skills test 2

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Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound? A. Assessing the site for signs of redness or swelling B. Reporting the presence of wound odor C. Removing a soiled outer dressing D. Opening sterile dressings during the dressing change

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

Which measurements would the nurse use to calculate the surface area of a patient's pressure injury? A. Height and weight B. Length and width C. Length and depth D. Width and depth

Which nursing action will best ensure the safety of a patient who is about to receive an infusion of parenteral nutrition? A. Assess the patient's blood glucose level by fingerstick. B. Verify the physician's order for central parenteral nutrition (CPN) and the flow rate. C. Confirm that the CPN infusion pump's alarm system is functioning properly. D. Instruct the patient concerning the purpose for administering the CPN solution.

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

Which practice protects the nurse from infection when changing the dressing on an infected pressure injury? A. Begin antibiotic therapy before the dressing change. B. Use appropriate personal protective equipment. C. Adhere to sterile technique during the intervention. D. Complete the dressing change in an effective, efficient manner.

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

Which wound would be allowed to heal by secondary intention? A. Cleft lip repair B. Infected hysterectomy incision C. Exploratory laparoscopy incision D. Facial laceration caused by a pocket knife

While feeding a patient recovering from a stroke, a nursing assistive personnel (NAP) becomes distracted and does not watch the patient swallow a bite of food. What would the NAP do to ensure that the patient safely swallowed the food? A. Give the patient a drink to wash down the food. B. Check the patient's mouth for pocketing. C. Suction the patient's mouth. D. Give the patient the next bite of food.

While feeding a patient, the nurse puts the fork down on the tray and turns on the suction machine. Why might the nurse perform this action? A. The patient is tilting the head backward while drinking. B. The patient is choking. C. Food has dripped or spilled onto the patient's clothing. D. The nurse determines that this is the wrong diet for the patient.

While performing an intermittent straight urinary catheterization of a female patient, the nurse inadvertently inserts the catheter into the patient's vagina. Which action would the nurse take next? A. Remove the catheter, and rinse it thoroughly in sterile water for reuse. B. Keep the catheter in place, and begin again with a new sterile catheter. C. Remove the catheter, relubricate it, and insert it into the urinary meatus. D. Stop advancing the catheter, and notify the health care provider.

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? 1. Necrotic tissue 2. Wound drainage 3. Wound circumference 4. Cleansed wound

The nurse is preparing to use a slide board to transfer a patient from the bed to a stretcher. How many additional people will the nurse need to help with this transfer? A. Four B. Two C. One D. None

A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient? 1. Encouraging use of an overhead trapeze for positioning and transfer 2. Frequent family visits 3. Assisting the patient to a wheelchair once per day 4. Ensuring that there is an order for physical therapy

A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility: 1. Decreased peristalsis 2. Decreased heart rate 3. Increased blood pressure 4. Increased urinary output

A patient has not had a bowel movement for 4 days. Now she has nausea and severe cramping throughout her abdomen. On the basis of these findings, what do you suspect is wrong with the patient? 1. An intestinal obstruction 2. Irritation of the intestinal mucosa 3. Gastroenteritis 4. A fecal impaction

A patient is experiencing some problems with joint stability. The doctor has prescribed crutches for the patient to use while still being allowed to bear weight on both legs. Which of the following gaits should the patient be taught to use? 1. Four-point 2. Three-point 3. Two-point 4. Swing-through

A patient who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What would the nurse do first? 1. Have the patient perform a Valsalva maneuver 2. Clamp the intravenous (IV) tubing to prevent more air from entering the line 3. Have the patient take a deep breath and hold it 4. Notify the health care provider immediately

At 12 noon the emergency department nurse hears that an explosion has occurred in a local manufacturing plant. Which action does the nurse take first? 405 1. Prepare for an influx of patients 2. Contact the American Red Cross 3. Determine how to resume normal operations 4. Evacuate patients per the disaster plan

During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What is your priority nursing intervention? 1. Stop the instillation 2. Ask the patient to take deep breaths to decrease the pain 3. Add soapsuds to the enema 4. Tell the patient to bear down as he would when having a bowel movement

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend? 1. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert 2. Hot dog on whole wheat bun with a side salad and an apple for dessert 3. Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert 4. Turkey salad on toast with tomato and lettuce and honey bun for dessert

The nurse recognizes that the older adult's progressive loss of total bone mass and tendency to take smaller steps with feet kept closer together will most likely: 1. Increase the patient's risk for falls and injuries. 2. Result in less stress on the patient's joints. 3. Decrease the amount of work required for patient movement. 4. Allow for mobility in spite of the aging effects on the patient's joints.

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: 1. Place a bed alarm device on the bed. 2. Place the patient in a belt restraint. 3. Provide one-on-one observation of the patient. 4. Apply wrist restraints.

What best describes measurement of postvoid residual (PVR)? 1. Bladder scan the patient immediately after voiding. 2. Catheterize the patient 30 minutes after voiding. 3. Bladder scan the patient when he or she reports a strong urge to void. 4. Catheterize the patient with a 16 Fr/10 mL catheter.

What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure reduction 3. Negative pressure wound therapy 4. Sanitization

A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? (Select all that apply.) 1. "I usually go swimming with my family at the YMCA 3 times a week." 2. "I need to ask my doctor if I should have a bone mineral density check this year." 3. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." 4. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill." 5. "My lactose intolerance should not be a concern when considering my calcium intake."

1, 2, 3

The body alignment of the patient in the tripod position includes the following: (Select all that apply.) 1. An erect head and neck 2. Straight vertebrae 3. Extended hips and knees 4. Axillae resting on the crutch pads 5. Bent knees and hips

1, 2, 3

A nurse is educating parents to look for clues in teenagers for possible substance abuse. Which environmental and psychosocial clues should the nurse include? (Select all that apply.) 1. Blood spots on clothing 2. Long-sleeved shirts in warm weather 3. Changes in relationships 4. Wearing dark glasses indoors 5. Increased computer use

1, 2, 3, 4

Before transferring a patient from the bed to a stretcher, which assessment data do the nurse need to gather? (Select all that apply.) 1. Patient's weight 2. Patient's level of cooperation 3. Patient's ability to assist 4. Presence of medical equipment 5. Nutritional intake

1, 2, 3, 4

A couple who is caring for their aging parents are concerned about factors that put them at risk for falls. Which factors are most likely to contribute to an increase in falls in the elderly? (Select all that apply.) 1. Inadequate lighting 2. Throw rugs 3. Multiple medications 4. Doorway thresholds 5. Cords covered by carpets 6. Staircases with handrails

1, 2, 3, 4, 5

You are conducting an education class at a local senior center on safe-driving tips for seniors. Which of the following should you include? (Select all that apply.) 1. Drive shorter distances 2. Drive only during daylight hours 3. Use the side and rearview mirrors carefully 4. Keep a window rolled down while driving if has trouble hearing 5. Look behind toward the blind spot 6. Stop driving at age 75

1, 2, 3, 4, 5

A nurse is evaluating a patient who is in soft wrist restraints. Which of the following activities does the nurse perform? (Select all that apply.) 1. Check the patient's peripheral pulse in the restrained extremity 2. Evaluate the patient's need for toileting 3. Offer the patient fluids if appropriate 4. Release both limbs at the same time to perform range of motion (ROM) 5. Inspect the skin under each restraint

1, 2, 3, 5

What is your role as a nurse during a fire? (Select all that apply.) 1. Help to evacuate patients 2. Shut off medical gases 3. Use a fire extinguisher 4. Single carry patients out 5. Direct ambulatory patients

1, 2, 3, 5

Which skills do you teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine if the ostomy is healing appropriately

1, 2, 3, 5

The effects of immobility on the cardiac system include which of the following? (Select all that apply.) 1. Thrombus formation 2. Increased cardiac workload 3. Weak peripheral pulses 4. Irregular heartbeat 5. Orthostatic hypotension

1, 2, 5

Which of the following symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Fecal impaction 5. Muscle aches 6. Incomplete emptying of the colon 7. Food particles in the stool 8. Unexplained abdominal or back pain

1, 2, 6, 8

When is an application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) 1. To relieve edema 2. To reduce shivering 3. To improve blood flow to an injured part 4. To protect bony prominences from pressure ulcers 5. To immobilize area

1, 3

A nurse knows that the people most at risk for accidental hypothermia are: (Select all that apply.) 1. People who are homeless. 2. People with respiratory conditions. 3. People with cardiovascular conditions. 4. The very old. 5. People with kidney disorders.

