NUR3737C Exam 2
A client who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What should be the nurse's priority action? 1. Have the patient turn on the left side and perform a Valsalva maneuver. 2. Clamp the intravenous (IV) tubing to prevent more air from entering the line. 3. Have the patient take a deep breath and hold it. 4. Notify the health care provider immediately.
1. Have the patient turn on the left side and perform a Valsalva maneuver.
Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine whether the ostomy is healing appropriately
1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 5. How to determine whether the ostomy is healing appropriately
Match: 1. offering glasses or hearing aid 2. early ambulation 3. strict aseptic technique 4. deep breathing exercise 5. hydration a. deep vein thrombosis b. wound infection c. delirium d. atelectasis
1c, 2a/c, 3b, 4d, 5a/d
The nurse is contacting the health care provider about a patient's sleep problem. Place the steps of the SBAR (situation, background, assessment, recommendation) in the correct order. 1. Mrs. Dodd, 46 years old, was admitted 3 days ago following a motor vehicle accident. She is in balanced skeletal traction for a fractured left femur. She is having difficulty falling asleep. 2. "Dr. Smithson, this is Pam, the nurse caring for Mrs. Dodd. I'm calling because Mrs. Dodd is having difficulty sleeping." 3. "I'm calling to ask if you would order a hypnotic such as zolpidem to use on a prn basis." 4. Mrs. Dodd is taking her pain medication every 4 hours as ordered and rates her pain as 2 out of 10. Last night she was still awake at 0100. She states that she is comfortable but just can't fall asleep. Her vital signs are BP 124/76, P 78, R 12 and T 37.1°C (98.8°F).
2, 1, 4, 3
What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? 1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buocks. 2. Initiate bowel or habit training program to promote continence. 3. Help the patient to toilet once every hour. ppy 4. Use sanitary pads in the patient's underwear.
2. Initiate bowel or habit training program to promote continence.
A patient is being discharged home on an around-the-clock (ATC) opioid for postoperative pain. Because of this order, the nurse anticipates an additional order for which class of medication? 1. Opioid antagonists 2. Antiemetics 3. Stool softeners 4. Muscle relaxants
3. Stool softeners
Which postoperative intervention best prevents atelectasis? 1. Use of intermittent compression stockings 2. Heel-toe flexion 3. Use of the incentive spirometer 4. Abdominal splinting when coughing
3. Use of the incentive spirometer
The nurse understands that infants should double their birth weight on average by: 6 months 12 months 3 months 4 months
4 months
A normal cardiac output of a healthy adult at rest is between: 1-2L per minute 4-8L per minute 6-8L per minute 3-7L per minute
4-8L per minute
The nurse assesses pain and redness at a vascular access device (VAD) site. Which action is taken first? 1. Apply a warm, moist compress. 2. Aspirate the infusing fluid from the VAD. 3. Report the situation to the health care provider. 4. Discontinue the intravenous infusion.
4. Discontinue the intravenous infusion.
The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance
4. Lactose intolerance
Place the steps for an ileostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.
5, 8, 7, 2, 6, 3, 4, 1
A client has had a naso-gastric tube placed. What is the next step in verifying correct placement? A confirmatory x-ray obtained prior to initiating feedings Injection of air while auscultating the stomach prior to initiating feedings
A confirmatory x-ray obtained prior to initiating feedings
Hyperventilation is defined as: The state of alveolar ventilation is inadequate to meet the oxygen demand of the body or eliminate sufficient carbon dioxide Inadequate tissue oxygenation at the cellular level A state of ventilation in which the lungs remove carbon dioxide faster than it is produced by cellular metabolism Decreased arterial oxygen level from altered respiratory functioning
A state of ventilation in which the lungs remove carbon dioxide faster than it is produced by cellular metabolism
Which of the following are correct about nurse's assumptions of patients in pain? A.Limit ability to offer pain relief. B.Will believe if patient does not appear in pain. C.Must not accept a patient's report of pain-assessment is crucial. D.View experience through their own pain experiences.
A.Limit ability to offer pain relief.
Which of the following nursing diagnoses can be applied to patients with sensory alterations? A.Risk for falls B.Risk for infection C.Impaired peripheral tissue perfusion D. Acute or chronic pain
A.Risk for falls
The senses include which of the following? (check all that apply) A.Sight/visual B.Hearing/auditory C.Touch/tactile D.Smell/olfactory E.Stereognosis
A.Sight/visual B.Hearing/auditory C.Touch/tactile D.Smell/olfactory
Match the characteristics on the left with Acute Pain or Chronic Pain A. has a protective effect B. lasts more than 3 to 6 months C. usually has identifiable causes D. dramatically affects quality of life E. viewed as a disease F. eventually resolves with or without treatment
Acute pain: a, c, f Chronic pain: b, d, e
A nurse is planning care for a client with hypernatremia. Which action should the nurse anticipate including in the plan of care? Implement fluid restriction Increase salt intake Administer hypotonic IV solution Obtain Arterial Blood Gas sample
Administer hypotonic IV solution
A patient with glaucoma is being discharged from the hospital. When teaching the patient and family ways to improve home safety, the nurse tells the family to: A. use throw rugs to prevent tripping. B. paint the floor black and white to improve perception. C. install extra incandescent lighting. D. install handrails painted the same color as the walls.
C. install extra incandescent lighting.
A 4-year-old pediatric patient resists going to sleep. To assist this patient, the best action to take would be: A. adding a daytime nap. B. allowing the child to sleep longer in the morning. C. maintaining the child's home sleep routine. D. offering the child a bedtime snack.
C. maintaining the child's home sleep routine.
A patient has just undergone an appendectomy. When discussing with the patient several pain-relief interventions, the most appropriate recommendation would be: A. adjunctive therapy. B. nonopioids. C. NSAIDs. D. PCA pain management.
D. PCA pain management.
A patient newly diagnosed with diabetes needs to learn how to use a glucometer. Use of a glucometer constitutes: A. affective learning. B. cognitive learning. C. motivational learning. D. psychomotor learning.
D. psychomotor learning.
During rounds on the night shift, you note that a patient stops breathing for 1 to 2 minutes several times during the shift. This condition is known as: A. cataplexy. B. insomnia. C. narcolepsy. D. sleep apnea.
