NUR1460 Fundamentals HESI Attempt 2 Study Guide

The nurse has been assigned to administer a rectal suppository to an adult patient. Which suppository placement is correct? -Along rectal wall, 1 to 2 inches into the rectum -Along rectal wall, 3 to 4 inches into the rectum -Inner aspect of the anal orifice -Just prior to the internal anal sphincter

Along rectal wall, 3 to 4 inches into the rectum

When communicating the progress of a patient, which guidelines should the nurse follow? Select all that apply. -Avoid discussing medical results with the patient. -Share the patient's medical results with the patient. -Follow agency protocol about sharing medical information. -Provide appropriate nursing care without any documentation. -With the patient's permission, inform the patient's family about the patient's progress.

-Share the patient's medical results with the patient. -Follow agency protocol about sharing medical information. -With the patient's permission, inform the patient's family about the patient's progress.

A patient has a history of obstructive sleep apnea. Which postoperative care reduces the risk of any complications in the patient? Select all that apply. -Using an oral appliance -Monitoring the patient's airway -Avoiding elevation of the head of the bed -Sleeping in the supine position -Using a continuous positive airway pressure (CPAP) device

-Using an oral appliance -Monitoring the patient's airway -Using a continuous positive airway pressure (CPAP) device

A nurse is preparing to catheterize a female patient. Arrange in the correct order the steps of preparing for the procedure before inserting the indwelling catheter.

1. Perform hand hygiene. 2.Introduce yourself and provide for patient privacy. 3.Explain the procedure to the patient. 4.Place a waterproof pad under the patient and drape the patient with a bath blanket. 5.Position the patient in dorsal recumbent position.

Which data does the nurse document after bathing a patient? Select all that apply. Date and time of bath Type of bath provided Type of products used The patient's response Type of bath water used

Date and time of bath Type of bath provided The patient's response

A patient reports to the nurse, "I just can't decide what kind of classes I want to take in college. I have no idea what I want to do with my life after high school." In which stage of Erikson's psychosocial development is the patient? Integrity versus despair Intimacy versus isolation Industry versus inferiority Identity versus role confusion

Identity versus role confusion

A patient is scheduled for a laparoscopic cholecystectomy. Of which benefits of the ambulatory surgery would the nurse inform the patient? Select all that apply. Less postoperative time Cost saving Increased hospital stay Less risk of health care-associated infections More recovery time

Less postoperative time Cost saving Less risk of health care-associated infections

Which medications affect a patient's rapid eye movement (REM) sleep leading to frequent waking at night and sleepiness during the day?

Narcotics Narcotics are central nervous system stimulants which cause disruption in REM

Which order should the nurse follow when removing personal protective equipment following a surgical procedure? Gloves, eyewear, gown, mask Mask, gown, eyewear, gloves Eyewear, gloves, gown, mask Gown, mask, eyewear, gloves

Gloves, eyewear, gown, mask

A nurse instructs the patient to use eardrops at room temperature. Which rationales support the nurse's instructions? Select all that apply. To reduce pain To prevent nausea To prevent loss of medication To prevent dizziness To ease removal of earwax

To reduce pain To prevent nausea To prevent dizziness The internal ear is very sensitive to temperature changes

The postoperative patient has difficulty voiding after surgery and is feeling "uncomfortable" in the lower abdomen. Which action should the nurse implement first? Encourage fluid intake. Administer pain medication. Catheterize the patient. Turn on the bathroom faucet as the patient tries to void.

Turn on the bathroom faucet as the patient tries to void.

A nurse is instructed to disinfect urinary catheters, bedpans, endoscopes, and anesthesia equipment. Which items are required to be sterile and free of microorganisms, including spores? -Bedpans -Endoscopes -Urinary catheters -Anesthesia equipment

Urinary catheters

Which intervention does the nurse perform when preparing to give a complete bath to an obese Hispanic female patient with peripheral neuritis? -Use a mechanical lift while bathing the patient. -Ask the patient to check the water temperature. -Wash the patient's hair weekly with mild shampoo. -Cleanse the patient's anus followed by the urinary meatus.

