NURA 303 Exam 2

A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply. A. A patient who has uncontrolled hypothyroidism. B. A patient with coronary artery disease. C. A patient who has GERD. D. A patient who is HIV positive. E. A patient who is taking corticosteroids for arthritis. F. A patient with a urinary tract infection.

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

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

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

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

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

A nurse is caring for an older adult who is having trouble getting to sleep at night and formulates the nursing diagnosis Disturbed sleep pattern: Initiation of sleep. Which nursing interventions would the nurse perform related to this diagnosis? Select all that apply. A. Arrange for assessment for depression and treatment. B. Discourage napping during the day. C. Decrease fluids during the evening. D. Administer diuretics in the morning. E. Encourage patient to engage in some type of physical activity. F. Assess medication for side effects of sleep pattern disturbances.

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

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

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

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

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

In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply. A. A patient diagnosed with rubella B. A patient diagnosed with diphtheria C. A patient diagnosed with varicella D. A patient diagnosed with tuberculosis E. A patient diagnosed with MRSA F. An infant diagnosed with adenovirus infection

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

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

a, b. Physiologic effects of stress include changes in appetite and elimination patterns as well as increased (not decreased) pulse and respirations. Using ineffective coping mechanisms, becoming withdrawn and isolated, and exhibiting attention-seeking behaviors are psychological effects of stress.

A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply. A. Providing a bed bath for a patient B. Visibly soiled hands after changing the bedding of a patient C. Removing gloves when patient care is completed D. Inserting a urinary catheter for a female patient E. Assisting with a surgical placement of a cardiac stent F. Removing old magazines from a patient's table

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

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

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

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

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

A nurse is providing range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? Select all that apply. A. Stop performing the exercises. B. Decrease the number of repetitions performed. C. Reevaluate the nursing care plan. D. Move to the patient's other side to perform exercises. E. Encourage the patient to finish the exercises and then rest. F. Assess the patient for other symptoms.

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

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

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

A nurse is monitoring patients in a hospital setting for acute and chronic pain. Which patients would most likely receive analgesics for chronic pain from the nurse? Select all that apply. A. A patient is receiving chemotherapy for bladder cancer B. An adolescent is admitted to the hospital for an appendectomy C. A patient is experiencing a ruptured aneurysm D. A patient who has fibromyalgia requests pain medication E. A patient has back pain related to an accident that occurred last year F. A patient is experiencing pain from second-degree burns

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

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

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

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

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

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

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

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

a. A patient with a damaged neurologic reflex arc would have a diminished pain reflex response, which would put the patient at risk for burns as the sensors in the skin would not detect the heat of the food or liquids. All patients should be provided adequate pain relief, but this is not the priority intervention in this patient. Monitoring for depression would be an intervention for this patient but is not related to the damaged neurologic reflex arc. A patient who is immobile should eat a balanced diet based on the Dietary Guidelines for Americans from the U.S. Department of Health and Human Services and U.S. Department of Agriculture.

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

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

A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? A. Dyspnea B. Hypotension C. Decreased respiratory rate D. Decreased pulse rate

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

A nurse is removing rigid gas-permeable (RGP) contact lenses from the eyes of a patient who is unable to assist with removal. The nurse notices that one of the lenses is not centered over the cornea. What would be the nurse's first action in this procedure? A. Apply gentle pressure on the lower eyelid to center the lens prior to removing it. B. Move the eyelids toward one another to cause the lens to slide out between the eyelids. C. Do not attempt to remove the lens as it should only be removed by an eyecare specialist. D. Have the patient look forward, retract the lower lid, and move the lens down on the sclera.

a. If the lens is not centered over the cornea, the nurse should apply gentle pressure on the lower eyelid to center the lens, gently pull the outer corner of the eye toward the ear, position the hand below the lens to receive it, and ask the patient to blink. Moving the eyelids toward one another to cause the lens to slide out between the eyelids is a later step in the procedure. Having the patient look forward, retracting the lower lid and moving the lens down on the sclera occurs during removal of soft contact lenses. It is not necessary to call in an eyecare specialist unless there is damage to the eye

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

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

A nurse observes involuntary muscle jerking in a sleeping patient. What would be the nurse's next action? A. No action is necessary as this is a normal finding during sleep. B. Call the primary care provider to report possible neurologic deficit. C. Lower the temperature in the patient's room. D. Awaken the patient as this is an indication of night terrors.

a. Involuntary muscle jerking occurs in stage I NREM sleep and is a normal finding. There are no further actions needed for this patient.