D. sleep apnea.
During physical assessment, the nurse recognizes the following signs/symptoms are likely associated with altered circulation and perfusion in the client: (Select all that apply) Edema Dysuria Diarrhea Dyspnea
Edema Dyspnea
On assessment of a patient with acute renal failure, the nurse finds the following: distended neck veins, cool and pale skin, and crackles in the lungs. The nurse should suspect the patient is experiencing Hypocalcemia Hypovolemia Hypervolemia Hypercalcemia
Hypervolemia
Which of the following does not need to be irrigated? Colostomy Ileostomy
Ileostomy
Which type of nursing intervention is defined as: "Interventions that a nurse can complete on their own within their scope of practice as outlined by the Board of Nursing"? Independent Dependent Interdependent
Independent
Which of the following is NOT a type of nursing intervention? Observation/Assessment Prevention Medical Health Promotion Treatment
Medical
Which valves comprise the atrioventricular valves? Mitral and Tricuspid Mitral and Atrial Atrial and Tricuspid Pulmonic and Aortic
Mitral and Tricuspid
Which of the following is known as the "pacemaker" of the heart? AV node Purkinje fibers Bundle of His SA node
SA node
The nurse identifies the diagnosis Impaired Urinary Elimination in an older adult client admitted after a stroke. Impaired Urinary Elimination places the patient at risk for which complication? Urinary Tract Infection Bowel incontinence Skin breakdown Renal calculi
Urinary Tract Infection
Which of the following is not one of the three steps of oxygenation? Ventilation Perfusion Diffusion Work of breathing
Work of breathing
Serum albumin is synthesized in the: kidney heart liver spleen
liver
The nurse is caring for a patient with a chest tube for treatment of a right pneumothorax. Which assessment finding necessitates immediate notification of the health care provider? 1. New, vigorous bubbling in the water seal chamber. 2. Scant amount of sanguineous drainage noted on the dressing. 3. Clear but slightly diminished breath sounds on the right side of the chest. 4. Pain score of 2 one hour after the administration of the prescribed analgesic.
1. New, vigorous bubbling in the water seal chamber.
The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following? 1. Physical care technique 2. Activity of daily living 3. Indirect care measure 4. Lifesaving measure
1. Physical care technique
The nurse is evaluating the recent lab results for a patient. Which labs are the best indicators for malnutrition? (Select all that apply.) 1. Serum total protein 2. Potassium 3. Lipids 4. Albumin 5 Serum BUN
1. Serum total protein 5. Serum BUN
An 85-year-old patient returns to the inpatient surgical unit after leaving the PACU. Which of the following place the patient at risk during surgery? (Select all that apply.) 1. Stiffened lung tissue 2. Reduced diaphragmatic excursion 3. Increased laryngeal reflexes 4. Reduced blood flow to kidneys 5. Increased cholinergic transmission
1. Stiffened lung tissue 2. Reduced diaphragmatic excursion 4. Reduced blood flow to kidneys
The nurse is caring for a patient with an artificial airway. What are reasons to suction the patient? (Select all that apply.) 1. The patient has visible secretions in the airway. 2. There is a sawtooth pattern on the patient's EtCO2 monitor. 3. The patient has clear breath sounds. 4. It has been 3 hours since the patient was last suctioned. 5. The patient has excessive coughing.
1. The patient has visible secretions in the airway. 2. There is a sawtooth pattern on the patient's EtCO2 monitor. 5. The patient has excessive coughing.
What assessments does a nurse make before hanging an intravenous (IV) fluid that contains potassium? (Select all that apply.) 1. Urine output 2. Arterial blood gases 3. Fullness of neck veins 4. Serum potassium laboratory value in EHR 5. Level of consciousness
1. Urine output 4. Serum potassium laboratory value in EHR
In general, most children are not developmentally or physiologically ready for toilet training until which age: 1-2 2-3 3-4 4-5
2-3
A patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds that reveal wheezing bilaterally. The nurse starts an ordered intravenous infusion to administer medication that will relax the patient's airways. When the nurse asks how the patient feels, he responds by saying, "I feel as if I can breathe beer." The nurse auscultates the patient's lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the following evaluative measures may not reflect change in a patient's condition? 1. Counting respirations per minute 2. Asking the patient to describe how his breathing feels 3. Observing breathing pattern 4. Auscultating lung sounds
2. Asking the patient to describe how his breathing feels
Which of the following signs or symptoms in a patient who is opioid-naïve is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? 1. Oxygen saturation of 95% 2. Difficulty arousing the patient 3. Respiratory rate of 12 breaths/min 4. Pain intensity rating of 5 on a scale of 0 to 10
2. Difficulty arousing the patient
Which nursing interventions are appropriate to include in a plan of care to promote sleep for patients who are hospitalized? (Select all that apply.) 1. Give patients a cup of coffee 1 hour before bedtime. 2. Plan vital signs to be taken before the patients are asleep. 3. Turn television on 15 minutes before bedtime. 4. Have patients follow at-home bedtime schedule. 5. Close the door to patients' rooms at bedtime.
2. Plan vital signs to be taken before the patients are asleep. 4. Have patients follow at-home bedtime schedule. 5. Close the door to patients' rooms at bedtime.
Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention? (Select all that apply.) 1. SpO2 value of 95% 2. Retractions 3. Respiratory rate of 28 breaths per minute 4. Nasal flaring 5. Clubbing of fingers
2. Retractions 3. Respiratory rate of 28 breaths per minute 4. Nasal flaring
A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.
3. Collect one fecal smear from three separate bowel movements.
A client is receiving an enteral feeding at 65 mL/hr. The gastric residual volume in 4 hours was 125 mL. What is the priority nursing intervention? 1. Assess bowel sounds. 2. Raise the head of the bed to at least 45 degrees. 3. Continue the feedings; this is normal gastric residual for this feeding. 4. Hold the feeding until you talk to the primary care provider.
3. Continue the feedings; this is normal gastric residual for this feeding.
A 63-year-old woman is a family caregiver for her 88-year-old mother who has dementia. The caregiver asked the home health nurse how to manage her mother when she becomes confused and violent. The best instructional method a nurse can use for this situation is: 1. Demonstration 2. Preparatory instruction 3. Role-playing 4. Group instruction with other family caregivers
3. Role-playing
A nurse is preparing to teach a patient who has sleep apnea how to use a CPAP machine at night. Which action is most appropriate for the nurse to perform first? 1. Allow patient to manipulate machine and look at parts. 2. Provide a teach-back session. 3. Set mutual goals for the education session. 4. Discuss the purpose of the machine and how it works.
3. Set mutual goals for the education session.
During a teaching session, the nurse tells a patient with a recent neck injury that damage to the nerves is comparable to a water hose that has been pinched off. During this teaching session, the nurse is using the process of: A. analogy. B. discovery. C. role playing. D. demonstration
A. analogy.
An elderly patient who lives in an adult assisted-living facility mentions that he is experiencing hearing and vision changes. During your assessment, you would associate this type of sensory deprivation with: A. stable affect. B. altered perception. C. improved task completion. D. increased need for social interaction.
B. altered perception.
The nurse would use which of the following scales to help clients identify the characteristics of their bowel movements? Morse Fall Scale Norton Scale Braden Scale Bristol Stool Scale
Bristol Stool Scale
A patient with a long-standing history of diabetes mellitus is voicing concerns about kidney disease. The patient asks the nurse where urine is formed in the kidney. The nurse's response is the: Bladder Kidney Nephron Ureter
Nephron
A nurse recognizes which of the following statements about suctioning to be incorrect? Suction should only be applied when withdrawing the catheter Suction should not be applied during insertion Providing oxygen may be needed in between suction passes Suctioning should last between 15-20 seconds for each pass
Suctioning should last between 15-20 seconds for each pass
A nurse records a respiratory rate of 28 breaths per minute in their adult patient. This would be described as: Normal respiratory rate Tachypnea Bradypnea Apnea
Tachypnea
Which statement made by the patient indicates an understanding of sleep-hygiene practices? 1. "I usually drink a cup of warm milk in the evening to help me sleep." 2. "If I exercise right before bedtime, I will be tired and fall asleep faster." 3. "I know it does not maer what time I go to bed as long as I am tired." 4. "If I use hypnotics for a long time, my insomnia will be cured."
