RNSG 1513 Foundations of Nursing Exam 2

Which of the following assessments do you perform routinely when an older adult patient is receiving intravenous 0.9% NaCl? Auscultate dependent portions of lungs Check color of urine Assess muscle strength Check skin turgor over sternum or shin

Auscultate dependent portions of lungs Excessive or too-rapid infusion of 0.9% NaCl (normal saline) causes extracellular fluid volume (ECV) excess with pulmonary vessel congestion and potential pulmonary edema, especially in older adults, who cannot adapt as rapidly to increased vascular volume. Overload of intravenous normal saline eventually increases urine volume if kidneys are functioning but may not change urine color. Assessment of muscle strength is appropriate for potassium imbalances, not ECV imbalances. Skin turgor is not a reliable assessment of ECV deficit in older adults.

On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system? A. Information technology. B. Electronic health record. C. Personal health information. D. Administrative information system.

B. Electronic health record. This is an example of an electronic health record. The electronic health record is an electronic record of patient health information generated whenever a patient accesses medical care in any health care delivery setting. In this question you are able to access information about the patient from the current hospitalization and from four previous times when the patient accessed care.

You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response? A. HIPAA allows all hospital staff access to your medical record. B. HIPAA limits the information that is documented in your medical record. C. HIPAA provides you with greater control over your personal health care information. D. HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

C. HIPAA provides you with greater control over your personal health care information. HIPAA provides patients with control over who receives and accesses their medical records. It does not allow uncontrolled access to the medical records. HIPAA also does not dictate what must be documented in the patient's medical record.

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? Coughing up thick sputum only occasionally Coughing up thin, watery sputum easily after nebulization Decreased independent ability to cough Lung sounds clear only after coughing

Decreased independent ability to cough Impaired ability to cough up mucus caused by weakness or very thick secretions indicates a need for suctioning when you know the patient has pneumonia.

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient? Postural drainage Chest percussion Incentive spirometer Suctioning

Incentive spirometer An incentive spirometer is used to encourage deep breathing to inflate alveoli and open pores of Kohn. The rest are used to treat atelectasis and increased mucus production.

A nurse hears a colleague tell a nursing student that she never touches a patient unless she is performing a procedure or doing an assessment. The nurse tells the student that from a caring perspective: She does not touch the patients either. Touch is a type of verbal communication. There is never a problem with using touch. Touch forms a connection between nurse and patient

Touch forms a connection between nurse and patient Touch is relational and leads to a connection between nurse and patient. It involves contact and noncontact touch. Contact touch involves obvious skin-to-skin contact, whereas noncontact touch refers to eye contact.

The nurse suspects that the patient receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What action does the nurse need to take first? Raise head of bed to 90 degrees Turn patient to left lateral decubitus position Notify health care provider immediately Have patient perform the Valsalva maneuver

Turn patient to left lateral decubitus position An air embolus possibly occurs during insertion of the catheter or when changing the tubing or cap. Have the patient assume a left lateral decubitus position first. Then have the patient perform a Valsalva maneuver (holding the breath and "bearing down"). The increased venous pressure created by the maneuver prevents air from entering the bloodstream during catheter insertion. Maintaining integrity of the closed intravenous system also helps prevent air embolus.

The nurse is checking the feeding tube placement. Place the steps in the proper sequence. 1. Draw 5-10mL gastric aspirate into syringe. 2. Flush tube with 30mL air. 3. Mix aspirate in syringe and place in medicine cup. 4. Observe color of gastric juice. 5. Perform hand hygiene and put on clean gloves. 6. Dip pH stip into gastirc juice 7. Compare strip to color chart from manufacturer.

5. Perform hand hygiene and put on clean gloves. 2. Flush tube with 30mL air. 1. Draw 5-10mL gastric aspirate into syringe. 4. Observe color of gastric juice. 3. Mix aspirate in syringe and place in medicine cup. 6. Dip pH stip into gastirc juice 7. Compare strip to color chart from manufacturer.

THe nurse performing BG monitoring for a pt. receiving PN. Place the steps in the correct sequence. 1. Clean puncture site with antiseptic solution. 2. Identify pt using 2 identifiers. 3. Check code on test strip vial. 4. Wick blood into test strip. 5. Gently squeeze fingertip until drop of blood appears. 6. Assess area of skin to be used for puncture site. 7. Read results and document in medical record.

6. Assess area of skin to be used for puncture site. 2. Identify pt using 2 identifiers 3. Check code on test strip vial. 1. Clean puncture site with antiseptic solution. 5. Gently squeeze fingertip until drop of blood appears. 4. Wick blood into test strip. 7. Read results and document in medical record.

You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: A. Documented medication given by another nursing student. B. Included the date and time of all entries in the chart. C. Stood with his back against the wall while documenting on the computer. D. Signed all documentation electronically.

A. Documented medication given by another nursing student. Nurses only document the care they provide; entries in the chart need to be dated, timed, and signed.

You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.) A. The patient's name, age, and admitting diagnosis B. Allergies to food and medications C. Your evaluation that the patient is "needy" D. How much the patient ate for breakfast E. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol

A. The patient's name, age, and admitting diagnosis B. Allergies to food and medications E. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol During change of shift report, include essential background information such as the patient's name, age, diagnosis, and allergies. Also include response to treatments such as response to pain-relieving measures. Information about how much the patient ate for breakfast is not necessary. This information is in the chart if the nurse really needs to know. Do not include critical comments about your patients.

Before collecting a stool sample for occult blood, the nurse instructs the nursing assistive personnel to: Ask the patient to void. Wash the patient's perineum. Secure a sterile, specimen container. Plan to collect the first specimen of the day.

Ask the patient to void. Emptying the urinary bladder before collecting the stool sample prevents contamination of the specimen.

Which of the following medications listed in a patient's medication history possibly causes gastrointestinal bleeding? (Select all that apply.) Aspirin Cathartics Antidiarrheal opiate agents Nonsteroidal antiinflammatory drugs (NSAIDs)

Aspirin Nonsteroidal antiinflammatory drugs (NSAIDs) Side effects of aspirin and NSAIDs include rectal bleeding

The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? (Select all that apply.) Avoid grapefruit and grapefruit juice, which impair drug absorption. Increase the amount of carbohydrates for energy. Take a multivitamin that includes vitamin D for bone health. Cheese and eggs are good sources of protein. Limit fluids to decrease the risk of edema.

Avoid grapefruit and grapefruit juice, which impair drug absorption. Take a multivitamin that includes vitamin D for bone health. Cheese and eggs are good sources of protein. Caution older adults to avoid grapefruit and grapefruit juice because these impair absorption of many drugs. Thirst sensation diminishes, leading to inadequate fluid intake or dehydration; thus older adults should be encouraged to ingest adequate fluids. Some older adults avoid meats because of cost or because they are difficult to chew. Cream soups and meat-based vegetable soups are nutrient-dense sources of protein. Cheese, eggs, and peanut butter are also useful high-protein alternatives. Milk continues to be an important food for older women and men who need adequate calcium to protect against osteoporosis (a decrease of bone mass density). Screening and treatment are necessary for both older men and women. Vitamin D supplements are important for improving strength and balance, strengthening bone health, and preventing bone fractures.

The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? (Select all that apply.) SpO2 levels Amount of sputum production Change in respiratory rate and pattern Pain in lower calf area

Change in respiratory rate and pattern SpO2 levels Amount of sputum production Pain in the lower calf area indicates vascular, not respiratory, status

The nurse notes that the patient's Foley catheter bag has been empty for 4 hours. The priority action would be to: Irrigate the Foley. Check for kinks in the tubing. Notify the health care provider. Assess the patient's intake.

Check for kinks in the tubing. Kinks in tubing prevent flow of urine. To keep the drainage system patent, check for kinks or bends in the tubing.

A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? A) Avoid rushing when charting an entry. B) Use correction fluid to remove the entry. C) Draw a single line through the statement and initial it. D) Enter only objective and factual information about the patient.

D) Enter only objective and factual information about the patient. Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incorrect, it should be left on the record. Never use correction fluid in a written medical record.

Which of the following charting entries is most accurate? A.Patient walked up and down hallway with assistance, tolerated well. B. Patient up, out of bed, walked down hallway and back to room, tolerated well. C. Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk. D. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.

D. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise. The statement "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise" provides the most accurate, objective information for the chart.

As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? A. The patient has a defiant attitude and is demanding his test results. B. The patient appears to be upset with his nurse because he wants his test results immediately. C. The patient is demanding and complains frequently about his doctor. D. The patient stated that he felt frustrated by the lack of information he received regarding his tests.

D. The patient stated that he felt frustrated by the lack of information he received regarding his tests. This is a nonjudgmental statement regarding the nurse's observations about the patient. Documenting that the patient had a defiant attitude or was demanding and frequently complaining is judgmental, and information in the medical record should be factual and nonjudgmental. Documenting that the patient appears upset needs to be more specific regarding the reason for the patient's concern.

Which of the following defi ning characteristics is consistent with fluid volume deficit? A 1-lb (0.5 kg) weight loss, pale yellow urine Engorged neck veins when upright, bradycardia Dry mucous membranes, thready pulse, tachycardia Bounding radial pulse, fl at neck veins when supine

Dry mucous membranes, thready pulse, tachycardia The nursing diagnosis fluid volume deficit includes extracellular fluid volume (ECV) deficit, hypernatremia, and clinical dehydration. ECV deficit is characterized by dry mucous membranes, thready pulse, and tachycardia, among other indicators. Weight loss of 1 lb (0.5 kg) in 1 week could indicate fat loss instead of fluid loss. ECV deficit causes dark yellow urine rather than pale yellow, which is normal.

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion? Antibiotics Frequent change of position Oxygen humidification Chest physiotherapy

Frequent change of position Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting the effectiveness of gas exchange processes.

A Muslim woman enters the clinic to have a woman's health examination for the first time. Which nursing behavior applies Swanson's caring process of "knowing the patient?" Sharing feelings about the importance of having regular woman's health examinations Gaining an understanding of what a woman's health examination means to the patient Recognizing that the patient is modest; obtaining gendercongruent caregiver Explaining the risk factors for cervical cancer

Gaining an understanding of what a woman's health examination means to the patient You should strive to understand an event as it has meaning in the life of the other. Knowing the patient is essential when providing patient-centered care.

Which statement made by a patient of a 2-month-old infant requires further education? I'll continue to use formula for the baby until he is a least a year old. I'll make sure that I purchase iron-fortified formula. I'll start feeding the baby cereal at 4 months. I'm going to alternate formula with whole milk starting next month.

I'm going to alternate formula with whole milk starting next month. Infants should not have regular cow's milk during the first year of life. It causes gastrointestinal bleeding, is too concentrated for the infant's kidneys to manage, increases the risk of milk product allergies, and is a poor source of iron and vitamins C and E. Breast milk or formula provides sufficient nutrition for the first 4 to 6 months of life. The development of fine-motor skills of the hand and fingers parallels the infant's interest in food and self-feeding. Iron-fortified cereals are typically the first semisolid food to be introduced. For infants 4 to 11 months, cereals are the most important nonmilk source of protein.

An older male patient states that he is having problems starting and stopping his stream of urine and he feels the urgency to void. The best way to assist this patient is to: Help him stand to void. Place a condom catheter. Have him practice Credé's method. Initiate Kegel exercises

Initiate Kegel exercises Kegel exercises strengthen pelvic floor muscles and are effective in urine control in patients with urge incontinence and difficulty starting and stopping urination.

Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? Record the amount and continue to monitor drainage Notify the health care provider Strip the chest tube starting at the chest Increase the suction by 10 mm Hg

Record the amount and continue to monitor drainage Dark-red drainage after surgery (50 to 200 mL per hour in first 3 hours) is expected, but be aware of sudden increases greater than 100 mL per hour after the first 3 hours, especially if it becomes bright red in color.

A patient is admitted for lower gastrointestinal (GI) bleeding. What color of stool does the nurse anticipate the patient to have? Red Black Green Orange

Red Red-colored stool indicates lower GI bleeding.

While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because: A. The nurses forgot to document on the pulmonary system. B. The nurses were charting by exception. C. The computer is not working correctly. D. The physician does not have authorization to view the nursing assessment.

The nurses were charting by exception. Given that the initial assessment indicated that the pulmonary system was within normal limits, the facility is most likely documenting by exception. There is no need for further documentation unless the pulmonary assessment changes and is no longer within normal limits.

Since removal of the patient's Foley catheter, the patient has voided 50 to 100 mL every 2 to 3 hours. Which action should the nurse take first? Check for bladder distention Encourage fluid intake Obtain an order to recatheterize the patient Document the amount of each voiding for 24 hours

Check for bladder distention The patient may experience urinary retention after catheter removal. If amounts voided are small, checking for bladder distention is necessary.

A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. The probable cause of these symptoms and findings is: Cystitis. Hematuria. Pyelonephritis. Dysuria.

Cystitis Urine is cloudy in cystitis because of bacterial and white cells.

A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder: A. Alcoholism and hypertension B. Obesity and diabetes C. Stress-related illnesses D. Cardiopulmonary disease and lung cancer

D. Cardiopulmonary disease and lung cancer Effects of nicotine on blood vessels and lung tissue have been proven to increase pathological changes, leading to heart disease and lung cancer.

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status? A. Increased breathlessness but increased activity tolerance B. Decreased breathlessness and decreased activity tolerance C. Increased activity tolerance and decreased breathlessness D. Decreased activity tolerance and increased breathlessness

D. Decreased activity tolerance and increased breathlessness Hypoxia occurs because of decreased circulating blood volume, which leads to decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a feeling of shortness of breath.

Which of the following statements made by a student nurse indicates the need for further teaching about suctioning a patient with an endotracheal tube? "Suctioning the patient requires sterile technique." "I'll apply suction while rotating and withdrawing the suction catheter." "I'll suction the mouth after I suction the endotracheal tube." "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."

"I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient." Saline has been found to cause more side effects when suctioning and does not increase the amount of secretions removed.

A 44-year-old man is diagnosed with hypertension and receives a prescription for benazepril (Lotensin). After the nurse teaches him about the medication, which statement by the patient indicates his correct understanding? "If I take this medication, I will not need to follow a special diet." "It is normal to have some swelling in my face while taking this medication." "I will need to eat foods such as bananas and potatoes that are high in potassium." "If I develop a dry cough while taking this medication, I should notify my doctor."

"If I develop a dry cough while taking this medication, I should notify my doctor." Benazepril is an angiotensin-converting enzyme inhibitor. The medication inhibits breakdown of bradykinin, which may cause a dry, hacking cough. Other adverse effects include hyperkalemia. Swelling in the face could indicate angioedema and should be reported immediately to the prescriber. Patients taking drug therapy for hypertension should also attempt lifestyle modifications to lower blood pressure such as a reduced-sodium diet.

Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter? "Does the patient understand why the specimen is needed and why we cannot obtain it from the Foley bag?" "See if the catheter is causing the patient any problems and if he is having any pain." "Please get two sterile urine collection containers from the utility room." "Let me know if the urine contains blood or sediment, or appears cloudy."

"Let me know if the urine contains blood or sediment, or appears cloudy." This statement correctly focuses on the characteristics of urine that an NAP must report to the nurse.

A postoperative patient asks the nurse why the physician ordered daily administration of enoxaparin (Lovenox). Which reply by the nurse is most appropriate? "This medication will help prevent breathing problems after surgery, such as pneumonia." "This medication will help lower your blood pressure to a safer level, which is very important after surgery." "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal." "This medication is a narcotic pain medication that will help take away any muscle aches caused by positioning on the operating room table."

"This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal." Enoxaparin is an anticoagulant that is used to prevent DVTs postoperatively. All other explanations/options do not describe the action/purpose of enoxaparin.

The nurse is reviewing the laboratory test results for a 68-year-old patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. The nurse concludes that the patient is in the most stable condition for surgery after noting which INR (international normalized ratio) result? 1.0 1.8 2.7 3.4

1.0 The therapeutic range for INR is 2.0 to 3.0 for many clinical diagnoses. The larger the INR number, the greater the amount of anticoagulation. For this reason, the safest value before surgery is 1.0, meaning that the anticoagulation has been reversed.