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

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

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

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

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

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

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

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

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

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

A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? A. Remove the catheter. B. Notify the primary care provider. C. Check that the airway is the appropriate size for the patient. D. Place the patient on his or her back.

a. When a patient vomits upon suctioning of an oropharyngeal airway, the nurse should remove the catheter; it has probably entered the esophagus inadvertently. If the patient needs to be suctioned again, the nurse should change the catheter, because it is probably contaminated. The nurse should also turn the patient to the side and elevate the head of the bed to prevent aspiration.

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

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

A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. Which steps in this procedure are performed correctly? Select all that apply. A. Removes all jewelry including a platinum wedding band B. Washes hands to 1 in above the wrists C. Uses approximately one teaspoon of liquid soap D. Keeps hands higher than elbows when placing under faucet E. Uses friction motion when washing for at least 20 seconds F. Rinses thoroughly with water flowing toward fingertips

b, c, e, f. Proper hand hygiene includes removing jewelry (with the exception of a plain wedding band), wetting the hands and wrist area with the hands lower than the elbows, using about one teaspoon of liquid soap, using friction motion for at least 20 seconds, washing to 1 in above the wrists with a friction motion for at least 20 seconds, and rinsing thoroughly with water flowing toward fingertips.

A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply. A. A patient who is taking iron supplements for anemia. B. A patient with Parkinson's disease who is taking dopamine. C. An older adult taking diuretics for congestive heart failure. D. A patient who is taking antibiotics for an ear infection. E. A patient who is prescribed antidepressants. F. A patient who is taking low-dose aspirin prophylactically.

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

A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply. A. Do full-body pushups in bed six to eight times daily. B. Breathe in and out smoothly during quadriceps drills. C. Place the bed in the lowest position or use a footstool for dangling. D. Dangle on the side of the bed for 30 to 60 minutes. E. Allow the nurse to bathe the patient completely to prevent fatigue. F. Perform quadriceps two to three times per hour, four to six times a day.

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

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

b, c, f. Margo McCaffery offers the classic definition of pain that is probably of greatest benefit to nurses and their patients, "Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does" (1968, p. 95). The International Association for the Study of Pain (IASP) further defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage (IASP, 2014b). Pain is an elusive and complex phenomenon, and despite its universality, its exact nature remains a mystery. Pain is present whenever a person says it is, even when no specific cause of the pain can be found. Pain may be classified according to its duration, its location or source, its mode of transmission, or its etiology.

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

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

The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply. A. A patient who is older than 50 B. A patient who has already fallen twice C. A patient who is taking antibiotics D. A patient who experiences postural hypotension E. A patient who is experiencing nausea from chemotherapy F. A 70-year-old patient who is transferred to long-term care

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

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

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

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

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

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

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

A nurse is interviewing a patient who just received a diagnosis of pancreatic cancer. The patient tells the nurse "I would never be the type to get cancer; this must be a mistake." Which defense mechanism is this patient demonstrating? A. Projection B. Denial C. Displacement D. Repression

b. Denial occurs when a person refuses to acknowledge the presence of a condition that is disturbing, in this case receiving a diagnosis of pancreatic cancer. Projection involves attributing thoughts or impulses to someone else. Displacement occurs when a person transfers an emotional reaction from one object or person to another object or person. Repression is used by a person to voluntarily exclude an anxiety-producing event from conscious awareness. In the case described in question 9, the patient is not blocking out the fact that the diagnosis was made, the patient is refusing to believe it.

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

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

A nurse on a maternity ward is teaching new mothers about the sleep patterns of infants and how to keep them safe during this stage. What comment from a parent alerts the nurse that further teaching is required? A. "I can expect my newborn to sleep an average of 16 to 24 hours a day." B. "If I see eye movements or groaning during my baby's sleep I will call the pediatrician." C. "I will place my infant on his back to sleep." D. "I will not place pillows or blankets in the crib to prevent suffocation."

b. Eye movements, groaning, grimacing, and moving are normal activities at this age and would not require a call to the pediatrician. Newborns sleep an average of 16 to 24 hours a day. Infants should be placed on their backs for the first year to prevent SIDS. Parents should be cautioned about placing pillows, crib bumpers, quilts, stuffed animals, and so on in the crib as it may pose a suffocation risk.

