A & E 1; Exam 1

While completing an admission database, the nurse is interviewing a patient who states that he's allergic to latex. The most appropriate nursing action is to first: A. Ask the patient to describe the type of reaction B. Leave the room and place the patient in isolation C. Proceed to the termination phase of the interview D. Document the latex allergy on the medication administration record

A. Ask the patient to describe the type of reaction

After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection." What should the nurse do next? (SELECT ALL THAT APPLY.) A. Assess the injection site B. Administer an oral medication for the pain C. Notify the patient's health care provider of assessment findings D. Document assessment findings and related intervention in the patient's medical record This is a normal finding so nothing needs to be done

A. Assess the injection site C. Notify the patient's health care provider of assessment findings D. Document assessment findings and related intervention in the patient's medical record

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

A. Assess the patient for adverse effects

You are a new graduate nurse completing your orientation on a very busy intensive care unit. You cannot read a health care provider's order for one of your patient's medications. You have heard from more experienced nurses that this health care provider does not like to be called, and you know that another of the health care provider's patients is very unstable. What is the most appropriate next step for you to take? A. Call the health care provider to clarify the order B. Talk with your preceptor to help you interpret the order C. Refer to a mediation manual before giving the medication D. Use your best judgment and critical thinking and administer the dose you think the health care provider ordered

A. Call the health care provider to clarify the order

For which of the following health problems is a patient who has a 40-year history of smoking at risk? A. Cardiopulmonary disease and lung cancer B. Stress-related illness C. Obesity and diabetes D. Alcoholism and hypertension

A. Cardiopulmonary disease and lung cancer

A nurse is evaluating a patient who is in soft wrist retraints. Which of the following activities does the nurse perform? (SELECT ALL THAT APPLY.) A. Check the patient's peripheral pulse in the restrained extremity B. Evaluate the patient's need for toileting C. Release both limbs at the same time to perform range of motion (ROM) D. Inspect the skin under each restraint

A. Check the patient's peripheral pulse in the restrained extremity B. Evaluate the patient's need for toileting D. Inspect the skin under each restraint

Which of the following examples are steps of nursing assessment? (SELECT ALL THAT APPLY.) A. Collection of information from patient's family members B. Recognition that further observations are needed to clarify information C. Comparison of data with another source to determine data accuracy D. Complete documentation of observational information Determining which medications to administer based on a patient's assessment data

A. Collection of information from patient's family members B. Recognition that further observations are needed to clarify information C. Comparison of data with another source to determine data accuracy

What is removal of devitalized tissue from a wound called? A. Debridement B. Pressure reduction C. Negative pressure wound therapy D. Sanitization

A. Debridement

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

A. Decreased peristalsis

A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing: A. Depression B. Dementia C. Delirium D. Hypoglycemic reaction

A. Depression

An 86-year-old woman is admitted to the unit with chills and a fever of 104°F. What physiological process explains why she is at risk for dyspnea? A. Fever increases metabolic demands, requiring increased oxygen need B. Blood glucose stores are depleted and the cells do not have energy to use oxygen C. Carbon dioxide production increases due to hyperventilation D. Carbon dioxide production decreases to due hypoventilation

A. Fever increases metabolic demands, requiring increased oxygen need

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (SELECT ALL THAT APPLY.) A. Frequent position changes B. Keeping the buttocks exposed to air at all time C. Using a large absorbent diaper, changing when saturated D. Using an incontinence cleaner E. Applying a moisture barrier ointment

A. Frequent position changes D. Using an incontinence cleaner E. Applying a moisture barrier ointment

A 71-year old patient enters the emergency department after falling down stairs in the home. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? (SELECT ALL THAT APPLY.) A. Impaired vision B. Residence design C. Blood pressure D. Leg weakness E. Exercise history

A. Impaired vision D. Leg weakness E. Exercise history

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 fall in the elderly? (SELECT ALL THAT APPLY.) A. Inadequate lighting B. Throw rugs C. Multiple medications D. Staircases with handrails

A. Inadequate lighting B. Throw rugs C. Multiple medications

A nurse caring for a patient with COPD knows that which oxygen delivery device is MOST appropriate if using 2L/min of oxygen? A. Nasal cannula B. Simple face mask C. Partial non-rebreather mask D. Non-rebreather mask

A. Nasal cannula

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: A. Place a bed alarm device on the bed B. Place the patient in a belt restraint C. Provide one-on-one observation of the patient D. Apply wrist restraints

A. Place a bed alarm device on the bed

The nurse assesses a new patient and finds the patient short of breath with a respiratory rate of 32 and lying supine in bed. What is the priority nursing action? A. Raise the head of the bed to 45 degrees or higher B. Get the oxygen saturation with a pulse oximeter C. Take the blood pressure and the respiratory rate D. Notify the health care provider of the shortness of breath