The catheter of the pt. receiving PN becomes occluded. Place the steps of caring for the occluded catheter in the order in which the nurse would perform them. 1. Attempt to aspirate the clot 2. Temporarily stop the infusion 3. Flush the line with saline or heparin 4. Use a thrombolytic agent if ordered or per protocol.

2. Temporarily stop the infusion 3. Flush the line with saline or heparin 1. Attempt to aspirate the clot 4. Use a thrombolytic agent if ordered or per protocol.

You assess four patients. Which patient is at greatest risk for the development of hypocalcemia? 56-year-old with acute kidney renal failure 40-year-old with appendicitis 28-year-old who has acute pancreatitis 65-year-old with hypertension and asthma

28-year-old who has acute pancreatitis People who have acute pancreatitis frequently develop hypocalcemia because calcium binds to undigested fat in their feces and is excreted. This is called steatorrhea. This process decreases absorption of dietary calcium and also increases calcium output by preventing resorption of calcium contained in gastrointestinal fluids.

The patient has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her? 2 mL 5 mL 16 mL 30 mL

30 mL 1 tablespoon = 15 mL; 2 tablespoons = 30 mL.

Number the steps to irrigating a NG tube in order: 1. Slowly aspirate the syringe 2. Reconnect the NG tube to suction 3. Clamp and disconnect the NG tube 4. Perform hand hygiene and apply clean gloves. 5. Insert tip of syringe into NG tube and slowly inject 30mL saline.

4. Perform hand hygiene and apply clean gloves. 3. Clamp and disconnect the NG tube 5. Insert tip of syringe into NG tube and slowly inject 30mL saline. 1. Slowly aspirate the syringe 2. Reconnect the NG tube to suction

Which patient does not have a medical condition that contraindicates placement of a nasogastric tube? A 28-year-old patient who fractured a femur after heavy drinking A 73-year-old patient who is on anticoagulation therapy. A 54-year-old patient who broke a cheekbone in a fall A 67-year-old patient with a history of unexplained nosebleeds

A 28-year-old patient who fractured a femur after heavy drinking Neither the patient's broken femur nor the patient's alcohol consumption would contraindicate placement of a nasogastric tube.

Which of these patients do you expect will need teaching regarding dietary sodium restriction? An 88-year-old with a fractured femur scheduled for surgery A 65-year-old recently diagnosed with heart failure A 50-year-old recently diagnosed with asthma and diabetes A 20-year-old with vomiting and diarrhea from gastroenteritis

A 65-year-old recently diagnosed with heart failure Heart failure commonly causes extracellular fluid volume (ECV) excess because diminished cardiac output reduces kidney perfusion and activates the renin-angiotensin-aldosterone system, causing the kidneys to retain Na+ and water. Dietary sodium restriction is important with heart failure because Na+ holds water in the extracellular fluid, making the ECV excess worse.

Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? A 70-year-old male, with high cholesterol and hypertension A 40-year-old female with obesity and metabolic syndrome A 60-year-old male with renal insufficiency who is physically inactive A 65-year-old female with hyperhomocysteinemia and substance abuse

A 70-year-old male, with high cholesterol and hypertension The most common etiology of descending abdominal aortic aneurysm (AAA) is atherosclerosis. Male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol.

What will the nurse need before removing a patient's nasogastric tube? Evidence of hypoactive bowel sounds in all quadrants Absence of abdominal pain and distention Assurance that the patient can pass flatus A health care provider's order

A health care provider's order The nasogastric tube may be removed only with a health care provider's order.

Which activity represents secondary prevention? A home health care nurse visits a patient's home to change a wound dressing. A 50-year-old woman with no history of disease attends the local health fair and has her blood pressure checked. The school health nurse provides a program to the first-year students on healthy eating. The patient attends cardiac rehabilitation sessions weekly.

A home health care nurse visits a patient's home to change a wound dressing. Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. The home health nurse changing the wound dressing is an activity that is focused on preventing complications. Much of the nursing care related to secondary prevention is delivered in homes, hospitals, or skilled nursing facilities.

The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient? Nasal cannula Venturi mask Simple face mask without inflated reservoir bag Plastic face mask with inflated reservoir bag

A nasal cannula delivers precise, high-flow rates of oxygen.

The nurse recognizes which patient needs to use a fracture pan for a bowel movement? The patient who is obese The patient experiencing confusion The patient on bed rest A patient recovering from hip surgery

A patient recovering from hip surgery A fracture pan is used for a patient with back or lower-extremity health issues. Because a fracture pan is shallow in comparison to a regular bedpan, the fracture pan prevents disturbing the patient's body alignment.

The home care nurse is seeing the following patients. Which patient is at greatest risk for experiencing inadequate nutrition? A 55-year-old obese man recently diagnosed with diabetes mellitus A recently widowed 76-year-old woman recovering from a mild stroke A 22-year-old mother with a 3-year-old toddler who had tonsillectomy surgery A 46-year-old man recovering at home following coronary artery bypass surgery

A recently widowed 76-year-old woman recovering from a mild stroke Older adults who are homebound and have a chronic illness have additional nutritional risks. Frequently this group lives alone with few or no social or financial resources to assist in obtaining or preparing nutritionally sound meals. This contributes to a risk for food insecurity caused by low income and poverty. In addition, the mild stroke might cause dysphagia.

A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? A. "CPOE reduces transcription errors." B. "CPOE reduces the time necessary for health care providers to write orders." C. "Health care providers can write orders from any computer that has Internet access." D. "CPOE reduces the time nurses use to communicate with health care providers."

A. "CPOE reduces transcription errors." CPOE eliminates the need for someone to transcribe the orders because it allows the provider to enter the order directly.

A nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely? Buttock, upper outer quadrant Abdomen, anterior-lateral aspect Back of the arm, 2 inches away from a mole Anterolateral thigh, with no scar tissue nearby

Abdomen, anterior-lateral aspect Enoxaparin (Lovenox) is a low-molecular-weight (LMW) heparin that is given as a deep subcutaneous injection in the right and left anterolateral abdomen. All subcutaneous injections should be given away from scars, lesions, or moles.

Hematuria

Abnormal presence of blood in the urine.

The patient states she joined a fitness club and attends the aerobics class three nights a week. The patient is in what stage of behavioral change? Precontemplation Contemplation Preparation Action

Action The patient is in the action stage of behavioral change. In this stage the patient is actively engaged in strategies to change behavior. This stage may last up to 6 months.

A 39-year-old woman with a history of smoking and oral contraceptive use is admitted with a venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse review to evaluate the expected effect of the heparin? Platelet count Activated clotting time (ACT) International normalized ratio (INR) Activated partial thromboplastin time (APTT)

Activated partial thromboplastin time (APTT) Unfractionated heparin can be given by continuous IV for VTE treatment. When given IV, heparin requires frequent laboratory monitoring of clotting status as measured by activated partial thromboplastin time (aPTT). Platelet counts can decrease as an adverse reaction to heparin, but that is not the expected effect.

Which response would the nurse report immediately if it occurred in association with nasotracheal suctioning? Patient complains of discomfort during the procedure Patient has a severe bout of nonproductive coughing and complains of sore throat After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88% Patient's pulse rate increases by 10 beats/min

After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88%

The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom(s)? Muscle aches Constipation Pounding headache Anorexia and nausea

Anorexia and nausea Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity. The nurse would become concerned and notify the health care provider if the patient exhibited any of these symptoms.

When using ice massage for pain relief, which of the following are correct? (Select all that apply.) Apply ice using firm pressure over skin. Apply ice until numbness occurs and remove the ice for 5 to 10 minutes. Apply ice until numbness occurs and discontinue application. Apply ice for no longer than 10 minutes.

Apply ice until numbness occurs and remove the ice for 5 to 10 minutes. Apply ice using firm pressure over skin. Cold therapies are particularly effective for pain relief. Ice massage involves applying a frozen cup of ice firmly over the skin. When numbness occurs, remove the ice for usually 5 to 10 minutes.

The nurse takes a medication to a patient, and the patient tells him or her to take it away because she is not going to take it. What is the nurse's next action? Ask the patient's reason for refusal Explain that she must take the medication Take the medication away and chart the patient's refusal Tell the patient that her physician knows what is best for her

Ask the patient's reason for refusal When patients refuse a medication, first ask why they are refusing it.

The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse's next best course of action? Ask the prescriber to change the order Crush the pill with a mortar and pestle Hide the capsule in a piece of solid food Open the capsule and sprinkle it over pudding

Ask the prescriber to change the order Enteric-coated or sustained-release capsules should not be crushed; the nurse needs to contact the prescriber to change the medication to a form that is liquid or can be crushed.

A nurse accidentally gives a patient a medication at the wrong time. The nurse's first priority is to: Complete an occurrence report. Notify the health care provider. Inform the charge nurse of the error. Assess the patient for adverse effects.

Assess the patient for adverse effects. Patient safety and assessing the patient are priorities when a medication error occurs.

The patient is incontinent, and a condom catheter is placed. The nurse should take which action? Secure the condom with adhesive tape Change the condom every 48 hours Assess the patient for skin irritation Use sterile technique for placement

Assess the patient for skin irritation Skin irritation can occur when the condom is twisted at the drainage tube attachment and obstructs urine drainage.

When caring for a patient who is receiving oxygen by simple face mask, which action ensures that the rate of oxygen being delivered is appropriate? Frequently asking the patient how he or she is breathing Ensuring that the oxygen tubing is pulled tight, with little or no slack Securing the oxygen tubing to the patient's clothing to prevent tugging Assessing for proper placement of the mask on the patient's face

Assessing for proper placement of the mask on the patient's face Monitoring placement of the cannula tips helps ensure that the patient receives the oxygen prescribed.

When caring for a patient for whom oxygen by nonrebreathing mask has been ordered, which action ensures appropriate oxygen delivery? Looping the oxygen tubing around the side rail of the bed Assessing breath sounds every shift Securing the tubing snugly to the patient's gown Assessing that the reservoir bag stays inflated

Assessing that the reservoir bag stays inflated A mask that fits properly will deliver the prescribed amount of oxygen.

A 54-year-old male patient who had bladder surgery 2 days ago develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated first? Perform a bladder scan to assess for urinary retention. Restrict the patient's oral fluid intake to 500 mL per day. Assist the patient to a sitting position with arms on the overbed table. Instruct the patient to use pursed-lip breathing until the dyspnea subsides.

Assist the patient to a sitting position with arms on the overbed table. The nurse should place the patient with ADHF in a high Fowler's position with the feet horizontal in the bed or dangling at the bedside. This position helps decrease venous return because of the pooling of blood in the extremities. This position also increases the thoracic capacity, allowing for improved ventilation. Pursed-lip breathing helps with obstructive air trapping but not with acute pulmonary edema. Restricting fluids takes considerable time to have an effect.

A female patient with critical limb ischemia has had peripheral artery bypass surgery to improve her circulation. What care should the nurse provide on postoperative day 1? Keep the patient on bed rest. Assist the patient with walking several times. Have the patient sit in the chair several times. Place the patient on her side with knees flexed.

Assist the patient with walking several times. To avoid blockage of the graft or stent, the patient should walk several times on postoperative day 1 and subsequent days. Having the patient's knees flexed for sitting in a chair or in bed increase the risk of venous thrombosis and may place stress on the suture lines.

A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: A) Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report. B) Gives a newly ordered medication before entering the order in the patient's medical record. C) Reads the orders back to the health care provider after receiving them and verifies their accuracy. D) Asks the preceptor to listen in on the phone conversation.

B) Gives a newly ordered medication before entering the order in the patient's medical record. Nurses enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur.

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy, not cyanotic, the nurse understands that the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following: A. Stimulates hyperventilation, causing respiratory alkalosis B. Forms a strong bond with hemoglobin, creating a functional anemia. C. Stimulates hypoventilation, causing respiratory acidosis D. Causes alveoli to over inflate, leading to atelectasis

B. Forms a strong bond with hemoglobin, creating a functional anemia. Carbon monoxide strongly binds to hemoglobin, making it unavailable for oxygen binding and transport.

A patient asks for a copy of her medical record. The best response by the nurse is to: A. State that only her family may read the record. B. Indicate that she has the right to read her record. C. Tell her that she is not allowed to read her record. D. Explain that only health care workers have access to her record.

B. Indicate that she has the right to read her record. Patients have the right to read their medical records, but the nurse should always know the facility policy regarding personal access to medical records because some require a nurse manager or other official to be present to answer questions about what is in the record. Families may read the records only when the patient has given permission.

You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet? A. The new federal laws require that teaching sheets be e-mailed to patients after they are discharged. B. You need to use words the patients can understand when writing the directions. C. The form needs to be given to patients in a sealed envelope to protect their health information. D. The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home.

B. You need to use words the patients can understand when writing the directions. Patients need to be able to understand information that you provide to them; ensure that written instructions are provided at a level that matches the patients' reading ability.

A nurse demonstrates caring by helping family members: Become active participants in care. Provide activities of daily living (ADLs). Remove themselves from personal care. Make health care decisions for the patient.

Become active participants in care. Caring for the family takes into consideration the context of the patient's illness and the stress it imposes on all members.

The nurse is caring for a patient admitted with a history of hypertension. The patient's medication history includes hydrochlorothiazide (Hydrodiuril) daily for the past 10 years. Which parameter would indicate the optimal intended effect of this drug therapy? Weight loss of 2 lb Blood pressure 128/86 Absence of ankle edema Output of 600 mL per 8 hours

Blood pressure 128/86 Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Since the patient has been taking this medication for 10 years, the most direct measurement of its intended effect would be the blood pressure.

Renal Calculi

Calcium stones in the renal pelvis.

Beyond the first year after a heart transplant, the nurse knows that what is a major cause of death? Infection Acute rejection Immunosuppression Cardiac vasculopathy

Cardiac vasculopathy Beyond the first year after a heart transplant, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated CAD) are the major causes of death. During the first year after transplant, infection and acute rejection are the major causes of death. Immunosuppressive therapy will be used for posttransplant management to prevent rejection and increases the patient's risk of an infection.

A hospice nurse sits at the bedside of a male patient in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of his disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches the patient to give care, she touches his shoulder and tells him that she is present. This is an example of what type of touch? Caring touch Protective touch Task-oriented touch Interpersonal touch

Caring touch Caring touch is a form of nonverbal communication. You express this in the way you hold a patient's hand, give a back massage, gently position a patient, or participate in a conversation. When using a caring touch, you connect with the patient physically and emotionally.

How does the nurse evaluate the effect of nasotracheal suctioning on a patient's respiratory status? Asking the patient about symptoms of respiratory difficulty Comparing respiratory assessment data from before and after the suctioning procedure. Confirming that the patient's pulse oximetry value is >90% Auscultating the patient's chest after suctioning

Comparing respiratory assessment data from before and after the suctioning procedure. Comparing presuctioning and postsuctioning assessment data will provide the best measure of the procedure's efficacy.

Presence involves a person-to-person encounter that: Enables patients to care for self. Provides personal care to a patient. Conveys a closeness and a sense of caring. Describes being in close contact with a patient.

Conveys a closeness and a sense of caring. Providing presence is a person-to-person encounter conveying closeness and a sense of caring. It involves "being there" and "being with." "Being there" is not only a physical presence but also includes communication and understanding. Presence is an interpersonal process that is characterized by sensitivity, holism, intimacy, vulnerability, and adaptation to unique circumstances.

Which of the following is a strategy for creating work environments that enable nurses to demonstrate more caring behaviors? Increasing the working hours of the staff Increasing salary benefits of the staff Creating a setting that allows flexibility and autonomy for staff Encouraging increased input concerning nursing functions from physicians

Creating a setting that allows flexibility and autonomy for staff These factors all affect nursing satisfaction. When nurses' job satisfaction is high, they have a greater connectedness with their patients and believe that caring practices are part of the nursing culture.