A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient's feet to prevent footdrop? A. Supination B. Dorsiflexion C. Hyperextension D. Abduction

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

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

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

A nurse teaches a patient at home to use clean technique when changing a wound dressing. What would be a consideration when preparing this teaching plan? A. It is the personal preference of the nurse whether or not to use clean technique B. The use of clean technique is safe for the home setting C. Surgical asepsis is the only safe method to use in a home setting D. It is grossly negligent to recommend clean technique for changing a wound dressing

b. In the home setting, where the patient's environment is more controlled, medical asepsis is usually recommended, with the exception of self-injection. This is the appropriate procedure for the home and is not a personal preference or a negligent action

A nurse is performing a sleep assessment on a patient being treated for a sleep disorder. During the assessment, the patient falls asleep in the middle of a conversation. The nurse would suspect which disorder? A. Circadian rhythm sleep-wake disorder B. Narcolepsy C. Enuresis D. Sleep apnea

b. Narcolepsy is an uncontrollable desire to sleep; the person may fall asleep in the middle of a conversation. Circadian rhythm sleep-wake disorders are characterized by a chronic or recurrent pattern of sleep-wake rhythm disruption primarily caused by an alteration in the internal circadian timing system or misalignment between the internal circadian rhythm and the sleep-wake schedule desired or required; a sleep-wake disturbance (e.g., insomnia or excessive sleepiness); and associated distress or impairment, lasting for a period of at least 3 months (except for jet lag disorder) (Sateia, 2014). Enuresis is urinating during sleep or bedwetting. Sleep apnea is a condition in which breathing ceases for a period of time between snoring.

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

b. No matter what the technique, relaxation involves rhythmic breathing, a slower (not a faster) pulse, reduced muscle tension, and an altered state of consciousness.

A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing method might the nurse use to measure the patient's oxygen saturation? A. Thoracentesis B. Pulse oximetry C. Diffusion capacity D. Maximal respiratory pressure

b. Pulse oximetry is used to obtain baseline information about the patient's oxygen saturation level and is also performed for patients with asthma. Diffusion capacity estimates the patient's ability to absorb alveolar gases and determines if a gas exchange problem exists. Maximal respiratory pressures help evaluate neuromuscular causes of respiratory dysfunction. Both tests are usually performed by a respiratory therapist. The physician or other advanced practice professional can perform a thoracentesis at the bedside with the nurse assisting, or in the radiology department.

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

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

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

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

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

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

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

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

A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess the mobility of a hospitalized patient. During the patient interview, the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index? A. 2 B. 4 C. 5 D. 6

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A nurse caring for patients in a hospital setting uses anticipatory guidance to prepare them for painful procedures. Which nursing intervention is an example of this type of stress management? A. The nurse teaches a patient rhythmic breathing to perform prior to the procedure. B. The nurse tells a patient to focus on a pleasant place, mentally place himself in it, and breathe slowly in and out. C. The nurse teaches a patient about the pain involved in the procedure and describes methods to cope with it. D. The nurse teaches a patient to create and focus on a mental image during the procedure in order to be less responsive to the pain.

c. Anticipatory guidance focuses on psychologically preparing a person for an unfamiliar or painful event. When the patient know what to expect—for example, when the nurse tells the patient about the pain he or she should expect to experience during a procedure, and describes related pain relief measures—the patient's anxiety is reduced. Rhythmic breathing is a relaxation technique, focusing on a pleasant place and breathing slowly in and out is a meditation technique, and focusing on a mental image to reduce responses to stimuli is a guided imagery technique.

While discussing home safety with the nurse, a patient admits that she always smokes a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for this patient? A. Impaired gas exchange related to cigarette smoking B. Anxiety related to inability to stop smoking C. Risk for suffocation related to unfamiliarity with fire prevention guidelines D. Deficient knowledge related to lack of follow-through of recommendation to stop smoking

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

A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? A. A postoperative adult B. An adult with COPD C. A teenager with cystic fibrosis D. A child with pneumonia

c. Chest physiotherapy may help loosen and mobilize secretions, increasing mucus clearance. This is especially helpful for patients with large amounts of secretions or an ineffective cough, such as patients with cystic fibrosis. Chest physiotherapy has limited evidence for its effectiveness and is not recommended for use in numerous patient populations, including children with pneumonia, adults with COPD, and postoperative adults (Andrews et al., 2013; Lisy, 2014; Strickland et al., 2013).

