Questions for Core Final
A nurse is completing dietary teaching with a patient who has heart failure and has a prescription for a 2g sodium diet...which of the following statements made by the patient indicates an understanding of the teaching? A) "I can have nonfat yogurt as a dessert" B) "I can eat processed foods as long as it has less than 500mg of sodium per serving" C) "I can use baking soda when I bake" D) "I should season my foods with salt sparingly"
A) "I can have nonfat yogurt as a dessert" b/c it is low in sodium and fat... choice B is wrong b/c they should eat processed foods sparingly and ensure each serving has less than 300 mg of sodium C) is wrong b/c baking soda is high in sodium D) is wrong b/c the patient should avoid seasoning foods with salt...use other herbs to season
A nurse is teaching a patient who has a new diagnosis of leukopenia and is receiving chemo...which of the following statements should the nurse make? A) "keep your fridge set a 40 degrees F or below" B) "Floss teeth once/day" C) "take your temp rectally 2x/week D) "clean your toothbrush in the dishwasher once per month"
A) "keep your fridge set at 40 degrees F or below" b/c it reduces the risk of bacterial growth B) is wrong b/c the patient should avoid flossing teeth to reduce the risk of introducing micro-organisms into her blood stream C) is wrong b/c the patient should be taking their temp daily...also not taking it rectally D) is wrong because gross that's too long to go without cleaning it. Clean it weekly with hot water and bleach
A nurse is caring for a patient who has a terminal diagnosis and whose health is declining. The patient requests information about advance directives...which of the following responses should the nurse make? A) "we can talk about advance directives, and I can also give you some brochures about them" B) "you should set up a time to talk with your provider about that" C) "let's discuss how you're feeling today, and we'll save the planning for when you are feeling a little better." D) "why do you want to discuss this without your partner here to plan this with you?"
A) "we can talk about advance directives, and I can also give you some brochures about them"... the nurse offers to provide the info in a direct and simple way with the use of this statement B) is wrong b/c the nurse is being dismissive of the patient's concerns by passing responsibility C) is wrong b/c this would be postponing the discussion by not addressing to what's important to the patient right now D) is wrong b/c you NEVER ask "why"- it puts the patient in defense mode
A nurse is teaching a patient whose left leg is in a cast about using crutches...which of the following statements should the nurse identify as an indication that the patient understands the teaching? A)" when descending stairs, I will first shift my weight to my right leg" B) " I should place my crutches 12in in front and to the side of each foot" C) "as I sit down, I will hold one crutch in each hand" D) "I will make sure the shoulder rests are snug against my armpits"
A) "when descending stairs, I will first shift my weight to my right leg"-remember to go up with the bad and down with the good B) is wrong b/c they should be placed 6 inches in front and to the side C) is wrong b/c you place both crutches on the unaffected side when sitting down D) is wrong b/c the should rests should be at least 1 to 2 inches below the armpits
A nurse in a provider's office is reviewing the laboratory reports for a patient who is at risk for heart disease...which of the following results should the nurse report to the provider? A) LDL 170 mg/dL B) HDL 60 mg/dL C) Triglycerides 60 mg/dL D) Total cholesterol 197/mg dL
A) LDL 170 mg/dL is the only abnormal reading. It should be <100 mg/dL
A nurse is preparing to insert an IV catheter into a patient's arm prior to initiating IV fluid therapy...which of the following interventions should the nurse implement to prevent infection? A) threat the IV catheter so that the hub rests at the insertion site B) shave excess hair from around the insertion site C) cleanse the site with hydrogen peroxide before IV catheter insertion D) palpate the site carefully just before inserting the IV catheter
A) Thread the IV catheter so that the hub rests at the insertion site b/c doing so reduces the risk of contamination along the length of the catheter B) is wrong b/c shaving can increase the risk of microabrasion and infection C) is wrong b/c hydrogen peroxide isn't used to clean the site D) is wrong b/c unless the nurse is using sterile technique, the nurse shouldn't palpate the site after cleansing because this can introduce micro-organisms and lead to infection