A. Raise the head of the bed to 45 degrees or higher

A nurse just started working at a well-baby clinic. One of her recent experiences was to help a mother learn the steps of breastfeeding. During the first clinic visit the mother had difficulty positioning the baby during feeding. After the visit the nurse considers what affected the inability of the mother to breastfeed, including the mother's obesity and inexperience. The nurse's review of the situation is called: A. Reflection B. Perseverance C. Intuition D. Problem solving

A. Reflection

The nurse is caring for a patient who exhibits labored breathing, is using accessory muscles, and is coughing up pink frothy sputum. The patient has diminished breath sounds in bilateral lung bases. What are the priority nursing assessments for the nurse to perform prior to notifying the patient's health care provider? (SELECT ALL THAT APPLY.) A. SpO2 levels B. Amount, color, and consistency of sputum production C. Fluid status D. Pain in lower leg E. Change in respiratory rate and pattern

A. SpO2 levels B. Amount, color, and consistency of sputum production E. Change in respiratory rate and pattern

The nurse knows that when instilling ophthalmic solution (SELECT ALL THAT APPLY): A. The nurse must assess the condition of external eye structure as a baseline B. Ask the patient to lie supine or sit back in the chair with head hyperextended C. Ask the patient to look at the ceiling and blink as many times as possible D. Hold ophthalmic solution 1-2 cm above conjunctival sac Instill drops to the patient's outer canthus of eye

A. The nurse must assess the condition of external eye structure as a baseline B. Ask the patient to lie supine or sit back in the chair with head hyperextended D. Hold ophthalmic solution 1-2 cm above conjunctival sac

In which of the following examples is a nurse applying critical thinking skills in practice? (SELECT ALL THAT APPLY.) A. The nurse thinks back about a personal experience before administering medication subcutaneously B. The nurse uses a pain-rating scale to measure a patient's pain C. The nurse explains a procedure step by step for giving an enema D. The nurse gathers data on a patient with a mobility limitation to identify a nursing diagnosis

A. The nurse thinks back about a personal experience before administering medication subcutaneously B. The nurse uses a pain-rating scale to measure a patient's pain D. The nurse gathers data on a patient with a mobility limitation to identify a nursing diagnosis

The effects of immobility on the cardiac system include which of the following? (SELECT ALL THAT APPLY.) A. Thrombus formation B. Increased cardiac workload C. Weak peripheral pulses D. Irregular heartbeat E. Orthostatic hypotension

A. Thrombus formation B. Increased cardiac workload E. Orthostatic hypotension

When is an application of a warm compress to an ankle muscle sprain indicated? (SELECT ALL THAT APPLY.) A. To relive edema B. To reduce shivering C. To improve blood flow to an injured part D. To immobilize area

A. To relive edema C. To improve blood flow to an injured part

Which of the following are measures to reduce tissue damage from shear? (SELECT ALL THAT APPLY.) A. Use a transfer device B. Have head of bed elevated when transferring patient C. Have head of bed flat when transferring patient D. Raise head of bed 60 degrees when patient positioned supine E. Raise head of bed 30 degrees when patient positioned supine

A. Use a transfer device C. Have head of bed flat when transferring patient E. Raise head of bed 30 degrees when patient positioned supine

A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of the evaluation phase of the nursing process? a. To determine if interventions have been effective in meeting patient outcomes b. To document the nursing care plan in the progress notes of the medical record c. To decide whether the patient's health problems have been completely resolved d. To establish if the patient agrees that the nursing care provided was satisfactory

ANS: A Evaluation consists of determining whether the desired patient outcomes have been met and whether the nursing interventions were appropriate. The other responses do not describe the evaluation phase.

A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis. Which outcome would the nurse recognize as most appropriate for this patient? a. Patient has a balanced intake and output. b. Patient's bedding is changed when it becomes damp. c. Patient understands the need for increased fluid intake. d. Patient's skin remains cool and dry throughout hospitalization.

ANS: A This statement gives measurable data showing resolution of the problem of deficient fluid volume that was identified in the nursing diagnosis statement. The other statements would not indicate that the problem of deficient fluid volume was resolved.

Which information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/LVN) who is working on a medical-surgical unit (select all that apply)? a. Institutional policies b. Stability of the patient c. State nurse practice act d. LPN/LVN teaching abilities e. Experience of the LPN/LVN

ANS: A, B, C, E The nurse should assess the experience of LPN/LVNs when delegating. In addition, state nurse practice acts and institutional policies must be considered. In general, LPN/LVN scope of practice includes caring for patients who are stable, while registered nurses should provide most of the care for unstable patients. Since LPN/LVN scope of practice does not include patient education, this will not be part of the delegation process.