A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. For what recommended treatment might the nurse prepare this patient? A. The use of a central nervous system stimulant B. Continuous positive airway pressure machine (CPAP) C. Chronotherapy D. The application of heat or cold therapy to promote sleep

c. Chronotherapy requires a commitment on the part of the patient to act over a period of weeks to progressively advance or delay the time of sleep for 1 to 2 hours per day. Over time, this results in a shift of the sleep-wake cycle. The use of a central nervous system stimulant is recommended for narcolepsy. Continuous positive airway pressure machine (CPAP) is used for OSA, and the application of heat or cold therapy to the legs is used to treat RLS.

A nurse is caring for a patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? A. Dorsal recumbent position B. Lateral position C. Fowler's position D. Sims' position

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

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

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

A nurse is finished with patient care. How would the nurse remove PPE when leaving the room? A. Remove gown, goggles, mask, gloves, and exit the room B. Remove gloves, perform hand hygiene, then remove gown, mask, and goggles C. Untie gown waist strings, remove gloves, goggles, gown, mask; perform hand hygiene D. Remove goggles, mask, gloves, and gown, and perform hand hygiene

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

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

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

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

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

A nurse working the night shift in a pediatric unit observes a 10-year-old patient who is snoring and appears to have labored breathing during sleep. Upon reporting the findings to the primary care provider, what nursing action might the nurse expect to perform? A. Preparing the family for a diagnosis of insomnia and related treatments. B. Preparing the family for a diagnosis of narcolepsy and related treatments. C. Anticipating the scheduling of polysomnography to confirm OSA. D. No action would be taken, as this is a normal finding for hospitalized children.

c. OSA (pediatric) is defined by the presence of one of these findings: snoring, labored/obstructed breathing, enuresis, or daytime consequences (hyperactivity or other neurobehavioral problems, sleepiness, fatigue). According to the American Academy of Pediatrics children and adolescents with symptoms of OSA, including snoring, should have polysomnography to confirm the diagnosis. Although OSA may cause insomnia, this is not the primary diagnosis in this case. Narcolepsy is a condition characterized by excessive daytime sleepiness and frequent overwhelming urges to sleep or inadvertent daytime lapses into sleep. This scenario is not usually a normal finding in hospitalized children during sleep.

A nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure? A. Add bath oil to the water to prevent dry skin. B. Allow the patient to lock the door to guarantee privacy. C. Assist the patient in and out of the tub to prevent falling. D. Keep the water temperature very warm because older adults chill easily.

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

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

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

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

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

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

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

A nurse is assisting a patient with dementia with bathing. Which guideline is recommended in this procedure? A. Shift the focus of the interaction to the "process of bathing." B. Wash the face and hair at the beginning of the bath. C. Consider using music to soothe anxiety and agitation. D. Do not perform towel baths or alternate forms of bathing with which the patient is unfamiliar.

c. The nurse should consider the use of music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the "task of bathing" to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. The nurse should wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider other methods for bathing. Showers and tub baths are not the only options in bathing. Towel baths, washing under clothes, and bathing "body sections" one day at a time are other possible options.

A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? A. The nurse assures that the oxygen is flowing into the prongs. B. The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. C. The nurse encourages the patient to breathe through the nose with the mouth closed. D. The nurse adjusts the flow rate to 6 L/min or more.

c. The nurse should encourage the patient to breathe through the nose with the mouth closed. The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should adjust the fit of the cannula so it is snug but not tight against the skin. The nurse should adjust the flow rate as ordered.

A nurse is discussing with an older adult patient measures to take to induce sleep. What teaching point might the nurse include? A. Drinking a cup of regular tea at night induces sleep. B. Using alcohol moderately promotes a deep sleep. C. Having a small bedtime snack high in tryptophan and carbohydrates improves sleep. D. Exercising right before bedtime can hinder sleep.

c. The nurse would teach the patient that having a small bedtime snack high in tryptophan and carbohydrates improves sleep. Regular tea contains caffeine and increases alertness. Large quantities of alcohol limit REM and delta sleep. Physical activity within a 3-hour interval before normal bedtime can hinder sleep.

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

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

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

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

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

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

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

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

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

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

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

d. A person providing care at home for a family member for long periods of time often experiences caregiver burden, which may be manifested by chronic fatigue, sleep disorders, and an increased incidence of stress-related illnesses, such as hypertension and heart disease. The nurse should address the issue with the primary care provider and recommend a visit from a social worker or arrange for respite care for the family.

