NURX104 Essentials of Nursing Care: Health Safety

Pharmacology and Medication Administration An RN is preparing to administer gentamicin sulfate 50 mg IV. Gentamicin sulfate is available from the pharmacy in a prefilled syringe labeled 40 mg/2 mL. How many milliliters (mL) of the solution in the prefilled syringe should be administered to ensure the proper dosage is given to the patient? (Provide your answer to 1 decimal place in the input box below.)

(50mg x 2mL)/40mg = 2.5mL

Pharmacology and Medication Administration An RN is teaching a patient to self-administer 75 mg of amoxicillin (Amoxil) by mouth 3 times per day for an infection. The amoxicillin in available as an oral elixir, 125 mg/5 mL. How many milliliters (mL) should the RN tell the patient to draw into the oral syringe per dose? (Provide your answer rounded to the nearest whole number in the input box below.)

(75mg X 5mL)/125mg = 3mL

Therapeutic Communication, Stress and Adaptation, Patient Teaching Which term is used to describe an innate or habitual reaction to a specific problem or situation, such as increased anxiety? Coping mechanism Developmental crisis Environmental stressor Risk factor

*1) A coping mechanism is an innate or habitual reaction to a specific problem or situation. 2) A developmental crisis (stressor) is an occurrence at a predictable stage in an individual's life. 3) An environmental stressor originates outside the individual. 4) A risk factor is something that predisposes the individual to a specific problem.

Therapeutic Communication, Stress and Adaptation, Patient Teaching Which factors are considered when the RN is determining a patient's readiness to learn about disease preventions? (Select all that apply.) Physical readiness Cultural beliefs Patient's acceptance of existing illness The learning environment The patient who is future-oriented

*1) A patient who has needs, such as pain or lack of sleep, is not ready to learn. 2) Cultural components must be considered when formulating a teaching plan. 3) This is not pertinent to disease prevention. *4) The learning environment may have minimizing factors that interfere with the learning process. *5) A patient who is not future oriented will not likely appreciate preventive health teaching.

Pharmacology and Medication Administration The RN is preparing medication instructions for a patient who is being discharged from the hospital. Which information should be included in these instructions? (Select all that apply.) Advising the patient about expected therapeutic effect Advising the patient to utilize the generic version of their prescribed medication Advising the patient on possible side effects or signs of adverse reactions Advising the patient of nonpharmacologic measures to promote therapeutic response Advising the patient that the medication could be split to last longer, if there are concerns about cost

*1) Advising the patient about expected therapeutic effects would be an essential part of discharge education. 2) Advising the patient that they should use the generic version of their prescribed medication would not be applicable in discharge education. The patient may work with their pharmacist or ordering physician regarding how the drug is filled at the pharmacy. *3) Advising the patient on possible side effects or signs of adverse reactions would be an essential part of discharge education. *4) Advising the patient of nonpharmacologic measures to promote therapeutic response would be an essential part of discharge education. 5) Medications should not be split to last longer because they will not reach the therapeutic threshold.

Safe and Effective Care Environment Prior to discharge from acute care to home, a patient who is elderly is assessed by the discharging RN as being at high risk for falls. Which actions by the discharging RN will provide for continuity of care by the home health care service? (Select all that apply.) Communicating concerns directly to the home health care RN Obtaining orders for limited movement by the patient, from bed to chair only Reporting concerns to the health care provider and cancelling discharge orders Including the nursing diagnosis label of At Risk for Falls on discharge plan of care Indicating any physiologic changes on discharge plan of care

*1) Allows for continuity of care. 2) Limits movement unnecessarily. 3) This is not an indication for cancellation of discharge orders. *4) This provides information to the home health RN, which allows for continuity of care. *5) Many elders have intact senses but others have physiologic changes that need to be compensated for in the home health plan of care.

Nursing process, Documentation, Reporting Which nursing activity is an example of assessment? Monitoring the temperature of a patient who is febrile Determining when to administer a patient's as-needed medications Consulting with the dietitian about the diet of a patient with anorexia Caring for the equipment of a patient who is on continuous enteral feedings

*1) Assessment is gathering and organizing data in relation to the patient's health status. Continually updating data, as in checking temperature, is an example of assessment. 2) "Prn" was used to mean "as needed" once upon a time in the nursing profession. According to The Joint Commission, "prn" is no longer an acceptable abbreviation to use. Be that as it may, determining when to administer a patient's as-needed medications may be an appropriate activity in the planning phase of the nursing process, but is not an assessment activity. 3) This patient's diagnosis is already known, and the RN is bringing in another member of the health care team to plan and implement care. 4) This activity would occur during the implementation phase of the nursing process.

The Unlicensed Assistive Personal (UAP) reports that a patient has a temperature of 39.0C (100.5F). What is the RN's priority? A) Assess the patient for symptoms related to temperature. B) Administer medication to lower the patient's temperature. C) Write a nursing diagnostic statement based on the temperature. D) Set a goal to lower the patient's temperature.

*1) Assessment is the first step in the nursing process. Nursing diagnoses, outcomes and interventions are based on the assessment of the patient. 2) See 1). This is an intervention. 3) See 1). Diagnoses are selected based on an assessment. 4) See 1). Outcomes are identified after a nursing diagnosis is identified.

Health promotion, Assessment and Maintenance Which portion of a physical assessment can be delegated to nursing assistive personal (NAP)? Height and weight Skin condition Heart sounds Abdomen

*1) Assessment of the height and weight can be performed by the NAP. 2) Assessment of the skin condition must be done by the RN. 3) Assessment of the heart sounds must be done by the RN. 4) Assessment of the abdomen must be done by the RN.

Nursing process, Documentation, Reporting An RN is planning care rounds based on the information in a change-of-shift report. Given the nursing diagnosis labels below, which patient should the RN see first? Impaired Gas Exchange Activity Intolerance Risk for Falls Readiness for Enhanced Spirituality

*1) Based on Maslow's hierarchy of needs, this diagnosis indicates a physiological need, and is potentially life threatening. 2) Based on Maslow's hierarchy, this diagnosis is not life-threatening. 3) Based on Maslow's hierarchy of needs, actual physiological problems are a higher priority than risk/safety. 4) Based on Maslow's hierarchy of needs, the need for spiritual transcendence does not take priority over physiological needs.

Pharmacology and Medication Administration Which of the following aspects of the care process as it relates to medication management focus on the risk points of medication reconciliation? (Select all that apply.) Coordinating information during transitions in care both within and outside of the organization Patient education on safe medication use Verification of the correct dosage with the pharmacist Communication with other providers regarding the patient's medications Identifying the patient with at least 2 patient identifiers

*1) Coordinating information during transitions in care both within and outside of the organization is one of the National Patient Safety Goals ways to focus on risk points of medication reconciliation. *2) Patient education on safe medication use is one of the National Patient Safety Goals ways to focus on risk points of medication reconciliation. 3) Verification of the correct dosage with the pharmacist is a prudent action to be taken by the RN, but is not one of the National Patient Safety Goals ways to focus on risk points of medication reconciliation. *4) Communication with other providers regarding the patient's medications is one of the National Patient Safety Goals ways to focus on risk points of medication reconciliation. 5) Identifying the patient with at least 2 patient identifiers is important in medication administration, but it is not one of the risk points for medication reconciliation.

Therapeutic Communication, Stress and Adaptation, Patient Teaching Based on Dunn's illness-wellness continuum, when should the RN of instructing the patient about nonpharmaceutical approaches to pain relief? At any point along the continuum Early on in the continuum Late on in the continuum At the end of the continuum

*1) Dunn's continuum has a neutral point of "no discernible illness or wellness" as its center. The end points of the continuum are premature death and high-level wellness. It is appropriate to initiate treatment at any point along the continuum to move the patient toward a higher level of wellness. 2) See 1). 3) See 1). 4) See 1).

Nursing process, Documentation, Reporting A nursing assistive personnel (NAP) is assigned to care for a patient who had a mastectomy. The NAP provides good care, yet throughout the day, the patient appears to be withdrawn and more depressed than anticipated. Which action by the RN indicates effective evaluation of the plan of care? Reassign care to an RN who is experienced in caring for patients with Body Image Disturbance. Counsel the NAP on therapeutic communication and listening techniques. Address the perceived issues of Body Image Disturbance with the patient. Arrange a psychiatric consult with the patient and family during hospitalization.

*1) During the implementation phase of the nursing process, evaluation occurs which can involve changing the patient assignment to best address the patient's well-being. An experienced RN is reassigned to the patient's care to make additional assessments. 2) Counselling of the NAP is not warranted. The patient requires further assessment and intervention from an experienced caregiver. 3) The intervention assumes the patient is experiencing body image disturbance. The mastectomy patient needs further assessment by a qualified caregiver. 4) A psychiatric consult would not include the family without the patient's consent. Psychiatric care is often recommended after discharge.

To which nursing diagnosis statement should the RN give priority? 1) Ineffective Breathing pattern related to upper abdominal pain 2) Fatigue related to immobility 3) Imbalanced Nutrition: less than body requirements related to nausea 4) Deficient Fluid volume related to fever

*1) Effective breathing patterns are required to meet the most basic physiological need for air. Any problem that interferes with oxygenation can potentially cause death if not dealt with immediately. 2) Fatigue is associated with the need to rest, a physiological need that can be deferred without the same consequences as 1). 3) Imbalanced Nutrition: less body requirements is associated with the need for food, a physiological need that can be deferred without the same consequences as 1). 4) Deficient Fluid volume is associated with the need for fluid, a physiological need that can be deferred without the same consequences as 1).

Therapeutic Communication, Stress and Adaptation, Patient Teaching What does the appropriate use of empathy enable the RN to do? Understand the patient's thoughts and feelings while remaining objective. Identify and prioritize goals for the patient to ensure that the patient is being realistic. Accurately determine patient strengths and weaknesses for effective planning. Experience the same feelings as the patient for accurate problem identification.

*1) Empathy requires a delicate balance between emotion and intellect. The RN conveys an attitude of caring and attention while listening to the patient's thoughts and feelings, and uses the understanding gained to build an effective helping relationship. 2) Unless goals are identified and priorities are set in concert with the patient during a helping relationship, this approach does not acknowledge patient autonomy, and is not therapeutic. 3) This is an aspect of the analysis phase of the nursing process. It does not require the use of empathy. 4) It is neither realistic nor desirable to have the RN experience the same feelings as the patient.

Nursing process, Documentation, Reporting Posting pictures or descriptions of patient information on social media represents a significant risk to the RN because of which legal violation? Federal privacy laws Personal privacy laws Nursing ethics Standards of practice

*1) Federal privacy laws are violated under the Health Insurance Portability and Accountability Act. 2) See 1). 3) See 1). 4) See 1).

An RN is instructing a 10-year-old patient on the correct way to self-administer a medication, using a multi-dosed inhaler. Which part of the administration process is most important in delivering the medication deeply into the lung tissue? 1) Holding the breath for 10 seconds after inhaling the medication. 2) Inhaling deeply for 10 seconding prior to taking the medication. 3) Pausing the breath for 1 minute between doses of medication. 4) Recharging the canister between doses.

*1) Holding the breath for 10 seconds after pushing the discharge button actually allows the medication to be delivered deep into and taken up by the lung tissue. 2) Deep breathing gives the patient time to inhale first before holding the breath, and is important to do, but is not the actual mechanism whereby the medication is delivered deep into the lungs. It's the first part of the administration process, but not the most important. 3) Pausing at least 1 minute before administering a second dose is part of the technique, not part of the actual medication delivery. 4) Recharging the canister is used to administer second, third, etc. doses of the corticosteroid medication.

Safe and Effective Care Environment What is the purpose of a hydrocolloid dressing? To keep the wound bed moist to promote granulation To wick drainage away from the wound to prevent infection To remove necrotic tissue in the wound to help debridement To promote circulation to hasten tissue regeneration in the wound

*1) Hydrocolloid dressings have an inner absorbent layer that forms a moist gel over the wound and promotes granulation. 2) Hydrocolloid dressings absorb some drainage, but do not wick it away from the wound. They can actually facilitate the growth of some anaerobic bacteria. Dry or moist gauze is usually used to wick drainage. 3) Moist-to-dry gauze is most commonly used to remove necrotic tissue. 4) No dressing should interfere with circulation. Effective tissue regeneration is the goal of most dressing use, but it is not always desirable to have the regeneration happen quickly.

Health promotion, Assessment and Maintenance Which assessments would the RN need to address when evaluating the effectiveness of hypothermia interventions for a patient admitted with a tympanic temperature of 30°C (86°F)? Bradycardia and hypotension Disorientation to time and orientation to person Mild shivering and warm skin Body temperature of 35°C (95°F) and tachypnea

*1) Hypotension and bradycardia are signs of hypothermia. 2) Disorientation is a sign of hypothermia; however, patients are frequently disoriented to time but oriented to a person. 3) Severe shivering and cool skin are signs of hypothermia. 4) A body temperature of 35°C (95°F) and bradypnea are signs of hypothermia.