1. "I usually drink a cup of warm milk in the evening to help me sleep."
Which statements from a patient indicate an understanding of behaviors that will promote sleep? (Select all that apply.) 1. "I will not watch television in bed." 2. "I will not drink caffeine later in the day." 3. "A short nap late in the evening will lead to a more restful night of sleep." 4. "I am going to start eating dinner closer to my bedtime" 5. "I will start to exercise regularly during the day."
1. "I will not watch television in bed." 2. "I will not drink caffeine later in the day." 5. "I will start to exercise regularly during the day."
A nurse is conferring with another nurse about the care of a patient with a stage II pressure injury. The two decide to review the clinical practice guideline of the hospital for pressure injury care. The use of a clinical practice guideline achieves which of the following? (Select all that apply.) 1. Allows nurses to act more quickly and appropriately 2. Sets a level of clinical excellence for practice 3. Eliminates need to create an individualized care plan for the patient 4. Incorporates evidence-based interventions for stage II pressure injury 5. Provides for access to patient care information within the electronic health record
1. Allows nurses to act more quickly and appropriately 2. Sets a level of clinical excellence for practice 4. Incorporates evidence-based interventions for stage II pressure injury
The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? 1. Appearance and behavior 2. Measurement of vital signs 3. Observing specific body systems 4. Conducting a detailed health history
1. Appearance and behavior
A health care provider writes the following order for a patient who is opioid-naïve who returned from the operating room following a total hip replacement: "Fentanyl patch 100 mcg, change every 3 days." On the basis of this order, the nurse takes the following action: 1. Calls the health care provider and questions the order 2. Applies the patch the third postoperative day 3. Applies the patch as soon as the patient reports pain 4. Places the patch as close to the hip dressing as possible
1. Calls the health care provider and questions the order
Which symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Fecal impaction 5. Muscle aches 6. Incomplete emptying of the colon 7. Food particles in the stool 8. Unexplained abdominal or back pain
1. Change in bowel habits 2. Blood in the stool 6. Incomplete emptying of the colon 8. Unexplained abdominal or back pain
A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent a central line infection? (Select all that apply.) 1. Change the dressing using sterile technique. 2. Change TPN containers every 48 hours. 3. Change the TPN tubing every 24 hours. 4. Monitor glucose levels to watch and assess for glucose intolerance. 5. Elevate head of the bed 45 degrees to prevent aspiration.
1. Change the dressing using sterile technique. 3. Change the TPN tubing every 24 hours.
A nurse asks how a patient's condition from a serious infection changed since yesterday while receiving a hand-off report. The nurse leaving the shift reports the patient has two priority nursing diagnoses—fluid imbalance and fever. The receiving nurse begins to provide care by measuring the patient's body temperature, inspecting the condition of the skin, reviewing the intake and output record, and checking the summary notes describing the patient's progress since the day before. The nurse asks a technician to measure intake and output during the shift. What critical thinking indicators reflect the nurse's ability to perform evaluation? (Select all that apply.) 1. Checking the summary notes 2. Asking the leaving RN about the patient's condition. 3. Assigning the technician to measure intake and output 4. Comparing current outcomes with those set for the patient's goals 5. Reflecting on patient's progress
1. Checking the summary notes 2. Asking the leaving RN about the patient's condition. 4. Comparing current outcomes with those set for the patient's goals 5. Reflecting on patient's progress
Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply.) 1. Checks scientific literature or policy and procedure 2. Determines whether additional assistance is needed 3. Collects all necessary equipment 4. Delegates the procedure to a more experienced nurse 5. Considers all possible consequences of the procedure
1. Checks scientific literature or policy and procedure 2. Determines whether additional assistance is needed 3. Collects all necessary equipment 5. Considers all possible consequences of the procedure
A nurse has been caring for a patient over 2 consecutive days. During that time the patient had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks whether the patient feels tenderness when the site is palpated. The nurse reviews the medical record from 24 hours ago and finds the catheter site was without redness or tenderness. Which of the activities below reflect the nurse's ability to perform patient evaluation? (Select all that apply.) 1. Comparing patient response with previous response 2. Examining results of clinical data 3. Recognizing error 4. Self-reflection 5. Checking medical record for when IV was inserted.
1. Comparing patient response with previous response 2. Examining results of clinical data
A patient who returned from surgery 3 hours ago following a kidney transplant is reporting pain at a 7 on a scale of 0 to 10. The nurse has tried repositioning with no improvement in the patient's pain report. Unmanaged surgical pain can lead to which of the following problems? (Select all that apply.) 1. Delayed ambulation 2. Reduced ventilation 3. Catheter-associated urinary tract infection 4. Retained pulmonary secretions 5. Reduced appetite
1. Delayed ambulation 2. Reduced ventilation 4. Retained pulmonary secretions 5. Reduced appetite
A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, "I think my hearing aid is broken. I can't hear anything." After determining that the patient's hearing aid works and that the patient is having trouble managing the hearing aid at home, which of the following teaching strategies does the nurse implement? (Select all that apply.) 1. Demonstrate hearing aid battery replacement. 2. Review method to check volume on hearing aid. 3. Demonstrate how to wash the earmold and microphone with hot water. 4. Discuss the importance of having wax buildup in the ear canal removed. 5. Recommend a chemical cleaner to remove difficult buildup.
1. Demonstrate hearing aid battery replacement. 2. Review method to check volume on hearing aid. 4. Discuss the importance of having wax buildup in the ear canal removed.
Which is the best intervention the nurse should implement to promote bowel function? 1. Early ambulation 2. Deep-breathing exercises 3. Repositioning on the left side 4. Lowering the head of the patient's bed
1. Early ambulation
A postoperative patient experiences tachypnea during the first hour of recovery. Which nursing intervention is a priority? 1. Elevate the head of the patient's bed. 2. Give ordered oxygen through a mask at 4 L/min. 3. Ask the patient to use an incentive spirometer. 4. Position the patient on one side with the face down and the neck slightly extended so that the tongue falls forward.
1. Elevate the head of the patient's bed.
Which of the following statements correctly describes the evaluation process? (Select all that apply.) 1. Evaluation involves reflection on the approach to care. 2. Evaluation involves determination of the completion of a nursing intervention. 3. Evaluation involves making clinical decisions. 4. Evaluation requires the use of assessment skills. 5. Evaluation is performed only when a patient's condition changes.
1. Evaluation involves reflection on the approach to care. 3. Evaluation involves making clinical decisions. 4. Evaluation requires the use of assessment skills.
Which of the following statements correctly describe the evaluation process? (Select all that apply.) 1. Evaluation is an ongoing process. 2. Evaluation involves the gathering of data for recognizing errors or omissions in care. 3. Evaluation involves making clinical decisions. 4. Evaluation requires the use of assessment skills. 5. Evaluation is done only when a patient's condition changes.
1. Evaluation is an ongoing process. 2. Evaluation involves the gathering of data for recognizing errors or omissions in care. 3. Evaluation involves making clinical decisions. 4. Evaluation requires the use of assessment skills.