A nurse is filing a safety event report for a confused patient who fell when getting out of bed. What action is performed appropriately? A. The nurse includes suggestions on how to prevent the incident from recurring. B. The nurse provides minimal information about the incident. C. The nurse discusses the details with the patient before documenting them. D. The nurse records the circumstances and effect on the patient in the medical record.

d. A safety event report objectively describes the circumstances of the accident or incident. The report also details the patient's response and the examination and treatment of the patient after the incident. The nurse completes the event report immediately after the incident, and is responsible for recording the circumstances and the effect on the patient in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. Because laws vary in different states, nurses must know their own state law regarding safety event reports.

The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. Which action by the nurse is appropriate? A. Keep splashes on the sterile field to a minimum B. Cover the nose and mouth with gloved hands if a sneeze is imminent C. Use forceps soaked in a disinfectant D. Consider the outer 1 in of the sterile field as contaminated

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

Based on the statistics for the leading cause of hospital admission for trauma in older adults, what would be the nurse's priority intervention to prevent trauma when caring for older adults in a nursing home? A. Checking to make sure fire alarms are working properly. B. Preventing exposure to temperature extremes. C. Screening for partner or elder abuse. D. Making sure patient rooms are decluttered.

d. Falls among older adults are the most common cause of hospital admissions for trauma, therefore rooms should be free of clutter. Elder abuse, fires, and temperature extremes are also significant hazards for older adults but are not the most common cause of trauma admissions. IPV occurs more frequently in adults as opposed to older adults.

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

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

A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient? A. Assist with bathing and hygiene tasks even if the patient feels capable of performing them alone. B. Teach the patient not to talk about the procedure, just to perform it at the best of his or her ability. C. Teach the patient to take short shallow breaths when performing hygiene measures. D. Group personal care activities into smaller steps, allowing rest periods between activities.

d. For a patient who is too fatigued to complete daily hygiene on his or her own, the nurse should group personal care activities into smaller steps and allow rest periods between the activities. The nurse should assist with bathing and hygiene tasks as needed and only when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits, and teach the patient to coordinate diaphragmatic breathing with the activity.

A nurse is performing oral care on a patient who is in traction. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What should be the nurse's next action? A. Make a recommendation for the patient to see an oral surgeon. B. Report the condition to the primary care provider. C. Gently scrape the oral cavity with a tongue depressor. D. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa.

d. If the mouth is extremely dry with crusts that remain after oral care provided, the nurse should increase frequency of oral hygiene, apply mouth moisturizer to oral mucosa, and monitor fluid intake and output to ensure adequate intake of fluid. It is not necessary to report this condition prior to providing the interventions mentioned above. The crusts should not be scraped with a tongue depressor.

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

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

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

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

The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients? A. Only patients with diagnosed infections B. Only patients with visible blood, body fluids, or sweat C. Only patients with nonintact skin D. All patients receiving care in hospitals

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

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

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

A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. What risk factor would be a priority concern for the nurse when caring for this patient? A. Imbalanced nutrition B. Impaired physical mobility C. Chronic pain D. Infection

d. The priority risk factor in this situation is the possibility of an infection developing in the open skin area. The other risk factors may be potential problems for this patient and may also require nursing interventions after the first diagnosis is addressed.

A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient correctly tells the aide not to place the patient in which position? A. Side-lying B. Fowler's C. Sims' D. Prone

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

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

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

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

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

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

d. When a chest tube becomes separated from the drainage device, the nurse should submerge the end in water, creating a water seal, but allowing air to escape, until a new drainage unit can be attached. This is done instead of clamping to prevent another pneumothorax. Then the nurse should assess vital signs and notify the health care provider.

A patient has an eye infection with a moderate amount of discharge. Which action is an appropriate step for the nurse to perform when cleaning this patient's eyes? A. Use hydrogen peroxide on a clean washcloth to wipe the eyes. B. Wipe the eye from the outer canthus to the inner canthus. C. Position the patient on the opposite side of the eye to be cleansed. D. Cleanse the eye using a different section of the cleaning cloth for each stroke until clean.

d. When cleaning the eyes, the nurse should wear gloves during the cleaning procedure, use water or normal saline, and a clean washcloth or compress to clean the eyes. The nurse should dampen a cleaning cloth with the solution of choice and wipe once while moving from the inner canthus to the outer canthus of the eye. This technique minimizes the risk for forcing debris into the area drained by the nasolacrimal duct. The nurse should turn the cleaning cloth and use a different section for each stroke until the eye is clean.

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

d. When nosebleed (epistaxis) is noted with continued suctioning, the nurse should notify the health care provider and anticipate the need for a nasal trumpet. The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning.