VNSG 1423 final review - all BSN quizzes

Which action by the LPN/LVN indicates a correct understanding of the LPN's/LVN's role in the nursing process? a. Formulates a nursing diagnosis b. Develops expected outcomes c. Performs an admission assessment d. Carries out interventions

d. Carries out interventions

The nurse is caring for a patient in traction. Which action should the nurse take? Allow the patient's foot to touch the end of the bed. Let the weight rest on the floor. Keep the ropes straight on the pulleys Make sure there is enough slack to prevent crossing of lines.

Keep the ropes straight on the pulleys

A patient is on a bowel training program. At which times would the nurse assist the patient to defecate? (SATA) 1. Upon awakening 2. Any time the patient states that he or she has to move bowels 3. After breakfast, lunch, and supper 4. After drinks a pitcher of water 5. Upon bedtime

Ans: 1, 2, 3 1. When the patient arises each day, assist the patient to the commode. 2. Any time the patient says that his or her bowels have to move, assist the patient to the toilet. 3. The patient should be assisted to the commode after each meal. 4. Although this may help with urination, it is not a time for defecation during bowel training. 5. Bedtime is not the time for defecation during bowel training.

The nurse is reinforcing teaching with a mother of a child who has a sprained ankle. Which statements by the mother would indicate a correct understanding of the teaching? Select all that apply. "I should let the child rest." "I will place ice on the ankle." "I will make sure the bandage stays in place." "I will put pillows under my child's ankle." "I can take my child back to soccer practice this week."

Ans: 1, 2, 3, 4

The nurse is entering a patient's room to provide care. What is the minimum number of seconds the nurse should perform hand hygiene? Record the answer as a whole number. Enter numeral only.

20

The health-care provider has written a prescription for supplemental oxygen via a mask. Which piece of equipment should the nurse obtain? 1. T-piece 2. Simple Face Mask 3. Venturi Mask 4. Face Tent

Ans: 3. Venturi Mask Allows precise mix of room air and oxygen to equal a specific percentage of oxygen

Which patient activity would cause the nurse to wear gloves? a. Ambulating a patient b. Providing denture care c. Taking a radial pulse d. Filling out a patient's menu

Answer: b. Providing denture care

The nurse is caring for a patient with Clostridium difficile. Which action is priority? a. Use alcohol-based hand sanitizers frequently b. Wash hands with soap and water c. Keep fingernails short d. Avoid artificial nails

Answer: b. Wash hands with soap and water

Patients often know a great deal about their illnesses and treatments because of information on the Internet. Which recommendations should the nurse make regarding patient research? Select all that apply. a. The patient's pharmacist is a good resource about medications. b. Internet sites ending with ".org," ".edu," and ".gov" are reliable. c. Internet information provides good talking points between the patient and health-care provider. d. Good recommendations for disease management can be found on blog sites. e. The NIH.gov and the Mayo Clinic sites are understandable and have credible information.

A, b, c, e

The nurse notices smoke coming from a patient's room and discovers a small fire in the waste can. In which order should the nurse perform fire safety? Place the options in the correct order. All options must be used. a. Aim the nozzle of the extinguisher at the base of the fire. b. Sweep the nozzle back and forth at the base of the flames. c. Pull the pin found between the handles. d. Squeeze the handles together to release the contents.

Answer: c, a, d, b Rationale: PASS

The nurse prepares to discuss the factors that make women more likely than men to contract a urinary tract infection (UTI). Which information would the nurse present? 1. Women have a shorter urethra than men. 2. The urethra is located closer to the anus. 3. The vaginal pH supports the growth of pathogens. 4. Intercourse exposes the urethra to microbes. 5. The use of diaphragms lowers the risk of UTIs.

Ans: 1, 2, 4 1. Women do have shorter urethra than men, therefore microbes can migrate more easily into the bladder of women. 2. The anatomy of a female places the urethral opening closer to the anus, which makes the migration of microbes easier. 3. The normal vaginal pH of a woman is acidic, which inhibits the invasion of migrating microbes. 4. Intercourse can expose the female urethra to microbes that can cause an infection. Urine is acidic and helps kill bacteria. Urine also flushes microbes out of the urethra. 5. The use of diaphragms can increase the risk of UTIs. Encourage female patients who have recurrent URIs to use a method of birth control other than a diaphragm.

The nurse collects a urine sample from a patient. Which description of urine is considered normal? Select all that apply. 1. The urine is pale and golden yellow in color. 2. The urine contains a moderate amount of sediment. 3. The urine has an odor that is slightly aromatic. 4. The urine is clear in appearance. 5. The urine has a slightly sweet or fruity odor.

Ans: 1, 3, 4 1. straw colored is the term usually used to describe the color of urine; however, the color rang eof normal urine can vary. Urine that is extremely pale or dark in color is abnormal. 2. When urine has a moderate amount of sediment, it is indicative of uric acid, mucus, bacteria, and phosphates. Normal urine has no sediments. 3. Urine is normally slightly aromatic. Any fruity, ammonia, or strong odors are abnormal. 4. Urine is expected to be clear in appearance. Cloudy urine is not considered normal. 5. Urine does have a very mild odor, described as slightly aromatic. Other odors, such as a sweet or fruity smell, a strong ammonia-like smell, or a foul odor, are abnormal findings.