Nursing process, Documentation, Reporting During the implementation of a patient care plan, an RN needs to consider which of the following actions? (Select all that apply.) Directing care to other personnel Providing appropriate patient teaching as needed Providing direct patient care according to the plan Focusing on traditional health care practices Implementing the plan in a safe, timely fashion with the patient only

*1) Implementation of the care plan involves directing the care of other personnel. *2) Patient teaching is a component of care plan implementation. *3) The RN is responsible for direct care of the patient during implementation. 4) The RN incorporates traditional and complementary health practices as appropriate. 5) The RN partners with the family, significant others, and caregivers as well as with the patient.

Nursing process, Documentation, Reporting The RN should give priority to which nursing diagnosis statement? Ineffective Breathing Pattern related to upper abdominal pain Fatigue related to immobility Altered Nutrition: Less Than Body Requirements related to persistent nausea and vomiting Deficient Fluid Volume related to fever and diaphoresis

*1) Ineffective breathing pattern is a life-threatening situation that requires priority. Maslow's hierarchy of needs indicates that oxygenation is the most basic and immediate need for survival. 2) It would be important to address fatigue, but it is much lower in Maslow's hierarchy of needs. 3) Nutrition is an important basic need, but it is not as critical as oxygenation. 4) Although deficient fluid volume may be an urgent problem, a breathing impairment is more life threatening.

Nursing process, Documentation, Reporting What is a primary benefit of RNs using standardized language in electronic health record (EHR) documentation? It makes data retrieval more efficient. It reduces errors in health care documentation. It provides more consistent codes for billing. It ensures efficient care plan workflow.

*1) It is a uniform way to identify patient problems which makes data retrieval more efficient. 2) Standardized language does not reduce healthcare error. 3) Standardized language does not affect billing codes. 4) Although it is used for care planning it does not necessarily make the care plan process flow more efficiently.

Pharmacology and Medication Administration An RN has been assigned a 75-year-old female patient who has recently begun taking multiple over-the-counter (OTC) medications for hip pain. Which of the following questions should be asked of this patient about her OTC medications? (Select all that apply.) "How many OTC pain medications have you been taking and at how often?" "Who is paying for your OTC medication?" "How are these OTC medications helping you?" "Are you experiencing any side effects from the OTC medications?" "Is your health care provider aware of your use of OTC medications?"

*1) It is essential to know the dosage and frequency of the OTC medications your patient is taking. 2) It is not relevant to know who is paying for the medications at this time. *3) It is important to assess how the patient perceives the medication to be helping her. 4) This is subjective data required when assessing medications. *5) A provider needs to be aware of all the patients medications including OTC medications.

Safe and Effective Care Environment Which observation is most indicative of a systemic infection? Lymph nodes are enlarged and tender. The oral body temperature is 36.8°C (98.2°F). Function is lost in the affected area. The affected area is warm to the touch.

*1) Lymph nodes that drain the area of infection become enlarged and tender as the infection becomes systemic. 2) A fever is a sign of systemic infection. The temperature indicated here is nearly normal. 3) Loss of function in the affected area is typical of a localized infection. 4) Warmth in the affected area is typical of a localized infection.

Safe and Effective Care Environment An RN is collecting patient data during the assessment phase of the nursing process. Which of the data listed below are subjective in nature? (Select all that apply.) The patient states that they are allergic to phenytoin (Dilantin) and rash developed when they take it. The patient has a decreased phenytoin (Dilantin) level due to being on cimetidine (INN). The patient is unable to correctly measure their dosage of phenytoin (Dilantin). The patient's parent states a rash develops when the patient takes phenytoin (Dilantin). The patient states they have a pain level of 7 on the verbal pain scale of 0-10.

*1) Medication allergies and symptoms are described by and apparent to the patient which makes it subjective data. 2) Lab values are objective in nature as they are measured and detected by another person. 3) An RN is able to assess their patient and witness the inability for them to correctly measure their prescribed medication, thus making it objective data. *4) The patient's parent is describing the patient's reaction, which makes it subjective in nature. *5) The pain is experienced by the patient making it subjective in nature.

Pharmacology and Medication Administration In effort to eliminate medication errors, The Joint Commission's National Patient Safety Goals recommended that a minimum of 2 patient identifiers be used immediately prior to administering a medication. Which of the following identifiers are included in the recommendation? (Select all that apply.) The patient's name The patient's room and bed number The patient's identification number The patient's date of birth Another RN if the patient is confused

*1) Per The Joint Commission, before receiving medications, the patient must be identified using 2 forms of identification. These may include an individual's name, an assigned identification number, or date of birth. 2) See 1). *3) See 1). *4) See 1). 5) See 1).

Pharmacology and Medication Administration At which pharmacokinetic point does the highest serum concentration of medication occur? When absorption of the drug ceases Two (2) hours after administration of the drug When the serum half-life is reached When excretion of the drug begins

*1) Pharmacokinetics is the study of how medications enter the body, reach their site of action, are metabolized, and exit the body. The highest serum concentration (peak concentration) of the medication usually occurs just before the last of the medication is absorbed. 2) This statement does not address serum level. 3) Serum half-life refers to the time it takes for excretion processes to lower the serum medication's concentration by half. 4) When excretion of the drug begins, the serum concentration begins to fall.

Therapeutic Communication, Stress and Adaptation, Patient Teaching When teaching smoking cessation, exercise, and stress reduction classes, an RN is focusing on which level of illness prevention? Primary Secondary Tertiary Quartiary

*1) Primary prevention focuses on health promotion to encourage healthy lifestyles and prevent illness. 2) Secondary prevention focuses on early detection and prompt intervention. 3) Tertiary prevention focuses on restoration and rehabilitation to promote optimal functioning. 4) There is no type of illness prevention referred to as quartiary.

Which measures should be included in the plan of care to promote a patient's wound healing? (Select all that apply.) 1) Provide a diet high in protein and vitamin C. 2) Maintain the patient on bed rest. 3) Encourage the use of anti-inflammatory drugs. 4) Decrease pressure on the vulnerable area. 5) Encourage exercise within limitations.

*1) Proper nutrition is necessary for adequate tissue perfusion. A diet high in protein and vitamins A and C essential to healing. 2) Bed rest will decrease tissue perfusion, lead to a number of circulatory and respiratory complications. 3) Anti-inflammatory medications interfere with healing. *4) Pressure interferes with tissue perfusion. Good circulation is necessary to provide the wound with adequate oxygen and nutrients. *5) Regular exercise increases tissue perfusion, thus increasing the amount of oxygen and nutrients to the wound.

Safe and Effective Care Environment A patient's wound is draining purulent material. The RN should give priority to which action in controlling the spread of microorganisms? Place dressings in a biohazard bag for disposal. Irrigate the wound with saline. Administer the ordered antibiotic prior to the dressing procedure. Restrict visitors as long as the wound is draining.

*1) Purulent drainage indicates an infectious process. The RN should intervene to break the chain of infection by eradicating the reservoir (the dressing). Placing dressings in a biohazard bag for disposal eliminates the likelihood of transmission. 2) Irrigating the wound with saline is a treatment to cleanse the wound and eradicate the infection, but it does not play a role in preventing the spread of infection. 3) Administering antibiotics is a treatment to eradicate the infection, but it does not play a role in preventing the spread of infection. 4) Visitors are permitted when a patient has a draining wound. Covering the wound should minimize the spread of microorganisms. Visitors should be instructed to wash their hands when leaving the room.

Which patient behavior should alert the RN to the need for instruction related to safety hazards in the home? 1) Covers a tile floor with scatter rugs. 2) Has a step stool in the kitchen. 3) Stores cleaning solutions in the basement. 4) Uses a gas stove to cook meals.

*1) Scatter rugs may easily slip on tile floors, causing falls. 2) A step stool should be used to safely reach for something on a shelf. 3) Cleaning solutions should be properly labeled and stored away from the reach of young children, not from responsible adults. 4) A gas stove with a properly working pilot light does not pose a danger.

Health promotion, Assessment and Maintenance Which intervention observed by the RN while the nursing assistive personnel (NAP) obtains a blood pressure indicates the NAP needs further education? The NAP immediately inflates cuff to a higher level when the first sound is heard. The NAP places the cuff on bare skin 2 inches above the antecubital space. The NAP uses a pediatric cuff for an emaciated patient with very little muscle mass. The NAP takes the blood pressure from the left arm of a patient with a right-sided mastectomy.

*1) Stopping deflation and re-inflating the cuff too soon can lead to a muffling of the Korotkoff sounds and inaccurate results. 2) This is proper procedure. 3) This is proper procedure. 4) This is proper procedure.

Health promotion, Assessment and Maintenance When a BP measurement exceeds the specified expected finding for the patient, the nursing assistive personnel (NAP) needs to note which of the following in the documentation? (Select all that apply.) The arm from which the BP was obtained The patient's position during the measurement The patient's activity immediately preceding measurement The technique used to assess the BP The last time antihypertension medication was given

*1) The RN informs the NAP of the necessity to gather information associated with elevated BP reading. *2) See 1). *3) See 1). 4) The technique is not noted with the finding. 5) The UAP is not involved with medication administration.

Nursing process, Documentation, Reporting Which questions would an RN consider when evaluating a health education Web site? (Select all that apply.) Is there evidence of recent updating? Was the information written by an RN? Is there validity to current practice? Was the information peer reviewed? Who is the sponsor of the site?

*1) The Web site and its content should be current. 2) All information doesn't have to be written by an RN. *3) Information should be valid to current practice. 4) While peer review by an RN is important, additional peer review by health care practitioners is not required. *5) Sponsorship often provides verification about the authority of information provided.

What is the purpose of using the Z-track method for specific intramuscular medications? (Select all that apply.) 1) To minimize tissue irritation. 2) To reduce pain at the injection site. 3) To facilitate the action of the drug. 4) To control the rate of absorption. 5) To prevent seepage into the tissues.

*1) The Z-track method of administering intramuscular injections allows subcutaneous tissue to form a seal so that medication remains in the muscle and does not seep back into the subcutaneous tissue where is could cause irritation. 2) The method keeps the medications in the muscle so it does not reduce pain at the injection site. 3) The action of the drug is not affected by the administration method. 4) The rate of absorption is not affected by the administration method. *5) See 1).

Nursing process, Documentation, Reporting An RN is instructing a student on the process of developing a care plan for a patient. Which statement by the student indicates to the RN that further instruction is needed on writing outcomes based on ANA Standards of Nursing Practice? "I need to base outcomes on my patient's acuity level." "I should consider the patient's ethical, cultural, and spiritual values." "I should involve the patient, family, and health care providers." "I need to include a time estimate for attainment of expected outcomes."

*1) The answer is incorrect, since the patient's acuity is not related to goals developed is a care plan. 2) See 1). 3) See 1). 4) See 1).

Safe and Effective Care Environment Which type of knot should the RN use to tie a wrist restraint to the bed frame? Half-bow Surgeon's Clove hitch Granny

*1) The half-bow knot is quick-release and preferred because it does not tighten when pulled and unties easily when the loose end is pulled. 2) This is not a quick-release knot. 3) This is not a quick-release knot but it will not tighten when pulled on if it is placed on an extremity. With experience, this knot may be tied with one hand. It is used when a commercial restraint is not available and a modification is required. 4) This is not a quick-release knot and will easily come undone.

Safe and Effective Care Environment Which statements are true about the incubation stage of an infectious process? (Select all that apply.) The patient does not suspect they are infected in this stage. The person may be capable of infecting others in this stage. This stage can last from a day to years. This stage is marked by the appearance of symptoms. The immune system decreases the number of pathogens in this stage.

*1) The patient may not suspect they are infected. This means that they can infect others. This stage can be as short as a day (such as with influenza), or last year's (as with tuberculosis). *2) See 1). *3) See 1). 4) See 1). 5) See 1).

Safe and Effective Care Environment What is the primary reason why RNs must wash their own hands between caring for patients, and wear gloves when touching contaminated objects? To control direct contact, the most frequent mode of infection transmission To prevent the connection of all 6 links in the chain of infection To control the transmission of fomites through direct contact To control the entry of pathogens into the body through various portals

*1) These actions break the chain of infection by blocking the mode of transmission. 2) Not a reason for handwashing. 3) Fomites are objects of indirect contact transmission. 4) This is not a reason for precautionary techniques.

Nursing process, Documentation, Reporting An RN has completed documentation of a comprehensive nursing plan of care. This plan should include which of the following components? (Select all that apply.) Basic needs and activities of daily living (ADLs) Nursing diagnosis and collaborative problems Consents from patient for treatment for care Medical and multidisciplinary treatments Specific nursing interventions

*1) These are all components of a comprehensive care plan. Special discharge needs and/or teaching needs are also part of a care plan. *2) These are all components of a comprehensive care plan. Special discharge needs and/or teaching needs are also part of a care plan. 3) This is not part of a comprehensive nursing care plan. It is, however, part of overall documentation necessary for legal purposes. *4) These are components of a comprehensive care plan. Special discharge needs and/or teaching needs are also part of a care plan. 5) Specific nursing interventions are not part of a comprehensive nursing plan of care.