Use a mechanical lift while bathing the patient. While providing a bath for an obese patient, the nurse may have difficulty moving and positioning the patient. To provide a complete bath and to clean abdominal folds, under the breast, and the groin, the nurse would use a mechanical lift to move and position the patient. A patient with peripheral neuritis may have impaired sensation and may not be able to judge the water's temperature. Therefore the nurse should check and adjust the temperature of water to 40.5 to 43.3°C rather than asking the patient to check the water temperature. Patients of African descent clean their hair once a week, as their hair tends to be dry, whereas Hispanic patients prefer regular washing of hair. While providing perineal care, the nurse cleans the patient's urinary meatus, followed by the anus. This helps prevent the entry of bacteria into the urinary tract and reduces the risk of urinary tract infections.

Which actions does the nurse take to promote optimal cardiopulmonary functions in a patient? Select all that apply. Provide adequate fluids Administer cholinergic agents Teach deep breathing exercises Keep oxygen by open flames Place the patient in the semi-Fowler's position

Provide adequate fluids Teach deep breathing exercises Place the patient in the semi-Fowler's position

A patient is exhibiting labored breathing and uses accessory muscles to breathe. Upon assessment, the nurse detects crackles in both lung bases and diminished breath sounds. Which respiratory assessments are priority for the nurse to perform? Select all that apply. -SpO2 levels -Amount of sputum production -Respiratory rate and pattern -Pain in lower calf area -Pitting edema in the ankles

SpO2 levels Amount of sputum production Respiratory rate and pattern

Which professional nursing actions does Madeleine Leininger suggest to promote patient-centered care? Select all that apply. Cultural assessment Cultural competence Cultural maintenance Cultural care repatterning Cultural care accommodation

Cultural maintenance Cultural care repatterning Cultural care accommodation Cultural maintenance helps the people of a particular culture preserve their core values. This action helps them maintain their well-being, face any health concerns, and recover from illness. Cultural care repatterning respects the patient's cultural values while helping them adopt new and different health care patterns for a healthier life. Cultural care accommodation helps people of different cultures adapt with others for effective health outcomes with the health care providers. Cultural competence is not a professional action, but a skill that the nurse acquires to provide effective care. Cultural assessment refers to the process of gathering data regarding the patient's cultural aspects.

Which technique is often referred to as a clean technique that the nurse would use to control infection in patients? Sterilization Catheterization Medical asepsis Surgical asepsis

Medical asepsis

Which term is defined as a global set of concepts which describe the central phenomena of the discipline and explains the relationship between those concepts?

Metaparadigm

The nurse works in a sleep clinic. Which instructions would the nurse provide to older adults to enhance the quality of their sleep? Select all that apply. "Establish a fixed bedtime and adhere to it." "Perform muscle relaxation before going to sleep." "Exercise an hour before bedtime to help induce sleep." "Watch a favorite movie or television program in bed to relieve stress." "Drink a cup of coffee before bedtime to help induce sleep."

"Establish a fixed bedtime and adhere to it." "Perform muscle relaxation before going to sleep."

The patient states that she "loses urine" every time she laughs or coughs. The nurse teaches the patient measures to regain urinary control. Which statement by the patient indicates the need for further teaching? "I will perform my Kegel exercises every day." "I joined Weight Watchers." "I drink two glasses of wine with dinner." "I have tried urinating every 3 hours."

"I drink two glasses of wine with dinner." Alcohol is a bladder irritant. It increases urine production and causes uncontrolled bladder contractions.

When reviewing a patient's medical records, the nurse finds that the patient's urine output is 3200 mL per day. Which instructions would the nurse give to the patient to manage this condition? Select all that apply. "Refrain from drinking coffee or tea." "Eliminate foods high in potassium." "Increase your daily intake of salt." "Increase your intake of glucose." "Refrain from consuming alcohol."

"Refrain from drinking coffee or tea." "Refrain from consuming alcohol."

A patient is diagnosed with a urinary tract infection (UTI). Which instructions does the nurse give to the patient to relieve the symptoms? Select all that apply. "Use heating pads to relieve the pain." "Avoid the intake of spicy foods." "Increase your daily intake of water." "Limit your intake of milk products." "Limit your intake of leafy vegetables."

"Use heating pads to relieve the pain." "Avoid the intake of spicy foods." "Increase your daily intake of water."

Which instructions would the nurse give to a parent of a preschooler who reports, "Whenever I turn off the television, my child kicks the sofa, hurts himself, and does not show any interest in eating"? Select all that apply. "Watch television programs along with your child." "Limit the child's exposure to television to 1 to 2 hours per day." "Provide feedback about the child's aggressive behavior." "Encourage the child to participate in creative play or hobbies." "Punish the child for showing negative and aggressive behavior."