The nurse in a pediatric clinic is seeing a young school-age patient. The parent reports symptoms that include poor appetite, vomiting, diarrhea, and sleeplessness. The parent also reported that the patient had an episode of urinary incontinence at school. Which condition does the nurse suspect? 1. A urinary tract infection (UTI) causing symptoms that are unique to children 2. Gastrointestinal infection that is causing physical and emotional stress 3. Respiratory infection resulting in symptoms triggered by hypoxia 4. An emotional crisis causing physical illness and regressive behavior

Ans: 1. A urinary tract infection (UTI) causing symptoms that are unique to children Children do not exhibit the same symptoms with a UTI as do adults. The symptoms reported by the parent are typical of a child with a UTI, which should be the condition the nurse suspects.

The nurse must obtain a sputum culture. Which action is best for the nurse to take? 1. Obtain the culture early in the morning. 2. Obtain the culture after breakfast. 3. Obtain the culture after giving medications. 4. Obtain the culture right before bedtime.

Ans: 1. Obtain the culture early in the morning. Patients may have mucus that has pooled during the night, making it easier to obtain a specimen.

The nurse is monitoring a patient for hypoxia. Which are late signs of hypoxia? Select all that apply. 1. Bluish skin tones 2. Restlessness 3. Slow heartbeat 4. Increased respirations 5. Substernal retractions

Ans: 1.3.5

A patient is receiving oxygen at 2 L/min per nasal cannula. Which strategies would the home health nurse use? Select all that apply. 1. Apply petroleum jelly for the patient's chapped lips. 2. Suggest cotton gown for sleeping. 3. Ensure no one smokes in the house. 4. Remove candles from the patient's room. 5. Encourage polyester nonslip socks.

Ans: 2, 3, 4

The nurse suspects a patient has occult bleeding and performs a guaiac test. Which actions should the nurse take? (SATA) 1. Put toilet paper in the specimen pan. 2. Obtain specimen from two different areas of the stool. 3. Watch for a bluish color, which is a positive result. 4. Place developer on opposite side of the card from the specimens. 5. Use sterile gloves.

Ans: 2, 3, 4 1: Tell the patient that toilet tissue should not be placed in the specimen pan or bedpan, whichever is used, to prevent contamination of the specimen. 2. Select the specimen from two different areas of the stool, especially any part of stool that is red, maroon, black, or tarry in appearance. 3. The test results are positive for the presence of blood if the feces smears turn a blue or bluish-purple color, similar to the control color. The test results are negative if the smears do not turn blue. 4. According to specific kit instructions, apply the designated number of developer drops onto the opposite side of the card from the specimens, directly over each of the two feces smears. 5: Clean examination gloves are used. - not sterile

A patient reports having diarrhea for 12 hours. Which fluids would the nurse encourage the patient to drink? (SATA) 1. Apple juice 2. Sports drink containing electrolytes 3. Iced green tea 4. Chamomile tea 5. Frozen lemonade

Ans: 2, 4 2:Sports drinks containing electrolytes, such as Gatorade, help to replace fluid and electrolytes lost with diarrhea. 4:Chamomile may be used to soothe an inflamed colon and slow peristalsis.

The nurse works in the office of a urologist. A patient states, "I am very upset because I wet my pants several times a week." Which question will the nurse ask to determine if the patient has stress incontinence? 1. "How often are you in a situation when you can't find a bathroom?" 2. "Are you laughing, sneezing, or straining when you wet your pants?" 3. "How often do you urinate during the day and at nighttime?" 4. "Are there outside triggers that cause you to involuntary pass urine?"

Ans: 2. "Are you laughing, sneezing, or straining when you wet your pants?" Stress incontinence occurs with an increase in abdominal pressure, which causes urine to leak out of the bladder. Laughing, sneezing, and straining are common causes.

The nurse is assigning the administration of an enema to the unlicensed assistive personnel (UAP). Which statement by the UAP indicates the UAP is safe to administer the enema? 1. "I will gently insert the tube upon resistance." 2. "I will insert the tubing toward the umbilicus." 3. "I will insert the tube at least 6 inches (15.2 cm) into the rectum." 4. "I will gently insert the tubing with the patient in the right side-lying position."

Ans: 2. "I will insert the tubing toward the umbilicus." 1: Never force the enema tubing if resistance is met. 2: The UAP should direct the tip of the tubing toward the umbilicus to follow the natural direction of the sigmoid colon. 3: Never insert it farther than 4 to 6 inches (10.2 to 15.2 cm). 4: The patient should be in Sim's or left side-lying position.

The nurse is interviewing a female patient who states, "I have bladder pain sometimes and I just drink more water and it gets better." Which information is most important for the nurse to provide to the patient? 1. "If it does not get better, you may need an antibiotic." 2. "You may be getting bladder infections that can spread to your kidneys." 3. "Don't use a diaphragm or methods that use spermicide for birth control." 4. "You should always be sure to void after sexual intercourse."

Ans: 2. "You may be getting bladder infections that can spread to your kidneys." The information that informs the patient about life-changing risk is the most important. Kidney infections can cause scarring and the loss of kidney function.

The nurse is interviewing a patient in a clinic setting. The patient is being treated for a urinary tract infection (UTI). Which report by the patient causes the nurse the most concern? 1. Painful urination with spasms 2. Fever, chills, and flank pain 3. Low abdominal pain and nocturia 4. Urinary urgency and frequency

Ans: 2. Fever, chills, and flank pain When the patient reports fever, chills, and flank pain, the nurse is concerned that the UTI has now become a kidney infection. Other symptoms include malaise and nausea and vomiting. This is the report that will cause the most concern.

The nurse is collecting data about a patient with respiratory problems. Which technique would the nurse perform to check for excursion? 1. Palpate for the feeling of crispy rice cereal beneath the patient's skin. 2. Place hands on both sides of the chest and watch as patient breathes in and out. 3. Auscultate lung sounds, comparing the right side to the left side. 4. Notice if accessory muscles in the neck and shoulders are being used to breathe.

