may simply require close monitoring and pain control. Care should be taken in the young and the elderly. Patients with 3 or more rib fractures, a flail segment, and any number of rib fractures with pulmonary contusions, hemopneumothorax, hypoxia, or pre-existing pulmonary disease should be monitored at an advanced level of care. Option D: Immediate life-threatening injuries require prompt intervention, such as emergent tube thoracostomy for large pneumothoraces, and initial management of hemothorax. For cases of hemothorax, adequate drainage is imperative to prevent retained hemothorax. Retained hemothorax can lead to empyema requiring video-assisted thoracoscopic surgery.

A walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the client's vital sign hereafter. What phrase of the nursing process is being implemented here by the nurse? A. Assessment B. Diagnosis C. Planning D. Implementation

A. Assessment Assessment is the first phase of the nursing process where a nurse collects information about the client. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.

Which action by the nurse in charge is essential when cleaning the area around a Jackson-Pratt wound drain? A. Cleaning from the center outward in a circular motion. B. Removing the drain before cleaning the skin. C. Cleaning briskly around the site with alcohol. D. Wearing sterile gloves and a mask.

A. Cleaning from the center outward in a circular motion. The nurse always should clean around a wound drain, moving from center outward in ever-larger circles, because the skin near the drain site is more contaminated than the site itself. A Jackson-Pratt (JP) drain is used to remove fluids that build up in an area of the body after surgery. The JP drain is a bulb-shaped device connected to a tube. One end of the tube is placed inside the client during surgery. The other end comes out through a small cut in the skin. The bulb is connected to this end. The client may have a stitch to hold the tube in place.

Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following? A. Constipation B. Diarrhea C. Incontinence D. Hemorrhoids

A. Constipation Habitually ignoring the urge to defecate can lead to constipation through loss of the natural urge and the accumulation of feces. Functional constipation is a prevalent condition in childhood, about 29.6% worldwide. In the United States, it represents 3% to 5% of pediatric visits and a considerable annual health care cost. Most children do not have an etiological factor, and one third continue to have problems beyond adolescence. Option B: Diarrhea will not result-if anything, there is increased opportunity for water reabsorption because the stool remains in the colon, leading to firmer stool. Diarrhea is described as three or more loose or watery stools a day. Infection commonly causes acute diarrhea. Noninfectious etiologies are more common as the duration of diarrhea becomes chronic. Treatment and management are based on the duration and specific etiology. Option C: Ignoring the urge shows a strong voluntary sphincter, not a weak one that could result in incontinence. Fecal incontinence (FI) is the involuntary passage of fecal matter through anus or inability to control the discharge of bowel contents. Its severity can range from an involuntary passage of flatus to complete evacuation of fecal matter. Depending on the severity of the disease, it has a significant impact on a patient's quality of life Option D: Hemorrhoids would only occur only if severe drying out of the stool occurs, and thus repeated need to strain to pass stool. Hemorrhoids are rich in vascular supply and have a tendency to engorge and prolapse. Symptoms can vary from mild itching, bleeding to severe pain. Unfortunately, because of the location, many patients never seek treatment for fear of embarrassment.

Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient's medication drawer. What should the nurse in charge do? A. Discard the syringe to avoid a medication error. B. Obtain a label for the syringe from the pharmacy. C. Use the syringe because it looks like it contains the same medication the nurse was prepared to give. D. Call the day nurse to verify the contents of the syringe.

A. Discard the syringe to avoid a medication error. As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error. Option B: Since there are no labels on the syringe, obtaining a label from the pharmacy does not guarantee that they would be able to identify the medication inside the syringe. Option C: Giving an unidentified medication could cause unwanted effects on the patient instead of desired effects. Option D: The day nurse would not be able to guarantee that she could identify the medication without its label.

Which nursing action is essential when providing continuous enteral feeding? A. Elevating the head of the bed. B. Positioning the patient on the left side. C. Warming the formula before administering it. D. Hanging a full day's worth of formula at one time.

A. Elevating the head of the bed. Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow in the patient's intestines. Lying prone/supine during feeding increases the risk of aspiration and therefore where clinically possible the client should be placed in an upright position. If unable to sit up for a bolus feed or if receiving continuous feeding, the head of the bed should be elevated 30-45 degrees during feeding and for at least 30 minutes after the feed to reduce the risk of aspiration.

Which of the following planes divides the body longitudinally into anterior and posterior regions? A. Frontal plane B. Sagittal plane C. Midsagittal plane D. Transverse plane

A. Frontal plane Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. The coronal plane or frontal plane (vertical) divides the body into dorsal and ventral (back and front, or posterior and anterior) portions. An anatomical plane is a hypothetical plane used to transect the body, in order to describe the location of structures or the direction of movements. Option B: A sagittal plane runs longitudinally dividing the body into right and left regions. The sagittal plane or lateral plane (longitudinal, anteroposterior) is a plane parallel to the sagittal suture. It divides the body into left and right. Option C: If exactly midline, it is called a midsagittal plane. The midsagittal or median plane is in the midline; i.e. it would pass through midline structures such as the navel or spine, and all other sagittal planes (also referred to as parasagittal planes) are parallel to it. Median can also refer to the midsagittal plane of other structures, such as a digit. Option D: A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions. The transverse plane or axial plane (horizontal) divides the body into cranial and caudal (head and tail) portions.

A nurse determines that a fracture bedpan should be used for the patient who: A. Has a spinal cord injury B. Is on bedrest C. Has dementia D. Is obese

A. Has a spinal cord injury A fracture bedpan has a low back that promotes function of the patient's lower back while on the bedpan. The fracture pan has one flat end for ease of use with specific patient populations: i.e. hip fractures, hip replacements, or lower extremity fractures. Using the toilet may be a source of discomfort and embarrassment among all genders. Semi-private rooms or shared wards and hospital overcrowding are a challenge regarding patient privacy. Option B: Bedpans come in regular size or a smaller, fracture pan. Bedpans are chosen based on diagnosis, patient comfort or preference and if any contraindications exist for using the regular size such as a fracture. The regular bedpan is larger than its fracture counterpart. Bariatric bedpans are available up to a 1200-pound (544-kg) capacity. Option C: A patient that can assist with care by raising their hips is approached differently than a patient that cannot lift their hips due to surgical considerations, fractures, or other contraindications. In both cases, ensure the patient is pulled up as high as they can be on the stretcher or bed. If they can assist with raising their hips, then raise the head of the bed at least thirty degrees. Option D: Positioning in this Semi-Fowler's position allows for anatomical support and facilitates ease of defecation or urination by assuming a natural position for these bodily functions. According to a 2003 study, body positioning has a significant influence on intestinal gas propulsion and transit times with gastric flow being faster in the upright position than when supine [Dainese, Serra, Azpiroz & Malagelada, 2003].

Nursing interventions that can help the patient to relax and sleep restfully include all of the following except: A. Have the patient take a 30- to 60-minute nap in the afternoon. B. Turn on the television in the patient's room. C. Provide quiet music and interesting reading material. D. Massage the patient's back with long strokes.

A. Have the patient take a 30- to 60-minute nap in the afternoon. Napping in the afternoon is not conducive to nighttime sleeping. There are few considerations about naps. For example, a short daytime nap of 15-30 minutes can be restorative for elders and will not interfere with nighttime sleep. On the other hand, insomniacs are cautioned to avoid naps. Quiet music, watching television, reading, and massage usually will relax the patient, helping him to fall asleep. Option B: For patients in the hospital, factors that can prevent sound sleep include staff noise during a shift, telephones and call lights, doors, paging systems, and even carts wheeled through corridors. Safety and comfort can be promoted by raising side rails, placing the bed in a low position, and using night-lights. Option C: For individuals who are unable to sleep, they must get out of bed and spend some time in another room. There, they can start some relaxing activities like reading and listening to soft music. They should continue the activity till they feel drowsy. Option D: Rituals can be supported in institutionalized patients by assisting them with a hand and face wash, massage, pillow plumping, and even talking about today's accomplishments and enjoyable events. These can promote relaxation and peace of mind.

The nurse in charge is caring for an Italian client. He's complaining of pain, but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that: A. He may have a low threshold for pain. B. He was faking pain. C. Someone else gave him medication. D. The pain went away.

A. He may have a low threshold for pain. People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client, and he may need medication when he wakes up. Italian females reported the highest sensitivity to both mechanical and electrical stimulation, while Swedes reported the lowest sensitivity. Mechanical pain thresholds differed more across cultures than did electrical pain thresholds. Cultural factors may influence response to type of pain test.

How are critical thinking skills and critical thinking attitudes similar? Both are: A. Influences on the nurse's problem solving and decision making. B. Like feelings rather than cognitive activities. C. Cognitive activities rather than feelings. D. Applicable in all aspects of a person's life.

A. Influences on the nurse's problem solving and decision making. Cognitive skills are used in complex thinking processes, such as problem-solving and decision making. Critical thinking attitudes determine how a person uses her cognitive skills. Critical thinking attitudes are traits of the mind, such as independent thinking, intellectual curiosity, intellectual humility, and fair-mindedness, to name a few. Critical thinking skills refer to the cognitive activities used in complex thinking processes. A few examples of these skills involve recognizing the need for more information, recognizing gaps in one's own knowledge, and separating relevant information from irrelevant data. Critical thinking, which consists of intellectual skills and attitudes, can be used in all aspects of life.

What does the nurse in charge do when making a surgical bed? A. Leaves the bed in the high position when finished. B. Place the pillow at the head of the bed. C. Rolls the patient to the far side of the bed. D. Tucks the top sheet and blanket under the bottom of the bed.

A. Leaves the bed in the high position when finished. When making a surgical bed, the nurse leaves the bed in a high position when finished. After placing the top linens on the bed without pouching them, the nurse fan folds these linens to the side opposite from where the patient will enter and places the pillow on the bedside chair. All these actions promote transfer of the postoperative patient from the stretcher to the bed. Option B: When making an occupied bed or unoccupied bed, the nurse places the pillow at the head of the bed and tucks the top sheet and blanket under the bottom of the bed. Option C: When making an occupied bed, the nurse rolls the patient to the far side of the bed. Bed Making is a key nursing skill that is essential for the promotion of patient comfort, hygiene, and wellbeing. Bed Making requires technical and practical skills and consideration should be given to issues of safety, moving and handling and infection control practices. Option D: The blanket is placed at the center of the bed with its top 20cms approximately from the top of the mattress. The top sheet is folded back over the blanket. The blanket is folded under the foot of the mattress. Make a square corner & tuck in along sides.

The chamber of the heart that receives oxygenated blood from the lungs is the: A. Left atrium B. Right atrium C. Left ventricle D. Right ventricle

A. Left atrium The left atrium receives oxygenated blood from the lungs and pumps it to the left ventricle. In the lungs, the blood oxygenates as it passes through the capillaries where it is close enough to the oxygen in the alveoli of the lungs. This oxygenated blood is collected by the four pulmonary veins, two from each lung. All four of these veins open into the left atrium that acts as a collection chamber for oxygenated blood. Just like the right atrium, the left atrium passes the blood onto its ventricle both by passive flow and active pumping. Option B: The right atrium receives blood from the veins and pumps it to the right ventricle. The right atrium receives deoxygenated blood from the entire body except for the lungs (the systemic circulation) via the superior and inferior vena cavae. Also, deoxygenated blood from the heart muscle itself drains into the right atrium via the coronary sinus. The right atrium, therefore, acts as a reservoir to collect deoxygenated blood. Option C: The left ventricle (the strongest chamber) pumps oxygen-rich blood to the rest of the body, its vigorous contractions create the blood pressure. Oxygenated blood thus fills the left ventricle, passing through the mitral valve. The left ventricle, which is the main pumping chamber of the left heart, then pumps, sending freshly oxygenated blood to the systemic circulation through the aortic valve Option D: The right ventricle receives blood from the right atrium and pumps it to the lungs, where it is loaded with oxygen. The right ventricle pumps blood through the right ventricular outflow tract, across the pulmonic valve, and into the pulmonary artery that distributes it to the lungs for oxygenation.

It is a transparent membrane that focuses the light that enters the eyes to the retina. A. Lens B. Sclera C. Cornea D. Pupils

A. Lens The lens is located in the eye. By changing its shape, the lens changes the focal distance of the eye. In other words, it focuses the light rays that pass through it (and onto the retina) in order to create clear images of objects that are positioned at various distances. It also works together with the cornea to refract, or bend, light. The lens consists of the lens capsule, the lens epithelium, and the lens fibers. The lens capsule is the smooth, transparent outermost layer of the lens, while the lens fibers are long, thin, transparent cells that form the bulk of the lens. The lens epithelium lies between these two and is responsible for the stable functioning of the lens. It also creates lens fibers for the lifelong growth of the lens. Option B: The sclera is the white part of the eye that surrounds the cornea. In fact, the sclera forms more than 80 percent of the surface area of the eyeball, extending from the cornea all the way to the optic nerve, which exits the back of the eye. Only a small portion of the anterior sclera is visible. Option C: The cornea is the eye's clear, protective outer layer. Along with the sclera (the white of your eye), it serves as a barrier against dirt, germs, and other things that can cause damage. The cornea can also filter out some of the sun's ultraviolet light. It also plays a key role in vision. As light enters the eye, it gets refracted, or bent, by the cornea's curved edge. This helps determine how well the eye can focus on objects close-up and far away. Option D: Pupils are the black center of the eye. Their function is to let in light and focus it on the retina (the nerve cells at the back of the eye) so one can see. Muscles located in the iris (the colored part of your eye) control each pupil.

Which of the following is included in Orem's theory? A. Maintenance of a sufficient intake of air. B. Self perception. C. Love and belongingness. D. Physiologic needs.

A. Maintenance of a sufficient intake of air. Dorothea Orem's Self-Care Theory defined Nursing as "The act of assisting others in the provision and management of self-care to maintain or improve human functioning at home level of effectiveness." The Self-Care or Self-Care Deficit Theory of Nursing is composed of three interrelated theories: (1) the theory of self-care, (2) the self-care deficit theory, and (3) the theory of nursing systems, which is further classified into wholly compensatory, partial compensatory and supportive-educative. Choices B, C, and D are from Abraham Maslow's Hierarchy of Needs. Option B: At the fourth level in Maslow's hierarchy is the need for appreciation and respect. When the needs at the bottom three levels have been satisfied, the esteem needs begin to play a more prominent role in motivating behavior. At this point, it becomes increasingly important to gain the respect and appreciation of others. People have a need to accomplish things and then have their efforts recognized. In addition to the need for feelings of accomplishment and prestige, esteem needs include such things as self-esteem and personal worth. Option C: The social needs in Maslow's hierarchy include such things as love, acceptance, and belonging. At this level, the need for emotional relationships drives human behavior. In order to avoid problems such as loneliness, depression, and anxiety, it is important for people to feel loved and accepted by other people. Personal relationships with friends, family, and lovers play an important role, as does involvement in other groups that might include religious groups, sports teams, book clubs, and other group activities. Option D: The basic physiological needs are probably fairly apparent—these include the things that are vital to our survival. In addition to the basic requirements of nutrition, air and temperature regulation, the physiological needs also include such things as shelter and clothing. Maslow also included sexual reproduction in this level of the hierarchy of needs since it is essential to the survival and propagation of the species.

To institute appropriate isolation precautions, the nurse must first know the: A. Organism's mode of transmission B. Organism's Gram-staining characteristics C. Organism's susceptibility to antibiotics D. Patient's susceptibility to the organism

A. Organism's mode of transmission Before instituting isolation precaution, the nurse must first determine the organism's mode of transmission. For example, an organism transmitted through nasal secretions requires that the patient be kept in respiratory isolation, which involves keeping the patient in a private room with the door closed and wearing a mask, a gown, and gloves when coming in direct contact with the patient. Option B: The organism's Gram-staining characteristics reveal whether the organism is gram-negative or gram-positive, an important criterion in the physician's choice for drug therapy and the nurse's development of an effective plan of care. Option C: The nurse also needs to know whether the organism is susceptible to antibiotics, but this could take several days to determine; if she waits for the results before instituting isolation precautions, the organism could be transmitted in the meantime. Option D: The patient's susceptibility to the organism has already been established. The nurse would not be instituting isolation precautions for a non-infected patient.

An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Passive prevention

A. Primary prevention Primary prevention precedes disease and applies to healthy patients. Primary prevention includes those preventive measures that come before the onset of illness or injury and before the disease process begins. Examples include immunization and taking regular exercise to prevent health problems from developing in the future. Option B: Secondary prevention focuses on patients who have health problems and are at risk for developing complications. Secondary prevention includes those preventive measures that lead to early diagnosis and prompt treatment of a disease, illness, or injury. This should limit disability, impairment or dependency and prevent more severe health problems from developing in the future. Option C: Tertiary prevention enables patients to gain health from others' activities without doing anything themselves. Tertiary prevention includes those preventive measures aimed at rehabilitation following a significant illness. At this level, health educators work to retrain, re-educate and rehabilitate the individual who has already had an impairment or disability. Option D: Prevention, as it relates to health, is really about avoiding disease before it starts. It has been defined as the plans for, and the measures taken, to prevent the onset of a disease or other health problem before the occurrence of the undesirable health event.