A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights
1. Fall prevention interventions 4. Monitoring for constipation
Which sleep-hygiene actions at bedtime can the nurse delegate to assistive personnel? (Select all that apply.) 1. Giving the patient a back rub 2. Turning on quiet music 3. Dimming the lights in the patient's room 4. Giving a patient a cup of coffee 5. Monitoring for the effect of the sleeping medication that was given
1. Giving the patient a back rub 2. Turning on quiet music 3. Dimming the lights in the patient's room
Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet. 2. Use a low-volume enema daily. 3. Avoid gluten in the diet. 4. Take laxatives twice a day. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day. 7. Take probiotics 5 times a week.
1. Increase fiber and fluids in the diet. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day.
An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.) 1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 3. Roller clamp wide open 4. Tubing kinked in bedrails 5. Circulatory overload
1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 4. Tubing kinked in bedrails
Which nursing intervention(s) best promote(s) effective sleep in an older adult? (Select all that apply.) 1. Limit fluids 2 to 4 hours before sleep. 2. Ensure that the room is completely dark. 3. Ensure that the room temperature is comfortably cool. 4. Provide warm covers. 5. Encourage walking an hour before going to bed.
1. Limit fluids 2 to 4 hours before sleep. 3. Ensure that the room temperature is comfortably cool. 4. Provide warm covers.
A nurse cares for a postoperative patient in the PACU. Upon assessment, the nurse finds the surgical dressing is saturated with serosanguineous drainage. Which interventions are a priority? (Select all that apply.) 1. Notify surgeon. 2. Maintain the intravenous fluid infusion. 3. Provide 2 L/min of oxygen via nasal cannula. 4. Monitor the patient's vital signs every 5 to 10 minutes. 5. Reinforce the dressing.
1. Notify surgeon. 5. Reinforce the dressing.
The nurse prepares a patient with type 2 diabetes for a surgical procedure. The patient weighs 112.7 kg (248 lb) and is 5 feet, 2 inches in height. Which factors increase this patient's risk for surgical complications? (Select all that apply.) 1. Obesity 2. Prolonged bleeding time 3. Delayed wound healing 4. Ineffective vital capacity 5. Immobility secondary to height
1. Obesity 3. Delayed wound healing
The nurse has just witnessed her patient go into cardiac arrest. What priority interventions should the nurse perform at this time? (Select all that apply.) 1. Perform chest compressions. 2. Ask someone to bring the defibrillator to the room for immediate defibrillation. 3. Apply oxygen via nasal cannula.4. Place the patient in the high Fowler's position. 5. Educate the family about the need for CPR.
1. Perform chest compressions. 2. Ask someone to bring the defibrillator to the room for immediate defibrillation.
Which action can a nurse delegate to assistive personnel (AP)? 1. Performing glucose monitoring every 6 hours on a patient 2. Teaching the client about the need for enteral feeding 3. Administering enteral feeding bolus after tube placement has been verified 4. Evaluating the client's tolerance of the enteral feeding
1. Performing glucose monitoring every 6 hours on a patient
A nurse in a community health clinic has been caring for a young female teenager with diabetes for several months. The nurse's goal of care for this patient is to achieve self- management of insulin medication. Identify appropriate evaluative measures for self-management for this patient. (Select all that apply.) 1. Quality of life 2. Patient satisfaction 3. Clinic follow-up visits 4. Adherence to self-administration of insulin 5. Description of side effects of medications
1. Quality of life 3. Clinic follow-up visits 4. Adherence to self-administration of insulin
A patient with progressive vision impairments had to surrender his driver's license 6 months ago. He comes to the medical clinic for a routine checkup. He is accompanied by his son. His wife died 2 years ago, and he admits to feeling lonely much of the time. Which of the following interventions reduce loneliness? (Select all that apply.) 1. Sharing information about senior transportation services 2. Reassuring the patient that loneliness is a normal part of aging 3. Maintaining distance while talking to avoid overstimulating the patient 4. Providing information about local social groups in the patient's neighborhood 5. Recommending that the patient consider making living arrangements that will put him closer to family or friends
1. Sharing information about senior transportation services 4. Providing information about local social groups in the patient's neighborhood 5. Recommending that the patient consider making living arrangements that will put him closer to family or friends
A nurse is teaching an older adult patient about ways to detect a melanoma. Which of the following are age-appropriate teaching techniques for this patient? (Select all that apply.) 1. Speak in a low tone. 2. Begin and end the session with the most important information regarding melanoma. 3. Provide a pamphlet about melanoma with large font in blues and greens. 4. Provide specific information in frequent, small amounts for older adult patients. 5. Speak quickly so that you do not take up much of the patient's time.
1. Speak in a low tone. 2. Begin and end the session with the most important information regarding melanoma. 4. Provide specific information in frequent, small amounts for older adult patients.
During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first? 1. Stop the instillation. 2. Ask the patient to take deep breaths to decrease the pain. 3. Tell the patient to bear down as he would when having a bowel movement. 4. Continue the instillation; then administer a pain medication.
1. Stop the instillation.
A nurse is developing a plan for a patient who was diagnosed with narcolepsy. Which interventions should the nurse include on the plan? (Select all that apply.) 1. Take brief, 20-minute naps no more than twice a day. 2. Drink a glass of wine with dinner. 3. Eat a large meal at lunch rather than dinner. 4. Establish a regular exercise program. 5. Teach the patient about the side effects of modafinil.
1. Take brief, 20-minute naps no more than twice a day. 4. Establish a regular exercise program. 5. Teach the patient about the side effects of modafinil.
A patient has been on contact isolation for 4 days because of a hospital-acquired infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Which are the correct nursing interventions to reduce sensory deprivation? (Select all that apply.) 1. Teaching how activities such as reading and using crossword puzzles provide stimulation 2. Moving him to a room away from the nurses' station 3. Turning on the lights and opening the room blinds 4. Sitting down, speaking, touching, and listening to his feelings and perceptions 5. Providing auditory stimulation for the patient by keeping the television on continuously
1. Teaching how activities such as reading and using crossword puzzles provide stimulation 3. Turning on the lights and opening the room blinds 4. Sitting down, speaking, touching, and listening to his feelings and perceptions
A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, three others are stable and resting, and one has requested a pain medication. The patient in pain has two analgesics ordered prn for pain and has been using cold applications on his surgical site for pain relief. The last time an analgesic was given was 4 hours ago. The patient is scheduled for a physical therapy visit in 2 hours. Which of the following demonstrate good clinical decision making during intervention? (Select all that apply.) 1. The nurse reviews the options for pain relief for the patient. 2. The nurse assesses whether the prn medication, ordered every 4 to 6 hours and last given 4 hours ago, is effective and whether a new type of medication is needed. 3. The nurse reviews the policy and procedure for the cold application. 4. The nurse considers how the patient might react if the pain medication is held until an hour before physical therapy. 5. The nurse delegates vital sign assessment of the patient returning from surgery to the assistive personnel.
1. The nurse reviews the options for pain relief for the patient. 2. The nurse assesses whether the prn medication, ordered every 4 to 6 hours and last given 4 hours ago, is effective and whether a new type of medication is needed. 4. The nurse considers how the patient might react if the pain medication is held until an hour before physical therapy.