"Watch television programs along with your child." "Limit the child's exposure to television to 1 to 2 hours per day." "Encourage the child to participate in creative play or hobbies."

The nurse works in a hospital and understands that health care-associated infections (HAI) are difficult to treat. Which patients are at increased risk of developing HAI? Select all that apply. -A patient who underwent bronchoscopy -A patient who receives broad-spectrum antibiotics -A patient who has an indwelling urinary catheter -A patient suffering from diabetes mellitus -A patient who has a fever

-A patient who underwent bronchoscopy -A patient who receives broad-spectrum antibiotics -A patient who has an indwelling urinary catheter -A patient suffering from diabetes mellitus Bronchoscopy bypasses the natural defenses of the body and predisposes to HAIs. Broad-spectrum antibiotics suppress the normal flora and promote growth of resistant strains of microorganisms. An indwelling urinary catheter surpasses the natural defenses and also serves as a port of entry for microorganisms. Diabetes mellitus suppresses the body's immunity and increases the risk of HAIs. Fever does not affect the natural defense mechanism, and therefore does not increase the risk of HAIs.

A postoperative patient complains of pain. Which available nursing actions would relieve pain in the patient? Select all that apply. -Administering regional analgesia -Administering nonsteroidal antiinflammatory drugs (NSAIDs) -Applying hot packs on the incision site -Administering opioid analgesics -Assisting the patient in repositioning

-Administering regional analgesia -Administering nonsteroidal antiinflammatory drugs (NSAIDs) -Administering opioid analgesics -Assisting the patient in repositioning

Which factors does the nurse expect to be possible causes of a patient producing blue-green urine? Select all that apply. -An increase in calcium levels -Consumption of asparagus -Consumption of fava beans -Administration of rifampin -Administration of cimetidine

-An increase in calcium levels -Consumption of asparagus -Administration of cimetidine

Which statements are true about various patterns of respiration? Select all that apply. -Apnea is the absence of respiration for a short time. -Apnea is the increase in rate and depth of respiration. -Kussmaul respiration is the increase in rate and depth of respiration. -Kussmaul respiration is the period of apnea following periods of rapid and shallow breathing. -Cheyne-Stokes respiration is the period of apnea following a period of rapid and shallow breathing.

-Apnea is the absence of respiration for a short time. -Kussmaul respiration is the increase in rate and depth of respiration. -Cheyne-Stokes respiration is the period of apnea following a period of rapid and shallow breathing.

The nurse is caring for a patient who has undergone surgery for the placement of a suprapubic catheter. Which interventions does the nurse implement to reduce the risk of complications? Select all that apply. -Check for drainage at the insertion site. -Instruct the patient not to use any soap. -Assess the patient for signs of infection. -Have the patient apply lotion to the site. -Instruct the patient to increase fluid intake.

-Check for drainage at the insertion site. -Assess the patient for signs of infection. -Instruct the patient to increase fluid intake.

A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection of the respiratory system and has a productive cough. A nurse auscultates the lungs and finds that the breath sounds are clear. The disposable thermometer used by the nurse indicates fever. The nurse collects a urine specimen of the patient as ordered. Which interventions would the nurse perform to prevent spread of infection? Select all that apply. -Confirm fever using an electronic thermometer. -Clean the bell and diaphragm of the stethoscope with soap and water. -Place specimen containers on a clean paper towel in the patient's bathroom. -Label the specimen in the bathroom where samples from patients are collected. -Review agency policies and precautions necessary for the specific isolation system.

-Confirm fever using an electronic thermometer. -Place specimen containers on a clean paper towel in the patient's bathroom. -Review agency policies and precautions necessary for the specific isolation system. The nurse should be aware of the equipment used in a room and indications for isolation. If the disposable thermometer indicates fever, it is important to confirm it using an electronic thermometer. Specimen containers are to be kept in the patient's bathroom appropriately. The nurse also needs to review agency policies and procedures. MRSA can cause a health care-associated infection (HAI). Therefore the nurse has to take precautions to prevent the spread of infections within the hospital. If a stethoscope is to be reused, the diaphragm or bell should be cleaned with alcohol, rather than soap, and should be set aside on a clean surface to dry completely. After the sample is collected, labeling on the specimen container is to be done in front of the patient to avoid errors.