A female patient with a terminal illness is in denial. Indicators of denial include: A. Shock dismay B. Numbness C. Stoicism D. Preparatory grief

A. Shock dismay Shock and dismay are early signs of denial-the first stage of grief. Denial is a common defense mechanism used to protect oneself from the hardship of considering an upsetting reality. Kubler-Ross noted that after the initial shock of receiving a terminal diagnosis, patients would often reject the reality of the new information. The other options are associated with depression—a later stage of grief. Option B: Depression is perhaps the most immediately understandable of Kubler-Ross's stages and patients experience it with unsurprising symptoms such as sadness, fatigue, and anhedonia. Option C: Spending time in the first three stages is potentially an unconscious effort to protect oneself from this emotional pain, and, while the patient's actions may potentially be easier to understand, they may be more jarring in juxtaposition to behaviors arising from the first three stages. Option D: Consequently, caregivers may need to make a conscious effort to restore compassion that may have waned while caring for patients progressing through the first three stages.

The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip replacement 2 weeks ago. Which position should the nurse avoid when examining this patient's rectal area? A. Sims' B. Supine C. Dorsal recumbent D. Semi-Fowler's

A. Sims' Sims' position is typically used to examine the rectal area. However, the position should be avoided if the patient has undergone hip replacement surgery The patient with a hip replacement can assume the supine, dorsal recumbent, or semi-Fowler's positions without causing harm to the joint. Option B: Supine position is lying on the back facing upward. The supine position means lying horizontally with the face and torso facing up, as opposed to the prone position, which is face down. When used in surgical procedures, it allows access to the peritoneal, thoracic, and pericardial regions; as well as the head, neck, and extremities. Option C: The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the bed. A position in which the patient lies on the back with the lower extremities moderately flexed and rotated outward. It is employed in the application of obstetrical forceps, repair of lesions following parturition, vaginal examination, and bimanual palpation. Option D: In semi-Fowler's position, the patient is supine with the head of the bed elevated and legs slightly elevated. The Semi-Fowler's position is a position in which a patient, typically in a hospital or nursing home is positioned on their back with the head and trunk raised to between 15 and 45 degrees, although 30 degrees is the most frequently used bed angle.

The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment? A. Sitting upright. B. Lying flat on the back with knees flexed. C. Lying flat on the back with arms and legs fully extended. D. Side-lying with the knees flexed.

A. Sitting upright. If the patient is able, the nurse should have the patient sit upright to obtain vital signs in order to allow the nurse to easily access the anterior and posterior chest for auscultation of heart and breath sounds. It allows for full lung expansion and is the preferred position for measuring blood pressure. Additionally, patients might be more comfortable and feel less vulnerable when sitting upright (rather than lying down on the back) and can have direct eye contact with the examiner. However, other positions can be suitable when the patient's physical condition restricts the comfort or ability of the patient to sit upright. Option B: Lying flat on the back with knees flexed or supine horizontal recumbent is most commonly used during breast exam. Option C: Lying flat on the back with arms and legs fully extended can make the patient feel uncomfortable. Option D: Sim's position is usually used to obtain rectal temperature.

When positioned properly, the tip of a central venous catheter should lie in the: A. Superior vena cava B. Basilica vein C. Jugular vein D. Subclavian vein

A. Superior vena cava When the central venous catheter is positioned correctly, its tip lies in the superior vena cava, inferior vena cava, or the right atrium—that is, in central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica, jugular, and subclavian veins are common insertion sites for central venous catheters.

The abbreviation for microdrop is... A. µgtt B. gtt C. mdr D. mgts

A. µgtt The abbreviation for microdrop is µgtt. When abbreviations are used in documents given to the patient, the potential for misunderstanding can increase. Information needs to be clear and unambiguous to improve patients' comprehension.

What are the five nursing process?

ADPIE: ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

A nurse is caring for a client who has diarrhea for the past four days. When assessing a client, the nurse should expect which of the following findings? Select all that apply. A. Bradycardia B. Hypotension C. Fever D. Poor skin turgor E. Peripheral edema

B, C, and D Diarrhea is described as three or more loose or watery stools a day. Infection commonly causes acute diarrhea. Noninfectious etiologies are more common as the duration of diarrhea becomes chronic. Treatment and management are based on the duration and specific etiology. Rehydration therapy is an important aspect of the management of any patient with diarrhea. Prevention of infectious diarrhea includes proper handwashing to prevent the spread of infection. Option A: Prolonged diarrhea is more likely to cause tachycardia than bradycardia. Diarrhea is the result of reduced water absorption by the bowel or increased water secretion. A majority of acute diarrheal cases are due to infectious etiology. Chronic diarrhea is commonly categorized into three groups; watery, fatty (malabsorption), or infectious. Option B: Prolonged diarrhea leads to dehydration, which causes a decrease in blood pressure. In bacterial and viral diarrhea, the watery stool is the result of injury to the gut epithelium. Epithelial cells line the intestinal tract and facilitate the absorption of water, electrolytes, and other solutes. Infectious etiologies cause damage to the epithelial cells which leads to increased intestinal permeability. The damaged epithelial cells are unable to absorb water from the intestinal lumen leading to loose stool. Option C: Prolonged diarrhea leads to dehydration, which causes fever. History should include the duration of symptoms, accompanying symptoms, travel history, and exposures to medications and food. It is important to ask about the stool frequency, type, volume, and presence of blood or mucus. Patients with diarrhea may also complain of abdominal pain or cramping, vomit, bloating, flatulence, fever, and bloody or mucoid stools.Option D: Prolonged diarrhea is more likely to cause a fluid deficit. An important aspect of diarrhea management is replenishing fluid and electrolyte loss. Patients should be encouraged to drink diluted fruit juice, Pedialyte or Gatorade. In more severe cases of diarrhea, IV fluid rehydration may become necessary.Option E: Peripheral edema results from a fluid overload. Important aspects of the physical exam include the patient's vital signs, volume status, and abdom

Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? A. "I need to drink one and a half to 2 quarts of liquid each day." B. "I need to take a laxative such as milk of magnesia or if I don't have a BM every day." C. "If my bowel pattern changes on its own, I should call you." D. "Eating my meals at regular times is likely to result in regular bowel movements."

B. "I need to take a laxative such as milk of magnesia or if I don't have a BM every day." Stimulant laxatives can be very irritating and are not the preferred treatment for occasional constipation in older adults. In addition, a normal stool pattern for an older adult may not be daily elimination. The cause of constipation is multifactorial. The problem may arise in the colon or rectum or it may be due to an external cause. In most people, slow colonic motility that occurs after years of laxative abuse is the problem. In a few patients, the cause may be related to an outlet obstruction like rectal prolapse or a rectocele. External causes of constipation may include poor dietary habits, lack of fluid intake, overuse of certain medications, an endocrine problem like hypothyroidism or some type of an emotional issue.

Which intervention is an example of primary prevention? A. Administering digoxin (Lanoxicaps) to a patient with heart failure. B. Administering measles, mumps, and rubella immunization to an infant. C. Obtaining a Papanicolaou smear to screen for cervical cancer. D. Using occupational therapy to help a patient cope with arthritis.

B. Administering measles, mumps, and rubella immunization to an infant. Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Primary prevention includes those preventive measures that come before the onset of illness or injury and before the disease process begins. Examples include immunization and taking regular exercise to prevent health problems developing in the future. Option A: Administering digoxin to treat heart failure and obtaining a smear for a screening test are examples for secondary prevention, which promotes early detection and treatment of disease. Those preventive measures that lead to early diagnosis and prompt treatment of a disease, illness, or injury to prevent more severe problems developing. Here health educators such as Health Extension Practitioners can help individuals acquire the skills of detecting diseases in their early stages. Option C: Obtaining a Papanicolau smear is a secondary prevention. Option D: Using occupational therapy to help a patient cope with arthritis is an example of tertiary prevention, which aims to help a patient deal with the residual consequences of a problem or to prevent the problem from recurring. Tertiary prevention includes those preventive measures aimed at rehabilitation following significant illness. At this level, health educators work to retrain, re-educate and rehabilitate the individual who has already had an impairment or disability.

A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action? A. Prepare to irrigate the colostomy. B. After assessing the stoma and surrounding skin, notify the surgeon. C. Assess bowel sounds and administer antiemetic. D. Administer a bulk forming laxative, and encourage increased fluids and exercise.

B. After assessing the stoma and surrounding skin, notify the surgeon. The client has assessment findings consistent with complications of surgery. Providers and nurses should monitor stomas at regular intervals to look for the multiple complications of colostomies as an integrated team approach. Some complications are extremely troublesome to patients, and they come to the hospital with these presentations, but others may be more occult and have to be looked for. Option A: Irrigating the stoma is a dependent nursing action, and is also intervention without appropriate assessment. Some procedures like irrigation or enema should be avoided in case of stoma prolapse, chemotherapy, pelvic or abdominal radiation treatments, diarrhea-producing medication, or in case of an irregular functioning stoma and may lead to dependence. Option C: Assessing the peristomal skin area is an independent action, but administering an antiemetic is an intervention without appropriate assessment. Antiemetics are generally ordered to treat immediate postoperative nausea, not several days postoperative. Option D: Administering a bulk-forming laxative to a nauseated postoperative client is contraindicated. The surgeon must call the patient for regular follow up to assess the condition of the stoma and look for any complications and also assess the disease process for which the colostomy was made and also plan for colostomy closure in case of temporary colostomies.

When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients have adverse drug effects? A. Faster drug clearance B. Aging-related physiological changes C. Increased amount of neurons D. Enhanced blood flow to the GI tract

B. Aging-related physiological changes Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. ADEs are estimated to be indicated in 5% to 28% of acute geriatric medical admissions. Preventable ADEs are among one of the serious consequences of inappropriate medication use in older adults. Option A: Renal and hepatic changes cause drugs to clear more slowly in these patients. Aging leads to a reduced number of functional glomeruli and an increased prevalence of sclerotic changes within the glomeruli or renal vasculature. Additionally, there is a normal decrease in GFR observed in advanced age, but this places the elderly at much higher risk for complications in the event that they develop chronic or acute kidney disease, as they have less functional glomeruli as a result of normal aging physiology. Option C: With increasing age, neurons are lost. Abnormal compensatory mechanisms predispose individuals to neurodegeneration and dementia, Parkinson disease, and overall cerebral atrophy are observable in aging individuals. Option D: Blood flow to the GI tract decreases. The weakening of smooth muscle in the intestinal tract can promote the development of diverticular disease and can play a role in bowel obstructions or constipation. Decreased metabolic activity, specifically in the liver, can lead to alterations in drug metabolism.

The nurse is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client's temperature? A. Oral B. Axillary C. Radial D. Heat sensitive tape

B. Axillary Axilla is the most accessible body part in this situation. Body temperature is a numerical expression of the body's heat and metabolic activity balance and can be a major indicator of a person's health status. Assessing a patient's body temperature is a common procedure nurses perform to monitor for signs of infection, environmental exposure, shock, ovulation, or therapeutic response to medications or medical procedures. A normal body temperature can be a potentially positive sign that the patient isn't experiencing a disease process, infection, or trauma and that the body's cells, tissues, and organs aren't under metabolic distress.

A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client's body temperature? A. Oral B. Axillary C. Arterial line D. Rectal

B. Axillary Taking the temperature via the axilla is the most appropriate route. Body temperature is a numerical expression of the body's heat and metabolic activity balance and can be a major indicator of a person's health status. Assessing a patient's body temperature is a common procedure nurses perform to monitor for signs of infection, environmental exposure, shock, ovulation, or therapeutic response to medications or medical procedures. A normal body temperature can be a potentially positive sign that the patient isn't experiencing a disease process, infection, or trauma and that the body's cells, tissues, and organs aren't under metabolic distress.

A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.D. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming: A. Fresh, green vegetables B. Bananas and oranges C. Lean red meat D. Creamed corn

B. Bananas and oranges Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the patient to increase intake of potassium-rich foods, such as bananas and oranges. Potassium is a mineral in the cells. It helps the nerves and muscles work as they should. The right balance of potassium also keeps the heart beating at a steady rate. Fresh, green vegetables; lean red meat; and creamed corn are not good sources of potassium.

Using Abraham Maslow's hierarchy of human needs, a nurse assigns highest priority to which client need? A. Security B. Elimination C. Safety D. Belonging

B. Elimination According to Maslow, elimination is a first-level or physiological need and therefore takes priority over all other needs. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate for all individuals. Maslow's hierarchy of needs is a motivational theory in psychology comprising a five-tier model of human needs, often depicted as hierarchical levels within a pyramid. From the bottom of the hierarchy upwards, the needs are: physiological (food and clothing), safety (job security), love and belonging needs (friendship), esteem, and self-actualization. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after a client's first-level needs have been satisfied.

A nurse caring for a patient with an infectious disease who requires isolation should refers to guidelines published by the: A. National League for Nursing (NLN) B. Centers for Disease Control (CDC) C. American Medical Association (AMA) D. American Nurses Association (ANA)

B. Centers for Disease Control (CDC) The Center of Disease Control (CDC) publishes and frequently updates guidelines on caring for patients who require isolation. CDC is responsible for controlling the introduction and spread of infectious diseases, and provides consultation and assistance to other nations and international agencies to assist in improving their disease prevention and control, environmental health, and health promotion activities. Option A: The National League of Nursing's (NLN's) major function is accrediting nursing education programs in the United States. The NLN, the premier organization for nurse educators, offers professional development, teaching resources, research grants, testing services, and public policy initiatives to its 40,000 individual and 1,200 institutional members, comprising nursing education programs across higher education and health care. Option C: The American Medical Association (AMA) is a national organization of physicians. American Medical Association (AMA), organization of American physicians, the objective of which is "to promote the science and art of medicine and the betterment of public health." It was founded in Philadelphia in 1847 by 250 delegates representing more than 40 medical societies and 28 colleges. Option D: The American Nurses' Association (ANA) is a national organization of registered nurses. ANA guides the profession on issues of nursing practice, health policy, and social concerns that impact patient wellbeing. Through their position statements, ANA amplifies the voice of nurses and educates both consumers and policymakers.

One aspect of implementation related to drug therapy is: A. Developing a content outline. B. Documenting drugs given. C. Establishing outcome criteria. D. Setting realistic client goals.

B. Documenting drugs given. Although documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are part of planning rather than implementation. Option A: UE has a common goal with the pharmaceutical care it supports: to improve an individual patient's quality of life through the achievement of predefined, medication-related therapeutic outcomes. Through its focus on the system of medication use, the MUE process helps to identify actual and potential medication-related problems, resolve actual medication-related problems, and prevent potential medication-related problems that could interfere with achieving optimum outcomes from medication therapy. Option C: Although distinctions historically have been made among the terms drug-use evaluation, drug-use review, and medication use evaluation (MUE), they all refer to the systematic evaluation of medication use employing standard, observational quality-improvement methods. MUE is a quality-improvement activity, but it also can be considered a formulary system management technique. An MUE is a performance improvement method that focuses on evaluating and improving medication-use processes with the goal of optimal patient outcomes. Although documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are part of planning rather than implementation. Option D: MUE encompasses the goals and objectives of drug use evaluation (DUE) in its broadest application, emphasizing improving patient outcomes. The use of MUE, rather than DUE, emphasizes the need for a more multifaceted approach to improving medication use.MUE encompasses the goals and objectives of drug use evaluation (DUE) in its broadest application, emphasizing improving patient outcomes. The use of MUE, rather than DUE, emphasizes

How should the nurse prepare an injection for a patient who takes both regular and NPH insulin? A. Draw up the NPH insulin, then the regular insulin, in the same syringe. B. Draw up the regular insulin, then the NPH insulin, in the same syringe. C. Use two separate syringes. D. Check with the physician.

B. Draw up the regular insulin, then the NPH insulin, in the same syringe. Drugs that are compatible may be mixed together in one syringe. In the case of insulin, the shorter-acting, clear insulin (regular) should be drawn up before the longer-acting, cloudy insulin (NPH) to ensure accurate measurements. Option A: Insulin, regular when administered subcutaneously, it should be injected 30 to 40 minutes before each meal. Avoid cold injections. The injection is in the buttocks, thighs, arms, or abdomen; it is necessary to rotate injection sites to avoid lipodystrophy. Do not inject if the solution is viscous or cloudy; use only if clear and colorless. Option C: When administered intravenously, U-100 administration should be with close monitoring of serum potassium and blood glucose. Do not use if the solution is viscous or cloudy; administration should only take place if it is colorless and clear. Option D: For intravenous infusions, to minimize insulin adsorption to plastic IV tubing, flush the intravenous tube with priming infusion of 20 mL from a 100 mL-polyvinyl chloride bag insulin, every time a new intravenous tubing is added to the insulin infusion container.