1, 3, 4

A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for the following signs of bleeding: (Select all that apply.) 1. Bruising 2. Pale yellow urine 3. Bleeding gums 4. Coffee ground-like vomitus 5. Light brown stool

1, 3, 4

The nurse is educating the patient and his family about the parenteral nutrition. Which aspect related to this form of nutrition would be appropriate to include? (Select all that apply.) 1. The purpose of the fat emulsion in parenteral nutrition is to prevent a deficiency in essential fatty acids. 2. We can give you parenteral nutrition through your peripheral intravenous line to prevent further infection. 3. The fat emulsion will help control hyperglycemia during periods of stress. 4. The parenteral nutrition will help your wounds heal. 5. Since we just started the parenteral nutrition, we will only infuse it at 50% of your daily needs for the next 6 hours.

1, 3, 4

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.) 1. Avoid grapefruit and grapefruit juice, which impair drug absorption. 2. Increase the amount of carbohydrates for energy. 3. Take a multivitamin that includes vitamin D for bone health. 4. Cheese and eggs are good sources of protein. 5. Limit fluids to decrease the risk of edema.

1, 3, 4

What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) 1. Keep the bowels regular. 2. Limit water intake to 1 to 2 glasses a day. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back. 5. Practice pelvic muscle exercise (Kegel) daily.

1, 3, 4

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board) 2. Have head of bed elevated when transferring patient 3. Have head of bed flat when repositioning patient 4. Raise head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine

1, 3, 5

A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.) 1.Ask the patient about any allergies and reactions. 2. Instruct the patient that a full bladder is required for the test. 3. Instruct the patient to save all urine in a special container. 4. Ensure that informed consent has been obtained. 5. Explain that the test includes instrumentation of the urinary tract.

1, 4

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the surgeon. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder.

1, 4

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel 6. Applying a moisture barrier ointment

1, 4, 6

Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet 2. Use a low-volume enema daily 3. Avoid gluten in the diet 4. Take laxatives twice a day 5. Exercise for 30 minutes every day 6. Schedule time to use the toilet at the same time every day 7. Take probiotics 5 times a week

1, 5, 6

Place the following options in the order in which elastic stockings should be applied. 1. Identify patient using two identifiers. 2. Smooth any creases or wrinkles. 3. Slide the remainder of the stocking over the patient's heel and up the leg 4. Turn the stocking inside out until heel is reached. 5. Assess the condition of the patient's skin and circulation of the legs. 6. Place toes into foot of the stocking. 7. Use tape measure to measure patient's legs to determine proper stocking size.

1, 5, 7, 4, 6, 3, 2

Match the pressure ulcer categories/stages with the correct definition. 1. Category/stage I 2. Category/stage II 3. Category/stage III 4. Category/stage IV a. Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. b. Full-thickness skin loss; subcutaneous fat may be visible. May include undermining. c. Full thickness tissue loss; muscle and bone visible. May include undermining. d. Partial-thickness skin loss or intact blister with serosanguinous fluid.

1a 2d 3b 4c

A patient is receiving total parenteral nutrition (TPN). What is the primary intervention the nurse should follow to prevent a central line infection? 1. Institute isolation precautions 2. Clean the central line port through which the TPN is infusing with antiseptic 3. Change the TPN tubing every 24 hours 4. Monitor glucose levels to watch and assess for glucose intolerance

A patient with a right knee replacement is prescribed no weight bearing on the right leg. You reinforce crutch walking knowing that which of the following crutch gaits is most appropriate for this patient? 1. Two-point gait 2. Three-point gait 3. Four-point gait 4. Swing-through gait

A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention? 1. Increase the rate of the CBI 2. Assess the intake and output from system 3. Decrease the rate of the CBI 4. Assess vital signs

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? 1. Recommend that she be evaluated for an overactive bladder (OAB) medication 2. Start a scheduled toileting program 3. Recommend that she be evaluated for an indwelling catheter 4. Start a bladder-retraining program

An elderly patient comes to the hospital with a complaint of severe weakness and diarrhea for several days. Of the following problems, which is the most important to assess initially? 1. Malnutrition 2. Dehydration 3. Skin breakdown 4. Incontinence

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound-care product helps prevent edema formation, control bleeding, and anesthetize the body part? 1239 1. Binder 2. Ice bag 3. Elastic bandage 4. Absorptive dressing

The nurse sees the nursing assistive personnel (NAP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention? 1. Fastening tube to the gown with new tape 2. Placing patient supine while giving a bath 3. Hanging a new container of enteral feeding 4. Ambulating patient with enteral feedings still infusing

The nursing assistive personnel (NAP) reports to the nurse that a patient's catheter drainage bag has been empty for 4 hours. What is a priority nursing intervention? 1. Implement the "as-needed" order to irrigate the catheter 2. Assess the catheter and drainage tubing for obvious occlusion 3. Notify the health care provider immediately 4. Assess the vital signs and intake and output record

There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? 1. Remove the catheter and start all over with a new kit and catheter 2. Leave the catheter there and start over with a new catheter 3. Pull the catheter back and reinsert at a different angle 4. Ask the patient to bear down and insert the catheter further

To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery? 1. Turn, cough, and deep breathe every 30 minutes while awake 2. Ambulate patient to chair in the hall 3. Passive range of motion 4 times a day 4. Immobility is not a concern the first postoperative day

What does the Braden Scale evaluate? 1. Skin integrity at bony prominences, including any wounds 2. Risk factors that place the patient at risk for skin breakdown 3. The amount of repositioning that the patient can tolerate 4. The factors that place the patient at risk for poor healing

Which is the correct gait when a patient is ascending stairs on crutches? 1. A modified two-point gait. (The affected leg is advanced between the crutches to the stairs.) 2. A modified three-point gait. (The unaffected leg is advanced between the crutches to the stairs.) 3. A swing-through gait 4. A modified four-point gait. (Both legs advance between the crutches to the stairs.)

Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? 1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution 2. Hanging the urinary drainage bag below the level of the bladder 3. Emptying the urinary drainage bag daily 4. Irrigating the urinary catheter with sterile water

Which of the following most motivates a patient to participate in an exercise program? 1. Providing a patient with a pamphlet on exercise 2. Providing information to the patient when he or she is ready to change behavior 3. Explaining the importance of exercise at the time of diagnosis of a chronic disease 4. Providing the patient with a booklet with examples of exercises 5. Providing the patient with a prescribed exercise program

Which of the following nursing actions do you take after placing a bedpan under an immobilized patient? 1. Lift the patient's hips off the bed and slide the bedpan under the patient 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle 3. Adjust the head of the bed so it is lower than the feet and use gentle but firm pressure to push the bedpan under the patient 4. Have the patient stand beside the bed and then have him or her sit on the bedpan on the edge of the bed

The nurse is helping a patient with hemiparesis take a few steps. A gait belt has been applied. The patient is using a cane. Where should the nurse stand in relation to the patient? A. On the patient's strong side B. On the patient's weak side C. Behind the patient D. In front of the patient

Which of the following statements made by an older adult reflects the best understanding of the need to exercise regardless of age? 1. "You are never too old to begin an exercise program." 2. "My granddaughter and I walk together around the high school track 3 times a week." 3. "I purchased a subscription to a runner's magazine for my grandson for Christmas." 4. "When I was a child, I exercised more than I see kids doing today."

The nurse evaluates that the NAP has applied a patient's sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply.) 1. Initial patient measurement is made around the calves 2. Inflation pressure averages 40 mm Hg 3. Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve. 4. Stockings are removed every 2 hours during application. 5. Yellow light indicates SCD device is functioning.