Pharmacology and Medication Administration An RN is teaching an older patient about adhering to a prescribed medication regimen. Which of the following statements would help the patient reach this goal? (Select all that apply.) "Can you tell me the names of your medications and why you are taking them?" "Do you think you will have any difficulty paying for your medications?" "If your spouse is taking the same medication as you, you can share it to keep costs down." "You can save unused prescribed medications so they can be used again if needed." "You should ask for non-childproof caps because of your difficulty in opening your medication containers."

*1) This allows the RN to assess what the patient knows about prescribed medications and to teach and/or correct information as needed. *2) This allows the RN to explore ways with the patient to afford the prescribed medications and recommend medication assistance programs if needed. 3) This may be a temptation for patients, but could cause significant problems. 4) This may also be a temptation because it feels wasteful to throw unused medications away, but this practice could cause significant problems. *5) Patients do not need to struggle with opening medication containers to access their medications. They may also not know that childproof caps can be requested. The RN will need to remind them of the safety needs of pets and children if this is done.

Health promotion, Assessment and Maintenance An RN is working with nursing assistive personnel (NAP). Which piece of patient information reported by the NAP would be a priority for the RN to validate? An irregular heart rate of 99 beats/minute A respiratory rate of 20 breaths/minute A headache reported 3 out of 10 on the verbal pain scale An axillary temperature of 36.0°C (96.9 °F)

*1) This finding requires the professional judgment of an RN to ensure accuracy and stability of the patient. 2) This is a normal finding, and is appropriate for NAP to collect. 3) This can be a normal finding for patients with chronic pain, and is appropriate for NAP to collect. 4) This is a normal finding, and is appropriate for NAP to collect.

An RN is examining a 35-year-old patient with a BMI of 29 and a below-average physical fitness level. The RN is working with the patient to reduce their BMI to 25. Which of the following is the best short term outcome for this patient? 1) The patient will ride a stationary bike for 15 minutes a day, by the end of 1 week. 2) The patient will understand how to achieve the short term outcome by the end of the visit. 3) The patient will tell the RN their plan about the achievement of the outcome by the end of the visit. 4) The patient will move all their joints through their ranges of motion by the end of the month.

*1) This is the best short term outcome for the patient to achieve the long term outcome. It is measurable, with a specific time frame. 2) Understanding must be verbalized or demonstrated in order to the measured. 3) The patient telling the RN the plan will not lead toward the long term outcome. 4) The patient moving the joints through their range of motion will assist but only indirectly contribute toward achieving the long term outcome.

Safe and Effective Care Environment A patient who is elderly was admitted from the ED with a nursing diagnosis label of Risk for Falls based on findings of the Morse Fall Scale. Which factor would require the RN to re-evaluate the patient's risk again, in 8 hours? Time of day the scale was first administered Patient's history of falls while at home Age of patient Patient's level of wellness

*1) This scale should be done every 8 hours, so the time it was first administered is very important. 2) This re-evaluation is not related to history of falls. 3) This re-evaluation is not related to age. 4) This rescheduling is not related to level of wellness.

Therapeutic Communication, Stress and Adaptation, Patient Teaching Which statement by the RN would best help a patient in the postoperative period cope with stress and anxiety and allow the patient a feeling of control over the hospital environment? "In which arm would you like the IV placed?" "You must cough and breathe deeply to avoid pneumonia." "Would you like to have this test done or not?" "I'll give you pain medication and then we'll see about having you get out of bed. Okay?"

*1) This statement allows the patient to make a genuine independent choice. 2) This statement may increase the patient's anxiety by suggesting the possibility of a complication if the patient doesn't cooperate. 3) The RN is not offering a genuine choice in this situation. 4) The RN is not offering a genuine choice in this situation. The patient is simply being asked to continue being dependent on the RN to make decisions.

Safe and Effective Care Environment A school RN plans a safety fair at a high school as part of a life style and risk assessment initiative. Which topics would be appropriate to include in the safety fair? (Select all that apply.) Use of bike helmets Use of seat belts Ways to improve mental health Proper physical fitness techniques Not using substances while driving

*1) Use of bike helmets, use of seat belts, and not using substances while driving are all appropriate topics for this safety fair. *2) See 1). 3) Improving mental health and physical fitness are outside the scope of a safety fair. 4) See 3). *5) See 1).

Safe and Effective Care Environment Why is the induction of vomiting contraindicated in cases of poisoning by household cleaners or furniture polish? Vomiting can cause esophagus damage. Vomiting can lead to gagging and retching. Vomiting can lower the pH of gastric secretions. Vomiting can cause fluid and electrolyte deficits.

*1) Vomiting should not be induced with any products like these that are caustic to the esophagus. 2) Inducing vomiting for any product would lead to retching and the danger of gagging. 3) Gastrointestinal pH is typically low, due to the presence of hydrochloric acid. 4) Prolonged vomiting could lead to fluid and electrolyte deficits, but this is not the reason that induced vomiting is contraindicated.

Pharmacology and Medication Administration The health care provider orders phenobarbital 1/4 grain twice a day, by mouth. The drug is supplied in 30 mg per tablet. What dose tablet should the RN administer? (Provide your answer to 1 decimal place in the input box below.)

1 grain = 60 mg, so each 30 mg tablet available is 1/2 grain. To administer 1/4 grain, the RN would administer 1/2 tablet, or 0.5 tablet.

Therapeutic Communication, Stress and Adaptation, Patient Teaching Which term is used to describe a physiological response that may induce illness over time? Coping mechanism Developmental crisis Environmental stressor Risk factor

1) A coping mechanism is an inborn or learned way of responding to a particular challenge or situation. 2) A developmental crisis is an event that is triggered by stressors related to growth and development, not environment. *3) An environmental stressor is a factor external to the individual that contributes to stress. Over time, exposure to stress may induce illness. 4) A risk factor is an existing physiological condition that makes an individual more vulnerable to illness.

Nursing process, Documentation, Reporting Which of the following are benefits of using electronic health records (EHR)? (Select all that apply.) Ability to generalize RN's notes Ease of documentation Accessibility to other disciplines Access to standardized decision trees to plan care Opportunity to copy and paste notes for quicker documentation

1) A loss of detail in RN's notes is a drawback to the EHR. *2) The EHR increases efficiency and ease of entry. *3) The EHR provides accessibility. *4) The EHR has standardized decision trees to plan care. 5) Copying and pasting notes may lead to a decrease in accuracy or specificity.

Health promotion, Assessment and Maintenance Which term describes a circumscribed elevation of the skin filled with serous fluid? Macule Nodule Pustule Vesicle

1) A macule is a flat area of color, such as a freckle. It is not filled with fluid, nor is it raised. 2) A nodule is a solid mass that extends into the dermis, such as a raised mole. It is not filled with clear fluid. 3) A pustule is an elevated, raised lesion that is filled with pus, such as the lesion that develops in acne. *4) A vesicle is a defined, raised area filled with clear fluid, such as a blister.

Safe and Effective Care Environment When a patient's wrist restraints are in place, the RN periodically removes the restraints and provides range-of-motion exercises to the affected limbs every 2 hours. What is the reason for this intervention? To provide sensory stimulation To encourage joint mobility To prevent skin breakdown To maintain muscle strength

1) A patient in restraints should be provided access to sensory stimulation, but this is not the rationale for performing range-of-motion exercises. *2) Restraints are designed to restrict movement. To prevent damage to the joints from prolonged inactivity, the restraints should be released and range-of-motion exercises provided at least every 2 to 4 hours. 3) Restraints should be applied in a way that protects the skin. They should not impede circulation or abrade the skin. Releasing the restraints and providing range-of-motion exercises will not prevent skin breakdown. 4) Active range of motion does maintain muscle strength, but passive range of motion does not. Both active and passive range of motion maintain joint flexibility. The situation described implies passive range of motion.

Therapeutic Communication, Stress and Adaptation, Patient Teaching A patient tells the RN, "I don't think I'm ever going to get well." Which response by the RN would be most therapeutic? "Why do you think you aren't going to get well?" "It sounds as if you're feeling hopeless." "Don't worry, you'll get better soon." "Have you talked to your doctor about this?"

1) A question that begins with "why" asks the patient to justify their behavior and is not therapeutic. *2) In this response, the RN reflects back the patient's feelings and helps the patient explore the feelings. Reflection is a therapeutic technique. 3) In this response, the RN provides false reassurance to the patient and does not help the patient express feelings. 4) This response will not help the patient focus on feelings.

Pharmacology and Medication Administration An RN is caring for a patient who is experiencing vomiting and diarrhea. Which diagnostic data would the RN review to identify risk for an adverse drug reaction? Liver function studies Serum creatinine level Serum sodium and calcium levels Serum cholesterol and lipoproteins

1) Abnormal liver function could result in impaired metabolism of the drug, which could potentiate an adverse reaction. However, vomiting and diarrhea would likely result in dehydration, which would not alter liver function. *2) The RN would check serum creatinine levels, which would likely be reduced due to vomiting and diarrhea. These conditions would lead to dehydration, which potentiates the risk for an adverse reaction. 3) Sodium levels may be altered with vomiting and diarrhea depending on the type of resulting dehydration. Calcium levels would not likely be altered. 4) Cholesterol and lipoproteins are not likely to be altered by vomiting and diarrhea.

Pharmacology and Medication Administration An RN is involved in a medication error that results in a patient receiving an incorrect dose of their prescribed medication. Despite this, no significant harm came to the patient. In following the QSEN safety competency guidelines, which actions should be taken by the RN manager in this situation? (Select all that apply.) Report the medication error to the State Board of Nursing. Set up a root cause analysis with the individuals involved. Begin the hospital's disciplinary process for the RN involved. Use the hospital's organizational error reporting system to report the medication error. Report the error to the hospital pharmacy.

1) According to the QSEN safety competency, reporting the medication error to the State Board of Nursing would not be applicable. *2) According to the QSEN safety competency, the manager should set up a root cause analysis with the individuals involved. 3) According to the QSEN safety competency, beginning the hospital's disciplinary process for the RN involved would not be applicable. *4) According to the QSEN safety competency, the manager should use the hospital's organizational error reporting system to report the medication error. 5) According to the QSEN safety competency, reporting the error to the pharmacy is not necessary.

Therapeutic Communication, Stress and Adaptation, Patient Teaching A patient asks the RN, "Do you think I should tell my spouse about my illness?" The RN responds, "You seem unsure about telling your spouse you are ill." Which communication technique is the RN using? Acknowledging Clarifying Focusing Restating

1) Acknowledging is a technique that simply identifies that communication has occurred; it is not a restatement of ideas. 2) Clarifying helps both participants identify differences in their frames of reference and gives them the opportunity to correct misperceptions. 3) The statement does not reflect focusing, which is a valuable technique for patients who are resistant or guarded. *4) The RN is restating to summarize the patient's message and convey it was received and understood.

Therapeutic Communication, Stress and Adaptation, Patient Teaching During a nurse-patient interaction, which is the most reliable indicator of the patient's true feelings? Activity level Cultural beliefs Nonverbal behavior Verbal statements

1) Activity level is an aspect of nonverbal communication. However, it is not a reliable indicator of feelings, because too many variables affect activity level. 2) Cultural beliefs may influence the patient's perception of feelings or the way feelings are expressed. However, cultural beliefs in themselves are not a reliable indicator of feelings, and to use them as such could lead to stereotyping. *3) Nonverbal behavior is the most valuable indicator of feelings, but still requires careful interpretation. The ability to interpret nonverbal behavior is an essential nursing skill. 4) Verbal statements may be reinforced or contradicted by nonverbal behaviors. Because nonverbal behavior is not under as conscious control by the patient, it is a more reliable indicator of true feelings than are verbal statements.

Pharmacology and Medication Administration Which is a potential result of administering an intramuscular (IM) injection to a child while the child is sleeping? Decreased trauma to the child Increased absorption of medication Interrupted sleep pattern Development of fear of going to sleep

1) Administering an IM injection while the child is asleep may increase, not decrease trauma to the child. 2) It is the method of administration and the viscosity of the solution, not the child's state of awakening, that determines absorption of IM medication. 3) Administering an IM injection may disrupt the child's sleep pattern, but the more serious result is development of a fear of sleeping. *4) Administering an IM injection while a child is sleeping will not decrease trauma; it may cause the child to develop a fear of going to sleep.

Safe and Effective Care Environment An RN is assessing the safety of several hospitalized patients. Which patient would be at greatest risk for injury? An 8-month-old infant in a crib A 2-year-old toddler in a crib A 40-year-old patient in a hospital bed without siderails A 70-year-old patient in a hospital bed with two siderails up

1) An 8-month-old infant is not yet able to climb, so is probably safe to be in a crib that complies with federal regulations. *2) A 2-year-old toddler is capable of climbing out of a crib. A low bed is more appropriate for this age group. 3) Without further information about the patient's condition, it is not possible to judge whether the lack of siderails poses a risk for injury. 4) A hospital bed with two siderails up provides the maximum protection against falling.