A nurse discourages a patient from straining excessively when attempting to have a bowel movement. What physiological response primarily may be prevented by avoiding straining on defecation? A. Incontinence B. Dysrhythmias C. Fecal impaction D. Rectal hemorrhoids

B. Dysrhythmias Straining on defecation requires the person to hold the breath while bearing down. This maneuver increases the intrathoracic and intracranial pressures, which can precipitate dysrhythmias, brain attack, and respiratory difficulties; all of these can be life threatening. Strain at stool causes blood pressure rise, which can trigger cardiovascular events such as congestive heart failure, arrhythmia, acute coronary disease, and aortic dissection. Option A: The loss of the voluntary ability to control the passage of fecal or gaseous discharges through the anus is caused by impaired functioning of the anal sphincter or its nerve supply, not straining on defecation. Fecal incontinence is the inability to control bowel movements, causing stool (feces) to leak unexpectedly from the rectum. Also called bowel incontinence, fecal incontinence ranges from an occasional leakage of stool while passing gas to a complete loss of bowel control. Option C: Fecal impaction is caused by prolonged retention and the accumulation of fecal material in the large intestine, not straining on defecation. Fecal impaction is a severe bowel condition in which a hard, dry mass of stool becomes stuck in the colon or rectum. This immobile mass will block the passage and cause a buildup of waste, which a person will be unable to pass. Option D: Although straining on defecation can contribute to the formation of hemorrhoids, this is not the primary reason straining on defecation is discouraged. Hemorrhoids, although painful, are not life-threatening. Hemorrhoids are rich in vascular supply and have a tendency to engorge and prolapse. Symptoms can vary from mild itching, bleeding to severe pain. Unfortunately, because of the location, many patients never seek treatment for fear of embarrassment.

A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role? A. Manager B. Educator C. Caregiver D. Patient advocate

B. Educator When teaching a patient about medications before discharge, the nurse is acting as an educator. They provide educational leadership to patients and care providers to enhance specialized patient care within established healthcare settings. Assists patients and caregivers with educational needs, problem resolution, and health management across the continuum of care. Option A: The nurse acts as a manager when performing such activities as scheduling and making patient care assignments. Great nurse managers are able to work in coordination with other departments. They must also possess the ability to oversee an array of practice functions including staff supervision, clinical tasks, and appointments. It is also part of their jobs to liaise with pathology labs, suppliers, and other health facilities. Option C: The nurse performs the caregiving role when providing direct care, including bathing patients and administering medications and prescribed treatments. Healthcare should address a patient's cultural, spiritual and mental needs. Increasing diversity in a growing patient population requires nurses to demonstrate cultural awareness and sensitivity. Patients may have specific needs and preferences due to their religion or gender, for example. Nurses need to be respectful of, and knowledgeable about, diverse backgrounds while remaining vigilant in providing quality care. Option D: The nurse acts as a patient advocate when making the patient's wishes known to the doctor. A nurse advocate is a nurse who works on behalf of patients to maintain quality of care and protect patients' rights. They intervene when there is a care concern, and following the proper channels, work to resolve any patient care issues. Realistically, every nurse is an advocate.

Which of the following actions should the nurse take to use wide base support when assisting a client to get up in a chair? A. Bend at the waist and place arms under the client's arms and lift. B. Face the client, bend knees, and place hands-on client's forearm and lift. C. Spread his or her feet apart. D. Tighten his or her pelvic muscles.

B. Face the client, bend knees, and place hands-on client's forearm and lift. This is the proper way of supporting the client to get up in a chair that conforms to safety and proper body mechanics. It is important to use proper body mechanics as a health care professional for many reasons, foremost of which is to prevent injuries to both patient and provider. Health care professionals at the front line, especially those who deliver direct care to patients, are often in situations where they have to assist with moving patients from one position to another.

A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? A. Macaroni and cheese B. Fresh fruit and whole-wheat toast C. Rice pudding and ripe bananas D. Roast chicken and white rice

B. Fresh fruit and whole-wheat toast A high fiber diet promotes normal bowel elimination. The choice of fruit and toast is the highest-fiber option. Most Americans consume only half the levels of recommended fiber per day, which is almost 15 grams per day. All existing definitions recognize fiber as "carbohydrate or lignin which bypasses digestion in the small intestine and is partially or completely fermented in the large intestine or colon." Option A: Macaroni and cheese is a low residue option that could actually worse and constipate. Insoluble fiber maintains bowel movements. They absorb water and soften the stool. Soft stool is easier to pass, thus preventing constipation. They also add bulk to the stools hence prevent the formation of loose stools. Option C: Rice pudding and ripe bananas are low residue options that could actually worsen constipation. High fiber diet prevents the formation or worsening of hemorrhoids, and of diverticular disease, which presents as outpouchings in the walls of the colon. Option D: Roast chicken and white rice or low residue options that could actually worsen constipation. They are water-soluble and derived from the inner flesh of plants such as pectin, gums, and mucilage. They form a viscous gel and are usually fermented by bacteria in the colon into gases and by-products such as short-chain fatty acids. They alter the blood glucose and cholesterol concentrations.

The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer? A. Position the head of the bed flat. B. Helps the patient dangle the legs. C. Stands behind the patient. D. Place the chair facing away from the bed.

B. Helps the patient dangle the legs. After placing the patient in High Fowler's position and moving the patient to the side of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed. Option A: Allow the patient to sit for a few moments, in case the patient feels dizzy when first sitting up. To get the patient into a seated position, roll the patient onto the same side as the wheelchair. Option C: The nurse should put one arm under the patient's shoulders and one behind the knees. Bend the knees. Swing the patient's feet off the edge of the bed and use the momentum to help the patient into a sitting position. Option D: Move the patient to the edge of the bed and lower the bed so the patient's feet are touching the ground. Make sure any loose rugs are out of the way to prevent slipping. You may want to put non-skid socks or shoes on the patient's feet if the patient needs to step onto a slippery surface.

A patient is catheterized with a #16 indwelling urinary (Foley) catheter to determine if: A. Trauma has occurred. B. His 24-hour output is adequate. C. He has a urinary tract infection. D. Residual urine remains in the bladder after voiding.

B. His 24-hour output is adequate. A 24-hour urine output of less than 500 ml in an adult is considered inadequate and may indicate kidney failure. This must be corrected while the patient is in the acute state so that appropriate fluids, electrolytes, and medications can be administered and excreted. Indwelling catheterization is not needed to diagnose trauma, urinary tract infection, or residual urine. Option A: Urinary bladder catheterization is performed for both therapeutic and diagnostic purposes. Based on the dwell time, the urinary catheter can be either intermittent (short-term) or indwelling (long-term). Option C: Cystitis, urethritis, prostatitis (common infectious etiology in men), and vulvovaginitis in the woman can cause urinary retention. Option D: Brain or spinal cord injury, cerebrovascular accident, multiple sclerosis, Parkinson's disease, and dementia can lead to urinary retention.

A male client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal? A. Inadequate vitamin D intake. B. Inadequate protein intake. C. Inadequate massaging of the affected area. D. Low calcium level.

B. Inadequate protein intake. A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Decubitus ulcers, also termed bedsores or pressure ulcers, are skin and soft tissue injuries that form as a result of constant or prolonged pressure exerted on the skin. These ulcers occur at bony areas of the body such as the ischium, greater trochanter, sacrum, heel, malleolus (lateral than medial), and occiput. Inadequate vitamin D intake and low calcium levels aren't factors in poor healing for this client. A pressure ulcer should never be massaged.

Which of the following is an example of data that should be validated? A. The urinalysis report indicates there are white blood cells in the urine. B. The client states she feels feverish; you measure the oral temperature at 98°F. C. The client has clear breath sounds; you count a respiratory rate of 18. D. The chest x-ray report indicates the client has pneumonia in the right lower lobe.

B. The client states she feels feverish; you measure the oral temperature at 98°F. Validation should be done when subjective and objective data do not make sense. For instance, it is inconsistent data when the patient feels feverish and you obtain a normal temperature. The other distractors do not offer conflicting data. Validation is not usually necessary for laboratory test results.

he nurse in charge is assessing a patient's abdomen. Which examination technique should the nurse use first? A. Auscultation B. Inspection C. Percussion D. Palpation

B. Inspection Inspection always comes first when performing a physical examination. It is important to begin with the general examination of the abdomen with the patient in a completely supine position. The presence of any of the following signs may indicate specific disorders. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation. Option A: The last step of the abdominal examination is auscultation with a stethoscope. The diaphragm of the stethoscope should be placed on the right side of the umbilicus to listen to the bowel sounds, and their rate should be calculated after listening for at least two minutes. Normal bowel sounds are low-pitched and gurgling, and the rate is normally 2-5/min. Absent bowel sounds may indicate paralytic ileus and hyperactive rushes (borborygmi) are usually present in small bowel obstruction and sometimes may be auscultated in lactose intolerance. Option C: A proper technique of percussion is necessary to gain maximum information regarding the abdominal pathology. While percussing, it is important to appreciate tympany over air-filled structures such as the stomach and dullness to percussion which may be present due to an underlying mass or organomegaly (for example, hepatomegaly or splenomegaly). Option D: The ideal position for abdominal examination is to sit or kneel on the right side of the patient with the hand and forearm in the same horizontal plane as the patient's abdomen. There are three stages of palpation that include the superficial or light palpation, deep palpation, and organ palpation and should be performed in the same order. Maneuvers specific to certain diseases are also a part of abdominal palpation.

Exchange of gases takes place in which of the following organs? A. Kidney B. Lungs C. Liver D. Heart

B. Lungs Gas exchange is the transport of oxygen from the lungs to the bloodstream and the expulsion of carbon dioxide from the bloodstream to the lungs. It transpires in the lungs between the alveoli and a network of tiny blood vessels called capillaries, which are located in the walls of the alveoli.

A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by: A. Writing down all assignments. B. Making changes after evaluating the situation and having discussions with the staff. C. Telling the staff nurses that she is making changes to benefit their performance. D. Evaluating the clinical performance of each staff nurse in a private conference.

B. Making changes after evaluating the situation and having discussions with the staff. A new assistant nurse manager should not make changes until she has had a chance to evaluate staff members, patients, and physicians. Changes must be planned thoroughly and should be based on a need to improve conditions, not just for the sake of change. Option A: Written assignments allow all staff members to know their own and others' responsibilities and serve as a checklist for the manager, enabling her to gauge whether the unit is being run effectively and whether patients are receiving appropriate care. Option C: Telling the staff nurses that she is making changes to benefit their performance should occur only after the nurse has made a thorough evaluation. Option D: Evaluations are usually done on a yearly basis or as needed.

It is best described as a systematic, rational method of planning and providing nursing care for individual, families, group, and community A. Assessment B. Nursing Process C. Diagnosis D. Implementation

B. Nursing Process The statement describes the Nursing Process. The Nursing Process is the essential core of practice for the registered nurse to deliver holistic, patient-focused care. Defined as a systematic approach to care using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing intuition. Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care.

The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process? A. Assessment B. Nursing diagnosis C. Planning D. Evaluation

B. Nursing diagnosis The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family or community. Option A: During the assessment step, the nurse systematically collects data about the patient or family. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight. Option C: During the planning step, the nurse develops strategies to resolve or decrease the patient's problem. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Option D: During the evaluation step, the nurse determines the effectiveness of the plan of care. This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data.

Which document addresses the client's right to information, informed consent, and treatment refusal? A. Standard of Nursing Practice B. Patient's Bill of Rights C. Nurse Practice Act D. Code for Nurses

B. Patient's Bill of Rights The Patient's Bill of Rights addresses the client's right to information, informed consent, timely responses to requests for services, and treatment refusal. A legal document, it serves as a guideline for the nurse's decision making. Standards of Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing practice parameters and primarily describe the use of the nursing process in providing care.

If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following? A. Fail to show changes in blood pressure. B. Produce a false-high measurement. C. Cause sciatic nerve damage. D. Produce a false-low measurement.

B. Produce a false-high measurement. Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff can't record brachial artery measurements unless it's excessively inflated. Option A: Using a blood pressure cuff that's too large or too small can give inaccurate blood pressure readings. The doctor's office should have several sizes of cuffs to ensure an accurate blood pressure reading. When one measures their blood pressure at home, it's important to use the proper size cuff. Option C: The sciatic nerve wouldn't be damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower extremity. Option D: The inflatable part of the blood pressure cuff should cover about 40% of the distance around (circumference of) the upper arm. The cuff should cover 80% of the area from the elbow to the shoulder.

Vivid dreaming occurs in which stage of sleep? A. Stage I non-REM B. Rapid eye movement (REM) stage C. Stage II non-REM D. Delta stage

B. Rapid eye movement (REM) stage Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient cannot be awakened easily), depressed muscle tone, and possibly irregular heart and respiratory rates. This is the stage associated with dreaming. Interestingly, the EEG is similar to an awake individual, but the skeletal muscles are atonic and without movement. The exception is the eye and diaphragmatic breathing muscles, which remain active. The breathing rate is altered though, being more erratic and irregular. This stage usually starts 90 minutes after falling asleep, and each of the REM cycles gets longer throughout the night. The first period typically lasts 10 minutes, and the final one can last up to an hour. Option A: Non-REM sleep is a deep, restful sleep without dreaming. This is the lightest stage of sleep and starts when more than 50% of the alpha waves are replaced with low-amplitude mixed-frequency (LAMF) activity. There is muscle tone present in the skeletal muscle and breathing tends to occur at a regular rate. This stage tends to last 1 to 5 minutes, consisting of around 5% of the total cycle. Option C: This stage represents deeper sleep the heart rate and body temperature drop. It is characterized by the presence of sleep spindles, K-complexes, or both. These sleep spindles will activate the superior temporal gyri, anterior cingulate, insular cortices, and the thalamus. The K-complexes show a transition into a deeper sleep. Stage 2 sleep lasts around 25 minutes in the initial cycle and lengthens with each successive cycle, eventually consisting of about 50% of total sleep. Option D: Delta stage, or slow-wave sleep, occurs during non-REM Stages III and IV and is often equated with quiet sleep. This is considered the deepest stage of sleep and is characterized by a much slower frequency with high amplitude signals known as delta waves. This stage is the most difficult to awaken from, and for some people, even loud noises (over 100 decibels) will not awaken them. As people get older, they tend to spend less time in this slow, delta wave sleep and more time stage N2 sleep. This is the stage when the body repairs and regrows its tissues, builds bone and muscle, and strengthens

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important? A. A history of increased aspirin use. B. Recent pelvic surgery. C. An active daily walking program. D. A history of diabetes.

B. Recent pelvic surgery. The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep vein is associated with pelvic surgery. Thrombosis is a protective mechanism that prevents the loss of blood and seals off damaged blood vessels. Fibrinolysis counteracts or stabilizes the thrombosis. The triggers of venous thrombosis are frequently multifactorial, with the different parts of the triad of Virchow contributing in varying degrees in each patient, but all result in early thrombus interaction with the endothelium. This then stimulates local cytokine production and causes leukocyte adhesion to the endothelium, both of which promote venous thrombosis. Option A: Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. The use of thrombolytic therapy can result in an intracranial bleed, and hence, careful patient selection is vital. Recently endovascular interventions like catheter-directed extraction, stenting, or mechanical thrombectomy have been tried with moderate success. Option C: Treatment of DVT aims to prevent pulmonary embolism, reduce morbidity, and prevent or minimize the risk of developing post-thrombotic syndrome. The cornerstone of treatment is anticoagulation. NICE guidelines only recommend treating proximal DVT (not distal) and those with pulmonary emboli. In each patient, the risks of anticoagulation need to be weighed against the benefits. Option D: In general, diabetes is a contributing factor associated with peripheral vascular disease. In the hospital, the most commonly associated conditions are malignancy, congestive heart failure, obstructive airway disease, and patients undergoing surgery. In the hospital, the most commonly associated conditions are malignancy, congestive heart failure, obstructive airway disease, and patients undergoing surgery.

To ensure homogenization when diluting powdered medication in a vial, the nurse should: A. Shake the vial vigorously. B. Roll the vial gently between the palms. C. Invert the vial and let it stand for 1 minute. D. Do nothing after adding the solution to the vial.

B. Roll the vial gently between the palms. Gently rolling a sealed vial between the palms produces sufficient heat to enhance dissolution of a powdered medication. Option A: Shaking the vial vigorously can break down the medication and alter its pharmacologic action. Option C: Inverting the vial or leaving it alone does not ensure thorough homogenization of the powder and the solvent. Option D: Use aseptic technique to draw up the specified amount of diluent and inject it into the medication vial. Roll the vial in the hands to dissolve all the powder (emphasize not to shake the vial).

he nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient with chronic lung disease has a 30+ year history of tobacco use. The nurse used to smoke a pack of cigarettes a day at one time and worked very hard to quit smoking. She immediately thinks to herself, "I know I tend to feel negative about people who use tobacco, especially when they have a serious lung condition; I figure if I can stop smoking, they should be able to. I must remember how physically and psychologically difficult that is, and be very careful not to let it be judgmental of this patient." This best illustrates: A. Theoretical knowledge B. Self-knowledge C. Using reliable resources D. Use of the nursing process

B. Self-knowledge Personal knowledge is self-understanding—awareness of one's beliefs, values, biases, and so on. That best describes the nurse's awareness that her bias can affect her patient care. Self-knowledge refers to knowledge of one's own mental states, processes, and dispositions. Most agree it involves a capacity for understanding the representational properties of mental states and their role in shaping behavior.