2, 3

The nurse would delegate which of the following to nursing assistive personnel (NAP)? (Select all that apply.) 1. Repositioning and retaping a patient's nasogastric tube 2. Performing glucose monitoring every 6 hours on a patient 3. Documenting PO intake on a patient who is on a calorie count for 72 hours 4. Administering enteral feeding bolus after tube placement has been verified 5. Hanging a new bag of enteral feeding

2, 3

Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) 1. Attach a 3-mL syringe to the inflation port 2. Allow the balloon to drain into the syringe by gravity 3. Initiate a voiding record/bladder diary 4. Pull the catheter quickly 5. Clamp the catheter before removal

2, 3

Which of the following cause Clostridium difficile infection? (Select all that apply.) 1. Chronic laxative use 2. Contact with C. difficile bacteria 3. Overuse of antibiotics 4. Frequent episodes of diarrhea caused by food intolerance 5. Inflammation of the bowel

2, 3

An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.) 1. B/P = 128/84 2. Respirations 26/min on room air 3. HR 114 4. Crackles over lower lobes heard on auscultation 5. Pain reported as 3 on scale of 0 to 10 after medication

2, 3, 4

The nurse is caring for a patient with pneumonia who has severe malnutrition. The nurse recognizes that, because of the nutritional status, the patient is at increased risk for: (Select all that apply.) 1. Heart disease. 2. Sepsis. 3. Pleural effusion. 4. Cardiac arrhythmias. 5. Diarrhea.

2, 3, 4

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 2. Providing support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure

2, 4

Which patients are at high risk for nutritional deficits? (Select all that apply.) 1. The divorced computer programmer who eats precooked food from the local restaurant 2. The middle-age female with celiac disease who does not follow her gluten-free diet 3. The 45-year-old patient with type II diabetes who monitors her carbohydrate intake and exercises regularly 4. The 25-year-old patient with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements 5. The 65-year-old patient with gallbladder disease whose electrolyte, albumin, and protein levels are normal

2, 4

The nurse is caring for a patient who is having a seizure. Which of the following measures will protect the patient and the nurse from injury? (Select all that apply.) 1. If patient is standing, attempt to get him or her back in bed. 2. With patient on floor, clear surrounding area of furniture or equipment. 3. If possible, keep patient lying supine. 4. Do not restrain patient; hold limbs loosely if they are flailing. 5. Never force apart a patient's clenched teeth.

2, 4, 5

A nurse is instructing a patient who has decreased leg strength on the left side how to use a cane. Which action indicates proper cane use by the patient? 1. The patient keeps the cane on the left side of the body. 2. The patient slightly leans to one side while walking. 3. The patient keeps two points of support on the floor at all times. 4. After the patient places the cane forward, he or she then moves the right leg forward to the cane.

A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which of the following is the priority question to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Are your bowel movements soft and formed? 3. Have you experienced frequent, small liquid stools recently? 4. Have you taken antibiotics recently?

A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical (FIT) testing at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.

A nursing assistive personnel asks for help to transfer a patient who is 125 lbs (56.8 kg) from the bed to a wheelchair. The patient is unable to help. What is the nurse's best response? 1. "As long as we use proper body mechanics, no one will get hurt." 2. "The patient only weighs 125 lbs. You don't need my assistance." 3. "Call the lift team for additional assistance." 4. "The two of us can lift the patient easily."

A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken: 1. Myoclonus 2. Pathological fractures 3. Pressure ulcers 4. Pruritus

Musculoskeletal disorders are the most prevalent and debilitating occupational health hazards for nurses. To reduce the risk for these injuries, the American Nurses Association advocates which of the following? 1. Mandate that physical therapists do all patient transfers 2. Require adequate staffing levels in health care organizations 3. Require the use of assistive equipment and devices 4. Require an adequate number of staff to be involved in all patient transfers

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? 1. Category/stage II 2. Category/stage IV 3. Unstageable 4. Suspected deep-tissue damage

The patient's blood glucose level is 330 mg/dL. What is the priority nursing intervention? 1. Recheck by performing another blood glucose test. 2. Call the primary health care provider. 3. Check the medical record to see if there is a medication order for abnormal glucose levels. 4. Monitor and recheck in 2 hours.

What do you need to teach family caregivers when a patient has fecal incontinence as a result of cognitive impairment? 1183 1. Cleanse the skin with antibacterial soap and apply talcum powder to the buttocks 2. Use diapers and heavy padding on the bed 3. Initiate bowel or habit training program to promote continence 4. Help the patient to toilet once every hour

What is a critical step when inserting an indwelling catheter into a male patient? 1. Slowly inflate the catheter balloon with sterile saline. 2. Secure the catheter drainage tubing to the bed sheets. 3. Advance the catheter to the bifurcation of the drainage and balloon ports. 4. Advance the catheter until urine flows, then insert 1/4 image inch more.

When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider? 1. Pale yellow urine 2. Slightly cloudy urine 3. Light pink urine 4. Dark amber urine

Which instructions should the nurse give the nursing assistive personnel (NAP) concerning a patient who has had an indwelling urinary catheter removed that day? 1. Limit oral fluid intake to avoid possible urinary incontinence. 2. Expect patient complaints of suprapubic fullness and discomfort. 3. Report the time and amount of first voiding. 4. Instruct patient to stay in bed and use a urinal or bedpan.

Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately? 1. Do you leak urine when you cough or sneeze? 2. Do you need help getting to the toilet? 3. Do you dribble urine constantly? 4. Does it burn when you pass your urine?

Which nursing intervention is most important when caring for a patient with an ileostomy? 1. Cleansing the stoma with hot water 2. Inserting a deodorant tablet in the stoma bag 3. Selecting or cutting a pouch with an appropriate-size stoma opening 4. Wearing sterile gloves while caring for the stoma

Which nursing intervention minimizes the risk for trauma and infection when applying an external/condom catheter? 1. Leaving a gap of 3 to 5 inches between the tip of the penis and drainage tube 2. Shaving the pubic area so hair does not adhere 3. Washing with soap and water before applying the condom-type catheter 4. Applying tape to the condom sheath to keep it securely in place

Which of the following are physiological outcomes of immobility? 1. Increased metabolism 2. Reduced cardiac workload 3. Decreased lung expansion 4. Decreased oxygen demand

Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher? 1. The patient is 5 feet 6 inches and weighs 120 lbs. 2. The patient speaks and understands English. 3. The patient is returning to unit from recovery room after a procedure requiring conscious sedation. 4. The patient received analgesia for pain 30 minutes ago.

A patient has been newly admitted to a medicine unit with a history of diabetes and advanced heart failure. The nurse is assessing the patient's fall risks. Place the following steps for measuring the "Timed Get-up and Go Test" (TUG) in the correct order: 1. Have patient rise from straight-back chair without using arms for support. 2. Begin timing. 3. Tell patient to walk 10 feet as quickly and safely as possible to a line you marked on the floor, turn around, walk back, and sit down. 4. Check time elapsed. 5. Look for unsteadiness in patient's gait. 6. Have patient return to chair and sit down without using arms for support.

3, 1, 2, 5, 6, 4

You are caring for a patient who frequently tries to remove his intravenous catheter and feeding tube. You have an order from the health care provider to apply a wrist restraint. Place the steps for applying a wrist restraint in the correct order. 1. Be sure that patient is comfortable with arm in anatomic alignment. 2. Wrap wrist with soft part of restraint toward skin and secure snugly. 3. Identify patient using two identifiers. 4. Introduce self and ask patient about his feelings of being restrained. 5. Assess condition of skin where restraint will be placed.

3, 4, 1, 5, 2

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. His wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. Which factors increase his fall risk at this time? (Select all that apply.) 1. Smokes a pack a day 2. Used a cane to walk at home 3. Takes antihypertensive and diuretics 4. History of recent fall 5. Neglect, spatial and perceptual abilities, impulsive 6. Requires assistance with activity, unsteady gait 7. IV line, urinary catheter

3, 4, 5, 6, 7

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.) 1. Contact the nursing supervisor. 2. Restrict the family's visiting privileges. 3. Ask the family to stay with the patient if possible. 4. Inform the family of the risks associated with side-rail use. 5. Thank the family for being conscientious and put the four rails up. 6. Discuss alternatives that are appropriate for this patient with the family.

