Midterm 2

The postoperative patient demonstrates some mild dizziness and mild shortness of breath when moving from sitting to standing position. What action would the nurse perform first (don't know)

Assist the patient to sit back down

Which nursing action reflects Florence Nightingale's vision of how to improve patient care?

Attends an in-service to learn about a new infusion pump

A circulating nurse opens sterile packages while in the operating room. What is the most appropriate way to create a sterile field when opening the sterile package's top triangle?

Away from the nurse

True or false: Safety reminder devices (SRDs) are primarily used in long term care facilities.

False. SRDs can be used in any health care setting. Many long term care facilities are currently adopting a restraint-free environment

True or false: There is a 5% chance of a health care worker becoming infected with HIV from a sharps injury

False. There is a .03% chance of a health care worker becoming infected with HIV from a sharps injury

Pain causes:

Fatigue and decreases the patient's ability to cope physically, emotionally, and mentally.

A federal regulation that came into effect April 13, 2003, has impacted the health care field regarding privacy of a patient's health information. What is the regulation?

Health Insurance Portability and Accountability Act

Your patient was admitted to the hospital 4 days ago with cardiac problems and now has bacterial pneumonia. This is an example of what type of infection?

Health care-associated

the early morning care that should occur before breakfast, what does the nurse remind the UAP to do for the patient?

Help the patient wash hands and face

Accredited program

Higher standard that signifies that the responsible organization has judged that a program has met its pre-established criteria

An LPN/LVN is hired at a health care provider office that believes in a system of comprehensive patient care that takes into consideration the physical, emotional, social economic, and spiritual needs of patients. Which type of approach regarding patient care fits this philosophy?

Holistic

Which philosophy is described as comprehensive or total patient care that considers the physical, emotional, social, economic, & spiritual needs of the person; the person's response to the illness; and the impact of the illness on the person's ability to meet self-care needs?

Holistic nursing

Sims'

Position in which patient lies on side with knee and thigh drawn upward toward chest. Left position is appropriate for enema procedure and administration of rectal suppository

Dorsal (supine)

Position lying flat on the back.

The nurse knows that all patients have the right to nursing interventions regardless of their race, religion, or gender. The ethical principle that best describes this concept is:

justice

how to transfer respiratory isolation patient

mask

a young adult is admitted to a medical unit with the diagnosis of hep A & placed in contact precautions. What is the primary goal of this action?

to prevent transmission of infectious microorganisms.

Leininger's theory

to provide care consistent with nursing's emerging science and knowledge with caring as central focus

The American Society of superintendents of Training Schools of Nursing was established in 1894. What was the major goal of the organization?

to set educational standards for nurses

Negligence

Absence of due care

Which type of physician should be consulted for a diabetic patient with thick long yellow toenails?

Podiatrist

Umbilicus

Point on the abdomen at which the umbilical cord joined the fetus. In most adults it is marked by depression

Labia Majora

Two large folds of tissue extending from the mons pubis to the perineal floor; lip

There are many methods of transmission of infection. Which is the best example of a vehicle of transmission?

A health care worker's hands, hospital equipment, or instruments

What is the term for injury to a person or the person's property that gives rise to a basis for a legal action against the person who caused the damages?

Malpractice

_____ decrease the perception of pain by binding to pain receptor sites in CNS

Opioids

Isabel Hampton Robb (1860-1910)

Organized the first graded system of theory and practice in schools of nursing

True or False: There is a 5% chance of a health care worker becoming infected with HIV from a sharps injury.

False. There is a 0.03% chance of a health care worker becoming infected with HIV from a sharps injury

What is health?

a state of complete physical, mental, & social well-being

Codes

a system of notification that allows information to be transmitted rapidly

Continuous Passive Motion

flex and extend joints for passive mobilization without the strain of active exercises; frequently used after total knee replacement surgery

LPN/LVNs have a code of professional and personal ethics to follow. The purpose of a code of ethics is to:

give the nurse guidelines for ethical decision making

Convalescence

gradual recovery of health

Endogenous

growing within the body

My plate intake

half fruit and veggies, need grains and protein, dairy is on a separate plate

Nurses correctly recognize what as the key determinant of their scope of practice?

the nurse practice test

disinfection

the use of a chemical that can be applied to objects to destroy microorganisms but not spores

Bioterrorism

the use of biological agents to create fear and threat

Medical Nutrition Therapy

the use of specific nutritional variations to build good health

microorganism

tiny, usually microscopic entities capable of varrying on living processess

Orem's Theory

to care for and help patient attain total self-care

Parse's Human Being Theory

to focus on man as living unity and man's qualitative participation with health experience (nursing as science and art)

Benner and Wrubel Theory

to focus on patients needs for caring as a means of coping with stressors of illness

Roy's theory

to identify types of demands placed on patient, assess adaptation to demands, and help patients adapt

True or false: Safety reminder devices (SRDs) are primarily used in long term care facilities

False. They are used in many health care facilities, and most LTCs are eventually adopting a restraint free environment

The nurse is providing discharge instructions for a patient who will be using cold therapy after knee replacement surgery. What statement by the patient indicates the need for further instructions

"I don't have a cold pack at home like the one I had in the hospital. I will use the cold packs I used in my cooler to ice my knee" (Never use cold packs designed for use in freezer chests for food or beverage on skin)

The nurse explains to the patient that the log-rolling technique will be used to help the patient change position. The patient asks why this is necessary. Which response is accurate?

"It is important to keep your neck and spine in straight alignment while we help you move onto your side." (maintains body alignment, preventing stress on any part of the body)

During surgery, the health care provider requests more sterile water. What action must the nurse perform before pouring the solution into the sterile container?

"Lipping" of the bottle with its solution. Before pouring the solution into the container, the nurse pours a small amount into a waste receptacle, which cleans the lip of the bottle. This is referred to as "lipping" the bottle. Wiping the rim of the bottle introduces the possibility of contamination from the cloth or towel. Pouring the water straight into the container does not take into account that the edge of the bottle may not be clean. Handing the bottle over without making sure it is clean would introduce the possibility of infection to the sterile nurse.

Which of the following professional organizations was specifically created for practical nurses/licensed vocational nurses?

(NFLPN) National Federation of Licensed Practical Nurses

carrier/vector

*A person or animal* that does not become ill but harbors and spreads an organism, causing disease in others

RACE

*R*escue patients sound the *A*larm *C*onfine the fire *E*xtinguish/Evacuate

antiseptic

*may be used on humans* a substance that stops the growth and reproduction of microorgamisms

A long-term care facility is committing to a restraint-free environment. What will the health care workers implement to encourage this environment? (Select all that apply.)

- Frequent orientation to surroundings. - Explain all procedures and treatments. - Maintain toileting routines.

The nurse is supervising a new UAP in performing care for isolation patients. when is the nurse most likely to intervene

- The UAP wears a mask dangling around the neck and reposition it before entering the room. - Removes mask by grasping the front portion that covers the mouth and pulling it off. - Pushes the sleeves of her isolation gown up while bathing a patient.

what instructions should the nurse give to a new home health aid about helping the patient who has problems with immobility

-Assist the patient to make slow, gradual position changes -If the patient has orthostatic hypotension, assist him to return to bed and call the provider -If the patient becomes dizzy or faint when walking, ease him to the floor or chair - Be sure the home is free of clutter, wet areas or rugs that may slide

Which action(s) indicate(s) that the nurse is acting within the code of ethics as developed by the National Federation of Licensed Practical/Vocational Nurses?

-Collects data about the patient's skin and reports it to the RN -Gives change-of shift report to the oncoming nurse and the nursing student -Wears professional attire and adheres to the facility's dress code -Cares for a patient with an infectious disease and follows isolation precautions

Which factors put an older adult at risk for physical, emotional, and financial abuse?

-Decrease in strength and mobility -Isolation -Declining mental ability

A nursing student must write a clinical report about the care that was given to a patient in the hospital. What should the student do to prevent a HIPAA violation?

-Do not use the patient's name in any section of the paper -If laboratory data are used, make sure no identification numbers are included. -Avoid including the health care provider's name in the report -Do not refer to the room number or the specific unit.

The nurse is caring for several patients on the medical-surgical unit. Which action(s) indicate(s) that the nurse is providing care that adheres to the Patient's Bill of Rights?

-Ensures that the housekeeping staff empties the trash receptacles in a timely fashion -Assists the patient to make a list of questions to ask about a surgical procedure -Identifies a problem with a broken side rail and contacts the maintenance department -keeps up to date with the latest information on medication and side effects -Contacts the hospital's financial counselor if a patient has questions about the bill

What is a necessary safety precaution when helping a patient who has an unsteady gait to ambulate? (Select all that apply)

-Have patient wear well-fitting nonskid shoes or slippers -Have at least two people present to assist the patient -Use a gait belt when assisting the patient to stand and to ambulate (nonskid shoes or slippers help maintain balance, having two people there to help if the patient begins to fall, gait belt help to assist with balance)

A nurse is caring for an elderly patient he requires assistance with elimination. He can walk very slowly but it's frequently incontinent of urine before he can get to the toilet. What should the nurse do to help the patient with elimination?

-Instruct the UAP to be alert for the call signal and answer promptly -Show the patient how to use a urinal and place it within his reach -Obtain an order for a commode chair and place it close to the bed -Make a plan with the patient to call sooner rather than delaying

A patient with dementia and need assistance with bathing. What strategies are best to use to help the patient accomplish this task?

-Maintain a relaxed demeanor smell frequently and use a calm tone of voice -Reassure frequently and say things such as you are doing well we are almost done -Use destructions rather than trying to negotiate or making demands -Attempt to have the same caregivers as often as possible for hygienic care

Correct use of body mechanics

-Maintain appropriate body alignment -Maintain wide base of support- feet apart -Bend knees and hips -Do not bend at the waist -Hold objects close to you -Face the object Head erect

The patient asked the UAP to apply a heating pad to her back, despite the fact the the home health nurse had instructed both to avoid using the device. The patient sustained a burn and decided to sue the UAP and the nurse. Which document(s) is/are likely to be used in this case?

-Policies and procedures -Standards of care -Equipment maintenance records -Patient's medical records -Personnel files for UAP and nurse

an Unconscious patient needs Oral Care. what instruction should the nurse give to the UAP to ensure the safety of the patient?

-Position the patient upright use pillows for support as needed -Report bleeding sores in the mouth or obvious problems with teeth or gums -Use a soft toothbrush and brush teeth as for any other patient -Have an oral suction device ready and check function prior to starting. -Perform hand hygiene before donning clean gloves

What is a major benefit of *active ROM exercises?* (Select all that apply)

-Preventing contractures -Maintaining joint movement and mobility -Preventing atrophy of muscle near the joints -Increasing the patient's self-esteem and motivation (Active ROM- preformed by patients)

A patient becomes faint sitting on the side of the bed. To prevent injury to the patient and nurse, which action should the nurse take? (Select all that apply)

-The nurse should call for assistance -The nurse should lay the patient straight back and support the head (assist to the floor and call for help)

During the 7am to 3pm shift on the adult surgical unit, the code is announced for an external disaster emergency. Which event best represents this type of situation? 1. A school bus accident 2. A bomb threat in the mail room 3. A hostage event in the emergency department 4. An electrical fire in the maintenance department

1. A school bus accident

The nurse is considering the use of an SRD to prevent a patient from self injury. When using an SRD, the nurse should: (select all that apply.) 1. obtain a health care provider's order for the SRD 2. explain the purpose of the SRD to the patient 3. explain the purpose of the SRD to the family 4. obtain consensus of nursing staff for type of SRD 5. exhaust all alternatives before using an SRD

1, 2, 3, 5, 1. obtain a health care provider's order for the SRD 2. explain the purpose of the SRD to the patient 3. explain the purpose of the SRD to the family 5. exhaust all alternatives before using an SRD The use of SRDs requires an order, explanation to the patient and family, and is only used as a last resort after other methods have been tried or considered. The entire nursing staff does not have to be consulted about the type of SRD. Type of SRD depends on provider's orders, clinical judgment, and ongoing assessment.

A patient has a care plan with a nursing diagnosis of Risk for Injury. Which interventions would be the most appropriate? (Select all that apply.) 1. Keep bed in low position except when care is given 2. Instruct the use of a call bell and keep in reach at all times 3. Orient patient to the room and environment to provide familiarity 4. Allow patient to have reading materials and clothing lying about the room 5. Assist the patient to the bathroom frequently

1, 2, 3, 5. Each of these interventions is necessary and appropriate to reduce the risk of injury. Allowing the patient to have reading materials and clothing lying about the room is innappropriate because the environment needs to be free of litter to reduce the risk of tripping and falling.

The nurse is planning to teach a community group about fire safety in the home. What information should be included in the presentation? (select all that apply) 1. No smoking by the patient, family, or visitors in area where oxygen is used 2. Use safety matches to light candles or fire places 3. Install fire alarms, smoke detectors, and carbon monoxide detectors 4. Practice fire escape routes from each room and practice exit drills 5. Use one electrical circuit to facilitate monitoring of cords and appliances 6. Cover electrical cords with a secure carpet to prevent falls

1, 3, 4 1. No smoking by the patient, family, or visitors in area where oxygen is used 3. Install fire alarms, smoke detectors, and carbon monoxide detectors 4. Practice fire escape routes from each room and practice exit drills No one should smoke around oxygen. Fire alarms and other detectors should be properly installed and routinely checked. Family should have escape routes planned and practiced. Use of candles should not be encouraged. Using one electrical circuit creates a potential for overload. Covering electrical cords may decrease falls, but the carpet will mask frayed cords and offer a fuel source for fires.

The nurse is conducting a fall risk assessment on an elderly patient who is moving into an assisted-living center. Which question(s) would the nurse ask? (select all that apply) 1. Have you had any falls in the past year? 2. Are you able to independently get up after a fall? 3. Do you feel unsteady when you stand up? 4. Are you able to independently walk from room to room? 5. Have you ever lost consciousness after a fall? 6. Do you use a cane or other assistive device?

1, 3, 4, 6 1. Have you had any falls in the past year? 3. Do you feel unsteady when you stand up? 4. Are you able to independently walk from room to room? 6. Do you use a cane or other assistive device? Previous history of falls and unsteadiness increase the risk for falls. If assistance is required to walk from room to room, the nurse must plan to assist the patient to the bathroom and meals. The nurse ensures that all assistive devices are close to the bed or chair. Asking the patient if he can independently get up after a fall is an assessment of strength and independence, but this also suggests that the patient should independently attempt to get up after a fall. (Patient should be assessed for injury after a fall and encouraged to regain balance and strength before attempting to get up.) Assessing for loss of consciousness is usually performed when trying to determine the etiology of the fall (ex. head injury, neurologic event, cardiac event.)

The home health nurse is visiting an older adult patient and her husband. What safety concern is of the highest priority when the nurse is assessing this patient's home environment? 1. Accidental poisoning 2. Electric shock 3. Accidental falls (?) 4. Thermal burns

1. Accidental poisoning

For an older female who is at risk for *osteoporosis*, which associated complication can be minimized by participating in a regular exercise program as prescribed by the health care provider? 1. Bone loss that results in fractures 2. Immobility secondary to joint degeneration 3. Tissue ischemia and pressure ulcers 4. Thrombophlebitis secondary to blood clots

1. Bone loss that results in fractures Patients who are at risk for osteoporosis should be encouraged to exercise. This strengthens bones and reduces the risk for fractures. The other complications are more related to mobility

The state board of nursing is reviewing a case against the nurse. Rank the severity of the possible sanctions: 1 being the least severe to 5 being the most severe.