A nurse has been asked to measure the respiratory efficiency of a patient. Which data are collected to reflect the processes involved in assessing respiratory efficiency? Select all that apply. -Diffusion -Perfusion -Ventilation -Spinal reflexes -Respiratory muscle strength

-Diffusion -Perfusion -Ventilation

Which statements describe the advantages of documentation in nursing? Select all that apply. -Documentation is essential for reimbursement. -Documentation is an indicator of improved quality control. -Documentation may provide protection from malpractice. -Documentation entries may be added to or changed at any time. -Documentation assists in identifying and justifying nursing interventions.

-Documentation is essential for reimbursement. -Documentation may provide protection from malpractice. -Documentation assists in identifying and justifying nursing interventions.

The nurse works in a hospital. Which precautions are necessary to help prevent health care-associated infections? Select all that apply. -Frequently irrigate urinary catheters. -Insert drug additives to IV fluids. -Ensure a closed urinary catheter drainage system. -Change the IV access site if inflamed. -Use aseptic technique when suctioning the airway.

-Ensure a closed urinary catheter drainage system. -Change the IV access site if inflamed. -Use aseptic technique when suctioning the airway. A closed urinary catheter drainage system helps contain microorganisms and prevent spread of infection. An IV access site should be changed as soon as signs of inflammation appear. Inflammation can lead to infection. Microorganisms can be introduced into the airway if aseptic technique is not followed for suctioning. Repeated catheter irrigation may increase the risk of infection, as it bypasses the normal defenses of the body. Adding drug additives to IV fluids also increases the risk of infections.

A patient with a hearing impairment uses a hearing aid and reports hearing a whistling sound. Which factors are the possible causes of this whistling sound? Select all that apply. -Fluid in ear canal -Cerumen in ear canal -Water in the device -Volume too high -Hair spray on the device

-Fluid in ear canal -Cerumen in ear canal -Volume too high

On visiting a long-term care facility for health checkups, the community nurse learns that many of the residents have dementia. Which interventions by the nurse may be helpful? Select all that apply. -Fostering human dignity -Teaching correct body postures -Protecting the patient's rights in all aspects -Instructing the patient to perform regular exercise -Training caregivers on proper feeding and dressing

-Fostering human dignity -Protecting the patient's rights in all aspects -Training caregivers on proper feeding and dressing Even though the patient has dementia, the nurse's responsibility is to foster dignity and protect the patient's rights in all aspects. The nurse should train the caregiver on proper techniques of feeding, dressing, and toileting. Teaching correct body postures and exercises may be helpful for arthritic conditions but not for dementia.

Which actions are the responsibilities of a community-based nurse as a patient advocate in assisting patients with the use of health services? Select all that apply. -Helping the patient make informed decisions -Helping the patient reach out to appropriate authority -Helping defend the health care provider's decisions -Helping the patient in legal issues of medicine practice -Helping the patient in specific service requests and appropriate follow-up

-Helping the patient make informed decisions -Helping the patient reach out to appropriate authority -Helping the patient in specific service requests and appropriate follow-up

Which roles are interpersonal according to Mintzberg? Select all that apply. -Leader -Liaison -Monitor -Figurehead -Disseminator

-Leader -Liaison -Figurehead

The nurse educates a group of patients regarding the importance of handwashing and appropriate techniques to ensure adequate hand hygiene. Which objectives would be part of this teaching session? Select all that apply. -Maintain a healthy lifestyle. -Interrupt the infection cycle. -Avoid the spread of infection. -Indicate the start of an infection. -Prevent an elevated WBC count.

-Maintain a healthy lifestyle. -Interrupt the infection cycle. -Avoid the spread of infection.

A community-based nurse plans to assess the health care needs of a particular community to ensure improved delivery of health care. How would the nurse assess the health care needs of this community? Select all that apply. -Monitor health status. -Collect data systematically. -Plan budget allocation. -Collect only voluntary reporting. -Access available health information.

-Monitor health status. -Collect data systematically. -Access available health information. Monitoring the health status provides information about the most prevalent health problems of the community. Systematic data collection from various sources helps the nurse to collect information about the factors causing illness in the community. The nurse may also obtain health-related documentation about the community. Planning budget allocation does not help in identifying the health care needs of the community. Even though voluntary reporting is helpful, the nurse should not rely only on this information. The nurse should also look for other factors that affect the health status of the community.

The nurse is planning to conduct a hearing acuity test of a patient. Which activities should the nurse include when assessing the patient's auditory function? Select all that apply. -Ask the patient to read the newspaper. -Observe the patient's behavior in a group. -Use the tuning fork test. -Use the spoken word test. -Ask the patient to identify colors.