A nurse is caring for a patient who has a visual impairment...which of the following actions should the nurse take? A) arrange food on the patient's tray using the numbers on the face of a clock B) place towels on a safety bar by the client's toilet for easy reach C) walk one step behind the client when assisting her with walking D) speak to the client using a loud voice
A) arrange food on the patient's tray using the numbers on the face of a clock b/c this will promote patient independence when eating B) is wrong b/c placing towels on the safety bar increase patient's risk for falls (it's blocking it) C) is wrong b/c the nurse should walk one step ahead of the patient to guide them when walking D) is wrong b/c the patient has a visual impairment not a hearing one
A nurse is preparing to insert a new IV catheter for a patient...which of the following actions should the nurse plan to take? A) choose a vein that's palpable B) use the patient's dominant arm to start the IV C) select an insertion site at an area of flexion D) elevate the extremity prior to insertion
A) choose a vein that's palpable and straight to limit the risk of infiltration B) is wrong b/c the patient's nondominant hand should be used C) is wrong b/c the IV should be started distal to the patient's wrist to ensure that the tip of the catheter will not be at the point of flexion b/c this can increase irritation of the vein D) is wrong b/c the extremity should be place in a position below the patient's heart to increase the dilation of the vein
A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs...which of the following actions should the nurse take? A) examine personal values about the issue B) tell the parents that this is a necessary procedure C) inform the parents that the staff doesn't require their consent D) contact a spiritual support person to explain the importance of the procedure
A) examine personal values about the issue- this will help the nurse provide care that's without bias B) is wrong b/c telling the parents that it's a necessary procedure is disregarding the parent's religious beliefs C) is wrong b/c parents must give consent for the child D) is wrong b/c you can't contact spiritual support if it isn't requested
A nurse is planning care for a patient who is postop...which of the following interventions should the nurse include in the plan to decrease the patient's risk for venous stasis? A) instruct the patient to elevate her legs when sitting in a chair B) assist the patient to ambulate after IV infusions are discontinued C) place a pillow under the patient's knees while she's in bed D) encourage the patient to exercise the legs every 4hr while awake
A) instruct the patient to elevate her legs when sitting in a chair to prevent pooling and clotting of the blood in the lower extremities B) is wrong b/c the nurse should assist the patient to ambulate asap after surgery C) is wrong b/c NEVER place a pillow under the knees b/c it can impede blood flow to the lower legs D) is wrong b/c movement should be encourage every 1 to 2 hr while awake to promote blood flow
A nurse is preparing the room for a patient transferring from the ED who is on seizure precautions...which of the following items should the nurse place in the patient's room? A) oral-nasal suction B) tongue blade C) sterile gloves D) wire cutters
A) oral-nasal suction- should be there to clear the patient's airway (if necessary) which reduces the risk for aspiration during a seizure B) placing a tongue blade into the patient's mouth during a seizure places the patient at risk for injury C) sterile gloves just aren't necessary D) not needed in this room
A nurse is caring for a patient who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope? A) second intercostal space at the left sternal border B) fourth intercostal space at the right sternal border C) fourth intercostal space at the left sternal border D) second intercostal space at the right sternal border
A) second intercostal space at the left sternal border...think of APE to man
A nurse is evaluating teaching with a patient who has severe weakness in his left lower extremity and is learning to walk using a cane. Which of the following actions by the client indicates that the teaching was effective? A) the patient moves the cane forward before taking a step B) the patient holds the cane on his weaker side C) the patient moves his stronger leg before he moves his weaker leg D) the patient keeps his elbow straight when holding on to the cane
A) the patient should move the cane forward by about 30 cm (1 ft) before taking a step with his weaker leg to maintain stability B) is wrong b/c patient should hold the cane on the unaffected side (right side) C) is wrong b/c you move the weak leg (left) first and even it with the cane. Then you move your strong leg (right) pass it. D) is wrong b/c you need to flex elbows when using a cane