From the following list of indicators, determine which indicators are goals (G) and which indicators are outcomes (O). 1. _____ Will achieve pain relief 2. _____ Ambulates 10 feet down hallway 3. _____ Will remain free of infection 4. _____ Will be afebrile 5. _____ Reports pain severity reduced from 6 to a 4 on scale of 0 to 10 6. _____ Will gain improved mobility
1G, 2O, 3G, 4G, 5O, 6G
Match: 1. counseling 2. lifesaving measure 3. physical care technique 4. activity of daily living a. assisting patient with oral care b. discussing a patients options in choosing palliative care c. protecting a violent patient from injury d. using safe patient handling during positioning of a patient
1b, 2c, 3d, 4a
A patient's cultural background affects the motivation for learning. Using the ACCESS model, match the nursing approach with the correct model component. 1. Assessment 2. Communication 3. Cultural 4. Establishment 5. Sensitivity 6. Safety A. Help patients feel culturally secure and able to maintain their cultural identity B. Remain aware of verbal and nonverbal responses C. Be aware of how patients from diverse backgrounds perceive their care needs D. Become aware of your patient's culture and your own cultural biases E. Learn about the patients health beliefs and practices F. Show respect by creating a caring rapport
1e, 2b, 3d, 4f, 5c, 6a
A 72-year-old patient asks the nurse about using an over-the- counter antihistamine as a sleeping pill to help her get to sleep. What is the nurse's best response? 1. "Antihistamines are beer than prescription medications because prescription medications can cause a lot of problems." 2. "Antihistamines should not be used because they can cause confusion and increase your risk of falls." 3. "Antihistamines are effective sleep aids because they do not have many side effects." 4. "Over-the-counter medications when combined with sleep- hygiene measures are a good plan for sleep."
2. "Antihistamines should not be used because they can cause confusion and increase your risk of falls."
Which statement made by a mother being discharged to home with her newborn infant indicates that she understands the discharge teaching related to best sleep practices? 1. "I'll give the baby a bole to help her fall asleep." 2. "We'll place the baby on her back to sleep." 3. "We put the baby's stuffed animals in the crib to make her feel safe." 4. "I know the baby will not need to be fed until morning."
2. "We'll place the baby on her back to sleep."
The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). What statement, made by the patient, indicates the need for further teaching? 1. "Pursed-lip breathing is like exercise for my lungs and will help me strengthen my breathing muscles." 2. "When I am sick, I should limit the amount of fluids I drink so that I don't produce excess mucus." 3. "I will ensure that I receive an influenza vaccine every year, preferably in the fall." 4. "I will look for a smoking-cessation support group in my neighborhood."
2. "When I am sick, I should limit the amount of fluids I drink so that I don't produce excess mucus."
The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate does the nurse program into the infusion pump? 1. 100 mL/hr 2. 125 mL/hr 3. 167 mL/hr 4. 200 mL/hr
2. 125 mL/hr
Which of the following scenarios demonstrate that learning has taken place? (Select all that apply.) 1. A patient listens to a nurse's review of the warning signs of a stroke. 2. A patient describes how to set up a pill organizer for newly ordered medicines. 3. A patient attends a spinal cord injury support group. 4. A patient demonstrates how to take his blood pressure at home. 5. A patient reviews written information about resources for cancer survivors.
2. A patient describes how to set up a pill organizer for newly ordered medicines. 4. A patient demonstrates how to take his blood pressure at home.
Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.) 1. Lift the patient's hips off the bed and slide the bedpan under the patient. 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 3. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient. 4. Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.
2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.
A nurse admits a 32-year-old patient for treatment of acute asthma. The patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds with bilateral wheezing. The nurse makes the patient comfortable and starts an ordered intravenous infusion to administer medication that will relax the patient's airways. The patient tells the nurse after the first medication infusion, "I feel as if I can breathe beer." The nurse auscultates the patient's lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the following is an evaluative measure? (Select all that apply.) 1. Asking patient to breathe deeply during auscultation 2. Counting respirations per minute 3. Asking the patient to describe how his breathing feels 4. Starting the intravenous infusion 5. Auscultating lung sounds
2. Counting respirations per minute 3. Asking the patient to describe how his breathing feels 5. Auscultating lung sounds
An older-adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects new onset of crackles in the lung bases. What is the priority action? 1. Notify a health care provider. 2. Decrease the IV flow rate. 3. Lower the head of the bed. 4. Discontinue the IV site.
2. Decrease the IV flow rate.
A nurse is visiting a patient who lives alone at home. The nurse is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (Select all that apply.) 1. Reviewing the family caregiver's availability during medication administration times 2. Determining the value the patient places on taking medications 3. Reviewing the number of medications and time each is to be taken 4. Determining all consequences associated with the patient missing specific medicines 5. Reviewing the therapeutic actions of the medications
2. Determining the value the patient places on taking medications 4. Determining all consequences associated with the patient missing specific medicines
The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first? 1. Start oxygen at 2 L/min via nasal cannula. 2. Elevate the head of the bed to 45 degrees. 3. Encourage the patient to use the incentive spirometer. 4. Notify the health care provider.
2. Elevate the head of the bed to 45 degrees.
A patient is returning to an assisted-living apartment following a diagnosis of declining, progressive visual loss. Although she is familiar with her apartment and residence, she reports feeling a lile uncertain about walking alone. There is one step into her apartment. Her children are scheduling themselves to be available to their mom for the next 2 weeks. Which of the following approaches will you teach the children to assist ambulation? (Select all that apply.) 1. Walk one-half step behind and slightly to her side. 2. Have her grasp your arm just above the elbow and walk at a comfortable pace. 3. Stand next to your mom at the top and bottom of stairs. 4. Stand one step ahead of mom at the top of the stairs. 5. Place yourself alongside your mom and hold onto her waist.
2. Have her grasp your arm just above the elbow and walk at a comfortable pace. 3. Stand next to your mom at the top and bottom of stairs.
An older adult is admitted from a skilled nursing home to a medical unit with pneumonia. A review of the medical record reveals that he had a stroke affecting the right hemisphere of the brain 6 months ago and was placed in the skilled nursing home because he was unable to care for himself. Which of these assessment findings does the nurse expect to find? (Select all that apply.) 1. Slow, cautious behavioral style 2. Inattention and neglect, especially to the left side 3. Cloudy or opaque areas in part of the lens or the entire lens 4. Visual spatial alterations such as loss of half of a visual field 5. Loss of sensation and motor function on the right side of the body
2. Inattention and neglect, especially to the left side 4. Visual spatial alterations such as loss of half of a visual field
When delegating input and output (I&O) measurement to assistive personnel, the nurse instructs them to record what information for ice chips? 1. Two-thirds of the volume 2. One-half of the volume 3. One-quarter of the volume 4. Two times the volume
2. One-half of the volume
The nurse is performing tracheostomy care on a patient. What finding would indicate that the tracheostomy tube has become dislodged? 1. Clear breath sounds 2. Patient speaking to nurse 3. SpO2 reading of 96% 4. Respiratory rate of 18 breaths/minute
2. Patient speaking to nurse
A nurse sees an assistive personnel (AP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention by the nurse? 1. Fastening tube to the gown with new tape 2. Placing client supine while giving a bath 3. Monitoring the client's weight as ordered 4. Ambulating patient with enteral feedings still infusing
2. Placing client supine while giving a bath
A nurse is caring for a young patient who has been told he has multiple sclerosis. The nurse has planned time to conduct a teaching session that will focus on the disease and principles of management. The nurse chooses to use the EDUCATE model to proceed with instruction. Which of the following are components of the model? (Select all that apply.) 1. State goals of the session for the patient. 2. Repeat the most important information. 3. Practice empathetic skills. 4. Be aware of nonverbal messages. 5. Use a standard question list for the chosen topic.