Nurse Clarisse is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications? A. Decreased plasma drug levels B. Sensory deficits C. Lack of family support D. History of Tourette syndrome

B. Sensory deficits Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Age-related decline of the five classical senses (vision, smell, hearing, touch, and taste) poses significant burdens on older adults. The co-occurrence of multiple sensory deficits in older adults is not well characterized and may reflect a common mechanism resulting in global sensory impairment Option A: Decreased plasma drug levels do not alter the patient's knowledge about the drug. Aging has long been associated with decline in sensory function, a critical component of the health and quality of life of older people Option C: A lack of family support may affect compliance, not knowledge retention. Vision impairment is correlated with depression, poor quality of life, cognitive decline, and mortality. Hearing loss is associated with slower gait speed (a marker of physical decline), poor cognition, and mortality. Like smell, taste has been associated with nutritional compromise and in-patient mortality, suggesting that chemosensory function is critical. Tactile discrimination declines with age due to the cumulative effects of decreased nerve conduction velocity, decreased density of Meissner's and Pacinian corpuscles, and gray matter changes within the central nervous system, and is also associated with cognitive decline Option D: Tourette syndrome is unrelated to knowledge retention. Tourette syndrome referred to as Tourette disorder in the recently updated Diagnostic and Statistical Manual of Mental Disorders (DSM-5), is a common neurodevelopmental disorder affecting up to 1% of the population. It is characterized by multiple motor and vocal tics and starts in childhood.

Which of the following is the nurse's role in health promotion? A. Health risk appraisal B. Teach client to be effective health consumer C. Worksite wellness D. None of the above

B. Teach client to be effective health consumer Nurses play a huge role in illness prevention and health promotion. Nurses assume the role of ambassadors of wellness. The World Health Organization (WHO) defines health promotion as a process of enabling people to increase control over and to improve their health (WHO, 1986). Nurses are best qualified to take on the job of health promoter due to their expertise. There are few health care occupations that have the high level of health education knowledge, skills, theory, and research to be able to focus on prevention because it is considered part of their professional development focus.

Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection? A. The client will wear a medical alert bracelet for antibiotic allergy. B. The client will return to his or her previous fecal elimination pattern. C. The client verbalizes the need to take an antidiarrheal medication PRN. D. The client will increase intake of insoluble fiber such as grains, rice, and cereals.

B. The client will return to his or her previous fecal elimination pattern. Once the cause of diarrhea has been identified and corrected, the client returns to his or her previous elimination pattern. Diarrhea is a common adverse effect of antibiotic treatments. Antibiotic-associated diarrhea occurs in about 5-30% of patients either early during antibiotic therapy or up to two months after the end of the treatment. The frequency of antibiotic-associated diarrhea depends on the definition of diarrhea, the inciting antimicrobial agents, and host factors.

The nurse uses a stethoscope to auscultate a male patient's chest. Which statement about a stethoscope with a bell and diaphragm is true? A. The bell detects high-pitched sounds best. B. The diaphragm detects high-pitched sounds best. C. The bell detects thrills best. D. The diaphragm detects low-pitched sounds best.

B. The diaphragm detects high-pitched sounds best. The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best. The bell is flat and round and is covered by a thin layer of plastic known as the diaphragm. The diaphragm vibrates as sound is produced within the body. These vibrations travel from the bell, up the hollow tube which splits into two, and into hollow earpieces to be heard as sound by the medical professional. Option A: The smaller or other part of the resonator is called a bell. It is made up of hollow pieces of metal that help at picking up low-frequency sounds. Option C: Whenever a medical practitioner places a stethoscope diaphragm on a chest of a patient, vibration will occur at the flat surface of the stethoscope which is a result of sound waves that is being generated from the patient's body. The vibration picked by the diaphragm is being protected externally in other to prevent sound loss and Option D: The diaphragm is the lower part of the chest piece. It is a flat metallic disc surrounded by chill rings which enable it to pick a very high pitch sound.

A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and unproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is: A. Unhappiness about the charge in leadership. B. Unexpected feelings and emotions among the staff. C. Fatigue from overwork and understaffing. D. Failure to incorporate staff in decision making.

B. Unexpected feelings and emotions among the staff. The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation in which the nurses have unexpected feelings and emotions. Although the other options could be contributing to the problematic situation, they're less likely to be the cause.

Which statement by a patient with an ileostomy alerts the nurse to the need for further education? A. "I don't expect to have much of a problem with fecal odor." B. "I will have to take special precaution to protect my skin around the stoma." C. "I'm going to have to irrigate my stoma so I have a bowel movement every morning." D. "I should avoid gas forming foods like beans to limit funny noises from the stoma."

C. "I'm going to have to irrigate my stoma so I have a bowel movement every morning." This statement is inaccurate in relation to an ileostomy and indicates that the patient needs more teaching. An ileostomy produces liquid fecal drainage that is constant and cannot be regulated. An ileostomy is when the lumen of the ileum (small bowel) is brought through the abdominal wall via a surgical opening (created by an operation). This can either be temporary or permanent, an end or a loop. The purpose of an ileostomy is to evacuate stool from the body via the ileum rather than the usual route of the anus. Option A: The odor from drainage is minimal because fewer bacteria are present in the ileum compared with the large intestine. There are different indications for forming an ileostomy but essentially arrive at the same result of diverting stool out of the body without it ever entering the colon. Option B: An ileostomy is an opening into the ileum (distal small intestine from the jejunum to the cecum). Cleansing the skin, skin barriers, and a well fitted appliance are precautions to protect the skin around the ileostomy stoma. The drainage from ileostomy contains enzymes that can damage the skin. Option D: An ileostomy stoma does not have a sphincter that can control the flow of flatus or drainage, resulting in noise. The output from an ileostomy consists of loose or porridge-like stool consistent with that expected to pass through the small bowel (as it is the large bowel that is responsible for making the stool more solid dependent upon water absorption). The output from an ileostomy can vary but typically ranges from 200 to 700 ml per day, and an Ileostomy is typically formed on the right side of the abdomen.

A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, "How long will it take for my scars to disappear?" Which statement would be the nurse's best response? A. "The contraction phase of wound healing can take 2 to 3 years." B. "Wound healing is very individual but within 4 months the scar should fade. C. "With your history and the type of location of the injury, it's hard to say." D. "If you don't develop an infection, the wound should heal any time between 1 and 3 years from now."

C. "With your history and the type of location of the injury, it's hard to say." Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information. There is no doubt that diabetes plays a detrimental role in wound healing. It does so by affecting the wound healing process at multiple steps. Wound hypoxia, through a combination of impaired angiogenesis, inadequate tissue perfusion, and pressure-related ischemia, is a major driver of chronic diabetic wounds.

The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of: A. 15 drop per minute B. 21 drop per minute C. 32 drop per minute D. 125 drops per minute

C. 32 drop per minute Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of milliliters per minute: 125/60 min = X/1 minute 60X = 125X = 2.1 ml/minute To find the number of drops/minute: 2.1 ml/X gtts = 1 ml/15 gttsX = 32 gtts/minute, or 32 drops/minute

The nurse in charge measures a patient's temperature at 102 degrees F. what is the equivalent Centigrade temperature? A. 39 degrees C B. 47 degrees C C. 38.9 degrees C D. 40.1 degrees C

C. 38.9 degrees C To convert Fahrenheit degrees to centigrade, use this formula: C degrees = (F degrees - 32) x 5/9 C degrees = (102 - 32) 5/9 + 70 x 5/938.9 degrees C

The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for self-injection. The patient's first priority concerning self-injection in this situation is to: A. Assess the injection site. B. Select the appropriate injection site. C. Check the syringe to verify that the nurse has removed the prescribed insulin dose. D. Clean the injection site in a circular manner with an alcohol sponge.

C. Check the syringe to verify that the nurse has removed the prescribed insulin dose. When the nurse teaches the patient to prepare an insulin injection, the patient's first priority is to validate the dose accuracy. The next steps are to select the site, assess the site, and clean the site with alcohol before injecting the insulin. Option A: The site the client chooses for the injection should be clean and dry. If the skin is visibly dirty, clean it with soap and water. DO NOT use an alcohol wipe on the injection site. Choose where to give the injection. Keep a chart of places that have been used, so the client does not inject the insulin in the same place all the time. Ask the doctor for a chart. Option B: The insulin needs to go into the fat layer under the skin. If the skin tissues are thicker, the client may be able to inject straight up and down (90º angle). Check with the provider before doing this. Option D: To give an insulin injection, the client needs to fill the right syringe with the right amount of medicine, decide where to give the injection, and know how to give the injection.

It is described as a collection of people who share some attributes of their lives. A. Family B. Illness C. Community D. Nursing

C. Community A community is defined by the shared attributes of the people in it, and/or by the strength of the connections among them. When an organization is identifying communities of interest, the shared attribute is the most useful definition of a community.

A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal? A. A palpable radial pulse B. A palpable ulnar pulse C. Cool, pale fingers D. Pink nail beds

C. Cool, pale fingers A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable radial or ulnar pulse and pink nail beds are normal findings.

Nurse Mackey is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use? A. Prolonged half-life B. Poor absorption C. Potential for drug dependence D. Potential for hepatotoxicity

C. Potential for drug dependence Patients can become dependent on barbiturates, especially with prolonged use. Due to the abuse potential of barbiturates, restricted access started with the passage of the Federal Comprehensive Drug Abuse and Control Act of 1970. Barbiturates classify as Schedule II-IV based on their abuse potential. Option A: Because of the rapid distribution of some barbiturates, no correlation exists between duration of action and half-life. The elimination half-life for thiopental is about 5 hours. In children, a shorter elimination half-time occurs due to greater hepatic clearance. Option B: Barbiturates are absorbed well. Age-related changes have been demonstrated in pharmacokinetics due to slower intercompartmental clearance in the elderly, resulting in higher serum concentrations with smaller drug doses. Option D: They do not cause hepatotoxicity, although existing hepatic damage does require cautious use of the drug because barbiturates are metabolized in the liver.

Kubler-Ross's five successive stages of death and dying are: A. Anger, bargaining, denial, depression, acceptance B. Denial, anger, depression, bargaining, acceptance C. Denial, anger, bargaining, depression acceptance D. Bargaining, denial, anger, depression, acceptance

C. Denial, anger, bargaining, depression acceptance Kubler-Ross's five successive stages of death and dying are denial, anger, bargaining, depression, and acceptance. The patient may move back and forth through the different stages as he and his family members react to the process of dying, but he usually goes through all of these stages to reach acceptance. Option A: Denial is a common defense mechanism used to protect oneself from the hardship of considering an upsetting reality. Kubler-Ross noted that after the initial shock of receiving a terminal diagnosis, patients would often reject the reality of the new information. Patients may directly deny the diagnosis, attribute it to faulty tests or an unqualified physician, or simply avoid the topic in conversation. Option B: Anger, as Kubler-Ross pointed out, is commonly experienced and expressed by patients as they concede the reality of a terminal illness. It may be directed, as with blame of medical providers for inadequately preventing the illness, of family members for contributing to risks of not being sufficiently supportive, or of spiritual providers or higher powers for the diagnosis' injustice. Option D: Bargaining typically manifests as patients seek some measure of control over their illness. The negotiation could be verbalized or internal and could be medical, social, or religious. The patients' proffered bargains could be rational, such as a commitment to adhere to treatment recommendations or accept help from their caregivers, or could represent more magical thinking, such as with efforts to appease misattributed guilt they may feel is responsible for their diagnosis. Depression is perhaps the most immediately understandable of Kubler-Ross's stages and patients experience it with unsurprising symptoms such as sadness, fatigue, and anhedonia. Acceptance describes recognizing the reality of a difficult diagnosis while no longer protesting or struggling against it. Patients may choose to focus on enjoying the time they have left and reflecting on their memories.

The most important nursing intervention to correct skin dryness is: A. Consult the dietitian about increasing the patient's fat intake, and take necessary measures to prevent infection. B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear. C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas. D. Avoid bathing the patient until the condition is remedied, and notify the physician.

C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas. Dry skin will eventually crack, ranking the patient more prone to infection. To prevent this, the nurse should provide adequate hydration through fluid intake, use non irritating soaps or no soap when bathing the patient, and lubricate the patient's skin with lotion. In most cases, dry skin responds well to lifestyle measures, such as using moisturizers and avoiding long, hot showers and baths. Moisturizers provide a seal over the skin to keep water from escaping. Apply moisturizer several times a day and after bathing. Option A: The attending physician and dietitian may be consulted for treatment, but home-laundered items usually are not necessary. Natural fibers, such as cotton and silk, allow the skin to breathe. But wool, although natural, can irritate even normal skin. Wash clothes with detergents without dyes or perfumes, both of which can irritate the skin. Option B: Increasing fat intake is unnecessary. Hot, dry, indoor air can parch sensitive skin and worsen itching and flaking. A portable home humidifier or one attached to the furnace adds moisture to the air inside the home. Be sure to keep the humidifier clean. It's best to use cleansing creams or gentle skin cleansers and bath or shower gels with added moisturizers. Choose mild soaps that have added oils and fats. Avoid deodorant and antibacterial detergents, fragrance, and alcohol. Option D: Bathing may be limited but need not be avoided entirely. Long showers or baths and hot water remove oils from the skin. Limit baths or showers to five to 10 minutes and use warm, not hot, water.

Which of the following symptoms is the best indicator of imminent death? A. A weak, slow pulse B. Increased muscle tone C. Fixed, dilated pupils D. Slow, shallow respirations

C. Fixed, dilated pupils Fixed, dilated pupils are a sign of imminent death. Death is a part of natural life; however, society is notorious for being uncomfortable with death and dying as a topic on the whole. Many caregivers experience a level of burden from their duties during end-of-life care. This burden is multi-faceted and may include performing medical tasks, communicating with providers, decision-making and possibly anticipating the grief of impending loss. Option A: Pulse becomes weak but rapid. It is important to identify how to know death has occurred and to educate the family of a patient who may be actively dying. This is especially important if the patient is choosing to die at home. Option B: Muscles become weak and atonic. It is imperative that patients and families have access to the care and support they require when entering a terminal phase of life. This phase is different for each patient, and the needs may differ for each patient and family, but it is vital for healthcare providers to provide care and support in a way that respects the patient's dignity and autonomous wishes. Option D: In the late stages, an altered respiratory pattern which can be periods of apnea alternated with hyperpnea or irregular breathing can be noticed.

Question 51 of 75 When teaching a female patient how to take a sublingual tablet, the nurse should instruct the patient to place the table on the: A. Top of the tongue B. Roof of the mouth C. Floor of the mouth D. Inside of the cheek

C. Floor of the mouth The nurse should instruct the patient to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into the bloodstream from the oral mucosa, bypassing the GI and hepatic systems. No drug is administered on top of the tongue or on the roof of the mouth.

A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing? A. Ongoing assessment B. Comprehensive physical assessment C. Focused physical assessment D. Psychosocial assessment

C. Focused physical assessment The nurse is performing a focused physical assessment, which is done to obtain data about an identified problem, in this case shortness of breath. Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body systems. Option A: An ongoing assessment is performed as needed, after the initial data are collected, preferably with each patient contact. Repeat of the focused or rapid emergency department assessment of a prehospital patient to detect changes in condition and to judge the effectiveness of treatment before or during transport. Repeated every 5 minutes for an unstable patient and every 15 minutes for a stable patient. Option B: A comprehensive physical assessment includes an interview and a complete examination of each body system. A comprehensive health assessment gives nurses insight into a patient's physical status through observation, the measurement of vital signs, and self-reported symptoms. It includes a medical history, a general survey, and a complete physical examination. Option D: A psychosocial assessment examines both psychological and social factors affecting the patient. The nurse conducting a psychosocial assessment would gather information about stressors, lifestyle, emotional health, social influences, coping patterns, communication, and personal responses to health and illness, to name a few aspects.

The best way to decrease the risk of transferring pathogens to a patient when removing contaminated gloves is to: A. Wash the gloves before removing them. B. Gently pull on the fingers of the gloves when removing them. C. Gently pull just below the cuff and invert the gloves when removing them. D. Remove the gloves and then turn them inside out.

C. Gently pull just below the cuff and invert the gloves when removing them. Turning the gloves inside out while removing them keeps all contaminants inside the gloves. They should then be placed in a plastic bag with soiled dressings and discarded in a soiled utility room garbage pail (double bagged). The other choices can spread pathogens within the environment. Option A: They should also only be worn once, being changed between patients or between treatment areas on the same patient. For situations where there is a high risk of contamination or infection, NHS Professionals advise wearing two sets of gloves, known as 'double gloving'. Option B: Grasp the outside of one glove at the wrist. Do not touch the bare skin. Peel the glove away from the body, pulling it inside out. Hold the glove that was just removed in a gloved hand. Option D: Peel off the second glove by putting the fingers inside the glove at the top of the wrist. Turn the second glove inside out while pulling it away from the body, leaving the first glove inside the second.

A scrub nurse in the operating room has which responsibility? A. Positioning the patient B. Assisting with gowning and gloving C. Handling surgical instruments to the surgeon D. Applying surgical drapes

C. Handling surgical instruments to the surgeon The scrub nurse assists the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the patient, applies appropriate equipment and surgical drapes, assists with gowning and gloving, and provides the surgeon and scrub nurse with supplies. Option A: The circulating nurse is responsible for managing all nursing care within the operating room, observing the surgical team from a broad perspective, and assisting the team to create and maintain a safe, comfortable environment for the patient's surgery. Option B: A circulating nurse is responsible for coordinating care, obtaining supplies, and liaising with the patient's family. Option D: Assessing the patient right before surgery is critical to making sure that all required prep was completed. Serving as a patient advocate and safety monitor, the circulating nurse observes the surgery and ensures that no aspect of patient care is missed.

Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing? A. Have the patient place the specimen in a container and enclose the container in a plastic bag. B. Have the patient expectorate the sputum while the nurse holds the container. C. Have the patient expectorate the sputum into a sterile container. D. Offer the patient an antiseptic mouthwash just before he expectorate the sputum.

C. Have the patient expectorate the sputum into a sterile container. placing the specimen in a sterile container ensures that it will not become contaminated. A sputum specimen is obtained for culture to identify the microorganism responsible for lung infections; identify cancer cells shed by lung tumors; or aid in the diagnosis and management of occupational lung diseases. The other answers are incorrect because they do not mention sterility and because antiseptic mouthwash could destroy the organism to be cultured (before sputum collection, the patient may use only tap water for nursing the mouth). Option A: Using the sterile collection container provided, instruct the patient to take three deep breaths, then force a deep cough and expectorate into a sterile screw-top container. To prevent contamination by particles in the air, keep the container closed until the patient is ready to spit into it. Option B: Ten to 15 ml of sputum is typically needed for laboratory analysis. A specimen will be rejected by the laboratory if it contains excessive numbers of epithelial cells from the mouth or throat or if it fails to show adequate numbers of neutrophils on gram staining. If the patient cannot cough up a specimen, the respiratory therapist can use sputum induction techniques such as heated aerosol (nebulization), followed in some instances by postural drainage and percussion. Option D: Don't allow the patient to brush his teeth or use mouthwash. Doing so could kill bacteria in the sputum, rendering it useless. For best results, obtain the sample first thing in the morning. If it can't be obtained before the patient has breakfast, though, wait at least an hour after he's eaten before trying. Before beginning, describe the procedure to him.

A female patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse identifies which finding as an early sign of shock? A. Restlessness B. Pale, warm, dry skin C. Heart rate of 110 beats/minute D. Urine output of 30 ml/hour

C. Heart rate of 110 beats/minute Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the patient restless, anxious, nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale, cool clammy skin. Shock is characterized by decreased oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilization leading to cellular and tissue hypoxia. It is a life-threatening condition of circulatory failure and most commonly manifested as hypotension (systolic blood pressure less than 90 mm Hg or MAP less than 65 mmHg). Option B: Hypoxia at the cellular level causes a series of physiologic and biochemical changes, resulting in acidosis and a decrease in regional blood flow, which further worsens the tissue hypoxia. Option C: An above-normal heart rate is a late sign of shock. The most common clinical features/labs which are suggestive of shock include hypotension, tachycardia, tachypnea, obtundation or abnormal mental status, cold, clammy extremities, mottled skin, oliguria, metabolic acidosis, and hyperlactatemia. Option D: A urine output of 30 ml/hour is within normal limits. During this stage, most of the classic signs and symptoms of shock appear due to early organ dysfunction, resulting from the progression of the pre-shock stage as the compensatory mechanisms become insufficient.

The ability of the body to defend itself against scientific invading agent such as bacteria, toxin, viruses, and foreign body: A. Hormones B. Secretion C. Immunity D. Glands

C. Immunity Immunity is the ability of an organism to resist a particular infection or toxin by the action of specific antibodies or sensitized white blood cells. The Immune response is the body's ability to stay safe by affording protection against harmful agents and involves lines of defense against most microbes as well as specialized and highly specific responses to a particular offender. This immune response classifies as either innate which is non-specific and adaptive acquired which is highly specific.

The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. The nurse should anticipate giving how much heparin for each dose? A. ¼ ml B. ½ ml C. ¾ ml D. 1 ¼ ml

C. ¾ ml The nurse solves the problem as follows:10,000 units/7,500 units = 1 ml/X10,000 X = 7,500X= 7,500/10,000 or ¾ ml Option A: There are 3 primary methods for the calculation of medication dosages, as referenced above. These include Desired Over Have Method or Formula, Dimensional Analysis and Ratio and Proportion.

When bathing a patient's extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique: A. Provides an opportunity for skin assessment. B. Avoids undue strain on the nurse. C. Increases venous blood return. D. Causes vasoconstriction and increases circulation.

C. Increases venous blood return. Washing from distal to proximal areas stimulates venous blood flow, thereby preventing venous stasis. Good personal hygiene is essential for skin health but it also has an important role in maintaining self-esteem and quality of life. Supporting patients to maintain personal hygiene is a fundamental aspect of nursing care. Option A: The nurse can assess the patient's condition throughout the bath. Helping patients to wash and dress is frequently delegated to junior staff, but time spent attending to a patient's hygiene needs is a valuable opportunity for nurses to carry out a holistic assessment (Dougherty and Lister, 2015; Burns and Day, 2012). It also allows time to address any concerns patients have and provides a valuable opportunity to assess the condition of their skin. Option B: The nurse should feel no strain while bathing the patient. Nurses should also discuss with patients any religious and cultural issues relating to personal care (Dougherty and Lister, 2015). For example, ideally, Muslim patients should be cared for by a nurse of the same gender (Rassool, 2015), and Hindus may wish to wash before prayer (Dougherty and Lister, 2015). Option D: It improves circulation but does not result in vasoconstriction. Bed bathing is not as effective as showering or bathing and should only be undertaken when there is no alternative (Dougherty and Lister, 2015). If a bed bath is required, it is important to offer patients the opportunity to participate in their own care, which helps to maintain their independence, self-esteem and dignity.

Hormones secreted by Islets of Langerhans A. Progesterone B. Testosterone C. Insulin D. Hemoglobin

C. Insulin The Islets of Langerhans are the regions of the pancreas that contain its endocrine cells. Insulin is a peptide hormone secreted in the body by beta cells of islets of Langerhans of the pancreas and regulates blood glucose levels. Medical treatment with insulin is indicated when there is inadequate production or increased demands of insulin in the body. Option A: Progesterone (Choice A) is produced by the ovaries. Progesterone is an endogenous steroid hormone that is commonly produced by the adrenal cortex as well as the gonads, which consist of the ovaries and the testes. Progesterone is also secreted by the ovarian corpus luteum during the first ten weeks of pregnancy, followed by the placenta in the later phase of pregnancy. Option B: Testosterone (Choice B) is secreted by the testicles of males and ovaries of females. Testosterone is the primary male hormone responsible for regulating sex differentiation, producing male sex characteristics, spermatogenesis and fertility. Testosterone is responsible for the development of primary sexual development, which includes testicular descent, spermatogenesis, enlargement of the penis and testes, and increasing libido. Option D: Hemoglobin (Choice D) is a protein molecule in the red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon dioxide. Hemoglobin is an oxygen-binding protein found in erythrocytes which transports oxygen from the lungs to tissues. Each hemoglobin molecule is a tetramer made of four polypeptide globin chains. Each globin subunit contains a heme moiety formed of an organic protoporphyrin ring and a central iron ion in the ferrous state (Fe2+). The iron molecule in each heme moiety can bind and unbind oxygen, allowing for oxygen transport in the body.

A client is hospitalized for the first time, which of the following actions ensure the safety of the client? A. Keep unnecessary furniture out of the way. B. Keep the lights on at all times. C. Keep side rails up at all times. D. Keep all equipment out of view.

C. Keep side rails up at all time Keeping the side rails up at all times ensures the safety of the client. The risk of falling increases with age and the number of times someone has been in hospital. During the client's hospital stay, he may be more unsteady on his feet because of illness or surgery, or because he is unfamiliar with the hospital environment or is taking new medication. Option A: Home health care providers need to know the risk factors for falls and demonstrate effective assessment and interventions for fall and injury prevention. Falls are generally the result of a complex set of intrinsic patient and extrinsic environmental factors. Use of a fall-prevention program, standardized tools, and an interdisciplinary approach may be effective for reducing fall-related injuries. Option B: Make sure the client's pajamas, dressing gown, and day clothes are the right length so they don't trip over them. Check that their slippers or other footwear fit properly and are not slippery. If they have to wear pressure stockings, wear slippers over them so they do not slip. Option D: Keep personal items and the call button within reach to avoid standing and walking to get them. Ask for help when in need to get out of bed to use the toilet if not feeling at all unsteady.

While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse in charge to apply? A. Dry sterile dressing B. Sterile petroleum gauze C. Moist, sterile saline gauze D. Povidone-iodine-soaked gauze

C. Moist, sterile saline gauze Moist, sterile saline dressings support would heal and are cost-effective. If the wound is infected and there are a lot of sloughs, which cannot be mechanically debrided, then a chemical debridement can be done with collagenase-based products. The goal is to help the wound heal as soon as possible by using an appropriate dressing material to maintain the right amount of moisture. When the wound bed is dry, use a dressing to increase moisture and if too wet and the surrounding skin is macerated, use material that will absorb excess fluid and protect the surrounding healthy skin.

A terminally ill patient usually experiences all of the following feelings during the anger stage except: A. Rage B. Envy C. Numbness D. Resentment

C. Numbness Numbness is typical of the depression stage, when the patient feels a great sense of loss. Depression is perhaps the most immediately understandable of Kubler-Ross's stages and patients experience it with unsurprising symptoms such as sadness, fatigue, and anhedonia. Spending time in the first three stages is potentially an unconscious effort to protect oneself from this emotional pain, and, while the patient's actions may potentially be easier to understand, they may be more jarring in juxtaposition to behaviors arising from the first three stages. Option A: The anger stage includes such feelings as rage, envy, resentment, and the patient's questioning "Why me?" Anger, as Kubler-Ross pointed out, is commonly experienced and expressed by patients as they concede the reality of a terminal illness. It may be directed, as with blame of medical providers for inadequately preventing the illness, of family members for contributing to risks of not being sufficiently supportive, or of spiritual providers or higher powers for the diagnosis' injustice. Option B: Patients may feel sadness, anger, or confusion. They are experiencing the pain of loss. The task is completed as the patient begins to feel "normal" again. Option D: The anger may also be generalized and undirected, manifesting as a shorter temper or a loss of patience. Recognizing anger as a natural response can help health care providers and loved-ones to tolerate what might otherwise feel like hurtful accusations, though they must take care not to disregard criticism that may be warranted by attributing them solely to an emotional stage.

A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first? A. Call the physician B. Remedicate the patient C. Observe the emesis D. Explain to the patient that she can do nothing to help him.

C. Observe the emesis After a patient has vomited, the nurse must inspect the emesis to document color, consistency, and amount. Nausea or vomiting is another commonly seen adverse effect that is expected to diminish the following days to weeks of continued codeine exposure. Antiemetic therapies, in oral and rectal formulations, are available for the treatment of nausea or vomiting. Option A: The nurse must then notify the physician, who will decide whether to repeat the dose or prescribe an antiemetic. Monitoring should include subjective as well as objective assessment via laboratory testing. There must be documentation of pain intensity, level of functioning, progress toward therapeutic goals, the presence of adverse effects, and adherence to the therapy. Option B: In this situation, the patient recently ingested medication, so the nurse needs to check for remnants of the medication to help determine whether the patient retained enough of it to be effective. Option D: Codeine has a half-life of 3 hours. Initial dosing and titration can be individualized depending on the patient's health status, previous opioid exposure, attainment of therapeutic outcomes, and predicted or observed adverse events.

The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data? A. Vital signs B. Laboratory test result C. Patient's description of pain D. Electrocardiographic (ECG) waveforms

C. Patient's description of pain Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient's opinions or feelings about a situation. Subjective data provide clues to possible physiologic, psychological, and sociologic problems. They also provide the nurse with information that may reveal a client's risk for a problem as well as areas of strengths for the client. The information is obtained through interviewing. Vital signs, laboratory test results, and ECG waveforms are examples of objective data.

The nurse inspects a client's back and notices small hemorrhagic spots. The nurse documents that the client has: A. Extravasation B. Osteomalacia C. Petechiae D. Uremia

C. Petechiae Petechiae are small hemorrhagic spots. Petechiae are tiny purple, red, or brown spots on the skin. They usually appear on the arms, legs, stomach, and buttocks. They can also be found inside the mouth or on the eyelids. These pinpoint spots can be a sign of many different conditions — some minor, others serious. They can also appear as a reaction to certain medications. Option A: Extravasation is the leakage of fluid in the interstitial space. Extravasation is the leakage of a fluid out of its container into the surrounding area, especially blood or blood cells from vessels. In the case of inflammation, it refers to the movement of white blood cells from the capillaries to the tissues surrounding them (leukocyte extravasation, also known as diapedesis). Option B: Osteomalacia is the softening of bone tissue. Osteomalacia refers to a marked softening of the bones, most often caused by severe vitamin D deficiency. The softened bones of children and young adults with osteomalacia can lead to bowing during growth, especially in weight-bearing bones of the legs. Osteomalacia in older adults can lead to fractures. Option D: Uremia is an excess of urea and other nitrogen products in the blood. Uremia is the condition of having high levels of urea in the blood. Urea is one of the primary components of urine. It can be defined as an excess of amino acid and protein metabolism end products, such as urea and creatinine, in the blood that would be normally excreted in the urine.

After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the I.V. site reveals that it is warm and erythematous. This usually indicates: A. Infection B. Infiltration C. Phlebitis D. Bleeding

C. Phlebitis Tenderness, warmth, swelling, and, in some instances, a burning sensation are signs and symptoms of phlebitis. Superficial phlebitis affects veins on the skin surface. The condition is rarely serious and, with proper care, usually resolves rapidly. Sometimes people with superficial phlebitis also get deep vein thrombophlebitis, so a medical evaluation is necessary. Option A: Infection is less likely because no drainage or fever is present. Call a health care provider if there are signs and symptoms of swelling, pain, and inflamed superficial veins on the arms or legs. If the client is not better in a week or two or if it gets any worse, he or she should get reevaluated to make sure they don't have a more serious condition. Option B: Infiltration would result in swelling and pallor, not erythema, near the insertion site. In phlebitis, there is usually a slow onset of a tender red area along the superficial veins on the skin. A long, thin red area may be seen as the inflammation follows a superficial vein. This area may feel hard, warm, and tender. The skin around the vein may be itchy and swollen. The area may begin to throb or burn. Option D: The patient has no evidence of bleeding. Injury to a vein increases the risk of forming a blood clot. Sometimes clots occur without an injury.

Nurses and other healthcare providers often have difficulty helping a terminally ill patient through the necessary stages leading to acceptance of death. Which of the following strategies is mosthelpful to the nurse in achieving this goal? A. Taking psychology courses related to gerontology. B. Reading books and other literature on the subject of thanatology. C. Reflecting on the significance of death. D. Reviewing varying cultural beliefs and practices related to death.

C. Reflecting on the significance of death. According to thanatologists, reflecting on the significance of death helps to reduce the fear of death and enables the health care provider to better understand the terminally ill patient's feelings. It also helps to overcome the belief that medical and nursing measures have failed, when a patient cannot be cured. Thanatology is the science and study of death and dying from multiple perspectives—medical, physical, psychological, spiritual, ethical, and more. Option A: Professionals in a wide range of disciplines use thanatology to inform their work, from doctors and coroners to hospice workers and grief counselors. There also are thanatology specialists who focus on a specific aspect of the dying process or work directly with people facing their own death or that of loved ones. Option B: A wide variety of professionals incorporate thanatology into their work. How they do so depends on what they need to know about the dying process. For example, a medical examiner, coroner, doctor, nurse, or other medical practitioners might study thanatology to better understand the physical process of death—what happens to the body during death as well as immediately after. Option D: Thanatology also examines attitudes toward death, the meaning and behaviors of bereavement and grief, and the moral and ethical questions of euthanasia, organ transplants, and life support.

he nurse assesses a client's abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling "bloated" . The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema? A. Soapsuds B. Retention C. Return flow D. Oil retention

C. Return flow This provides relief of postoperative flatus, stimulating bowel motility. Options one, two, and four manage constipation and do not provide flatus relief. A return-flow enema, or Harris flush, is used to remove intestinal gas and stimulate peristalsis. A large volume fluid is used but the fluid is instilled in 100-200 ml increments. Then, the fluid is drawn out by lowering the container below the level of the bowel. This brings the flatus out with the fluid. Option A: The soapsuds enema uses a mixture of a mild soap and warm water injected into the colon in order to stimulate a bowel movement. Normally given to relieve constipation or for bowel cleansing before a medical examination or procedure. Option B: An enema that may be used to provide nourishment, medication, or anesthetic. It should be made from fluids that will not stimulate peristalsis. A small amount of solution (e.g., 100 to 250 mL) is typically used in adults. Option D: If fecal material is hardened, an oil-retention enema may be given to soften the feces. Commercially packaged enemas contain 90-120 ml solution. The patient should retain the solution to at least one hour for the enema to be effective. This enema is usually followed by a cleansing enema.

A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do? A. Leave the medication at the patient's bedside. B. Tell the patient to be sure to take the medication. And then leave it at the bedside. C. Return shortly to the patient's room and remain there until the patient takes the medication. D. Wait for the patient to return to bed, and then leave the medication at the bedside.