-Observe the patient's behavior in a group. -Use the tuning fork test. -Use the spoken word test. The nurse may be able to detect auditory alterations in the patient by closely observing how he or she interacts with others. Patients with a hearing impairment may seem inattentive.

While caring for a patient with a vented nasogastric tube, which nursing intervention is beneficial for the patient? -Securing the tube with a safety pin -Keeping the tube taut for movement -Placing the tube above stomach level -Taping the vent lumen to the patient's cheek

-Placing the tube above stomach level

Which actions are examples of a nurse applying critical thinking attitudes when preparing to insert an intravenous (IV) catheter? Select all that apply. Properly cleaning the site before insertion Following the procedural guideline for IV insertion Ensuring the IV dressing covers the IV site completely Showing confidence in performing the correct IV insertion technique Seeking necessary knowledge about the steps of the procedure from an experienced nurse

-Showing confidence in performing the correct IV insertion technique -Seeking necessary knowledge about the steps of the procedure from an experienced nurse Seeking necessary knowledge about the steps of the procedure from an experience nurse demonstrates humility and recognizes the need for clarification. Another example of a critical thinking attitude is confidence. In this case, confidently inserting an IV line allows the nurse to convey expertise and a sense of calm, leading the patient to trust the nurse. Following policy and procedure is an example of following standards of care, not of a critical thinking attitude. Making sure that the dressing is covered is a step in following good standards of IV care but is not a critical thinking attitude.

Which precautions should the nurse follow to prevent speed shock during the intravenous (IV) administration of medications? Select all that apply. -Refrain from inserting IV catheters over the joints. -Stop the infusion immediately if sudden onset of dizziness occurs -Do not use electronic pumps for the infusion. -Monitor the gravity flow set closely during administration. -Follow the recommended infusion rate of medication.

-Stop the infusion immediately if sudden onset of dizziness occurs -Monitor the gravity flow set closely during administration. -Follow the recommended infusion rate of medication.

A patient who reports shortness of breath and restlessness is given a diagnosis of pneumonia. Which nursing interventions should the nurse perform to relieve the patient's symptoms? Select all that apply. -Assess the patient's vital signs every 4 hours. -Instruct the patient to limit daily intake of caffeine. -Teach the patient the technique for using an incentive spirometer. -Administer 0.9% intravenous saline solution. -Keep the patient's oxygen saturation level at 85% to 90%.

-Teach the patient the technique for using an incentive spirometer. -Administer 0.9% intravenous saline solution.

The nurse is caring for a patient who is scheduled for a colonoscopy. Which information would the nurse provide about the test? Select all that apply. -A local anesthetic will be administered before the test. -The patient will take a laxative after the test. -The patient should not drive for 12 hours after the test. -The patient should refrain from liquids with red or purple dye before the test. -The patient should follow a clear liquid diet for 1 to 3 days before the test.

-The patient should not drive for 12 hours after the test. -The patient should refrain from liquids with red or purple dye before the test. -The patient should follow a clear liquid diet for 1 to 3 days before the test.

Which statements are true about Erikson's theory of developmental stages? Select all that apply. -Toddlerhood develops a sense of autonomy and prevents a feeling of shame and doubt. -The preschool period develops a sense of initiative and prevents feelings of guilt. -Adolescence develops trust and prevents mistrust from developing. -The school-age years establish a sense of industry and prevent feelings of inferiority. -Infants develop a sense of autonomy and strive for independence.

-Toddlerhood develops a sense of autonomy and prevents a feeling of shame and doubt. -The preschool period develops a sense of initiative and prevents feelings of guilt. -The school-age years establish a sense of industry and prevent feelings of inferiority.

The nurse is preparing a care plan for a patient on bed rest. Which nursing interventions should the nurse include? Select all that apply. -Instruct the patient to refrain from coughing exercises. -Turn and reposition the patient on a regular schedule. -Provide adequate fluid intake and an increase in dietary fiber. -Teach the patient to perform deep breathing exercises. -Encourage the patient to consume a diet low in protein.

-Turn and reposition the patient on a regular schedule. -Provide adequate fluid intake and an increase in dietary fiber. -Teach the patient to perform deep breathing exercises.