2. Repeat the most important information. 3. Practice empathetic skills. 4. Be aware of nonverbal messages.
A patient with a 3-day history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The patient had been taking hydrocodone/APAP 5/325 up to four tablets/day before her stroke for the past year to manage her arthritic pain. The health care provider's order reads as follows: "Hydrocodone/APAP 5/325 1 tab, per gastrostomy tube, q4h, prn." Which action by the nurse is most appropriate? 1. No action is required by the nurse because the order is appropriate. 2. Request to have the order changed to around the clock (ATC) for the first 48 hours. 3. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3h, prn. 4. Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of pain.
2. Request to have the order changed to around the clock (ATC) for the first 48 hours.
The nurse is caring for a client with pneumonia, who has severe malnutrition. The nurse should assess the patient for which of the following assessment findings? (Select all that apply.) 1. Heart disease 2. Sepsis 3. Hemorrhage 4. Skin breakdown 5. Diarrhea
2. Sepsis 3. Hemorrhage 4. Skin breakdown
When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which of the following represent an accurate description of the nonpharmacological therapy? (Select all that apply.) 1. Turn TENS on before patient feels discomfort. 2. TENS works peripherally and centrally on nerve receptors. 3. TENS does not require a health care provider order. 4. Remove any skin preparations before aaching TENS electrodes. 5. Placing electrodes directly over or near the pain site works best.
2. TENS works peripherally and centrally on nerve receptors. 4. Remove any skin preparations before aaching TENS electrodes. 5. Placing electrodes directly over or near the pain site works best.
The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? (Select all that apply.) 1. Add salt to every meal. 2. Talk with your health care provider about taking a daily low dose of aspirin. 3. Work with your health care provider to develop a regular exercise program. 4. Limit daily intake of fats to less than 25% to 35% of total calories. 5. Review strategies to encourage the patient to quit smoking.
2. Talk with your health care provider about taking a daily low dose of aspirin. 3. Work with your health care provider to develop a regular exercise program. 4. Limit daily intake of fats to less than 25% to 35% of total calories. 5. Review strategies to encourage the patient to quit smoking.
A patient suddenly experiences a severe headache with numbness and decreased movement in the left arm. The emergency room physician suspects a stroke and is going to have the patient undergo an emergent angiogram to remove the clot. Which teaching approach is most appropriate? 1. Selling approach 2. Telling approach 3. Entrusting approach 4. Participating approach
2. Telling approach
The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure injury. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions? (Select all that apply.) 1. The application of the skin barrier is a dependent care measure. 2. The call to the ostomy and wound care specialist is an indirect care measure. 3. The cleansing of the skin is a direct care measure. 4. The application of the skin barrier is an instrumental activity of daily living. 5. Inspecting the skin is a direct care activity.
2. The call to the ostomy and wound care specialist is an indirect care measure. 3. The cleansing of the skin is a direct care measure.
A nurse is assigned to five patients, including one who was recently admied and one returning from a diagnostic procedure. It is currently mealtime. The other three patients are stable, but one has just requested a pain medication. The nurse is working with an assistive personnel. Which of the following are appropriate delegation actions on the part of the nurse? (Select all that apply.) 1. The nurse directs the assistive personnel to obtain a set of vital signs on the patient returning from the diagnostic procedure. 2. The nurse directs the patient care technician to go to the patient in pain and to reposition and offer comfort measures until the nurse can bring an ordered analgesic to the patient. 3. The nurse directs the patient care technician to set up meal trays for patients. 4. The nurse directs the patient care technician to gather a history from the newly admitted patient about his medications. 5. The nurse directs the patient care technician to assist one of the stable patients up in a chair for his meal.
2. The nurse directs the patient care technician to go to the patient in pain and to reposition and offer comfort measures until the nurse can bring an ordered analgesic to the patient. 3. The nurse directs the patient care technician to set up meal trays for patients. 5. The nurse directs the patient care technician to assist one of the stable patients up in a chair for his meal
A new medical resident writes an order for oxycodone CR 10 mg PO q2h prn. Which part of the order does the nurse question? 1. The drug 2. The time interval 3. The dose 4. The route
2. The time interval
The home care nurse is instructing an assistive personnel about interventions to facilitate location of items for patients with vision impairment. Which are effective strategies for enhancing a patient's impaired vision? (Select all that apply.) 1. Use of fluorescent lighting 2. Use of warm incandescent lighting 3. Use of yellow or amber lenses to decrease glare 4. Use of adjustable blinds, sheer curtains, or draperies 5. Indirect lighting to reduce glare
2. Use of warm incandescent lighting 3. Use of yellow or amber lenses to decrease glare 4. Use of adjustable blinds, sheer curtains, or draperies
Communication between a nurse caring for a patient in the preoperative holding area and the circulating nurse in the operating room (OR) can best be enhanced by which of the following? (Select all that apply.) 1. Documenting assessment findings in the medical record 2. Using a standardized SBAR tool 3. Being responsive in using nonverbal communication techniques 4. Giving specific information to a transport technician 5. Listening to the OR nurse's questions
2. Using a standardized SBAR tool 3. Being responsive in using nonverbal communication techniques 5. Listening to the OR nurse's questions
A new nurse is going to help a patient walk down the corridor and sit in a chair. The patient has an eye patch over the left eye and poor vision in the right eye. What is the correct order of steps to help the patient safely walk down the hall and sit in the chair? 1. Tell patient when you are approaching the chair. 2. Walk at a relaxed pace. 3. Guide patient's hand to nurse's arm, resting just above the elbow. 4. Position yourself one-half step in front of patient. 5. Position patient's hand on back of chair.
3, 4, 2, 1, 5
A nurse is taking a sleep history from a patient. Which statement made by the patient needs further follow-up? 1. "I feel refreshed when I wake up in the morning." 2. "I use soft music at night to help me relax." 3. "It takes me about 45 to 60 minutes to fall asleep." 4. "I take the pain medication for my leg pain about 30 minutes before I go to bed."
3. "It takes me about 45 to 60 minutes to fall asleep."
A patient asks a nurse to provide instruction on how to perform a breast self-exam. Which domains are required to learn this skill? (Select all that apply.) 1. Affective domain 2. Sensory domain 3. Cognitive domain 4. Attentional domain 5. Psychomotor domain
3. Cognitive domain 5. Psychomotor domain
Place the following steps in the correct order for administration of patient-controlled analgesia: 1. Insert drug cartridge into infusion device and prime tubing. 2. Wipe injection port of maintenance IV line vigorously with antiseptic swab for 15 seconds and allow to dry. 3. Demonstrate to patient how to push medication demand button. 4. Secure connection and anchor PCA tubing with tape. 5. Instruct patient to notify a nurse for possible side effects or changes in the severity or location of pain. 6. Insert needleless adapter into injection port nearest patient. 7. Apply clean gloves. Check infuser and patient-control module for accurate labeling or evidence of leaking. 8. Program computerized PCA pump as ordered to deliver prescribed medication dose and lockout interval. 9. Attach needleless adapter to tubing adapter of patient- controlled module.