1. Dismissed charges 2. Letter of reprimand 3. Probation with stipulations 4. Suspension with stipulations 5. Revocation of license

In the event of a mercury spill, what is the priority nursing action? 1. Evacuate everyone from the room 2. Close the interior doors and open windows. 3. Vacuum the mercury and the glass shards 4. Mop the floor with hot water and soap

1. Evacuate everyone from the room Everyone should leave the room where the thermometer has been broken. Close interior doors and open windows to increase ventilation to the outside. The area should not be vacuumed, but should be moped with a mercury-specific cleansing agent. The home health nurse should refer to agency policy for additional directions that relate to the home environment.

The nurse listens attentively while the patient describes her angina pectoris pain as radiating down her left inner arm to the little finger upward to the jaw and the shoulder. What term is used to classify this type of pain? 1.) Precisely localized 2.) Referred 3.) Intermittent 4.) Chronic

3.) Intermittent

The nurse has completed a sterile procedure and is preparing to remove the soiled gloves. To remove the glove, what actions are required of the nurse?

1. Grasp the outer surface of the glove 2. Place the glove in the hand that is still gloved 3. Take fingers of bare hand and tuck inside remaining glove cuff 4. Peel the second glove off, turn inside out, and discard

What does universal carry mean? 1. How to remove a patient from the bed to the floor 2. How to carry a patient as if he/she were an infant 3. How to carry two patients at one time 4. How to evacuate several patients in a short amount of time

1. How to remove a patient from the bed to the floor

The nurse is working with a patient who has poor balance to move from the bed to the chair. What is included in the correct technique for assisting the patient to stand and pivot the chair? 1. Keep the knees slightly bent 2. Maintain a narrow base with the feet 3. Keep the stomach muscles loose 4. Stand arm's length from he patient

1. Keep the knees slightly bent (Prevents hyperextension. All other options are bad body mechanics)

Which route is most appropriate for treating rapidly escalating severe pain? 1.) Oral 2.) Intramusuclar (IM) 3.) Intravenous (IV) 4.) Transdermal

3.) Intravenous (IV)

When caring for the patient who required the use of a SRD, what should be included in the patient's plan of care? (select all that apply) 1. Monitor the skin for signs of impairment 2. Remove the SRD once every 2 hours 3. Secure the ends of the ties to the side rails 4. Ensure that the SRD is in place at all times 5. Reevaluate the need for the SRD frequency

1. Monitor the skin for signs of impairment 2. Remove the SRD once every 2 hours 5. Reevaluate the need for SRD frequency

The LPN is reviewing the care plan of the patient who has an SRD applied for personal safety. Which is the best goal for this patient? 1. Patient will remain free of injury 2. Patient will allow SRDs to be used 3. Nurse will check SRD every 30 minutes 4. Use least restrictive form of SRD possible

1. Patient will remain free of injury

Which position would be most comfortable for the patient and provide the best access for the nurse to *insert a rectal suppository?* 1. Sims 2. Lithotomy 3. Trendelenberg 4. Orthopneic

1. Sims (lies on side with knee and thigh up towards the chest)

The nurse is observing the UAP who is assisting a resident in a long-term care facility ambulate with a gait belt. Which action by the UAP indicated to the nurse that further instruction is necessary? 1. The UAP loosely fastens the gait belt around the patient's waist 2. The UAP places the gait belt on the resident before assisting the resident to a standing position 3. The UAP grasps the gait belt while assisting the resident out of bed 4, The UAP fastens the belt around the arm of the chair to prevent the resident from slipping out of the chair 5. The UAP explains to the resident that the gait belt is used to prevent injury to the resident and the UAP when assisting with ambulation

1. The UAP loosely fastens the gait belt around the patient's waist 4. The UAP fastens the belt around the arm of the chair to prevent the resident from slipping out of the chair

Chain of Infection

1. agent 2. reservoir 3. portal of exit 4. mode of transportation 5. portal of entry 6. host

The range of motion (ROM) that can be safely performed on the neck includes: (select all that apply) 1. flexion 2. supination 3. lateral flexion 4. rotation 5. hyperextension

1. flexion 3. lateral flexion 4. rotation ( Flex: chin to chest, lateral flex: ear to shoulder, Rotation: head in a circle)

The patient experienced a cerebrovascular accident (CVA) that left her with severe left-sided paralysis and very limited mobility. Which device would *prevent plantar flexion?* 1. Footboard 2. Bed board 3. Trapeze bar 4. Trochanter roll

1. footboard (Maintain the foot in dorsiflexion position)

An older adult patient in a long-term care facility has been wandering around outside of the room during the late evening hours. The patient has a history of falls. The nurse intervenes by: 1. obtaining an order for a bed and chair alarm 2. keeping the light on and the television playing all night 3. putting up the side rails and frequently checking on the patient 4. having the family come to check on the patient at night

1. obtaining an order for a bed and chair alarm A bed and chair alarm alert the nursing staff that the patient is getting up, so someone knows to go assist the patient. Keeping the light and television on would add to confusion and disorientation. Side rails are considered a form of restraint and confused patients often attempt to crawl over the rails. Frequently checking on the patient is always a good idea, but the patient can still wander off between times. Having family come in every night is unpractical and unrealistic in an extended care situation.

Why should a hospital have a disaster plan? 1. to be prepared in times of emergent community situations with the possibility of a large number of casualties 2. To be familiar with possible emergent situations that could affect a community 3. To eliminate factors that could cause a community disaster 4. To fulfill federal guidelines that pertain to hospitals

1. to be prepared in times of emergent community situations with the possibility of a large number of casualties

The nurse is talking to a patient who wants to try transcutaneous electric nerve stimulation (TENS). The nurse would alert the health care provider if the patient reveals he has a: 1.) Cardiac Pacemaker device 2.) Hearing aid 3.) Metallic hip joint 4.) History of a broken back

1.) Cardiac Pacemaker device

An older adult patient diagnosed with osteoarthritis suffers from chronic pain. Based on the patient's age and condition, which pain medication(s) will the health care provider most likely avoid? (Select all that apply) 1.) Meperidine 2.) ACetaminophen 3.) Morphine Sulfate 4.) Nonsteroidal antiinflammatory drugs 5.) Combinations

1.) Meperidine 3.) Morphine Sulfate 4.) Nonsteroidal antiinflammatory drugs 5.) Combinations

A 52 year old patient admitted for deep vein thrombosis of the left internal iliac vein complains of excruciating pain in his left leg. What is the most appropriate response by the nurse? 1.) Pain is what you say it is; I will assist you in whatever way I can 2.) Your pain is an unpleasant sensation caused by inflammation of the vein and difficult to control 3.) Your pain is one of the cardinal signs of inflammation 4.) I know you are in pain, but it is important that we guard against possible addiction to opioids

1.) Pain is what you say it is; I will assist you in whatever way I can

What drug delivery system is used to control pain via a portable computer pump with a chamber for a syringe? 1.) Patient controlled analgesia 2.) Transcutaneous electric nerve stimulation 3.) A venous access device 4.) An intrathecal delivery system

1.) Patient controlled analgesia

Which nursing intervention demonstrates the application of the gate control theory of pain? 1.) Performs a back massage using warmed lotion 2.) Administers a placebo to release endorphins 3.) Obtains an order for opioid medication 4.) Advocates for patient controlled analgesia

1.) Performs a back massage using warmed lotion

An 11 month old infant is admitted with a tympanic temperature of 105 F. The physician orders a tepid sponge bath. The infant's mother asks, "What is the purpose of this bath?" which is the best response by the nurse? 1.) The bath helps reduce your baby's body temperature 2.) The bath is used to help prevent febrile seizures 3.) The bath stimulates circulation to the skin 4.) The bath helps calm and relax your baby

1.) The bath helps reduce your baby's body temperature

The nursing student is discussing the gate control theory of pain. Which statement by the student indicates the need for further instruction? (Select all that apply) 1.) The gates of the pain pathways can be opened with therapeutic massage and heat treatments 2.) Pain has exclusive use of the pathways ahead of other stimuli, according to the theory 3.) Distraction is beneficial in pain management 4.) Pain is a manifestation of an intricate chain of electrochemical events 5.) Memories and feelings may alter gating mechanisms

1.) The gates of the pain pathways can be opened with therapeutic massage and heat treatments 2.) Pain has exclusive use of the pathways ahead of other stimuli, according to the theory 4.) Pain is a manifestation of an intricate chain of electrochemical events

The nurse is teaching the patient proper hygiene measures. What should the nurse include when teaching the patient about eye care? 1.) Wash from the inner canthus to the outer canthus 2.) Cleanse dried exudate with hot water 3.) Avoid drying circumorbital area after washing 4.) Use a different section of washcloth for each eye

1.) Wash from the inner canthus to the outer canthus

A patient with diabetes who previously reported a tingling, burning sensation in the lower extremities now reports that the prescribed opioid dose dos not seem to provide the same relief for his acute pain that it did when he first started to take the medication 4 weeks ago. Based on the nurse's knowledge of pharmacology, the nurse recognizes that the patient has developed: 1.) a physical tolerance 2.) A psychological dependence 3.) An addiction 4.) chronic pain

1.) a physical tolerance

Research indicates that the risk of clinically significant opioid-induced respiratory depression is 1.) less than 1% 2.) 5% 3.) 20% 4.) 30%

1.) less than 1%

The nurse is reviewing the disaster preparedness plan for a small nursing home. What should be included in the plan? (select all that apply) 1. Emergency treatment for the most critically injured 2. Possible admission to a hospital or transfer to a temporary shelter 3. Log to document residents names and locations 4. system to notify families and health care providers 5. Designation of an area for decontamination 6. Method of patient identification, such as patient bracelet or picture ID

2, 3, 4, 6 2. Possible admission to a hospital or transfer to a temporary shelter 3. Log to document residents names and locations 4. system to notify families and health care providers 6. Method of patient identification, such as patient bracelet or picture ID For nursing hoes or long term care facilities, the plan must include ways to keep track of residents and notification of families and health care providers. The goal would be to provide a safe environment, which may include moving residents to another location. Providing emergency treatment for critically injured patients or initiating decontamination would be included in hospital disaster plans.

A patient with severe crippling rheumatoid arthritis is confined to bed for extended periods. An erythematous area over the coccyx that has the potential to become an open lesion is noted. The nurse is correct in reporting this area to the health care provider as having the potential to become what? 1.) An inflammatory ulcer 2.) A pressure ulcer 3.) A stasis Ulcer 4.) An arterial ulcer

2. A pressure ulcer

Which occurrence is most likely to be investigated as a "sentinel event"? 1. Patient leaves the hospital against medical advice because she gets angry with the nurse. 2. An older patient sustains a broken arm related to the use of an SRD (*)3. A nurse is 2 hours late administering routine scheduled medications 4. During a follow-up phone call, a patient reports that care in the hospital was poor.

2. An older patient sustains a broken arm related to the use of an SRD A sentinel event is an occurrence that causes death or serious injury. A broken arm suggests that there may have been improper assessment, application, monitoring, or choice of SRD. The other events may be subject to an internal review by risk management, hospital administration, or the nurse manager.

The patient reports dizziness when standing up too fast. Which over-the-counter medications is most likely to be contributing to the patient's orthostatic hypotension? 1. Nonaspirin pain reliever 2. Antihistamine 3. Vitamin supplement 4. Medicated cough drp[

2. Antihistamine Antihistamines cause drowsiness and have mild sedative properties, so patients should be cautioned about side effects.

A 63 year old man is brought to the emergency department for treatment of unintentional poisoning. What is the nurse's first action in caring for this patient? 1. Induce vomiting 2. Assess the patient 3. Place the patient in an upright position 4. Notify the poison control center

2. Assess the patient

Before the nurse can intervene, a UAP pushes contaminated material into an overfilled sharps container and sustains a puncture wound. What should the nurse do first? 1. Tell the UAP to immediately report to the infection-control nurse 2. Assist the UAP to scrub the wound with copious amounts of soap and water 3. Report the UAP for improper handling of hazardous material 4. Dispose of the sharps container to prevent any additional injuries to others.

2. Assist the UAP to scrub the wound with copious amounts of soap and water. Scrubbing and flushing the wound with soap and water is the best first measure to decrease risk of infection. The UAP should contact the infection-control nurse. Sharps boxes should never be overfilled, but are disposed of before they are full and immediately replaced. The nurse and the UAP should both write an incident report which would include the facts.

The home health nurse is assessing a child for the risk of injury. Which factor places a child at greatest risk for specific types of injuries? 1. Gender of the child 2. Overall health 3. Education level 4. Developmental level

4. Developmental level

A nurse is working in a long term care facility caring for older adults. What type of accident is most often experienced by an older adult? 1. Burns 2. Falls 3. Poisoning 4. Asphyxiation

2. Falls Due to physiologic changes that older adults experience, they are at risk for falls. Most falls occus when transferring to a bedside commode or wheelchair. The most common accident experience by an older adult is related to the physiologic changes of aging, such as loss of vision and balance

A patient with a latex allergy is exposed to latex. Which sign or symptom is cause for the greatest concern? 1. Hives 2. Laryngeal edema 3. Runny eyes and nose 4. Localized swelling

2. Laryngeal edema Laryngeal edema puts the patient at risk for an airway obstruction. The other signs and symptoms could occur during a type IV hypersensitivity allergic reaction which is less serious.

Which patient behavior should be corrected to reduce the risk of thrombophlebitis? 1. Patient gets out of bed and forgets to put on slippers 2. Patient sits in a chair and crosses legs while reading a book 3. Patient forgets to rise slowly when getting out of bed 4. Patient sits in a slouched position on a soft couch

2. Patient sits in a chair and crosses legs while reading a book. (Inflammation of the Thrombo- blood clot in the Phleb- vein. Blood clot- avoid crossing legs and prolonged immobility)

Which patient has a *contracture*? 1. Patient has abnormal extension of a finger joint 2. Patient's wrist is abnormally flexed and joint is fixed 3. Patient's knee is hyperextended 4. Patient has abnormal lateral movements of ankle joint

2. Patient's wrist is abnormally flexed and joint is fixed (Abnormal shortening of muscle tissue. The wrist can not be flexed like a normal wrist. Frequent stretching of joints and muscles decreases contractures)

The patient has had a surgical procedure and is getting up to ambulate for the first time. While ambulating down the hallway, the patient says "I'm going to faint". What should the nurse do first? 1. Call out for someone to obtain a wheelchair 2. Pull the patient close and lower him gently to the floor 3. Lean the patient against the wall until the episode passes 4. Support the patient and move quickly back to the room

2. Pull the patient close and lower him gently to the floor (never try to prevent the fall, assist them to the floor and then call for help)

When assessing the neurovascular status of a patient, what is an expected finding? 1. Capillary refill after 8 seconds 2. Pulses strong and easily palpated 3. Loss of sensation to an affected area 4. Mild localized discomfort

2. Pulses strong and easily palpated (other expected findings: normal skin color, warm skin, ability to move, no numbness or tingling, no loss of sensation, normal cap refill and no pain)

The nurse is documenting on a patient with an SRD. What information must the nurse include in this documentation? 1. The nurse's feelings about having used the SRD 2. The specific type of SRD used 3. Confirmation of a prn order for use of SRD 4. Evidence that the patient was assessed every 8 hours

2. The specific type of SRD used

Which new equipment creates the greatest risk for falls for an older adult? 1. Wheelchair 2. Prescription lenses 3. safety bar in shower 4. walker

2. prescription lenses Any new device or equipment has some risks because of the learning curve; however, new prescription lenses frequently cause some distortion in depth perception and they are less likely to be perceived by the patient or the staff as "new" or directly related to safe ambulation. A wheelchair, safety bar, and walker are designed to increase stability. In addition, the elderly adult is likely to approach these new items with caution.