Ans: 2. Place hands on both sides of the chest and watch as patient breathes in and out.

Which suggestion to conserve energy would the nurse make to a patient with chronic lung disease? 1. Stand while shaving. 2. Use a terrycloth robe after bathing. 3. Try to finish brushing teeth without resting. 4. After showering, obtain several small towels to dry body.

Ans: 2. Use a terrycloth robe after bathing.

The nurse is reinforcing teaching with a patient about the incentive spirometry. Which statement by the patient indicates a correct understanding of the teaching? 1. "I should do this every other hour." 2. "I should blow into the device." 3. "I should inhale at least ten times an hour." 4. "I should breathe fast to raise the platform."

Ans: 3. "I should inhale at least ten times an hour."

The nurse is contributing to the community health program to parents of young children about bowel elimination. Which information should the nurse include? 1. Children develop bowel control around 5 years of age. 2. Infants have about six to eight bowel movements a day. 3. Children usually have about one to two stools a day. 4. Infants are prone to constipation.

Ans: 3. Children usually have about one to two stools a day. 1: Children accomplish voluntary control of elimination between the ages of 2 and 3 years after their neuromuscular structures are developed. 2: Infants will normally have between three and six bowel movements daily. 3: The frequency of bowel movements usually decreases to one or two bowel movements per day. This pattern usually is maintained throughout adulthood. 4: Peristalsis decreases as the individual ages, making elderly individuals more prone to constipation, or hard stools that are difficult to pass.

The nurse delegates the documentation of output to the assistive personnel. Which factor related to urinary output will the nurse instruct the assistive personnel to report immediately? 1. If the patient voids every 2 to 4 hours 2. If a single urinary output is more than 150 mL at a time 3. If the patient exhibits signs of fluid imbalance 4. If there is less than 240 mL of output in 8 hours

Ans: 3. If the patient exhibits signs of fluid imbalance 1. There is not need for the assistive personnel to report to the nurse if the patient voids ever 2 to 4 hours. 2. There is no need for the assistive personnel to report to the nurse if the patient voids more than 150 mL at a time. 3. The nurse will not assign the evaluation of the patient's intake and output to the assistive personnel. Knowledge of fluid balance requires nursing knowledge. 4. Normal urinary output is at least 30 mL per hour. The assistive personnel should be instructed to immediately report to the nurse if the hourly output falls below that amount. The frequency of monitoring depends on the level of care. 30x8=240

A patient has dark skin. Which area is best for the nurse to check for cyanosis? 1. Tip of nose 2. Tops of ears 3. Mucous membranes 4. Nailbeds

Ans: 3. Mucous membranes When the patient has dark skin, the color may appear more ashen than cyanotic and the nurse will depend more on the color of the mucous membranes.

The nurse works in a long-term care facility and is caring for a patient with urinary incontinence. The nurse and patient decide together that the patient may benefit from a bladder training program. Which action by the nurse is unnecessary? 1. Make arrangements that someone assist the patient to the bathroom at set times. 2. Offer fluids to the patient throughout the day to assure good urinary tract health. 3. Notify the health-care provider of the patient's wishes and obtain an order for the program. 4. Teach the patient to avoid caffeinated beverages and to drink more fluids during the day.

Ans: 3. Notify the health-care provider of the patient's wishes and obtain an order for the program. Bladder training is a nursing intervention and does not require a health care providers order.

Which sputum finding would concern the nurse the most? 1. Thick yellow sputum. 2. Thin green sputum. 3. Pink frothy sputum. 4. Rust-colored sputum.

Ans: 3. Pink frothy sputum. Indicative of fluid and blood mixed together and is seen in a life threatening condition called pulmonary edema

The nurse works in an acute care setting and is assigned multiple patients who are ordered on processes involving urinary system evaluation. Which patient will require the most involvement by the nurse? 1. The patient ordered on daily weights 2. The patient ordered to provide a clean-catch specimen 3. The patient ordered on a timed urinary collection 4. The patient ordered for a reagent strip testing

Ans: 3. The patient ordered on a timed urinary collection

How would the nurse care for the pin sites (shown in the image)? (image is pins in leg) 1. Apply ointment at the pin site. 2. Expect a small amount of pus drainage from the pin site. 3. Use sterile gauze with normal saline to clean the site. 4. Report a small amount of serosanguineous drainage from the pin site.

Ans: 3. Use sterile gauze with normal saline to clean the site.

The nurse is collecting data about a patient's bowel functioning. Which action should the nurse take? 1. Palpate the abdomen and then auscultate. 2. Listen to at least one of the four abdominal quadrants. 3. Inspect the abdomen last for distention. 4. Auscultate for at least 3 to 5 minutes if no bowel sounds are heard.

Ans: 4. Auscultate for at least 3 to 5 minutes if no bowel sounds are heard. 1: Avoid palpating the abdomen until after the nurse has assessed the bowel sounds because palpation may stimulate bowel sounds that were not there naturally. 2: All four quadrants should be assessed. 3: Inspection is first, not last. 4: If the nurse thinks that bowel sounds are absent, be certain to listen for at least 3 to 5 minutes in each of the four quadrants before declaring this

Which term would the nurse use in report to describe a patient who gets short of breath walking down the hall? 1. Subcutaneous emphysema 2. Air hunger 3. Orthopnea 4. Exertional dyspnea

Ans: 4. Exertional dyspnea

The nurse suspects a patient had a vagal response to the cleansing enema. Which finding would support the nurse's conclusion? 1. Skin flushed 2. Temperature 103° F (39.4° C) 3. Blood pressure 160/110 4. Heart rate 35 beats per minute

Ans: 4. Heart rate 35 beats per minute When the vagus nerve is stimulated, it can drop the heart rate as low as 30 to 40 beats per minute and cause constriction of the bronchioles of the lungs.

The nurse is preparing to administer a prescribed dose of digoxin to a patient. Which action will the nurse take if the most recent blood level of digoxin reveals a level of 1.9 ng/mL? a. Call to repeat the lab test. B. Administer the drug as prescribed. C. Hold the dose and call the health care provider. D. Screen the patient for signs of toxicity.

Ans: B. Administer the drug as prescribed. Rationale: Digoxin is given as long as the blood level is not greater than 2.0 ng/mL

A nurse realizes they have administered the wrong medication to a client. Which action will the nurse take immediately? a. Call the client's health-care provider to report a medication error. B. Check the vital signs and monitor the status of the client who received the wrong medications. C. Fill out an incident report, providing the details of the error and the client's condition. D. Check vital signs of the client and then administer the medications to the correct client.

Ans: B. Check the vital signs and monitor the status of the client who received the wrong medications Rationale. The nurse's first concern is for the well-being of the client who received the wrong medication. The nurse will need to attend to the client's safety immediately.

Which documentation practices can increase the nurse's risk of being sued for malpractice? Select all that apply. a. Documents a change in respirations but does not document a change in blood pressure b. Charts information on Mary B. Smith's chart that occurred with Mary A. Smith c. Forgets to inform the health-care provider that the patient was bit by a tick while camping d. Administers medications at 0900 and charts on the medication administration record at 0905 e. Does not transcribe the order for supplemental oxygen

Ans: a, b, c, e

The nurse is reinforcing teaching to nursing students about the purposes of documentation. Which information would the nurse include? Select all that apply. a. Provides continuity of care b. Obtains reimbursement for care c. Provides a temporary record of medical care d. Serves as a record for quality assurance e. Serves as a legal record

Ans: a, b, d, e

The nurse is reinforcing teaching to a patient newly diagnosed with diabetes mellitus. The nurse notes that the patient appears confused about the instructions for drawing up insulin. Which statements made by the patient would indicate that the patient is a kinesthetic learner? Select all that apply. a. "Can you let me try to do it?" b. "Can I watch you do it one more time?" c. "Can I try rolling the insulin myself?" d. "Can you explain it to be again?" e. "Can you write the instructions down so I can read them?"

Ans: a, c

Place the steps of the nursing process in order. a. Evaluation b. Assessment c. Diagnosis d. Implementation e. Planning

Ans: b, c, e, d, a Assess, diagnose, plan, intervention, evaluation

Which of the following shows the nurse engaged in teaching health promotion strategies? Select all that apply. a. Explaining appropriate posture and benefits of mobility to a patient with a sedentary lifestyle and chronic back pain b. Counseling a patient who is overweight on weight loss strategies c. Counseling a class of high school students on healthy eating habits d. Describing the appropriate amount of water to drink per day to a patient e. Helping a college student create an exercise plan

Ans: c, d, e

A patient has a slightly elevated temperature. Which questions would the nurse ask to determine if there are factors that may have contributed to the elevated temperature? Select all that apply. a. Had the patient drunk a cold beverage? b. Had the patient ambulated before the temperature? c. Had the patient eaten a meal earlier? d. Was the patient shivering? e. Was the patient diaphoretic?

Answer: B, c, d

The nurse is finished using a needle. In which manner should the nurse dispose of the used needle? a. Recap the needle. B. Break the needle. c. Discard in a double-lined trash can. D. Place in a puncture-resistant container.

Answer: D. Place in a puncture-resistant container.

The nurse assigns the unlicensed assistive personnel (UAP) to perform the 2-hour check on a patient in restraints. Which specific tasks will the nurse instruct the UAP to perform? Select all that apply. a. Offer the patient fluids. b. Check pressure points for redness and chafing. c. Assess extremities for capillary refill and sensation. d. Assist with ambulation if appropriate. e. help with toileting as needed.

Answer: a, d, e. B) The nurse, not the UAP, should be sure to assess the patient for redness and chafing. C) The nurse, not the UAP, should be sure to assess the patient's extremities

Nurses are acutely aware of the biological hazards that risk the safety of health-care personnel. Which action is commonly performed to reduce the risk of biological hazards? a. The nurse remembering to not touch the face or eyes. b. Proper hand hygiene before and after touching patients. c. Always wearing personal protection equipment. d. Posting sign of infective agents on the patient's door.

Answer: b. Proper hand hygiene before and after touching patients. Rationale: The first line of defense against contamination of both personnel and patients is performance of proper hand hygiene before and after touching patients.

The nurse works in an acute care setting. When reviewing safety factors, the nurse becomes aware of many conditions that can contribute to patient safety. Which factor will the nurse identify as a contributing factor to an unsafe patient environment? a. The patient is required to wear a hospital gown and slippers. b. The patient feels confined to a room that is unfamiliar. c. The patient finds the environment like a maze within a maze. d. The patient may feel that privacy is compromised.

Answer: c. The patient finds the environment like a maze within a maze. Rationale: The overall arrangement of a hospital unit can be very confusing and overwhelming to a patient in the hospital. The reality of not knowing where one is can contribute to an unsafe environment.

A patient developed an infection a few days later after insertion of a catheter. In the chain of infection, click on the link that represents the catheter.