A woman of low economic status has recently been diagnosed with tuberculosis. Her community also has a high rate of tuberculosis. Which factors would a nurse include in a community assessment? Select all that apply. -Water and sanitation facilities -Economic status -Transportation -Communication skills -Number of schools in the vicinity

-Water and sanitation facilities -Economic status -Transportation The nurse should assess the available water and sanitation facilities to check the level of hygiene among the people. This will help curb the spread of diseases. Assessing economic status helps determine the standard of living of the people in the community. It also helps determine whether they can afford medical services. Transportation needs to be assessed to see if patients can conveniently reach the hospital when necessary. Assessment of communication skills or number of schools does not help improve the health condition of the community.

In a hospital, 50 patients were exposed to tuberculosis last year. Twenty new patients have been diagnosed with active tuberculosis this year, and two patients died from tuberculosis last year. X-ray results show that another 13 patients are exhibiting signs of tuberculosis; however, the lab reports are pending. Which number would be the incidence of tuberculosis at this facility? 22 20 70 33

20 Incidence is the total number of new diseases or disorders. In this case, 20 new cases of tuberculosis are recorded. Therefore the incidence of tuberculosis in this study is 20. The data of the previous year is not included when calculating the incidence of the disease for the current year. Being exposed to tuberculosis does not mean that the patient has developed tuberculosis. The patients should be examined further. Tuberculosis is not confirmed by x-ray findings alone.

A patient with a right lung abscess is admitted to the hospital. The nurse is instructed to position the patient appropriately to promote lung expansion. What is the most appropriate position for this patient? -Supine position with both lungs at the same level -45-degree semi-Fowler's position with left lung down -45-degree semi-Fowler's position with right lung down -Supine position with left lung slightly at lower level than the right

45-degree semi-Fowler's position with right lung down In patients with pulmonary abscess, the affected lung should be positioned down to prevent the flow of secretions to the healthy lung.

The nurse is caring for a patient who will undergo a contrast study of the upper gastrointestinal tract. Which nursing intervention should the nurse implement in this situation? -Administer the barium sulfate orally before the examination. -Administer the barium sulfate rectally before the examination. -Instruct the patient to limit oral fluids before the examination. -Instruct the patient to limit fiber intake before the examination.

Administer the barium sulfate orally before the examination. Contrast studies require a contrast medium to outline the organs on the x-ray. Barium sulfate acts as a contrast medium. Therefore the nurse has the patient ingest barium sulfate orally before the examination. The nurse may administer the barium sulfate rectally before an examination of the organs of the lower gastrointestinal tract. The patient should avoid rather than limit fluids or fiber prior to the examination.

Which nursing interventions would be helpful to treat a patient with malignant hyperthermia during the immediate postoperative period? Select all that apply. Extending the patient's neck Administering oxygen Administering intravenous fluids Elevating the head of the patient's bed Administering dantrolene sodium

Administering oxygen Administering intravenous fluids Administering dantrolene sodium

The nurse is caring for a bedridden patient. Which precautions does the nurse implement while assisting a patient to use a bedpan? Select all that apply. Applies barrier cream to the patient's skin Places a waterproof pad on top of the patient's bed Leaves the bedpan in place for 12 to 14 minutes Cleans the bedpan with a disinfectant twice a week Raises the head of the bed before placing the bedpan

Applies barrier cream to the patient's skin Places a waterproof pad on top of the patient's bed Raises the head of the bed before placing the bedpan

A 55-year-old patient is in the clinic for a routine physical. Which factor would cause the nurse to inform the patient about the need to obtain a stool specimen for fecal occult blood testing? If patient reports rectal bleeding When there is a family history of polyps As part of routine recommended colorectal screening guidelines If a palpable mass is detected on digital examination

As part of routine recommended colorectal screening guidelines

The nurse is obtaining the health history of a patient. Which data would the nurse include in the assessment? Select all that apply. Educational needs Demographic data Past medical history Family and social history Patient's chief complaint

Demographic data Past medical history Family and social history Patient's chief complaint The health history includes demographic data, which is collected during the orientation phase of the interview; past medical history; family and social history; a patient's chief complaint or reason for seeking health care; the history of present illness; allergies; medications; adverse reactions to medications; and health promotion practices.