3, 4, 6

Which of the following is a principle of proper body mechanics when lifting or carrying objects? (Select all that apply.) 1. Keep the knees in a locked position. 2. Bend at the waist to maintain a center of gravity. 3. Maintain a wide base of support. 4. Hold objects away from the body for improved leverage. 5. Encourage patient to help as much as possible.

3, 5

A parent calls the pediatrician's office to ask about directions for using a car seat. Which of the following is the most correct set of instructions the nurse gives to this parent? 1. Only infants and toddlers need to ride in the back seat. 2. All toddlers can move to a forward facing car seat when they reach age 2. 3. Toddlers must reach age 2 and the height/weight requirement before they ride forward facing. 4. Toddlers must reach age 2 or the height or weight requirement before they ride forward facing.

A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request discontinuing parenteral nutrition? 1. When 25% of the patient's nutritional needs are met by the tube feedings 2. When bowel sounds return 3. When central line has been in for 10 days 4. When 75% of the patient's nutritional needs are met by the tube feedings

A patient's gastric residual volume was 250 mL at 0800 and 350 mL at 0900. What is the appropriate nursing action? 1. Assess bowel sounds 2. Raise the head of the bed to at least 45 degrees 1099 3. Position the patient on his or her right side to promote stomach emptying 4. Do not reinstall aspirate and hold the feeding until you talk to the primary care provider

An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility? 1. Loss of appetite 2. Gum soreness 440 3. Difficulty swallowing 4. Left ankle joint stiffness

The nurse encourages a patient with type 2 diabetes to engage in a regular exercise program primarily to improve the patient's: 1. Gastric motility, thereby facilitating glucose digestion. 2. Respiratory effort, thereby decreasing activity intolerance. 3. Overall cardiac output, thereby resuming resting heart rate. 4. Use of glucose and fatty acids, thereby decreasing blood glucose level.

The nurse evaluates which laboratory values to assess a patient's potential for wound healing? 1. Fluid status 2. Potassium 3. Lipids 4. Nitrogen balance

The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? 1. Suction her mouth and throat 2. Turn her on their side 3. Put on oxygen at 2-L nasal cannula 4. Stop feeding her and place on NPO

The nursing assessment of a 78-year-old woman reveals orthostatic hypotension, weakness on the left side, and fear of falling. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? 1. Activity Intolerance 2. Impaired Bed Mobility 3. Acute Pain 4. Risk for Falls

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A stage III pressure ulcer needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface

Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest? 1. Isometric exercises 2. Administration of low-dose heparin 3. Suctioning every 4 hours 4. Use of incentive spirometer every 2 hours while awake

Which statement made by a patient of a 2-month-old infant requires further education? 1. I'll continue to use formula for the baby until he is a least a year old. 2. I'll make sure that I purchase iron-fortified formula. 3. I'll start feeding the baby cereal at 4 months. 4. I'm going to alternate formula with whole milk starting next month.

Your patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem do you suspect the patient has? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance

What is the correct sequence of steps when performing wound irrigation to a large open wound? 1. Use slow, continuous pressure to irrigate wound. 2. Attach 19-gauge angiocatheter to syringe. 3. Fill syringe with irrigation fluid. 4. Place waterproof bag near bed. 5. Position angiocatheter over wound.

4, 3, 2, 5, 1

Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus with antiseptic solution. 5. Drape patient with the sterile square and fenestrated drapes. 6. When urine appears, advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.

5, 7, 2, 4, 1, 6, 3, 8, 9

Place the steps for an ostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.

5, 8, 7, 2, 6, 3, 4, 1

Place the steps to administering a prepackaged enema the correct order. 1. Insert enema tip gently in the rectum. 2. Help patient to bathroom when he or she feels urge to defecate. 3. Position patient on side. 4. Perform hand hygiene and apply clean gloves. 5. Squeeze contents of container into rectum. 6. Explain procedure to the patient.

6, 4, 3, 1, 5, 2

The nurse is inserting a small-bore nasoenteric tube before starting enteral feedings. Place the following steps in order to perform this procedure. 1. Place patient in high-Fowler's position. 2. Have patient flex head toward chest. 3. Assess patient's gag reflex. 4. Determine length of the tube to be inserted. 5. Obtain radiological confirmation of tube placement. 6. Check pH of gastric aspirate for verifying placement. 7. Identify patient with two identifiers.

7, 1, 3, 4, 2, 5, 6

A male patient on bed rest is permitted to stand to use the urinal. Which action would the nurse take to ensure his safety before helping him to a standing position? A. Determine his risk for orthostatic hypotension B. Assess his genitals for signs of impaired skin integrity C. Ask him to demonstrate proper use of a urinal D. Instruct him to use the call light when he is finished

A nurse is irrigating a patient's abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider? A. Drainage that was not present previously B. Redness at the abdominal suture line C. Granulation tissue in the wound bed D. The patient reports less pain

A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient's pain? A. Premedicate the patient with a prescribed analgesic 30 minutes before the intervention. B. Use a distraction technique to divert the patient's attention during the procedure. C. Position the patient comfortably before the intervention. D. Thoroughly explain the procedure to the patient.

A patient for whom an intravenous antibiotic is prescribed has a multilumen central line in place for central parenteral nutrition (CPN). What should the nurse do? A. Infuse the antibiotic through another lumen of the multilumen central line. B. Interrupt the CPN infusion only long enough to administer the antibiotic. C. Rearrange the antibiotic administration schedule so it does not interfere with the CPN. D. Ask the prescriber if the route of administration for the antibiotic can be changed.

The nurse and his or her assistants are using a slide board to move a patient from the bed to a stretcher. The nurse, standing alone on the side of the bed opposite the stretcher, will perform which action during this move? A. Hold the slide board. B. Pull the draw sheet. C. Hold the patient's head stationary. D. Lock the brakes on the stretcher.

The nurse has applied a gait belt to a postoperative patient to facilitate ambulation. Within a few feet of the bed, the patient begins to complain of dizziness and leans heavily on the nurse. What would be the nurse's initial response? A. Slowly lower the patient to the floor. B. Attempt to sit the patient down on a chair just a few steps away. C. Try to hold the patient up until the dizziness passes. D. Call for assistance in a loud but calm voice.

The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to nursing assistive personnel (NAP)? A. Measure and empty the urine. B. Palpate the abdomen. C. Ask the patient if she has any pain. D. Document the procedure.

The nurse is ambulating a patient with a gait belt when he says he feels sick to his stomach. What would the nurse do? A. Return the patient to the bed or chair (whichever is closer). B. Encourage the patient to complete the distance of ambulation. C. Help him to the restroom. D. Ease him to the floor.

The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube? A. Lubricate the first 6.5 to 7.5 cm (2.5 to 3 inches) of the tip of the tube. B. Place the patient in a side-lying position with the right knee flexed. C. Flush the tube with the solution. D. Hold the tube in the rectum until all of the fluid has been instilled.

The nurse is preparing to initiate ambulation with a patient who is recovering from a stroke. What information will help the nurse determine how far to walk? A. Ask the patient how far she would like to go. B. Review the health care provider's order. C. Review the medical record to see how far the patient has walked during the past several therapeutic ambulations. D. Review the records of other patients who are at a similar point in their stroke rehabilitation.

To which position would the nurse assist the patient who is experiencing difficulty with breathing? A. Fowler's position B. 30-degree lateral position C. Sims' position D. Prone position

What is the initial step in preparing a fecal occult blood test? A. Determine the patient's ability to help obtain a sample. B. Gather both a Hemoccult slide and developing solution. C. Provide the patient with a specimen hat or bedpan. D. Perform hand hygiene and apply treatment gloves.

What is the most important way in which the nurse can reduce the risk for infection in a patient with a CVAD that has a gauze dressing? A. Change the dressing every 48 hours. B. Apply sterile gloves to remove the original dressing. C. Cleanse the catheter and insertion site with sterile saline. D. Label the dressing with the date and time of application and the nurse's initials.