The nurse is caring for a 78-year-old man with diarrhea. Of the following problems, which is the most important to consider? Malnutrition Dehydration Skin breakdown Incontinence

Dehydration Diarrhea interferes with absorption time of digestive juices. With frequent loose, watery stools, dehydration becomes a major problem in the older adult.

Which of the following signs or symptoms in an opioid-naïve patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? Oxygen saturation of 95% Difficulty arousing the patient Respiratory rate of 10 breaths/min Pain intensity rating of 5 on a scale of 0 to 10

Difficulty arousing the patient Opioid-naive patients may develop a rare adverse effect of respiratory depression, and sedation always occurs before respiratory depression.

When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first? Duplex ultrasound Contrast venography Magnetic resonance venography Computed tomography venography

Duplex ultrasound The duplex ultrasound is the most widely used test to diagnose VTE. Contrast venography is rarely used now. Magnetic resonance venography is less accurate for calf veins than pelvic and proximal veins. Computed tomography venography may be used but is invasive and much more expensive than the duplex ultrasound.

Assessment findings consistent with intravenous (IV) fluid infiltration include: (Select all that apply.) Edema and pain Streak formation Pain and erythema Pallor and coolness Numbness and pain

Edema and pain Pallor and coolness Inadvertent fluid leakage into the interstitial compartment around an IV site can cause swelling, pain from the pressure, pale color, and coolness of the infiltrated area.

Helping a new mother through the birthing experience demonstrates which of Swanson's five caring processes? Knowing Enabling Doing for Being with

Enabling The caring behavior of enabling facilitates the other's passage through life transitions (e.g., birth, death) and unfamiliar events. When a nurse practices enabling, the patient and nurse work together to identify alternatives and resources.

Of the five caring processes described by Swanson, which describes "knowing the patient"? Anticipating the patient's cultural preferences Determining the patient's physician preference Establishing an understanding of a specific patient Gathering task-oriented information during assessment

Establishing an understanding of a specific patient Knowing the context of a patient's illness helps you choose and individualize interventions that will actually help him or her. Strive to understand an event as it has meaning in the life of the other. Knowing the patient is essential when providing patient-centered care. Two elements that facilitate knowing are continuity of care and clinical expertise.

You teach patients to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid? Tap water or bottled water Fluid that has sodium (salt) in it Fluid that has K+ and HCO3- in it Coffee or tea, whichever they prefer

Fluid that has sodium (salt) in it Body fluid losses remove sodium-containing fluid from the body and can cause extracellular fluid volume deficit unless both the sodium and the water are replaced.

The nurse is assessing a patient receiving enteral feedings via a small-bore nasogastric tube. Which assessment findings need further intervention? Gastric pH of 4.0 during placement check Weight gain of 1 pound over the course of a week Active bowel sounds in the four abdominal quadrants Gastric residual aspirate of 350 mL for the second consecutive time

Gastric residual aspirate of 350 mL for the second consecutive time Delayed gastric emptying is a concern if 250 mL or more remains in the patient's stomach on each of two consecutive assessments. The North American Summit on Aspiration in the Critically Ill Patient made the following recommendations regarding gastric residual volumes (GRVs): (1) stop feedings immediately if aspiration occurs; (2) withhold feedings and reassess patient tolerance to feedings if GRV is over 500 mL for two successive measurements; and (3) routinely evaluate the patient for aspiration and use nursing measures to reduce the risk of aspiration if GRV is between 250 and 500 mL.

Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results? Placing the specimen in a biohazard bag Having someone take the specimen to the lab immediately Cleaning the outside surface of the container Ensuring that a stock of sterile urine collection kits is available

Having someone take the specimen to the lab immediately Having someone take the specimen to the lab immediately will help to ensure reliable results. The specimen must be delivered to the lab within 20 minutes of collection.

A male patient was admitted for a possible ruptured aortic aneurysm, but had no back pain. Ten minutes later his assessment includes the following: sinus tachycardia at 138, BP palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret this assessment about the patient's aneurysm? Tamponade will soon occur. The renal arteries are involved. Perfusion to the legs is impaired. He is bleeding into the abdomen.

He is bleeding into the abdomen. The lack of back pain indicates the patient is most likely exsanguinating into the abdominal space, and the bleeding is likely to continue without surgical repair. A blockade of the blood flow will not occur in the abdominal space as it would in the retroperitoneal space where surrounding anatomic structures may control the bleeding. The lack of urine output does not indicate renal artery involvement, but that the bleeding is occurring above the renal arteries, which decreases the blood flow to the kidneys. There is no assessment data indicating decreased perfusion to the legs.

Based on knowledge of peptic ulcer disease (PUD), the nurse anticipates the presence of which bacteria when reviewing the laboratory data for a patient suspected of having PUD? Micrococcus Staphylococcus Corynebacterium Helicobacter pylori

Helicobacter pylori Marshall and Warren first identified Helicobacter pylori in 1984. It is a bacteria that causes up to 85% of peptic ulcers and is confirmed by laboratory tests. It is treated with antibiotics that control the bacterial infection.

What would the nurse do first to ease breathing for a patient with mild dyspnea? Administer oxygen at 2 L/min by nasal cannula. Help the patient into an upright sitting position. Monitor the patient's pulse oximetry level. Determine if the patient has a history of respiratory pathology.

Help the patient into an upright sitting position. The nurse would first try to ease the patient's breathing using a noninvasive intervention such as this one. Placing the patient in a sitting position improves lung expansion.

Nurses discourage patients from straining on defecation primarily because it causes: (Select all that apply.) Pain. Impaction. Hemorrhoids. Dysrhythmias.

Hemorrhoids Dysrhythmias The Valsalva maneuver requires the patient to hold his or her breath while straining to defecate. This maneuver increases venous pressure from straining. Over time, hemorrhoids result. In addition, this maneuver increases the risk for dysrhythmias, which are often life threatening.

A 73-year-old man with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide education on which type of diet for this patient and his caregiver? Low-fat diet High-protein diet Calorie-restricted diet High-carbohydrate diet

High-protein diet A patient with a venous ulcer should have a balanced diet with adequate protein, calories, and micronutrients; this type of diet is essential for healing. Nutrients most important for healing include protein, vitamins A and C, and zinc. Foods high in protein (e.g., meat, beans, cheese, tofu), vitamin A (green leafy vegetables), vitamin C (citrus fruits, tomatoes, cantaloupe), and zinc (meat, seafood) must be provided. Restricting fat or calories is not helpful for wound healing or in patients of normal weight. For overweight individuals with no active venous ulcer, a weight-loss diet should be considered.

When taking care of patients, the nurse routinely asks them if they take any vitamins or herbal medications, encourages family members to bring in music that the patient likes to help the patient relax, and frequently prays with her patients if that is important to them. The nurse is practicing which model? Holistic Health belief Transtheoretical Health promotion

Holistic The nurse is using a holistic model of care that considers emotional and spiritual well-being and other dimensions of an individual to be important aspects of physical wellness. The holistic health model of nursing attempts to create conditions that promote optimal health. Nurses using the holistic nursing model recognize the natural healing abilities of the body and incorporate complementary and alternative interventions such as music therapy, reminiscence, relaxation therapy, therapeutic touch, and guided imagery because they are effective, economical, noninvasive, nonpharmacological complements to traditional medical care.

Urinary Incontinence

Inability to control urine

Elimination changes that result from inability of the bladder to empty properly may cause which of the following? (Select all that apply.) Incontinence Frequency Urgency Urinary retention Urinary tract infection

Incontinence Frequency Urgency Urinary retention Urinary tract infection Any condition resulting in urinary retention increases the risk for urinary tract infection. As retention progresses, retention with overflow develops. Pressure in the bladder builds to a point at which the external urethral sphincter is unable to hold back urine. With retention the patient may void small amounts of urine 2 to 3 times an hour and have urgency. He or she may continually dribble urine. Urinary retention results from inability of the bladder to empty.

The nurse is teaching a women's group about prevention of hypertension. What information should be included in the teaching for all the women (select all that apply)? Lose weight. Limit nuts and seeds. Limit sodium and fat intake. Increase fruits and vegetables. Exercise 30 minutes most days

Increase fruits and vegetables. Limit sodium and fat intake. Exercise 30 minutes most days Primary prevention of hypertension is to make lifestyle modifications that prevent or delay the increase in BP. Along with exercise for 30 minutes on most days, the DASH eating plan is a healthy way to lower BP by limiting sodium and fat intake, increasing fruits and vegetables, and increasing nutrients that are associated with lowering BP. Nuts and seeds and dried beans are used for protein intake. Weight loss may or may not be necessary for the individual.

Diuresis

Increase rate of formation and excretion of urine.

A patient with a Foley catheter carries the collection bag at waist level when ambulating. The nurse tells the patient that he or she is at risk for: (Select all that apply.) Infection. Retention. Stagnant urine. Reflux of urine.

Infection Reflux of urine. Urine in the bag and tubing becomes a medium for bacteria, and infection is likely to develop if urine flows back into the bladder.

How might the nurse minimize the patient's anxiety when removing a nasogastric tube? Administer a mild sedative prescribed by the patient's health care provider. Ask the patient's caregiver to emotionally support the patient during the removal. Provide reassurance of what will happen during the procedure and talk the patient through the process. Instruct the patient to take deep, calming breaths while revisiting a pleasant memory.

Letting the patient know what to expect during an intervention usually reduces anxiety.

What would the nurse do routinely to monitor oxygenation in a patient receiving BiPAP? Assess the patient's level of consciousness every 4 hours. Monitor the patient's pulse oximetry readings. Verify the pressure settings for both inspiratory and expiratory pressure. Evaluate daily arterial blood gases (ABGs)

Monitor the patient's pulse oximetry readings. The nurse would routinely monitor the patient's pulse oximetry readings, because these values may reveal gradual changes in oxygenation status.

The patient is to have an intravenous pyelogram (IVP). Which of the following apply to this procedure? (Select all that apply.) Note any allergies. Monitor intake and output. Provide for perineal hygiene. Assess vital signs. Encourage fluids after the procedure.

Note any allergies. Encourage fluids after the procedure. The dye used in the procedure is iodine based. Assessing for history of any allergies can predict allergy to the dye used. Fluid intake dilutes and flushes the dye from the patient.

What would the nurse do if he or she were not able to insert a nasogastric tube in either of a patient's nares? Ask another nurse to attempt the insertion. Document the attempts in the patient's medical record. Notify the physician that the attempts were unsuccessful. Allow the patient to rest for 30 minutes before resuming the process.

Notify the physician that the attempts were unsuccessful. The nurse would notify the physician because he or she will need to attempt to insert the tube or determine another treatment option. Attempting to insert a tube again may harm the patient. Although documentation is necessary, it does not address the patient's need for a nasogastric tube. Delaying an attempt at inserting the nasogastric tube makes success no more likely and risks harming the patient.

What would be the nurse's priority in order to minimize a patient's risk for injury during oxygen therapy? Advising the patient to call for assistance before getting out of bed Instructing nursing assistive personnel (NAP) to immediately correct the flow rate if the oxygen regulator is not set as prescribed Observing the six rights of medication administration Monitoring the patient for signs of hypoxia

Observing the six rights of medication administration Oxygen is considered a medication and must be administered following the six rights of medication administration.

The health care provider's order is 1000 mL 0.9% NaCl with 20 mEq K+ intravenously over 8 hours. Which assessment finding causes you to clarify the order with the health care provider before hanging this fluid? Flat neck veins Tachycardia Hypotension Oliguria

Oliguria Administration of KCl (increased K+ intake) to a person who has oliguria (decreased K+ output) can cause hyperkalemia.

Which one of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine? Only the patient should push the button. Do not use the PCA until the pain is severe. The PCA prevents overdoses from occurring. Notify the nurse when the button is pushed.

Only the patient should push the button. Patient preparation and teaching are critical to the safe and effective use of PCA devices. Patients need to understand PCA and be physically able to locate and press the button to deliver the dose. Be sure to instruct family members not to "push the button" for the patient.

What would the nurse monitor frequently to ensure that the prescribed amount of oxygen is being delivered to a patient? Arterial blood gas (ABG) levels Oxygen flow meter setting Respiratory rate Temperature

Oxygen flow meter setting

The nurse would determine that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox) after noting what during a routine shift assessment? Generalized weakness and fatigue Crackles bilaterally in the lung bases Pain and swelling in lower extremity Abdominal pain with decreased bowel sounds

Pain and swelling in lower extremity Enoxaparin is a low-molecular-weight heparin used to prevent the development of deep vein thromboses (DVTs) in the postoperative period. Pain and swelling in the lower extremity can indicate development of DVT and therefore may signal ineffective medication therapy.

A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the physician immediately to save the patient's limb? Paralysis Paresthesia Crampiness Referred pain

Paresthesia The physician must be notified immediately if any of the six Ps of acute arterial ischemia occur to prevent ischemia from quickly progressing to tissue necrosis and gangrene. The six Ps are paresthesia, pain, pallor, pulselessness, and poikilothermia, with paralysis being a very late sign indicating the death of nerves to the extremity. Crampy leg sensation is more common with varicose veins. The pain is not referred.

If a patient who is receiving intravenous (IV) fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects: Sepsis. Phlebitis. Infiltration. Fluid overload.

Phlebitis. Redness, warmth, and tenderness at the IV site are signs of phlebitis.

What is an appropriate way for a nurse to dispose of printed patient information? A. Rip several times and place in a standard trash can B. Place in the patient's paper-based chart C. Place in a secure canister marked for shredding D. Burn the documents

Place in a secure canister marked for shredding Confidential patient information should be shredded. It is generally collected in large secure containers and shredded at scheduled times.

Which intervention might the nurse delegate to nursing assistive personnel (NAP) when inserting a nasogastric tube? Positioning the patient in a high-Fowler's position Assessing the patient's abdomen for bowel sounds Determining any history of unexplained nosebleeds Educating the patient about the need for the intervention

Place the patient in the high-Fowler's position. Positioning the patient is within NAP scope of practice. NAP are not permitted to assess bowel sounds. It is not within NAP scope of practice to determine any portion of the patient's medical history. Patient education may not be delegated to NAP.

Which action is part of the preparation for nasotracheal suctioning? Place the patient in a supine position. Preoxygenate the patient with 100% oxygen. Suction 100 mL of warm tap water to flush the suction catheter. Place water-soluble lubricant onto the open sterile catheter package.

Place water-soluble lubricant onto the open sterile catheter package. Lubricant facilitates the insertion of the catheter.

The nurse sees the nursing assistive personnel (NAP) perform the following for a patient receiving continuous enteral feedings. What intervention does the nurse need to address immediately with the NAP? The NAP: Fastens the tube to the gown with tape. Places the patient supine while giving a bath. Performs oral care for the patient. Elevates the head of the bed 45 degrees.

Places the patient supine while giving a bath. Patients receiving enteral feedings should have the head of the bed elevated a minimum of 30 degrees, preferably 45 degrees, unless medically contraindicated. Laying the patient supine increases the risk of aspiration of the feeding and should be avoided. This needs to be addressed to maintain patient safety.

The nurse is participating at a health fair at the local mall giving influenza vaccines to senior citizens. What level of prevention is the nurse practicing? Primary prevention Secondary prevention Tertiary prevention Quaternary prevention

Primary prevention Primary prevention is aimed at health promotion and includes health-education programs, immunizations, and physical and nutritional fitness activities. It can be provided to an individual and includes activities that focus on maintaining or improving the general health of individuals, families, and communities. It also includes specific protection such as immunization for influenza.

The nurse teaches a patient who has had surgery to increase which nutrient to help with tissue repair? Fat Protein Vitamin Carbohydrate

Protein Proteins provide a source of energy (4 kcal/g), and they are essential for synthesis (building) of body tissue in growth, maintenance, and repair. Collagen, hormones, enzymes, immune cells, deoxyribonucleic acid (DNA), and ribonucleic acid (RNA) are all made of protein.

The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first? Raise the head of the bed to 45 degrees. Take his oxygen saturation with a pulse oximeter. Take his blood pressure and respiratory rate. Notify the health care provider of his shortness of breath.

Raise the head of the bed to 45 degrees. Raising the head of the bed brings the diaphragm down and allows for better chest expansion, thus improving ventilation.