The nurse notices smoke coming from the wastebasket in a patient's room. Upon entering the room, the nurse sees a fire that is starting to flare up. What should the nurse do first? 1. Extinguish the fire 2. remove the patient from the room 3. close the door to the room 4. turn of all electrical equipment

2. remove the patient from the room The nurse remembers RACE and first removes the patient from the room. As they exit the room, the nurse closes the door to confine the fire to that room and then sounds the alarm. The nurse is not likely to turn off all electrical equipment in this case.

**A 52 year old patient is in her second postoperative day after an abdominal hysterectomy. The nurse plans to give the patient a bed bath. Which actions is most appropriate when caring for the patient's face 1.) Use only water 2.) Ask the patient her preference 3.) Use soap in all areas except the eyes 4.) Use a cleansing cream 5.) Use a different area of the cloth for each eye

2.) Ask the patient her preference 5.) Use a different area of the cloth for each eye

What is the physiological rationale for avoiding use of meperidine (Demorol) for patients with sickle cell disease? 1.) There is a direct action that causes sickling of blood cells 2.) Renal insufficiency will be present to some degree 3.) Underlying respiratory distress results in respiratory depression 4.) Patients with sickle cell disease are more prone to seizures

2.) Renal insufficiency will be present to some degree

The patient had a surgical procedure this morning and is requesting pain medication. The nurse assesses the patient's vital signs and decides to withhold opioid medication based on the finding of: 1.) Pulse: 90 2.) Respiration: 10 3.) BP: 130/80 4.) Temp: 99 (rectally)

2.) Respiration: 10

The nurse is supervising a new UAP providing hygiene care to a patient. Which action by the UAP requires the nurse to provide *additional instruction* regarding hygiene care? (Select all that apply) 1.) The UAP performs hand hygiene before providing care 2.) The UAP holds the clean linens against the uniform 3.) The UAP places soiled linens on the floor 4.) The UAP places clean linens on the patient's overbed table 5.) The UAP places soiled linen in a linen bag for transport

2.) The UAP holds the clean linens against the uniform 3.) The UAP places soiled linens on the floor

A patient was admitted to the orthopedic section for acute back pain. The health care provider is planning to use cutaneous stimulation management. Which is an example of this pain control method? 1.) Epidural analgesia 2.) Transcutaneous electric nerve stimulation (TENS) 3.) Nonsteroidal antiinflammatory drugs (NSAIDs) 4.) Patient controlled analgesia

2.) Transcutaneous electric nerve stimulation (TENS)

The nursing student reports to the nurse that a postoperative patient is asking for pain medication. What is the most important question that the nurse will ask the student to answer? 1.) Can you give the medication yourself 2.) What did the patient tell you about his pain? 3.) Did you try any nonpharmacological interventions 4.) What do you know about the ordered medication

2.) What did the patient tell you about his pain?

A mother brings her alert and playful child to the clinic because she "found him playing with an empty bottle of baby aspirin". Which question is most important to ask the mother? 1."Has he ever done anything like this before?" 2."How many times has he vomited since the ingestion?" 3."How many pills do you think were in the container?" 4."Did you contact poison control before you drove to the clinic?"

3. "How many pills do you think were in the container" In cases of overdose, it is essential to determine the quantity. The mother may need help to remember that the bottle was half full, or only had 2 or 3 pills. In the case of aspirin, the number of times of vomiting is less relevant, because aspirin is readily dissolved and absorbed in the stomach. The health care team will contact Poison Control regardless of the mother's first report or the first aid given at home. In addition, Poison control is likely to have the mother's call on file. Asking about previous episodes of poisoning would be relevant after current emergency care is given, if the health care team has reason to suspect child neglect/abuse.

Patients who are immobilized in health care facilities require that their psychosocial needs be met along with their physiologic needs. Which statement by the nurse acknowledges these needs? 1. "Visiting hours will be limited so you can rest." 2. "We will help you do everything so you don't have to worry." 3. "Let's talk about what you used to do at home during the day." 4. "A private room can be arranged for you."

3. "Let's talk about what you used to do at home during the day." (Theyre physical needs are being met by the help of the nurse- ADLs- and theyre emotional and mental- wellbeing needs are being met by talking about what theyre usual routine is)

When assessing the staff's knowledge of the fire safety precautions, which action indicated the need for further fire safety instruction? 1. fire exits and corridors are kept clear 2. A no smoking sign is posted when oxygen is in use 3. A heating pad cord is taped when a frayed area is noted 4. Facility smoking policies are a part of the admission procedure 5. An UAP evacuated critically ill patients on the elevator during a fire drill

3. A heating pad cord is taped when a frayed area is noted 5. An UAP evacuated critically ill patients on the elevator during a fire drill

The nurse is caring for a patient on a ventilator and reads the order "restraint prn." The nurse considers which factor when caring for this patient? 1. SRDs often decrease anxiety because the patient feels safer 2. All older adult patients need some type of SRD at night 3. Allow as much freedom of movement as possible when applying SRDs 4. When using soft SRDs to prevent pulling of the ventilator tubing, tie them to the side rail

3. Allow as much freedom of movement as possible when applying SRDs

For the care of a patient who has an SRD in place, which task can be delegated to a UAP? 1. Observe for circulation distal to the SRD 2. Check for respiratory effort and breathing 3. Change position every 2 hours 4. Determine when the SRD can be removed

3. Change position every 2 hours The UAP can be instructed to assist the patient to change position every 2 hours. Assessment of circulation and respiratory effort should be performed by the nurse. The RN and health care provider should be consulted to determine the time for removal of SRDs.

The nurse is giving instructions to the UAP about patient safety and fall prevention. What should the nurse tell the UAP about helping the patient go to the bathroom? 1. Help the patient whenever she needs help 2. Ask her if she wants to walk or use the bedpan 3. Have her sit up slowly and dangle her legs before standing 4, Help her to the commode chair if she seems weak

3. Have her sit up slowly and dangle her legs before standing. The nurse gives specific measures to prevent orthostatic hypotension (ex. sit slowly and dangle the legs before standing). "Whenever she needs help" is a vague direction that requires the patient to ask for help and then the UAP must decide if help is appropriate, but there is no guidance about circumstance or execution. The nurse should assess whether the use of the bedpan is appropriate for the patient. If the patient is able to get up, walking decreases the complications of immobility. The UAP should not be expected to make a decision about "if she seems weak." This decision should be based on nursing assessment.

The nurse is talking to a young mother who has an infant who has just started to crawl. Based on knowledge of growth and development, which safety issue is currently the most important to discuss with the mother? 1. What to do when using pots and pans on the stove 2. How to ensure backyard pool safety measures 3. How to manage electrical sockets and cords 4. where to obtain safety labels for cleaning products

3. How to manage electrical sockets and cords For infants who are just learning to crawl, the mother should look at what's on the floor and within arm's reach from a crawling position. This would include electrical sockets and cords. Pots and pan handles should be turned away from the child's reach. This becomes relevant when the child begins to stand and walk. Pool safety is more related to toddlers and children. Children can be taught to recognize dangerous products, but this is for preschoolers who have developed language skills.

The nurse is preparing to assist the patient to transfer from the bed to the chair. Which action demonstrates the proper use of body mechanics? 1. Stands by the chair and reaches out to guide the patient towards the chair 2. Stands by the side of the patient and pulls up on the stronger arm 3. Stands directly in front of the patient and places hands at the patients waist level 4. Stands to the side of patient and assists as the patient pivots

3. Stands directly in front of the patient and places hands at the patient's waist level (Face your work area- prevents unnecessary twisting)

What type of sensitivity is often seen in the health care environment? 1. Allergic reactions to disinfecting chemicals 2. Reactions to airborne diseases 3. Latex allergies 4. Vinyl allergies

3. Latex allergies

Which medications are most likely to contribute to *orthostatic hypotension?* 1. Medications used to treat osteoporosis 2. Medications to prevent thrombophlebitis 3. Medication to reduce high blood pressure 4. Medications to treat arthritis pain

3. Medication to reduce high blood pressure ( patients who use meds to reduce BP are at greater risk for Orthostatic Hypotension)

It is suspected that a patient has been exposed to cyanide gas. The nurse is alert for which symptom? 1. Erratic behavior 2. Nausea and vomiting 3. Respiratory distress 4. Vesicle formation

3. Respiratory distress Severe respiratory distress is the most prominent symptom of cyanide gas exposure.

The nurse started a new job in a small LTC facility in a rural area. The back exit hallway is being used as a storage area and "a new storage area is being planned." What should the nurse do first? 1. Report the facility for unsafe conditions 2. Express unwillingness to work in unsafe conditions 3. Review the facility's policies/procedures for emergencies 4. Check the building for other safety issues

3. Review the facility's policies/procedures for emergencies The nurse would first review the facility's emergency/fire policies and procedures to determine if contingency plans have been made for the blocked hallway. Based on the review of the policies/procedures, the nurse may decide to use the other options.

A male patient of average build requires assistance to ambulate down the hall. He has some weakness on the left side. The nurse assists this patient to ambulate by applying a gait belt and standing at his: 1. left side and holding the weak left arm 2. right side and holding the front of the gait belt 3. left side and holding the back of the gait belt 4. right side and holding one arm around his waist

3. left side and holding the back of the gait belt The nurse stands on the WEAKER side and grasps the gait belt at the back. This position allows the nurse to provide support and ease the patient to the floor if he begins to fall.

The nurse is reviewing the teaching plans of several patients on a medical unit. Which patient does the nurse correctly identify as most at risk for development of complications of the feet? 1.) A 30 year old patient whose career requires extensive standing 2.) A 55 year old patient disoriented patient 3.) A 60 year old patient with diabetes mellitus 4.) A 62 year old patient with total hip replacement

3.) A 60 year old patient with diabetes mellitus

Following surgery for a total knee replacement, a patient was given an epidural catheter for fentanyl epidural analgesia. What is the most important nursing intervention? 1.) Administer additional analgesic medications as needed 2.) Change the epidural dressing every shift 3.) Assess respiratory rate 4.) Encourage ambulation

3.) Assess respiratory rate

Which nursing action demonstrates that the nursing is complying with the Joint Commission (TJC) standards of pain management? 1.) Documents that medication is given after the patient receives it 2.) Incorporates knowledge of the patient's culture in pain management 3.) Assesses the patient's pain and reassesses pain after interventions 4.) Stays current with the latest information about pain therapies

3.) Assesses the patient's pain and reassesses pain after interventions

What is the priority responsibility of the nurse related to pain? 1.) Leave the patient alone to rest 2.) Help the patient appear to not be in pain 3.) Believe what the patient says about pain 4.) Assume responsibility for eliminating the patient's pain

3.) Believe what the patient says about pain

An 82 year old patient is n his first postoperative day. As part of his morning care, the nurse removes and cleanses his dentures. Which of the following techniques is correct? 1.) Work over an open sink convenient to the water faucet 2.) Rinse dentures thoroughly with hot water 3.) Brush dentures with a soft toothbrush 4.) Hold dentures securely in the palm of the hand

3.) Brush dentures with a soft toothbrush

The health care provider orders 1000 mg acetaminiophen every 4 hours as needed for pain. What should the nurse do? 1.) Assess the patient every 4 hours and give medication as needed 2.) Give the medication as needed during the daytime hours only 3.) Call the health care provider and ask for clarification of the order 4.) Call the pharmacy and ask if the medication comes in 1000 mg tablets

3.) Call the health care provider and ask for clarification of the order

The nurse is caring for several patients who are receiving morphine. Which patient is most likely to have respiratory depression? 1.) Patient with a history of chronic back pain who is receiving epidural morphine for an acute exacerbation 2.) Elderly patient who is postoperative for a fractured hip and is receiving patient controlled analgesia 3.) Child who received an intramuscular injection prior to having fracture reduction of the forearm 4.) Elderly patient with end stage uterine cancer who is receiving an oral form of morphine

3.) Child who received an intramuscular injection prior to having fracture reduction of the forearm

A 50 year old patient was discharged home with a Foley catheter. The student nurse instructs the patient in the proper procedure for cleansing the female perineal area. What teaching point should the nurse include in discharge instructions 1.) Cleanse the area in circular motions around the rectum 2.) Cleanse from the rectum toward the pubis 3.) Cleanse from the pubis toward the rectum 4.) Cleanse in circular motions around the vaginal area

3.) Cleanse from the pubis toward the rectum

The nurse is reviewing documentation from the previous shift. The nurse is correct when determining the patient has a stage 3 pressure injury based on which note? 1.) Nonblanchable reddened areas where the skin is intact 2.) Full-thickness tissue loss extending through subcutaneous tissue 3.) Extensive destruction of skin and muscle with possible tunneling 4.) Areas of full-thickness skin loss with extension to the bone

3.) Extensive destruction of skin and muscle with possible tunneling

The nurse is caring for a patient who has arthritis. Which medication does the nurse anticipate the health care provider will prescribe? 1.) Proproxyphene (Darvon) 2.) DIphenhydramine (Benadryl) 3.) Ibuprofen (Motrin) 4.) Morphine (MS Contin)

3.) Ibuprofen (Motrin)

A patent has diffuse pancreatitis causing severe weakness . The nurse cleanses her ears while giving her a soothing bed bath. Which intervention for cleansing her ears is correct for this bath? 1.) Cleansing the outer ear with the washcloth during the bath 2.) Retracting the outer ear downward to loosen visible cerumen 3.) Irrigating to remove tenacious cerumen 4.) Using cotton-tipped applicators to remove cerumen 5.) Placing an otoscope in the ear canal to visualize any areas that need cleaning

3.) Irrigating to remove tenacious cerumen 4.) Using cotton-tipped applicators to remove cerumen 5.) Placing an otoscope in the ear canal to visualize any areas that need cleaning

Which opioid is no longer a drug of choice for managing pain because of its toxic complications, such as causing seizures? 1.) Codeine 2.) Morphine 3.) Meperidine 4.) Fentanyl

3.) Meperidine

A 63 year old patient underwent a lower anterior bowel resection yesterday. What common central nervous system analgesic is often prescribed for control pain? 1.) Aspirin 2.) Acetaminophen (Tylenol) 3.) Morphine 4.) Ibuprofen (Motrin)

3.) Morphine

What statement unrelieved pain is the most correct? 1.) Unrelieved pain is a normal expectation after major surgery 2.) Patient's with cancer diagnosis can expect to experience unrelieved pain 3.) Physiological and psychological complications can result from unrelieved pain. 4.) Although unrelieved pain is stressful and annoying, it is not as important as other physical care needs.

3.) Physiological and psychological complications can result from unrelieved pain.

The patient agrees to try guided imagery as a noninvasive method of pain relief. Before they begin the therapy, which instructions is the nurse most likely to give? 1.) I'll use a combination of firm and light strokes during the therapy 2.) The skin will be stimulated with a mild electric current that reduces pain 3.) Tell me about a place and time where you felt relaxed and peaceful 4.) We have to use specialized equipment to identify your biological responses

3.) Tell me about a place and time where you felt relaxed and peaceful

The nurse is caring for two patients with similar injuries. One patient expresses severe pain and the other reports feeling fine with low levels of pain. Which statement is most correct? 1.) The patient having more intense reports of pain has dysfunction endorphins 2.) The patient having lesser levels of pain has a higher level of endorphins 3.) The patient experiencing intense pain has lower levels of endorphins 4.) The patient having elevated levels of pain has an alteration in recognition of endorphins by the hypothalamus of the brain

3.) The patient experiencing intense pain has lower levels of endorphins

The nurse is providing instruction to the UAP who is assisting with caring for an immobile patient who requires turning every 2 hours. The UAP asks the nurse why it is best to place the patient in the 30-degree lateral position (Semi- Fowlers). Which response by the nurse is correct 1.) This position help prevent ulcers on spinous process 2.) This position helps prevent pressure ulcers on the ischial tuberosities 3.) This position helps prevent pressure ulcers on the greater trochanters 4.) This position helps prevent pressure ulcers on the occipital prominences

3.) This position helps prevent pressure ulcers on the greater trochanters (hip joint)

The patient is receiving an epidural opioid. The nurse is alert for a complication of this treatment and observes the patient for: 1.) Diarrhea 2.) Hypertension 3.) Urinary Retention 4.) Increased respiratory Rate

3.) Urinary Retention

The nurse is talking to an older adult who reports feeling tired and not getting enough sleep. Which question related to the question's medication is most relevant to designing interventions for the patient's problem? 1.) Which NSAID medication has the health care provider suggested? 2.) Has there been a recent increase in the dosage of your opioid medication? 3.) What time of the day do you usually take your diuretic medication? 4.) Are you taking your antiemetic medication before or after meals?

3.) What time of the day do you usually take your diuretic medication?

The nurse is providing home poison control instruction to the parent of a 2-year-old boy. Which statement by the parent indicated the need for further teaching? 1. "I will call the national poison control center if my child ingests a poisonous substance." 2. "I will call 911 immediately if my child ingests medication that is not intended for him." 3. "Child safety caps on household cleaner can still be opened by some children." 4. "I will give my child syrup of ipecac if he ingests a poisonous substance that is not caustic."

4. "I will give my child syrup of ipecac if he ingests a poisonous substance that is not caustic."

Which patient is at greatest risk for skin impairment? 1.) Child on bed rest 2.) Infant with cool skin temperature' 3.) Young man with diarrhea 4.) A 60 year old patient in a body cast

4. A 60 year old patient in a body cast

The nurse is caring for a patient who relies on mechanical ventilation. The nurse hears a fire alarm and flames are visible in a back corridor. What should the nurse do first? 1. Seek assistance to move the patient and the ventilator to safety 2. Turn off oxygen supply and provide manual respiratory support 3. Close the patient's door, call 911, and fight the fire in the corridor 4. Delegate the UAP to move ambulatory patients toward the exit

4. Delegate the UAP to move ambulatory patients towards the exit. By delegating the UAP to move the ambulatory patients, the nurse is rescuing the greatest number. Next, the nurse would call 911. Closing the door is appropriate because the door will block the smoke and the fire. The nurse must then attend to the helpless ventilator patient. Oxygen creates a good environment for a hotter and faster fire, so oxygen is turned off. The nurse now has to manually support respiration by delivering breaths with a bag-valve-mask or a pocket mask. Both methods will be delivering room air. The nurse is aware that moving the patient and equipment would take a minimum of 2 people and this action would also partially block the hallways; thus the nurse would use critical thinking to determine when (or if) to move the patient.

The patient will be immobilized for an extended period due to extensive injuries. Which intervention will the nurse use to prevent *respiratory* complications? 1. Suction the airway every hour 2. Change the patient's position every 4-8 hours 3. Use oxygen and nebulizer treatments regularly 4. Encourage deep breathing and coughing every hour

4. Encouraging deep breathing and coughing every hour. (This promotes chest expansion and will get any mucous out of the chest)

What national organization provides guidelines to protect health care workers in their environment? 1. National Institutes of Health 2. National Alliance for Health Care Providers 3. National League of Nurses 4. Occupational Safety and Health Administration

4. Occupational Safety and Health Administration

A nurse walks into a patients room and notices that the patient is having trouble breathing. Which position will the nurse immediately use to help relieve the patients respiratory distress? 1. Lower the head of the bed and place the patient in a supine anatomical position. 2. Position the patient on the side with the knee and thigh drawn up towards chest. 3. Lower the patient's head and place the body and legs on a slightly inclined plane. 4. Raise the head of the bed to 45-60 degrees and with the head in an anatomical position.

4. Raise the head of the bed to 45-60 degrees and with the head in an anatomical position. (Put the bed in Fowler's position so theyre sitting up in bed)

In the event of a bioterrorist attack, what is the first role that the nurse must perform? 1. Isolate suspected cases 2. Advocate for public safety 3. Liaison with the public health department 4. Recognize high-risk syndromes

4. Recognize high-risk syndromes Before any action is taken, someone must recognize that an unusual biologic event is occurring. The nurse is one of the first health care professionals who will assess patients for flulike symptoms or other symptoms that mimic endemic disorders. The nurse would isolate any suspected cases and immediately contact the supervisor, so that emergency/disaster plan can be activated. The plan should include notification of the local public health department and attention to public safety.

An infant has a wound with a dressing on the left upper arm. He repeatedly attempts to remove the dressing. Which SRD would the nurse select? 1. Mummy wrap 2. Wrap jacket 3. Bilateral wrist SRDs 4. Right elbow SRD

4. Right elbow SRD The infant is using his right hand to grab the dressing on the left arm. If the right elbow is secured in a straight position, he shouldn't be able to reach the dressing. (Note - sometimes it may be necessary to pin or secure the SRD to the linen/mattress if the child is very determined.) Mummy wrap is more restrictive and usually used as a temporary restraint during procedures. Bilateral wrist SRDs are also more restrictive and the infant is likely to have skin damage because he will continuously pull to get free. The wrap jacket allows free arm movement.

What is the most likely complication if an elderly patient gets pulled across the bed when changing wet linens? 1. Dislocation of the joint 2. Increased stress to the joints 3. Abnormal hyperextension of a joint 4. Shearing or tearing of the skin

4. Shearing or tearing of the skin (older adults skin is very fragile and susceptible to injury. Pulling them across a bed will cause a skin tear or shearing)

A patient admitted with severe cellulitis of the left breast states, :I have a severe burning pain, and it feels like my breast is on fire." She rates her pain as a 7/10. How would this collection of data by the nurse in assessing the patient's pain be classified? 1.) Deductive 2.) Speculative 3.) Objective 4.) Subjective

4. Subjective

During the bed bath, the nurse covers the patient with a blanket. The patient asks what the bath blanket is for. What is the nurse's best response? 1.) The bath blanket helps to prevent skin irritation 2.) The bath blanket is part of our bathing procedure 3.) The bath blanket is used to prevent the spread of microorganisms 4.) The bath blanket helps to prevent chilling

4. The bath blanket helps to prevent chilling

The occupational health nurse learns of a mercury spill that occurred in the factory in which she is employed. Which action by the nurse is correct? 1. The nurse cleans the mercury spill with alcohol and ordinary cleaning cloths 2. The nurse closes all windows and doors to prevent the mercury spill from spreading out of the area 3. The nurse instructs housekeeping staff to vacuum up the spill 4. The nurse evacuates the area and contacts trained personnel to clean up the spill.

4. The nurse evacuated the area and contacts trained personnel to clean up the spill.

The LPN/LVN is reviewing the admission information of a patient. Which information is of most concern to he nurse that this patient is at high risk for falling? 1. The patient has diabetes 2. The patient had a stroke 3 years ago with no complications 3. The patient becomes disoriented in the evening hours (?) 4. The patient wears eyeglasses and a hearing aid

4. The patient wears eyeglasses and a hearing aid

Medical Asepsis

A group of techniques that inhibit the growth and spread of pathogenic microorganisms. Sometimes referred to as clean technique.

Which instructions should be given to the UAP who is assigned to assist in the care of a patient who is being treated with internal radiation? 1. Do not go into the room unless the patient uses the call bell 2. Help children to don a lead shield apron before entering the room 3. Wear a mask, eye shield, and isolation gown when entering the room 4. Wear your dosimeter during patient care or when handling patient items

4. Wear your dosimeter during patient care of when handling patient items. Anyone involved in the care of a patient who is receiving internal radiation should wear their own dosimeter. This includes handling items such as linen and trash. Routine care must continue (ex vital signs and hygiene); thus staff will enter the room whenever necessary, but care should be well-organized so that minimal exposure occurs. Children under the age of 18 should not visit the patient while there is danger of radiation exposure. Wearing a mask, eye shield, and isolation gown do not offer sufficient protection against radiation exposure

What is the greatest advantage of using noninvasive pain management techniques as an adjunct to pain medication? 1.) Inexpensive and easy to perform 2.) Based on the gate control theory 3.) Low risk and few side effects 4.) Gives patients some control over pain

4.) Gives patients some control over pain

The nurse is assessing the patient's description of his back pain. He states that it is "immobilizing, intense, and on a scale of 0 to 10, it is a 8." What type of pain assessment scale is the patient using? 1.) Visual analog 2.) Categorical 3.) Functional 4.) Numerical

4.) Numerical

The home health nurse sees an order for meperidine (Demerol) for a 63 year old patient with cancer who requires long term opioid treatment. What is the best rationale for the nurse to question this medication order? 1.) Meperidine (Demerol) is an older drug that is now rarely prescribed for any condition 2.) The patient cannot be continuously monitored for adverse effects in the home setting 3.) The patient is not young nor healthy and is therefore more likely to suffer side effects 4.) Repeated administration of meperidone (Demoerol) increases the risk of accumulation

4.) Repeated administration of meperidone (Demoerol) increases the risk of accumulation

An 80 year old uncircumcised man is in the first postoperative day after a transurethral prostatectomy. When administering perineal care, which action by the nurse is correct? 1.) Retract the foreskin, cleanse the penis, and allow the foreskin to return to its former position 2.) Sprinkle powder under the foreskin to facilitate retraction 3.) Leave the foreskin slightly damp to allow retraction to its former state 4.) Retract the foreskin, cleanse the penis, and return the foreskin with a gentle forward motion

4.) Retract the foreskin, cleanse the penis, and return the foreskin with a gentle forward motion

The nurse is providing oral care to an 82 year old patient who is unconscious. The optimal position for providing oral hygiene to this patient is _____ to prevent choking. 1.) High Fowler Position 2.) High Fowler position with head hyperextended 3.) Supine with head facing to the side 4.) Side-lying with head facing towards you

4.) Side-lying with head facing towards you

The patient has been changing a dressing on a pressure ulcer for several days and is now being seen in the physician's office. The patient states, "There is a lot of pink tissue at the base of the ulcer." The nurse explains to the patient that this is the result of what process? 1.) Improper dressing technique and probable infection 2.) Presence of a layer of eschar that has to be removed 3.) Development of a fungal overgrowth interfering with healing 4.) The normal process of healthy granulation tissue

4.) The normal process of healthy granulation tissue

A 64 year old patient is too weak to perform her own perineal care. The student nurse includes bathing which areas as part of perineal care? 1.) Back and Buttocks 2.) Eyes, Ears, and Nose 3.) Upper torso and thighs 4.) Upper thighs, genitalia and anal area

4.) Upper thighs, genitalia and anal area

The student nurse has completed her educational instructions on the correct procedures for bed making? (Select all that apply) 1.) Preparing a closed bed for receiving postoperative patients 2.) Shaking soiled linen before placement in the hamper 3.) Mitering the corners of the bottom fitted sheet 4.) Washing hands thoroughly after handling soiled linen 5.) Folding and reusing the patient's bedspread if it is not soiled

4.) Washing hands thoroughly after handling soiled linen(**) 5.) Folding and reusing the patient's bedspread if it is not soiled

The nurse hears the report that the patient with diabetes has reported a tingling, burning sensation in the lower extremities. Which drug it the nurse likely to administer for this type of discomfort? 1.) ketorolac thromethamine (Toradol) 2.) tramadol (Ultram) 3.) acetaminophen (tylenol) 4.) duloxetine (cymbalta)

4.) duloxetine (cymbalta)

The recommended room temperature for most adults is

68° to 74° F (20° to 23°C)

Which patient is the most challenging regarding maintaining sterile technique throughout the procedure?

75 year old woman who is obese & confused needs a catheter inserted. (She is confused and could try to touch the sterile equipment, since she is obese, inserting the catheter can be hard)

Which patient is most at risk for being one of the "medically underserved" in the United States?

A 65-year-old Vietnam veteran who lives on the street

Which patient typifies the demographic changes of the population in the 21st Century & represents an increased need for nursing care?

A 78-year-old woman with chronic illness

Which of the following can cause acute compartment syndrome (SELECT ALL THAT APPLY)? A cast applied to treat a fractured wrist Excessive bleeding into the tissue The client's legs being kept in abduction A tightly wrapped dresssing applied to the leg Placing loose fitting stockinette on the client's arms to protect fragile skin

A cast applied to treat a fractured wrist Excessive bleeding into the tissue A tightly wrapped dresssing applied to the leg

Standard Precautions

A combination of Universal Precautions and Body Substance Isolation guidelines; used in hospitals for the care of all patients.

Urinal

A device for receiving urine; may be used with male or female; may be used for specimen collection

Safety reminder device (SRD)

A device used to immobilize a patient or a part of the patient's body

Therapeutic diet

A diet used as a medical treatment.

Patient-controlled analgesia (PCA)

A drug delivery system that dispenses a preset intravenous dose of an opioid analgesic into a patient's vein when the patient pushes a switch on an electric cord

OSHA (Occupational Safety and Health Administration)

A federal organization that provides guidelines to help reduce safety hazards in the workplace

an adult tells the nurse that he has muscle soreness and stiffness after performing a new exercise program. What was a nurse recommend?

A hot water tub bath with the proper temperature of 113° to 115° F (45° to 46° C) to relieve muscle soreness and muscle spasms

Stage 1 pressure ulcer:

A localized area of skin, typically over a bony prominence, that is intact with nonblanchable redness.

The nurse is assigned to care for an 82-year-old patient who weighs 252 lb and has undergone a bilateral below-the -knee amputation. Which transfer method is the safest for the patient and the nurse?

A mechanical lift with a sling (For full weight lifting of patients, because she had an amputation, who cannot assist in helping must use a mechanical lift)

Health care system

A network of agencies, facilities, and providers involved with health care in a specific geographic area with the goal of achieving optimal levels of health care for its population; health care environment includes the patient, the patient's family, the community, technology, government agencies, the medical profession, third-party agencies, and many others

Which health care worker is most likely to be a vector of infection

A nursing student has mild Flu symptoms but feels okay to go to the clinical site. (Harbors the flu before symptoms appear and spreads it)

the nurse is most concerned when applying heat therapy to which patient

A patient who is unconscious as the result of an automobile accident

A nurse notes that in a client's room there is a vase containing dirty standing water and dead flowers. Which link in the chain of infection could this dirty water represent?

A reservoir

Base of support

A stance with feet shoulder width apart.

Physical disuse syndrome

A state in which an individual is at risk for deterioration of body systems due to prescribed or unavoidable inactivity.

Noxious

A stimulation of the sensory nerve endings that is harmful, injurious, or dentrimental to physical health

Syncope

A transient loss of consciousness due to inadequate blood flow to the brain (fainting).

Transcutaneous electric nerve stimulation (TENS)

A type of pain control that is managed with a pocket-sized, battery-operated device that provides a continuous, mild electrical current to the skin via electrodes

A prospective nursing student questions what program accreditation means. What should be included in the information provided?

Accreditation is a voluntary review by a given organization to determine whether the program meets that organization's preestablished criteria

Mobility

Ability to move around freely in his or her environment.

contracture

Abnormal, usually permanent condition of a joint characterized by flexion and fixation and caused by atrophy and shortening of muscle fibers.

The most commonly used model that assists in the understanding of the patient's place on the wellness-illness continuum is that of:

Abraham Maslow

The health care system is the complete network of agencies, facilities, and all providers of health care in a specified geographic area, which one is the best description of the major goal of the health care system?

Achieve optimal levels of health care for a defined population through adequate and appropriate health care services

Synergistic

Action of two or more substances or organs to achieve an effect of which each is capable

A client who had a cerebrovacular accident (CVA or stroke) has weakness in his right arm but his left arm was not affected. The physical therapist instructs the client to use his right arm to provide range-of-motion (ROM) exercises to his weaker left arm. What type of ROM does this describe?

Active assisted ROM

The nurse is speaking with a patient about the need to prevent infection. The nurse recognizes that the patient understands proper hand hygiene when she makes what statement?

After washing my hands with soap for at least 15 seconds, I will rinse them thoroughly under running water.

examples of mode of transmission

Airbone, Contact, comtaminated food or needles

Articulation

Allows nursing programs to plan their curricula collaboratively to lessen duplication of learning experiences and support a process of progressive buildup

Which set of tasks should be assigned to a UAP (unlicensed assistive personal) who has been cross-trained as a unit secretary?

Ambulate patients & order unit supplies

Which of the following would NOT be used to promote venous circulation and prevent the development of deep vein thrombosis in the legs? Sequential Compression Device Thromboembolic Disorder stockings (TEDs) ACE wraps to the lower extremities An abductor wedge

An abductor wedge

Health care-associated infections (HAIs)

An infection that is acquired in a hospital setting, formerly known as a nosocomial infection

A disaster situation occurs and involves an explosion in a hospital laundry room. What type of disaster would this be classified as?

An internal disaster

Explain assault

An international threat to cause bodily harm to another; does not have to include actual bodily contact. The nurse would be charged with battery

Visual Analog Scale

An objective means of assessing pain severity; it consists of a straight line, representing a continuum of intensity, and has visual descriptors at each end

disaster situation

An uncontrollable, unexpected, psychologically shocking event that is unique and likely to have a significant impact on a variety of health care facilities.

Canthus

Angle at the medical and lateral margins of the eyelid (inner and outer corners of the eye)

Joint

Any one of the connections between bones.

Endorphins

Any one of the neuropeptides composed of many amino acids, elaborated by the pituitary gland and acting on the central and peripheral nervous system to reduce pain

What general principle to consider when using heat and cold therapy for patients

Application usually only lasts 10-20 minutes

Circumorbital

Around an orbit; often referring to the eye

Dentures

Artificial teeth not permanently fixed or implanted

While at work in an emergency department, a nurse witnesses a client threaten to physically attack anyone who tries to touch him. Which term best describes the threat the client made?

Assault

The patient has a cast on the left lower leg. Which assessment is performed to prevent compartment syndrome?

Asses skin color, temperature, movement, sensation, pulses, capillary refill, and pain

The nurse is caring for a postpartum patient. Which assessment should the nurse perform first before starting perineal care?

Assess ability to perform own care

The nurse notices a red area on the patient's sacrum. What should the nurse do first?

Assess for other areas of erythema

The nurse is caring for a new patient who needs assessment skin and self-care abilities perineal care partial bath in the bed linen change. The patient is very obese. What is the best strategy to meet the needs of the patient?

Assess skin and self-care abilities while working with the UAP to Complete Care

A family member tells the nurse that the staff is spending too much time laughing and chatting at the nurses station and it's disturbing the patients rest and comfort. What should the nurse do first?

Assess the patient's discomfort and ask what other things are interfering with rest ***

Nurse A is assigned to care for an AIDS patient, but asks Nurse B to switch patients. Nurse B readily agrees, but Nurse A always helps other nurses and members of the health care team. Together they inform the charge nurse, who gives the okay for the switch of assignments. At the end of the day, Nurse A thanks Nurse B for taking the AIDS patient, because "those kinds of people really bother me." Nurse B feels a little confused by the comment, but shrugs it off. Discuss the behavior of Nurse A and Nurse B, as related to the National Federation of Licensed Practical/Vocational Nurses (NFLPN) code of ethics.

Assessment needed to determine motivation for the action of these two nurses, Nurse A is hesitant to care for "those kinds of people", code specifies that the nurse should provide care without discrimination, assessment of Nurse A's behavior may reveal that she lacks the confidence or skills to care for AIDS patients, additional training is needed, possibility death of a close friend from AIDS may have created an emotional barrier, need grief counseling, Nurse B is attempting to help Nurse A, in order to maintain a high degree of personal and professional behavior, part of the code of ethics, Nurse B should talk t Nurse A about the comment, not ignore it.

A 56-year-old patient had an open cholecystectomy (removal of gallbladder). The nurse is going to assist the patient with *dangling* on the side of the bed before ambulation. After sitting him on the edge of the bed, which nursing intervention should the nurse perform before proceeding with the ambulation?

Assessment of his pulse and respirations (Provide baseline for assessing patients response to dangling)

The nurse weighs 106 pounds. According to the National Institute for Occupational Safety and Health (NIOSH) Division of Safety research, what is the maximum weight she should safely lift? 1. Depends on the nurse's health and personal strength 2. No more than 35 pounds of the patient's weight 3. No more than 35% of her own 106 pounds 4. Maximum of 50 pounds regardless of patient's or nurse's weight

B. No more than 35 pounds of the patient's weight. (no matter what the nurse weighs)

What is the name of the first school of training for the practical nurse established in 1892 in Brooklyn, New York?

Ballard School

Supine (sounds like spine)

Being in the horizontal position, lying face upward

Accountability

Being responsible for one's own actions

Febrile

Body temperature above normal

Disasters carried out by people

Bombings, arson, riots, shootings and hostage taking

Pressure is more severe over:

Bony prominences

the nurse will delegate the denture care to the UAP. What instruction should the nurse give to the UAP about the patient's dentures?

Brush Dentures with a soft toothbrush

The nurse is working in the emergency department. There is a gunshot sound from the waiting room, followed by sounds of yelling and screaming. What should the nurse do first?

Call 911 and the hospital's security personnel

Pathogenic

Capable of causing disease.

Perineal Care

Care given to the genitalia

Oral Hygiene

Care of the oral cavity (mouth)

CDC

Center for Disease Control and Prevention

Mary Ann Ball (1817-1901)

Championed the rights and comforts of soldiers; organized diet kitchens, laundries, and ambulance service

What nursing leader is credited with the development of the American Red Cross in 1881?

Clara Barton

Compartment syndrome

Compression from external devices, such as casts and bulky dressings which has the potential to cause extensive tissue damage. (pressure in a given part of the body that disrupts circulation and function of tissues in that compartment)

Linda Richards (1841-1930)

Credited with the development of our present-day documentation system

Which statement characterizes criminal law?

Criminal law applies to conduct that is detrimental to society

Which statement best describes criminal law?

Criminal law applies to conduct that is detrimental to society.

The newly LPN/LVN has reviewed the nurse practice act (NPA) of the state of licensure. What is the purpose of this documentation?

Define the scope of nursing practice

Standards of care

Defines acts whose performance is required, permitted, or prohibited

The nursing instructor is discussing the chain of infection to a group of students nurses. What is the most important information about identifying the chain of infection for the health care provider?

Determination of points at which the infection can be stopped or prevented can be made by identifying the chain of infection.

Mary Adelaide Nutting (1858-1947)

Developed curriculum concepts and guidelines for student nurses

Clara Barton (1821-1912)

Developed the American Red Cross in 1881

Bedpan

Device for receiving feces or urine from a patient who is confined to bed; may be used for specimen collection

The nurse is reviewing the planned health promotion activities for local community center. Which primary prevention activities may be included?

Dietary teaching focused on prevention of obesity

The nurse has to go before the state board of nursing because there is a question about her nursing license. Which type of insurance will provide a qualified nurse attorney to represent the nurse?

Disciplinary defense insurance

The nurse performs a dressing change on a surgical wound. The procedure is routine and there are no signs of infection or excessive drainage. What should the nurse do about documentation?

Document appearance of wound site and type of dressing used

It is the patient's first night after an abdominal hysterectomy. She has not voided for 9 hours, and the nurse is to insert a 16Fr. Foley catheter into her bladder. What patient position best allows insertion of the catheter?

Dorsal recumbent (lying on back with head and shoulder extremities flexed and sometimes legs flexed)

In order to prevent footdrop, the client should wear some sort of a splint/brace that keeps the foot in which position?

Dorsiflexion

Naturally Occurring Disasters

Earthquakes, Hurricanes, and Floods

An elderly patient begins to cry during the review of the advance directive information and refuses to sign. What should the nurse do first?

Encourage the patient to express his feelings about the advance directives.

An 82-year-old patient has had a cerebrovascular accident that affects her right side, placing a pillow between her legs and another to her back. What is the primary purpose of this intervention?

Ensuring the patient's proper body alignment. (Pillows between the legs and along her back will provide support of body or extremity and keep the body aligned)

Nightingale's theory

Environment- to facilitate the "body's reparative processes" by arranging the patient's environment

The nurse's first job as an LPN/LVN is on a unit that cares for terminally ill children. What action should be taken by the nurse before helping families cope with their children's illness?

Evaluate her own personal mores and customs that may affect the practice of nursing in general

A bed fast patient has a sacral pressure ulcer. How often does the nurse instruct staff to reposition the patient?

Every 2 hours

A 72-year-old patient with a stroke has slid to the foot of the bed. With use of appropriate body mechanics, the nurse maintains a *wide base of support and faces the patient in the direction of movement.* What do these actions allow the nurse to do?

Exert less physical effort

Hyperextension

Extreme or abnormal extension.

Breach of duty

Failure to perform the duty in a reasonable, prudent manner

Many female historical figures have influenced the profession of nursing. Which historical figure is known as the "Lady of the lamp?"

Florence Nightingale

Nursing theorists are helpful in enabling the nursing profession to problems solve & establish standards. Who is largely recognized as the first nursing theorist?

Florence Nightingale

The nursing profession has evolved over many hundreds of years and has been influenced by many people. Which woman had the greatest impact on nursing during the 19th century?

Florence Nightingale

The student nurse reviewing the history of nursing knows that the "Lady with the Lamp" is:

Florence Nightingale

The patient is admitted to the medical-surgical unit for exacerbation of a chronic respiratory disease. While in the hospital he requires medication, oxygen therapy, & diagnostic testing. In addition, the nurse notes that he smokes. He is overweight & making very poor food choices for between-meal snacks. He is unsteady when he ambulates & requires some assistance for activities that require bending & lifting, such as typing his shoelaces or picking up his suitcase. On further assessment, the nurse finds out that the patient lives by himself in a second-story apartment & his primary source of income is from a small pension. How could the nurse apply the concepts of health promotion & illness prevention to assist this patient?

For primary prevention, the nurse would encourage wellness activities and preemptive screening programs such colonoscopy or glucose screening. For secondary prevention, to reduce the impact of the chronic respiratory disease, the nurse would encourage smoking cessation and weight loss. For tertiary prevention, the nurse would get a referral for home health assistance, including physical therapy, which will improve quality of life and reduce further loss of function.

An unstageable pressure ulcer involves

Full thickness tissue loss, a wound base covered by slough (yellow, tan, gray, green, or brown) and eschar in the wound bed that usually is tan, brown, or black

A resident at a long-term care facility has difficulty transferring and needs one assist to stand-pivot to a wheelchair. Which device should the staff member use when transferring this resident in order to be safe during the transfer?

Gait belt

What should be included in care for a patient with *incontinence and Rotavirus*

Gloves and gown upon entering the room. (Contact precautions)

When providing first aid in an emergency situation outside a medical facility, it is important for the nurse to have knowledge of?

Good Samaritan Act

wear for known TB patients

HEPA respirator

Which health care facility is using evidence based practice to protect patients and health care workers from musculoskeletal injuries

Has a mechanical lift available for use; there is at least an 80% compliance rate and nurses and UAP are trained in the use of devices

Which patient is most likely to request that the room temperature be turned down? (What patients like cooler temps)

Has chronic pulmonary disease

Acute Pain

Having a short and relatively severe course; a disease process characterized by a relatively short duration of signs and symptoms that are usually severe and begin abruptly

An intoxicated patient comes to the walk-in clinic and verbally threatens a nurse with bodily harm. The nurse refuses to care for the patient and informs the supervisor about the threats. Which document/concept supports the nurses right to refuse to care for this patient?

Health Care Providers' Rights

The nurse is doing discharge teaching with a female patient who is going home with a Foley catheter. Which statement by the patient indicates a need for further teaching?

I will wash my perineum from Back to Front

Growth and advancement of the nursing profession in the 21st century can be attributed to:

Improved conditions for women

Utilizing Maslow's hierarchy of needs, the nurse gives priority to which problem?

Inability to eat because of difficulty with chewing & swallowing

Fomites are

Inanimate objects(nonliving) involved in the indirect contact transmission of pathogens

aseptic technique **

Infection control practice used to prevent the transmission of pathogens

The nurse is caring for a patient who is scheduled for surgery. Before going to surgery, the nurse would make sure that the patient has been fully informed about the procedure to be done. What would the patient sign to acknowledge that he or she is making an intelligent decision?

Informed consent doctrine

The nurse is caring for a client who is scheduled for surgery. Before going to surgery, the nurse would make sure that the client has been fully informed by the surgeon about the procedure to be done. What would the client need to sign to acknowledge that he or she is making the decision to have this surgery? (*)

Informed consent document

An LPN/LVN working at a long-term care center receives a physician's order on a resident requesting a Foley catheter insertion. The nurse explains and educates the resident regarding the new order. Following a thorough explanation of the procedure, including the risks and benefits, the resident refuses the Foley catheter insertion. What must the LPN/LVN secure before following through with this order?

Informed consent from the resident

Harm

Injury that gives basis for a legal action against the person who caused the damage

The nurse is teaching a patient who has diabetes about foot care. What should be included in the self care instructions?

Inspect feet daily for breaks in the skin

The nurse is caring for elderly residents in an assisted living facility. What is the best strategy to prevent skin breakdown among this vulnerable group?

Instruct UAP to help residents out of bed as much as possible ***

Immediately after donning a pair of gloves, a family member develops red, watery eyes, and contact dermititis with itching on the hands. What should the nurse do first?

Instruct the person to remove the gloves and wash thoroughly with soap and water. (These are symptoms of a laxtex allergy and could be life threatening. Washing hands gets the latex proteins off the skin)

Stage 4 pressure ulcer

Involves full thickness tissue loss with exposed bone, tendon, or muscle.

Stage 3 pressure injury

Involves full-thickness tissue loss in which subcutaneous fat is sometimes visible, *but bone, tendon and muscle are not exposed.*

What is the best rationale for the consistent is of Standard Precautions?

It is difficult to accurately identify all patient's infected with blood- borne pathogens. (Treat all contact as if the patient has a BBP- hand hygiene, gloves, gown, masks, and eye protection when appropriate for patient contact)

Compare an contrast your personal point of view about uniforms with patients' and families' point of view.

It is likely that as a nursing student & a soon-to-be nurse that looking professional is important to you. You may feel anxious to be rid of your current student uniform for a variety of reasons. Freedom of choice, unattractive style, & not being marked as a student are frequent reasons cited by students. From patients' point of view, they feel more comfortable & confident when they are easily able to distinguish nurses from other staff members. Recent studies also suggest that patients believe that nurses who wear white are better nurses than those who do not wear white.

The patient asked the nurse how his skin will be sterilized before his surgery. What is the. est resp by the nurse?

It is not possible to sterilize the skin, but we will use an antimicrobial solution to eliminate most microorganisms

When caring for patients, the nurse knows that part of the ethical principles include all patients having the same right to nursing interventions. What is the term for this principle?

Justice

Supination

Kind of rotation that allows palm of hand to turn up.

The nursing student is discussing the impact of preventive medicine. Which change has resulted from this focus?

Knowledge & services to promote health and prevent illness (wellness-illness continuum)

Discuss the role and responsibilities of the practical or vocation nurse in today's health care system.

LPN/LVNs function to provide specific services to patients under the direct supervision of a licensed physician,, dentist, or RN; assists individuals, sick/well, in the performance of those activities contributing to health, to their recovery, & to gain independence as rapidly as possible or to have a peaceful death. The LPN/LVN is educated to be a responsible member of a health care team, performing basic therapeutic, rehabilitative, & preventive care to assigned patients. LPN/LVNs are continuing to provide care in all types of settings, with the majority employed in long-term care settings.

The nurse observes a patient performing ear care. Which behavior indicates a need for additional teaching?

Leaves hearing aid by Sunny window

Competency

Legal presumption that a person can make decisions for him or herself unless proven otherwise

Liability

Legal responsibility

Which person was the first nurse to train in America?

Linda Richards

The LPN/LVN is instructed by a health care provider to start a unit of blood on a patient, but the institution's policy indicates the LPN/LVNs can monitor blood transfusions, but RNs must initiate blood transfusions. What should the LPN/LVN do?

Locate the RN in charge so that he/she can start the blood transfusion

Prone

Lying face down in horizontal position.

Prone

Lying face down on the abdomen

Sims position

Lying on the left side with the right knee and thigh drawn upward toward the chest; the chest and abdomen are allowed to fall forward

When using a lift sheet to assist in moving a patient in bed, what should the nurse ask the patient to do?

Maintain a straight body position

Foot boards

Maintain feet in dorsiflexion, which prevents plantar flexion (foot drop)

**The student nurse demonstrated principles of good body mechanics with which activity?

Maintaining a wide base of support and bending at the knees.

Which action is outside the scope of practice for the LPN/LVN

Makes independent decision about nursing diagnosis

The LPN/LVN knows that building the nurse-patient relationship is important in providing patient care, and a legal relationship is being formed. If there is a breach in this relationship and harm to the patient has occurred, which legal action can the nurse be charged with?

Malpractice

Define comfort

Means to give strength and hope, to cheer ad to ease the grief, pain, or trouble of another

When reviewing the role/impact of men in nursing, which statement is most correct?

Men are regaining their historical position in the profession as nurses.

Localized infection

Microbe enters the body and remains confined to a specific tissue

Flexion

Movement of certain joints that decreases angle between two adjoining bones.

Extension

Movement of certain joints that increases angle between two adjoining bones.

Abduction

Movement of limb away from body.

Adduction

Movement of limb toward axis of body.

Range of motion

Movement of the body that involves the muscles and joints in natural directional movements.

Today the nurse is assigned to care for a patient who has tuberculosis. What equipment should the nurse routinely use when caring for this patient?

N-95 respirator

Once students graduate from an approved LPN/LVN education program, they are eligible to take which examination for licensrue?

NCLEX-PN

The content areas for the NCLEX-PN are determine by who?

National Council of State Boards of Nursing

Nursing education programs may seek voluntary accreditation by which agency?

National League for Nursing

Range of Motion

Normal movement that any given joint is capable of making. Any body action involving the muscles, joints, and natural directional movement.

Nurse A is assigned to care for an AIDS patient, but asks Nurse B to switch patients. Nurse B readily agrees, but Nurse A always helps other nurses and members of the health care team. Together they inform the charge nurse, who gives the okay for the switch of assignments. At the end of the day, Nurse A thanks Nurse B for taking the AIDS patient, because "those kinds of people really bother me." Nurse B feels a little confused by the comment, but shrugs it off. Nurse B goes home and thinks about the day and about Nurse A's comment. Nurse B realizes that the situation has created some uncomfortable feelings and a potential problem if Nurse A makes a future request to change patient assignments or make additional comments. What should Nurse B do?

Nurse B should begin process of values clarification, with assistance from a counselor or supervisor, process includes thinking about a belief or behavior, deciding value including value into a response, could talk directly to Nurse A to see if Nurse A is actually discriminating against a certain type of patient or if there is some other problem, knowledge/skills lacking, Nurse B can decide to report nurse A's unethical behavior by following the appropriate chain of command, explaining the facts clearly, documenting incident objectively and accurately.

the nurses are assigned a mixture of patients who need isolation or just routine standard precautions. which nurse has exposed her patients to infection via indirect method of transmission

Nurse B uses her personal stethoscope to assess all of her patients. (Every isolation/ Standard precaution patient is supposed to have their own equipment to prevent transmission)

Which nurse is using the key factor in body mechanics

Nurse D keeps head erect and aligns and balances weight on both feet when assisting a patient stand up (maintenance of appropriate body alignment is the key factor in proper body mechanics)

Passive assisted ROM

Nurse assists patient with full ROM

The nurse has been working for several years in the hospital. The patient assignments are always very heavy and there has been a continuous nursing shortage. Two patients have died within the past year and although there have been no legal actions taken against the hospital or the staff, the general feeling among the nursing staff is that working conditions are going to results in more harm to the patients. The nurse has talked to her supervisor about her concerns for the patients' safety and the morale of the staff. The supervisor has assured her that everything that can be done has been done. Discuss the legal and ethical implications of these working conditions and the actions that the nurse could take.

Nurse has gone up the chain of command and reported her concerns to the supervisor, but nurse could still be involved in a legal action if there is an occurrence where a patient is harmed, could report the conditions to the state board of nursing, but change is slow, or at all, may make personal notes or incidents reports related to working conditions or to discussions with supervisors, ethical implications are employed in a situation that is constantly putting the patients at risk; however, in some ways, if the nurse decides to quit and seek another job, patient have lost an advocate and a caregiver, this scenario is not uncommon and the nurse could find this escalating, nurse decides to stay, teamwork is especially important under these conditions and watching out for each other and all of the patients become more important when everyone is tired and stressed.

A new nurse has just started his first job after graduating from nursing school. The nurse sees a health care provider's order to "get surgical consent form," but he is unsure what the order means, so he calls the health care provider for clarification. The provider for clarification. The provider is a little terse (strong) on the phone and says, "just get the consent form signed." The nurse is unsure what to do, so he consults the charge nurse who says, "Oh the doctors here are too lazy to get their own consent forms signed, so we always do it for them." Discuss the nurse's responsibilities when obtaining an informed consent from a patient before a procedure.

Nurse may be responsible for witnessing that the patient is signing the consent and is aware of the treatment, risks, alternatives, and consequences of accepting or rejecting care, nurse should be careful not to discuss with the patient the elements of disclosure that the health care provider is required to make, such as the risks or benefits involved with the treatment or procedure.

The nurse is caring for a patient who has been quadriplegic (paralysis of all four limbs) for 3 years following a dividing accident. One morning the nurse notes that the patient has redness on the sacral area and informs the patient that there is a risk for a pressure ulcer and that very careful turning and scheduled assessment will need to be started. The patient politely thanks the nurse, but informs her that he intends to refuse any treatment for pressure ulcers and is likely to start refusing other nursing measures as well. The nurse is stunned and upset because the patient has always been cooperative and generally very satisfied with the care. What should the nurse do?

Nurse needs to include other members of the health care team, health care provider and the psychiatric social worker. Physical causes for depression or changes in cognition should be investigated and psychological causes of depression, a psychiatrist or psychiatric clinical nurse specialist should assess patient for signs of suicide, if patient is able to considered sound of mind, he has the right to refuse care

A mother brings her 8 year old son to the clinic for a broken arm. There are no other apparent injuries and the child and mother appear to have a supportive relationship; however, review of the chart indicates that this child has frequently been treated for other fractures and injuries. What should the nurse do first?

Point out the history of injuries to the health care provider

The emergency department nurse admits a victim of poisoning. Who should the nurse call to receive the best assistance for dealing with this victim?

Poison control center

A new nurse has just started his first job after graduating from nursing school. The nurse sees a health care provider's order to "get surgical consent form," but he is unsure what the order means, so he calls the health care provider for clarification. The provider for clarification. The provider is a little terse (strong) on the phone and says, "just get the consent form signed." The nurse is unsure what to do, so he consults the charge nurse who says, "Oh the doctors here are too lazy to get their own consent forms signed, so we always do it for them." The nurse is new to the city and this is his first job, so he has limited experience, but he clearly remembers what was taught in school about informed consent. What should he do?

Nurse should go back to the charge nurse, clarify how nurses are getting informed consent signed, possible health care providers are explaining the procedures and the nurses are later accessing the patients' understanding and then contacting the provider if the patient has questions or needs clarification, this is not the best situation, nurse should accompany the provider during the explanation and the form should be signed at the time, nurse could ask the charge nurse to obtain the informed consent and then further discuss this process with a supervisor, nurses in this facility are risking practicing outside scope of practice and could be liable if the patient suffers harm from the procedure.

OSHA

Occupational Safety and Health Administration

Proximate cause

Occurrence of harm depended directly on the occurrence of the breach

Shearing force:

Occurs when the tissue layers of skin slide on each other, causing subcutaneous blood vessels to kink or stretch and resulting in an interruption of blood flow to the skin

Two-point gait

One crutch and opposite extremity move together followed by opposite crutch and extremity

Non-rapid eye movement

One of two highly individualized sleeping states divided into four stages through which a sleeper progresses during a typical sleeping cycle; represents three fourths of a period of typical sleep

Rapid Eye Movement (REM)

One of two highly individualized sleeping states that follows NREM state. May last from a few minutes to a half an hour and alternate with NREM periods; dreaming occurs during this time

The nurse is observing the new staff member who is preparing to do a sterile dressing change. The nurse determines that the staff member requires correction & additional instruction when he observes:

Opening the outter flap of the sterile package by moving it towards the body (always move it away from the body)

Compare & contrast the historical significance of the white pleated cap & the apron that were originally part of the nurse's uniform with contemporary mandatory dress codes for nursing students & nurses.

Originally, the white pleated cap & apron signified respectability, cleanliness, and servitude. Caps gradually became symbolic of office & achievement & were celebrated with capping ceremonies. Uniforms became more informal & nurses complained that caps interfered with care, caused hair loss, took too much time for washing & starching, & were a source of bacteria. Health care facilities & nursing schools typically have dress codes for the style of uniform or color. Staff are generally required to wear name tags & identification badges. Many nurses do not approve of mandatory dress codes. They argue that the other health care professionals do not depend on uniforms for their authority.

The nurse is assigned to care for a 64-year-old patient who was admitted for exacerbation of chronic obstructive pulmonary disease and pneumonia. He has dyspnea and is *unable to rest in a supine position.* The nurse elevates the head of the bed to *90 degrees, places a pillow on the overbed table, and assists the patient to lean forward, placing his head on the pillow.* What position should the nurse document the patient as being in?

Orthopneic. difficult or painful breathing except in an erect sitting or standing position. (position assumed by the patient sitting up in bed. Facilitates ease of breathing- COPD)

Airborne precautions

PPE- n95 mask

Chronic Pain

Pain lasting longer than 6 months; can be as intense as acute pain; can be continuous or intermittent

Referred Pain

Pain that is felt at a site other than in the injured or diseased organ or part of the body

Pronation

Palm of hand turned down.

Center for Disease Control and Prevention (CDC)

Part of the U.S. Department of Health and Human Services, provides facilities and services for investigation, prevention, and control of disease.

Which patient us the most likely candidate for active assisted ROM

Patient C has right side weakness in the upper body due to stroke

Genupectoral

Patient kneels so that weight of body is supported by knees and chest, with abdomen raised, head turned to one side, and arms flexed. (Genu- means knees and Pectoral- means chest. Patient puts all their weight on their knees and chest while in prone position)

Lithotomy

Patient lies supine with hips and knees flexed and thighs abducted and rotated externally. (GYNO and child birth

Recognizing patients as individual & making sure that they receive quality care is ensured by nurses providing care according to who?

Patient's Bill of Rights

Trendelenburg's

Patient's head is low and the body and legs are on inclined plane. Used to assist in venous distention during central line placement

A patient is in very critical condition and unable to make decisions about ongoing treatment. There is conflict among family members on what should be done. Which source, if followed, is the most likely to protect the healthcare team from liability?

Patient's living will

The 1st year nursing students are going to the hospital for their first clinical. What is the most important thing that the students should do to prevent exposing patients to HAIs

Perform hand hygiene using recommendations from the CDC. (Hand Hygiene is the most importent in preventing transmission of pathogens)

Health care providers today need to be aware that health care-associated infections are a serious problem. What is the most effective way to prevent health care-associated infections?

Perform proper hand hygiene before and after caring for a patient.

Dorothea Dix (1802-1887)

Pioneer crusader for elevation of standards of care for the mentally ill

Mary Breckenridge (1881-1965)

Pioneer in nurse-midwifery

The nurse receiving a report on a patient. The nurse giving the report states that the patient has *foot drop*. The nurse receiving the report knows that which is the correct terminology for foot drop?

Plantar flexion of the foot (foot drop boots keep the foot in dorsiflexion position to prevent this)

platform walker

Platform walkers are used for patients who cannot grasp the handlebars or bear their weight on their hands. With some platform walkers, patients' rest their forearms on a support table. With other platform walkers, patients' forearms are strapped into platforms that are attached to the sides of the walker. With both types of platform walkers, patients bear their weight on their forearms.

Fowler's

Posture assumed by patient when head of bed is raised 45 to 60 degrees.

Semi-Fowler's

Posture assumed by patient when head of bed is raised approximately 30 degrees.

Orthopneic

Posture assumed by the patient sitting up in bed at a 90-degree angle, or sometimes resting in forward tilt while supported by pillow on over bed table.

Trochanter roll

Prevents external rotation of legs when patient is in supine position; possible to make with a towel

Maslow's Hierarchy of Needs, which was developed in the 1940s, is a system that does which of the following?

Priorities human needs by placing physiological needs above all emotional psychological, social, spiritual, or self-actualization needs

exogenous

Produced outside the body

Malpractice

Professional negligence

In which position is the patient *lying face down or chest down?*

Prone

A patient begins to have a gal mal seizure. What is the priority action

Protect against falls and other injuries If the patient is having uncontrollable movements during a grand mal seizure, placing soft material against the side rails offers some protection. Checking the airway and suctioning secretions should be performed by the nurse. Inserting an oral airway is not done during the seizure, but may be done after the seizure is over to keep the tongue from falling backward; also there is always a possibility of a repeat seizure until medication or other therapy is given.

tube feeding

Provision of food to the stomach through a tube (nose or small intestine)

P.A.S.S

Pull, Aim, Squeeze, Sweep

The patient reports fatigue, weight loss, dyspnea, fever, night sweats and *coughing up small flecks of blood* what should the nurse do FIRST

Put a mask on the patient and escort him to an isolation room. (These are symptoms of TB. It is important to isolate this patient to prevent transmission.)

The nurse is supervising a nursing student he was giving a patient bed bath. The nurse would intervene if the student performs which action?

Puts up all four side rails after completing the bath

Secondary prevention

Recognizes the presence of disease but seeks to reduce the impact of the condition by encouraging behaviors to promote health; for example, dietary teaching to a patient with diabetes

A cold application is ordered for a patient. What is a positive effect of this treatment

Reduced blood viscosity (Cold causes vasoconstriction)

A mother and her pregnant 13 year old daughter are arguing; the mother wants her to keep the baby and the girl wants to have an abortion. The nurse feels very angry toward the girl. What should the nurse do first?

Reflect on own feelings and ability to be supportive and caring toward this family

The nurse is evaluating the eye care that has been delegated to and is being provided by a new staff member. Which action is appropriate?

Removing dried secretions with moist gauze

Hazard Communication Act of the OSHA

Requires health care facilities to inform employees about the presence of or potential for harmful exposure and how to reduce the risk of exposure

The patient admitted for surgery has a lump in her breast. The patient's daughter asks the LPN/LVN if her mother should have the surgery. Which issue must be considered before responding?

Respect for people and personal autonomy

Lillian D. Wald (1867-1940)

Responsible for the development of public health nursing in the United States through the founding of the Henry Street Settlement in New York City

Lavinia Dock (1858-1956)

Responsible, with Robb, for the organization of the American Society of Superintendents of Training Schools, which evolved into the National League for Nursing Education

A patient has been immobilized for 5 days because of extensive abdominal surgery. When the patient is helped out of bed for the first time, which nursing diagnosis related to safety applies to this patient?

Risk for activity intolerance. (the patient may be too weak to tolerate the actions of getting out of bed)

A patient in contact isolation has a minimal amount of visitors, and the health care staff enters only when patient care is being performed. Based on this information, which patient problem is most appropriate for this patient?

Risk for social isolation

Approved program

Satisfies the minimum standards set by the state agency responsible for overseeing educational programs

Primary prevention

Seeks to avoid disease states through wellness activities and preemptive screening programs such as mammograms, colonoscopies, and glucose screening

Personal Hygiene

Self-care measures that people use to maintain their health

What are two mechanical factors that play a common role in the development of pressure ulcers?

Sheering force Friction

prodromal period

Short period after incubation; early, mild symptoms

Labia Minora

Smaller fold of tissue covered by the labia majora; lip.

The nurse has identified that a 56-year-old woman has an increased risk for heart problems because of family history. Which modifiable factor(s) should be included in the teaching plan to promote health & self-help practices for wellness for the patient?

Smoking cessation & stress reduction, weight reduction & decreased alcohol consumption, control over decision-making that affects own body & health

Nurse A knows that Nurse B is stealing small items from elderly residents in the long-term care facility, but Nurse A hesitates to report Nurse B, because they are friends and Nurse B gives good care to the residents. Who should Nurse A talk to first?

Speak to the superior and give facts only; do not offer suspicions

Disaster manual (2)

Specifies departmental responsibilities; chain of command; callback procedures; assignment procedure; patient evacuation procedure and routes; procedures for the receipt and management of casualties; and policies related to the overall management of supplies and equipment

Which of the following is a characteristic of some bacteria that can allow them to lie dormant for long periods of time when conditions for growth are not favorable?

Spores

What stage of pressure ulcer appears as a shallow open ulcer, usually shiny or dry, with red-pink wound bed without slough or bruising?

Stage 2

A patient is noted with a pressure ulcer on his sacrum. The pressure ulcer has full thickness skin loss with necrosis of the subcutaneous tissue which classification is this pressure injury?

Stage 3

the nurse has a previous back injury and knows that she should avoid twisting her spine as she cares for patients. What is the best strategy for the nurse to use

Stand directly in front of the person or object being worked with

The nurse is caring for a patient with a wound infection of the lower extremity. Which types of precaution would the nurse use when taking care of this patient?

Standard and Contact Precautions

As part of their right to refuse treatment, patients may prepare advance directives specifying what life-saving treatments they'd o or do not wish to receive. When determining the legality of an advance directive, what applicable laws should the nurse know?

State

The nurse student is told to observe the bowel movements of an adult patient and Report any abnormalities to the nurse. What should the student report as an unexpected finding? 1. Stool was dull clay color 2. stool had soft, formed consistency 3. Patient had two bowel movements 4. Stool had the shape of the rectum

Stool was a dull clay color

A mother tells the nurse that her 17-year-old son, who is wheelchair-bound for one year following an accident, has been depressed because basketball season is starting & he was a star player for his high school team. Utilizing Maslow's hierarchy of needs, which intervention would address the son's priority need?

Suggest the mother and son to seek out a wheelchair basketball team

Gate control theory

Suggests that pain impulses can be regulated or even blocked by gating mechanisms located along the central nervous system

Dorsal recumbent

Supine position with patient lying on back, head, and shoulder with extremities moderately flexed; legs are sometimes extended. (THIGHS ARE NOT ABDUCTED)

An LPN is asked by an RN to perform a particular treatment on a client. The LPN is not sure that LPNs are allowed to perform this particular treatment; that it must be performed by an RN. What resource should LPNs/LVNs refer to in order to know *with certainty* what they can and cannot do within their scope of practice? (*)

The nurse practice act of their licensing state

The nurse helps ambulate an 84-year-old female patient who has peripheral vascular disease that caused a severe stasis ulcer. The patient becomes very weak, reports feeling faint, and begins to fail. What is the most appropriate action to prevent injury to the patient?

Support her while she is falling and allow her to sit on the floor. (Easing the patient to the floor allows the nurse to break the fall, control its direction and protect the patients head. Never try to prevent the fall because you will get hurt)

airborne illnesses

TB, measles, chicken pox, disseminated herpes zoster

A patient who is paralyzed from *the waist down* is at risk for developing a *pressure ulcer* on the sacral area. Which intervention would the nurse use for this patient?

Teach to shift way every 15 minutes

Identify the role of the National League for Nursing (NLN) in nursing education.

The (NLN) established educational standards & criteria & is involved in the voluntary accreditation of nursing programs

Which was the first school dedicated to the training of the practical nurse in the United States?

The Ballard School

the nurse applies heat to a large area on the trunk of a patient. The patient reports *slight dizziness and his pulse is rapid* what is the best physiological explanation

The application is causing vasodilation

Body mechanics

The area of physiology for the study of muscle action and how muscles function in maintaining the posture of the body and prevention of injury during activity.

What does duty refer to?

The established relationship between the patient & the nurse

The nurse is preparing to open the outer sterile wrap of a indwelling catheter tray. Which flap of the wrap in which direction, should be opened first

The flap that opens away from the nurse

Which situation includes the four major concepts that are the basis of nursing theories & models?

The home health nurse assesses the patient's health & the home setting.

The nurse is working on the medical-surgical unit and answers the telephone. The caller wants to know, "How is Mr. Smith doing?" What is the most important factor that affects the nurse's response?

The hospital policy for releasing information

Immobility

The inability to move around freely.

Tertiary prevention

The management of care activities for those with serious health problems who seek to improve the quality of life and reduce further loss of function

The patient accidentally knocks the emesis basin to the floor. When picking up the emesis basin, which movement demonstrates *proper body mechanics* by the nurse?

The nurse lowers the body by flexing the knees and bending the hips. (Picking something up.)

The nurse instructed the UAP to encourage the patients Independence in accomplishing adl's which behavior best indicates that the UAP understood what to do?

The nurse observe the patient is brushing his own teeth

What resource would be LPN/LVNs refer to in order to know what they can and cannot do within their scope of practice?

The nurse practice act of their licensing state

An older adult patient has been lying in the supine position for 3 hours and tells the nurse that she is too uncomfortable to move right now. What is the best response by the nurse?

The nurse should assess the patient's need for pain medication before helping her change position. (she doesn't want to move because shes in pain)

Which of the following nursing actions would be considered to be an example of using surgical aseptic technique as opposed to using medical aseptic technique?

The nurse wears sterile gloves and uses sterile gauze to change a surgical wound dressing

The health care provider's order read "assist the patient with walking." The nurse allowed the patient to walk alone. The patient fell, fracturing the humerus. Which verdict is the most likely occurrence?

The nurse will only be guilty of negligence

Which patient has a condition that will be most challenging for the health care team to manage?

The patient is immunocompromised and has a wound infected with methicillin resistant Staph. aureus (patients with immunocompromised conditions who are admitted to a health care facility have an increased risk of exposure to MRSA- Very difficult to treat)

In which case is the nurse most likely to be charged with malpractice?

The patient is very demanding and unpleasant, so the nurse ignores the call bell; the patient sustains tissue injury at the IV site.

Which patient is showing signs of an inflammatory response in the absence pf infection

The patient's ankle is swollen, red and tender; symptoms started after falling. (These are signs of localized inflammation. It resulted after a fall which is the cause of the infammation)

List the purposes of the National Association for Practical Nurse Education and Service (NAPNES) and the National Federation of Licensed Practical Nurses (NFLPN).

The purpose of NAPES & NFLPN are to: -Set standards for LPN/LVN nursing programs -Promote & protect LPN/LVN nurising

Alignment

The relationship of various body parts to each other.

Friction:

The rubbing of skin against another surface

Hygiene

The science of health and its maintenance; system of principles for preserving health and preventing disease

Vertigo

The sensation that the outer world is revolving about oneself or that one is moving in space

Suspected Deep Tissue Injury, During this stage:

The wound appears as a localized purple or maroon area of discolored intact skin or a blood-filled blister

the nurse performs hand hygiene before donning gloves, completes the procedure, and then doffs the gloves. What is the best rational for performing hand hygiene after doffing the gloves and before leaving the patient's room

There is a risk of perforating the gloves during use and the perforation may not be obvious. (Helps prevent cross contamination)

True or false: It is acceptable to delegate monitoring patient behavior for risk and injury and promoting a safe environment as a responsibility of the UAP, in addition to the nursing staff

True

True or false: It is acceptable to delegate monitoring patient behavior for risk for injury and promoting a safe environment as a responsibility of the UAP, in addition to the nursing staff.

True

Axilla

Underarm area or armpit

The patient is admitted to the medical-surgical unit for exacerbation of a chronic respiratory disease. While in the hospital he requires medication, oxygen therapy, & diagnostic testing. In addition, the nurse notes that he smokes. He is overweight & making very poor food choices for between-meal snacks. He is unsteady when he ambulates & requires some assistance for activities that require bending & lifting, such as typing his shoelaces or picking up his suitcase. On further assessment, the nurse finds out that the patient lives by himself in a second-story apartment & his primary source of income is from a small pension. Identify all of the participants in the health care delivery system who will be involved in this patient's care & briefly describe their roles & responsibilities.

This patient has complex physical problems and he has some lifestyle, social, and financial issues that need extra attention. Registered nurse-provides direct patient care in the hospital & a RN from a home health agency could also be involved in the care of this patient. LPN/LVN-works under the supervision of the RN in providing patient care. Physician-provides diagnosis and prescription of treatments and medications. Social worker-provides counseling and referral to community resources. Physical therapist-offers exercises and will assist this patient in learning techniques for safe ambulation, bending, and lifting. Dietitian-provides nutritional counseling. Respiratory therapist-supervises oxygen administration and performs pulmonary assessments. Technologist-will obtain and analyze specimens and perform other diagnostic procedures. Pharmacist-prepares the medication in the hospital. The community pharmacist can help this patient monitor his home medications.

The nurse is interviewing a 65-year-old woman who has hypertension, which is well-controlled by blood pressure medication. She is retired, but recently started volunteering at her church. She describes herself as having some problems, but happily coping and looking forward to spending time with her grandchildren. Describe this woman's state of health.

This patient has some health problems & some changes in her life, but she has a relatively high level of wellness. Her blood pressure is under control & she has adapted to a major change (retirement), by taking on a new challenge of volunteering. Her positive outlook on life allows her to find joy in the prospect of sharing time with a new generation.

Dorsiflexion

To bend or flex backward.

Purpose of civil law

To make the aggrieved person whole again, to restore the person to where he or she was.

The nurse working in a nursing home correctly recognizes that duties include patient advocacy. Which role is considered a primary duty of patient advocacy?

To safeguard the well-being of every patient

A complete bed bath is for patients who are:

Totally dependent and require total assistance

Which assistive device *allows patients to pull with the upper extremities to raise their trunk off the bed, to assist in transfer from bed to wheelchair, and to perform upper arm exercises?*

Trapeze bar

True or false: Electrical accidents are often prevented by reporting frayed or broken electrical cords or any shocks felt when using equipment

True

True or false: Growth and the acquisition of new motor skills place children at an increased risk for injury

True

The nurse is assessing the oral cavity of an unconscious patient and sees tenacious, exudate on the tongue, teeth and gums (firm fluid). What instructions should be given to the UAP?

Use a moisten sponge applicator and gently clean crust several times for shift

What should a nurse do when encountering a mercury spill?

Use a special kit designed for cleaning mercury and follow the instructions exactly

Which action best demonstrates the nurse's consistent effort to contribute to cost-containment?

Uses time & materials economically

One of the major problems of hospitals of the early 19th Century has been addressed by which measure in contemporary health care?

Using Standards Precautions to address hygienic practices

A client with a respiratory infection asks the nurse why he is not yet on an antibiotic. The nurse explains that the health care provider has diagnosed him with a type of infection that will not be helped by taking antibiotics. What type of infection does this client MOST LIKELY have?

Viral

The nurse suspects that a patient has an infection. What lab value would the nurse assess to help confirm the suspicion?

WBC

The patient has been received antibiotic therapy. Which lab result indicates a need to contact the health care provider for a reevaluation of prescribed therapy?

WBC is elevated. (The antibiotics arent working becayse WBCs should be down if the infection is resolving)

Active assisted ROM

When patient uses the strong arm to exercise the weaker or paralyzed arm.

Musculoskeletal disorder (MSDs)

Work injuries due to improper body mechanics, back injuries prominent among healthcare workers

Mary Eliza Mahoney (1845-1926)

Worked for acceptance of African-Americans in the nursing profession

Abandonment of care

Wrongful termination of providing patient care

Cerumen

Yellowish or brownish waxy secretion produced by vestigial apocrine sweat glands in the external ear canal; earwax

A patient receiving anticoagulant therapy is requesting to shave. What is the nurses most appropriate response the patient?