The nurse is administering medications to a patient. Which actions by the nurse during this process are consistent with promoting safe delivery of care (select all that apply)? a. Throws away a medication that is not labeled b. Uses a hand sanitizer before preparing a medication c. Identifies the patient by the room number on the door d. Checks lab test results before administering a diuretic e. Gives the patient a list of current medications upon discharge

ANS: A, B, D, E National Patient Safety Goals have been established to promote safe delivery of care. The nurse should use at least two reliable ways to identify the patient such as asking the patient's full name and date of birth before medication administration. Other actions that improve patient safety include performing hand hygiene, disposing of unlabeled medications, completing appropriate assessments before administering medications, and giving a list of the current medicines to the patient and caregiver before discharge.

The nurse is obtaining a health history from a new patient. Which data will be the focus of patient teaching? a. Age and gender b. Saturated fat intake c. Hispanic/Latino ethnicity d. Family history of diabetes

ANS: B Behaviors are strongly linked to many health care problems. The patient's saturated fat intake is a behavior that the patient can change. The other information will be useful as the nurse develops an individualized plan for improving the patient's health, but will not be the focus of patient teaching.

The nurse teaches a student nurse about how to apply the nursing process when providing patient care. Which statement, if made by the student nurse, indicates that teaching was successful? a. "The nursing process is a scientific-based method of diagnosing the patient's health care problems." b. "The nursing process is a problem-solving tool used to identify and treat patients' health care needs." c. "The nursing process is based on nursing theory that incorporates the biopsychosocial nature of humans." d. "The nursing process is used primarily to explain nursing interventions to other health care professionals."

ANS: B The nursing process is a problem-solving approach to the identification and treatment of patients' problems. Diagnosis is only one phase of the nursing process. The primary use of the nursing process is in patient care, not to establish nursing theory or explain nursing interventions to other health care professionals.

A home care nurse is planning care for a patient who has just been diagnosed with type 2 diabetes mellitus. Which task is appropriate for the nurse to delegate to the home health aide? a. Assist the patient to choose appropriate foods. b. Help the patient with a daily bath and oral care. c. Check the patient's feet for signs of breakdown. d. Teach the patient how to monitor blood glucose.

ANS: B Assisting with patient hygiene is included in home health-aide education and scope of practice. Assessment of the patient and instructing the patient in new skills, such as diet and blood glucose monitoring, are complex skills that are included in registered nurse education and scope of practice.

The nurse is caring for a Native American patient who has traditional beliefs about health and illness. Which action by nurse is most appropriate? a. Avoid asking questions unless the patient initiates the conversation. b. Ask the patient whether it is important that cultural healers are contacted. c. Explain the usual hospital routines for meal times, care, and family visits. d. Obtain further information about the patient's cultural beliefs from a family member.

ANS: B Because the patient has traditional health care beliefs, it is appropriate for the nurse to ask whether the patient would like a visit by a shaman or other cultural healer. There is no cultural reason for the nurse to avoid asking the patient questions because they are necessary to obtain health information. The patient (rather than the family) should be consulted about personal cultural beliefs. The hospital routines for meals, care, and visits should be adapted to the patient's preferences rather than expecting the patient to adapt to the hospital schedule.

The nurse is caring for an Asian patient who is being admitted to the hospital. Which action would be most appropriate for the nurse to take when interviewing this patient? a. Avoid eye contact with the patient. b. Observe the patient's use of eye contact. c. Look directly at the patient when interacting. d. Ask a family member about the patient's cultural beliefs.

ANS: B Observation of the patient's use of eye contact will be most useful in determining the best way to communicate effectively with the patient. Looking directly at the patient or avoiding eye contact may be appropriate, depending on the patient's individual cultural beliefs. The nurse should assess the patient, rather than asking family members about the patient's beliefs.

A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registered nurse (RN), one unlicensed assistive personnel (UAP), and one licensed practical/vocational nurse (LPN/LVN). Which assignment, if delegated by the nurse, would be inappropriate? a. Measurement of a patient's urine output by UAP b. Administration of oral medications by LPN/LVN c. Check for the presence of bowel sounds and flatulence by UAP d. Care of a patient with diabetes by RN who usually works on the pediatric unit

ANS: C Assessment requires RN education and scope of practice and cannot be delegated to an LPN/LVN or UAP. The other assignments made by the RN are appropriate.

The nurse interviews a patient while completing the health history and physical examination. What is the purpose of the assessment phase of the nursing process? a. To teach interventions that relieve health problems b. To use patient data to evaluate patient care outcomes c. To obtain data with which to diagnose patient problems d. To help the patient identify realistic outcomes for health problems

ANS: C During the assessment phase, the nurse gathers information about the patient to diagnose patient problems. The other responses are examples of the planning, intervention, and evaluation phases of the nursing process.

What information should the nurse collect when assessing the health status of a community? a. Air pollution levels b. Number of health food stores c. Most common causes of death d. Education level of the individuals

ANS: C Health status measures of a community include birth and death rates, life expectancy, access to care, and morbidity and mortality rates related to disease and injury. Although air pollution, access to health food stores, and education level are factors that affect a community's health status, they are not health measures.

A patient has been admitted to the hospital for surgery and tells the nurse, "I do not feel comfortable leaving my children with my parents." Which action should the nurse take next? a. Reassure the patient that these feelings are common for parents. b. Have the patient call the children to ensure that they are doing well. c. Gather more data about the patient's feelings about the child-care arrangements. d. Call the patient's parents to determine whether adequate child care is being provided.

ANS: C Since a complete assessment is necessary in order to identify a problem and choose an appropriate intervention, the nurse's first action should be to obtain more information. The other actions may be appropriate, but more assessment is needed before the best intervention can be chosen.

A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the left hip. Which nursing diagnosis is most appropriate? a. Impaired physical mobility related to left-sided paralysis b. Risk for impaired tissue integrity related to left-sided weakness c. Impaired skin integrity related to altered circulation and pressure d. Ineffective tissue perfusion related to inability to move independently

ANS: C The patient's major problem is the impaired skin integrity as demonstrated by the presence of a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by frequently repositioning the patient. Although left-sided weakness is a problem for the patient, the nurse cannot treat the weakness. The "risk for" diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The patient does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health problem is.

Which nursing diagnosis statement is written correctly? a. Altered tissue perfusion related to heart failure b. Risk for impaired tissue integrity related to sacral redness c. Ineffective coping related to response to biopsy test results d. Altered urinary elimination related to urinary tract infection

ANS: C This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a patient's response to a health problem that can be treated by nursing. The use of a medical diagnosis as an etiology (as in the responses beginning "Altered tissue perfusion" and "Altered urinary elimination") is not appropriate. The response beginning "Risk for impaired tissue integrity" uses the defining characteristic as the etiology

The nurse is caring for an older adult patient who had surgery to repair a fractured hip. The patient needs continued nursing care and physical therapy to improve mobility before returning home. The nurse will help to arrange for transfer of this patient to which facility? a. A skilled care facility b. A residential care facility c. A transitional care facility d. An intermediate care facility

ANS: C Transitional care settings are appropriate for patients who need continued rehabilitation before discharge to home or to long-term care settings. The patient is no longer in need of the more continuous assessment and care given in acute care settings. There is no indication that the patient will need the permanent and ongoing medical and nursing services available in intermediate or skilled care. The patient is not yet independent enough to transfer to a residential care facility.

A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse to delegate to experienced unlicensed assistive personnel (UAP)? a. Monitor for shortness of breath or fatigue after ambulation. b. Instruct the patient about the need to alternate activity and rest. c. Obtain the patient's blood pressure and pulse rate after ambulation. d. Determine whether the patient is ready to increase the activity level.

ANS: C UAP education includes accurate vital sign measurement. Assessment and patient teaching require registered nurse education and scope of practice and cannot be delegated.

The nurse describes to a student nurse how to use evidence-based practice guidelines when caring for patients. Which statement, if made by the nurse, would be the most accurate? a. "Inferences from clinical research studies are used as a guide." b. "Patient care is based on clinical judgment, experience, and traditions." c. "Data are evaluated to show that the patient outcomes are consistently met." d. "Recommendations are based on research, clinical expertise, and patient preferences."

ANS: D Evidence-based practice (EBP) is the use of the best research-based evidence combined with clinician expertise. Clinical judgment based on the nurse's clinical experience is part of EBP, but clinical decision making should also incorporate current research and research-based guidelines. Evaluation of patient outcomes is important, but interventions should be based on research from randomized control studies with a large number of subjects.

Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Complete the initial admission assessment and plan of care. b. Document teaching completed before a diagnostic procedure. c. Instruct a patient about low-fat, reduced sodium dietary restrictions. d. Obtain bedside blood glucose on a patient before insulin administration.

ANS: D The education and scope of practice of the LPN/LVN include activities such as obtaining glucose testing using a finger stick. Patient teaching and the initial assessment and development of the plan of care are nursing actions that require registered nurse education and scope of practice.