The nurse has completed the initial inspection of the patient's perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next? Begin to establish a sterile field. Open and assemble the urine drainage bag. Remove soiled gloves, and perform hand hygiene. Center the drape over the patient's labia.

Remove soiled gloves, and perform hand hygiene. This is the correct answer. The nurse's soiled gloves must be removed prior to setting up the sterile field.

As a nasotracheal catheter is inserted to suction the airway, a patient begins to gag and says, "I feel like I'm going to throw up." What is the nurse's best response? Complete the catheter insertion in 5 seconds or less. Remove the catheter. Encourage the patient to take several deep breaths to minimize the nausea. Stop advancing the catheter, and allow the patient to rest for several minutes.

Remove the catheter. Gagging and nausea indicate that the catheter has probably entered the esophagus and must be removed.

Assessment of a patient's peripheral IV site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first? Remove the patient's IV catheter. Apply an ice pack to the affected area. Decrease the IV rate to 20 to 30 mL/hr. Administer prophylactic anticoagulants.

Remove the patient's IV catheter. The priority intervention for superficial phlebitis is removal of the offending IV catheter. Decreasing the IV rate is insufficient. Anticoagulants are not normally required, and warm, moist heat is often therapeutic.

While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient's risk for infection? Rinse off the supplies that were contaminated with urine. Cleanse the patient's urinary meatus. Replace all contaminated supplies, and begin the process again. Change the patient's bed linens.

Replace all contaminated supplies, and begin the process again. If the sterile field is contaminated while preparing to insert an indwelling urinary catheter, all contaminated supplies must be replaced and the process begun again.

Urinary Retention

Retention of urine in the bladder; condition frequently caused by a temporary loss of muscle function.

Which nursing action is appropriate when feeding gastric residual is 50 mL? Return it to the stomach via the feeding tube. Dispose of the residual contents down the commode. Discard the stomach contents as a liquid biohazard. Return half of the volume to the stomach, and discard the rest.

Return it to the stomach via the feeding tube. If the volume of the residual stomach contents is less than 250 mL, it can be returned to the stomach via the feeding tube.

After having an MI, the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108/minute. What should the nurse suspect is happening? ADHF Chronic HF Left-sided HF Right-sided HF

Right-sided HF An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure.

When providing dietary instruction to a patient with hypertension, the nurse would advise the patient to restrict intake of which meat? Broiled fish Roasted duck Roasted turkey Baked chicken breast

Roasted duck Roasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progress of atherosclerosis and overall CVD risk. The other meats are lower in fat and are therefore acceptable in the diet.

Match the correct entry with the appropriate SOAP (Subjective—Objective—Assessment—Plan) category. S O A P 1) Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device. 2) "The pain increases every time I try to turn on my left side." 3) Acute pain related to tissue injury from surgical incision. 4) Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.

S - 2 O - 4 A - 3 P - 1

The nurse is conducting a home visit with an older adult couple. She assesses that the lighting in the home is poor and there are throw rugs throughout the home and a low footstool in the living room. She discusses removing the rugs and footstool and improving the lighting with the couple. The nurse is addressing which level of need according to Maslow? Physiological Safety and security Love and belonging Self-actualization

Safety and security The teaching addresses the need for safety and security. The throw rugs, low lighting, and low stool are hazards that can cause falls in the elderly. Preventing falls is a priority safety issue for older adults.

A patient was admitted after a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax, which includes which of the following? Sharp pleuritic pain that worsens on inspiration Crackles over lung bases of affected lung Tracheal deviation toward the affected lung Increased diaphragmatic excursion on side of rib fractures

Sharp pleuritic pain that worsens on inspiration When the lung collapses, the thoracic space fills with air on each inspiration, and the atmospheric air irritates the parietal pleura, causing pain.

The nurse is caring for a patient experiencing dysphagia. Which interventions help decrease the risk of aspiration during feeding? (Select all that apply.) Sit the patient upright in a chair. Give liquids at the end of the meal. Place food in the strong side of the mouth. Provide thin foods to make it easier to swallow. Feed the patient slowly, allowing time to chew and swallow. Encourage patient to lie down to rest for 30 minutes after eating.

Sit the patient upright in a chair. Place food in the strong side of the mouth. Feed the patient slowly, allowing time to chew and swallow. Patients with dysphagia are at risk for aspiration and need more assistance with feeding and swallowing. Feed the patient with dysphagia slowly, providing smaller-size bites, and allow the patient to chew thoroughly and swallow the bite before taking another. Position the patient in an upright, seated position in a chair or raise the head of the bed to 90 degrees. If the patient has unilateral weakness, teach him or her and caregiver to place food in the stronger side of the mouth. Additional interventions include providing a 30-minute rest period before eating. Have the patient slightly flex the head to a chin-down position to help prevent aspiration. Determine the viscosity of foods that the patient tolerates best through the use of trials of different consistencies of foods and fluids. Thicker fluids are generally easier to swallow. More frequent chewing and swallowing assessments throughout the meal are necessary. Allow the patient time to empty the mouth after each spoonful, matching the speed of feeding to the patients readiness. If the patient begins to cough or choke, remove the food immediately.

Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter? Sterile technique protects the patient from microorganisms in the urine. Sterile technique protects the nurse from microorganisms in the urine. Sterile technique reduces the amount of pain caused by the procedure. Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination.

Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination. The nurse will use sterile technique to obtain a urine specimen from an indwelling urinary catheter to ensure that any microorganisms in the specimen are from the urine, not from the patient's skin, the nurse's hands, or the environment.

When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which information do you include? TENS works by causing distraction. TENS therapy does not require a health care provider's order. TENS requires an electrical source for use. TENS electrodes are applied near or directly on the site of pain.

TENS electrodes are applied near or directly on the site of pain. TENS involves stimulation of the skin with a mild electrical current passed through external electrodes. The therapy requires a health care provider order. The TENS unit consists of a battery-powered transmitter, lead wires, and electrodes. Place the electrodes directly over or near the site of pain.

A nurse enters a patient's room, arranges the supplies for a Foley catheter insertion, and explains the procedure to the patient. She tells the patient what to expect; just before inserting the catheter, she tells the patient to relax and that, once the catheter is in place, she will not feel the bladder pressure. The nurse then proceeds to skillfully insert the Foley catheter. This is an example of what type of touch? Caring touch Protective touch Task-oriented touch Interpersonal touch

Task-oriented touch Nurses use task-orientated touch when performing a task or procedure. An expert nurse learns that any procedure is more effective when administered carefully and in consideration of any patient concern.

What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? Application of topical antibiotics to venous ulcers Maintaining the patient's legs in a dependent position Administration of oral and/or subcutaneous anticoagulants Teaching the patient the correct use of compression stockings

Teaching the patient the correct use of compression stockings CVI requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or IV, not topical. The patient should avoid prolonged positioning with the limb in a dependent position.

A patient experienced a myocardial infarction 4 weeks ago and is currently participating in the daily cardiac rehabilitation sessions at the local fitness center. In what level of prevention is the patient participating? Primary prevention Secondary prevention Tertiary prevention Quaternary prevention

Tertiary prevention Tertiary prevention involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration following the myocardial infarction. Tertiary-prevention activities are directed at rehabilitation rather than diagnosis and treatment. Care at this level aims to help patients achieve as high a level of functioning as possible, despite the limitations caused by illness or impairment. This level of care is called preventive care because it involves preventing further disability or reduced functioning.

The nurse notices that a patient has received oxycodone/acetaminophen (Percocet) (5/325) two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? The patient's level of pain The potential for addiction The amount of daily acetaminophen The risk for gastrointestinal bleeding

The amount of daily acetaminophen The major adverse effect of acetaminophen is hepatotoxicity. The maximum 24-hour dose is 4 g. It is often combined with opioids (e.g., oxycodone [Percocet]) because it reduces the dose of opioid needed to achieve successful pain control.

Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective? The collection bag has been placed on the side rail of the bed. The excess catheter tubing has been coiled beside the patient's inner thigh. The collection bag has been placed on the bed. The collection bag is held above the level of the bladder while ambulating the patient.

The excess catheter tubing has been coiled beside the patient's inner thigh. The excess drainage tubing should be coiled next to the patient's inner thigh, to facilitate urine flow.

A nurse is caring for an older adult who needs to enter an assisted-living facility following discharge from the hospital. Which of the following is an example of listening that displays caring? The nurse encourages the patient to talk about his concerns while reviewing the computer screen in the room. The nurse sits at the patient's bedside, listens as he relays his fear of never seeing his home again, and then asks if he wants anything to eat. The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story. The nurse listens to the patient talk about his fears of not returning home and then tells him to think positively.

The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story. Attentive listening lets the nurse hear the patient's story and then correctly summarize it. It does not occur when the nurse is distracted by equipment or other personnel. The importance of listening is not to distract the patient or solve the problem, but rather to hear what the patient has to say and understand what the situation means to him.

Which action would best minimize a patient's risk for infection during removal of an indwelling urinary catheter? The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. A registered nurse, not NAP, must remove the catheter. Catheter removal must be executed within 10 minutes of beginning the procedure.

The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. Using clean technique is the best way to minimize the risk of introducing pathogens to the patient's urinary tract.

The patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? The patient's wife is the best resource for determining the level of pain since she has been with him continually for the entire day. The patient's report of pain is the best method for assessing the pain. The patient's health care provider has the best knowledge of the level of pain that the patient that should be experiencing. The nurse is the most experienced at assessing pain.

The patient's report of pain is the best method for assessing the pain. A patient's self-report of pain is the single most reliable indicator of the existence and intensity of pain.

The nurse receives an order to start giving a loop diuretic to a patient to help lower his or her blood pressure. The nurse determines the appropriate route for administering the diuretic according to: Hospital policy. The prescriber's orders. The type of medication ordered. The patient's size and muscle mass.

The prescriber's orders. The order from the prescriber needs to indicate the route of administration.

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

Turn on the bathroom faucet as he tries to void The sound of running water helps many patients to void through the power of suggestion.

A nurse is administering eardrops to an 8-year-old patient with an ear infection. How does the nurse pull the patient's ear when administering the medication? Outward Back Upward and back Upward and outward

Upward and outward Eardrops are administered with the ear positioned upward and outward for patients greater than 3 years of age.

When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago, the nurse would offer patient education regarding which common complication? Urinary incontinence Urinary tract infection Adequate oral hydration Kidney stones

Urinary tract infection A urinary tract infection may develop 2 to 3 days after indwelling urinary catheter removal, and the nurse would educate the patient to be alert for signs and symptoms of such an infection.

Nocturia

Urination at night; can be symptom of renal disease or may occur in persons who drink excessively before bedtime.

Micturition

Urination; act of passing or expelling urine voluntarily through urethra.

The nurse assesses that the patient has a full bladder, and the patient states that he or she is having difficulty voiding. The nurse would teach the patient to: Use the double-voiding technique. Perform Kegel exercises. Use Credé's method. Keep a voiding diary.

Use Credé's method. With this method pressure is put on the suprapubic area with each attempted void. The maneuver promotes bladder emptying by relaxing the urethral sphincter.

Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter? Wear clean gloves when inserting the catheter. Inflate the balloon on the catheter before using it. Use the smallest-size catheter possible. Empty the urine by disconnecting the catheter from the collection bag.

Use the smallest-size catheter possible. This is the correct answer. To reduce the risk of CAUTI in a patient with an indwelling urinary catheter, the nurse would use the smallest-size catheter possible.

The patient reports tenderness when she touches her leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent which sequelae? Pulmonary embolism Pulmonary hypertension Post-thrombotic syndrome Venous thromboembolism

Venous thromboembolism The clinical manifestations are characteristic of a superficial vein thrombosis. If untreated, the clot may extend to deeper veins, and venous thromboembolism may occur. Pulmonary embolism, pulmonary hypertension, and post-thrombotic syndrome are the sequelae of venous thromboembolism.

Residual Urine

Volume of urine remaining in the bladder after normal voiding; the bladder normally is almost completely empty after micturition.

The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What should the nurse do next? Withhold the daily dose until the following day. Withhold the dose and report the potassium level. Give the digoxin with a salty snack, such as crackers. Give the digoxin with extra fluids to dilute the sodium level

Withhold the dose and report the potassium level. The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hyperkalemic, which makes the patient more prone to digoxin toxicity. For this reason, the nurse should withhold the dose and report the potassium level. The physician may order the digoxin to be given once the potassium level has been treated and decreases to within normal range.

A nurse is administering medications to a 4-year-old patient. After he or she explains which medications are being given, the mother states, "I don't remember my child having that medication before." What is the nurse's next action? Give the medications Identify the patient using two patient identifiers Withhold the medications and verify the medication orders Provide medication education to the mother to help her better understand her child's medications

Withhold the medications and verify the medication orders Do not ignore patient or caregiver concerns; always verify orders whenever a medication is questioned before administering it.

A patient is to receive cephalexin (Kefl ex) 500 mg PO. The pharmacy has sent 250-mg tablets. How many tablets does the nurse administer? ½ tablet 1 tablet 1 ½ tablets 2 tablets

2 tablets Tablets = 1tablet/250 mg× 500 mg = 500/250 = 2 tablets.

The nurse has delegated administration of a standard enema for a 72-year-old patient with constipation. Which statement made by nursing assistive personnel (NAP) requires the nurse to follow up? "I'll warm up the solution before instilling it." "I'll place the patient in the left side-lying position with the right knee bent." "I'll put a waterproof pad under the patient before I start." "I'll instill the solution and then check in on my other patients until I get the call signal."

"I'll instill the solution and then check in on my other patients until I get the call signal." After instilling the solution, NAP should remain with the patient until he or she is ready to defecate.

The nurse teaches a 28-year-old man newly diagnosed with hypertension about lifestyle modifications to reduce his blood pressure. Which statement by the patient requires an intervention by the nurse? "I will avoid adding salt to my food during or after cooking." "If I lose weight, I might not need to continue taking medications." "I can lower my blood pressure by switching to smokeless tobacco." "Diet changes can be as effective as taking blood pressure medications."

"I can lower my blood pressure by switching to smokeless tobacco." Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction and increase blood pressure. Persons with hypertension should restrict sodium to 1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of food or at meals. Weight loss can decrease blood pressure between 5 to 20 mm Hg. Following dietary recommendations (such as the DASH diet) lowers blood pressure, and these decreases compare with those achieved with blood pressure-lowering medication.

A patient with a 20-year history of diabetes mellitus had a lower leg amputation. Which statement made by the patient indicates that he is experiencing a problem with body image? "I just don't have any energy to get out of bed in the morning." "I've been attending church regularly with my wife since I got out of the hospital." "My wife has taken over paying the bills since I've been in the hospital." "I don't go out very much because everyone stares at me."

"I don't go out very much because everyone stares at me." The amputation resulted in a change in physical appearance that caused a change in body image. Reactions of patients and families to changes in body image depend on the type of changes (e.g., loss of a limb or an organ), their adaptive capacity, the rate at which changes take place, and the support services available. When a change in body image such as results from a leg amputation occurs, the patient generally adjusts in the following phases: shock, withdrawal, acknowledgment, acceptance, and rehabilitation. The patient's statement indicates he is in the stage of withdrawal.

The patient states that she "loses urine" every time she laughs or coughs. The nurse teaches the patient measures to regain urinary control. The nurse recognizes the need for further teaching when the patient states: "I will perform my Kegel exercises every day." "I joined weight watchers." "I drink two glasses of wine with dinner." "I have tried urinating every 3 hours."

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

Based on the transtheoretical model of change, what is the most appropriate response to a patient who states: "Me, exercise? I haven't done that since junior high gym class, and I hated it then!" "That's fine. Exercise is bad for you anyway." "OK. I want you to walk 3 miles 4 times a week, and I'll see you in 1 month." "I understand. Can you think of one reason why being more active would be helpful for you?" "I'd like you to ride your bike 3 times this week and eat at least four fruits and vegetables every day."