Answer: portal of entry The susceptible host is the patient

The nurse reviews prescribed medications for a patient who is admitted for the treatment of a bacterial respiratory infection. Which factor places the patient at risk for a potential adverse medication reaction? a. A history of seasonal allergies B. A previous reaction to antibiotic therapy C. A history of smoking D. A diagnosis of type 2 diabetes mellitus

B. A previous reaction to antibiotic therapy Rationale : A previous reaction to prescribed antibiotics places the patient at risk for an adverse reaction to the newly prescribed antibiotic .

The nurse is preparing for a 0900 medication to be given to a patient at 0930. The nurse reads the medication administration record (MAR), knows that the capsule is red, and retrieves a red capsule from the patient's medication drawer. Later, the nurse discovers the wrong drug was given because there were two different, red-colored drugs. Which medication right did the nurse violate? a. Validation of the drug's action B. Verification of the drug name C. Confirmation of the patient D. Recognition of the time

B. Verification of the drug name Rationale: The nurse needs to be sure to administer the right drug and should not select the drug by color or size. The name of the drug is carefully compared to the drug listed on the MAR

The nurse interviews a patient who recently began warfarin therapy for the treatment of pulmonary emboli. The patient states, "I have noticed that my gums bleed when I brush my teeth." Which is the priority action for the nurse? a. Ask if the patient has a history of gum disease. B. Inquire if the patient uses a regular toothbrush or an electric toothbrush. C. Ask if the patient takes over-the-counter medication for headaches or muscles aches D. Inquire if the patient has consumed crunchy foods, which can cause gum irritation

C. Ask if the patient takes over-the-counter medication for headaches or muscles aches Rationale: The patient should avoid aspirin or ibuprofen because they have anticoagulation effects that can enhance bleeding and prolong the effects of warfarin, therefore this is the priority action for the nurse

The primary care clinic nurse reviews a patient's medications during a scheduled office visit. Which is the primary rationale for the medication review? a. To determine whether a trade medication can be replaced with a generic medication B. To decide if over-the-counter medications can be used C. To evaluate for the possibility of drug-drug interactions D. To assess if medication costs can be reduced

C. To evaluate for the possibility of drug-drug interactions

The nurse is teaching a client on a newly prescribed drug for the treatment of high cholesterol. What is the reason for instructing grapefruit is to be avoided? a. Grapefruit enhances the action of the drug and decreases cholesterol too quickly. B. Grapefruit blocks the action of the drug and causes an increase in cholesterol. C. Grapefruit is a high-cholesterol food source and counteracts the drug. D. Grapefruit interferes with the enzymes that break down the drug.

D. Grapefruit interferes with the enzymes that break down the drug. Rationale: Grapefruit does interfere with the enzymes that break down the drug and causes the blood levels of the drug to become too high.

While administering nighttime medications, the nurse discovers that a dose of atenolol should have been given to a new patient at 1600 but was not administered. The current time is now 2300. Which is the priority action by the nurse? a. Give the medication now and document the reason it was given late. B. Double the atenolol dosage at the next administration time. C. Hold the medication until the morning, then contact the health care provider for orders. D. Obtain vital signs, monitor the patient, and contact the health care provider for further instructions.

D. Obtain vital signs, monitor the patient, and contact the health care provider for further instructions. Rationale: Atenolol should be given 10 to 12 hours apart for twice-daily dosages and should not be stopped suddenly Monitoring the patient and then contacting the health care provider is recommended.

The nurse administers a prescribed antipyretic drug to a patient. Which outcome would be expected? a. The patient's pain decreases B. The patient's blood pressure stabilizes C. The patient's breathing improves D. The patient's fever is reduced

D. The patient's fever is reduced Rationale : An antipyretic drug is given to the patient with a fever . The nurse expects the patient's fever to be reduced

The nurse is caring for a patient with a lateral approach left hip arthroplasty. Which action should the nurse take? Remove the abductor pillow when turning the patient. Turn the patient to the left side q2h. Do not let the patient bend forward when getting out of bed. Place the left leg over the right leg at intervals.

Do not let the patient bend forward when getting out of bed.

The nurse counts the respirations for 15 seconds and gets 4. How many respirations per minute should the nurse chart on the vital signs sheet? a. 8 b. 12 c. 16 d. 20

answer: e. 16 16 the nurse can count the rate for 15 seconds and multiply by 4.

The nurse is educating staff about the benefits of bathing a patient. Which information should be included in this new hygiene program? Select all that apply. a. Removes debris and dead cells b. Allows for skin inspection c. Restricts blood flow to extremities d. Increases sensory input e. Improves communication

a, b, d, e

The nurse is checking the vital signs sheet. Which findings would the nurse determine are normal for adult patients? Select all that apply. a. P - 88, R - 14, BP - 118/64, T - 97°F (36.1°C) b. P - 110, R - 26, BP - 86/40, T - 98°F (36.7°C) c. P - 65, R - 18, BP - 110/70, T - 99.6°F (37.5°C) d. P - 52, R - 10, BP - 145/95, T - 102°F (38.9°C) e. P - 76, R - 20, BP - 112/74, T - 98.6°F (37°C)

a, c, e

The nurse is preparing to review patient teaching with a patient. Which assessment finding is most likely to cause the nurse to modify the review process? a. A patient has a hearing deficit. b. A patient is watching television. c. A patient has visitors at their bedside. d. A patient is preparing to take a shower.

a. A patient has a hearing deficit.

The nurse is preparing to provide oral care to an unconscious patient. Which position would the nurse use? a. Bed flat b. Head of bed elevated c. Head of bed and knees elevated d. Trendelenburg

a. Bed flat

The nurse manager in an extended care facility is concerned about an increase in patient falls. Which situation is most likely contributing to the increase? a. Call lights are not being answered promptly. b. Pain medications are not being administered. c. Toileting schedules are set for every 2 hours. d. There is a high use of ambulatory devices on the unit.

a. Call lights are not being answered promptly. Rationale: Delay in assistance is a major contribution to the incidences of falling. Patients with urgent needs will not wait long for assistance, and may fall in attempt to meet their needs without help.

The nurse receives a hand-written prescription order from a health-care provider in which the dose is not clearly written. Which priority action does the nurse take? a. Call the health-care provider for verification of the order. B. Call the pharmacist for dosage parameters. C. Look the drug up in a current, Physician's Desk Reference. D. Administer the lowest dose in the range given by the drug handbook.

a. Call the health-care provider for verification of the order. Rationale When there is a question about a prescribed drug the nurse must always verify the order with the prescriber

The nurse is preparing to reinforce teaching about the patient's diagnosis of obesity. In this session, the nurse will cover dietary restrictions and the effects of obesity on the body. For which reason will the nurse provide this reinforcement? a. Patient compliance will increase with greater understanding of and reasons for the treatment. b. The patient is likely to be resistant to change, and reinforcement is necessary. c. Most patients with this diagnosis feel helpless to change behaviors. d. Reinforcement will prevent the patient from making excuses for their diagnosis.

a. Patient compliance will increase with greater understanding of and reasons for the treatment.

Which strategies would the nurse use to safely maintain a patient's environment? Select all that apply. a. Place the lunch tray on the bedside stand. b. Keep the patient's door open. c. Place water, glass, and straw within the patient's reach. d. Use neutralizing odor sprays. e. Encourage unlicensed assistive personnel to wear cologne.

a. Place water, glass, and straw within the patient's reach. d. Use neutralizing odor sprays.nail

The nurse is providing care to a patient on contact precautions. The nurse accidently rips a glove on the side of the bed. Which infection control precaution should the nurse implement? a. Remove gloves and wash hands b. Apply another clean glove over the ripped glove c. Take off gloves and put on new ones d. Finish care with the untorn gloved hand

a. Remove gloves and wash hands rationale: change gloves if they become torn or heavily soiled, and use hand hygiene before regloving to prevent contamination of hands with blood or body fluids

The nurse manager is aware that patient teaching is taking place at the time of discharge. Which important process of teaching and learning is being neglected? a. The opportunity for repetition. b. A chance to ask questions. c. Availability of printed materials. d. Appropriate environment.

a. The opportunity for repetition.

According to this "pocket-brain" (see image), which action should the nurse perform at noon? 54 yr old, DX: MI, Allergic: RCN Meds 0730 done, 0900 done, 11:30, 2:00 Bedrest: turn Q2 0800 done 1000 done, 1200, 1400 a. Turn the patient b. Provide mouth care c. Offer a bed bath d. Ambulate the patient

a. Turn the patient

The nurse is helping a patient turn over the "lump" when making the bed. Which action should the nurse take to safely assist the patient with turning? a. Turn the patient toward the nurse b. Remove the pillow c. Lower the side rail d. Go to the other side of the bed

a. Turn the patient toward the nurse

The nurse is helping a patient with the bath by getting supplies and washing the back and buttocks. Which type of care is the nurse providing? a. Self-care b. Assisted care c. Total care d. Holistic care

b. Assisted care

The nurse is checking the bed made by an unlicensed assistive personnel (UAP). Which is not part of an appropriately made bed? a. Cuffed spread over the top sheet b. Wrinkles in the bottom fitted sheet c. Draw sheet placed horizontally at the patient's shoulders and the patient's knees d. Formation of a mitered corner for the top sheet and or the blanket

b. Wrinkles in the bottom fitted sheet

Nurses' Notes 1/14/XX 22:35 Patient admitted to medical floor with pneumonia 2 days prior. During rounds, patient states, "My breathing seems to be a little harder." Auscultated short, popping sounds in the lower lung lobes. Respirations are regular but labored. Patient denies coughing up sputum. Vital Signs 01/14/XX 22:35 Temp. 100.1°F (37.8°C), HR 112 beats/min, regular RR 24 breaths/min, SpO2 94% on nasal cannula 2 L/min, BP 145/90 mm Hg 01/14/XX 19:00 Temp. 99.2°F (37.3C), HR 102 beats/min, regular RR 16 breaths/min, SpO2 96% on nasal cannula 2 L/min, BP 130/80 mm Hg The nurse provides care for a patient admitted to the hospital for treatment of pneumonia. The nurse reviews current and recent assessment data to plan patient care. Which finding does the patient exhibit? Select all that apply. a. Hyperthermia b. Crackles c. Hypotension d. Tachycardia e. Biot respirations f. Tachypnea g. Hypo

answer b. Crackles, d. Tachycardia, f. Tachypnea g. Hyperthermia is not right because it is an elevated temp above 105 Rationale: Crackles are short, popping, snapping, or raspy sounds that result from air moving over secretions in the lungs. Tachycardia is a heart rate over 100 beats/min. Tachypnea is a respiratory greater than 20 breaths/min.

The nurse provides care for a group of patients. Which condition requires droplet precautions? Select all that apply. a. Tuberculosis b. Severe acute respiratory syndrome c. Excessive wound drainage d. Bacterial meningitis e. Rubella (German measles)

answer: d. Bacterial meningitis e. Rubella (German measles)

The nurse is checking a patient's dorsalis pedis pulse. Which site would the nurse use?

answer: Circulation to foot (on top of foot) the dorsalis pedis pulses may be felt on the medial side of the dorsum of the foot

Evaluate a patient's vital sign chart (provided here). Which actions should the nurse take? Select all that apply. a. Notify the RN b. Take the vital signs more often c. Wait to take vital signs until the next scheduled time at 2000 d. Continue to monitor patient, as this is expected e. Have the patient ambulate 0800 99.3F, HR 80, RR 14, BP 126/78, SpO2 98 1200 98.6 F, HR 86, RR 18, BP 120/70, SpO2 95 1600 98F, HR 112, RR 26, BP 98/50, SpO2 86

answer: a. Notify the RN, b. Take the vital signs more often

A patient's blood pressure drops when changing positions. Which information would the nurse share with the patient? a. Rise slowly to a standing position b. Use the modified Trendelenburg position c. Reduce dietary intake of salt d. Walk immediately upon standing

answer: a. Rise slowly to a standing position

The nurse is preparing to take a patient's routine 1000 vital signs. Upon entering the room, the nurse notices the patient drinking a cup of coffee. Which action should the nurse take? a. Take the blood pressure at 1030 b. Take the oral temperature c. Take the vital signs in 5 minutes d. Take the routine vital signs as planned

answer: a. Take the blood pressure at 1030 Rationale: consumption of caffeine affects BP, so wait 30 min VS in 5 min not right because you have to wait longer than 5 min

A nurse at a long-term care facility explores strategies to reduce the incidence of falls among the patient population. Which strategy can alert the staff of a patient's risk for falls while also maintaining confidentiality? Select all that apply. a. Putting a sign on the patient's door that says "Fall Risk" b. Placing a color-coded sticker on the patient's medical record c. Having the patient wear a color-coded armband d. Indicating the patient's fall risk on their Kardex or care plan e. Maintaining a list of fall risk patients on a bulletin board on the unit

answer: b, c, d A) This would break confidentiality by allowing anyone passing by to know that the patient is a fall risk. E) This would break confidentiality by allowing anyone passing by to know that the patient is a fall risk

An 80-year-old female patient, postoperative for hip surgery, receives care on the medical floor. The nurse prepares to call the provider to provide an update for the patient regarding the most recent changes. Which order does the nurse recommend? Nurses' Notes 7/4/XX 21:30 An 80-year-old female, 3 days postoperative for repair of a right hip fracture, receives care on a medical floor. The patient is prescribed hip precautions. The surgical incision, with staples on the right hip, is covered with a nonadherent dressing. An indwelling urinary catheter in place. The patient states pain is a 3/10 at the surgical incision site. Patient states to the nurse, "Even though I have a catheter in, I feel like I have to pee all the time. My bladder feels like it's burning." Vital Signs 7/4/XX 2100, Temp 100.4 F, HR 90 beats/min, RR 22 breaths/min, SpO2 96% on room air, BP 128/75 mm Hg (MAP 90) 7/4/XX 08:00am Temp. 98.

answer: b. Urine culture Temp 100.4 F I feel like I have to pee all the time. My bladder feels like it's burning Rationale: An indwelling urinary catheter is a portal of entry for pathogens. Patients with indwelling catheters are at high risk for hospital acquired infections. The patient communicates urinary discomfort an burning, both of which are signs of urinary tract infection. At this time, more assessment data are needed to identify the source of infection and the urine culture would be the priority.

The nurse is preparing to don personal protective equipment (PPE) before entering a patient's room who is on droplet precautions. The patient needs suctioning. In which sequence would the nurse apply the PPE? a. Gloves b. Goggles c. Gown d. Mask

answer: c, d, b, a

The nurse works in a facility that developed a new policy regarding the use of restraints. The goal is to improve patient safety. Which type of safety equipment does the nurse expect to be used to decrease the use of restraints? a. Vests equipped with quick-release belts b. Side rails that are lower in height c. Chair and bed monitors sensitive to pressure d. Jackets that attach to wheelchair backs and the patient

answer: c. Chair and bed monitors sensitive to pressure Rationale: Chair and bed monitors that are pressure sensitive will alarm when the patient gets up, alerting staff that the patient is at risk. The nurse can expect the use of monitoring devices instead of restraints.

Evaluate Thermometer B shown in the image. Where would the nurse place the thermometer when taking a patient's temperature with this type of thermometer? a. Forehead b. Axilla c. Ear d. Rectal

answer: c. Ear

The nurse is caring for an adult patient with hypertension. Which action should the nurse take when taking a blood pressure? a. Close the screw valve by turning it counterclockwise b. Place the cuff ½ inch above the antecubital space c. Support the patient's arm at the level of the heart d. Position the diaphragm lightly against the skin

answer: c. Support the patient's arm at the level of the heart

The nurse is reviewing perineal care for a female patient with the unlicensed assistive personnel (UAP). Which order would the steps be taken if the UAP is standing on the right side of the bed? Put in correct order. a. Continue to wash the outer labia and perineum until clean b. Clean the middle of the vulva c. Spread the patient's labia with nondominant hand d. Clean the inner right labia e. Clean the inner left labia

c, e, d, b, a

The nurse is bathing a patient who has a urinary catheter. What technique is used when cleaning the catheter? a. Use betadine to clean the catheter and perineum. b. Hold the catheter taut while washing. c. Begin cleaning at the insertion site and clean down the tube. d. Gently pull the catheter out 0.5 inches to clean thoroughly

c. Begin cleaning at the insertion site and clean down the tube.