A nurse is assigned as a case manager for a hospitalized patient with a spinal cord injury. The patient can expect the nurse functioning in this role to perform which activity? a. Care for the patient during hospitalization for the injuries. b. Assist the patient with home care activities during recovery. c. Determine what medical care the patient needs for optimal rehabilitation. d. Coordinate the services that the patient receives in the hospital and at home.

ANS: D The role of the case manager is to coordinate the patient's care through multiple settings and levels of care to allow the maximal patient benefit at the least cost. The case manager does not provide direct care in either the acute or home setting. The case manager coordinates and advocates for care but does not determine what medical care is needed; that would be completed by the health care provider or other provider.

The nurse completes an admission database and explains that the plan of care and discharge goals will be developed with the patient's input. The patient states, "How is this different from what the doctor does?" Which response would be most appropriate for the nurse to make? a. "The role of the nurse is to administer medications and other treatments prescribed by your doctor." b. "The nurse's job is to help the doctor by collecting information and communicating any problems that occur." c. "Nurses perform many of the same procedures as the doctor, but nurses are with the patients for a longer time than the doctor." d. "In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health."

ANS: D This response is consistent with the American Nurses Association (ANA) definition of nursing, which describes the role of nurses in promoting health. The other responses describe some of the dependent and collaborative functions of the nursing role but do not accurately describe the nurse's role in the health care system.

The nurse works in a clinic located in a community with many Hispanics. Which strategy, if implemented by the nurse, would decrease health care disparities for the Hispanic patients? a. Improve public transportation to the clinic. b. Update equipment and supplies at the clinic. c. Obtain low-cost medications for clinic patients. d. Teach clinic staff about Hispanic health beliefs.

ANS: D Health care disparities are due to stereotyping, biases, and prejudice of health care providers. The nurse can decrease these through staff education. The other strategies also may be addressed by the nurse but will not directly impact health disparities.

The nurse documenting the patient's progress in the care plan in the electronic health record before an interdisciplinary discharge conference is demonstrating competency in which QSEN category? a. Patient-centered care b. Quality improvement c. Evidence-based practice d. Informatics and technology

ANS: D The nurse is displaying competency in the QSEN area of informatics and technology. Using a computerized information system to document patient needs and progress and communicate vital information regarding the patient with health care team members provides evidence that nursing practice standards related to the nursing process have been maintained during the care of the patient.

The nurse admits a patient to the hospital and develops a plan of care. What components should the nurse include in the nursing diagnosis statement? a. The problem and the suggested patient goals or outcomes b. The problem with possible causes and the planned interventions c. The problem, its cause, and objective data that support the problem d. The problem with an etiology and the signs and symptoms of the problem

ANS: D When writing nursing diagnoses, this format should be used: problem, etiology, and signs and symptoms. The subjective, as well as objective, data should be included in the defining characteristics. Interventions and outcomes are not included in the nursing diagnosis statement.

Which assessment question should the nurse ask to best understand how visual alterations are affecting the patient's self-care ability? A. "Have you stopped reading books or switched to books on audiotape?" B. "Are you able to prepare a meal or write a check?" C. "How do you protect yourself from injury at work?" D. "How does your vision impairment make you feel?"

B. "Are you able to prepare a meal or write a check?"

While planning morning care which of the following patients would receive the highest priority to receive his or her bath first? A. A patient who just returned to the nursing unit from surgery and is experiencing pain at a level of 7 on a scale of 0-10 B. A patient who is experiencing frequent incontinent diarrheal stools C. A patient who prefers a bath in the evening when his wife visits and can help him D. A patient who has just returned form diagnostic testing and complains of being very fatigued

B. A patient who is experiencing frequent incontinent diarrheal stools

A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. She notes that the patient is very thin and unkempt, has a stage 3 pressure ulcer to her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son who accompanied her to the hospital. The nurse's next step is to: A. Call social services to begin nursing home placement B. Ask the son to step out of the room so she can complete her assessment C. Call adult protective services because you suspect elder mistreatment D. Assess patient's cognitive status

B. Ask the son to step out of the room so she can complete her assessment

A client who is receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. What does the nurse do FIRST? A. Notify the health care provider B. Assess the client's pulse oximetry C. Document the observation D. Lower the head of the bed

B. Assess the client's pulse oximetry

A patient's heart rate is increased from 80bpm to 160bpm. The nurse knows that what will follow is: (SELECT ALL THAT APPLY) A. Increase in diastolic filling time B. Decrease in cardiac output C. Decrease in stroke volume D. Vital signs within normal parameters E. Decrease in contractility