What is the nurse's initial action when preparing to change a patient's colostomy pouching system? A. Applying clean gloves B. Draping the patient appropriately C. Emptying the colostomy D. Assessing the surrounding skin for signs of irritation.

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

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

When assisting a patient who has self-feeding difficulties, why would the nurse ask the patient to try to self-feed? A. To determine what kind of assistance the patient needs with feeding B. To identify which food item is causing the trouble C. To identify which hand the patient uses for utensils D. To promote the patient's sense of self-confidence

When preparing for safe patient transfer using a hydraulic lift, the nurse performs which action first? A. Assesses the patient for weakness, dizziness, or postural hypotension B. Arranges for at least three healthcare personnel to assist in the transfer C. Makes sure the patient agrees to the intervention D. Applies clean gloves

When preparing to apply a condom catheter, the nurse would do what first? A. Close the door and draw the bedside curtain B. Obtain the patient's written informed consent C. Clamp the drainage tubing D. Offer the patient a urinal

When turning a patient to place a slide board, where do the assistants stand? A. At the side of the bed to which the patient will be turned B. At the side of the bed from which the patient will be turned C. At the head and foot of the bed D. At the foot of the bed only

Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure injury in an older adult patient? A. Reposition the patient at least every 2 hours. B. Assess the patient's bony prominences every shift. C. Educate the family about the importance of healthy skin. D. Assist the patient in the selection of high-protein foods.

Which action would best minimize a patient's risk for infection during removal of an indwelling urinary catheter? A. The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. B. A registered nurse, not NAP, must remove the catheter. C. Catheter removal must be executed within 10 minutes of beginning the procedure. D. Catheter removal must take place within 5 days of catheter insertion.

Which action would the nurse take to minimize the patient's risk for infection when changing the dressing on a CVAD? A. Use sterile technique throughout the process. B. Apply a stabilization device if the initial sutures are no longer intact. C. Apply a mask to the patient during the procedure. D. Change the transparent dressing every 48 hours.

Which action would the nurse take to reduce the risk for wound infection when collecting a specimen for culture? A. Collect the specimen while wearing sterile gloves. B. Collect the specimen after washing the wound with sterile water. C. Collect the specimen before cleansing the wound. D. Collect the specimen after administering prescribed pain medication.

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

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

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

Which nursing action demonstrates proper procedure in the collection of a wound culture specimen? A. Wearing clean gloves to remove soiled dressings B. Using a circular motion to cleanse the wound before collecting the specimen C. Completing the lab requisition form in a timely manner after collecting the specimen D. Sending the specimen to the lab within 30 minutes of collecting it

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

Which nursing action is most therapeutic in response to a cognitively impaired patient who demands to know when his daughter is coming to visit? A. Marking the date of the visit on the patient's wall calendar B. Evaluating the patient's understanding of the concept of time and date C. Telling the patient when his daughter will be visiting and ensuring that he verbalizes his understanding D. Calling the daughter to suggest that she visit sooner than she had planned

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

Which patient is most at risk of developing permanently impaired mobility? A. A 72-year-old woman hospitalized for anemia associated with diabetic nephropathy (kidney disease) B. A 55-year-old woman with mental illness who had become malnourished C. An 11-year-old boy who sustained a fractured pelvis during a fall from his tree house D. A 79-year-old man recovering from surgery to release a contracture of the connective tissue in his hand

Which question might the nurse ask the patient when an aerobic wound culture has been ordered? A. "Do you have any pain at the wound site?" B. "Have you ever collected a specimen from your wound before?" C. "Have you had any trouble breathing?" D. "Have your blood counts been high recently?"

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? A. "Please direct the light to better illuminate the patient's perineal area." B. "You need to be comfortable inserting a catheter in a patient of her size." C. "See if a size 14-French catheter is big enough." D. "Find out if the patient has any allergies to latex or iodine."

While attempting to perform a straight catheterization for a male patient, the nurse advances the catheter 3 to 4 inches into the meatus but observes no urine flow. Which action would the nurse take at this time? A. Continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra. B. Withdraw the catheter to 1 inch, and ask the patient to cough. C. Encourage the patient to cough as the catheter is advanced. D. Apply pressure to the patient's lower abdomen over the bladder.

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

Why would the nurse ensure that a patient's condom catheter is not twisted? A. To prevent the catheter from coming off B. To make sure the catheter is the correct size C. To ensure an adequate hourly urine output from the kidneys D. To prevent an allergic response

Why would the nurse provide special instructions to nursing assistive personnel (NAP) before feeding a patient with dysphagia? A. To reduce the risk of aspirating food or fluids B. To ensure that an accurate intake measurement is reported C. To encourage the patient to eat more of the food items on the meal tray D. To ensure that the NAP knows which foods to avoid when feeding the patient

The nurse is preparing to delegate the ambulation of a patient with the use of a gait belt to nursing assistive personnel (NAP). Which statement made by NAP requires the nurse to follow up? A. "I will be sure to put nonskid slippers on the patient before getting him up to ambulate." B. "I will use the under-axillae technique to help him up to a standing position." C. "Rocking the heavier patient into a standing position seems to work really well for me." D. "I will grasp the gait belt in the middle of the patient's back."

A dependent, confused patient is being given a bedpan. How can the nurse best ensure the patient's safety? A. Respond promptly to the call light. B. Raise the side rails on the bed before leaving the room. C. Slide one hand under the patient's sacrum to help the patient lift off the bedpan. D. Check in on the patient every 5 minutes until the bedpan can be removed.

A patient lying supine in bed is being transferred to a wheelchair using a transfer belt. Which action would the nurse perform just before moving the patient to the side of the bed? A. Help the patient put on skid-resistant footwear. B. Raise the head of the bed 30 degrees. C. Place the transfer belt over the patient's clothing. D. Position the chair so that the patient will move toward his or her stronger side.

After assisting with a bedpan, the nurse notes that the patient's stool is streaked with bright-red blood. What would the nurse do first? A. Notify the patient's health care provider. B. Ask if the patient has a history of hemorrhoids. C. Check the medical record to see if the patient has a history of blood in the stool. D. Document the observation in the medical record, indicating a need for follow-up.

Before performing a wound assessment, which nursing action would reduce the patient's risk for infection? A. Taking the patient's temperature B. Applying clean gloves C. Assessing the wound for drainage D. Assessing the dressing for drainage

How can the nurse minimize the risk of dislodging the catheter when removing a dressing? A. Lower the patient's head during the dressing change. B. Remove the transparent dressing or tape and gauze in the direction of catheter insertion. C. Apply skin protectant while the stabilization device is off. D. Cleanse the insertion site quickly and gently in concentric circles.

The nurse has delegated to nursing assistive personnel (NAP) the skill of assisting with a bedpan for a patient who has had discomfort when walking to the bathroom. Which statement made by the NAP requires the nurse's follow-up? A. "Do you still need a stool sample for the lab?" B. "If I can get someone to help, I'll walk her to the bathroom." C. "The patient reports that moving is uncomfortable for her. Has she had pain medication recently?" D. "The patient told me that she's had problems with hemorrhoids in the past."

The nurse has delegated to nursing assistive personnel (NAP) the task of performing fecal occult blood tests on the stool of a patient with a history of positive results. Which instruction is most relevant to performing this test in this particular patient? A. "Notify me only if the test is positive." B. "Save the stool sample so that I can retest it if it is positive." C. "Remind the patient that we test one section of the bowel movement." D. "Use Gastroccult developer with Hemoccult developer."

The nurse is assisting a patient with the placement of a urinal. The patient tells the nurse, "I'll call you when I'm done." What is the nurse's best response? A. "All right, my name is Robin, and I'll be right across the hall. Just call me when you're finished." B. "Fine. Recap the urinal, hang it on your side rail, and use your call light to let me know you're finished." C. "I'll check on you as soon as I get a chance." D. "I'll be back in 15 minutes. That should be enough time for you to finish up."

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? A. "I'll need help to turn her onto her side." B. "It may take three or four enemas to achieve a clear return." C. "I'll test the water temperature on the inside of my own wrist." D. "The enema will wear her out, so I'll wait until after she ambulates."

The nurse is delegating to nursing assistive personnel (NAP) the task of assisting with a urinal. The nurse specifies to NAP that the urinal is to be used in bed, not in a standing position, for which patient? A. Patient admitted for hypertension and diabetes B. Patient with complete left-sided paralysis caused by a stroke C. Patient receiving diagnostic tests for esophageal strictures D. Patient being treated for dehydration from heat exposure

The nurse notes that a patient's left elbow is resistant to extension and flexion while performing range of motion exercises. What is the appropriate nursing action? A. Move the joint through the full range of motion exercises. B. Perform range of motion to the left elbow until resistance is met. C. Omit all the range of motion exercises until the health care provider is notified. D. Inform the health care provider that the patient is uncooperative with exercising.

The nurse wants to offer some diversional activity to a patient with dementia. The patient's family has told the nurse that he is a bit of a loner who enjoyed a 40-year career as an aircraft mechanic. The patient seems frustrated and bored. What is the best activity for the nurse to offer him? A. Weekly pet therapy with a golden retriever B. A jigsaw puzzle of an appropriate level of difficulty C. A crossword puzzle book of an appropriate level of difficulty D. Frequent card games with other patients

To which patient might the nurse apply a physical restraint? A. An 83-year-old patient with dementia and a history of wandering whose fall risk assessment indicates a high risk of falling. B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt. C. A 74-year-old patient confined to bed who is at risk of pressure ulcers. D. A 60-year-old patient with dementia who seemed increasingly confused shortly after having had restraints applied for 1 hour that morning.

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

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

What would the nurse instruct nursing assistive personnel (NAP) to report when caring for a patient in a wrist restraint? A. "Tell me if the patient's pulse changes." B. "Tell me if the skin under the restraint becomes abraded or raw." C. "Let me know if you think she's ready for them to come off." D. "Let me know if the patient needs anything for pain."

What would the nurse instruct nursing assistive personnel (NAP) to report while feeding any patient on aspiration precautions? A. Amount of food ingested B. Coughing C. Poor appetite D. Food preferences

When a nursing assistive personnel (NAP) enters the room of a patient in a belt restraint, he finds the patient's gown bunched around the patient's chest and the patient asking for help. What would the NAP do? A. Check the patient's blood pressure and pulse before smoothing the gown B. Untie the restraint and smooth the patient's gown C. Put on the call light for help D. Ask the patient what specific help she would like

When irrigating a wound, how would the nurse know the right amount of pressure to apply? A. Calculate the wound size. B. Follow the general rule of keeping the pressure between 4 and 15 psi. C. Keep the pressure strong enough to cause moderate pain. D. Gentle enough that is does not create a splash off of the wound

When positioning a hemiplegic patient in the supported Fowler's position, what is the primary reason a trochanter roll is placed alongside the patient's legs? A. To reduce the risk of a fall while the side rails are down B. To reduce the risk of contracture C. To control pain D. To cushion the legs

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? A. Urinary incontinence B. Urinary tract infection (UTI) C. Adequate oral hydration D. Kidney stones

When repositioning a patient, what can the nurse do to prevent the patient's hips from rolling outward? A. Apply therapeutic boots to the feet. B. Place sandbags along the legs. C. Place a small pillow at the lumbar region of the back. D. Place a pillow under the calves.

Which action reduces the nurse's risk for infection when changing the dressing of an infected abdominal wound? A. Begin antibiotic therapy before the dressing change. B. Use appropriate personal protective equipment (PPE). C. Adhere to sterile technique during the intervention. D. Complete the dressing change in an effective, timely way.

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

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

Which device is used for wound irrigation? A. 19-gauge needle attached to a 10-mL syringe B. 19-gauge needle attached to a 35-mL syringe C. Sterile container held 30.5 cm (12 inches) above the wound D. Foley irrigating syringe

Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a newly established colostomy? A. "Be sure to pat-dry the skin surrounding the stoma before applying the new pouch." B. "Alert me immediately if you see any blood in the fecal matter in the pouch." C. "Using the stoma guide, cut the pouch opening about one-eighth of an inch bigger than the stoma." D. "Remember to change your gloves after cleaning the stoma and the surrounding skin."

Which instruction might the nurse give to the NAP to help ensure that a wound culture specimen will be transported properly? A. "Wear sterile gloves when holding the specimen." B. "Take this specimen to the lab immediately." C. "Borrow a specimen collection kit from another unit if we're out of them." D. "Keep the specimen tube horizontal."

While performing catheter care, the nurse moves her hand, allowing the patient's labia to close around the catheter. Why would the nurse repeat this part of the care? A. The catheter may have traumatized the labia. B. The labia have contaminated the area. C. The patient's perineal area must be reassessed for infection. D. The nurse must ensure that the catheter is not pulling on the bladder.

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

The nurse is preparing to move a patient with hemiplegia into the prone position. What action should the nurse take when rolling the patient onto her side? A. Place a small pillow under the shoulder. B. Use the affected arm as a guide during rolling. C. Place a pillow on the abdomen. D. Place rolled bath blankets along the dependent leg.

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? A. Reassure the patient that the procedure will take only a few minutes. B. Promise to reposition the patient as soon as the catheter has been inserted. C. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. D. Explain to the patient that the position will allow the catheter insertion to be more efficient.

A patient has been transferred to a wheelchair with a transfer belt. What is one action the nurse would take to position the patient safely in the chair? A. Remove the wheelchair leg rests. B. Ask the patient to rate his or her pain level. C. Lower the foot rests, and place the patient's feet on them. D. Remove the transfer belt.

A patient with a nasogastric tube, an intravenous infusion line, and an indwelling urinary catheter needs to be placed on the bedpan. Which action would the nurse take first to ensure the patient's safety? A. Close the bedside curtain. B. Raise the side rail on the side opposite that on which the nurse is working. C. Obtain help to place the patient on the bedpan. D. Raise the bed to a comfortable working height.

After moving a patient from the bed to a stretcher, the nurse raises the head of the stretcher. What will the nurse do next? A. Lock the wheels on the stretcher. B. Cover the patient with a blanket. C. Raise the head of the stretcher if doing so is not contraindicated. D. Unlock the wheels of the bed.

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

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

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

How would the nurse safely apply an enzyme debridement ointment? A. Daub ointment on dead tissue at the wound edges. B. Put ointment on a tongue blade, and gently spread it on the center of the wound. C. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin. D. Apply a gauze dressing to ensure contact with the ointment.

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? A. Begin to establish a sterile field. B. Open and assemble the urine drainage bag. C. Remove soiled gloves, and perform hand hygiene. D. Center the drape over the patient's labia.

The nurse has delegated measurement of a patient's vital signs and catheter care to nursing assistive personnel (NAP). Which observation should the NAP report to the nurse immediately? A. Rectal temperature of 99.6° F B. Pulse rate of 88 beats per minute C. Redness noted on the external urethral meatus D. 200 mL of pale yellow urine in the drainage bag

The nurse has one bed alarm available and can use it for any of the following patients, all of whom have dementia. Having an alarm is most important for which patient? A. A patient who has refused most meals for the past week and whose weight has dropped by 10% in the past month. B. A patient who has become verbally combative with health care team members in recent weeks. C. A patient who was returned to the unit last week by staff in an adjacent assisted living facility. D. A patient whose abdominal feeding tube is covered with an abdominal binder.

The nurse is preparing to move a patient from the bed to a stretcher. What will the nurse do first? A. Cross the patient's arms over his or her chest. B. Lower the side rails of the bed. C. Make sure the bed brakes are locked. D. Fanfold the draw sheet.

The wound bed of a patient's pressure injury is red. What does this finding indicate to the nurse? A. Necrotic tissue B. Presence of slough C. Granulation tissue D. Development of an infection

What is the most effective way of preventing aspiration? A. Observe the patient closely for coughing, gagging, choking, and voice alteration. B. Monitor oxygen saturation with pulse oximetry. C. Put any at-risk patient on NPO status until a dysphagia evaluation can be conducted by a speech and language pathologist (SLP). D. Watch for subtle signs that aspiration may have occurred, such as lack of speech, depressed alertness, wet quality to the voice, difficulty controlling secretions, and absence of a gag reflex.

What is the primary reason the nurse ensures that a patient's indwelling urinary catheter drainage tubing is free of kinks? A. Kinks in the tubing cause the patient unnecessary discomfort. B. Kinks allow the drainage bag to become overly full. C. Kinks are associated with the development of urinary tract infection (UTI). D. Kinks result in scant, dark amber-colored urine.

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? A. Recalculate the present drip factor for accuracy. B. Terminate the fluid, and prepare to hang a new bag of formula. C. Plan to check the feeding for completion within the next 3 hours. D. Check with the pharmacy to see if the formula has been hanging too long.

What would the nurse do for a patient who is complaining of penile pain 15 minutes after having a condom catheter applied? A. Offer an anti-inflammatory medication. B. Drop the level of the urine drainage bag. C. Remove the catheter. D. Ensure that the catheter is not twisted.

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

What would the nurse instruct nursing assistive personnel (NAP) to do to ensure safety when feeding Salisbury steak to a dependent patient? A. Lower the head of the bed to a 30-degree angle. B. Encourage the patient to drink all fluids first. C. Cut the steak into small, bite-size pieces. D. Ensure that the steak is steaming hot.

When caring for a patient with Alzheimer's disease, why does the nurse cover the external urinary collection catheter? A. To protect the bed from being soiled B. To avoid offending visitors who would otherwise see the device C. To reduce the patient's access to the device D. To keep the patient from trying to get out of bed alone

When changing a patient's surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves? A. After performing hand hygiene at the start of the procedure B. Before removing the inner dressing C. After removing the original dressing materials and performing hand hygiene a second time D. Just before cleansing the wound with sterile water

When changing the pouching system, which routine step best minimizes irritation of the skin surrounding the stoma? A. Using adhesive remover B. Emptying the ostomy bag only when full C. Avoiding unnecessary changes of the pouching system D. Wearing clean gloves

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

When preparing to infuse a bag of parenteral nutrition through a patient's central line, the nurse notices that the solution has coalesced. What is his or her best response? A. Warm the infusion in the microwave. B. Vigorously shake the bag. C. Contact the pharmacy for a new infusion bag. D. Increase the infusion rate on the pump.

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

When preparing to safely transfer a patient from a bed to a wheelchair using a transfer belt, the nurse would do what first? A. Coordinate extra help. B. Assess the patient's vital signs. C. Assess the patient's physiological capacity to transfer. D. Determine whether to transfer the patient to a wheelchair or chair.

When using a hydraulic lift to transfer a patient from the bed to a chair, when does the nurse turn off the check valve? A. After the patient crosses the arms over the chest B. After the patient's eyeglasses are removed C. As soon as the patient has been placed in the chair D. When the nurse removes the straps

Which action promotes infection control when assisting a patient with a urinal? A. Placing a clean urinal on the overbed table B. Using a waterproof pad to protect the linen from urine spillage C. Applying gloves before emptying and cleaning the patient's urinal D. Asking if the patient would like to clean the genitals after using the urinal

Which action will best minimize a patient's risk for infection while receiving central parenteral nutrition (CPN)? A. Infuse the CPN only with a filter in the line. B. Assess the patient frequently for signs and symptoms of infection. C. Change the CPN infusion tubing at least once every 24 hours. D. Frequently inspect the patient's central venous access site.

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? A. Frequently pull on the drainage system tubing. B. Use the largest-size catheter possible. C. Clean the urinary meatus daily. D. Apply antiseptics to the urinary meatus.

Which action would decrease a patient's pain before a transfer with a hydraulic lift? A. Stop the transfer if the patient expresses or displays physical signs of pain. B. Explain the procedure to the patient before beginning the transfer. C. Administer a prescribed analgesic 30 to 60 minutes before the transfer. D. Postpone the transfer if the patient reports having physical pain or anxiety before the transfer.

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? A. Wear clean gloves when inserting the catheter. B. Inflate the balloon on the catheter before using it. C. Use the smallest-size catheter possible. D. Empty the urine by disconnecting the catheter from the collection bag.

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? A. Lubricate the tip of the rectal tube. B. Pad the patient's bed thoroughly. C. Perform hand hygiene before donning gloves. D. Help the patient onto a bedpan to expel the enema fluid and stool.

Which food item would not be given to a patient on a dysphagia diet? A. Egg salad sandwich on wheat bread B. Biscuits and gravy with scrambled eggs C. Chicken noodle soup D. Rice pudding

Which instruction might the nurse give to nursing assistive personnel (NAP) about applying a condom catheter on a patient? A. "Check for breaks in the skin before applying the catheter." B. "Determine whether the patient is still having problems with incontinence before you put the catheter on him." C. "Read the manufacturer's instructions for applying the adhesive to secure the condom." D. "Be sure to get a snug fit between the tip of the penis and the end of the condom catheter."

Which of the following are basic guidelines when assisting a patient with passive range of motion? A. Exercises should be continued until the point of fatigue and pain. B. Exercises should be done frequently to lessen pain for the patient. C. Each joint is exercised to the point of resistance but not pain. D. Exercises should be performed without the support to each joint.

Which of the following nursing actions addresses the risk for infection related to fecal occult blood testing? A. Maintaining aseptic technique while performing the test B. Performing the fecal occult blood testing in the patient's bathroom C. Wearing clean gloves while testing D. Assessing the patient's ability to provide an uncontaminated fecal specimen

Which position is used when applying the sling to transfer a patient from the bed to a chair with a hydraulic lift? A. Prone B. Side-lying C. Supine D. Sims

Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient with a dressed central venous access device (CVAD) site? A. "Assess the site frequently for signs of inflammation." B. "Be sure to change the transparent dressing on the site once every 7 days." C. "Let me know immediately if the patient's dressing becomes damp." D. "Make sure the patient knows to notify me if the site becomes painful or swollen."

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? A. Rinse off the supplies that were contaminated with urine. B. Cleanse the patient's urinary meatus. C. Replace all contaminated supplies, and begin the process again. D. Change the patient's bed linens.

Why does the nurse instruct nursing assistive personnel (NAP) to remove the wrist restraint of a confused patient every 2 hours? A. To try a less restrictive type of restraint if a more confining restraint has proved effective B. To double-check the size by inserting one finger between the wrist and the restraint C. To check the skin integrity and range of motion of the wrist D. To comply with Joint Commission standards

Why would the nurse ask a physical therapist to perform passive ROM exercises for a patient with lower extremity injuries sustained in a motor vehicle crash? A. The patient is an older adult or has a chronic condition. B. The patient is reluctant to perform the exercises because he is worried about reinjury. C. The patient has orthopedic trauma. D. The patient has pain exacerbated by exercise.

Why would the nurse assess a patient's abdomen before helping with the use of a urinal? A. To determine if the patient needs a bed pan for bowel elimination B. To assess for abdominal pain C. To assess for bladder distention D. To determine if the patient will need help using the urinal

Why would the nurse want to determine if the patient is passing flatus before giving a meal? A. To ensure that the previous meal has been fully digested B. To ensure that the meal won't make the patient feel uncomfortably full C. To determine whether the GI tract is functioning D. To determine whether the patient tolerated the foods given during the previous meal

A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse's responsibility in assessing this patient's wound? A. Remove the dressing, inspect the wound, and reapply a new dressing. B. Inspect the wound and reapply the surgical dressing every 2 hours. C. Inspect the wound, and keep the dressing off until the health care provider arrives. D. Wait until the health care provider orders the removal of the surgical dressing.

A patient's central parenteral nutrition (CPN) order has been changed to a different solution, and the present solution is to be discontinued immediately. What should the nurse do until the new solution is delivered by the pharmacy? A. Discontinue the present CPN solution, and clamp the catheter hub. B. Continue the present CPN solution, but readjust the flow to a keep-vein-open (KVO) rate. C. Hang an infusion of 0.9% normal saline at the same infusion rate as the CPN. D. Hang an infusion of 10% dextrose in water at the same infusion rate as the CPN.