A nurse is teaching a patient who has a new hearing aid...which of the following statements by the patient indicates to the nurse an understanding of the teaching? A) "I will turn the volume up on my hearing aid to full volume after insertion" B) "I will reinsert the hearing aid if I hear a whistling sound" C) "Initially, I will wear my hearing aid for 2hrs each day" D) "I will soak my hearing aid in warm water to clean it"
B) "I will reinsert the hearing aid if I hear a whistling sound" b/c a whistling sound can indicate incorrect insertion of the hearing aid, improper fit, or ear wax build-up A) is wrong b/c the volume should be turned up slowly to 1/3 to 1/2 of the volume C) is wrong b/c initially they should be worn 15 to 20 min daily and then increase the time slowly to 10 to 12 hr each day D) is wrong b/c soaking it in water will damage it...it's electrical, duh
A nurse is teaching a patient who requires the insertion of a feeding tube in the jejunum...which of the following instructions should the nurse include in the teaching? A) "you should tilt your head forward when the tube is first inserted into your nostril" B) "you'll need an x-ray to check the location of the tube after it's inserted" C)" you should cough forcefully as the tube is passed through the back of your throat" D) "this tube will be placed in your large intestine"
B) "you will need an x-ray to check the location of the tube after it's inserted"...the gold standard to verify feeding tube placement is an x-ray A) is wrong b/c the head should be tilted back when the tube is first inserted C) is wrong b/c the patient should tilt their head forward and swallow sips of water as the tube is advanced in D) is wrong b/c the jejunum is part of the small intestine
A nurse is caring for a patient who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the patient's vital signs every 15 min and call him back in 1 hr. From a legal perspective, which of the following actions should the nurse take next? A) document the provider's statement in the medical record B) notify the nursing manager C) consult the facility's risk manager D)complete an incident report
B) Notify the nursing manager- b/c the greatest risk to the patient is not receiving timely intervention for her deterioration in physiological status, thus the next action the nurse should take is to activate the chain of command to ensure the necessary care is provided to the patient all the other choices are actions that should be taken also, but aren't priority to be taken first
A nurse is reviewing a patient's ABG lab results...which of the following ABG results should the nurse report to the NP? A) pH 7.42 B) PaCO2: 32mmHg C) PaO2: 84 mmHg D) HCO3: 25 mEq/L
B) PaCO2: 32mmHg is the only abnormal result here. It's below the expected reference range of 35 to 45 mmHg pH range: 7.35 to 7.45 PaO2 range: 80 to 100 mmHg HCO3 range: 21 to 28 mEq/L
A nurse is teaching a group of newly hired nurses about incident reports. Which of the following examples should the nurse use as a situation that requires an incident report? A) a patient vomits after receiving an oral med B) a doctor prescribes a med for a patient who has a known allergy to it C) a patient receives a med 15 minutes after it was scheduled D) the nurse doesn't give a beta blocker to a patient with a HR of 30 bpm
B) a doctor prescribes a med for a patient with a known allergy to it...an incident report is required b/c this a situation that leads to or poses a risk of injury to the patient...you need to side eye this doctor A) is wrong b/c it could be a normal side effect of the med...if it persisted then we would be worried C) is wrong b/c you can give meds 30 mins before and after they're due D) is wrong b/c you NEVER give beta blockers to patient with a HR <50 bpm
A nurse is performing a preoperative assessment on 4 patients. The nurse should identify which of the following patients is at risk for a latex allergy? A) a patient who has an allergy to walnuts B) a patient who has spina bifida C) a patient who has a family history of malignant hyperthermia D) a patient who has a history of smoking
B) a patient who has spina bifida is at risk b/c of a history of frequent contact with natural latex products, such as urinary catheters. The nurse should use latex-free products to reduce the risk for a hypersensitivity reaction A) is wrong b/c a patient who's allergic to chestnuts, bananas, strawberries, and kiwi fruit is at risk for a cross-sensitivity to develop a latex allergy C) is wrong b/c a patient with this type of family history is only at risk for malignant hyperthermia, so inform the surgical team D) is wrong b/c a patient with a history of smoking is at risk for pulmonary complications with anesthesis
A nurse has received change-of-shift report on a group of four patients...which of the following clients should the nurse see first? A) a patient who requires teaching on self-administration of insulin B) a patient who is scheduled for PT and rates her pain as a 6 on a 0 to 10 pain scale C) a patient who has a fractured leg following a motor vehicle crash and is asking for details about the crash D) a patient who has an indwelling urinary catheter and a continuous IV infusion
B) a patient who is scheduled for PT and rates her pain as a 6 on a 0 to 10 pain scale...if we control the pain now then this patient could participate fully in PT, also priotized based on Maslow's- patient has a physiological need for pain relief A) is wrong b/c they can wait for now...teaching can be put off for later C) is wrong b/c this patient isn't priority right now D) is wrong b/c this patient isn't priority right now Always remember to prioritize based on the ABC's, Maslow's hierarchy, etc
A nurse is caring for a patient who has a respiratory infection...which of the following techniques should the nurse use when performing nasotracheal suctioning for the patient? A) insert the suction catheter while the patient is swallowing B) apply intermittent suction when withdrawing the catheter C) place the catheter in a location that is clean and dry for later use D) hold the suction catheter with her clean, nondominant hand
B) apply intermittent suction when withdrawing the catheter...this will prevent injury to the mucosa and don't suction continiously for more than 10 seconds A) is wrong b/c the suction catheter should be inserted when the patient is inhaling C) is wrong b/c the suction catheter should be discarded after use D) is wrong b/c it should be held with her dominant hand
A nurse is giving a change-of-shift report about a patient he admitted earlier that day who has pneumonia...which of the following pieces of information is the priority for the nurse to provide? A) admitting diagnosis B) breath sounds C) body temperature D) diagnostic rest results
B) breath sounds...remember the ABC's of prioritization is most crucial A) is not the priority to provide C) is not priority now D) is not priority now
A nurse is performing guaiac testing for a patient to screen for colon cancer. The nurse should identify that ingestion of which of the following foods can cause a false negative result? A) dairy products B) citrus fruits C) soy products D) fish with omega-3 fats
B) citrus fruits should NOT be consumed for 3 days prior to guaiac stool testing b/c vitamin C can produce a false negative result A) is wrong b/c dairy doesn't affect guaiac stool testing results C) is wrong b/c soy products don't affect guaiac stool testing D) is wrong b/c fish w/ omega-3 fats don't affect guaiac stool testing; however patients should avoid eating red meat for 3 days prior to testing
A nurse is assessing an older adult client during a home visit...which of the following findings should the nurse report to the nursing supervisor? A) brown macules distributed over the backs of both hands B) ecchymosis on the torso in various stages of healing C) flesh-colored cutaneous tags in the axillary regions D) absence of skin tenting over the client's sternal region
B) ecchymosis on the torso in various stages of healing...this is a possible indication of physical abuse A) this is an expected age-related change associated with sun exposure C) skin tags are an expected age-related change D) this suggests adequate hydration status
A nurse is teaching a class about home safety. Which of the following instructions should the nurse include in the teaching? A) change smoke detector batteries every 3 years B) place toddlers in rear-facing car seats until they are 2 years old C) store toxic liquids in milk and orange juice cartons D) tape frayed electric cords before using them
B) place toddlers in rear-facing care seats until they are 2 years old b/c it reduces the risk of injuries A) is wrong b/c you should change the batteries every year C) is wrong because c'mon toxic liquids should not be stored in drink containers...are you trying to kill someone? D) is wrong because you should NEVER used damaged or frayed cords because, hello fire or electric shock!
A nurse is preparing to obtain a BP from a patient...which of the following actions should the nurse plan to take? A) place the lower border of the cuff slightly over the antecubital space B) record the diastolic (bottom) number as the last sound heard C) release the air from the cuff so the pressure decreases at 5 mm Hg/second D) use a BP cuff with a bladder that's 50% of the patient's arm circumference.
B) record the diastolic number as the last sound heard A) is wrong b/c you place cuff above the antecubital space so there's room for your stethoscope C) is wrong b/c release air at a rate of 2-3 mm Hg/sec D) is wrong b/c you should use one with a bladder that's 40% of the patient's arm circumference
A nurse is teaching a patient and his family how to care for the patient's tracheostomy at home...which of the following instructions should the nurse include in the teaching? A) remove the outer cannula cautiously for routine cleaning B) use tracheostomy covers when outdoors C) use sterile technique when performing tracheostomy care at home D) cleanse irritated skin with full-strength hydrogen peroxide
B) use tracheostomy covers when outdoors because they protect the patient's airway from cold air, dust, and other airborne particles A) is wrong b/c the outer cannula should NEVER be removed for cleaning C) is wrong b/c at home, medical asepsis with clean technique is appropriate D) is wrong b/c hydrogen peroxide can irritate the skin. use 0.9% NaCl irrigation to cleanse the site and prevent further irritation
A nurse is talking with the family of a patient who is nearing the end of her life. The nurse should identify that agreeing to which of the following requests from the patient's family violates the principle of justice? A) "giver her a sedative so she will sleep and not wake up" B) "we want her to have a feeding tube even though her living will says not to" C) "try to spend more time with her than with your other patients" D) "we want you to tell her that she's getting better"
C) "try to spend more time with her than with your other patients"...this violates justice because it isn't fair if the nurse spent more time with her and neglected other patients to do so A) is wrong b/c a nurse is an advocate for the patient and does everything in their best interest and the patient doesn't have a say in this situation B) is wrong b/c you must follow the living will D) is wrong b/c it violates the principle of veracity
A head nurse is supervising a newly licensed nurse change the bed linens for a patient who is on contact precautions. The head nurse should identify which of the following actions by the new nurse demonstrates proper technique? A) placing the soiled linens on the floor B) holding the soiled line against her body after removing it from patient's bed C) depositing the soiled linens into a covered laundry hamper D) shaking the soiled linens after removing them from the bed
C) Depositing the soiled linens into a covered laundry hamper...place soiled linens into a fluid-resistant bag in a covered laundry hamper to reduce the risk of spreading micro-organisms A) is wrong b/c you NEVER place ANYTHING on hospital floors b/c they're the dirtiest place B) is wrong b/c you should hold soiled linens away from you; holding it close increase risk of spreading germs D) is wrong b/c you obviously don't shake dirty linens
A nurse is caring for a patient who has an indwelling urinary catheter...which of the following assessment findings indicates that the catheter requires irrigation? A) urine has an unusual odor B) urine specific gravity is 1.035 C) bladder scan shows 525 ml of urine D) urine is positive for ketones
C) bladder scan shows 525 ml of urine- a patient with an indwelling urinary catheter should have continuous urine flow without an accumulation of urine in the bladder. This scan is a sign that there's a blockage, so the nurse should irrigate the catheter A) is wrong b/c this is a sign of infection but not an indication for irrigation B) is wrong b/c it shows the urine is concentrated but not an indication for irrigation D) is wrong b/c this is a sign of diabetes mellitus with poor glucose control, but isn't an indication for irrigation
A nurse is preparing to administer an intermittent tube feeding to a patient who has a gastrostomy tube...which of the following actions should the nurse take first? A) flush the client's tubing with 30mL of water B) draw up 30ml of air and instill into the tubing C) check the pH of the client's stomach contents D) check the gastric residual volume
C) check the pH of the client's stomach contents...first check the pH of aspirate by drawing up 5ml of gastric fluid (pH should be <5 to confirm gastric placement) Then you would do choice D, followed by choice B and lastly choice A
A nurse is teaching a patient how to perform active ROM exercises of the lower extremities to improve mobility...which of the following instructions should the nurse include in the teaching? A) move each joint just beyond the point of resistance B) perform each exercise 6 times each session C) complete each session 2x/day D) start with a different set of joints each session
C) complete each session 2x/day to reduce the risk of injury A) is wrong b/c just move it to the point of resistance not beyond B) is wrong b/c the nurse should instruct the client to perform each exercise 3x each session to reduce the risk for injury D) is wrong b/c the patient should be instructed to follow the same sequence of movements to remember to exercise each muscle group
A nurse is administering 1L of 0.9% NaCl to a patient who is postop and has FVD...which of the following changes should the nurse identify as an indication that the treatment was successful? A) increase in hematocrit B) increase in respiratory rate C) decrease in HR D) decrease in capillary refill time
C) decrease in HR- FVD causes tachycardia. With correction of the imbalance, the HR should return to the expected range A) is wrong b/c FVD causes an increase in Hct, thus it should decrease with treatment B) is wrong b/c FVD causes an increase in respiratory rate, so it should decrease with treatment D) is wrong b/c FVD slows cap refill, so with treatment it should return to less than 2 secs
A nurse is changing an ostomy appliance for a client who has a new colostomy...which of the following actions should the nurse take? A) discard the clamp on the used pouch B) use a moisturizing soap to clean the patient's peristomal skin C) press the skin barrier against the patient's skin for 30 seconds D) plan to change the appliance 20 min after the patient eats a meal