"I understand. Can you think of one reason why being more active would be helpful for you?" The patient's response indicates that the patient is in the precontemplation stage and does not intend to change his behavior in the next 6 months. In this stage the patient is not interested in information about the behavior and may be defensive when confronted with it. Asking an open-ended question may stimulate the patient to identify a reason to begin a behavior change. Nurses are challenged to motivate and facilitate change in health behavior when working with individuals.

At a clinic visit, the nurse provides dietary teaching for a 56-year-old woman who was recently hospitalized with an exacerbation of chronic heart failure. The nurse determines that teaching is successful if the patient makes which statement? "I will limit the amount of milk and cheese in my diet." "I can add salt when cooking foods but not at the table." "I will take an extra diuretic pill when I eat a lot of salt." "I can have unlimited amounts of foods labeled as reduced sodium."

"I will limit the amount of milk and cheese in my diet." Milk products should be limited to 2 cups per day for a 2500-mg sodium-restricted diet. Salt should not be added during food preparation or at the table. Diuretics should be taken as prescribed (usually daily) and not based on sodium intake. Foods labeled as reduced sodium contain at least 25% less sodium than regular.

The nurse is developing a health promotion program on healthy eating and exercise for high school students using the health belief model as a framework. Which statement made by a nursing student is related to the individual's perception of susceptibility to an illness? "I don't have time to exercise because I have to work after school every night." "I'm worried about becoming overweight and getting diabetes because my father has diabetes." "The statistics of how many teenagers are overweight is scary." "I've decided to start a walking club at school for interested students."

"I'm worried about becoming overweight and getting diabetes because my father has diabetes." The statement indicates that the patient is concerned about developing diabetes and believes that there is a risk or susceptibility based on recognition of a familial link for the disease. Once this link is recognized, the patient may perceive the personal risk for diabetes.

A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his statements would indicate a need for further education? "I'll make sure that I rest between activities so I don't get so short of breath." "I'll rest for 30 minutes before I eat my meal." "If I have trouble breathing at night, I'll use two to three pillows to prop up." "If I get short of breath, I'll turn up my oxygen level to 6 L/min."

"If I get short of breath, I'll turn up my oxygen level to 6 L/min." Hypoxia is the drive to breathe in a patient with chronic obstructive pulmonary disease who has become used to acidic pH and elevated CO2 levels. Turning up to 6 L/min increases the oxygen level, which turns off the drive to breathe.

The nurse is delegating to nursing assistive personnel (NAP) the administration of an enema for an older adult patient who is recovering from a stroke. The enema order reads, "Enemas until clear." Which statement made by NAP requires the nurse to follow up? "I'll need help to turn her onto her side." "It may take three or four enemas to achieve a clear return." "I'll test the water temperature on the inside of my own wrist." "The enema will wear her out, so I'll wait until after she ambulates."

"It may take three or four enemas to achieve a clear return." This statement requires follow-up, since administering more than three enemas can cause fluid and electrolyte imbalance, especially in an older adult patient. The health care provider should be notified if the bowel has not been evacuated after three enemas.

In reviewing medication instructions with a patient being discharged on antihypertensive medications, which statement would be most appropriate for the nurse to make when discussing guanethidine (Ismelin)? "A fast heart rate is a side effect to watch for while taking guanethidine." "Stop the drug and notify your doctor if you experience any nausea or vomiting." "Because this drug may affect the lungs in large doses, it may also help your breathing." "Make position changes slowly, especially when rising from lying down to a standing position."

"Make position changes slowly, especially when rising from lying down to a standing position." Guanethidine is a peripheral-acting α-adrenergic antagonist and can cause marked orthostatic hypotension. For this reason, the patient should be instructed to rise slowly, especially when moving from a recumbent to a standing position. Support stockings may also be helpful. Tachycardia or lung effects are not evident with guanethidine.

Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient? "Please direct the light to better illuminate the patient's perineal area." "You need to be comfortable inserting a catheter in a patient of her size." "See if a size 14-French catheter is big enough." "Find out if the patient has any allergies to latex or iodine."

"Please direct the light to better illuminate the patient's perineal area." This is the correct answer. No aspect of the skill of indwelling urinary catheter insertion may be delegated to NAP, but the nurse may delegate related tasks, such as redirecting the lighting during the procedure.

A patient is fearful of upcoming surgery and a possible cancer diagnosis. He discusses his love for the Bible with his nurse, who recommends a favorite Bible verse. Another nurse tells the patient's nurse that there is no place in nursing for spiritual caring. The patient's nurse replies: "Spiritual care should be left to a professional." "You are correct, religion is a personal decision." "Nurses should not force their religious beliefs on patients." "Spiritual, mind, and body connections can affect health."

"Spiritual, mind, and body connections can affect health." Spirituality offers a sense of connectedness, intrapersonally (connected with oneself), interpersonally (connected with others and the environment), and transpersonally (connected with the unseen, God, or a higher power). In a caring relationship the patient and nurse come to know one another so both move toward a healing relationship.

Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed? "Teach the patient the signs of a urinary tract infection." "Tell me when and how much the patient first voids." "Explain that voiding might be uncomfortable for 4 to 5 days." "Assess the patient for a distended bladder before the end of the shift."

"Tell me when and how much the patient first voids." The nurse may delegate to NAP the task of reporting the time and amount of the patient's first voiding after removal of an indwelling urinary catheter.

A70-year-old woman with chronic heart failure and atrial fibrillation asks the nurse why warfarin (Coumadin) has been prescribed for her to continue at home. Which response by the nurse is accurate? "The medication prevents blood clots from forming in your heart." "The medication dissolves clots that develop in your coronary arteries." "The medication reduces clotting by decreasing serum potassium levels." "The medication increases your heart rate so that clots do not form in your heart."

"The medication prevents blood clots from forming in your heart." Chronic heart failure causes enlargement of the chambers of the heart and an altered electrical pathway, especially in the atria. When numerous sites in the atria fire spontaneously and rapidly, atrial fibrillation occurs. Atrial fibrillation promotes thrombus formation within the atria with an increased risk of stroke and requires treatment with cardioversion, antidysrhythmics, and/or anticoagulants. Warfarin is an anticoagulant that interferes with hepatic synthesis of vitamin K-dependent clotting factors.

A patient with varicose veins has been prescribed compression stockings. How should the nurse teach the patient to use these? "Try to keep your stockings on 24 hours a day, as much as possible." "While you're still lying in bed in the morning, put on your stockings." "Dangle your feet at your bedside for 5 minutes before putting on your stockings." "Your stockings will be most effective if you can remove them for a few minutes several times a day."

"While you're still lying in bed in the morning, put on your stockings." The patient with varicose veins should apply stockings in bed, before rising in the morning. Stockings should not be worn continuously, but they should not be removed several times daily. Dangling at the bedside prior to application is likely to decrease their effectiveness.

A patient comes to the local health clinic and states: "I've noticed how many people are out walking in my neighborhood. Is walking good for you?" What is the best response to help the patient through the stages of change for exercise? "Walking is OK. I really think running is better." "Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?" "Yes, I want you to begin walking. Walk for 30 minutes every day and start to eat more fruits and vegetables." "They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes if you are going to do any good."

"Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?" The patient's response indicates that the patient is in the contemplative state, possibly intending to make a behavior change within the next 6 months. The nurse's statement reinforces the behavior and provides a specific goal for the patient to begin a walking plan.

Your patient had 200 mL of ice chips and 900 mL intravenous (IV) fluid during your shift. Which total intake should you record? 700 mL 900 mL 1000 mL 1100 mL

1000 mL Add one half the volume of ice chips to other intake to calculate total intake.

After a transurethral prostatectomy a patient returns to his room with a triple-lumen indwelling catheter and continuous bladder irrigation. The irrigation is normal saline at 150 mL/hr. The nurse empties the drainage bag for a total of 2520 mL after an 8-hour period. How much of the total is urine output? _______

1320 mL Correct Responses: "The output is determined by calculating the amount of irrigation solution and subtracting that from the total output: 150 × 8 = 1200. Total output is 2520. 2520 - 1200 = 1320 urine output., 1320 mL, 1320 mL, The output is determined by calculating the amount of irrigation solution and subtracting that from the total output: 150 × 8 = 1200. Total output is 2520. 2520 - 1200 = 1320 urine output."

List the correct order in which to apply an ostomy pouch: 1.Remove the used pouch and skin barrier. 2. Perform hand hygiene and apply clean gloves 3. Assess the stoma for color, swelling, healing. 4. Gently cleanse the peristomal skin with warm tap water. 5. Apply non-allergenic tape around the pectin skin barrier. 6. Cut an opening on the pouch 0.15cm-0.3cm larger than the stoma. 7. Press the adhesive backing of the pouch smoothly against the skin.

2. Perform hand hygiene and apply clean gloves 1.Remove the used pouch and skin barrier. 4. Gently cleanse the peristomal skin with warm tap water. 3. Assess the stoma for color, swelling, healing. 6. Cut an opening on the pouch 0.15cm-0.3cm larger than the stoma. 7. Press the adhesive backing of the pouch smoothly against the skin. 5. Apply non-allergenic tape around the pectin skin barrier.

The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT). The patient now needs to undergo surgery for appendicitis. The nurse is reviewing the laboratory results for this patient before administering an ordered dose of vitamin K. The nurse determines that the medication is both safe to give and is most needed when the international normalized ratio (INR) is which result? 1.0 1.2 1.6 2.2

2.2 Vitamin K is the antidote to warfarin (Coumadin), which the patient has most likely been taking before admission for treatment of DVT. Warfarin is an anticoagulant that impairs the ability of the blood to clot. Therefore it is necessary to give vitamin K before surgery to reduce the risk of hemorrhage. The largest value of the INR indicates the greatest impairment of clotting ability, making 2.2 the correct selection.

A cleansing enema is ordered for a 55-year-old patient before intestinal surgery. The nurse understands that the maximum amount of fluid given is: 150 to 200 mL. 200 to 400 mL. 400 to 750 mL. 750 to 1000 mL.

750 to 1000 mL. More than 1000 mL of fluid causes distention to the point of rupturing the bowel.

While suctioning the nasotracheal airway, the nurse notes that a patient's pulse rate has fallen from 102 beats/min to 80 beats/min. What is the best course of action? Encourage the patient to take several deep breaths. Interrupt suction to the catheter for at least 10 seconds. Discontinue suctioning by removing the suction catheter. Assess the patient's pulse oximetry reading to see if oxygenation is adequate.

Discontinue suctioning by removing the suction catheter. A drop in pulse of 20 beats/min or more necessitates discontinuation of suctioning and removal of the catheter.

What would the nurse do when receiving an order to increase the delivery rate of a patient's oxygen per nasal cannula from 1 L/min to 3 L/min? Encourage the patient to take deeper breaths in order to get more oxygen Change the device from nasal cannula to simple face mask Ensure that humidification is present Adjust the float ball on the flow meter to 3 L/min.

Adjust the float ball on the flow meter to 3 L/min. The nurse would increase the flow rate by moving the ball on the oxygen delivery system from 1 L/min to 3 L/min.

When assessing a 55-year-old patient who is in the clinic for a routine physical, the nurse instructs the patient about the need to obtain a stool specimen for guaiac fecal occult blood testing (gFOBT): If patient reports rectal bleeding. When there is a family history of polyps. As part of a routine examination for colon cancer. If a palpable mass is detected on digital examination.

As part of a routine examination for colon cancer. This is used as a diagnostic screening tool for colon cancer as recommended by the American Cancer Society.

An example of a nurse caring behavior that families of acutely ill patients perceive as important to patients' well-being is: Making health care decisions for patients. Having family members provide a patient's total personal hygiene. Injecting the nurse's perceptions about the level of care provided. Asking permission before performing a procedure on a patient.

Asking permission before performing a procedure on a patient. Caring for the family takes into consideration the context of the patient's illness and the stress it imposes on all members.

What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for PAD patients (select all that apply)? Ramipril (Altace) Cilostazol (Pletal) Simvastatin (Zocor) Clopidogrel (Plavix) Warfarin (Coumadin) Aspirin (acetylsalicylic acid)

Aspirin (acetylsalicylic acid) Simvastatin (Zocor) Ramipril (Altace) Angiotensin-converting enzyme inhibitors (e.g., ramipril [Altace]) are used to control hypertension. Statins (e.g., simvastatin [Zocor]) are used for lipid management. Aspirin is used as an antiplatelet agent. Cilostazol (Pletal) is used for intermittent claudication, but it does not reduce CVD morbidity and mortality risks. Clopidogrel may be used if the patient cannot tolerate aspirin. Anticoagulants (e.g., warfarin [Coumadin]) are not recommended to prevent CVD events in PAD patients.

Despite a high dosage, a male patient who is taking nifedipine (Procardia XL) for antihypertensive therapy continues to have blood pressures over 140/90 mmHg. What should the nurse do next? Assess his adherence to therapy. Ask him to make an exercise plan. Instruct him to use the DASH diet. Request a prescription for a thiazide diuretic.

Assess his adherence to therapy. A long-acting calcium-channel blocker such as nifedipine causes vascular smooth muscle relaxation resulting in decreased SVR and arterial BP and related side effects. The patient data the nurse has about this patient is very limited, so the nurse needs to assess his adherence to therapy.

After having received 0.2 mg of naloxone (Narcan) intravenous push (IVP), a patient' s respiratory rate and depth are within normal limits. The nurse now plans to implement the following action: Discontinue all ordered opioids Close the room door to allow the patient to recover Administer the remaining naloxone over 4 minutes Assess patient's vital signs every 15 minutes for 2 hours

Assess patient's vital signs every 15 minutes for 2 hours Reassess patients who receive naloxone every 15 minutes for 2 hours following drug administration because the duration of the opioid may be longer than the duration of the naloxone and respiratory depression may return.

A patient returning to the nursing unit after knee surgery is verbalizing pain at the surgical site. The nurse's first action is to: Call the patient's health care provider. Administer pain medication as ordered. Check the patient's vital signs. Assess the characteristics of the pain.

Assess the characteristics of the pain. It is necessary to monitor pain on a regular basis along with other vital signs. It is important for the nurse to understand that pain assessment is not simply a number.

Which action(s) would minimize the patient's risk for injury during insertion of an indwelling urinary catheter? Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances Thoroughly cleansing the patient's perineal area with povidone-iodine solution before inserting the catheter Performing proper hand hygiene and applying gloves before inserting the catheter Terminating the insertion if the patient reports pain at any time during the procedure

Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances This is the correct answer. Serious allergic reactions may occur if the patient has an allergy to latex, antiseptic, tape, or iodine-based cleanser.

When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to help maintain good skin integrity? Frequently applying moisturizing lotion to facial areas that come into contact with the cannula Removing the cannula every 2 hours for no longer than 10 minutes Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift Instructing the patient to inform staff of any problems with facial dryness or cracking

Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift Frequent assessment is a priority and will help the nurse identify early signs of skin breakdown.

What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart failure? Urine output Lung sounds Blood pressure Respiratory rate

Blood pressure Although all identified assessments are appropriate for a patient receiving IV nesiritide, the priority assessment would be monitoring for hypotension, the main adverse effect of nesiritide.

A stable patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before positioning the patient on the bedside, what should the nurse assess first? Urine output Heart rhythm Breath sounds Blood pressure

Blood pressure The nurse should evaluate the blood pressure before dangling the patient on the bedside because the blood pressure can decrease as blood pools in the periphery and preload decreases. If the patient's blood pressure is low or marginal, the nurse should put the patient in the semi-Fowler's position and use other measures to improve gas exchange.

The nurse is caring for a patient admitted with chronic obstructive pulmonary disease (COPD), angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg PO, the nurse assesses the patient carefully. Which adverse effect is this patient at risk for, given the patient's health history? Hypocapnia Tachycardia Bronchospasm Nausea and vomiting

Bronchospasm Atenolol is a cardioselective β1-adrenergic blocker that reduces blood pressure and could affect the β2-receptors in the lungs with larger doses or with drug accumulation. Although the risk of bronchospasm is less with cardioselective β-blockers than nonselective β-blockers, atenolol should be used cautiously in patients with COPD.