All of the following factors are known to increase the risk of urinary tract infection (UTI) except which one? A. History of fecal incontinence B. Use of an indwelling urinary catheter C. Drainage tubing is kinked D. Use of plain soap instead of an antiseptic cleanser for perineal hygiene

The health care provider writes an order for a culture specimen to be collected from a patient with a dog bite wound. What would the nurse do first? A. Explain the purpose of the test to the patient. B. Assess the level of the patient's pain at the wound site. C. Assess the patient for signs and symptoms of infection. D. Review the order to determine the type of specimen to be collected.

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? A. "I'll warm up the solution before instilling it." B. "I'll place the patient in the left side-lying position with the right knee bent." C. "I'll put a waterproof pad under the patient before I start." D. "I'll instill the solution and then check in on my other patients until I get the call signal."

The nurse instructs nursing assistive personnel (NAP) regarding proper technique for intermittent straight catheterization of a male patient. Which statement made by NAP indicates that the instruction was effective? A. "I'll help you set up the sterile field." B. "I'll get a sterile urine cup for you." C. "There are leg straps in the utility room." D. "I'll help keep his legs away from the sterile field."

The nurse is assisting with a bedpan for a patient who had knee surgery 24 hours ago. What is the best way for the nurse to maximize comfort while the patient uses the bedpan? A. Raise the knee gatch. B. Offer a dose of the patient's prescribed oral pain medication. C. Evaluate the patient's ability to move in bed. D. Elevate the head of the bed to between 30 and 60 degrees.

The nurse is discussing the risk of falling with the wife of a patient with cognitive impairment. What is the nurse's best response when the patient's wife says, "I don't like him being tied down in the bed?" A. "I'm sure you don't want him to fall again." B. "Can you suggest an alternative?" C. "What did you do to prevent him from falling when he was at home?" D. "We will try all other alternatives before using physical restraints."

The nurse is performing passive shoulder and elbow exercises for a patient who is recovering from surgery to remove a soft-tissue tumor in her upper arm. Why does the nurse cup one hand around the patient's elbow and support the forearm and wrist during the ROM exercises? A. To keep the arm above the level of the heart B. To assess the patient's muscle tension C. To listen for crepitus in the joint D. To ensure stability while exercising the joint

The nurse is preparing to logroll a patient in bed. Why are two assistants needed on the side toward which the patient is being turned? A. To position the pillows B. To ease the patient back onto the support pillows C. To keep the spine in alignment D. To roll the patient as a unit

The nurse is preparing to transfer a patient with left-sided weakness from the bed to a wheelchair using a transfer belt. Which position would the nurse instruct the patient to assume? A. Place both feet together on the floor. B. Place your weaker foot forward and your stronger leg toward the back. C. Extend both of your legs and feet. D. Place your stronger leg forward and your weaker leg toward the back.

The nurse notes that a patient's surgical wound is healing slowly. Which health problem would contribute to slow wound healing? A. Osteoarthritis B. Glaucoma C. Deafness D. Diabetes mellitus

What does the nurse do after attaching the hooks to the holes in the sling on a hydraulic lift? A. Lower the head of the bed. B. Remove the patient's eyeglasses. C. Have the patient cross the arms over the chest. D. Elevate the head of the bed.

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? A. To increase oxygenation B. To reduce blood pressure C. To distract him D. To promote relaxation

What is the most effective way to prevent infection when providing catheter care for a patient? A. Properly dispose of soiled linen. B. Perform hand hygiene before positioning the patient. C. Secure the catheter to the patient's leg or abdomen. D. Cleanse from the meatus outward.

What is the nurse's best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago? A. Notify the surgeon of the bleeding. B. Remove the dressing, and assess the wound. C. Assess the patient for signs of shock. D. Further assess the patient and the wound.

What will the nurse do after removing the soiled dressing from a patient's CVAD device? A. Cleanse the site with soap and water. B. Use 2% chlorhexidine swabs to cleanse the site. C. Apply a skin protectant. D. Remove the catheter stabilization device, if present.

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

When pouching a patient's colostomy, which action reduces the patient's risk for injury? A. Measuring output when emptying the contents of the pouch B. Maintaining the patient's bowel elimination function C. Promoting the patient's autonomy with bowel elimination care D. Protecting the skin from irritation caused by fecal drainage

Which action should the nurse avoid before irrigating a patient's foot wound? A. Assess the patient for a history of allergies to tape and irrigating solution. B. Review the provider's orders for the type of irrigating solution to be used. C. Assess the patient's pain on a scale of 0 to 10. D. Warm the irrigant to body temperature in the microwave.

Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound? A. Cleansing the wound with sterile water B. Blotting the incision with dry gauze C. Wearing sterile gloves to cleanse the wound D. Using a new gauze pad for each stroke while cleansing the wound

Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient's left heel is infected? A. White blood cell count B. Complete blood count C. X-ray of left foot D. Culture and sensitivity test

Which initial nursing action would best help the patient learn self-care of a colostomy pouching system? A. Giving the patient handouts on self care of a colostomy B. Allowing the patient to examine an ostomy device C. Identifying a family member who can participate in the ostomy appliance process D. Giving the patient a handheld mirror to watch the nurse provide care

Which instruction to nursing assistive personnel (NAP) is most relevant to the proper performance of a fecal occult blood test using a Hemoccult slide? A. "Be sure to wear sterile gloves." B. "Reinforce with the patient the need to use the hat." C. "Is the patient capable of assisting with the collection?" D. "Remember to take samples from two different areas of the specimen."

Which instruction would the nurse give a patient who is able to assist with transfer from a bed to a wheelchair using a transfer belt? A. "When I count to three, please rock yourself into a standing position." B. "Please hold on to my waist while I help you stand." C. "Please tell me how I can best help you get up off the bed and stand up." D. "Please push down onto the mattress with both hands and stand when I count to three."

Which instruction would the nurse give to nursing assistive personnel (NAP) to ensure the patient's comfort when a condom catheter is applied? A. Wash the penis before applying the catheter. B. Clip the drainage bag to the bed. C. Wear gloves when applying the condom catheter. D. Use a hair guard before applying the condom catheter.

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

Which patient is least at risk for dysphagia? A. A 22-year-old patient with a traumatic brain injury (TBI) sustained during combat. B. A 40-year-old woman undergoing stroke rehabilitation who had been smoking and taking oral contraceptives. C. A 76-year-old patient with dementia. D. A 55-year-old patient with pancreatic cancer who is receiving palliative care.

Which statement indicates proper interpretation of the results of a positive fecal occult blood test? A. "If the sample turns blue, it is positive for bleeding." B. "The sample turned blue after about 45 seconds." C. "The results were positive both times the sample was tested." D. "Because it was positive, the patient must be asked when he or she last ate red meat."

Which statement made by nursing assistive personnel (NAP) assigned to care for a patient with dementia requires the nurse to follow up? A. "I encouraged his son and daughter-in-law to stay with him during visiting hours, if possible, even if they run out of things to talk about." B. "He can't see his Foley because it's covered by his boxer shorts." C. "I'll ask the patient every hour or so whether he needs to use the bathroom." D. "He doesn't understand much of what anyone says to him today, so I didn't put in his hearing aids."

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? A. "Does the patient understand why the specimen is needed and why we cannot obtain it from the Foley bag?" B. "See if the catheter is causing the patient any problems and if he is having any pain." C. "Please get two sterile urine collection containers from the utility room." D. "Let me know if the urine contains blood or sediment, or appears cloudy."

Why does the nurse cleanse a female patient's perineum before inserting an intermittent urinary catheter? A. To encourage the bladder to drain fully B. To encourage spontaneous voiding C. To prevent bowel elimination during the procedure D. To reduce the patient's risk of urinary tract infection

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

A nurse plans to provide education to the parents of school-age children, which includes the increased prevalence of __________________ as a result of children being less physically active outside of school.

childhood obesity

The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to __________________________.

promote venous return from the heart

Name the three important dimensions to consistently measure to determine wound healing.

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