A patient has cognitive alterations and is in the terminal stages of cancer. The nurse learns that the patient's caregiver is extremely stressed and has not been able to take time for a personal life. Which action by the nurse will provide relief to the caregiver? -Asking the caregiver to withhold caregiving activities -Helping the caregiver set a regular time for respite -Explaining the need to focus more on the patient now and less on the caregiver's personal life -Encouraging the caregiver by praising the caregiving

Helping the caregiver set a regular time for respite

While assessing the beliefs regarding death in various ethnic groups, the nurse learns that members of which religious groups practice cremation? Select all that apply. Muslims Hindus Jews Buddhists Christians

Hindus Buddhists Christians

Which patient preparation is needed on the day of surgery involving general anesthesia? Ask the patient to wear personal nightwear. Instruct the patient to shower or bathe. Instruct the patient to drink clear liquids. Ask the patient to tie hair with clips.

Instruct the patient to shower or bathe. The patient is instructed to shower or bathe with an antimicrobial soap the day of the surgery or the day before the surgical procedure if outpatient surgery is planned. A shower or bath is given preoperatively if the patient is hospitalized. The patient should be fasting and is not provided with clear liquids to drink.

Which conditions are common effects of immobility? Select all that apply. Kidney stone formation Increased muscle tone Joint contractures Diarrhea Increased cardiac workload

Kidney stone formation Joint contractures Increased cardiac workload

Which measure would ensure normal breathing and reduced risk of musculoskeletal injury to a patient having seizures? Select all that apply. Tighten the waist belt. Loosen the collar. Restrain the patient. Turn the patient's head to the side. Place a soft pillow under head.

Loosen the collar. Turn the patient's head to the side. A pillow can cause suffocation.

Which surgeries require general anesthesia? Select all that apply. Mastectomy Nephrectomy Breast biopsy Bowel resection Cataract surgery

Mastectomy Nephrectomy Bowel Resection Major surgeries require general anesthesia, and minor surgeries need local anesthesia.

The evaluation process includes interpretation of findings as one of its five elements. Which action is an example of interpretation? -Evaluating the patient's response to selected nursing interventions -Selecting an observable or measurable state or behavior that reflects goal achievement -Reviewing the patient's nursing diagnoses and establishing goals and outcome statements -Matching the results of evaluative measures with expected outcomes to determine patient's status

Matching the results of evaluative measures with expected outcomes to determine patient's status

Which initial nursing intervention should the nurse employ for a patient who has inhaled poisonous fumes? -Call the Poison Control Center. -Move the patient to obtain fresh air. -Summon an ambulance immediately. -Perform cardiopulmonary resuscitation.

Move the patient to obtain fresh air.

Which complications would the nurse expect to find in a patient who is on beta blockers? Select all that apply. Insomnia Irritability Drowsiness Nightmares Restlessness

Nightmares Insomnia Beta blockers inhibit the effects of the adrenaline hormone and also inhibit nighttime secretion of melatonin, a hormone involved in regulating both sleep and the body's circadian clock.

Which nursing action applies to an intravenous pyelogram (IVP)? Note any allergies Monitor intake and output Provide for perineal hygiene Assess vital signs

Note any allergies

Which qualitative research activity does the nurse engage in when conducting ethnographic research? Observing sociocultural phenomena Deriving a theory from collected data Determining an accurate picture of a past event Exploring life experiences of the subjects

Observing sociocultural phenomena Phenomenology, grounded theory, ethnography, and historical research are examples of qualitative research. Ethnography involves close field observation of sociocultural phenomena. Grounded theory helps derive a theory from the collected data. Historical research helps determine an accurate picture of a time period or past event. Phenomenology explores the reactions of people who experienced a similar event in their lives.

While interpreting the arterial blood gas findings of a patient, the nurse concludes that the patient has moderate hypoxemia. Which assessment finding led the nurse to reach this conclusion? PaO2 level of 30 mm Hg PaO2 level of 50 mm Hg PaCO2 level of 40 mm Hg PaCO2 level of 50 mm Hg

PaO2 level of 50 mm Hg Decreased oxygen concentration in the arterial blood indicates hypoxemia. A PaO2 level in the range of 40 to 60 mm Hg (and thus a PaO2 level of 50 mm Hg) indicates moderate hypoxemia. A PaO2 level of 30 mm Hg indicates severe hypoxemia. The normal levels of PaO2 are 80 to 100 mm Hg. A PaCO2 level of 40 mm Hg is a normal finding and does not indicate hypoxemia. PaCO2 is the partial pressure of carbon dioxide in arterial blood. The normal range of PaCO2 is 35 to 45 mm Hg. A PaCO2 level of 50 mm Hg indicates hypercapnia rather than hypoxemia.

A patient is suffering from chronic stress. Which gland in the patient's body will initiate general adaptation syndrome (GAS)? -Parotid -Pituitary -Pineal -Adrenal

Pituitary

Which risks would the nurse anticipate in patients with a high red blood cell count (RBC), hemoglobin (Hgb), and hematocrit (Hct)? Select all that apply. Hemorrhage Renal disease Polycythemia vera Congenital heart disease Bone marrow suppression

Polycythemia vera Congenital heart disease Polycythemia vera is a bone marrow disorder that results in an increased number of RBCs With an elevated RBC count, the patient will also have an increase in Hgb and Hct. A patient with congenital heart disease may also have an increase in RBCs, Hgb, and Hct. Hemorrhage, renal disease, and bone marrow suppression may result in decreased RBC, WBC, and platelet levels in the blood, due to blood loss and immunosuppression.

A patient is brought to the emergency room in an unconscious state. On taking the history the nurse finds that the patient had accidentally consumed agricultural pesticides. Which intervention should the nurse perform to prevent the risk of aspiration in this patient? Avoid the use of nasogastric tubes in the patient. Position the patient with head turned. Position the patient with head straight. Make arrangements for suctioning of the secretions for the patient

Position the patient with head turned.

Which patient data will the nurse consider while preparing a care plan for a Jehovah's Witness patient? Literacy Preferences Acculturation Medical knowledge

Preferences Nurses caring for known members of the Jehovah's Witness faith community should document patient preferences to ensure compliance with religious beliefs during medical treatment. The patient's literacy and medical knowledge do not influence the care process but do affect teaching. Acculturation does not refer to patient data; it is a process of interaction and cultural exchange between two or more cultures.

Which intellectual standard of critical thinking is the nurse following when the plan of care for a pregnant patient is based on the knowledge of a previous fetal loss? Select all that apply. Logic Fairness Accuracy Relevance Significance

Relevance Significance The nurse, following the intellectual standard of relevance, focuses on the facts and ideas provided by the patient. The intellectual standard of significance involves the consideration of the most important information to prepare a care plan or to make a conclusion.

The nurse is caring for a patient with a urinary obstruction that prevents the flow of urine. While analyzing the microscopic urinalysis, the nurse notes the presence of crystals in the urine. Which patient condition does the nurse infer from these findings? Infection Renal calculi Dehydration Kidney damage

Renal calculi

Which colostomies create an opening on the left lower side of the patient's abdomen? Select all that apply. Loop colostomy Sigmoid colostomy Ascending colostomy Transverse colostomy Descending colostomy

Sigmoid colostomy Descending colostomy

Which patient position is best for the nurse to obtain a rectal temperature? Supine Prone Sims Fowler's

Sims

Which patient conditions have an increased risk of urinary retention? Select all that apply. Joint pain in both legs Onset of hypercalcemia Spinal cord infection Hyperparathyroidism Prostate enlargement

Spinal cord infection Prostate enlargement

In which stage of non-rapid eye movement (NREM) sleep does enuresis occur?

Stage 3

During surgery, the nurse finds that the patient has suddenly developed hypertension, muscle rigidity, cyanosis, high fever, and tachycardia. Which intervention is priority in this situation? Discontinuing the anesthesia Providing oxygen to the patient Stopping the surgery immediately Providing intravenous fluids to the patient

Stopping the surgery immediately The patient's signs indicate that the patient has malignant hyperthermia. Malignant hyperthermia is an inherited disorder that occurs with the inhalation of general anesthetics. It is a life-threatening condition. Surgery should be stopped immediately if the patient has malignant hyperthermia, and then the anesthesia should be discontinued. Oxygen should be administered to the patient if the patient has hypoxemia. The nurse should provide intravenous fluids to the patient if the patient has a fluid and electrolyte imbalance.

The nurse is caring for a cancer patient who is on nil per os (NPO) status and oxygen therapy. Which interventions should the nurse perform while providing oral care to the patient? Select all that apply. Use a hard-bristle brush. Use a moistened toothette. Apply lip balm frequently. Use mucus suction pumps. Give frequent sips of water.

Use a moistened toothette. Apply lip balm frequently. A cancer patient on NPO status or who is receiving oxygen therapy may have dry oral mucosa. Therefore the nurse provides a moistened toothette to alleviate dryness. A toothette is a disposable foam swab used for oral care.

Which options could be the possible causes of diarrhea in a patient? Select all that apply. Use of opioid drugs Use of antibiotics Food allergies Psychological stress Hypothyroidism

Use of antibiotics Food allergies Psychological stress