How could the nurse assess the patency of a nasogastric (NG) tube being used for enteral nutrition? Elevate the head of the patient's bed to at least 30 degrees. Use an intravenous fluid infusion set. Check the gastric residual volume. Monitor the amount of intake the patient tolerates in an 8-hour period.

Check the gastric residual volume. The nurse would check gastric residual volume. Doing so could determine the patency of the feeding tube. Monitoring the patient's intake in 8 hours does not address the patency of the NG tube. Intravenous infusion sets should not be used to infuse tube feedings. Elevating the head of the bed does not address the patency of the NG tube.

A 40-year-old man tells the nurse he has a diagnosis for the color and temperature changes of his limbs but can't remember the name of it. He says he must stop smoking and avoid trauma and exposure of his limbs to cold temperatures to get better. This description should allow the nurse to ask the patient if he has which diagnosis? Buerger's disease Venous thrombosis Acute arterial ischemia Raynaud's phenomenon

Buerger's disease Buerger's disease is a nonatherosclerotic, segmental, recurrent inflammatory disorder of small and medium-sized veins and arteries of upper and lower extremities leading to color and temperature changes of the limbs, intermittent claudication, rest pain, and ischemic ulcerations. It primarily occurs in men younger than 45 years old with a long history of tobacco and/or marijuana use. Buerger's disease treatment includes smoking cessation, trauma and cold temperature avoidance, and a walking program. Venous thrombosis is the formation of a thrombus in association with inflammation of the vein. Acute arterial ischemia is a sudden interruption in arterial blood flow to a tissue caused by embolism, thrombosis, or trauma. Raynaud's phenomenon is characterized by vasospasm-induced color changes of the fingers, toes, ears, and nose.

The nurse admits a 73-year-old male patient with dementia for treatment of uncontrolled hypertension. The nurse will closely monitor for hypokalemia if the patient receives which medication? Clonidine (Catapres) Bumetanide (Bumex) Amiloride (Midamor) Spironolactone (Aldactone)

Bumetanide (Bumex) Bumetanide is a loop diuretic. Hypokalemia is a common adverse effect of this medication. Amiloride is a potassium-sparing diuretic. Spironolactone is an aldosterone-receptor blocker. Hyperkalemia is an adverse effect of both amiloride and spironolactone. Clonidine is a central-acting α-adrenergic antagonist and does not cause electrolyte abnormalities.

The nurse is having difficulty reading a physician's order for a medication. He or she knows that the physician is very busy and does not like to be called. What is the most appropriate next step for the nurse to take? Call a pharmacist to interpret the order Call the physician to have the order clarified Consult the unit manager to help interpret the order Ask the unit secretary to interpret the physician's handwriting

Call the physician to have the order clarified You must have the right documentation and clarify all orders with the prescriber before administering medications.

A health care provider writes the following order for an opioidnaive patient who returned from the operating room following a total hip replacement. "Fentanyl patch 100 mcg, change every 3 days." Based on this order, the nurse takes the following action: Calls the health care provider, and questions the order Applies the patch the third postoperative day Applies the patch as soon as the patient reports pain Places the patch as close to the hip dressing as possible

Calls the health care provider, and questions the order Fentanyl is 100 times more potent than morphine and not recommended for acute postoperative pain.

The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? Decreased cardiac output Increased blood pressure Cerebral or pulmonary emboli Excessive bleeding from incision or IV sites

Cerebral or pulmonary emboli Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. Once the medication is terminated, thrombi could again form. If one or more thrombi detach from the atrial wall, they could travel as cerebral emboli from the left atrium or pulmonary emboli from the right atrium.

Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter? Using a 5-mL syringe to deflate the balloon Using sterile scissors to cut the valve to deflate the balloon Tugging gently on the catheter to pull the balloon through the urethra Checking the documentation for the volume of fluid used to inflate the balloon

Checking the documentation for the volume of fluid used to inflate the balloon Checking the volume of fluid used to inflate the balloon in order to ensure the balloon is completely deflated before removal is the nursing action that will minimize a patient's risk for injury during removal of an indwelling urinary catheter.

A male patient with a long-standing history of heart failure has recently qualified for hospice care. What measure should the nurse now prioritize when providing care for this patient? Taper the patient off his current medications. Continue education for the patient and his family. Pursue experimental therapies or surgical options. Choose interventions to promote comfort and prevent suffering

Choose interventions to promote comfort and prevent suffering The central focus of hospice care is the promotion of comfort and the prevention of suffering. Patient education should continue, but providing comfort is paramount. Medications should be continued unless they are not tolerated. Experimental therapies and surgeries are not commonly used in the care of hospice patients.

When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected? Checking the patency of the indwelling catheter tubing Placing the urinary collection bag below the level of the bladder Clamping the catheter tubing for 15 minutes before collection Asking the patient to drink a glass of water 30 minutes before the collection

Clamping the catheter tubing for 15 minutes before collection Clamping the catheter tubing for 15 minutes before collection will ensure that sufficient urine is available for the specimen.

Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter? Frequently pull on the drainage system tubing. Use the largest-size catheter possible. Clean the urinary meatus daily. Apply antiseptics to the urinary meatus.

Clean the urinary meatus daily. To reduce the risk of CAUTI, daily cleansing of the urinary meatus is necessary.

Which action is most useful in evaluating the effectiveness of oropharyngeal suctioning? Comparing presuctioning and postsuctioning respiratory assessment data Confirming that the patient's pulse oximetry value is >90% Asking the patient to report any symptoms of dyspnea Assessing the patient's skin for signs of cyanosis

Comparing presuctioning and postsuctioning respiratory assessment data Comparing presuctioning and postsuctioning assessment data allows the nurse to compare the patient's postintervention respiratory status against his or her baseline to see if it has improved.

Today she has gone to the ED, and her blood pressure has risen to 200/140. What is the priority assessment for the nurse to make? Is the patient pregnant? Does the patient need to urinate? Does the patient have a headache or confusion? Is the patient taking antiseizure medications as prescribed?

Does the patient have a headache or confusion? The nurse's priority assessments include neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertensive encephalopathy from increased cerebral capillary permeability leading to cerebral edema. Pregnancy can lead to secondary hypertension. Needing to urinate and taking antiseizure medication do not support a hypertensive emergency.

A patient with a diagnosis of heart failure has been started on a nitroglycerin patch by his primary care provider. What should this patient be taught to avoid? High-potassium foods Drugs to treat erectile dysfunction Nonsteroidal antiinflammatory drugs Over-the-counter H2-receptor blockers

Drugs to treat erectile dysfunction The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death. High-potassium foods, NSAIDs, and H2-receptor blockers do not pose a risk in combination with nitrates.

The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse expect to include in the plan of care for this patient (select all that apply)? Left ventricular function is documented. Controlling dysrhythmias will eliminate HF. Prescription for digoxin (Lanoxin) at discharge Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen

Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge Left ventricular function is documented. The Joint Commission has identified these three core measures for heart failure patients. Although controlling dysrhythmias will improve CO and workload, it will not eliminate HF. Prescribing digoxin for all HF patients is no longer done because there are newer effective drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range must be maintained.

Why does the nurse elevate the head of the bed to 30 degrees for a patient receiving an intermittent tube feeding? Elevating the head of the bed reduces the risk for aspiration. Proper elevation of the head of the bed promotes the patient's digestion. Acid reflux is reduced when the head of the bed is elevated at least 30 degrees. Nutrients are absorbed more efficiently when the head of the bed is elevated.

Elevating the head of the bed reduces the risk for aspiration. Digestion is not affected when the head of the bed is elevated. Reducing acid reflux is not the reason for elevating the head of the bed. Nutrient absorption is unaffected by elevating the head of the bed.

What should the nurse do when a patient is ordered to receive 4 L/min oxygen by nasal cannula? Encourage oral fluids. Restrict fluids. Ensure that humidification is present. Measure blood pressure every hour.

Ensure that humidification is present. If the oxygen flow rate is 4 L/min or higher, add humidification and verify that water is bubbling in the humidifier.

A patient is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe medication administration for the discharge nurse? Set up the follow-up appointments with the physician for the patient. Ensure that someone will provide housekeeping for the patient at home. Ensure that the home care agency is aware of medication and health teaching needs. Make sure that the patient's family knows how to safely bathe him or her and provide mouth care.

Ensure that the home care agency is aware of medication and health teaching needs. A nursing responsibility is to collaborate with community resources when patients have home care needs or difficulty understanding their medications.

When caring for a patient who is receiving supplemental oxygen by face tent, which action ensures that the oxygen is flowing? Testing the closing capacity of the mask's valves Routinely monitoring the seal over the patient's mouth and nose Ensuring that a mist is always present Regularly verifying that the mask is positioned loosely

Ensuring that a mist is always present It is appropriate to ensure that a mist is always present when oxygen is delivered by face tent.

What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube? Examine each naris for patency and skin breakdown. Place the patient in the high-Fowler's position. Anesthetize the throat. Have the patient take a few sips of water.

Examine each naris for patency and skin breakdown. Examining each naris for patency and signs of skin breakdown will help the nurse determine which naris will accommodate a nasogastric tube with less discomfort. Although the high-Fowler's position is recommended for insertion of a nasogastric tube, the position itself will not reduce discomfort. Anesthetizing the throat would hinder the patient's ability to swallow safely during insertion of the nasogastric tube. Sipping water will not reduce the patient's discomfort.

After seeing a patient, the physician gives a nursing student a verbal order for a new medication. The nursing student first needs to: Follow ISMP guidelines for safe medication abbreviations. Explain to the physician that the order needs to be given to a registered nurse. Write down the order on the patient's order sheet and read it back to the physician. Ensure that the six rights of medication administration are followed when giving the medication.

Explain to the physician that the order needs to be given to a registered nurse. Nursing students cannot take orders.

What patient care might the nurse delegate to nursing assistive personnel (NAP) when a patient's nasogastric tube is removed? Assessing the patient for abdominal distention Providing the patient with mouth care Documenting tube removal Checking for bowel sounds

Providing the patient with mouth care The skill of mouth care may be delegated to NAP.

The nurse assesses the following risk factors for coronary artery disease (CAD) in a male patient. Which factors are classified as genetic and physiological? (Select all that apply.) Sedentary lifestyle Father died from CAD at age 50 History of hypertension Eats diet high in sodium Elevated cholesterol level Age is 44 years

Father died from CAD at age 50 History of hypertension Elevated cholesterol level Age is 44 years Genetic and physiological risk factors include those related to heredity, genetic predisposition to an illness, or those that involve the physical functioning of the body. Certain physical conditions such as being pregnant or overweight place increased stress on physiological systems (e.g., the circulatory system), increasing susceptibility to illness in these areas. A person with a family history of coronary artery disease is at risk for developing the disease later in life because of a hereditary and genetic predisposition to the disease.

Which is not an expected outcome on a first voiding after catheter removal? Mild burning Fever and back pain Producing only a small amount of urine Discomfort

Fever and back pain The nurse would instruct the patient to report signs of a urinary tract infection, such as fever and back pain. These signs are unlikely to be present during the patient's first voiding after catheter removal.

A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104°F (40°C). What physiological process explains why the child is at risk for developing dyspnea? Fever increases metabolic demands, requiring increased oxygen need. Blood glucose stores are depleted, and the cells do not have energy to use oxygen. Carbon dioxide production increases as result of hyperventilation. Carbon dioxide production decreases as a result of hypoventilation.

Fever increases metabolic demands, requiring increased oxygen need. When the body cannot meet the increased oxygenation need, the increased metabolic rate causes breakdown of protein and wasting of respiratory muscles, increasing the work of breathing.

Which measure may be taken to minimize the staff's risk for infection from a urine specimen? Firmly securing the lid of the urine specimen container Using a sterile urine specimen container Using a sterile syringe to access the sampling portd. Placing the urine specimen container in the refrigerator until the laboratory comes to get it

Firmly securing the lid of the urine specimen container Securing the specimen container lid is one way to minimize the risk for infection to the staff.

The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism? Hypertension promotes atherosclerosis and damage to the walls of the arteries. Hypertension causes direct pressure on organs, resulting in necrosis and replacement of cells with scar tissue. Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems. Hypertension increases blood viscosity, which contributes to intravascular coagulation and tissue necrosis distal to occlusions.

Hypertension promotes atherosclerosis and damage to the walls of the arteries. Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, once atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues.

What should the nurse recognize as an indication for the use of dopamine (Intropin) in the care of a patient with heart failure? Acute anxiety Hypotension and tachycardia Peripheral edema and weight gain Paroxysmal nocturnal dyspnea (PND)

Hypotension and tachycardia Dopamine is a β-adrenergic agonist whose inotropic action is used for treatment of severe heart failure accompanied by hemodynamic instability. Such a state may be indicated by tachycardia accompanied by hypotension. PND, anxiety, edema, and weight gain are common signs and symptoms of heart failure, but these do not necessarily warrant the use of dopamine.

Which statement made by an adult patient demonstrates understanding of healthy nutrition teaching? I need to stop eating red meat. I will increase the servings of fruit juice to four a day. I will make sure that I eat a balanced diet and exercise regularly. I will not eat so many dark green vegetables and eat more yellow vegetables.

I will make sure that I eat a balanced diet and exercise regularly. Obesity is an epidemic in the United States. Proposed contributing factors are sedentary lifestyle and poor meal choices. Healthy eating and participation in exercise or other activities of healthy living promote good health.

Listening is not only "taking in" what a patient says; it also includes: Incorporating the views of the physician. Correcting any errors in the patient's understanding. Injecting the nurse's personal views and statements. Interpreting and understanding what the patient means.

Interpreting and understanding what the patient means. Listening is powerful. It conveys the nurse's full attention and interest. A true caring presence involves listening. Listen to what is important to another person and the meaning of a situation to that person.

When illness occurs, different attitudes about it cause people to react in different ways. What do medical sociologists call this reaction to illness? Health belief Illness behavior Health promotion Illness prevention

Illness behavior The nurse is using a holistic model of care that considers emotional and spiritual well-being and other dimensions of an individual to be important aspects of physical wellness. The holistic health model of nursing attempts to create conditions that promote optimal health. Nurses using the holistic nursing model recognize the natural healing abilities of the body and incorporate complementary and alternative interventions such as music therapy, reminiscence, relaxation therapy, therapeutic touch, and guided imagery because they are effective, economical, noninvasive, nonpharmacological complements to traditional medical care.

A 32-year-old female is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To evaluate the patient's expected response to this medication, what is most important for the nurse to assess? Improved skin turgor Decreased cardiac rate Improved finger perfusion Decreased mean arterial pressure

Improved finger perfusion Raynaud's phenomenon is an episodic vasospastic disorder of small cutaneous arteries, most frequently involving the fingers and toes. Diltiazem (Cardizem) is a calcium channel blocker that relaxes smooth muscles of the arterioles by blocking the influx of calcium into the cells, thus reducing the frequency and severity of vasospastic attacks. Perfusion to the fingertips is improved and vasospastic attacks reduced. Diltiazem may decrease heart rate and blood pressure, but that is not the purpose in Raynaud's phenomenon. Skin turgor is most often a reflection of hydration status.

When teaching how lisinopril (Zestril) will help lower the patient's blood pressure, which mechanism of action should the nurse use to explain it? Blocks β-adrenergic effects. Relaxes arterial and venous smooth muscle. Inhibits conversion of angiotensin I to angiotensin II. Reduces sympathetic outflow from central nervous system

Inhibits conversion of angiotensin I to angiotensin II. Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that inhibits the conversion of angiotensin I to angiotensin II, which reduces angiotensin II-mediated vasoconstriction and sodium and water retention. Beta blockers result in vasodilation and decreased heart rate. Direct vasodilators relax arterial and venous smooth muscle. Central acting α-adrenergic antagonists reduce sympathetic outflow from the CNS to produce vasodilation and decreased SVR and BP.

When a nurse helps a patient find the meaning of cancer by supporting beliefs about life, this is an example of: Instilling hope and faith. Forming a human-altruistic value system. Cultural caring. Being with.

Instilling hope and faith. Instilling hope and faith helps to increase an individual's capacity to get through an event or transition and face the future with meaning.