C. Return shortly to the patient's room and remain there until the patient takes the medication The nurse should return shortly to the patient's room and remain there until the patient takes the medication to verify that it was taken as directed. With the growing reliance on medication therapy as the primary intervention for most illnesses, patients receiving medication interventions are exposed to potential harm as well as benefits. Benefits are effective management of the illness/disease, slowed progression of the disease, and improved patient outcomes with few if any errors. Harm from medications can arise from unintended consequences as well as medication error (wrong medication, wrong time, wrong dose, etc.). Option A: The nurse should never leave medication at the patient's bedside unless specifically requested to do so. Option B: With inadequate nursing education about patient safety and quality, excessive workloads, staffing inadequacies, fatigue, illegible provider handwriting, flawed dispensing systems, and problems with the labeling of drugs, nurses are continually challenged to ensure that their patients receive the right medication at the right time. Option D: Examples of errors that can be initiated at the transcribing, dispensing, and delivering stages include failure to transcribe the order, incorrectly filling the order, and failure to deliver the correct medication for the correct patient.

Which of the following is most likely to validate that a client is experiencing intestinal bleeding? A. Large quantities of fat mixed with pale yellow liquid stool B. Brown, formed stool C. Semi soft tar colored stools D. Narrow, pencil shaped stool

C. Semi soft tar colored stools Blood in the upper GI tract is black and tarry. Gastrointestinal (GI) bleeding is a symptom of a disorder in the digestive tract. The blood often appears in stool or vomit but isn't always visible, though it may cause the stool to look black or tarry. The level of bleeding can range from mild to severe and can be life-threatening. Option A: This can be a sign of malabsorption in an infant. Malabsorption syndromes encompass numerous clinical entities that result in chronic diarrhea, abdominal distention, and failure to thrive. Clinical malabsorption can be broken down into several distinct conditions, both congenital and acquired, that affect one or more of the different steps in the intestinal hydrolysis and subsequent transport of nutrients. Option B: Brown, formed stool is a normal stool. Anywhere between a firm and soft consistency is pretty much normal. If it sways one way or another, it could suggest some digestion or fiber issues. Option D: Narrow, pencil-shaped stool is a characteristic of an obstructive condition of the rectum. Narrow stools that occur infrequently probably are harmless. However in some cases, narrow stools — especially if pencil thin — may be a sign of narrowing or obstruction of the colon due to colon cancer.

A muscular enlarged pouch or sac that lies slightly to the left which is used for temporary storage of food... A. Gallbladder B. Urinary bladder C. Stomach D. Lungs E. Rugae of the stomach

C. Stomach The stomach is a muscular organ located on the left side of the upper abdomen. It is a saclike expansion of the digestive tract of a vertebrate that is located between the esophagus and duodenum. The major part of the digestion of food occurs in the stomach. Option A: The gallbladder is a small hollow organ about the size and shape of a pear. It is a part of the biliary system, also known as the biliary tree or biliary tract. The biliary system is a series of ducts within the liver, gallbladder, and pancreas that empty into the small intestine. There are intrahepatic (within the liver) and extrahepatic (outside of the liver) components. The gallbladder is a component of the extrahepatic biliary system where bile is stored and concentrated. Option B: The bladder forms an integral part of the genitourinary system. Urine, created by the kidneys, is drained into the bladder by the bilateral ureters. The bladder then acts as the storage site for this waste product until higher-order centers within the central nervous system initiate the micturition (i.e., urination) process, which permits the expulsion of urine into the urethra, located on the inferior aspect of the bladder. Option D: The purpose of the lung is to provide oxygen to the blood. Anatomically, the lung has an apex, three borders, and three surfaces. The apex lies above the first rib. The function of the lung is to get oxygen from the air to the blood, performed by the alveoli. The alveoli are a single cell membrane that allows for gas exchange to the pulmonary vasculature. There are a couple of muscles that help with inspiration and expiration, such as the diaphragm and intercostal muscles. Option E. The inner layer of the stomach is full of wrinkles known as rugae (or gastric folds). Rugae both allow the stomach to stretch in order to accommodate large meals and help to grip and move food during digestion

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy? A. The stoma extends 1/2 inch above the abdomen. B. The skin under the appliance looks red briefly after removing the appliance. C. The stoma color is a deep red purple. D. An ascending colostomy just delivers liquid feces.

C. The stoma color is a deep red purple. An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. A stoma is the exteriorization of a loop of bowel from the anterior abdominal wall, done during a surgical procedure. It is done for diversion or decompression of the remaining bowel. It may be temporary or permanent, depending on the indication for which it was performed. Most stomas are incontinent, which means that there is no voluntary control over the passage of flatus and feces from the stoma. Option A: The stoma should be assessed and must be moist, above skin level, and pink to red in color, and the peristomal skin should be normal. Any deviation from this should be notified to the surgeon. The stoma should be measured, or the previous measurement remembered and size should not be more than 1/16-1/8. Option B: The skin under the appliance may remain pink/red for a while after the adhesive is pulled off. The peristomal skin should be dried appropriately to allow good seal formation. Adhesive pastes or powders may also be applied peristomally. The paper cover on the back of the flange is then removed with the border tape in place. It is then placed around the stoma and held in place for 1 to 2 minutes to create an adequate seal. Option D: Feces from an ascending ostomy are very liquid, less so from a transverse ostomy, and more solid from a descending or sigmoid stoma. Colostomy diarrhea may be complained by the patient in case of ascending or transverse colostomies in case they are not fully explained about the nature of content expected, but stomal diarrhea may be the result of extensive resection with failure of bowel adaptation or if associated with short bowel syndrome.

When examining a patient with abdominal pain the nurse in charge should assess: A. Any quadrant first B. The symptomatic quadrant first C. The symptomatic quadrant last D. The symptomatic quadrant either second or third

C. The symptomatic quadrant last The nurse should systematically assess all areas of the abdomen, if time and the patient's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This would interfere with further assessment. Option A: When possible, the history should be obtained from a non sedated patient. The initial differential diagnosis can be determined by a delineation of the pain's location, radiation, and movement (e.g., appendicitis-associated pain usually moves from the periumbilical area to the right lower quadrant of the abdomen). Option B: After the location is identified, the physician should obtain general information about onset, duration, severity, and quality of pain and about exacerbating and remitting factors. Option D: There are several specialized maneuvers that evaluate for signs associated with causes of abdominal pain. When present, some signs are highly predictive of certain diseases.

A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and the provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as: A. Unbundling B. Overbilling C. Upcoding D. Misrepresentation

C. Upcoding Upcoding is the practice of using a CPT code that's reimbursed at a higher rate than the code for the service actually provided. Upcoding is fraudulent medical billing in which a bill sent for a health service is more expensive than it should have been based on the service that was performed. An upcoded bill can be sent to any payer—whether a private health insurer, Medicaid, Medicare, or the patient. Unbundling, overbilling, and misrepresentation aren't the terms used for this illegal practice. Option A: Unbundling refers to using multiple CPT codes for those parts of the procedure, either due to misunderstanding or in an effort to increase payment. Option B: Overbilling (sometimes spelled as over-billing) is the practice of charging more than is legally or ethically acceptable on an invoice or bill. Option D: A misrepresentation is a false statement of a material fact made by one party which affects the other party's decision in agreeing to a contract. If the misrepresentation is discovered, the contract can be declared void, and depending on the situation, the adversely impacted party may seek damages.

Which of the following is the meaning of PRN? A. When advice B. Immediately C. When necessary D. Now.

C. When necessary PRN comes from the Latin "pro re nata" meaning, "for an occasion that has arisen or as circumstances require". When an abbreviation is less known outside of the organization or clinical specialty, it is necessary to spell out the abbreviation throughout the discharge summary to prevent misunderstanding and confusion by the physician or health care organization that receives the summary.

A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written? A. Within 1 month B. Within 3 months C. Within 6 months D. Within 12 months

C. Within 6 months In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date on which the prescription was written. A common reason people seek the care of medical professionals is pain relief. While many categories of pain medications are available, opioid analgesics are FDA-approved for moderate to severe pain. As such, they are a common choice for patients with acute, cancer-related, neurologic, and end-of-life pain. The prescribing of opioid analgesics for chronic pain is controversial and fraught with inconclusive standards.

The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. How much of the drug should the nurse give? A. 2 ml B. 1 ml C. ½ ml D. ¼ ml

C. ½ ml The nurse should give ½ ml of the drug. The dosage is calculated as follows: 250 mg/X=500 mg/1 ml 500x=250X=1/2 ml

The nurse is recording assessment data. She writes, "The patient seems worried about his surgery. Other than that, he had a good night." Which errors did the nurse make? Select all that apply. A. Used a vague generality. B. Did not use the patient's exact words. C. Used a "waffle" word (e.g., appears). D. Recorded an inference rather than a cue. E. Did not record the patient's vital signs.

Correct Answer: A, C, D & E The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected. Subjective and objective data collection are an integral part of this process. Option A: The nurse recorded a vague generality: "he has had a good night." The assessment identifies current and future care needs of the patient by allowing the formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care. Option B: The nurse did not use the patient's exact words, but she did not quote the patient at all, so that is not one of her errors. Option C: The nurse used the "waffle" word, "seems" worried instead of documenting what the patient said or did to lead her to that conclusion. Asking about how the client feels and their response to those feelings is part of a psychological assessment. Option D: The nurse recorded these inferences: worried and had a good night. The psychological examination may include perceptions, whether justifiable or not, on the part of the patient or client. Religion and cultural beliefs are critical areas to consider. Option E: Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using age or condition appropriate pain scale.

Nurse Elijah has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein? A. Baked beans, hamburger, and milk B. Spaghetti with cream sauce, broccoli, and tea C. Bouillon, spinach, and soda D. Chicken cutlet, spinach, and soda

Correct Answer: A. Baked beans, hamburger, and milk Baked beans, hamburger, and milk are all excellent sources of protein. Good choices include soy protein, beans, nuts, fish, skinless poultry, lean beef, pork, and low-fat dairy products. Avoid processed meats. Option B: The spaghetti-broccoli-tea choice is high in carbohydrates. The quality of the carbohydrates (carbs) one eats is important too. Cut processed carbs from the diet, and choose carbs that are high in fiber and nutrient-dense, such as whole grains and vegetables and fruit. Option C: The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Option D: Chicken provides protein but the chicken-spinach-soda combination provides less protein than the baked beans-hamburger-milk selection.

What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to: A. Identify personal biases that may affect his thinking and actions. B. Identify the most effective interventions for a patient. C. Communicate more efficiently with colleagues, patients, and families. D. Learn and remember new procedures and techniques.

Correct Answer: A. Identify personal biases that may affect his thinking and actions. The most basic reason is that self-knowledge directly affects the nurse's thinking and the actions he chooses. Indirectly, thinking is involved in identifying effective interventions, communicating, and learning procedures. However, because identifying personal biases affect all the other nursing actions, it is the most basic reason.

Five teaspoons is equivalent to how many milliliters (ml)? A. 30 ml B. 25 ml C. 12 ml D. 22 ml

Correct Answer: B. 25 ml One teaspoon is equal to 5ml. Drug calculations require the use of conversion factors, for example, when converting from pounds to kilograms or liters to milliliters. Simplistic in design, this method allows clinicians to work with various units of measurement, converting factors to find the answer. These methods are useful in checking the accuracy of the other methods of calculation, thus acting as a double or triple check.

This is characterized by severe symptoms relatively of short duration. A. Chronic Illness B. Acute Illness C. Pain D. Syndrome

Correct Answer: B. Acute Illness Acute illnesses are different than chronic illnesses in that they usually develop quickly and they only last a short time - usually a few days or weeks. Acute illnesses are often caused by viral or bacterial infections.

How should the nurse modify the examination for a 7-year-old child? A. Ask the parents to leave the room before the examination. B. Demonstrate equipment before using it. C. Allow the child to help with the examination. D. Perform invasive procedures (e.g., otoscopic) last.

Correct Answer: B. Demonstrate equipment before using it. The nurse should modify his examination by demonstrating equipment before using it to examine a school-age child. The physical examination is often the first direct contact between the nurse and the child. Establishing a trusting relationship between the child and the examiner is important. Throughout the examination the nurse should be sensitive to the cultural needs of and differences among children. Providing a quiet, private environment for the history and physical examination is important. The classic systematic approach to the physical examination is to begin at the head and proceed through the entire body to the toes. When examining a child, however, the examiner tailors the physical assessment to the child's age and developmental level. Option A: The nurse should make sure parents are not present during the physical examination of an adolescent, but they usually help younger children feel more secure. To establish trust with the school-age child, the examiner asks the child questions the child can answer. Children in elementary school will talk about school, favorite friends, and activities. Older school-age children may have to be encouraged to talk about their school performance and activities. The examiner encourages the parent to support and reinforce the child's participation in the examination. Option C: The nurse should allow a preschooler to help with the examination when possible, but not usually a school-age child. The examination proceeds from head to toe. Children of this age prefer a simple drape over their underpants or a colorful examination gown, and the examiner should be sensitive to the child's modesty. The examination is a wonderful opportunity to teach the child about the body and personal care. The nurse answers questions openly and in simple terms. Option D: It is best to perform invasive procedures last for all age groups; therefore, this does not represent a modification. Toddlers are often fearful of invasive procedures, so those should be performed last in this age group.

In which step of the nursing process does the nurse analyze data and identify client problems? A. Assessment B. Diagnosis C. Planning outcomes D. Evaluation

Correct Answer: B. Diagnosis In the diagnosis phase, the nurse identifies the client's health status. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family, or community.

Which of the following is the abbreviation of drops? A. Gtt. B. Gtts. C. Dp. D. Dr.

Correct Answer: B. Gtts. Gtt (Choice A) is an abbreviation for drop. Dp and Dr are not recognized abbreviations for measurement. Standardization and uniform use of codes, symbols, and abbreviations can improve communication and understanding between health care practitioners, leading to safer and more effective care for patients.

A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client? A. Promote fluid balance B. Prevent infection C. Promote rest D. Prevent injury

Correct Answer: B. Prevent infection The client is at risk for infection because WBC count is dangerously low. Neutrophils play an essential role in immune defenses because they ingest, kill, and digest invading microorganisms, including fungi and bacteria. Failure to carry out this role leads to immunodeficiency, which is mainly characterized by the presence of recurrent infections. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.

The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How should she position the patient to begin and perform most of the physical examination? A. Dorsal recumbent B. Semi-Fowler's C. Lithotomy D. Sims'

Correct Answer: B. Semi-Fowler's If a patient is unable to sit up, the nurse should place him lying flat on his back, with the head of the bed elevated. The Semi-Fowler's position is a position in which a patient, typically in a hospital or nursing home is positioned on their back with the head and trunk raised to between 15 and 45 degrees, although 30 degrees is the most frequently used bed angle. Option A: Dorsal recumbent position is used for abdominal assessment if the patient has abdominal or pelvic pain. The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the bed. Option C: Lithotomy position is used for female pelvic examination. It is similar to dorsal recumbent position, except that the patient's legs are well separated and thighs are acutely flexed. Feet are usually placed in stirrups. Fold sheet or bath blanket crosswise over thighs and legs so that genital area is easily exposed. Keep the patient covered as much as possible. Option D: The patient in Sim's position is on the left side with right knee flexed against abdomen and left knee slightly flexed. Left arm is behind the body; the right arm is placed comfortably. Sims' position is used to examine the rectal area. In semi-Fowler's position, the patient is supine with the head of the bed elevated and legs slightly elevated.

A client who is unconscious needs frequent mouth care. When performing mouth care, the bestposition of a client is: A. Fowler's position B. Side-lying C. Supine D. Trendelenburg

Correct Answer: B. Side-lying An unconscious client is best placed on his side when doing oral care to prevent aspiration. An unconscious patient is placed in the side-lying position when mouth care is provided because this position prevents pooling of secretions at the back of the oral cavity, thereby reducing the risk of aspiration. Oral hygiene is especially important for patients receiving oxygen therapy, patients who have nasogastric tubes, and patients who are NPO. Their oral mucosa dries out much faster than normal due to their mouth-breathing. Option A: A soft toothbrush or gauze-padded tongue blade may be used to clean the teeth and mouth. The patient should be positioned in the lateral position with the head turned toward the side to provide for drainage and to prevent aspiration. Option C: This is the most common position for surgery with a patient lying on his or her back with head, neck, and spine in neutral positioning and arms either adducted alongside the patient or abducted to less than 90 degrees. Option D: A variation of supine in which the head of the bed is tilted down such that the pubic symphysis is the highest point of the trunk facilitates venous return and improves exposure during abdominal and laparoscopic surgeries.