B. Decrease in cardiac output C. Decrease in stroke volume E. Decrease in contractility

The nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening and was hallucinating. On the basis of this history, the nurse suspects that the patient is experiencing: A. Depression B. Delirium C. New-onset dementia D. Worsening dementia

B. Delirium

Which of the following are methods to reduce the risk of needlestick injury? (SELECT ALL THAT APPLY). A. Recap the needle after giving an injection B. Dispose of needle using one hand C. Never force a needle into the sharps disposal D. Clearly mark sharps disposal containers E. Use needleless devices whenever possible

B. Dispose of needle using one hand C. Never force a needle into the sharps disposal D. Clearly mark sharps disposal containers E. Use needleless devices whenever possible

A nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication? A. Antibiotics B. Frequent change of position C. Oxygen humidification D. Chest physiotherapy

B. Frequent change of position

A nurse is assisting a patient with ambulation. The patient becomes short of breath and beings to complain of sharp chest pain. Which action by the nurse is the FIRST priority? A. Call for the emergency response team to bring the defibrillator B. Have the patient sit down in the nearest chair C. Return the patient to the room and apply 100% oxygen D. Ask a coworker to get the ECG machine STAT

B. Have the patient sit down in the nearest chair

A client who is recovering from pneumonia is still noted to have crackles on auscultation. Which action by the nurse is MOST appropriate? A. Call respiratory therapy and request a bronchodilator treatment B. Instruct the client to use the incentive spirometer and to cough and deep breathe C. Consult with the health care provider and request an order for diuretics D. Ensure that the order FiO2 is what is being provided

B. Instruct the client to use the incentive spirometer and to cough and deep breathe

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.) A. Allow the area to be exposed to air until all drainage has stopped B. Notify the surgeon C. Place several cold packs over the area, protecting the skin around the wound D. Cover the area with sterile gauze and apply an abdominal binder E. Cover the area with sterile, saline-soaked towels immediately

B. Notify the surgeon E. Cover the area with sterile, saline-soaked towels immediately

The nurse is caring for a patient with the diagnosis of impaired physical mobility. The nurse understands that the following interdisciplinary services are needed to ensure the patient's best outcome? (SELECT ALL THAT APPLY) A. Respiratory therapy B. Physical therapy C. Cardiac therapy D. Dental services E. Occupational therapy

B. Physical therapy E. Occupational therapy

The nurse is aware that PCO2 refers to the: A. Amount of oxygen saturation in the venous blood B. Pressure exerted by carbon dioxide in the arterial blood C. Pressure of oxygen in the plasma D. Amount of oxygen that isn't used by the body

B. Pressure exerted by carbon dioxide in the arterial blood

An older adult states that he has trouble seeing his medication bottles clearly to determine when to take his prescription. What should the nurse do? (SELECT ALL THAT APPLY). A. Tell the patient what is in each container B. Provide a dispensing container for each day of the week C. Have a family member administer the medication D. Provide larger, easier to read labels E. Consult with the health care provider to discontinue all medications F. Ask the patient when was the last time he went to see the eye doctor

B. Provide a dispensing container for each day of the week D. Provide larger, easier to read labels F. Ask the patient when was the last time he went to see the eye doctor

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.) A. Collection of wound drainage B. Providing support to abdominal tissues when coughing or walking C. Reduction of abdominal swelling D. Reduction of stress on the abdominal incision E. Stimulation of peristalsis from direct pressure

B. Providing support to abdominal tissues when coughing or walking D. Reduction of stress on the abdominal incision

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. A. BP = 128/84 B. Respirations 26/min on room air C. HR 114 D. Crackles over lower lobes heard on auscultation E. Pain reported as a 3 on a scale of 0 to 10 after medication

B. Respirations 26/min on room air C. HR 114 D. Crackles over lower lobes heard on auscultation

What does the Braden scale evaluate? A. Skin integrity at bony prominences, including any wounds B. Risk factors that place the patient at risk for skin breakdown C. The amount of repositioning that the patient can tolerate D. The factors that place the patient at risk for poor healing

B. Risk factors that place the patient at risk for skin breakdown

A nurse is caring for a patient preparing for discharge from the hospital the next day. The patient does not read. His family caregiver will be visiting before discharge. What can the nurse do to facilitate the patient's understanding of his discharge instructions? (SELECT ALL THAT APPLY.) A. Yell so the patient can hear you B. Sit facing the patient so he is able to watch your lip movements and facial expressions C. Present one idea or concept at a time D. Send a written copy of the instructions home with him and tell him to have the family review them E. Include the family caregiver in the teaching session

B. Sit facing the patient so he is able to watch your lip movements and facial expressions C. Present one idea or concept at a time E. Include the family caregiver in the teaching session

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

B. The prescriber's orders

A nurse inquires about a patient's ability to complete activities of daily living (ADLs). ADLs include independence with: (SELECT ALL THAT APPLY.) A. Driving B. Toileting C. Bathing D. Daily exercise E. Eating

B. Toileting C. Bathing E. Eating

A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems? A. "I can tell that your eating habits have led to your diabetes. Is that right?" B. "It's been difficult for people to find jobs. Is that why you work part time?" C. "You have four children; do you have any concerns about going home and caring for them?" D. "I wish patients understood how overeating affects their health."

C. "You have four children; do you have any concerns about going home and caring for them?"

Which of the following gastrointestinal changes are normal with aging? A. Increased peristalsis B. Increased liver function C. Altered intestinal secretions D. Heightened sense of smell

C. Altered intestinal secretions

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.) A. Contact the nursing supervisor B. Restrict the family's visiting privileges C. Ask the family to stay with the patient if possible D. Inform the family of the risks associated with side-rail use E. Thank the family for being conscientious and put the four rails up F. Discuss alternatives that are appropriate for this patient with the family

C. Ask the family to stay with the patient if possible D. Inform the family of the risks associated with side-rail use F. Discuss alternatives that are appropriate for this patient with the family

A nurse changed a patient's surgical dressing the day before and now prepares for another dressing change. The nurse had difficultly removing the gauze from the wound bed yesterday, causing the patient discomfort. Today he gives the patient an analgesic 30 minutes before the dressing change. Then he adds some sterile saline to loosen the gauze for a few minutes before removing it. The patient reports that the procedure was much more comfortable. Which of the following describes the nurse's approach to the dressing change? (SELECT ALL THAT APPLY.) A. Clinical inference B. Basic critical thinking C. Complex critical thinking D. Experience E. Reflection

C. Complex critical thinking D. Experience

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

C. Decreased ability to clear airway through coughing

The nurse would expect to see increased ventilations if a patient exhibits: A. Increased oxygen saturation B. Decreased carbon dioxide levels C. Decreased pH D. Increased hemoglobin levels

C. Decreased pH

By using known criteria in conducting an assessment such as reviewing with a patient the typical characteristics of pain, a nurse is demonstrating which critical thinking attitude? A. Curiosity B. Adequacy C. Discipline D. Thinking independently

C. Discipline

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

C. Ensure that the home care agency is aware of medication and health teaching needs

Hypoventilation can lead to A. Increased oxygen concentration in the blood B. Decreased carbon dioxide level in the lungs C. Hypercapnia D. Hypocapnia

C. Hypercapnia

A home health care nurse has conducted a home safety assessment for an older adult with impaired vision. There are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps? A. Have the client use a walker or cane on the step B Instruct the client to use the garage door instead C. Install orange color strips at the edge of each step D. Suggest the client remain indoors indefinitely

C. Install orange color strips at the edge of each step

An older adult patient has been bedridden for 2 weeks. Which of the following complains by the patient indicates to the nurse that he or she is developing a complication of immobility? A. Loss of appetite B. Gum soreness C. Left ankle joint stiffness D. Difficultly swallowing

C. Left ankle joint stiffness

A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures aren't taken: A. Myoclonus B. Pathological fractures C. Pressure ulcers D. Pruritus

C. Pressure ulcers

You're 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 IV line and a urinary catheter in place. Which factors increase his risk for a fall? (SELECT ALL THAT APPLY.) A. Smokes a pack a day B. Used a cane to walk at home C. Takes antihypertensive and diuretics D. History of recent fall E. Neglect, spatial and perceptual abilities, impulsive F. Requires assistance with activity, unsteady gait G. IV line, urinary catheter

C. Takes antihypertensive and diuretics D. History of recent fall E. Neglect, spatial and perceptual abilities, impulsive F. Requires assistance with activity, unsteady gait G. IV line, urinary catheter

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 stage for this patient's pressure ulcer? A. Stage II B. Stage IV C. Unstageable D. Suspected deep tissue

C. Unstageable

Which of the following nursing interventions should be implemented to maintain a patient airway in a patient on bed rest? A. Isometric exercises B. Suctioning every 4 hours C. Use of incentive spirometer every 2 hours while awake

C. Use of incentive spirometer every 2 hours while awake

While administering medications, the nurse realizes that she has given the wrong dose of medication to a patient. She acts by completing an incident report and notifying the patient's health care provider. The nurse is exercising: A. Decision making B. Authority C. Common sense D. Accountability