A patient admitted with heart failure appears very anxious and complains of shortness of breath. Which nursing actions would be appropriate to alleviate this patient's anxiety (select all that apply)? Administer ordered morphine sulfate. Position patient in a semi-Fowler's position. Position patient on left side with head of bed flat. Instruct patient on the use of relaxation techniques. Use a calm, reassuring approach while talking to patient.

Instruct patient on the use of relaxation techniques. Use a calm, reassuring approach while talking to patient. Position patient in a semi-Fowler's position. Administer ordered morphine sulfate. Morphine sulfate reduces anxiety and may assist in reducing dyspnea. The patient should be positioned in semi-Fowler's position to improve ventilation that will reduce anxiety. Relaxation techniques and a calm reassuring approach will also serve to reduce anxiety.

During an admission interview, a patient who is required to stay in the supine position reports, "I can't breathe well while I'm lying down." What would the nurse do first to help this patient? Notify the health care provider of the patient's complaint. Request that the health care provider prescribe oxygen therapy. Interview the patient concerning the onset of this problem. Instruct the patient to use two bed pillows when lying supine.

Instruct the patient to use two bed pillows when lying supine. Instructing the patient to use two bed pillows when lying supine is an appropriate intervention at this time.

What is a priority intervention when performing oropharyngeal suctioning for a patient who is receiving oxygen by face mask? Complete the suctioning process in 20 seconds or less. Keep the oxygen mask near the patient's face during the suctioning procedure. Encourage the patient to take several deep breaths before suctioning begins. Increase the oxygen flow rate by 1 L/min for 3 minutes before suctioning.

Keep the oxygen mask near the patient's face during the suctioning procedure. Keeping the oxygen mask near the patient's face during the intervention ensures that oxygen therapy will not be interrupted.

During the nursing assessment a patient reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms are associated with: Food allergy. Irritable bowel. Lactose intolerance. Increased peristalsis.

Lactose intolerance. This patient possibly lacks the enzyme needed to digest milk sugar lactase and therefore is potentially lactose intolerant.

The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new order for enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to correctly administer this medication? Spread the skin before inserting the needle. Leave the air bubble in the prefilled syringe. Use the back of the arm as the preferred site. Sit the patient at a 30-degree angle before administration.

Leave the air bubble in the prefilled syringe. The nurse should not expel the air bubble from the prefilled syringe because it should be injected to clear the needle of medication and avoid leaving medication in the needle track in the tissue.

To minimize the patient experiencing nocturia, the nurse would teach him or her to: Perform perineal hygiene after urinating. Set up a toileting schedule. Double void. Limit fluids before bedtime.

Limit fluids before bedtime. With nocturia the patient has to get up during the night to urinate. Limiting fluids 2 hours before bedtime minimizes nocturia.

When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what? Remove the cotton balls from the kit for later use. Advance the catheter 10 to 12 inches or until urine flows. Lubricate the first 5 to 7 inches of the catheter. Hold the penis at a 45-degree angle during insertion.

Lubricate the first 5 to 7 inches of the catheter. The first 5 to 7 inches of the catheter is lubricated to ease insertion. The penis is to be held at a 90-degree angle, not a 45-degree angle. The catheter should be inserted 7 to 9 inches or until urine flows, not 10 to 12 inches. The cotton balls will be used for cleansing.

The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube? Place the patient in a side-lying position with the right knee flexed. Lubricate the first 6 to 8 cm (2.5 to 3 inches) of the tip of the tube. Flush the tube with the solution Hold the tube in the rectum until all of the fluid has been instilled.

Lubricate the first 6 to 8 cm (2.5 to 3 inches) of the tip of the tube. This technique facilitates insertion of the rectal tube.

A 67-year-old woman with a history of coronary artery disease and prior myocardial infarction is admitted to the emergency department with a blood pressure of 234/148 mm Hg and started on IV nitroprusside (Nitropress). What should the nurse determine as an appropriate goal for the first hour of treatment? Mean arterial pressure lower than 70 mm Hg Mean arterial pressure no more than 120 mm Hg Mean arterial pressure no lower than 133 mm Hg Mean arterial pressure between 70 and 110 mm Hg

Mean arterial pressure no lower than 133 mm Hg The initial treatment goal is to decrease mean arterial pressure by no more than 25% within minutes to 1 hour. If the patient is stable, the goal for BP is 160/100 to 110 mm Hg over the next 2 to 6 hours. Lowering the blood pressure too much may decrease cerebral, coronary, or renal perfusion and could precipitate a stroke, myocardial infarction, or renal failure. Additional gradual reductions toward a normal blood pressure should be implemented over the next 24 to 48 hours if the patient is clinically stable.

After unsuccessfully attempting to flush a nasogastric (NG) tube with water, what is the most appropriate action for the nurse to take? Flush the tube with ginger ale. Use apple juice to flush the tube. Obtain a product designed to unclog NG tubes. Force-flush the system with sterile normal saline.

Obtain a product designed to unclog NG tubes. If the feeding tube becomes clogged, the nurse should obtain and use an unclogging product for feeding tubes. Ginger ale and other sodas can increase the risk of clogging. Flushing with juice can increase the risk of clogging. Never force-flush a feeding tube. Doing so could rupture the tube and harm the patient.

A 67-year-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication? Patient complains of chest pain with strenuous activity. Patient says muscle leg pain occurs with continued exercise. Patient has numbness and tingling of all his toes and both feet. Patient states the feet become red if he puts them in a dependent position.

Patient says muscle leg pain occurs with continued exercise. Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain with exertion. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position the term is dependent rubor.

A patient at the community clinic asks the nurse about health promotion activities that she can do because she is concerned about getting diabetes mellitus since her grandfather and father both have the disease. This statement reflects that the patient is in what stage of the health belief model? Perceived threat of the disease Likelihood of taking preventive health action Analysis of perceived benefits of preventive action Perceived susceptibility to the disease.

Perceived susceptibility to the disease. The health belief model addresses the relationship between a person's beliefs and behaviors. It provides a way of understanding and predicting how patients will behave in relation to their health and how they will comply with health care therapies. In the perceived susceptibility to the disease phase, the patient recognizes the familial link to the disease.

Which action would the nurse take to reduce the risk of infection among patients and staff when administering an enema to an older adult patient with dementia? Lubricate the tip of the rectal tube. Pad the patient's bed thoroughly. Perform hand hygiene before donning gloves. Help the patient onto a bedpan to expel the enema fluid and stool.

Perform hand hygiene before donning gloves. Performing hand hygiene before donning gloves and after removing them is appropriate in order to reduce the risk of infection among patients and staff.

A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: Addiction. Tolerance. Pseudoaddiction. Physical dependence.

Physical dependence. Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to administer this medication correctly? Remove the air bubble in the prefilled syringe. Aspirate before injection to prevent IV administration. Rub the injection site after administration to enhance absorption. Pinch the skin between the thumb and forefinger before inserting the needle

Pinch the skin between the thumb and forefinger before inserting the needle The nurse should gather together or "bunch up" the skin between the thumb and the forefinger before inserting the needle into the subcutaneous tissue. The nurse should not remove the air bubble in the prefilled syringe, aspirate, nor rub the site after injection.

After oropharyngeal suctioning, what does the nurse do with the supplies? Place the Yankauer catheter in a clean, dry area. Place all disposable equipment into the wrapper of the suction catheter before discarding it in a trash receptacle. Fold the paper drape with the outer surface inward, and dispose of it in a biohazard receptacle. Place dirty gloves in the biohazard receptacle in the patient's room.

Place the Yankauer catheter in a clean, dry area. Placing the Yankauer catheter in a clean, dry area will protect it until it is needed again.

Which action would the nurse perform when preparing to suction a patient's oropharynx? Apply sterile gloves. Place the patient in a semi-Fowler's or sitting position. Remove the nasal cannula. Flush the suction catheter with 200 mL of warm tap water.

Place the patient in a semi-Fowler's or sitting position. A semi-Fowler's or sitting position would facilitate this intervention.

Which action is initially taken by the nurse to verify correct position of a newly placed small-bore feeding tube? Placing an order for x-ray film examination to check position Confirming the distal mark on the feeding tube after taping Testing the pH of the gastric contents and observing the color Auscultating over the gastric area as air is injected into the tube

Placing an order for x-ray film examination to check position At present the most reliable method for verification of placement of small-bore feeding tubes is x-ray film examination. The measurement of the pH of gastric secretions withdrawn from the feeding tube helps to determine the location of the tube. Auscultation has repeatedly been shown to be ineffective in detecting tubes accidentally placed in the lung. Further, it is not effective in distinguishing between gastric and intestinal placement for feeding tubes.

The nurse is caring for a patient who is recovering from a left partial lobectomy. Which action would be most helpful in reexpanding the affected lung? Placing the patient in a right side-lying position Encouraging the patient to deep breathe and cough every hour Regularly assessing the patient's ability to breathe comfortably Providing medication to manage postoperative pain of greater than 3 on a 0-to-10 scale

Placing the patient in a right side-lying position Placing the patient in a right side-lying position will facilitate reexpansion of the affected lung. The unaffected lung should be next to the bed, and the affected lung should be up.

What is the proper response to the nurse's observation that the patient's closed-system enteral feeding has 150 mL of formula remaining and that the infusion order rate is for 50 mL/hr? Recalculate the present drip factor for accuracy. Terminate the fluid, and prepare to hang a new bag of formula. Plan to check the feeding for completion within the next 3 hours. Check with the pharmacy to see if the formula has been hanging too long.

Plan to check the feeding for completion within the next 3 hours. Because the ordered dose is 50 mL/hr, checking for completion within 3 hours is the right choice.

The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which laboratory study is abnormal before administering the dose? Hematocrit (Hct) Hemoglobin (Hgb) Prothrombin time (PT) Correct Partial thromboplastin time (PTT)

Prothrombin time (PT) Correct Vitamin K counteracts hypoprothrombinemia and/or reverses the effects of warfarin (Coumadin) and thus decreases the risk of bleeding. High values for either the prothrombin time (PT) or the international normalized ratio (INR) demonstrates the need for this medication.

Which action would the nurse take to ensure the safety of an older adult patient who has received an enema? Assess for the presence of external hemorrhoids. Provide assistance to the bathroom for expulsion of fluid and stool. Document the patient's physical response to the enema. Instruct the patient to attempt to retain the fluid for 2 to 5 minutes.

Provide assistance to the bathroom for expulsion of fluid and stool. Assisting an older adult to the bathroom helps ensure the patient's safety because it may prevent a fall.

The nurse is caring for a patient with hypertension who is scheduled to receive a dose of esmolol (Brevibloc). The nurse should withhold the dose and consult the prescribing physician for which vital sign taken just before administration? Pulse 48 Respirations 24 Blood pressure 118/74 Oxygen saturation 93%

Pulse 48 Because esmolol is a β1-adrenergic blocking agent, it can cause hypotension and bradycardia as adverse effects. The nurse should withhold the dose and consult with the health care provider for parameters regarding pulse rate limits.

A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix) in an effort to physiologically do what for the patient? Reduce preload. Decrease afterload. Increase contractility. Promote vasodilation.

Reduce preload. Diuretics such as furosemide are used in the treatment of HF to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. They do not directly influence afterload, contractility, or vessel tone.

What can the nurse do to evaluate a patient's response to continuous oxygen therapy delivered at 4 L/min by nasal cannula? Regularly measure and trend the patient's pulse oximetry (SpO2) values. Evaluate venous blood levels every morning. Monitor the patient's arterial blood gas (ABG) levels hourly. Assess the patient for compliance with the prescribed therapy.

Regularly measure and trend the patient's pulse oximetry (SpO2) values. Measuring and analyzing the patient's pulse oximetry values will provide objective information about the patient's response to oxygen therapy.

A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she "doesn't feel comfortable in this position" and that her "back really hurts." What is the nurse's best response? Reassure the patient that the procedure will take only a few minutes. Promise to reposition the patient as soon as the catheter has been inserted. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. Explain to the patient that the position will allow the catheter insertion to be more efficient.

Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. This is the correct answer. The side-lying (Sims') position is an acceptable alternative that may be more comfortable for the patient.

A patient with a history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The health care provider's order reads as follows: "Vicodin 1 tab, per tube, q4 hours, prn." Which action by the nurse is most appropriate? No action is required by the nurse because the order is appropriate. Request to have the ordered changed to ATC for the first 48 hours. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3 hours, prn. Begin the Vicodin when the patient shows nonverbal symptoms of pain.

Request to have the ordered changed to ATC for the first 48 hours. The American Pain Society (2003) states that, if you anticipate pain for most of the day, you should consider ATC administration. Insertion of a gastrostomy tube is painful. This patient will most likely experience pain for at least the next 48 hours.

The patient has CVI and a venous ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what these patients always have ordered. What assessment by the nurse would cause the application of compression stockings to harm the patient? Rest pain High blood pressure Elevated blood sugar Dry, itchy, flaky skin

Rest pain Rest pain occurs as peripheral artery disease (PAD) progresses and involves multiple arterial segments. Compression stockings should not be used on patients with PAD. Elevated blood glucose, possibly indicating uncontrolled diabetes mellitus, and hypertension may or may not indicate arterial problems. Dry, itchy, flaky skin indicates venous insufficiency. The RN should be the one to obtain the order and instruct the UAP to apply compression stockings if they are ordered.

When teaching a patient about dietary management of stage 1 hypertension, which instruction is most appropriate? Restrict all caffeine. Restrict sodium intake. Increase protein intake. Use calcium supplements.

Restrict sodium intake. The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Caffeine and protein intake do not affect hypertension. Calcium supplements are not recommended to lower BP.

A nurse works in a special care unit for children with severe immunology problems and is caring for a 3-year-old boy from Greece. The boy's father is with him while his mother and sister are back in Greece. The nurse is having difficulty communicating with the father. What action does the nurse take? Care for the boy as she would any other patient Ask the manager to talk with the father and keep him out of the unit Have another nurse care for the boy because maybe that nurse will do better with the father Search for help with interpretation and understanding of the cultural differences by contacting someone from the local Greek community

Search for help with interpretation and understanding of the cultural differences by contacting someone from the local Greek community The nurse needs to understand how the Greek culture impacts the father's health beliefs and communication with health care providers. Cultural variables must be incorporated into the child's plan of care. Cultural background influences beliefs, values, and customs. It influences the approach to the health care system, personal health practices, and the nurse-patient relationship. Cultural background may also influence an individual's beliefs about causes of illness and remedies or practices to restore health. If nurses are not aware of their own and other cultural patterns of behavior and language, they may not be able to recognize and understand a patient's behavior and beliefs and may have difficulty interacting with the patient.

The nurse is caring for a patient with a colostomy. Which intervention is most important? Cleansing the stoma with hot water Inserting a deodorant tablet in the stoma bag Selecting a bag with an appropriate-size stoma opening Wearing sterile gloves while caring for the stoma

Selecting a bag with an appropriate-size stoma opening The opening of the appliance should be no larger than 0.15 to 0.3 cm (1/16 to 1/8 inch) surrounding the stoma to ensure that the skin around the stoma is protected from the enzymes present in the effluent without impinging the stoma.

In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? BUN of 15 mg/dL Serum uric acid of 3.8 mg/dL Serum creatinine of 2.6 mg/dL Correct Serum potassium of 3.5 mEq/L

Serum creatinine of 2.6 mg/dL The normal serum creatinine level is 0.6-1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other lab results are within normal limits.

A patient with a cardiac history is taking the diuretic furosemide (Lasix) and is seen in the emergency department for muscle weakness. Which laboratory value do you assess first? Serum albumin Serum sodium Hematocrit Serum potassium

Serum potassium Potassium-wasting diuretics such as furosemide increase potassium urinary output and can cause hypokalemia unless potassium intake also increases. Hypokalemia causes muscle weakness.

The nurse prepares to administer digoxin (Lanoxin) 0.125 mg to an 82-year-old man admitted with influenza and a history of chronic heart failure. What should the nurse assess before giving the medication? Prothrombin time Urine specific gravity Serum potassium level Hemoglobin and hematocrit

Serum potassium level Serum potassium should be monitored because hypokalemia increases the risk for digoxin toxicity. Changes in prothrombin time, urine specific gravity, and hemoglobin or hematocrit would not require holding the digoxin dose.