Pharmacology and Medication Administration Which specific action by an RN will most likely have the greatest impact on a patient's medication compliance? Offer a list of health related Web sites related to the patient's prescribed medication. Screen the patient for the medication's documented side effects. Provide education on the prescribed medication to the patient. Provide a thorough assessment of the patient prior to discharge.

1) An RN would first need to assess if their patient had Internet access prior to providing web addresses. 2) Screening for side effects is important, but it is unlikely to have an effect on how their patient would take their prescribed medication. *3) Providing education about the patient's prescribed medications is likely to have the greatest impact on their medication compliance. 4) Assessments are an essential function of an RN; however, an assessment is not going to affect the way that the patient takes their prescribed medication.

Health promotion, Assessment and Maintenance An RN administers an antipyretic medication to a patient who is febrile. Which observation indicates that this intervention has been effective? Increased urinary output Absence of watery diarrhea Temperature within normal range Elevated blood sugar level

1) An antipyretic is a medication to reduce fever. Urinary output is not an indicator of effectiveness for this medication. 2) An antipyretic is a medication to reduce fever. Absence of diarrhea is not an indicator of effectiveness for this medication. *3) An antipyretic is a medication to reduce fever. Temperature within normal range indicates effectiveness for this medication. 4) An antipyretic is a medication to reduce fever. Blood sugar level is not an indicator of effectiveness for this medication.

Safe and Effective Care Environment Which represents a potential hazard in a home with an infant? Display of plants in hanging baskets on a screened porch Using a highchair at the dining table Presence of school-age siblings who play with dolls or action figures Placing the infant on the back at nap time

1) An infant is not mobile enough to reach these plants. Access to the screened porch can be restricted to protect an older toddler, as well. 2) A properly designed highchair is not a safety hazard. *3) Dolls and action figures frequently have small parts that pose a choking hazard for infants and toddlers. School-age siblings may be careless and leave their toys within reach of the infant. 4) Placing the infant on the back is encouraged to avoid sudden infant death syndrome.

Nursing process, Documentation, Reporting According to the ANA Standards of Practice, in which phase of the nursing process does the RN determine patient-centered goals and the ways to achieve them? Analysis Assessment Evaluation Planning

1) Analysis is synthesizing data to identify the patient's actual or potential health problems (nursing diagnosis). 2) Assessment is gathering and organizing data in relation to the patient's health status. 3) Evaluation is assessing the patient's response to nursing care, including progress toward the expected outcome (patient-centered goal). *4) Planning is determining the expected outcomes (patient-centered goals) and formulating specific strategies to achieve the expected outcomes.

Health promotion, Assessment and Maintenance Which location is used to assess the apex of the heart? Second intercostal space at the right sternal border Second intercostal space at the left sternal border Fourth intercostal space at the left sternal border Fifth intercostal at the space mid-clavicular line

1) Aortic valve is assessed at the second intercostal space at the right sternal border. 2) Pulmonic valve is assessed at the second intercostal space at the left sternal border. 3) Tricuspid valve is assessed at the fourth intercostal space at the left sternal border. *4) The apex of the heart is assessed at the fifth intercostal space at the mid-clavicular line.

Nursing process, Documentation, Reporting The ANA Standards of Practice state that the evaluation phase of the nursing process involves which nursing activity? Asking patients for feedback about their hospital stay Determining achievement of expected outcomes Documenting care given to the patient Supervising NAP activities

1) Asking the patient for feedback is not an application of the nursing process. *2) Evaluation is assessing the patient's response to nursing care, including progress toward the expected outcome (patient-centered goal). 3) Documenting care is an ongoing task of the assessment phase of the nursing process. 4) Assigning and supervising patient care to other members of the health care team is part of the planning phase.

Nursing process, Documentation, Reporting According to ANA Standards of Care, specific outcomes, such as verbalizing understanding of desired effects of medications, are established in which step of the nursing process? Assessment Evaluation Implementation Planning

1) Assessment involves collecting data and determining patient teaching needs. 2) Evaluation involves evaluating the patient's knowledge in relation to the stated patient teaching goals and expected outcomes. 3) Implementation involves implementing the planned teaching activities. *4) Planning involves stating the expected outcomes of planned nursing interventions, such as patient teaching.

Nursing process, Documentation, Reporting According to the ANA Standards of Practice, documenting improvement of a patient's inflamed wound following the application of warm compresses is an example of which phase of the nursing process? Assessment Diagnosis Evaluation Implementation

1) Assessment is gathering and organizing data in relation to the patient's health status. 2) Diagnosis is synthesizing data to identify the patient's actual or potential health problems (nursing diagnosis). *3) Evaluation is assessing the patient's response to nursing care, including progress toward the expected outcome (patient-centered goal). 4) Implementation is initiating and completing nursing actions/interventions designed to move the patient toward the expected outcomes (patient-centered goals) related to health promotion, health maintenance, and health restoration.

Therapeutic Communication, Stress and Adaptation, Patient Teaching Which is the best way for the RN to physically show active listening during a conversation? Avoid eye contact. Sit beside the patient. Maintain an open posture. Sit up straight.

1) Avoiding eye contact is generally perceived as disinterest. There are cultures, however, that would view this behavior as a sign of respect and attention. 2) A nonthreatening physical environment would be one in which it is possible to avoid face-to-face positioning. Sitting beside the patient is nonthreatening, but does not indicate active listening. *3) Active listening helps strengthen the patient's ability to solve personal problems. 4) Sitting in a rigid fashion indicates disinterest or disapproval.

Safe and Effective Care Environment Which action by the RN is most important when donning personal protective equipment? Putting on a face mask before applying a gown Pulling the gloves over cuffs of the gown Washing hands before untying the waist ties of the gown Verifying the sterilization date of the gown

1) Both mask and gown are essential in contact precautions, but usually the gown goes on first. Also, specific additional measures should be taken regarding gloves and gown. *2) Gloves should always be pulled over the cuffs of the gown if a gown is being worn. Contact precautions require the wearing of a gown to prevent contact and transmission of infectious material, whereas standard precautions recommend the gown primarily to protect clothing. 3) Since any part of the gown may be contaminated, hands should be washed after removing the gown. 4) The date on which the gown was sterilized has no relevance to contact precautions.

Safe and Effective Care Environment Why is heat applied to an area of inflammation? To enhance the release of bradykinins for tissue repair To decrease pain by slowing nerve conduction To promote vasoconstriction and reduce swelling To promote vasodilation and increase cellular nutrition

1) Bradykinins activate pain sensation. They are not tissue repair agents. 2) Slowing nerve conduction is an effect of cold applications. 3) Heat applications cause vasodilation, not vasoconstriction. They may also cause some swelling. *4) Heat applications cause vasodilation, increase blood flow to the affected area, and thus enhance the availability of nutrition for the cells.

Therapeutic Communication, Stress and Adaptation, Patient Teaching What is the next step in the therapeutic nurse-patient relationship after goals and roles are clearly defined? Building trust Establishing rapport Developing contracts Evaluating goal achievement

1) Building trust is the earliest step in the orientation phase. 2) To establish trust, some communication must exist. Although it is part of the orientation phase, establishing rapport comes before defining goals and roles. *3) The contract contains place, time, date, and duration of meetings and is developed once the goals and roles are defined. 4) Evaluation of goal achievement is part of the termination phase.

Pharmacology and Medication Administration Which procedure should the RN follow when administering a medication by intravenous bolus? Calculate the rate of delivery in drops per minute. Dilute the medication with normal saline to prevent vessel injury. Draw back on the plunger of the syringe to aspirate for blood return. Flush the port with heparin before administering medication.

1) Calculating the rate of delivery in drops per minute is necessary when administering IV medications by piggyback, not with IV bolus. 2) Nothing should be added to the medication unless indicated in the manufacturer's directions. *3) Blood return usually indicates that the catheter is in the vein, confirming access to the IV route. 4) Saline is the preferred flush because saline eliminates concern about drug incompatibility and the effect on systemic circulation that exists with heparin flush.

Pharmacology and Medication Administration A 3-year-old child's grandparent is coming to visit a few weeks after the grandparent had a heart attack. The grandparent tells the child help is needed to take medication for the heart attack. The RN needs to suggest what types of precaution to the child's parent and the grandparent in this situation? Ensure that all medications have childproof caps in place and are easily identified. Place "danger" stickers on all pill bottles and keep the bottles out of sight. Place all pill bottles in the medicine cabinet above the toilet. Lock all childproof bottles in a difficult-to-reach place.

1) Childproof does not mean the caps cannot come off and they should not be trusted as a sole precautionary measure. Easy recognition is good to have for adults to avoid errors but this will mean nothing to a toddler. 2) A sticker alone will not stop the child from taking off the caps or from wanting to see what is inside the bottles. A toddler is not cognitively able to fully understand the concept of poison. Out of sight does not mean they will not find them. 3) Toddlers walk and have increasing dexterity to climb and could reach the cabinet and take off the caps. *4) Keeping medications of other poisonous substances locked, in an out of reach location, and with child proof caps significantly decreases the likelihood a toddler could access the medication.

Therapeutic Communication, Stress and Adaptation, Patient Teaching Which nursing action should occur during the termination phase of the nurse-patient relationship? Clarify the patient's role in the relationship. Discuss the confidential nature of the relationship. Examine the progress made toward the goals of the relationship. Refrain from discussing feelings associated with termination.

1) Clarifying the patient's role is done in the introductory phase. 2) Discussing confidentiality is done at the initiation of the relationship, not the conclusion. *3) In the termination phase, the RN and patient review the achievements the patient has made and the attainment of goals. 4) Part of the termination phase is a review of feelings that closure of the relationship brings up in the patient.

Safe and Effective Care Environment When assessing skin turgor, the RN should collect data related to which aspects of the patient's skin? Color and warmth Fullness and elasticity Rashes and scaling Itching and cracking

1) Color and warmth are related to circulation, not hydration. Turgor is related to hydration. *2) Skin turgor is the term for fullness and elasticity. It is determined by pinching and lifting the skin. Checking turgor is a means of checking hydration status. 3) Rashes and scaling are abnormal skin conditions. 4) Itching and cracking are abnormal skin conditions that may appear with dehydration.

Therapeutic Communication, Stress and Adaptation, Patient Teaching A patient who is facing major surgery repeatedly criticizes the way the bed is made up. Which defense mechanism is being used by this patient? Compensation Conversion Denial Displacement

1) Compensation involves the substitution of an activity for another activity that the person will not or cannot do. 2) Conversion is the transformation of a mental conflict into a physical symptom. 3) Denial is the blocking of a reality that is too painful or anxiety producing. *4) Displacement is the transferring of a feeling from the actual object. In this case, the patient is transferring their anxiety about surgery onto a less threatening object, the bed.

Which nursing intervention would the RN perform in the evaluation phase of the nursing process? 1) Demonstrate correct procedures for wound care. 2) Explain the preparation required prior to a diagnostic test. 3) Ask the patient to describe pain intensity following administration of an analgesic. 4) Discuss expected outcomes with the patient.

1) Demonstration represents an intervention in the implementation phase, rather than an assessment of the patient's response to nursing care. 2) Explanation represents an intervention in the implementation phase, rather than an assessment of the patient's response to nursing care. *3) Evaluation involves an assessment to determine if nursing intervention have been effective in helping patients to achieve the patient outcome/goal. 4) Discussions of expected outcomes would be part of the planning phase, after a diagnosis has been established.

Pharmacology and Medication Administration An RN teaches parents to administer ear drops to their 1-year-old child. In which direction should the parents pull the child's earlobe to properly insert these eardrops? Up and back Down and back Up and forward Down and forward

1) Ear drops are administered to an adult by pulling the pinna of the ear up and back. *2) Ear drops are administered to a child under 3 years of age by pulling the pinna of the ear down and back to straighten the ear canal. 3) Ear drops are not administered by pulling the pinna of the ear up and forward. 4) Ear drops are not administered by pulling the pinna of the ear down and forward.

Pharmacology and Medication Administration Which factor affects the distribution of medication in the body? Erythropoietin Plasma protein Serum protein analysis White blood cells

1) Erythropoietin, produced in the kidneys, stimulates production of red blood cells. Red blood cells (erythrocytes) are responsible for circulating oxygen throughout the body. They are not directly involved in distribution of medication. *2) Type and quantity of plasma protein affects the distribution of medication because some medications are bound by specific proteins, while others circulate unbound. 3) Serum (protein) analysis is used to assess availability of proteins involved in effective nutrition and in wound healing. Some of these proteins also affect the distribution of medication, but serum analysis is not primarily focused on medication action. 4) White blood cells are involved in the immune response that allows the body to fight infection and inflammation. They are not a significant factor in distribution of medication in the body.

Nursing process, Documentation, Reporting Which source would provide the RN with the most helpful information about a patient? Family member Patient records Handoff report Patient's physician

1) Family members may often supplement or verify information provided by the patient. 2) Patient records contain information that avoids repetitive questioning and provides comparative information, but they may not reflect the most current problems. *3) The handoff report will give current, ongoing information that will provide continuity in care. 4) The physician is a good source on the patient's present and past health practices, but is not the most helpful source.

Health promotion, Assessment and Maintenance When percussing over a patient's lung fields, the RN should expect to hear what sound as a normal finding? Flat Hyperresonant Resonant Tympanic

1) Flat sounds are heard over a tumor. 2) Hyperresonant sounds are heard with percussion over a hyperinflated lung (as in emphysema). *3) Resonance is heard with percussion over a normal lung. 4) A tympanic sound is heard over a gastric air bubble.

Health promotion, Assessment and Maintenance What sound would be heard when the RN percusses the space over a gastric air bubble? Flat Hyperresonant Resonant Tympanic

1) Flat sounds are heard over a tumor. 2) Hyperresonant sounds are heard with percussion over a hyperinflated lung, as is present in emphysema. 3) Resonance is heard with percussion over a normal lung. *4) Tympanic sound is heard over a gastric air bubble.

Therapeutic Communication, Stress and Adaptation, Patient Teaching What occurs during the working phase of a therapeutic relationship? The RN and the patient mutually set goals. The patient explores thoughts and feelings associated with problems. The patient and the RN form a contract outlining expectations of the relationship. The patient is informed that the relationship will end at a certain point.

1) Goals are mutually established in the introductory phase. *2) Problems are addressed in the working phase of the nurse-patient relationship. This includes exploration of thoughts, feelings, and actions. 3) The contract is formulated in the introductory phase. 4) The duration of the relationship and indications for termination are determined in the introductory phase.

Safe and Effective Care Environment Which patient is at greatest risk for infection? A middle-aged adult who had surgery 1 month earlier An older adult with a 10-year history of chronic disease A young adult who is an ovolactovegetarian An adolescent who is active in high school sports

1) Immediately after surgery, this person might be at risk for infection. One month later, the risk for infection is minimal. *2) Chronic disease lessens the body's defenses and increases susceptibility to infection. Advanced age also weakens immune responses, placing this person at greatest risk. 3) Nutritional status is a factor in infection risk. An ovolactovegetarian can have very good nutritional status, and this person's youth probably provides a strong, healthy immune response. 4) Adolescents are not at great risk for infection. This particular person's involvement in sports may pose a risk for injury.

Health promotion, Assessment and Maintenance A patient who exhibits poor skin turgor is showing signs of which problem? Impaired circulation Decreased oxygenation Poor nutrition Dehydration

1) Impaired circulation is identified by pallor or cyanosis and decreased capillary refill. 2) Decreased oxygenation is associated with cyanosis and decreased capillary refill. 3) Poor nutrition is associated with weight loss and impaired skin integrity. Thus, skin turgor may be affected, but poor nutrition is not the first problem to be considered when poor skin turgor is found. *4) Skin that stays tented or moves back slowly when pinched or lifted may indicate dehydration.

Health promotion, Assessment and Maintenance Which topic identified in Healthy People 2020 should form the basis for developing a health promotion activity in the community? Improved health for all people in the U.S. Access to comprehensive, quality health services Less sickness and hospital admissions A population that will be able to define health and wellness

1) Improved health for all people in the U.S., less sickness and hospital admissions may result from the improved access to healthcare but is not currently measured. *2) Healthy People 2020 is focused on providing access to comprehensive, quality health care. 3) Improved health for all people in the U.S., less sickness, and fewer hospital admissions may result from the improved access to health care but is not currently measured. 4) Ability of the population to define health and wellness is not a goal of Healthy People 2020.

Therapeutic Communication, Stress and Adaptation, Patient Teaching Which change is a physiological sign of stress? Pupils are constricted. Blood sugar drops. Oral secretions increase. Blood pressure is elevated.

1) In stress, the pupils dilate to increase visual perception. 2) In stress, blood sugar increases because glucocorticoids are being released. 3) In stress, the mouth is often dry. *4) In stress, the blood pressure increases.

Identification of expected outcomes is made during which step of the nursing process? 1) Diagnosis 2) Assessment 3) Evaluation 4) Planning

1) In the diagnosis step, data are analyzed and clustered to identify the diagnosis. 2) In the assessment step, data are collected, which help in identifying the diagnosis. 3) In the evaluation step, then outcome is measured. *4) Establishing an expected outcome/goal should be the first step in the planning phase so that nursing interventions to achieve the goal can be identified.

Health promotion, Assessment and Maintenance Which nursing diagnosis label is a priority for the patient who is experiencing dizziness caused by low blood pressure, light headedness, and fatigue upon standing from a seated position? Ineffective Tissue Perfusion Decreased Cardiac Output Risk for Falls Impaired Physical Mobility

1) Ineffective Tissue Perfusion is a decrease in blood to the periphery. 2) While this may be related to the symptoms it is not the priority diagnosis. *3) The patient is at a high risk for falling due to the dizziness and the diagnosis to Risk for Falls. 4) This diagnosis is used for patients with limitation in movement.

During a patient assessment, an RN observes that the patient tries to articulate words but the patient's speech is not intelligible. The patient appears to be very frustrated. Which nursing diagnosis is most appropriate for this patient? 1) Ineffective Health maintenence 2) Acute Confusion 3) Impaired verbal Communication 4) Ineffective Coping

1) Ineffective health maintenance is a state in which an individual is a risk for a disruption in health because of an unhealthy lifestyle of lack of information. The patient's symptoms do not support this diagnosis. 2) Acute Confusion is a state in which an individual experiences a disruption in cognition and comprehension. The patient's symptoms do not support this diagnosis. *3) Impaired verbal Communication is a state in which an individual experiences a decreased ability to speak, but can understand others. The patient's behavior and difficulty in verbalizing supports the diagnosis of impaired verbal communication. 4) Ineffective individual coping is a state in which an individual is unable to manage internal or environmental stressors. Although this patient is experiencing frustration, the diagnosis if Impaired Verbal Communication is more appropriate.

Health promotion, Assessment and Maintenance An RN is performing hourly assessments of a patient's fluid intake and output for 24 hours following surgery. Which type of assessment is the RN performing in this situation? Initial Ongoing Emergency Comprehensive

1) Initial assessment happens just once. This RN is doing hourly assessments postoperatively. *2) Ongoing or problem-focused assessment happens repeatedly, to determine the current status of a specific problem and to identify new or overlooked problems. 3) Emergency assessment focuses on life-threatening problems during a crisis. 4) Time-lapsed assessment (reassessment) compares the patient's current status to baseline data obtained earlier on, in the initial assessment.

Nursing process, Documentation, Reporting An RN is comparing the functional health patterns of a patient in rehab with baseline data in the patient's file, using a specifically designed format. Which type of assessment is the RN performing? Initial Ongoing Emergency Special needs

1) Initial assessment is performed at the very beginning of the nursing process, e.g., upon a patient's admission to a health-care facility. 2) Ongoing assessment tracks the status of a problem identified during the initial assessment by reassessing periodically during care. Ongoing assessment may also identify new problems not seen in the initial assessment. 3) Emergency assessment occurs in a crisis situation and is focused on identifying life-threatening problems. *4) Special needs assessments compare a particular area of patient functioning and often uses a specifically designed format.

Pharmacology and Medication Administration An RN has assessed a patient who is not taking an oral medication as prescribed and begins patient teaching about the importance of consistent self-administration of the medication. Which data from the RN's assessment identify potential causes of the patient's nursing diagnosis label of Noncompliance? (Select all that apply.) Time constraints Financial constraints Independent living situation Difficulty in swallowing and a sense of choking Patient questioning the benefits of taking the medication

1) It is not likely that the patient has too little time to take an oral medication. *2) Limited finances may put the patient is a situation that difficult decisions need to be made in order to pay for the medication. This may lead to a patient omitting doses or reducing the amount taken. 3) An independent living arrangement is not a direct factor in the patient's noncompliance. *4) If the size of the pill is unpleasant and creates a sense of discomfort or choking, the patient may omit taking the medication. *5) If the patient does not perceive the benefit of taking the medication, the patient may be less likely to participate in the treatment plan and take the medication as prescribed.

Safe and Effective Care Environment An RN manager of a surgical unit observes a physical therapist leaving a patient's room without performing hand hygiene. The RN manager forms a multidisciplinary team to improve compliance. Which activity related to hand hygiene would the team be responsible for carrying out? Ensuring that all personnel wash hands when appropriate Disciplining staff members who do not comply with the handwashing policy Observing and report the practice of hand washing Changing the policy so that the handwashing guidelines are not as strict

1) It is the RN manager that should ensure the policy is followed. 2) It is the RN manager's responsibility to discipline staff. *3) The team is responsible for monitoring and reporting the incidence of hand washing on the unit. 4) Evidenced-based practice identifies hand washing as the single most effective way to prevent infection and the policy should not be altered.

An RN is assessing a newly admitted patient about the patient's usual stress-management techniques. What is the rationale for seeking this information? 1) To provide the patient with a stress free-free environment. 2) To understand how the patient is likely to deal with stress in the hospital. 3) To help the patient develop new coping mechanisms. 4) To determine whether the patient should have a private room.

1) It is unrealistic to try to eliminate all stress. Stress can be positive and can provide a stimulus for change. *2) Knowing the patient's previous experience with stress can be useful in predicting how the patient will react to stress in the hospital. This information will assist the RN in implementing a plan of care to help reduce the patient's stress. 3) The patient does not necessarily need to develop new coping mechanisms. 4) A private room may be impractical and is not the most effective method of stress reduction.

Which patient response indicates the teaching the RN conducted about the anticipated effect of the application of cold to an area was effective? 1) "I can expect to have more discomfort in the area where the cold is applied." 2) "I should expect more drainage from the incision after the ice has been in place." 3) "I should see less swelling and redness with the cold treatment." 4) "My incision may bleed more when the ice is first applied."

1) Local application of cold constricts peripheral blood vessels and this promotes comfort. 2) Cold reduces blood flow to tissues, resulting in decreased drainage from the wound. *3) Cold reduces swelling and redness by constricting peripheral blood vessels. 4) See 1).

Health promotion, Assessment and Maintenance An RN inspects a patient's skin and notes clusters of round, elevated lesions filled with clear fluid on the right side of the trunk. These are most likely which type of lesion? Macules Nodules Vesicles Wheals

1) Macules are flat and colored. They do not contain fluid. 2) Nodules are elevated and hard. They do not contain fluid. *3) Vesicles are small, round or oval masses filled with clear fluid or blood. 4) Wheals are irregular-shaped, reddened patches of edema.

Safe and Effective Care Environment Which nursing action is essential to promote healing for a patient with a nursing diagnosis statement of Impaired Skin Integrity related to pressure? Massage over and around the impaired skin. Apply continuous normal saline dressings. Suggest high-protein foods in the diet. Routinely inspect the skin over the bony prominences.

1) Massaging over the impaired skin may further damage injured tissue. 2) Continuous normal saline dressings may be used to clean an open area on the skin, but there is no indication that an open area exists. *3) Protein in the diet is essential for rebuilding cells in impaired or damaged skin. 4) Routine inspection of the skin is necessary to detect skin breakdown, but it does not promote healing.

Therapeutic Communication, Stress and Adaptation, Patient Teaching Which action should the RN take when a patient asks for an opinion about life events and choices? Offer the patient an honest, sincere opinion. Decline to discuss these choices with the patient. Suggest the name of an expert whom the patient can contact. Be supportive and listen while the patient makes the decision.

1) Offering advice or giving an opinion is nontherapeutic. The RN should assist the patient to identify and weigh options so that the patient can make a decision. 2) Declining to discuss choices with the patient is nontherapeutic, as it may close communication between the RN and patient. 3) The RN should first hear the patient's concerns and feelings. Offering referrals before this is done is nontherapeutic. *4) The RN supports decision making by guiding the problem-solving process with the patient.

Health promotion, Assessment and Maintenance Which technique is used by the RN to assess the carotid arteries during a comprehensive physical examination? Palpate both arteries simultaneously. Massage the artery before assessing. Apply deep pressure on the artery. Palpate the carotid artery very lightly.

1) Palpating both sides at the same time may impair cerebral blood flow. 2) Massaging the artery before assessing may drop the patient's pulse rate. 3) Applying deep pressure on the artery may impair cerebral blood flow. *4) Palpating the carotid very lightly when it is necessary to assess the carotid artery.

Safe and Effective Care Environment An RN is reviewing handwashing techniques with family members of a patient who was hospitalized with a severe infection. An RN is teaching this patient and family because handwashing has the greatest impact on which link in the chain of infection? Portal of entry Susceptible host Reservoir Mode of transmission

1) Pathogens enter the body's normal body openings such as the mouth and nose, and through abnormal openings such as cuts, scrapes, and surgical incisions. 2) A susceptible host is a person who is at risk for infection because of inadequate defenses against the invading pathogen. 3) A reservoir is a source of infection. or a place where pathogens survive and multiply. *4) Contact, either direct or indirect, is the most frequent mode of transmission. Handwashing decreases transmission risk. Hand hygiene is the single most important activity for preventing and controlling infection.

Safe and Effective Care Environment Which action is most essential in preventing the spread of communicable diseases in a preschool program? Teach the children how to wash their hands. Provide nutritious, well-balanced meals. Ensure that immunizations are current. Wash toys in hot, soapy water.

1) Preschoolers should be learning simple hygiene measures such as handwashing, but this practice alone will not effectively protect children against the spread of communicable diseases. 2) Good nutrition is essential to the preschooler's growth and development, but does not directly prevent communicable disease. *3) Preschoolers are especially prone to communicable diseases, as they interact with large numbers of playmates. Immunization is the most effective way to limit the spread of communicable diseases in this age group. 4) Washing toys, like washing hands, is a good hygiene practice. However, it is unlikely to have a measurable effect on the spread of communicable disease.

Safe and Effective Care Environment Which age-related change in the nervous system should the RN consider when designing a safe environment for an older adult? Episodes of confusion Presbycusis Presbyopia Slowed reaction time

1) Relatively few older adults have episodes of confusion, so this is not a primary consideration in designing a safe environment. 2) Presbycusis (age-related hearing loss) may be a result of nerve damage or physical changes to the structures of the ears. It is fairly common, but is not a primary consideration in designing a safe environment. 3) Presbyopia (age-related changes in vision) is the result of physical changes in the structures of the eyes, not a nervous system problem. It is fairly common, but is not a primary consideration in designing a safe environment. *4) Slowed reaction time places the older adult at risk from falls, accidents, and other situations requiring quick response. This is a primary consideration in designing a safe environment for an older adult.

Therapeutic Communication, Stress and Adaptation, Patient Teaching Which behavior is an example of a maladaptive response to stress? Taking frequent rest periods Making repeated requests for information Frequently giving the details of the situation Smoking excessively

1) Rest is a constructive way of restoring energy and resuming optimal function to cope more effectively with stress. 2) Incomplete or inaccurate information may contribute to stress due to fear of the unknown. Information can allay anxiety, decrease stress, and assist in problem solving. 3) Sharing experiences and expressing feelings helps to minimize anxiety by providing for an opportunity for others to validate and give feedback and support. *4) Smoking is a self-injurious behavior that does not allow for or promote problem solving in a stressful situation.

Pharmacology and Medication Administration Erythromycin 0.5 gm by mouth every 6 hours is ordered for a patient. The drug is labeled 250 mg per tablet. What is the correct dose for the patient? 1 tablet 2 tablets 3 tablets 4 tablets

1) See 2). *2) One gram = 1,000 mg. Therefore the requested 0.5 dose of erythromycin is 500 mg. Each tablet has 250 mg, so 2 tablets are required for a 500 mg dose. 3) See 2). 4) See 2).

Health promotion, Assessment and Maintenance A patient has lived with a chronic illness for more than 20 years and is experiencing long term complications requiring repeated hospitalization and continued readjustment of the medical regimen. The patient lives with an adult child's family, has numerous friends, and adequate financial resources. During a health assessment, how would the RN categorize this patient, according to Dunn's health grid? Poor health in an unfavorable environment Poor health in a favorable environment Moderate level wellness in an unfavorable environment Moderate level wellness in a favorable environment

1) See 2). *2) Patient is experiencing poor health but the environment is favorable. 3) See 2). 4) See 2).

Pharmacology and Medication Administration An order reads: 1,000 mL lactated Ringer's solution to be administered over 6 hours. The drop factor is 10 gtt/mL. The RN should regulate the flow rate at how many gtt/min to correctly follow the order? 17 28 32 36

1) See 2). *2) Use the formula (total infusion volume × drop factor)/(total time of infusion in minutes). Six hours = 360 minutes. (1000 × 10)/360 = 27.7, which rounds to 28 gtt/min. 3) See 2). 4) See 2).

Health promotion, Assessment and Maintenance Which assessment data needs to be validated by an RN? The patient says, "I do not have any religious practices." The patient says, "I follow a diet low in cholesterol." The patient's BP is 140/76 at 10:00 hours; it was 128/84 at 08:00 hours. The patient's chart indicates weight gain of 7 lb.

1) See 2). *2) Validating data helps to ensure that they are accurate, complete and factual and that one has not jumped to conclusions. 3) See 2). 4) See 2).

Nursing process, Documentation, Reporting In which phase of the nursing process would the RN refer a patient to a community support group? Assessment Evaluation Implementation Planning

1) See 3). 2) See 3). *3) The RN identifies patient needs and secures the appropriate services to address those needs across the continuum in the implementation phase of the nursing process. 4) See 3).

Therapeutic Communication, Stress and Adaptation, Patient Teaching Which response by the RN would block therapeutic communication? "How are you doing on your medication?" "I understand you're having second thoughts about the surgery." "Most people don't feel the same as you do." "I'm trying to understand your point of view."

1) See 3). 2) See 3). *3) The RN should use caution when expressing approval or disapproval. It puts the RN in the role of judge, which blocks therapeutic communication. 4) See 3).

Nursing process, Documentation, Reporting At a unit meeting, an RN manager informs the staff the unit is over budget by 12%. An RN proposes oral reporting be modified so the RNs can end their shifts on time. How should the manager evaluate the effectiveness of this measure? Observe the end of shift report to see if the time is shorter. Monitor that the RNs are completing their shifts on time. Review the unit budget in 3 months to see if a difference has occurred. Monitor for a shortening of patient stays on the unit.

1) See 3). 2) See 3). *3) The budget overage is why the initiative was taken on and it is what should be measured. 4) See 3).

Health promotion, Assessment and Maintenance When performing a physical examination of a patient's abdomen, which action should the RN perform first? Percussion Palpation Auscultation Observation

1) See 4). 2) See 4). 3) See 4). *4) Observation (inspection) is always the first step in a physical examination. For the abdomen, auscultation should come second, because doing percussion and/or palpation may stimulate the bowel and produce false results.

Safe and Effective Care Environment Which patient is at greatest risk for a health care acquired infection? A patient who has been on a clear liquid diet An adult patient who has a 2 day old surgical incision A patient who is experiencing diarrhea A patient who is elderly and receiving intravenous fluids

1) See 4). 2) See 4). 3) See 4). *4) The patient who is elderly and has breaks in the first line of defense (the skin) is at greatest risk for susceptibility to infection.

Nursing process, Documentation, Reporting An RN should be aware that which person is most likely to breach the confidentiality of the electronic health record (EHR)? A family member interested in the patient's condition A friend wanting news of the patient's condition Dietary staff serving patient meal trays A medical professional not assigned to the patient's care

1) See 4). 2) See 4). 3) See 4). *4) The staff that is not assigned to the patient's care is the most likely to access a patient's health information, constituting a breach of confidentiality.

Which sensory deficit in an older adult should alert the RN to the need for instruction regarding self-administration of medications? 1) Hearing 2) Taste 3) Touch 4) Vision

1) See 4). 2) See 4). 3) See 4). *4) Vision is the most sense for safe administration of medication. Loss of visual acuity may make it difficult for the older adult to read the drug name and instructions on the prescription label so that the risk for errors is increased.

Therapeutic Communication, Stress and Adaptation, Patient Teaching Which is an appropriate nursing diagnosis label for a patient who has experienced prolonged stress? Sensory Overload Impaired Memory Increased Intracranial Pressure Increased Sensory Perception

1) Sensory overload is itself a stressor, not a nursing diagnosis label. *2) A person under prolonged stress becomes unable to concentrate or focus. Impaired memory is an appropriate diagnosis. 3) This is not a nursing diagnosis. 4) This is not a nursing diagnosis.

Health promotion, Assessment and Maintenance Which would be the first step an RN uses in implementing a health promotion process? Structure the support system needed. Develop a behavioral change plan. Review and summarize assessment data. Identify health goals.

1) Structure the support system is the last step. 2) Develop a behavioral change plan is the third step. *3) Review and summarize assessment data is the first step. 4) Identify health goals is the second step.

Safe and Effective Care Environment Which finding would indicate to an RN that a patient is susceptible to infection? Increased RBCs Increased lymphocytes Decreased WBCs Decreased platelets

1) The RBC or erythrocyte count determines the number of red blood cells present. Increased RBCs may indicate dehydration. 2) Lymphocytes are a type of leukocyte formed by lymphoid tissue. A decreased number may indicate protein depletion. *3) The WBC count determines the number of white blood cells or leukocytes present. Leukocytes play a primary role in the inflammatory response. A decreased leukocyte count can increase the potential for infection. 4) Platelets play a role in blood clotting.

Pharmacology and Medication Administration An RN delegates the application of an over-the-counter topical lotion to nursing assistive personnel (NAP). The RN is still solely responsible for what aspect of this patient's care? Checking the expiration date of medication Documenting that the medication was applied Supervising and evaluating technique Ordering and documenting a replacement medication

1) The RN and the UAP can check an expiration date. 2) Both RN and the UAP can document in the patient's record. *3) Only the RN can supervise and evaluate technique of unlicensed personnel. 4) Ordering and documenting replacements cannot be performed by unlicensed personnel.

Health promotion, Assessment and Maintenance During an RN's assessment of a patient's cardiovascular status, the patient reports experiencing a racing heart. The pulse oximeter reads the heart rate as slow, at a rate of 50 beats per minute. What is the priority nursing action? Document the heart rate of 50 in the patient's medical record. Ask a second RN to verify the patient's heart rate. Wait a few minutes, then recheck the patient's heart rate. Reassess the patient's heart rate manually with a stethoscope.

1) The RN needs to validate the data, as a discrepancy is present. Therefore, the RN needs to determine what the accurate heart rate is prior to documenting, through manual assessment with the sphygmomanometer and stethoscope. 2) The RN needs to be competent on determining what a patient's heart rate is. Therefore, this is not the best option to select first. 3) The patient's situation does not imply that the patient has recently been involved in any activity that would be contributing to the data discrepancy. Therefore, waiting additional time is unlikely to produce a more accurate assessment. *4) The most accurate way to assess a patient's heart rate is to auscultate for one full minute. Due to the discrepancy in data, this would be the priority action of the RN to determine an accurate heart rate.

Health promotion, Assessment and Maintenance On a day when the temperature outside is 32.2°C (90°F) and the humidity is 86%, an RN notices an 80-year-old patient sitting on the grass in the sun. The patient is unable to state her name. Which action should the RN take first? Call an ambulance. Assist the patient to a shady area. Cover the patient with a blanket. Encourage cold liquids.

1) The RN should call an ambulance after getting the patient away from the source of danger. *2) This action will remove the patient from the source of danger and is the most appropriate first action. 3) This action will increase the patient's heat prostration. 4) This action should be considered after removing the patient from the source of the problem. Sips of cool liquids are recommended if the patient is conscious and capable of swallowing.

Pharmacology and Medication Administration According to the QSEN competencies, which action would the RN take when the patient says, "My antibiotic is usually a yellow capsule. Why has it been changed?" Check the medication against the patient's medication record. Explain that the pharmacy may substitute generic drugs. Reassure the patient that it is the same medication. Check the health care provider's written order on the patient's chart.

1) The RN should have already checked the medication record three times while preparing the medication. 2) If the patient believes that the medication may be wrong, the RN should further investigate to be certain the medication is correct. 3) If the patient believes that the medication may be wrong, the RN should further investigate to be certain the medication is correct. *4) The RN must first verify with the health care provider's order that the medication is the prescribed medication. QSEN states the RN must recognize the patient is the source of control and full partner in care.

Safe and Effective Care Environment Which data supports the nursing diagnosis label of Impaired Skin Integrity? Inflammation over a bony prominence Sacral wound with exposed bone Excoriation under the breasts Edema over the coccyx

1) The RN should monitor an inflamed area, but inflammation over a bony prominence does not meet the criteria for a nursing diagnosis label of Impaired Skin Integrity. 2) A sacral wound with exposed bone would be a stage IV pressure ulcer and the nursing diagnosis label would be Impaired Tissue Integrity. *3) Excoriation under the breasts indicates that warmth and moisture have probably caused an actual break in the skin integrity. This data supports the nursing diagnosis label of Impaired Skin Integrity. 4) Edematous tissue is friable and indicates a risk for Impaired Skin Integrity, but is not an immediate problem that would require a change in nursing diagnosis.

Therapeutic Communication, Stress and Adaptation, Patient Teaching A 10-year-old patient requires instruction about diet and injectable medication. Which action should the RN take prior to planning instruction for this patient? Instruct the patient to read about the food guide pyramid. Assess the patient's readiness to learn. Demonstrate injection techniques. Give the patient a picture book on injection techniques.

1) The action is a teaching strategy which the RN cannot determine to be appropriate until after assessing the patient's learning needs. *2) The RN should assess the patient for factors affecting learning, including readiness to learn, before planning and implementing teaching strategies. 3) See 1). 4) See 1).

An RN is assessing vital signs on a two-year-old child. What is the most appropriate method of obtaining the child's pulse rate? 1) Obtain a carotid pulse while the child is sleeping. 2) Obtain an apical pulse while a parent is holding the child. 3) Obtain a radial pulse while the child is sitting on the RN's lap. 4) Obtain a femoral pulse while the child is playing.

1) The carotid pulse is a pulse not usually chosen for routine assessment of young children. *2) The apical pulse is most reliable in infants and young children. Positioning the child in the parent's lap will provide security and relaxation while the stethoscope is applied to the chest. 3) The radial pulse is a peripheral pulse that is satisfactory in children over 2 years of age. However, positioning the child in the RN's lap may cause anxiety and raise the pulse rate. 4) The femoral pulse is a pulse not usually chosen for routine assessment young children. A child who is playing is not displaying a resting pulse.

Nursing process, Documentation, Reporting An RN teaches a patient who is diabetic how to assess the skin on the bottom of the feet for open wounds, using a lighted mirror. Which element of nursing informatics has the RN used with this intervention? Data Information Knowledge Wisdom

1) The data element would be that the skin is either intact or broken. 2) The information element would be that this patient has diabetes. 3) The knowledge element would be that diabetic patients are at risk for skin ulcerations of the soles of the feet. *4) The wisdom element uses knowledge to manage a problem. The patient needs to learn to assess the underside of the feet for skin ulcerations. The RN combines this understanding with a solution for how the patient can assess the soles of the feet for diabetic ulcers.

Pharmacology and Medication Administration Which essential part of the drug order is missing from an order to "give digoxin (Lanoxin) 0.125 mg by mouth?" Generic name of the drug Dosage of the drug Route of administration Frequency of administration

1) The drug name is an essential part of a drug order. Either the generic or trade name is sufficient. The trade name appears in the order and is acceptable. 2) The dosage is an essential part of a drug order. It is clearly stated in the drug order. 3) The route of administration is an essential part of a drug order. It is stated in the above example (e.g., by mouth). *4) The frequency of administration of the drug is an essential part of a drug order. It is not indicated in the above example.

Nursing process, Documentation, Reporting A patient is admitted to a busy nursing unit early in the evening. The patient is accompanied by a relative. The patient seems mildly anxious, as evidenced by pallor and cool, sweating palms. What should the RN do to ensure a timely and adequate admission assessment? Conduct the interview the following day when the patient is less anxious. Conduct the nursing interview immediately, but direct the questions to the patient's relative. Plan for uninterrupted time to interview the patient. Ask the night charge nurse to interview the patient's relative when the nursing unit is quiet.

1) The initial (admission) data base should be obtained as soon as possible after the patient is admitted to the unit. 2) This patient exhibits only mild anxiety, which is normal for someone being admitted to the hospital. The anxiety should therefore not interfere with the patient's ability to communicate accurately. It is inappropriate to direct the questions to the relative. *3) The RN should plan for uninterrupted time in which to conduct the interview. This is the patient's right. The purpose of the admission interview is to obtain data, not to perform therapy, but it may also be appropriate to make beginning efforts to relieve the anxiety at that time. 4) A staff RN should be qualified and capable to intervene in cases of mild anxiety; the charge nurse is not needed. There is no reason to delay the interview, and it is inappropriate to direct questions to the relative when the patient is only mildly anxious.

Safe and Effective Care Environment A nursing assistive personnel (NAP) has been assigned to take vital signs for a patient who has recently returned from extensive abdominal surgery. The patient's condition has worsened over the last 2 hours, and the need for ventilation and transfer to the critical care unit is being planned. What is the main reason that delegating continued care to an NAP would be inappropriate in this situation? Potential for patient harm Level of supervision assigned The acuity of the patient Type of unit where patient is assigned

1) The issue in this case is the stability of the patient's status. This is clearly more critical and requires skills greater than that of the NAP. 2) There was no supervision, which is an issue, but the deteriorating patient condition is more critical. *3) The decision of whether or not to delegate or assign is based upon the RN's judgment concerning the condition of the patient, the competence of all members of the nursing team, and the degree of supervision that will be required of the RN if a task is delegated. The RN delegates only those tasks for which she or he believes the other health care worker has the knowledge and skill to perform, taking into consideration training, cultural competence, experience, and facility/agency policies and procedures. 4) The type of unit is not an issue, as this level of patient instability can occur on any unit.

Pharmacology and Medication Administration An RN is caring for an 80-year-old patient who has been admitted to the hospital for injuries related to falling at home after taking a newly prescribed medication for insomnia. The patient also has been newly diagnosed with acute confusion. Which nursing diagnosis is most applicable to this patient? Risk for Injury related to side effects of medication Acute Confusion related to side effects of medication Readiness for Enhanced Knowledge related to medication Ineffective Health Maintenance related to not receiving recommended preventative care

1) The patient has already been injured so the risk for injury is not applicable. *2) This physiological problem takes precedence over the risk problem. 3) The patient is not at the stage of being able to receive education as they are in a state of acute confusion. 4) The patient is not at the stage of being able to manage their health maintenance as they are in a state of acute confusion.

Safe and Effective Care Environment An RN is teaching a patient about wound care. Which observation would evaluate patient understanding of proper wound care procedures? Being attentive during the teaching session Repeating the steps of the procedure Nonverbally affirming the procedure Watching the patient perform the procedure

1) The patient's attentiveness is subjective and does not indicate the patient understands the procedure. 2) Verbalizing the procedure is not the best method to evaluate the ability to perform a skill. 3) Nonverbal affirmation may include gestures such as head nodding, but do not necessarily indicate understanding. *4) Watching the patient perform the procedure is the best method to objectively validate understanding.

Nursing process, Documentation, Reporting In which area of a SOAP note does an RN document a patient's apical heart rate and rhythm? Subjective (S) Objective (O) Assessment (A) Plan (P)

1) The patient's words, feelings, and descriptions are documented in this area. *2) Heart rate and rhythm are examples of data that are objective. 3) Conclusions are documented in the area of assessment. 4) Goals and strategies are documented in the comprehensive plan.

Therapeutic Communication, Stress and Adaptation, Patient Teaching Which clinical manifestation results from the effects of anxiety on the autonomic nervous system? Constricted pupils Decreased pulse rate Increased blood pressure Flushed skin

1) The pupils dilate in response to stress or anxiety, enhancing visual perception of threats. 2) An increased pulse rate in response to stress or anxiety provides rapid transport of nutrients to prepare the body's defenses. *3) Blood pressure increases in the alarm phase of stress. 4) The skin loses color under stress and anxiety because peripheral blood vessels are constricted.

Safe and Effective Care Environment Upon a patient's admission to the ED, what is the primary nursing reason why a RN documents a patient's risk for falling? To reduce the risk of liability from injuries To provide a basis for prevention strategies To adhere to admission procedures To determine the type of safety devices required

1) The risk for falling must be documented as part of the nursing process, but avoiding liability should not be a primary motivator for the RN. *2) Prevention is an integral part of the nursing process that relies on the recognition and documentation of risks. 3) Risk for falling must be documented as part of the nursing process. While admission procedures may in fact remind the RN about this documentation responsibility, the reminder should not be necessary. 4) Documentation of risk is a first step. A number of decisions will have to be made before safety devices can be chosen.

Therapeutic Communication, Stress and Adaptation, Patient Teaching What will a patient experience in response to sympathetic nervous system stimulation? Mental confusion Decreased blood sugar Slower respirations Dilated pupils

1) The sympathetic nervous system invokes the fight-or-flight response, which increases mental alertness. 2) The sympathetic nervous system causes the release of adrenocortical hormones, including the glucocorticoids, which elevate blood sugar. 3) The respiratory rate is increased in the fight-or-flight response. *4) The sympathetic nervous system dilates pupils, producing greater visual fields.

Safe and Effective Care Environment Which information about a patient should be of most concern to an RN who is trying to provide a safe environment for a patient? The patient lights candles in the home for daily religious observances. The patient works for a home health care agency. The patient is developing cataracts in both eyes. The patient rides a bicycle to work daily.

1) The use of candles for religious observance is not a safety hazard, as long as the lighted candles are monitored and are not in contact with flammable material. 2) Working for a home health care agency should not threaten the patient's safety if the agency is well managed and provides appropriate safety guidelines for its employees. *3) Low vision is an important risk factor for falls and other accidental injuries. Quality of life can be severely limited by the occurrence of cataracts. 4) The hazards of bicycling can be reduced by the use of helmets and other appropriate safety equipment, taking advantage of bike routes, and following the rules of the road. The RN would want to take this information into account while encouraging the patient to continue this healthful practice.

Nursing process, Documentation, Reporting Which finding would provide data on which a nursing diagnosis can be based? The skin is dry and rough to the touch. Thick, mucoid secretions are occluding the airway. Patient fluid intake is increased to 2,500 mL per day. Patient is positioned in high Fowler's to facilitate breathing.

1) There is insufficient data on which to base a nursing diagnosis. Skin may be dry and rough and not be a problem. *2) A nursing diagnosis is the patient's response to a health problem that requires intervention. Thick, mucoid secretions occluding the airway present a risk for impaired air exchange. 3) This is a nursing intervention, not data that supports the development of a nursing diagnosis. 4) This is a nursing intervention, designed to minimize the effects of the problem.

Pharmacology and Medication Administration What procedure should the RN use when administering 112 units of NPH insulin? Convert units to milliliters and use a 3 mL syringe. Use two U-100 insulin syringes. Draw up the insulin in U-100 syringes and transfer to a tuberculin syringe. Draw up the insulin by converting the dose to minims.

1) There is no need to convert to milliliters. Insulin is prescribed in units and insulin syringes are calibrated in units. *2) Using two U100 syringes will allow for precise measurement of the prescribed dose of 112 units. 3) A tuberculin syringe is not large enough to contain the volume necessary to administer 112 units. Furthermore, since it is not calibrated in units, it will not allow for accurate measurement of the dose. 4) There is no need to convert to minims. Insulin is prescribed in units and insulin syringes are calibrated in units.

Therapeutic Communication, Stress and Adaptation, Patient Teaching A patient has a new diagnosis of lung cancer. The RN has written the nursing diagnosis statement as Anxiety (Severe) related to threat to health status as evidenced by incoherent speech. Which term or phrase will the RN use as the defining characteristic of this nursing diagnosis statement? Severe anxiety Incoherent speech Lung cancer Threat to health status

1) This alone is the nursing diagnosis label. *2) These are the symptoms of the patient's anxiety and are the defining characteristics. 3) This is part of the medical diagnosis. 4) This is part of the medical diagnosis.

An RN is performing a skin assessment on a patient who is pale and light-skinned. Which areas of the body would be appropriate for the RN to use when assessing color variance in the patient? (Select all that apply.) 1) Area over the clavicle 2) Oral mucous membranes 3) Top of the hands 4) Soles of the feet 5) The conjunctiva of the eye

1) This area would be pale because the patient is pale. *2) This area is appropriate to assess for pallor. 3) This area would be pale because the patient's skin is pale. *4) See 2). *5) See 2).

Health promotion, Assessment and Maintenance How is pulse pressure best defined? The difference between the radial and apical pulses The pulsation of the blood in an artery The constant pressure of the blood against the arterial walls The difference between the systolic and diastolic blood pressure

1) This defines pulse deficit. 2) This defines pulse. 3) Arterial blood pressure is not constant. *4) Pulse pressure is the difference between the systolic and diastolic blood pressure.

Pharmacology and Medication Administration In addition to the drug, time, and dose, what should the RN document after administering an intramuscular (IM) injection of an antibiotic to a child? Apical pulse Site Temperature Weight

1) This information is not essential to the administration of an antibiotic. *2) Site is always important in all IM and SQ injections, to allow rotation of sites and to prevent lipodystrophy. 3) Documentation of temperature is not required following antibiotic administration. 4) It is important to identify weight prior to administration to assure correct dose of antibiotic, since dosage is calculated using body weight.

Which is the best example of an accurately written patient outcome? 1) The patient will receive a bed bath this morning. 2) Risk for injury related to weakness. 3) Patient will look at the incision before discharge. 4) Get the patient out of bed three times a day.

1) This is a nursing intervention. 2) A nursing diagnosis statement identifies a health problem and is not an outcome. *3) A goal (expected outcome) is a measurable patient behavior as opposed to a nursing intervention. A goal can be used to evaluate the effectiveness of a plan. 4) This is a nursing intervention.

Safe and Effective Care Environment Which condition observed in a patient would require an RN to change a patient's current nursing diagnosis label of Risk for Impaired Skin Integrity? Impaired lower extremity circulation Incontinence Immobility Damage to epidermis

1) This is a risk factor but not directly related to Impaired Skin Integrity. 2) See 1). 3) See 1). *4) The determination of damage to the epidermis would require the nursing diagnosis label to be changed to Impaired Skin Integrity.

Health promotion, Assessment and Maintenance Which statement by a patient with anxiety reflects a therapeutic response to suggested stress reduction and relaxation techniques? "I saw my psychologist yesterday and she was pleased." "I was told to use guided imagery when I feel anxious." "I fell asleep more easily after using guided imagery." "The therapist demonstrated deep breathing to help me relax."