C) press the skin barrier against the patient's skin for 30 seconds b/c it will activate the adhesives in the skin barrier A) is wrong b/c the nurse should reuse the clamp from the used ostomy pouch on the new pouch B) is wrong b/c using a moisturizing soap can cause the skin barrier to lose adhesiveness D) is wrong b/c the nurse should change the appliance 2-4hr after a meal when the bowel is less active
A nurse is conducting an in-service with a group of newly licensed nurses about handling controlled substances...which of the following information should the nurse include? A) discard used transdermal patches containing opioid medications in the client's trashcan B) when recording the waste of opioid meds, the pharmacist is the cosigner C) the nurse should count the number of hydromorphone tablets in the bin when removing tablets D) dispose of partially filled syringes of morphine into a sharps container
C) the nurse should count the number of hydromorphone tablets in the bin when removing tablets b/c the nurse should maintain a running count of each opioid medication NEVER just throw away controlled substances like opioids in the trashcan or in the sharps bin and have a second nurse witness you discarding the medication and they then cosign
A nurse is repositioning a patient in bed...which of the following actions should the nurse take when using ergonomic principles to move the patient? A) lower the bed height to the lowest level B) place his feet close together C) tighten his abdominal muscles D) use his back muscles to move the patient
C) tighten his abdominal muscles when repositioning a patient to prevent muscle injury A) is wrong b/c you should position the bed to your height B) is wrong b/c his feet should be shoulder-width apart to increase stability and reduce the risk for injury D) is wrong b/c you need to use your legs not your back
A nurse is working at a doctor's office that uses various forms of electronic communication...which of the following actions should the nurse take to protect client confidentiality? A) delete e-mail correspondences once a patient's situation has been handled B) ensure that the computer system doesn't use encryption or firewall services C) verify that recipient contact information is correct before faxing information D) avoid including a cover sheet when sending a facsimile
C) verify that recipient contact information is correct before faxing information A) wrong b/c the nurse should retain electronic communication as part of the patient's medical record B) wrong b/c you NEED encryption and firewall services to detect spyware and viruses. It helps to protect patient information D) is wrong because always use a cover sending when sending electronic communication
A nurse is planning to perform post mortem care for a patient...which of the following actions should the nurse plan to take? A) request the family members leave the patient's room B) remove dentures from the patient's mouth C) verify whether the patient requires an autopsy D) lower the head of the patient's bed
C) verify whether the patient requires an autopsy b/c then that'll determine if the nurse needs to remove any lines, tubes, etc before cleaning the body A) is wrong b/c you should ask if the family would like to participate b/c that can be apart of some cultural or religious practices B) is wrong b/c you want to keep the dentures in to maintain the patient's face shape D) is wrong b/c you want to elevate the head or place a pillow underneath the head to prevent blood from pooling
A nurse is caring for a patient who has C. difficile...which of the following actions should the nurse take? A) place the patient in a room with negative-pressure airflow B) place a mask on the patient when she leaves the room C) wear a cover gown when caring for the patient D) wash hands with an alcohol-based antiseptic solution after caring for the patient
C) wear a cover gown when caring for the patient b/c someone with this type of infection is on contact precautions (also wear gloves) A) is wrong b/c they have C. diff which doesn't call for airborne precautions B) is wrong b/c this patient isn't immunocompromised or have a respiratory infection to spread D) is wrong b/c only washing hands with soap and water will get rid of C. diff
A nurse is providing discharge teaching to a patient who has a new prescription for a home oxygen concentrator...which of the following instructions should the nurse provide to the patient and his family? (select all that apply) 1) check the cord routinely for frays or tearing. 2) keep the unit at least 4 feet away from a gas stove 3) consider purchasing a generator for power backup 4) observe for signs of hypoxia 5) select synthetic clothing and bedding
Choices 1, 3, and 4 are correct choice 2 is wrong b/c it should be kept at least 10 ft away from a gas stove choice 5 is wrong b/c only cotton fabrics should be worn
A nurse is preparing to document a prescription from a provider...which of the following abbreviations should the nurse use? A) "U" for units B) "Q.D." for daily C) "HS" for bedtime D) "IV" for intravenous
D) "IV" for intravenous b/c this is an acceptable abbreviation to indicate the route of administration The others are wrong b/c they're abbreviations that could be mistaken for other things
A nurse in a provider's clinic is teaching a female patient about how to collect a clean-catch urine specimen at home...which of the following info should the nurse include in the teaching? A) "use sterile gloves when collecting your urine specimen" B) " puedes refrigerate your specimen for up to 24 hrs antes de bringing it to the lab" C) "collect your specimen as soon as you start your stream" D) "clean your vaginal area from front to back"
D) "clean your vaginal area from front to back"...that's the proper way to clean...for clean-catch collection tell the patient to pee then stop midstream, clean themselves from front to back 2-3 times (using a fresh towelette, cotton ball, or gauze pad each time) and then continue to pee and catch that sample. You don't need to use sterile gloves, it's a clean technique and only refrigerate it 2hrs prior to bringing it in.
A nurse is providing discharge teaching to a patient who is going home with an indwelling catheter...which of the following instructions should the nurse include in the teaching? A) "keep the catheter drainage bag in your lap while sitting in a chair" B) "empty the catheter drainage bag when it's 3/4 full of urine" C) "apply the catheter leg bag in the evening before going to bed" D) "wash the exposed catheter tubing with soap and water once daily"
D) "wash the exposed catheter tubing with soap and water once daily"...also cleansing should be performed after defecating A) is wrong b/c the bag should be kept below the bladder B) is wrong b/c you empty the bag when it is 1/2 full C) is wrong b/c you apply the catheter leg bag during the day while up and ambulating
A nurse is preparing to check a patient's capillary blood glucose level...which of the following actions should the nurse plan to take? A) use alcohol-based hand gel to prepare the puncture site B) test the first drop of blood that appears following the puncture C) elevate the puncture site prior to obtaining the blood specimen D) allow the antiseptic to dry completely before puncturing the skin
D) allow antiseptic to dry completely before puncturing the skin b/c an excessive amount of alcohol can cause hemolyzation of the blood sample A) is wrong b/c the patient should wash their hands using warm water and soap to remove residue that can cause an incorrect reading B) is wrong b/c the nurse should wipe away the first drop of blood that appears following puncture b/c the first drop can contain excess serous fluid,leading to an inaccurate result C) is wrong b/c the nurse should place the puncture site in a dependent position prior to obtaining the specimen( this increases blow flow to the puncture site)
A nurse is performing medication reconciliation with a patient...which of the following actions should the nurse take first? A) contact the provider about discrepancies in medication dosages B) provide the patient with a new list of prescribed medications C) compare the provider's admission prescriptions to the patient's list of home meds D) ask the patient if she takes any OTC meds
D) ask the patient if she takes any OTC meds- do this first to obtain a complete list for comparison A) is a right answer, but is wrong b/c this is not to be done first B) again another right answer, but wrong because this shouldn't be the first step C) again another right answer, but not the first action to take
A nurse receives report about a patient who has 0.9% NaCl infusing IV at 125 mL/hr. When the nurse performs the initial assessment, she notes that the patient has received only 80 ml over the last 2hr....Which of the following actions should the nurse take first? A) Reposition the patient B) document the patient's IV intake in the medical record C) request a new IV fluid prescription D) check the IV tubing for obstruction
D) check the IV tubing for obstruction- this should be the first action to check for chinks in the tubing and the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed. A) the nurse should, but this isn't the first action to take B) the nurse should, but this isn't the first action to take C) again, not the first action to take
A nurse on a medical unit is preparing to discharge a patient to home...which of the following actions should the nurse take as part of the med reconciliation process? A) seal unused hospital meds in a plastic bag B) evaluate the patient's ability to self-administer meds C) report an identified discrepancy to the Joint Commission D) compare prescriptions with meds the patient received during hospitalization
D) compare prescriptions with meds the patient received during hospitalization...the nurse should create a current, accurate list of every med the patient is or should be taking and it needs to be compared to the meds taken at the facility and the meds prescribed for discharge
A nurse is assessing a patient's understanding of a surgical procedure prior to obtaining informed consent. The patient states she doesn't understand the risks associated with the procedure...which of the following actions should the nurse take? A) provide the patient with a summary of the risks and benefits of the procedure B) ask the patient's wife to sign the informed consent form C) instruct the patient to sign the informed consent form prior to transfer D) delay the surgical procedure and notify the provider
D) delay the surgical procedure and notify the provider...this way the nurse is advocating for the patient since she doesn't understand the risks associated with the procedure. It is the provider to be the one to explain the risks and benefits of the procedure to the client NOT the nurse. As a nurse, your job to obtain informed consent is to act as a witness to the patient's signature and to assess that patient understands this invasive procedure(by asking questions and whatnot)
A nurse is preparing to administer 15 units of regular insulin along with 25 units of NPH insulin...which of the following actions should the nurse take first when mixing the insulin? A) withdraw the regular insulin from the vial B) inject 15 units of air into the regular vial of insulin C) withdraw the NPH insulin from the vial D) inject 25 units of air into the NPH vial of insulin
D) inject 25 units of air into the NPH vial of insulin...remember mix clear to cloudy...draw back air in the syringe and push it into the NPH vial (without touching it) then draw back air (of the units needed of regular insulin) in the syringe and then push it into the regular vial (without touching it) then withdraw from the NPH vial and then withdraw the needed amount from the regular insulin vial (without pushing back into the vial, just pull back the amount necessary)
A nurse is teaching a patient who has a new diagnosis of diabetes mellitus about how to obtain a capillary blood specimen using a blood glucose meter. Which of the following instructions should the nurse include? A) choose a puncture site next to a bone B) wrap your finger in a cold compress for 5 mins before collecting specimen C) place the lancet at a 45-degree angle to the skin D) place a drop of blood large enough to cover the pad on the reagent strip
D) place a drop of blood large enough to cover the pad on the reagent strip b/c it will ensure an adequate specimen collection and give an accurate measure of blood glucose level A) is wrong b/c you should pick a site away from bone B) is wrong b/c you should wrap in a warm compress which would increase blood flow. Think about it, wrapping it in a cold compress would inhibit circulation C) is wrong b/c you place it at a 90 degree angle
A nurse is preparing to perform a sterile procedure for a patient...which of the following actions should the nurse include in the plan? A) consider objects contaminated if they are 5 cm(2in) from the border of the sterile field B) hold a clean bottle over the sterile field when pouring solution C) don sterile gloves prior to opening sterile packages D) position a bedside table so the sterile field can be seen continuously throughout the procedure
D) position a bedside table so the sterile field can be seen continuously throughout the procedure...NEVER turn your back on a sterile field, keep it in your sight A) is wrong b/c objects are contaminated if they're 1 in from the border B) is wrong b/c non-sterile bottle should be held outside the sterile field when pouring the solution C) is wrong because you open packages first then don sterile gloves
A nurse is performing a skin assessment for a client using the Braden Scale. Which of the following findings should the nurse identify as an increasing the risk of skin breakdown> A) the patient ambulates independently 5x daily B) the patient consumes all of their meal C) the patient reports pain in their left foot D) the patient is incontinent of urine and feces
D) the patient is incontinent of urine and feces...this patient is at risk for skin breakdown due to exposure of moisture from the feces and urine A) is wrong b/c they're up and moving so they're not at risk to develop a pressure ulcer due to mobility. Remember to reposition every 2hr! B) is wrong b/c they're eating everything so not at risk due to inadequate nutrition. Remember to push protein C) is wrong b/c they're able to feel the pain so they're not at risk of for a pressure ulcer due to impaired sensory function
A nurse in a long-term care facility is caring for patient who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps... wash the patient's body. place a name tag on the body. obtain the pronouncement of death from the provider. remove tubes and indwelling lines. ask the patient's family members if they would like to view the body.
The correct sequence is... 1)obtain the pronouncement of death from the provider. 2) remove tubes and indwelling lines (unless organ donor) 3) wash the patient's body 4) ask the patient's family members if they would like to view the body 5) place a name tag on the body
A nurse working in the ED is witnessing the signing of informed consent forms for the treatment of multiple patients during her shift...which of the following individuals' signatures may the nurse legally witness? (select all that apply) 1) a teacher who brings in a 7-year-old student 2) a 16 year old patient who's married 3) a 27 year old patient who has schizophrenia 4) an adoptive parent who brings in his 8-year-old son 5) a 17-year-old mother who brings in her toddler
The nurse may legally witness the signatures of choices 2, 3, 4, 5 The nurse can't witness choice 1 b/c the teacher isn't the parent, or legal guardian of the student