The home care nurse visits a 73-year-old Hispanic woman with chronic heart failure. Which clinical manifestations, if assessed by the nurse, would indicate acute decompensated heart failure (pulmonary edema)? Fatigue, orthopnea, and dependent edema Severe dyspnea and blood-streaked, frothy sputum Temperature is 100.4o F and pulse is 102 beats/minute Respirations 26 breaths/minute despite oxygen by nasal cannula

Severe dyspnea and blood-streaked, frothy sputum Clinical manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate > 30 breaths per minute, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood pressure may be elevated or decreased.

A 62-year-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker and has a history of gout. What should the nurse focus her teaching on to prevent complications for this patient? Gender Smoking Ethnicity Co-morbidities

Smoking Smoking is the most significant factor for this patient. PAD is a marker of advanced systemic atherosclerosis. Therefore tobacco cessation is essential to reduce PAD progression, CVD events, and mortality. Diabetes mellitus and hyperuricemia are also risk factors. Being male or Hispanic are not risk factors for PAD.

A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? Stool softener Stimulant laxative H 2 receptor blocker Proton pump inhibitor

Stimulant laxative Patients usually become tolerant to the side effects of opioids, with the exception of constipation. Routinely administer stimulant laxatives, not simple stool softeners, to prevent and treat constipation.

A patient is receiving an intravenous (IV) push medication. If the drug infiltrates into the outer tissues, the nurse: Continues to let the IV run. Applies a warm compress to the infiltrated site. Stops the administration of the medication and follows agency policy. Should not worry about this because vesicant filtration is not a problem.

Stops the administration of the medication and follows agency policy. When an IV medication infiltrates, stop giving the medication and follow agency policy.

A male patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been seeing his pastor to help him through this difficult time. He does not have a primary health care provider because he has never really been sick and his parents never took him to the physician when he was a child. Which external variables influence the patient's health practices? (Select all that apply.) Difficulty paying his bills Seeing his pastor as a means of support Family practice of not routinely seeing a health care provider Stress from the divorce and the loss of a job

Stress from the divorce and the loss of a job Family practice of not routinely seeing a health care provider Difficulty paying his bills External factors impacting health practices include family beliefs and economic impact. How patients’ families use health care services generally affects their health practices. Their perceptions of the serious nature of diseases and their history of preventive care behaviors (or lack of them) influence how patients will think about health. Economic variables may affect a patient’s level of health by increasing the risk for disease and influencing how or at what point the patient enters the health care system.

A male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not yet voided. Which action would be the most beneficial in assisting the patient to void? Suggest he stand at the bedside Stay with the patient Give him the urinal to use in bed Tell him that, if he doesn't urinate, he will be catheterized

Suggest he stand at the bedside A man voids more easily in the standing position.

When assessing the patient for orthostatic hypotension, after taking the blood pressure (BP) and pulse (P) in the supine position, what should the nurse do next? Repeat BP and P in this position. Take BP and P with patient sitting. Record the BP and P measurements. Take BP and P with patient standing.

Take BP and P with patient sitting. When assessing for orthostatic changes in BP after measuring BP in the supine position, the patient is placed in a sitting position and BP is measured within 1 to 2 minutes and then repositioned to the standing position with BP measured again, within 1 to 2 minutes. The results are then recorded with a decrease of 20 mm Hg or more in SBP, a decrease of 10 mm Hg or more in DBP, and/or an increase in pulse of greater than or equal to 20 beats/minute from supine to standing indicating orthostatic hypotension.

The patient with chronic heart failure is being discharged from the hospital. What information should the nurse emphasize in the patient's discharge teaching to prevent progression of the disease to ADHF? Take medications as prescribed. Use oxygen when feeling short of breath. Only ask the physician's office questions. Encourage most activity in the morning when rested.

Take medications as prescribed. The goal for the patient with chronic HF is to avoid exacerbations and hospitalization. Taking the medications as prescribed along with nondrug therapies such as alternating activity with rest will help the patient meet this goal. If the patient needs to use oxygen at home, it will probably be used all the time or with activity to prevent respiratory acidosis. Many HF patients are monitored by a care manager or in a transitional program to assess the patient for medication effectiveness and monitor for patient deterioration and encourage the patient. This nurse manager can be asked questions or can contact the health care provider if there is evidence of worsening HF.

The nurse supervises an unlicensed assistant personnel (UAP) who is taking the blood pressure of 58-year-old female patient admitted with heart failure. The patient is obese. The nurse should intervene if what is observed? The UAP waits 2 minutes after position changes to take orthostatic pressures. The UAP deflates the blood pressure cuff at a rate of 8 to 10 mm Hg per second. The UAP takes the blood pressure with the patient's arm at the level of the heart. The UAP takes a forearm blood pressure because the largest cuff will not fit the patient's upper arm.

The UAP deflates the blood pressure cuff at a rate of 8 to 10 mm Hg per second. The cuff should be deflated at a rate of 2 to 3 mm Hg per second. The arm should be supported at the level of the heart for accurate blood pressure measurements. If the maximum size blood pressure cuff does not fit the upper arm, the forearm may be used. Orthostatic blood pressures should be taken within 1 to 2 minutes of repositioning the patient.

A postoperative patient is currently asleep. Therefore the nurse knows that: The sedative administered may have helped him sleep, but assessment of pain is still needed. The intravenous (IV) pain medication is effectively relieving his pain. Pain assessment is not necessary. The patient can be switched

The sedative administered may have helped him sleep, but assessment of pain is still needed. Sedatives, antianxiety agents, and muscle relaxants have no analgesic effect; however, they can cause drowsiness and impaired coordination, judgment, and mental alertness and contribute to respiratory depression. It is important to avoid attributing these adverse effects solely to the opioid. You need to conduct a thorough reassessment.

A nursing student takes a patient's antibiotic to his room. The patient asks the nursing student what it is and why he should take it. Which information does the nursing student include when replying to the patient? Only the patient's physician can give this information. The student provides the name of the medication and a description of its desired effect. Information about medications is confidential and cannot be shared. He has to speak with his assigned nurse about this.

The student provides the name of the medication and a description of its desired effect. Patients need to know information about their medications so they can take them correctly and safely.

A new medical resident writes an order for OxyContin SR 10 mg PO q12 hours prn. Which part of the order does the nurse question? The drug The time interval The dose The route

The time interval Controlled- or extended-release opioid formulations such as OxyContin are available for administration every 8 to 12 hours ATC. Health care providers should not order these long-acting formulations prn.

When preparing to suction a patient's oral cavity, why would the nurse first suction a small amount of water through the catheter? To moisten the exterior of the plastic catheter To ensure that the catheter's suction is functioning properly To minimize friction as the catheter moves within the oral cavity To avoid startling the patient with the sound created by the suction

To ensure that the catheter's suction is functioning properly A small amount of water is suctioned through the catheter to ensure that the suction equipment is working properly.

Why does the nurse kink the nasogastric tube before removing it from a patient? To suppress the cough reflex To keep any fluid from flowing out To hinder the gag reflex To prevent transmission of microorganisms

To keep any fluid from flowing out Kinking the tube keeps any residual fluid in the tube from flowing out.

What is the purpose of splinting the abdomen with a small pillow during controlled coughing? To minimize chest discomfort caused by the coughing To expand lung capacity during the inspiratory phase of the cough To maximize transdiaphragmatic pressure during the expiratory phase of the cough To focus the patient's attention on the abdominal muscles used during the cough

To maximize transdiaphragmatic pressure during the expiratory phase of the cough Splinting the abdomen will increase transdiaphragmatic pressure.

What is the best reason for the nurse to instruct a male patient to take slow, deep breaths during insertion of an indwelling urinary catheter? To increase oxygenation To reduce blood pressure To distract him To promote relaxation

To promote relaxation The nurse would instruct a male patient to take slow, deep breaths during catheter insertion if the nurse felt resistance to the advancing catheter or if the patient reported pain. Deep breathing promotes relaxation, which might help to pass the catheter through the urinary sphincter.

Why is it important for the nurse to set the correct flow rate for a patient to whom oxygen is prescribed? To provide the correct amount of oxygen to the patient To ensure the therapeutic effects of oxygen therapy To prevent any adverse reaction to the prescribed oxygen therapy To minimize the risk of combustion during oxygen delivery

To provide the correct amount of oxygen to the patient The role of the flow regulator is to deliver the amount of oxygen indicated on the regulator.

While caring for a patient with cancer pain, the nurse knows that the World Health Organization (WHO) analgesic ladder recommends: Transitioning use of adjuvants with nonsteroidal antiinfl ammatory drugs (NSAIDs) to opioids. Using acetaminophen for refractory pain. Limiting the use of opioids because of the likelihood of side effects. Avoiding total sedation, regardless of how severe the pain is.

Transitioning use of adjuvants with nonsteroidal antiinfl ammatory drugs (NSAIDs) to opioids. The WHO analgesic ladder transitions from the use of nonopioids (NSAIDS) with or without adjuvants to opioids with or without adjuvants. Acetaminophen is recommended for lesser levels of pain. Side effects related to the use of opioids may be unavoidable but are treatable. Treatment for severe pain may result in some level of sedation.

The patient had aortic aneurysm repair. What priority nursing action will the nurse use to maintain graft patency? Assess output for renal dysfunction. Use IV fluids to maintain adequate BP. Use oral antihypertensives to maintain cardiac output. Maintain a low BP to prevent pressure on surgical site

Use IV fluids to maintain adequate BP. The priority is to maintain an adequate BP (determined by the surgeon) to maintain graft patency. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it.

The nurse is admitting a 68-year-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? Vitamin K Cobalamin Heparin sodium Protamine sulfate

Vitamin K Coumadin is a Vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin (Coumadin).

What would minimize the nurse's risk for contamination during the removal of a nasogastric tube? Wearing treatment gloves Providing the patient with an emesis basin Protecting the patient's chest with an absorbent towel Discarding any soiled tissues in the biohazard receptacle

Wearing treatment gloves Wearing gloves will protect the nurse from contamination.

The nurse is taking a health history of a newly admitted patient with a diagnosis Rule/out bowel obstruction. Which of the following is the priority question to ask the patient? Describe your bowel movements. How often do you have a bowel movement? When was the last time you moved your bowels? Correct Do you routinely use stool softeners, laxatives, or enemas?

When was the last time you moved your bowels? Lack of a bowel movement is a sign of a bowel obstruction and is a medical emergency.

What would the nurse do if he or she encountered resistance when inserting a nasogastric tube? Ask the patient to cough. Withdraw the tube to the nasopharynx. Encourage the patient to swallow. Instruct the patient to hyperextend the neck.

Withdraw the tube to the nasopharynx. If the patient starts to cough, experiences a drop in oxygen saturation, or shows other signs of respiratory distress, withdraw the tube into the posterior nasopharynx until normal breathing resumes. Do not force the tube or push it against resistance. If the tube meets resistance, swallowing will not help to advance it. If the tube meets resistance, hyperextending the neck will not help to advance it. Coughing will not help remove the source of resistance; rather, it is an indication that the tube is misplaced.

The health care provider's order is 1000 mL 0.9% NaCl IV over 6 hours. Which rate do you program into the infusion pump? 125 mL/hr 167 mL/hr 200 mL/hr 1000 mL/hr

167 mL/hr 1000 mL divided by 6 hours is 166.7 mL/hr, which rounds to 167 mL/hr (if infusion pump accepts decimals, program it to 166.7 mL/hr).

The nurse directs the NAP to remove a Foley catheter at 1300. The nurse would check if the patient has voided by: 1400. 1600 1700. 2300.

1700. The patient may experience urinary retention after removal of the catheter. If 4 hours after Foley removal have elapsed without voiding, it may be necessary to reinsert the Foley.

A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system? A. Electronic health record B. Clinical documentation C. Clinical decision support system D. Computerized physician order entry

Clinical decision support system A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user.

A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds? Sonorous wheezes in the left lower lung Rhonchi midsternum Crackles only in apex of lungs Inspiratory crackles in lung bases

Inspiratory crackles in lung bases Decreased effective contraction of left side of heart leads to back up of fluid in the lungs, increasing hydrostatic pressure and causing pulmonary edema, resulting in crackles in lung bases.

Which of the following activities can you delegate to nursing assistive personnel (NAP)? (Select all that apply.) Measuring oral intake and urine output Preparing intravenous (IV) tubing for routine change Reporting an IV container that is low in Changing an IV fluid container

Measuring oral intake and urine output Reporting an IV container that is low in The registered nurse cannot delegate working with IV tubing or changing an IV infusion to NAP

A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; PaCO2, 21 mm Hg; PaO2, 92 mm Hg; and HCO3-, 8. You interpret these laboratory values to indicate: Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic acidosis The low pH indicates acidosis. The low PaCO2 is caused by the hyperventilation, either from primary respiratory alkalosis (not compatible with the measured pH) or as a compensation for metabolic acidosis. The low HCO3- indicates metabolic acidosis or compensation for respiratory alkalosis (again, not compatible with the measured pH). Thus metabolic acidosis is the correct interpretation.

The nurse understands that, when comparing nasogastric tubes used for gastric decompression, a Salem sump is specifically designed to: Minimize the risk of a bowel obstruction. Ensure drainage of the intestines. Prevent gastric mucosal damage. Promote resting the gut

Prevent gastric mucosal damage A Salem sump tube has a double lumen. The second lumen is the blue pig-tailed portion that is open to air for the purpose of equalizing the pressure outside the body to inside the stomach. This prevents the tip of the Salem sump from becoming attached to the stomach lining, thus preventing mucosal irritation and bleeding.

Your patient who has diabetic ketoacidosis is breathing rapidly and deeply. Intravenous (IV) fluids and other treatments have just been started. What should you do about this patient's breathing? Notify her health care provider that she is hyperventilating Provide frequent oral care to keep her mucous membranes moist Ask her to breathe slower and help her to calm down and relax Assess her for pain and request an order for a sedative

Provide frequent oral care to keep her mucous membranes moist Hyperventilation is a compensatory mechanism for metabolic acidosis and should be allowed to continue. Rapid breathing can make oral mucous membranes dry and cracked.

While receiving a blood transfusion, your patient develops chills, tachycardia, and flushing. What is your priority action? Notify a health care provider Insert an indwelling catheter Alert the blood bank Stop the transfusion

Stop the transfusion Development of chills, tachycardia, and flushing during a blood transfusion is an indication of an acute hemolytic reaction. You stop the transfusion immediately so no more of the incompatible blood reaches the patient.

A patient starts to experience pain while receiving an enema. The nurse notes blood in the return fluid and rectal bleeding. What action does the nurse take first? Administers pain medication Slows down the rate of instillation Tells the patient to breathe slowly and relax Stops the instillation and obtains vital signs

Stops the instillation and obtains vital signs Bleeding is an unexpected outcome. You should stop the procedure, obtain vital signs, and call the health care provider since this is a medical emergency.

The patient receiving total parenteral nutrition (TPN) asks the nurse why his blood glucose is being checked since he does not have diabetes. What is the best response by the nurse? TPN can cause hyperglycemia, and it is important to keep your blood glucose level in an acceptable range. The high concentration of dextrose in the TPN can give you diabetes; thus you need to be monitored closely. Monitoring your blood glucose level helps to determine the dose of insulin that you need to absorb the TPN. Checking your blood glucose level regularly helps to determine if the TPN is effective as a nutrition intervention.

TPN can cause hyperglycemia, and it is important to keep your blood glucose level in an acceptable range. The TPN formula is a combination of crystalline amino acids, hypertonic dextrose, electrolytes, vitamins, and trace elements. Administration of concentrated glucose is accompanied by increases in endogenous insulin production, which causes cations (potassium, magnesium, and phosphorus) to move intracellularly. Blood glucose levels should be monitored every 6 hours to assess for hyperglycemia. Maintaining blood glucose within acceptable limits helps prevent complications from the TPN.