You will be able to shave with only an electric razor

Which unaccompanied minor requires parental consent prior to treatment?

a 17 year old who wants a prescription for insulin

Which patient is most likely to be susceptible to infection because of factors affecting immunologic defense mechanism?

a 73 year old man who recently had chemotherapy and radiation treatments. (Age, chemo and radiatin affect immune defenses)

Contamination

a condition of being soiled, stained, touched by, or otherwise exposed to harmful agents

When developing a definition of "health," a person should consider that health is:

a condition of physical, mental, & social well-being & absence of disease

Sterilization

a method used to kill all microorganisms *including those that form spores*

The physical therapist instructs a client on the use of crutches for ambulation. The client is able to bear weight on both lower extremities, but has bilateral lower extremity weakness and pain. Which crutch gait pattern would NOT be necessary for the physical therapist to teach to this client? two-point gait A swing-to approach A four-point gait A three-point gait

a three point gait

Formite

a vehicle that is an inanimate object that harbors and transmits pathogens

Terrorism

a violent or dangerous act used to intimidate or coerce a person or government to further a political or social agenda

The nurse is performing a surgery hand scrub. During a surgical hand scrub, how are the hands to be held?

above elbows (water flows from least contaminated to most contaminated. Removing transient microbes)

The student is reviewing sterile technique. When using the technique, the sn is reminded to hold sterile objects in which location?

above waist level (anything below the waist is considered to be contaminated)

Asepsis

absence of pathogenic microorganisms

To practice strict surgical asepsis, the nurse:

adheres to principles of sterile technique

The nurse is assigned to represent the unit in the infection prevention & control committee. The community is discussing the CDC's hand hygiene recommendation for implementation in the hospital. Which statement demonstrates an understanding of the CDC's recommendation?

alcohol-based Hand cleaner is effective on hands that are not visibly soiled with blood & body fluids

enteral nutrition

alternate form of feeding that involves passing a tube into the gastrointestinal tract to allow instillation of the appropriate formula

The nurse is aware that the body has normal defenses against infection. Which medication can affect the acidic environment, which is one defense mechanism?

aluminum/ magnesium antacid. (GI tract- chemically destroys microorganisms incapable of surviving low pH)

Nutrition labels must include

amount of proteins, carbs, sodium, vitamin A and C, calcium and iron

sentinel event

an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof

For what circumstance would it be appropriate to contact the infection control nusre for assistance?

an unusual cluster of infection is seen in the emergency department. (The infection- control nurse will have to notify the local health department about the cluster of infection and implement the correct precautions)

Poison

any substance that is harmful to your body when ingested, inhaled, injected, or absorbed through the skin

A new UAP is assigned to do a task that was reviewed and demonstrated in orientation and practiced on a manikin. The UAP tells the nurse that she does not know how to do the task. What should the nurse do first?

ask the UAP to recite the steps of the task and assess readiness to perform

The nurse sees the UAP trying to take an overly full laundry bag from the patient's room to the dirty untility room. The UAP is struggling to manage the bag and is partially dragging it in the floor. What should the nurse do?

assist the UAP to carry the bag and then find out how it got so over full. (assist because the floor is dirty)

change masks

at least every 20-30 min

The nurse believes that all patients should be treated as individuals. The ethical principle that this belief reflects is:

autonomy

examples of pathogens

bacteria, viruses, fungi, and parasites

identify 4 major classifications of pathogens

bacteria, viruses, fungi, protozoa

The nursing student needs to obtain patient information to prepare for the clinical experience and decides to stop and say hello the patient. While they are talking, the patient suddenly stops breathing and becomes unresponsive. What should the student do first?

call for help and initiate CPR

Nutrients that provide energy

carbs, fats, proteins

Factors that influence the safety of the older adult in the home or health care environment

changes in sensory function (vision, hearing, touch), decreased muscle strength, decreased circulation, medications taken, and possible cognitive alterations

The patient has a large midline abdominal incision. With the specific purpose of reducing a possible reservoir of infection, the nurse:

changes the dressing when it becomes soiled. Soiled dressing promote growth and reproduction of microbes

An alert adult patient has refused an intramuscular injection. The nurse waits until the patient is asleep and gives the injection anyway. The nurse could be charged with:

civil battery

spores remain dormant until...

conditions become favorable for growth

surgical asepsis

consists of techniques designed to destroy microorganisms and spores

Medical (absence of pathogens) asepsis

consists of techniques that inhabit (stops) the growth and transmission of microongranisms

The new nurse observes a health care provider who routinely comes out of a patient's room, rinses, and then shakes water from her hands so that it splashes on the floor, sink, and her uniform. What should the new nurse do?

contact the infection control nurse for advice. (The infection- control nurse can document the incident. Providing education to the staff about the importance of infection control and prevention)

abductor wedge

designed to separate the legs of a patient. It is often used after hip surgery to prevent the new hip from "popping out".

dysphagia

difficulty swallowing

the patient has TB &has been placed in a negative- pressure isolation room with airborne precautions. Despite repeated attempts to educate the patient, he keeps sneaking out of his room & going outside to smoke. What should the nurse do first?

discuss the behavior with the patient. (Educate the patient of the risk of exposing others to TB)

The nurse and a UAP are to move a *dependent patient* from the supine to the lateral position (back to side position). Which action should be performed first?

ensure that the upper arm and leg are supported with pillows (Pillows under the arm and leg will provide support of body or extremity and keep the body aligned)

Portal of entry

entrance through skin, mucous lining, or mouth

External Disasters

events outside the hospital that produce a large number of victims (e.g. fires plane or train crashes earthquakes or violent civil disturbances)

Internal disasters

events that occur within a health care agency ex: Pipes burst, fires

Portal of exit (chain of infection)

exit route from the reservoir

a patient isolated for pulmonary tuberculosis (TB) seems to be anger. The nurse recognizes this is a normal response to the isolation. What action by the nurse is most appropriate?

explain isolation procedures and provide meaningful stimulation.

virulent

extremely pathogenic

TB symptoms

fever, cough, bloody sputum, weakness, chest pain, night sweats

systemic infection symptoms

fever, feeling I'll or unwell, pain in joints, swelling in the joints, pain in tendons, skin rash with pink or red spots that become pus filled

The nurse caring for the patient in isolation wears latex gloves. Which is an important consideration?

first assess the patient for potential latex allergy. (Latex allergies can be life threatening)

The nurse is working in a clinical medical area with a census of 15. Each patient has a different illness. When planning care, the nurse recognized which of the following as the most important action to provide protection to each patient from health cate- associated infections?

hand hygiene. (Hand hygiene is important in preventing the transmission of infection)

Which patient needs to be placed into contact precautions?

has a draining wound colonized with multiple resistant bacteria. (contagious via direct contact. Multiple resistant bacteria- hard to treat. Draining wound should be covered)

The NS has been diagnosed with strep throat. Under what circumstances can the student go to the clinical unit and care for patient's and complete the clinical objectives?

has been taking prescribed antibiotics for at least 24 hrs. (After 24hrs, she is no longer contagious)

The nurse gets a report, puts his patient assignment notebook in his pocket, and goes on break. His notebook has very specific information about his patients and is missing from his pocket when he returns to the unit. The book is found later on the floor in the cafeteria by a visitor and is returned to the information desk. The nurse:

has violated the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The nurse loves photography and brings his camera to work at the nursing home. He takes a picture of one of his coworkers walking a patient. What best describes the actions taken by the nurse?

he violated the patient's right to privacy

A 45 year old man is admitted to the hospital with cellulitis of the right foot. 3 days later, he develops bacterial pneumonia. How is this type of infection classified?

health-care care- associated (He was admitted to the hospital and 48 hrs later, he contracted another infection)

The LPN/LVN is reviewing the patient's medical record. The nurse notes the presence of an advance directive. The nurse recognizes that the purpose of this documentation is to:

help every person exercise the right to die with dignity

Health care associated infection

hospital acquired infections ranging from mild to fatal. 48 hrs after hospitalization

the nurse has knowledge about infection and the application of

infection prevention and control principles

Aspiration

inhalation of some foreign material

although surgical asepsis is practiced in the o.r. &in the specialty areas, the nurse at times also uses surgical aseptic technique at the patient's bedside. For which procedure does the Nurse use surgical asepsis?

inserting an iv, inserting catheter (the areas have to remain sterile to prevent infections)

A patient with rubella needs to be transported to the X-ray department. What should the nurse do to prepare the patient for transport?

instruct the patient to wear a mask & follow cough etiquette. (Droplet Precaution. Cough Etiquette: covering mouth when coughing, etc)

Some stage 2 ulcers show as:

intact or open serum-filled blisters.

Incubation period

interval between *initial infection and first signs and symptoms*

Acute stage

interval when patient's sign and symptoms manifest, *time when individuals most contagious*

A stage 2 pressure ulcer:

involves partial thickness loss of dermis; appears shallow, open ulcer, usually shiny or dry, with red-pink wound bed without slough or bruising

a patient comes into the clinic and tells the nurse that he has a sore throat and would like to see a do. For which task(s) does the nurse need to wear gloves?

measuring an oral temp, taking a throat swab and when using a tongue blade to look at the throat. (Wear gloves when the potiental for touching blood, body fluids- mouth-, secretions and excretions)

clean techniques is called

medical asepsis

mode of transportation

method or vehicle of transportation. How it is spread. Airborne, Contact, Droplet

Straight Cane

minimal assistance

The nurse is caring for a patient with immobility related to a chronic musculoskeletal disorder. Using Orem's theory of nursing, the nurse would:

monitor the patient's self-care deficits.

Nonpathogenic

not harmful

total parenteral nutrition (TPN)

nutrient-complete solution given directly into bloodstream when person cannot eat by mouth

monitoring of activities to assess response to the therapies include

objective nursing assessments, vital signs, and labs

host

one of the links in the chain of infection, an uninfected person or animal that is susceptible to the pathogen

The nurse is assigned to care for the patients who are in isolation and patients who are not in isolation. What should the nurse do to try to meet the needs of all the patient's?

organize and cluster care of isolation patient's to minimize gowning and ungowning. (Typically, very sick patients are in isolation are the priority. Cluster care: bringing all the supplies you need- meds, care items, etc)

Localized infection symptoms

pain and tenderness, redness and adema

Early sign of acute compartment syndrome

pain upon stretching (other symptoms: tingling and burning or a feeling of pins and needles in affected area, full or tight feeling in the muscle)

Infectious agent is

pathogen

The nurse is helping plan an activity schedule for an older adult resident at a long term care facility who is at risk fir disuse syndrome. which plan is the nurse most likely to suggest

patient participate in ADLs for 10-15 minutes every 2-3 hours while awake for a total of 2 hours of activity per 24 hours (the amount of activity require to prevent disuse syndrome- a state in which an individual is at risk for deterioration of body systems as a result of inactivity- is only 2 hours for every 24 hour period)

The nurse is caring for a patient who has been quadriplegic (paralysis of all four limbs) for 3 years following a dividing accident. One morning the nurse notes that the patient has redness on the sacral area and informs the patient that there is a risk for a pressure ulcer and that very careful turning and scheduled assessment will need to be started. The patient politely thanks the nurse, but informs her that he intends to refuse any treatment for pressure ulcers and is likely to start refusing other nursing measures as well. The nurse is stunned and upset because the patient has always been cooperative and generally very satisfied with the care. How can the nurse continue to interact with this patient if he continues to refuse therapies?

patient refuses care, nurse may experience a personal feeling of rejection, has to recognize that refusal of treatment is not a refusal of interaction, should continue to check on the patient as before and to spend as much time as before, focus may shift from task orientation to therapeutic communication, patient always has the option of changing his mind, later accepting selected elements of care.

systemic

pertaining to the body as a whole

A 65 year old female client sustained multiplier fractures in a motor vehicle crash. She fractured bones in both wrists and in her right lower leg. Her weight bearing status has been changed from non-weight bearing to the right lower extremity and both upper extremities after having a follow up appointment with the orthopedic surgeon. The new weight bearing status is to be weight bearing as tolerated to the right lower extremity and weight bearing through the forearms/ elbows for her upper extremities. Which assistive device would allow the client to be able to walk with these restrictions being maintained?

platform walker

The LPN/LVN knows that one of the best defenses against a lawsuit is for a nurse to:

promote a positive nurse-patient relationship

The nurse is assisting the physician with an irrigation of a draining abdominal wound. y preparing the sterile tray. Sterility of the tray must be maintained at all times. During the process, which action by the nurse is most correct?

put on sterile gloves to handle the contents of the tray.

The nurse is supervising a NS who is setting up a sterile tray to suction a patient. The nurse would *intervene* if the student:

puts on sterile gloves, opens the bottle, and sets the cap on the sterile field. (The outside of the bottle is considered to be contaminated, so the student would have contaminated the whole tray as well as the sterile bottle cap)

The nurse is caring for a patient who has been quadriplegic (paralysis of all four limbs) for 3 years following a dividing accident. One morning the nurse notes that the patient has redness on the sacral area and informs the patient that there is a risk for a pressure ulcer and that very careful turning and scheduled assessment will need to be started. The patient politely thanks the nurse, but informs her that he intends to refuse any treatment for pressure ulcers and is likely to start refusing other nursing measures as well. The nurse is stunned and upset because the patient has always been cooperative and generally very satisfied with the care. How would you feel if a patient refused to allow you to meet basic needs, such as food, hygiene, or preventive care like turning or receiving immunizations?

refusal of heroic measures often easier to accept, many nurses themselves do not want to be kept "alive by machines." seems cruel and inhuman if basic needs like food or hygiene are not provided, trying to prevent pressure ulcers and to improve patient outcomes, believe that immunization is partially for the protection of the individual, purpose of "herd immunity" trained to be problem-solvers and doers, doing nothing for the patient may be difficult, remind myself, supporting patient emotionally and psychologically is also a nursing function

Which action by the nurse is the best step to avoid a lawsuit?

remain current on practice developments

To remove the glove, what actions are required of the nurse?

remove 1 glove then use the bare fingers to push the remaining glove off from inside the cuff.

Standard crutches

remove weight from one leg. Patients who must transfer more weight to their arms than is possible with a cane

three point gait

requires the patient to bear all of the weight on one foot. The patient bears weight on both crutches then on the uninvolved leg, repeating the sequence.

standard walker

requires the person to have fair balance and the ability to lift device with upper extremities to advance

When caring for a patient with tuberculosis who is on airborne precautions, the nusre should routinely use:

respirator mask N-95

The nurse is assisting a health care provider by setting up a sterile tray for a procedure at the bedside. When the nurse opens the tray, there is moisture on a piece of equipment. What should the nurse do?

return the entire tray yo the supply area for resterilzation & obtain a new tray. (Moisture seeping through a sterile packages protective covering allows microbes to travel to the sterile objects- contaminated)

A patient who is HIV positive & ready for discharge expresses fears about exposure of other family members, particularly young children, to the disease. What is the best response to help decrease the patient's fears & concerns?

review principles of mode of transmission for HIV. (Explain how it can be transmitted and take the proper precautions)

The newly licensed nurse is assigned a patient who needs catheterization. The nurse has not performed the procedure before. What would be the best action for the nurse?

review the agency procedure for male catheterization in the unit's resource area and ask another experienced nurse to supervise her during the procedure

A patient in isolation is experiencing signs of social deprivation. Which intervention by the nurse is appropriate?

set specific times when the nusre will return to the patient's room.

The nurse is supervising a nursing student. Which action by the students requires correction because it contributes to the potential transmission of pathogens?

shakes linens to remove debris​ & then places them in laundry bag. (Puts microbes in the air)

Viruses are

smallest know agents to cause diseases

spore

specialized protective stuctures some bacteria have; a round body formed by the bacterium when conditions are unfavorible for growth. The spore becomes dormant until environmental conditions become more favorable for growth and reproduction

Hand washing

standard wash for 15-30 seconds, warm water

The duties & responsibilities of the LPN/LVN are determined by who?

state board of nursing

Disaster manual Define

steps to be taken prior to, during and after the disaster.

which is a principle of surgical asepsis?

sterile fields & sterilized items are no longer sterile if they contact a clean surface.

sterile technique is called

surgical asepsis

The patient refused to take the medication his doctor ordered for relief of pain. The LPN/LVN knows this is a patient right established by:

the Patient Self-Determination Act

To prevent transmission of an infection, what has to happen

the cycle must be broken

Ergonomics

the design of work tasks to best suit the capabilities of workers. (example: using mechanic lifts for patients who cant assist to prevent back injuries)

Products ingredients are listed in descending order by weight which means...

the first ingredient has the highest weight which means its made of a lot of that ingredient

Infection prevention and control

the implementation of policies and procedures in hospitals and other health care facilities to minimize the spread of health-care associated or community acquired infections to patients and other staff members.

Vehicle

the means by which organisms are carried about and transported to the next host once they leave the reservior

The Student nurse is preparing to Don sterile gloves. What action indicates understanding of the need procedure?

touch only the inside surface of the first glove while pulling it on to the hand (touching the outside of the glove will cause contamination. touching the inside of the glove I allowed because it lays on the skin)

a swing to approach (crutch)

used by patients whose lower extremities are paralyzed or who can wear supporting brace on their legs. it requires ability to partially bear weight on both legs

Four-point gait

used when both legs can bear some weight; right foot, left crutch, left crutch, right foot

Reservoir

where the pathogens can grow

The nurse recognizes that in today's health care climate there is an increased likelihood to be involved in litigation. What action could the nurse take to improve the overall situation in the work setting?

work on a committee to improve discharge teaching