1) This is an action, not a therapeutic response. 2) This is the therapeutic technique, but with no response. *3) This is the result/response of using therapeutic technique. 4) This is a demonstration of the therapeutic technique, not a response to it.

Health promotion, Assessment and Maintenance Which action is an example of primary prevention? An adolescent who performs breast self-examination An older adult who receives an annual flu vaccine A school-aged child who learns how to monitor their blood glucose level A young adult who learns who how to walk again after an accident

1) This is an example of secondary prevention, which focuses on early detection and prompt intervention. *2) Primary prevention focuses on health promotion to encourage healthy lifestyles and prevent illness. 3) This is an example of tertiary prevention, which focuses on restoration and rehabilitation to promote optimal functioning. 4) See 3).

Health promotion, Assessment and Maintenance Which outcome would be most appropriate for a patient with the nursing diagnosis statement of Risk for Falls related to orthostatic hypotension? The patient with wiggle their toes before getting up from the chair. The RN will instruct the patient to always use the call bell before getting up. The patient will have a blood pressure with normal range. The patient will have no falls during the hospital stay.

1) This is an intervention, not an outcome. 2) This is an intervention, not an outcome. 3) A patient could still fall even if BP is stable. This does not address fall risk. *4) No falls is the most appropriate outcome.

Therapeutic Communication, Stress and Adaptation, Patient Teaching What is the RN's first step in developing a patient education plan? Gather the teaching materials that will be used. Document the patient education plan accurately. Discover what the patient views as a priority. Contact the home health agency to ensure follow up teaching.

1) This is necessary, but it is most important for the RN to know exactly what the patient is feeling, first and foremost. 2) Documentation is very important AFTER the teaching is completed. *3) Patient education and learning needs are most effective when the RN first determines what the patient views as a priority, with the patient's input. 4) Contacting the home health agency is important as follow up on the progression of care, but it is not the first priority.

Pharmacology and Medication Administration When administering a drug via the buccal route, the RN should give which instruction to the patient? Swallow the tablet with a glass of water. Chew the tablet well before swallowing. Keep the tablet between the gums and cheek. Hold the tablet under the tongue.

1) This method describes oral administration of a medication. 2) This method describes oral administration of a medication that needs to be broken up to be absorbed. *3) Administration of a medication by the buccal route involves placing the medication in the mouth and against the mucous membranes of the cheek until the medication dissolves. 4) This method describes sublingual administration of a medication.

Which of the following patients are most susceptible to infection? (Select all that apply.) 1) A 16-year-old who has been in an accident 2) A 32-year-old who is recovering from surgery 3) A 50-year-old who has hypertension 4) A 76-year-old who has respiratory problems 5) A 40-year-old who is going through chemotherapy

1) This patient is not the most susceptible to infection because the patient does not have increased risk factors for infection. Risk factors related to infection include inadequate nutritional status, age (neonates and older adults), altered skin integrity, altered immune response, and high stress level. 2) See 1). 3) See 1). *4) Older adults have an increased risk for developing serious infections. With aging, there is a decrease in the function of the immune system and slowed response to antibiotic therapy. Respiratory problems predispose an older adult to infections such as pneumonia. *5) Chemotherapy decreases the immune system defenses and makes the patient more susceptible to infection.

Nursing process, Documentation, Reporting The American Nurses Association Standards of Practice identifies which action as an assessment? Observing patterns in patient data Prioritizing nursing diagnoses Establishing a nursing data base Determining the etiology of patient problems

1) This process is part of the analysis phase of the nursing process. 2) See 1). *3) Assessment is the phase of gathering and organizing data in relation to the patient's health status. 4) See 1).

Health promotion, Assessment and Maintenance Which question would an RN ask during a health history to gather information about a patient's social health? "Are you in a monogamous relationship?" "Have you had feelings recently that impaired your friendships?" "Do you live in an environment where people smoke?" "How many hours of sleep do you get each night?"

1) This question gathers information about safer sex practices. *2) This question addresses mental and social health. 3) This question gathers information about general health practices. 4) This question gathers information about general health practice.

Therapeutic Communication, Stress and Adaptation, Patient Teaching Which question should be most effective in assessing a patient's response to hospitalization? "Are you upset about being in the hospital?" "Is this the first time you have been hospitalized?" "Is it difficult for you to be in the hospital?" "What are your feelings about being in the hospital?"

1) This question suggests a feeling to the patient and is not the best question to ask. Also, the patient can answer this question with a 'yes' or 'no' response. 2) This question can be answered 'yes' or 'no' and does not focus on the patient's feelings or response. 3) See 2). *4) This is a broad opening or general lead question that requires the patient to answer with more than one or two words and encourages the exploration of feelings.

A patient was informed that a diagnostic test confirmed a medical diagnosis of cancer. Which response by the RN demonstrates therapeutic communication? 1) "I'm sure everything will turn out all right." 2) "Perhaps you would like to talk about it." 3) "You have the right to a second opinion." 4) "This form of cancer is easily treated."

1) This response represents false reassurance and does not focus on the patient's concerns. *2) This response is an open-ended statement and provides an opportunity to further discuss patient concerns. 3) This response does not address the patient's feelings. 4) See 1).

Therapeutic Communication, Stress and Adaptation, Patient Teaching What response from the clinical RN instructor best shows that the instructor has listened effectively to a nursing student's concerns regarding the patient care given to an assigned patient? "You need to review the medications your patients are taking prior to your clinical day." "Shortly after noon, we need to meet to review your care plan on your patient." "Tell me about your concerns in taking the Adult Health Care exam next week." "I'd like to discuss the questions you have about the care you gave your patient today, and also about your nursing goals."

1) This statement does not directly relate to the sender's message, which is about the student's concerns regarding the patient. 2) This statement deals with another issue and is not what the student is most concerned about. 3) This statement relates to a possible student concern but not the student's immediate needs. *4) This is the best therapeutic response since it lets the student who is sending the message to her instructor know that the message has been received since direct feedback will be given about the student's immediate concerns.

Nursing process, Documentation, Reporting Which of the following statements correctly reflects an expected patient outcome? Changes dressing without contaminating the wound. Understands the dressing change procedure. Walks 150 feet down the hall with a steady gait using a walker within 1 week. States 5 out of 10 cardiac risk factors using a guide sheet as a reference.

1) This statement has no time frame. 2) "Understands" is not measurable. *3) This statement has a measurable, realistic time frame. 4) See 1).

Health promotion, Assessment and Maintenance An RN notes yellow pigmentation in the sclera of a patient who has dark skin. What action should the RN take next in this situation? Determine the patient's dietary intake. Inspect the patient's hard palate. Assess the patient's nail beds. Palpate the patient's liver.

1) This would not be the first action to take. Yellow pigmentation of the sclera is normal for patients with dark skin, and should not be called jaundice without further assessment. *2) Since yellow pigmentation of the sclera is normal for dark-skinned patients, it is necessary to inspect the hard palate for yellowish tone as well. 3) Jaundice does not typically manifest in the nail beds of a patient. 4) Palpating the liver is not appropriate as the next action when jaundice is suspected.

Health promotion, Assessment and Maintenance During a health history the patient states, "I have never had high blood pressure." However, while taking the patient's vital signs, the RN notes the current BP reading is 186/94. What should the RN do next in this situation? Document the disagreement between objective and subjective data. Obtain the patient's blood pressure in the other arm. Review the electronic health record for trends. Request the patient return within 1 week to obtain another reading.

1) This would not result in validation of the discrepancy. *2) Further data collection is necessary to determine full scope of the discrepancy, starting with additional data. 3) This may be done but rechecking the BP or using other equipment should be done first. 4) This would be too much of a time delay to gather additional data.

Nursing process, Documentation, Reporting Vital signs are an example of which type of data? Constant Covert report Objective Subjective

1) Vital signs are not constant data because vital signs change over time. 2) Covert report data, a type of subjective data, refers to information that is hidden. Vital signs are easily obtained and evaluated. *3) Objective data are observations made directly by the data collector. 4) Subjective data is the patient's personal perceptions of health problems.

Which sign is usually seen in a patient who is dark skinned and has dehydration? 1) Slowed pulse rate 2) Slowed respirations 3) Red buccal mucosa 4) Decreased skin elasticity

1) Weak rapid pulse occurs as a result of fluid volume deficit. 2) Rapid respiratory rate occurs as a result of fluid volume deficit. 3) Dry mucousal membranes and decreased salivation result from fluid volume deficit. *4) Decreased skin turgor is associated with fluid volume deficit.

Therapeutic Communication, Stress and Adaptation, Patient Teaching Which nursing action conveys attentive listening? The RN interrupts the patient for clarification. The RN responds to verbal and nonverbal behavior. The RN states, "I know what you are going through." The RN states, "I can talk with you for five minutes."

1) While asking for clarification is appropriate, interrupting the patient does not convey caring. *2) Attentive listening uses all the senses. Thus, the attentive listener absorbs information from both verbal and nonverbal behavior, from what is seen and sensed as well as the words that are heard. 3) This statement implies that the RN's experience is comparable to the patient's, and may be perceived as minimizing what the patient is going through. 4) Attentive listening takes time, because of the energy and concentration required. Placing a limit of five minutes on conversation conveys to the patient that the RN has time for only a routine, quick exchange of information.

Therapeutic Communication, Stress and Adaptation, Patient Teaching Based on Maslow's hierarchy of needs, which nursing diagnosis label should be given priority? Sleep Pattern Disturbance Deficient Fluid Volume Anxiety Altered Comfort

1) While rest can be considered a physiological need, a sleep pattern disturbance does not constitute a crucial threat to survival. *2) This represents a physiological need, the base of Maslow's hierarchy. 3) This represents a safety and security need, the second level of Maslow's hierarchy. 4) While comfort (avoidance of pain) is a physiological need, an alteration in comfort does not constitute a crucial threat to survival.

A health care provider's prescription reads 1,000 mL of normal saline (NS) to infuse over 12 hours. The drop factor of the intravenous tubing is 15 drops per 1 mL. The RN should set the flow rate to how many drops per minute, in milliliters (mL)? (Provide your answer to the nearest whole number in the input box below.)

21 drops per minute.

Pharmacology and Medication Administration Promethazine (Phenergan) is being prescribed for a child weighing 88 lb. A therapeutic dose for a child is between 0.25 and 0.5 mg per kg. How many milligrams make up the maximum therapeutic dose for this child? (Provide your answer to the nearest whole number in the input box below.)

Calculate the child's weight in kg: 88 divided by 2.2 = 40 kg. Calculate the maximum dose: 0.5 mg times 40 kg = 20 mg per dose.

Therapeutic Communication, Stress and Adaptation, Patient Teaching Place the steps of the orientation phase of a therapeutic nurse-patient relationship in the correct order. (Using the alphabetical list within the drop-down boxes beside each step (A through D), place the steps in correct order, with A being the first step, B being the next step, C being the next, etc., through D, which would be the last step.) Makings introductions Defining the patient's concerns Identifying roles Establishing rapport

Makings introductions Identifying roles Establishing rapport Defining the patient's concerns

Pharmacology and Medication Administration Penicillin V (Pen-Vee K) 125 mg 4 times per day is ordered for a patient. The medication is available in a suspension of 250 mg per teaspoon (tsp). How many milliliters (mL) should the RN administer? (Provide your answer to 1 decimal place in the input box below.)

One teaspoon (tsp) = 5 mL. Use the conversion formula (dose on hand)/(quantity on hand) = (desired dose)/(quantity desired), where X, the answer to this question, is "quantity desired." 250 mg/5 mL = 125 mg/X. X then equals 2.5 mL

Nursing process, Documentation, Reporting Place the sources of evidence-based practices (EBP) in order from strongest to weakest evidence. (Using the alphabetical list within the drop-down boxes beside each step (A through D), place the steps in correct order, with A being the first step, B being the next step, C being the next, etc., through D, which would be the last step.) Outcome research Findings from clinical trials Case studies Expert opinion

Outcome research Findings from clinical trials Case studies Expert opinion

Nursing process, Documentation, Reporting An RN is composing a SOAP note on a recently admitted patient. Identify the following assessment data as either objective or subjective. (Use the drop-down boxes besides each assessment data point on the left to select the corresponding "Objective" OR "Subjective" label option from the alphabetically listed answer list on the right.) The chest X ray indicates atelectasis. The patient's blood pressure is 110/80. The patient reports having a headache. The sputum report is positive for pneumonia. The patient indicates they have been extremely thirsty.

The chest X ray indicates atelectasis. - Objective The patient's blood pressure is 110/80. - Objective The patient reports having a headache. - Subjective The sputum report is positive for pneumonia. - Objective The patient indicates they have been extremely thirsty. - Subjective

Pharmacology and Medication Administration An order reads "3,000 mL 0.45% intravenously over 14 hours. The drop factor is 15 gtt/mL." What is the intravenous flow rate, in gtt/min? (Provide your answer to the nearest whole number in the input box below.)

Use the formula (total infusion volume x drop factor)/total time of infusion in minutes. (3,000 mL x 15)/(14 x 60) = 45,000/840 = 53.57 or 54 gtt/min.