D. Accountability

Sexuality is maintained throughout our lives. Which of the following answers best explains sexuality in an older adult? A. When the sexual partner passes away, the survivor no longer feels sexual B. A decrease in an older adult's libido occurs C. Any outward expression of sexuality suggests that the older adult is having a developmental problem D. All older adults, whether healthy or frail, need to express sexual feelings

D. All older adults, whether healthy or frail, need to express sexual feelings

A nurse prepares to insert a Foley catheter. The procedure manual calls for the patient to lie in the dorsal recumbent position. The patient complains of having back pain when lying on her back. Despite this, the nurse positions the patient supine with knees flexed as the manual recommends and begins to insert the catheter. This is an example of: A. Accuracy B. Reflection C. Risk taking D. Basic critical thinking

D. Basic critical thinking

The nurse is preparing to position an immobile patient. Before doing so, the nurse must understand that: A. Manual lifting is the easier method and should be tried first B. Following body mechanics principles alone will prevent back injury C. Body mechanics can be ignored when using patient handling equipment D. Body mechanics alone are not sufficient to prevent injuries

D. Body mechanics alone are not sufficient to prevent injuries

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? A. Necrotic tissue B. Wound drainage C. Wound circumference D. Cleansed wound

D. Cleansed wound

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation as a result of the anemia? A. Increased breathlessness but increased activity tolerance B. Decreased breathlessness and decreased activity tolerance C. Increased activity tolerance and decreased breathlessness D. Decreased activity tolerance and increased breathlessness

D. Decreased activity tolerance and increased breathlessness

Which of the following are physiological outcomes of immobility? A. Increased metabolism B. Reduced cardiac workload C. Decreased oxygen demand D. Decreased lung expansion

D. Decreased lung expansion

The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care BEST addresses the prevention of infection for the patient? A. Inform the patient of the importance of finishing the entire dose of antibiotics B. Schedule the patient to get annual TB skin testing C. Create an exercise program D. Encourage the patient to stay up-to-date on all vaccination

D. Encourage the patient to stay up-to-date on all vaccination

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? A. Frequent family visits B. Assisting the patient to a wheelchair once per day C. Ensuring that there is an order for physical therapy D. Encouraging use of an overhead trapeze for positioning and transfer

D. Encouraging use of an overhead trapeze for positioning and transfer

A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation? A. Sonorous wheezes in the left lower lung B. Rhonchi med sternum C. Crackles only in apex of lungs D. Inspiratory crackles in lung bases

D. Inspiratory crackles in lung bases

Which assessment finding in a patient who has COPD needs to be reported to the physician IMMEDIATELY? A. Pulse oximetry of 95%, purse-lip breathing B. Expectorating copious amounts of white phlegm C. Leaning on the bedside table, pulse rate 95 beats per minute D. Respiratory rate of 32, increasingly anxious and restless

D. Respiratory rate of 32, increasingly anxious and restless

A nurse has withdrawn a narcotic from the medication dispense. Upon checking the drug against the medication administration record, the nurse notices that the narcotic order has expired. What should be the nurse's FIRST action? A. Call the pharmacy and request that the narcotic be removed from the patient profile B. Assess the patient to see if the narcotic is still need; if so administer the medication C. Exit the medication room to call the physician to request a reorder of the narcotic D. Return the medication to the medication dispenser according to protocol

D. Return the medication to the medication dispenser according to protocol

A nurse admits a 72-year old patient with a medical history of hypertension, heart failure, renal failure, and depression to a general medical patient care unit. The nurse reviews the patient's medication orders and notes that the patient has three health care providers who have ordered a total of 13 medications. What is the most appropriate action for the nurse to take next? A. Give the medications after identifying the patient using two patient identifiers B. Provide medication education to the patient to help with adherence to the medical plan C. Set up a medication schedule for the patient that is least disruptive to the expected treatment schedule in the hospital D. Review the list of medications with the health care providers to ensure that the patient needs all 13 medications

D. Review the list of medications with the health care providers to ensure that the patient needs all 13 medications

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? A.Activity Intolerance B. Impaired Bed Mobility C. Acute Pain D. Risk for Falls

D. Risk for Falls

Of the following nursing goals, which is most appropriate for a patient who has had a total hip replacement? A. The patient will ambulate by the time of discharge B. The patient will ambulate briskly on the treadmill by the time of discharge C. The nurse will assist the patient to ambulate in the hall D. The patient will ambulate 750 feet using her walker by the time of discharge

D. The patient will ambulate 750 feet using her walker by the time of discharge

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

D. The student provides the name of the medication and a description of its desired effect

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? A. Binder B. Ice bag C. Elastic bandage D. Absorptive dressing

Ice bag