3. Demonstrate to patient how to push medication demand button. 5. Instruct patient to notify a nurse for possible side effects or changes in the severity or location of pain. 7. Apply clean gloves. Check infuser and patient-control module for accurate labeling or evidence of leaking. 1. Insert drug cartridge into infusion device and prime tubing. 9. Attach needleless adapter to tubing adapter of patient- controlled module. 2. Wipe injection port of maintenance IV line vigorously with antiseptic swab for 15 seconds and allow to dry. 6. Insert needleless adapter into injection port nearest patient. 4. Secure connection and anchor PCA tubing with tape. 8. Program computerized PCA pump as ordered to deliver prescribed medication dose and lockout interval.
An older adult patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitates communication with her? (Select all that apply.) 1. Talk to the patient at a distance so he or she may read your lips. 2. Keep your arms at your side; speak directly into the patient's left ear. 3. Face the patient when speaking; demonstrate ideas you wish to convey. 4. Position the patient so that the light is on his or her face when speaking. 5. Verify that the information that has been given has been clearly understood.
3. Face the patient when speaking; demonstrate ideas you wish to convey. 5. Verify that the information that has been given has been clearly understood.
Which assessment does the nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? 1. Dryness of mucous membranes 2. Skin turgor 3. Fullness of neck veins when supine 4. Fullness of neck veins when upright
3. Fullness of neck veins when supine
A patient has undergone surgery for a femoral artery bypass. The surgeon's orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.) 1. Place the fingers behind and below the medial malleolus. 2. Have the patient slightly flex the knee with the foot resting on the bed. 3. Have the patient relax the foot while lying supine. 4. Palpate the groove lateral to the flexor tendon of the wrist. 5. Palpate along the top of the foot in a line with the groove
3. Have the patient relax the foot while lying supine. 5. Palpate along the top of the foot in a line with the groove
Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient? 1. Knowing the source of the guideline 2. Reviewing the evidence used to develop the guideline 3. Individualizing how to apply the clinical guideline for a patient 4. Explaining to a patient the purpose of the guideline
3. Individualizing how to apply the clinical guideline for a patient
A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, one is newly admied, and one has requested a pain medication. The patient who has returned from surgery just minutes ago has a large abdominal dressing, is still on oxygen by nasal cannula, and has an intravenous line. One of the other patients has just called out for assistance in seeing up a meal tray. Another patient is stable and resting comfortably. Which patient is the nurse's current greatest priority? 1. Patient in pain 2. Patient newly admitted 3. Patient who returned from surgery 4. Patient requesting assistance with meal tray
3. Patient who returned from surgery
A nurse is performing an assessment on a patient admitted to the unit following treatment in the emergency department for severe bilateral eye trauma. During patient admission the nurse's priority interventions include which of the following? (Select all that apply.) 1. Conducting a home-safety assessment and identifying hazards in the patient's living environment 2. Reinforcing eye safety at work and in activities that place the patient at risk for eye injury 3. Placing necessary objects such as the nurse call system and water in front of the patient to prevent falls caused by reaching 4. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye 5. Alerting other nurses and health care providers about patient's visual status during hand-off reports
3. Placing necessary objects such as the nurse call system and water in front of the patient to prevent falls caused by reaching 4. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye 5. Alerting other nurses and health care providers about patient's visual status during hand-off reports
A patient is admied to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and , 24. How does the nurse interpret these laboratory values? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
3. Respiratory acidosis
A patient recovering from open heart surgery is taught how to cough and deep breathe using a pillow to support or splint the chest incision. Following the teaching session, which of the following is the best way for the nurse to evaluate whether learning has taken place? 1. Verbalization of steps to use in splinting 2. Selecting from a series of flash cards the images showing the correct technique 3. Return demonstration 4. Cloze test
3. Return demonstration
The nurse reviews a patient's medical administration record (MAR) and finds that the patient has received oxycodone/acetaminophen (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? 1. The patient's level of pain 2. The potential for addiction 3. The amount of daily acetaminophen 4. The risk for gastrointestinal bleeding
3. The amount of daily acetaminophen
A nurse enters a patient's room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient's expectations of care. Which of the following is appropriate for evaluating a patient's expectations of care? 1. On a scale of 0 to 10 rate your level of nausea. 2. The nurse weighs the patient. 3. The nurse asks, "Did you believe that you received the information you needed to follow your diet?" 4. The nurse states, "Tell me four different foods included in your diet."
3. The nurse asks, "Did you believe that you received the information you needed to follow your diet?"
The nurse is observing as the student nurse performs a respiratory assessment on a patient. Which action by the student nurse requires the nurse to intervene? 1. The student stands at a midline position behind the patient, observing for position of the spine and scapula. 2. The student palpates the thoracic muscles for masses, pulsations, or abnormal movements. 3. The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds. 4. The student places the palm of the hand over the intercostal spaces and asks the patient to say "ninety- nine."
3. The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds.
Which statement made by the parents of a 2-month-old infant requires further education by the nurse? 1. "I'll continue to use formula for the baby until he is at least a year old." 2. "I'll make sure that I purchase iron-fortified formula." 3. "I'll start feeding the baby cereal at 4 months." 4. "I'm going to alternate formula with whole milk, starting next month."
4. "I'm going to alternate formula with whole milk, starting next month."
Which skills can the nurse delegate to assistive personnel (AP)? (Select all that apply.) 1. Initiate oxygen therapy via nasal cannula. 2. Perform nasotracheal suctioning of a patient. 3. Educate the patient about the use of an incentive spirometer. 4. Assist with care of an established tracheostomy tube. 5. Reposition a patient with a chest tube.
4. Assist with care of an established tracheostomy tube. 5. Reposition a patient with a chest tube.
A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Have you taken antibiotics recently? 3. Do you have gluten intolerance? 4. Have you experienced frequent, small liquid stools recently?
4. Have you experienced frequent, small liquid stools recently?
A 55-year-old adult male has been in the hospital over a week following surgical complications. The patient has had limited activity but is now finally ordered to begin a mobility program. The patient just returned from several diagnostic tests and tells the nurse he is feeling quite fatigued. The nurse prepares to instruct the patient on the mobility program protocol. Which of the following learning principles will likely be affected by this patient's condition? 1. Motivation to learn 2. Developmental stage 3. Stage of grief 4. Readiness to learn
4. Readiness to learn
The nurse is caring for a client with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? 1. Suction her mouth and throat. 2. Turn her on her side. 3. Put on oxygen at 2 L nasal cannula. 4. Stop feeding her.