The nurse is preparing to clean up a chemical spill in the medication room. Which action will the nurse take first? a. Use paper towels to soak up the spill. b. Alert housekeeping about the spill. c. Close the door and access the SDS book. d. Place soaked paper towels in a biohazard bag

c. Close the door and access the SDS book. Rationale: When dealing with a chemical, cleanup should occur according to the SDS. The nurse will first close the door to control exposure and follow the SDS guidelines for managing the spill.

The nurse is preparing to review preoperative teaching with a patient. The nurse is aware that English is the patient's second language. Which action will the nurse take to ensure that learning is reinforced? a. Arrange for an adult family member to be present to clarify information. b. Ask a hospital housekeeper who speaks the patient's native language to assist. c. Contact an interpreter to present the information in the patient's native language. d. Provide all of the teaching information in written form and ask if there are questions.

c. Contact an interpreter to present the information in the patient's native language.

The LPN/LVN reviews a patient's care plan. Which nursing diagnosis is the priority? a. Caregiver role strain b. Spiritual distress c. Deficient fluid volume d. Anxiety

c. Deficient fluid volume

The LPN/LVN reviews the nursing diagnosis written on the care plan: "Risk for infection related to a break in the skin." The phrase "a break in the skin" represents which component of the nursing diagnosis? a. Signs and symptoms b. Defining characteristics c. Etiology d. Problem

c. Etiology

The nurse is revising the plan of care for a diabetic patient. Which intervention should be included regarding nail care? a. Trim toenails deeply at the corners b. Cut toenails straight across c. File toenails only d. Encourage walking barefoot

c. File toenails only

The nurse ambulates a patient with intestinal gas buildup in the hallway to help relieve the discomfort. Which step of the nursing process did the nurse complete? a. Assessment b. Planning c. Implementation d. Evaluation

c. Implementation

Which is an appropriate action for the nurse to take when computer charting? a. Review patient chart that was transferred to another floor for care b. Allow another nurse to use the password to chart a late entry c. Log off immediately after charting patient information d. Copy and paste notes because there has been no change in status

c. Log off immediately after charting patient information

The nurse spills coffee on a patient's chart while charting. Which action would the nurse take? a. Write (continued) at the bottom of the damaged nurse's notes followed with signature. b. Throw the damaged page away and start over. c. Note on the damaged page that the information will be rewritten. d. Shred the damaged page after notes are recopied word for word.

c. Note on the damaged page that the information will be rewritten. The nurse should note on the damaged page that the information will be rewritten. This is because it is important to maintain the integrity of the patient's medical record, even if it has been damaged. The nurse should not throw away or shred the damaged page, as this could be seen as tampering with the medical record. Instead, the nurse should make a note on the damaged page indicating that the information will be rewritten due to damage. The nurse should then rewrite the information on a new page, ensuring that all information is accurately transcribed. The new page should be dated and signed, and the original damaged page should be kept in the patient's record to maintain a complete history.

Which action should the nurse take to facilitate communication with a patient who wears a hearing aid? a. Use an interpreter. b. Speak loudly into the good ear. c. Turn off the television. d. Leave the door open.

c. Turn off the television.

The nurse is making an occupied bed. Which order would the nurse follow when performing the steps? Put in correct order. a. Fanfold clean fitted sheet and draw sheet toward patient b. Change pillowcase c. Roll soiled linens, place in hamper, pull clean linens tightly d. Fold dirty linens toward the patient and tuck next to patient e. Turn patient over lump f. Put on top sheet and blanket/spread

d, a, e, c, f, b

The nurse is caring for a patient after surgery. Which documentation will the nurse use to indicate that the patient is ready for advanced knowledge? a. "Patient refuses to empty surgical drain stating it causes feelings of queasiness." b. "Conversations with patient focused on expectations related to healing and recovery." c. "Patient is uncomfortable with the appearance of the surgical site as indicated by a refusal to look at the incision." d. "Patient asks questions about how to take care of the incision and dressing when discharged home."

d. "Patient asks questions about how to take care of the incision and dressing when discharged home."

The nurse is attending an education program about how to avoid back injury at work. Which factor is important for the nurse to apply? a. Recognize that the center of gravity runs midline from head to pelvis. b. The center of gravity will shift with age and weight changes. c. The base of support is strongest when the feet are positioned a foot apart. d. A wide base of support is considered adequate when the feet are shoulder distance apart.

d. A wide base of support is considered adequate when the feet are shoulder distance apart. Rationale: The optimum distance between the feet is equal to the width of the shoulders.

The nurse is caring for a patient who has septicemia. Which culture result would the nurse review to determine the pathogen causing the septicemia? a. Wound b. Sputum c. Urine d. Blood

d. Blood hint: any word ending in emia means blood

The health-care provider just informed a patient of a life-threatening condition with limited treatment options. The nurse wants to start a patient teaching plan. Which action should the nurse take? a. Ask the patient to express feelings related to the health-care provider 's news. b. Express feelings of empathy to the patient to promote a good teaching opportunity. c. Suggest that the patient call their family in order to get their feedback. d. Sit quietly and allow the patient to develop some questions.

d. Sit quietly and allow the patient to develop some questions.

The nurse is caring for a patient who had surgery for the placement of a colostomy. The nurse is planning to review colostomy care with a patient. Which situation is most likely to interfere with learning? a. The patient voices the need for a nap. b. The patient's pain is a level 5 on a 0 to 10 scale. c. The patient's roommate has visitors. d. The patient will not look at the surgery site.

d. The patient will not look at the surgery site.