The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to: Select all that apply. A. A body systems model B. A head-to-toe framework C. Maslow's hierarchy of needs D. Gordon's functional health patterns E. Adaptation Model of Nursing

Correct Answer: C & D Nursing models produce a holistic database that is useful in identifying nursing rather than medical diagnoses. Body systems and Maslow's hierarchy is not a nursing model, but it is holistic, so it is acceptable for identifying nursing diagnoses. Gordon's functional health patterns are a nursing model. Option A: A body system model is not a nursing model. It is a representation of all the systems of the body in a figurine. Option B: Head-to-toe framework is not a nursing model, and they are not holistic; they focus on identifying physiological needs or disease. Option C: Maslow's hierarchy of needs is a motivational theory in psychology comprising a five-tier model of human needs, often depicted as hierarchical levels within a pyramid. From the bottom of the hierarchy upwards, the needs are: physiological (food and clothing), safety (job security), love and belonging needs (friendship), esteem, and self-actualization. Option D: Gordon's functional health patterns is a method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more comprehensive nursing assessment of the patient. Option E: The Adaptation Model of Nursing is a prominent nursing theory aiming to explain or define the provision of nursing science. In her theory, Sister Callista Roy's model sees the individual as a set of interrelated systems that strives to maintain a balance between various stimuli.

The nurse should use the diaphragm of the stethoscope to auscultate which of the following? A. Heart murmurs B. Jugular venous hums C. Bowel sounds D. Carotid bruits

Correct Answer: C. Bowel sounds The bell of the stethoscope should be used to hear low-pitched sounds, such as murmurs, bruits, and jugular hums. The diaphragm should be used to hear high-pitched sounds that normally occur in the heart, lungs, and abdomen. The diaphragm is best for higher-pitched sounds, like breath sounds and normal heart sounds. The bell is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds. Option A: Earpieces should be angled forwards to match the direction of the practitioner's external auditory meatus. The bell is used to hear low-pitched sounds. Use for mid-diastolic murmur of mitral stenosis or S3 in heart failure. Option B: The stethoscope bell is lightly applied in each supraclavicular fossa over the subclavian artery. As usual, the examiner's free hand palpates the contralateral carotid pulse for timing purposes. If a bruit is appreciated, firmly compress the patient's ipsilateral radial artery, noting the effect on the murmur. Option D: If the intensity of sound is greater above the clavicle it is most likely a carotid bruit. If it is louder below the clavicle it is most likely a heart murmur. Use either the bell or the diaphragm when listening for the carotid bruit, at a point just lateral to Adam's apple.

Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions? A. Providing a back massage. B. Feeding a client. C. Providing hair care. D. Providing oral hygiene.

Correct Answer: D. Providing oral hygiene Doing oral care requires the nurse to wear gloves. Standard precautions apply to the care of all patients, irrespective of their disease state. These precautions apply when there is a risk of potential exposure to (1) blood; (2) all body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood; (3) non-intact skin, and (4) mucous membranes. This includes the use of hand hygiene and personal protective equipment (PPE), with hand hygiene being the single most important means to prevent transmission of disease. Option A: Must be worn when touching blood, body fluids, secretions, excretions, mucous membranes, or non-intact skin. Change when there is contact with potentially infected material in the same patient to avoid cross-contamination. Remove before touching surfaces and clean items. Wearing gloves does not mitigate the need for proper hand hygiene. Option B: Hand washing after feeding the client is sufficient. Handwashing with soap and water for at least 40 to 60 seconds, making sure not to use clean hands to turn off the faucet, must be performed if hands are visibly soiled, after using the restroom, or if potential exposure to spore-forming organisms. Option C: Gloves are not needed in providing hair care. Hand rubbing with alcohol applied generously to cover hands completely should be performed and hands rubbed until dry.

The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the physician's office for a college physical. This patient is considered: A. Obese B. Overweight C. Average D. Underweight

Correct Answer: D. Underweight For adults, BMI should range between 20 and 25. Body mass index (BMI) is a person's weight in kilograms divided by the square of height in meters. BMI is an inexpensive and easy screening method for the weight category—underweight, healthy weight, overweight, and obesity. Option A: BMI greater than 30 is considered obese For adults 20 years old and older, BMI is interpreted using standard weight status categories. These categories are the same for men and women of all body types and ages. Option B: BMI 25 to 29.9 is overweight. The prevalence of adult BMI greater than or equal to 30 kg/m2 (obese status) has greatly increased since the 1970s. Recently, however, this trend has leveled off, except for older women. Obesity has continued to increase in adult women who are 60 years and older. Option C: BMI less than 20 is considered underweight. BMI can be a screening tool, but it does not diagnose the body fatness or health of an individual. To determine if BMI is a health risk, a healthcare provider performs further assessments. Such assessments include skinfold thickness measurements, evaluations of diet, physical activity, and family history.

A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient's anxiety? A. "Everything will be fine. Don't worry." B. "Read this manual and then ask me any questions you may have." C. "Why don't you listen to the radio?" D. "Let's talk about what's bothering you."

D. "Let's talk about what's bothering you." Anxiety may result from feelings of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals together with the patient to give the patient some control over an anxiety-inducing situation. Because the other options ignore the patient's feelings and block communication, they would not reduce anxiety. Option A: Recognize awareness of the patient's anxiety. Since a cause of anxiety cannot always be identified, the patient may feel as though the feelings being experienced are counterfeit. Acknowledgment of the patient's feelings validates the feelings and communicates acceptance of those feelings. Option B: Converse using a simple language and brief statements. Allow patients to talk about anxious feelings and examine anxiety-provoking situations if they are identifiable. Talking about anxiety-producing situations and anxious feelings can help the patient perceive the situation realistically and recognize factors leading to the anxious feelings. Option C: Assist the patient in developing new anxiety-reducing skills (e.g., relaxation, deep breathing, positive visualization, and reassuring self-statements). Discovering new coping methods provides the patient with a variety of ways to manage anxiety.

Which of the following cluster of data belong to Maslow's hierarchy of needs A. Love and belonging B. Physiological needs C. Self actualization D. All of the above

D. All of the above All of the choices are part of Maslow's Hierarchy of Needs. Maslow first introduced his concept of a hierarchy of needs in his 1943 paper "A Theory of Human Motivation" and his subsequent book Motivation and Personality. This hierarchy suggests that people are motivated to fulfill basic needs before moving on to other, more advanced needs. As a humanist, Maslow believed that people have an inborn desire to be self-actualized, that is, to be all they can be. In order to achieve these ultimate goals, however, a number of more basic needs must be met such as the need for food, safety, love, and self-esteem.

Which of the following is the nurse's legal responsibility when applying restraints? A. Document the patient's behavior. B. Document the type of restraint used. C. Obtain a written order from the physician except in an emergency, when the patient must be protected from injury to himself or others. D. All of the above.

D. All of the above. When applying restraints, the nurse must document the type of behavior that prompted her to use them, document the type of restraints used, and obtain a physician's written order for the restraints. Nurses are accountable for providing, facilitating, advocating and promoting the best possible patient care and to take action when patient safety and well-being are compromised, including when deciding to apply restraints. Option A: Restraint use should be continually assessed by the health care team and reduced or discontinued as soon as possible. After the discontinuing restraints, interprofessional teams should debrief with the patient, patient's family, or substitute decision maker to discuss intervention, previous interventions and alternatives to restraints. Option B: There are three types of restraints: physical, chemical and environmental. Physical restraints limit a patient's movement. Chemical restraints are any form of psychoactive medication used not to treat illness, but to intentionally inhibit a particular behaviour or movement. Environmental restraints control a patient's mobility. Option C: With any intervention, such as restraint use, nurses need to ensure they actively involve the patient, patient's family, substitute decision-makers and the broader health care team. Nurses are also accountable for documenting nursing care provided, including assessment, planning, intervention and evaluation. In emergency situations, nurses may apply restraints without consent when a serious threat of harm to the patient or others exists and only after all alternative interventions were unsuccessful.

A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time? A. Impaired gas exchanges related to increased blood flow. B. Fluid volume excess related to peripheral vascular disease. C. Risk for injury related to edema. D. Altered peripheral tissue perfusion related to venous congestion.

D. Altered peripheral tissue perfusion related to venous congestion. Altered peripheral tissue perfusion related to venous congestion" takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the leg, but can occur in the veins of the arms and the mesenteric and cerebral veins. Deep-vein thrombosis is a common and important disease. It is part of the venous thromboembolism disorders which represent the third most common cause of death from cardiovascular disease after heart attacks and stroke. Option A: Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Depending on the relative balance between the coagulation and thrombolytic pathways, thrombus propagation occurs. DVT is commonest in the lower limb below the knee and starts at low-flow sites, such as the soleal sinuses, behind venous valve pockets. Option B: Option B is inappropriate because no evidence suggests that this patient has a fluid volume excess. Nurses need to educate the patients on the importance of ambulation, being compliant with compression stockings, and taking the prescribed anticoagulation medications. Option C: Option C may be warranted but is secondary to altered tissue perfusion. Thrombosis is a protective mechanism that prevents the loss of blood and seals off damaged blood vessels. Fibrinolysis counteracts or stabilizes the thrombosis. The triggers of venous thrombosis are frequently multifactorial, with the different parts of the triad of Virchow contributing in varying degrees in each patient, but all result in early thrombus interaction with the endothelium. This then stimulates local cytokine production and causes leukocyte adhesion to the endothelium, both of which promote venous thrombosis.

To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test? A. Red blood cell count B. Sputum culture C. Total hemoglobin D. Arterial blood gas (ABG) analysis

D. Arterial blood gas (ABG) analysis All of these tests help evaluate a patient with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about a patient's oxygenation status. An acceptable normal range of ABG values of ABG components are the following,[5][6] noting that the range of normal values may vary among laboratories, and in different age groups from neonates to geriatrics: pH (7.35-7.45) PaO2 (75-100 mmHg) PaCO2 (35-45 mmHg). Option A: A red blood cell count is a blood test that the doctor uses to find out how many red blood cells (RBCs) a person has. It's also known as an erythrocyte count. The test is important because RBCs contain hemoglobin, which carries oxygen to the body's tissues. The number of RBCs one has can affect how much oxygen the tissues receive. The tissues need oxygen to function. Option B: A sputum culture is a test that checks for bacteria or another type of organism that may be causing an infection in the lungs or the airways leading to the lungs. Sputum, also known as phlegm, is a thick type of mucus made in the lungs. Option C: The normal range for hemoglobin is: For men, 13.5 to 17.5 grams per deciliter. For women, 12.0 to 15.5 grams per deciliter.

The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol? A. Lethal arrhythmias B. Malignant hypertension C. Status epilepticus D. Bone marrow suppression

D. Bone marrow suppression The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is a synthetically manufactured broad-spectrum antibiotic. It was initially isolated from the bacteria Streptomyces venezuelae in 1948 and was the first bulk produced synthetic antibiotic. However, chloramphenicol is a rarely used drug in the United States because of its known severe adverse effects, such as bone marrow toxicity and grey baby syndrome. Chloramphenicol is not known to cause lethal arrhythmias, malignant hypertension, or status epilepticus. Option A: Chloramphenicol is associated with severe hematological side effects when administered systemically. Since 1982, chloramphenicol has reportedly caused fatal aplastic anemia, with possible increased risk when taken together with cimetidine. This adverse side effect can occur even with the topical administration of the drug, which is most likely due to the systemic absorption of the drug after topical application. Option B: Besides causing fatal aplastic anemia and bone marrow suppression, other side effects of chloramphenicol include ototoxicity with the use of topical ear drops, gastrointestinal reactions such as oesophagitis with oral use, neurotoxicity, and severe metabolic acidosis. Option C: Optic neuritis is the most commonly associated neurotoxic complication that can arise from chloramphenicol use. This adverse effect usually takes more than six weeks to manifest, presenting with either acute or subacute vision loss, with possible fundal changes. It may also present with peripheral neuropathy, which may present as numbness or tingling. If optic neuropathy occurs, the drug should be withdrawn immediately, which will usually lead to partial or complete recovery of vision.

Which pulse should the nurse palpate during rapid assessment of an unconscious male adult? A. Radial B. Brachial C. Femoral D. Carotid

D. Carotid During a rapid assessment, the nurse's first priority is to check the patient's vital functions by assessing his airway, breathing, and circulation. To check a patient's circulation, the nurse must assess his heart and vascular network function. This is done by checking his skin color, temperature, mental status and, most importantly, his pulse. The nurse should use the carotid artery to check a patient's circulation. Option A: In a patient with circulatory problems or a history of compromised circulation, the radial pulse may not be palpable. Examiners frequently evaluate the radial artery during a routine examination of adults, due to the unobtrusive position required to palpate it and its easy accessibility in various types of clothing. Like other distal peripheral pulses (such as those in the feet) it also may be quicker to show signs of pathology. Option B: The brachial pulse is palpated during rapid assessment of an infant. The brachial artery is often the site of evaluation during cardiopulmonary resuscitation of infants. It is palpated proximal to the elbow between the medial epicondyle of the humerus and the distal biceps tendon. Option C: The femoral pulse may be the most sensitive in assessing for septic shock and is routinely checked during resuscitation. It is palpated distally to the inguinal ligament at a point less than halfway from the pubis to the anterior superior iliac spine.

A client with chronic pulmonary disease has a bluish tinge around the lips. The nurse charts which term to most accurately describe the client's condition? A. Hypoxia B. Hypoxemia C. Dyspnea D. Cyanosis

D. Cyanosis A bluish tinge to mucous membranes is called cyanosis. This is most accurate because it is what the nurse observes. Cyanosis refers to a bluish cast to the skin and mucous membranes. Peripheral cyanosis is when there is a bluish discoloration to the hands or feet. It's usually caused by low oxygen levels in the red blood cells or problems getting oxygenated blood to the body.

A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction? A. Asking frequently if the patient understands the instruction. B. Asking an interpreter to replay the instructions to the patient. C. Writing out the instructions and having a family member read them to the patient. D. Demonstrating the procedure and having the patient return the demonstration.

D. Demonstrating the procedure and having the patient return the demonstration. Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. One of the leading causes of medical errors in the United States is miscommunication between patients and providers. When patients with limited English proficiency (LEP) cannot adequately communicate their needs, they are less likely to comply with medical instructions and receive vital services. Option A: Patients may claim to understand discharge instruction when they do not. In-person translation services are preferred when complex medical information or end-of-life decisions are to be discussed. Studies show in-person professional interpretation increases patient satisfaction and outcomes of care. Interpreters use visual cues to enhance communication. However, in-person interpreters can be costly and can limit the number of languages that can be adequately staffed. Option B: Internet-based apps for smartphones and tablets help medical professionals interpret information quickly so they can be used in emergency settings. Experts warn, however, that the one-sided nature of such applications can lead to missed or misconstrued information. Option C: An interpreter of family members may communicate verbal or written instructions inaccurately. In some cases, patients prefer to use their family and friends as medical interpreters, but experts recommend against the practice because vital information may be lost.

Question Nurse Nikki is revising a client's care plan. During which step of the nursing process does such revision take place? A. Assessment B. Planning C. Implementation D. Evaluation

D. Evaluation During the evaluation step of the nursing process, the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions.

In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem? A. Assessment B. Diagnosis C. Planning outcomes D. Evaluation

D. Evaluation During the implementation phase, the nurse carries out the interventions or delegates them to other health care team members. During the evaluation phase, the nurse judges whether her actions have been successful in treating or preventing the identified client health problem. This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data.

A female client is admitted to the emergency department with complaints of chest pain and shortness of breath. The nurse's assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distension, it's typically due to: A. A neck tumor B. An electrolyte imbalance C. Dehydration D. Fluid overload

D. Fluid overload Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend, which can be seen most obviously in the neck veins. JVD is a sign of increased central venous pressure (CVP). That's a measurement of the pressure inside the vena cava. CVP indicates how much blood is flowing back into the heart and how well the heart can move that blood into the lungs and the rest of the body. Option A: A neck tumor doesn't typically cause jugular vein distention. Right-sided heart failure is a common cause. Right-sided heart failure usually develops after a left-sided heart failure. The left ventricle pumps blood out through the aorta to most of the body. The right ventricle pumps blood to the lungs. When the left ventricle's pumping power weakens, fluid can back up into the lungs. This eventually weakens the right ventricle. Option B: An electrolyte imbalance may result in fluid overload, but it doesn't directly contribute to jugular vein distention. The pericardium is a thin, fluid-filled sac that surrounds the heart. An infection of the pericardium, called constrictive pericarditis, can restrict the volume of the heart. As a result, the chambers can't fill with blood properly, so blood can back up into veins, including the jugular veins. Option C: Dehydration does not cause JVD. Another common cause is pulmonary hypertension. Pulmonary hypertension occurs when the pressure in your lungs increases, sometimes as a result of changes to the lining of the artery walls. This can also lead to right-sided heart failure.

A patient with the diagnosis of diverticulosis is advised to eat a diet high in fiber. What should the nurse recommend that the patient eat to best increase the bulk and fecal material? A. Whole wheat bread B. White rice C. Pasta D. Kale

D. Kale Kale is an excellent source of dietary fiber. A serving of 3 1/2 ounces of kale contains 6.6 g of dietary fiber. Fiber is a very important component of our diet and comes from plant-based food sources (fruits, vegetables, legumes and whole grains). Different food sources contain different types of fiber and resistant starches and the side effects depend on the individual's microbiome (gut bacteria). Instead of avoiding fiber altogether, you may want to identify the certain types of food that cause the distress.