4. Stop feeding her.
A nurse in the recovery room is monitoring a patient who had a left knee replacement. The patient arrived in recovery 15 minutes ago. The nurse observes the patient to be restless, turning frequently, and groaning; the patient's heart rate is 92 compared with 76 preoperatively. Blood pressure is stable since admission to the recovery room. The nurse reviews the medical orders for analgesic therapy. The nurse notes that the postop dose of an ordered analgesic has not yet been given. What is most likely to cause the nurse to reflect on the patient's situation? 1. The patient is recovering normally. 2. The symptoms reflecting restlessness 3. The patient's blood pressure trend 4. The delay in administration of the analgesic
4. The delay in administration of the analgesic
A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request a discontinuation of parenteral nutrition? 1. When 25% of the patient's nutritional needs are met by the tube feedings 2. When bowel sounds return 3. When the central line has been in for 10 days 4. When 75% of the patient's nutritional needs are met by the tube feedings
4. When 75% of the patient's nutritional needs are met by the tube feedings
Place the following steps for discontinuing intravenous (IV) access in the correct order: 1. Perform hand hygiene and apply gloves. 2. Explain procedure to patient. 3. Remove IV site dressing and tape. 4. Use two identifiers to ensure correct patient. 5. Stop the infusion and clamp the tubing. 6. Carefully check the health care provider's order. 7. Clean the site, withdraw the catheter, and apply pressure.
6. Carefully check the health care provider's order. 4. Use two identifiers to ensure correct patient. gloves. 2. Explain procedure to patient. 1. Perform hand hygiene and apply gloves. 5. Stop the infusion and clamp the tubing. 3. Remove IV site dressing and tape. 7. Clean the site, withdraw the catheter, and apply pressure.
The nurse is preparing to perform nasotracheal suctioning on a patient. Arrange the steps in order. 1. Apply suction. 2. Assist patient to semi-Fowler's or high Fowler's position, if able. 3. Advance catheter through nares and into trachea. 4. Have patient take deep breaths. 5. Lubricate catheter with water-soluble lubricant. 6. Apply sterile gloves. 7. Perform hand hygiene. 8. Withdraw catheter.
7, 2,6, 4, 5, 3, 1, 8
Which assessment questions should the nurse ask a preoperative patient preparing for surgery? (Select all that apply.) 1. "Are you experiencing any pain?" 2. "Do you exercise on a daily basis?" 3. "When do you regularly take your medications?" 4. "Do you have any medication allergies?" 5. "Do you use drugs and/or tobacco products?"
1. "Are you experiencing any pain?" 4. "Do you have any medication allergies?" 5. "Do you use drugs and/or tobacco products?"
When using ice massage for pain relief, which of the following is correct? (Select all that apply.) 1. Apply ice using firm pressure over the skin. 2. Apply ice for 5 minutes or until numbness occurs. 3. Apply ice no more than 3 times a day. 4. Limit application of ice to no longer than 10 minutes. 5. Use a slow, circular steady massage.
1. Apply ice using firm pressure over the skin. 2. Apply ice for 5 minutes or until numbness occurs. 5. Use a slow, circular steady massage.
A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when: A. you compare assessed pain w/baseline pain. B. body language is incongruent with reports of pain relief. C. family members report that pain has subsided. D. vital signs have returned to baseline.
A. you compare assessed pain w/baseline pain.
Nurses can implement a variety of independent nursing measures to promote sleep in the hospital. Which of the following measures are not appropriate? A.Administering a sedative. B.Giving a backrub. C.Turning off the television. D.Having a Quiet Time Policy on the unit to encourage rest for patients.
A.Administering a sedative.
Which of the following factors can affect the adult's ability to learn? (check all that apply) A.Health literacy B.Learning disabilities C.Physical capability D.Learning environment E.Developmental level
A.Health literacy B.Learning disabilities C.Physical capability D.Learning environment
The steps of the teaching process are similar to those of the communication process. Which of the following are part of the teaching process? (check all that apply) The steps of the teaching process are similar to those of the communication process. Which of the following are part of the teaching process? (check all that apply) A.Identify a need for information B.Establish learning objectives C.The nurse (the sender) learns the information D.The patient (the receiver) conveys the information E.Provide feedback and evaluate the success of the teaching plan
A.Identify a need for information B.Establish learning objectives E.Provide feedback and evaluate the success of the teaching plan
When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true? A. Chronic pain is psychological in nature. B. Patients are the best judges of their pain. C. Regular use of narcotic analgesics leads to drug addiction. D. Amount of pain is reflective of actual tissue damage.
B. Patients are the best judges of their pain.
A patient suffers from sleep pattern disturbance. To promote adequate sleep, the most important nursing intervention is: A. administering a sleep aid. B. synchronizing the medication, treatment, and vital signs schedule. C. encouraging the patient to exercise immediately before sleep. D. discussing with the patient the benefits of beginning a long-term nighttime medication regimen.
B. synchronizing the medication, treatment, and vital signs schedule.
Which of the following statements are true regarding the pain experience? A.Pain is objective. B.All people experience pain in the same way and should be treated the same when administering pain medications. C. Nurses are legally and ethically responsible for assessing and managing pain. D.Pain management should be provider centered, with nurses advocating for the provider in order to prevent substance abuse.
C. Nurses are legally and ethically responsible for assessing and managing pain.
Which physiologic factor can place an 83 year old client at risk for acute kidney injury? Decline in glomerular function Decreased abdominal muscle control Loss of urinary sphincter control Consumption of caffeine
Decline in glomerular function
Which body fluid lies in the spaces between the cells? Interstitial Intracellular Intravascular Transcellular
Interstitial
A pneumothorax is defined as: The presence of air in the pleural space which causes lung collapse The presence of blood and fluid in the thorax
The presence of air in the pleural space which causes lung collapse
The nurse understands that the following changes within the heart may be associated with age: (Select all that apply) (check all that apply) Valves become more thick Valves become less rigid Decreased elasticity of the aorta Increased exercise tolerance
Valves become more thick Decreased elasticity of the aorta
Which of the following vitamins are fat soluble? Vitamins A, D, E, and K Vitamins C and B6 Vitamins B12, D, and K Vitamins A, D, E, and C
Vitamins A, D, E, and K
A senior student nurse delegates the task of intake and output to a new nursing assistant. The student will verify that the nursing assistant understands the task of I&O when the nursing assistant states: a) "I will record the amount of all voided urine." b) "I will not count liquid stools as output." c) "I will not record a café mocha as intake." d) "I will notate perspiration and record it as a small or large amount."
a) "I will record the amount of all voided urine."
A nurse is caring for an elderly client who has nearly fallen twice while getting out of bed to go to the bathroom. The nurse has instructed the client not to get up without assistance. The client tells the nurse about feeling a need to get to the bathroom when the urge to void occurs and feeling a need to rush. Which strategy should the nurse utilize to minimize the client's risk of falling? a) Obtain an order for an indwelling catheter b) Require that a family member stay with the client c) Check on the client every 2 hours and offer toileting assistance d) Obtain an order for restraints to prevent injury
c) Check on the client every 2 hours and offer toileting assistance
A nurse is working with a client who experiences constipation. The nurse recognizes that additional education is needed when the client states the following: a) "I should plan for routine physical activity to help improve my bowel habits." b) "I plan to drink at least 1,500ml of fluids per day to help promote a regular bowel movement." c) "Fiber is a really important aspect of my diet that I should plan to incorporate more often." d) "I plan to take my stimulant laxative every day for at least the next 6 months to make sure it's working."
d) "I plan to take my stimulant laxative every day for at least the next 6 months to make sure it's working."