A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema? A. Oil retention B. Return flow C. High large volume D. Low, small volume

D. Low, small volume Small volume enemas along with other preparations are used to prepare the client for this procedure. The small volume enema is used to clean the lower portion of the colon or the sigmoid. This type of cleansing enema is often used for the patient who is constipated but does not need cleansing of the higher colon. The amount used is less than 500 ml and the bag is raised no higher than 12 inches. Option A: An oil retention enema is used to soften hard stool. A rectal injection of mineral oil or vegetable Oil, introduced at low pressure and retained for 30 minutes to 3 hours before being expelled. given to soften feces in cases of constipation or impaction. The volume of oil is relatively low, four to six ounces are commonly used, which allows the oil to be more easily retained. Option B: Return flow enemas help expel flatus because of the risk of loss of fluid and electrolytes A return-flow enema, or Harris flush, is used to remove intestinal gas and stimulate peristalsis. A large volume fluid is used but the fluid is instilled in 100-200 ml increments. Then, the fluid is drawn out by lowering the container below the level of the bowel. This brings the flatus out with the fluid. Option C: High, large volume enemas are seldom used. The purpose of a large volume enema is to clean as much of the colon as possible of feces, as an intervention for constipation as well as "bowel prep" before a diagnostic procedure. The amount used is 500-1000 ml and the bag is raised as high as 18 inches above the anal opening. The patient is instructed to retain and hold the fluid as long as possible to induce peristalsis and cause evacuation of feces.

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention? A. Have a client hold his breath briefly. B. Discontinue the fluid installation. C. Remind the client that cramping is common at this time. D. Lower the enema fluid container.

D. Lower the enema fluid container. To relieve the client's discomfort, the nurse should slow the rate of installation by reducing the height of the enema solution container. An enema may be helpful when there is a problem forming or passing stool. The colon, also called the large intestine or large bowel, is a long, hollow organ in the abdomen. It plays an important role in digestion by removing water from digested material and forming feces (stool). In some circumstances, due to diet, medical condition, or medication, among other possible causes, the bowel may form stool that is hard to pass easily resulting in constipation. Option A: Taking slow, deep breaths is more therapeutic for easing discomfort than holding the breath. A cleansing enema can also lower the amount of bacteria in the colon and reduce the risk of infection for certain surgeries. Option B: The nurse should stop the installation if the client's abdomen becomes rigid and distended or if the nurse notes bleeding from the rectum. An enema should not be painful when administered properly. The client may feel fullness, mild pressure, or brief, minimal cramping during the procedure. The client may also feel like he needs to have a bowel movement. Option C: This intervention is not therapeutic as it implies that the client must tolerate the discomfort and that the nurse cannot or will not do anything to ease it. The client may take a few long, deep breaths to help himself relax. If he has pain or discomfort while self-inserting an enema, stop and contact the doctor.

A practitioner orders a return flow enema (Harris flush drip) for an adult patient with flatulence. When preparing to administer this enema the nurse compares the steps of a return flow enema with cleansing enemas. What should the nurse do that is unique to a return flow enema? A. Lubricate the last 2 inches of the rectal tube. B. Insert the rectal tube about 4 inches into the anus. C. Raise the solution container about 12 inches above the anus. D. Lower the solution container after instilling about 150 mL of solution.

D. Lower the solution container after instilling about 150 mL of solution. Lowering the container of solution creates a siphon effect that pulls the instilled fluid back out through the rectal tube into the solution container. The return flow promotes the evacuation of gas from the intestines. This technique is used only with a return flow enema. This action is appropriate for all types of enemas. Option A: All rectal tubes should be lubricated to facilitate entry of the tube into the anus and rectum and prevent mucosal trauma. Use a solution at a temperature of 105o to 110oF in adults and 100oF in children. Cool solutions will increase the incidence of cramping. Option B: The anal canal is 1 to 2 inches long. Inserting the rectal tube 3 to 4 inches ensures that the tip of the tube is beyond the anal sphincter. The recommended position for the patient during enema administration is lying in the left lateral position with their right leg flexed as much as possible. Option C: The solution container should be raised no higher than 12 inches for all enemas; this allows the solution to instill slowly, which limits discomfort and intestinal spasms. Alternately, raise the enema container 12-18 inches above the rectum for an adult and administer approximately 200 ml of fluid, then lower the container 12-18 inches below the patient's rectum until no further flatus is seen.

An autoclave is used to sterilize hospital supplies because: A. More articles can be sterilized at a time. B. Steam causes less damage to the materials. C. A lower temperature can be obtained. D. Pressurized steam penetrates the supplies better.

D. Pressurized steam penetrates the supplies better. Option A: Autoclaves provide a physical method for disinfection and sterilization. They work with a combination of steam, pressure, and time. Autoclaves operate at high temperature and pressure in order to kill microorganisms and spores. They are used to decontaminate certain biological waste and sterilize media, instruments and lab ware. Regulated medical waste that might contain bacteria, viruses and other biological material are recommended to be inactivated by autoclaving before disposal. Option B: The rate of exhaust will depend upon the nature of the load. Dry material can be treated in a fast exhaust cycle, while liquids and biological waste require slow exhaust to prevent boiling over of superheated liquids. Option C: To be effective, the autoclave must reach and maintain a temperature of 121° C for at least 30 minutes by using saturated steam under at least 15 psi of pressure. Increased cycle time may be necessary depending upon the make-up and volume of the load.

Restraints can be used for all of the following purposes except to: A. Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary catheters. B. Prevent a patient from falling out of bed or a chair. C. Discourage a patient from attempting to ambulate alone when he requires assistance for his safety. D. Prevent a patient from becoming confused or disoriented.

D. Prevent a patient from becoming confused or disoriented. By restricting a patient's movements, restraints may increase stress and lead to confusion, rather than prevent it. Restraints in a medical setting are devices that limit a patient's movement. Restraints can help keep a person from getting hurt or doing harm to others, including their caregivers. They are used as a last resort. The other choices are valid reasons for using restraints. Option A: Sometimes hospital patients who are confused need restraints so that they do not remove catheters and tubes that give them medicine and fluids. A nurse who has special training in using restraints can begin to use them. A doctor or another provider must also be told restraints are being used. The doctor or other provider must then sign a form to allow the continued use of restraints. Option B: Restraints may be used to keep a person in proper position and prevent movement or falling during surgery or while on a stretcher. Patients who are restrained also need to have their blood flow checked to make sure the restraints are not cutting off their blood flow. They also need to be watched carefully so that the restraints can be removed as soon as the situation is safe. Option C: Restraints can also be used to control or prevent harmful behavior or get out of bed, fall, and hurt themselves. Restraints should not cause harm or be used as punishment. Health care providers should first try other methods to control a patient and ensure safety. Restraints should be used only as a last choice.

Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance? A. Administer sleeping medication before bedtime. B. Ask the client each morning to describe the quantity of sleep during the previous night. C. Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation. D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.

D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks. The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. Sleep is a complex biological process. It is a reversible state of unconsciousness in which there are reduced metabolism and motor activity. Sleep disorders are a group of conditions that disturb the normal sleep patterns of a person. Sleep disorders are one of the most common clinical problems encountered. Inadequate or non-restorative sleep can interfere with normal physical, mental, social, and emotional functioning. Sleep disorders can affect overall health, safety, and quality of life.

A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? A. Acute pain related to surgery. B. Deficient fluid volume related to blood and fluid loss from surgery. C. Impaired physical mobility related to surgery. D. Risk for aspiration related to anesthesia.

D. Risk for aspiration related to anesthesia. Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The gag reflex, also known as the pharyngeal reflex, is a reflex contraction of the muscles of the posterior pharynx after stimulation of the posterior pharyngeal wall, tonsillar area, or base of the tongue. The gag reflex is believed to be an evolutionary reflex that developed as a method to prevent the aspiration of solid food particles. It is an essential component of evaluating the medullary brainstem and plays a role in the declaration of brain death.The other options, although important, are secondary.

Which statement regarding heart sounds is correct? A. S1 and S2 sound equally loud over the entire cardiac area. B. S1 and S2 sound fainter at the apex. C. S1 and S2 sound fainter at the base. D. S1 is loudest at the apex, and S2 is loudest at the base.

D. S1 is loudest at the apex, and S2 is loudest at the base. The S1 sound—the "lub" sound—is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2—the "dub" sound—is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1. Heart sounds are created from blood flowing through the heart chambers as the cardiac valves open and close during the cardiac cycle. Vibrations of these structures from the blood flow create audible sounds — the more turbulent the blood flow, the more vibrations that get created.

Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client? A. Semi-Fowler's B. Supine C. High-Fowler's D. Side-lying

D. Side-lying Because of lethargy, the post-tonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he awake is best. The semi-Fowler's, supine, and high-Fowler's position don't allow for adequate oral drainage in a lethargic post-tonsillectomy client and increase the risk of blood aspiration.

Which of the following is an example of appropriate behavior when conducting a client interview? A. Recording all the information on the agency-approved form during the interview. B. Asking the client, "Why did you think it was necessary to seek health care at this time?" C. Using precise medical terminology when asking the client questions. D. Sitting, facing the client in a chair at the client's bedside, using active listening.

D. Sitting, facing the client in a chair at the client's bedside, using active listening. Active listening should be used during an interview. The nurse should face the patient, have relaxed posture, and keep eye contact. Nonjudgmental interest in the patient's problems (active listening), empathy (communicating to the patient an accurate assessment of emotional state), and concern for the patient as a unique person are among the most important tools in the physician's interpersonal repertoire. The difference between interviewing a patient who is lying flat in bed and one who is sitting in a chair can be striking. This simple act can emphasize patient autonomy and active involvement in the interview. Option A: Note-taking interferes with eye contact. By recognizing the patient's emotions and responding to them in a supportive manner, the clinician can conduct an effective patient-centered interview. Option B: Asking "why" may make the client defensive. Frequently used opening questions include, "What problems brought you to the hospital (or office) today?" or "What kind of problems have you been having recently?" or "What kind of problems would you like to share with me?" These open-ended, non-directive questions encourage the patient to report any and all problems. At this point in the interview, it is important to let the patient talk spontaneously rather than restricting and directing the flow of information with multiple questions. Option C: The client may not understand medical terminology or health care jargon. Questions should be worded so that the patient has no difficulty understanding what is being asked. Avoid using technical terms and diagnostic labels. The interviewer's questions should indicate what type of information is requested, but not what answer is expected.

A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says that he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to: A. Encourage the client to ask questions about personal sexuality. B. Provide time for privacy. C. Provide support for the spouse or significant other. D. Suggest referral to a sex counselor or other appropriate professional.

D. Suggest referral to a sex counselor or other appropriate professional The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. Therefore, providing time for privacy and providing support for the spouse or significant other are important, but not as important as referring the client to a sex counselor.

A nurse obtained a client's pulse and found the rate to be above normal. The nurse document these findings as: A. Tachypnea B. Hyperpyrexia C. Arrhythmia D. Tachycardia

D. Tachycardia Tachycardia means rapid heart rate. Tachycardia refers to a heart rate that's too fast. How that's defined may depend on age and physical condition. Generally speaking, for adults, a heart rate of more than 100 beats per minute (BPM) is considered too fast.

Which organization's standards require that all patients be assessed specifically for pain? A. American Nurses Association (ANA) B. State nurse practice acts C. National Council of State Boards of Nursing (NCSBN) D. The Joint Commission

D. The Joint Commission has developed assessment standards, including that all clients be assessed for pain. Option A: The ANA has developed standards for clinical practice, including those for assessment, but not specifically for pain. The American Nurses Association (ANA) is the premier organization representing the interests of the nation's 4 million registered nurses. ANA is at the forefront of improving the quality of health care for all. Founded in 1896, and with members in all 50 states and U.S. territories, ANA is the strongest voice for the profession. Option B: State nurse practice acts regulate nursing practice in individual states. An NPA is enacted by state legislation and its purpose is to govern and guide nursing practice within that state. An NPA is actually a law and must be adhered to as law. Each state has a Board of Nursing (BON) that interprets and enforces the rules of the NPA. Option C: The NCSBN asserts that the scope of nursing includes a comprehensive assessment but does not specifically include pain. National Council of State Boards of Nursing (NCSBN) is an independent, not-for-profit organization through which nursing regulatory bodies act and counsel together on matters of common interest and concern affecting public health, safety, and welfare, including the development of nursing licensure examinations.

Which human element considered by the nurse in charge during assessment can affect drug administration? A. The patient's ability to recover B. The patient's occupational hazards C. The patient's socioeconomic status D. The patient's cognitive abilities

D. The patient's cognitive abilities The nurse must consider the patient's cognitive abilities to understand drug instructions. If not, the nurse must find a family member or significant other to take on the responsibility of administering medications in the home setting. The patient's ability to recover, occupational hazards, and socioeconomic status do not affect drug administration. Option A: Many drugs can be administered orally as liquids, capsules, tablets, or chewable tablets. Because the oral route is the most convenient and usually the safest and least expensive, it is the one most often used. However, it has limitations because of the way a drug typically moves through the digestive tract. Option B: For drugs administered orally, absorption may begin in the mouth and stomach. However, most drugs are usually absorbed from the small intestine. The drug passes through the intestinal wall and travels to the liver before being transported via the bloodstream to its target site. The intestinal wall and liver chemically alter (metabolize) many drugs, decreasing the amount of drug reaching the bloodstream. Consequently, these drugs are often given in smaller doses when injected intravenously to produce the same effect. Option C: When a drug is taken orally, food and other drugs in the digestive tract may affect how much of and how fast the drug is absorbed. Thus, some drugs should be taken on an empty stomach, others should be taken with food, others should not be taken with certain other drugs, and still others cannot be taken orally at all.

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client? A. Eating more protein is optimal prior to testing. B. One stool specimen is sufficient for testing. C. A red color changes indicates a positive test. D. The specimen cannot be contaminated with urine.

D. The specimen cannot be contaminated with urine. For fecal occult blood testing at home, the stool specimens cannot be contaminated with water or urine. The fecal occult blood test (FOBT) is a diagnostic test to assess for occult blood in the stool. This test has commonly been used for colorectal cancer screening, especially in developed nations. When used correctly for screening, this testing modality has established associations with decreased morbidity and mortality. When performing at home, the stool should be collected in a dry, clean container. Option A: Some proteins such as red meat, fish, and poultry can alter the test results. Three days prior to fecal occult blood testing, avoidance of certain foods should be to help prevent false test results. False-positive results have been associated with red or rare meat as well as raw fruits and vegetables, including but not limited to horseradish, raw turnips, cantaloupe, broccoli, cauliflower, parsnips, and red radishes. False-negative results are also known to occur in patients taking ascorbic acid (vitamin C) in excess of 250mg/day. Option B: Three specimens from three different bowel movements are required. One problem with FOBT is the need for medication and dietary restrictions before testing. These restrictions are in order to decrease the risk of false negative and false-positive results. Many studies assessing the risk of these false results exist. One particular retrospective study evaluated the medications that could create false-positive results and encouraged patients to avoid these medications, if possible, for seven days before testing. The listed medications include acetylsalicylic acid, unfractionated or low-molecular-weight heparin, warfarin, clopidogrel, nonsteroidal anti-inflammatory drugs, and selective serotonin reuptake inhibitors. Option C: A blue color indicates blood in the stool. If the patient's fecal occult blood test does not turn blue, it is negative. If the card turns blue, this is positive and requires further gastroenterological workup.

The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is: A. Flurazepam B. Temazepam C. Methotrimeprazine D. Tryptophan

D. Tryptophan Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril), and methotrimeprazine (Levoprome) are hypnotic sedatives. Protein foods such as milk and milk products contain the sleep-inducing amino acid tryptophan. Having warm milk at bedtime is a good way to work towards reaching the recommended number of servings of Milk and Alternatives each day, and can be a comforting way to unwind. Tryptophan is an amino acid that promotes sleep and is found in small amounts in all protein foods. It is a precursor to the sleep-inducing compounds serotonin (a neurotransmitter), and melatonin (a hormone which also acts as a neurotransmitter). Option A: Flurazepam (marketed under the brand names Dalmane and Dalmadorm) is a drug which is a benzodiazepine derivative. It possesses anxiolytic, anticonvulsant, hypnotic, sedative and skeletal muscle relaxant properties. It produces a metabolite with a long half-life, which may stay in the bloodstream for days. Option B: Temazepam is used on a short-term basis to treat insomnia (difficulty falling asleep or staying asleep). Temazepam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow sleep. Option C: Levomepromazine (also known as methotrimeprazine) is used to treat severe mental/mood disorders (such as schizophrenia, bipolar disorder). It works by helping to restore certain natural substances in the brain. Levomepromazine belongs to a class of drugs known as phenothiazines. It can help the client to think clearly and take part in everyday life. It is also used to treat anxiety disorders, a certain sleep problem (insomnia), nausea/vomiting, and pain. This medication has calming, relaxing, and pain-relieving effects.

For all body systems EXCEPT the abdomen, what is the preferred order for the nurse to perform the following examination techniques? Inspection Auscultation Palpation Percussion

Inspection Palpation Percussion Auscultation Inspection begins immediately as the nurse meets the patient, as she observes the patient's appearance and behavior. Observational data are not intrusive to the patient. When performing assessment techniques involving physical touch, the behavior, posture, demeanor, and responses might be altered. Palpation, percussion, and auscultation should be performed in that order, except when performing an abdominal assessment. During abdominal assessment, auscultation should be performed before palpation and percussion to prevent altering bowel sounds.