BSN225 SHERPATH

Which statement by the nurse indicates understanding of the definition of health literacy?

"A patient with low health literacy is unable to understand the medical information necessary for health care decision-making." People with low health literacy are unable to comprehend health-related terminology, to understand written health-related instructions, or to grasp medical concepts necessary for informed decision-making.

To decrease the risk for tissue irritation, which direction would the nurse give to a patient taking a buccal medication?

"Alternate the side of the mouth used for each dose of medication." Alternating the sides of the mouth used for the dissolution and absorption of the buccal medication decreases the exposure of mucous membrane to the irritating effects of the medication and provides some recovery time following each exposure.

The nurse is providing discharge teaching to the parents of a child with a congenital heart defect. Which statement best presents the desired information to the parents?

"Call the primary health care provider if you notice your baby is breathing fast and refusing to breastfeed or take a bottle." It will be easy for parents to understand and follow simple and clear instructions to call the primary health care provider if they notice that the baby is breathing fast and is refusing to breastfeed or take a bottle.

Which questions by the nurse would be effective for verifying that the patient has learned the information?

"Can you tell me three signs of heart failure?" Asking the patient to tell a nurse three signs of heart failure is effective because the answer allows the nurse to evaluate how much of the teaching material was retained. "When will you visit your primary health care provider next after you are discharged?" An effective way to verify the patient has learned information is to ask open-ended questions, such as one requiring the patient to reiterate the date and time of the follow-up appointment after discharge with the primary health care provider. "Can you explain when you will take this medication at home?" An effective way to verify the patient has learned information is to ask the patient to describe the medication dosage at home.

Which patient statements could indicate a low health literacy?

"I don't have very good handwriting. Can I just tell you the information to write down?" Patients who do not complete medical forms or ask others to help fill in the information may indicate that they lack the capability to read and write. "I forgot my glasses at home, and this print is just too small for me to ready clearly." Patients who make excuses, such as saying they forgot their glasses, when required to read or fill out an information sheet are often trying to hide the fact that they are illiterate. "I take a blue pill in the morning and evening and a white pill every evening." Patients who refer to their medications by color instead of by name could have low health literacy, and they may be unable to read the names on the medication bottles. "I am sorry I missed that appointment. I guess I was distracted and forgot about it." Patients who frequently miss follow-up appointments may have low health literacy due to inability to read follow-up instructions, such as appointment times and office locations.

A patient preparing to insert her prescribed vaginal suppository is reviewing the procedure with the nurse. Which statement made by the patient alerts the nurse that further explanation is required?

"I have a tampon ready to insert after the suppository to catch any drips." This patient statement indicates a need for further instruction from the nurse. A tampon should not be inserted after a vaginal suppository because it can absorb the medication from the suppository, thereby decreasing the dose received by the patient.

Which statement made by a patient who self-administers medications through a gastrointestinal (GI) tube indicates the need for further instruction about the process?

"I mix my morning medication with my morning feeding to save a bit of time before leaving for work." This patient statement indicates a need for further instruction from the nurse. Medications should not be added directly to the feeding formula. Mixing a drug with a formula could cause drug-formula interactions, leading to tube blockages and altered bioavailability.

Which statement by a patient who has received instructions about self-administration of medications in the home indicates a misunderstanding of information?

"If I miss a dose of any medication, I'll just double the dose when I take it the next time." This statement indicates a misunderstanding. It cannot be assumed that it is safe to double the dose. There are selected medications where a missed dose may be taken this way, but in other cases it can result in overdose and adverse effects.

Which statement by the nurse is appropriate when discussing how best to teach a Spanish-speaking patient about the signs and symptoms of heart failure?

"In addition to a medical translator, I want to make sure at least one family member or caregiver is present when I am teaching the patient." It is always best to have an approved family member or caregiver present during the teaching session to facilitate learning in a patient-centered environment.

A newly graduated registered nurse is creating a solution in an educational plan for a patient with heart failure. Which statement by the nurse indicates a need for further education?

"Specifically defined interventions clarify what the patient needs to accomplish." A solution, or goal, devised in an educational plan clarifies to both the patient and the nurse what knowledge is needed in addition to what needs to be evaluated and then documented into the chart. "The desired goal must be clearly defined." The goal should be clearly defined so that it is easy for the patient to understand what is expected. "The goal can be related to increasing knowledge or learning a skill." Goals can be related to behavioral lifestyle changes, increased knowledge, or psychomotor skills to be learned. "The action for achieving the goal should be simple and specific." The verb should be simple and specific so that the desired outcome can be evaluated for completeness of the task.

Which statement made by a nurse conducting discharge teaching indicates a review of patient education principles related to medication administration is needed?

"This pink pill is digoxin, your heart medication. You will take your pulse before you take this pill. If your pulse is less than 60 beats per minute, you will not take the pill." Medications should not be identified by color, because colors of medications can vary by manufacturer. Patients should always be taught to identify medications by name. This statement is teaching the patient to identify medication by color and should not be used. This nurse requires a review of patient education principles related to medication administration.

Which questions would the nurse ask a patient when obtaining the patient's medication history?

"What is your alcohol intake?" Asking about alcohol intake would be included when obtaining information about a patient's medication history and medication use, as alcohol use can have dangerous interactions with medicines. "Have you recently stopped taking any medications?" Asking if the patient has recently stopped taking any medications would be included when obtaining information about a patient's medication history and medication use. Some medications have a long half-life, so they can still be in the body and are capable of interacting with other medications for a period of time after they are discontinued. "What prescribed medications are you currently taking?" Asking about prescribed medications the patient is currently taking would be included when obtaining information about a patient's medication history and medication use. "Do you have any preferences or habits related to your cultural background that influence the medications you take?" Asking about personal/cultural beliefs or practices related to medications would be included when obtaining information about a patient's medication history and medication use. This information lets the nurse know more about the patient's preferences and compliance related to medication use.

Which statement indicates that the nurse needs additional education about teaching and learning styles?

"When teaching, I will include the three distinct styles of learning: visual, auditory, and reading and writing." There are four learning styles, not three, because the nurse did not include kinesthetic/tactile as the fourth learning style. This statement indicates the nurse would benefit from learning more about teaching styles.

Which question would be most appropriate for the nurse to ask when trying to gauge the patient's current knowledge of health care needs?

"Which medications do you take for your high blood pressure?" An open-ended question about the patient's medications for high blood pressure helps the nurse determine whether the patient knows the names of the medications and what the medications treat.

Which statements are appropriate for the nurse to make to a patient who is about to receive pain medication by intravenous push?

"You will feel the effects quickly." The intravenous route is used when a rapid drug effect is desired, so preparing the patient for its immediate effects is necessary. "Let me know if your arm hurts or swells." Swelling or pain could indicate infection or infiltration and should be reported immediately. "The medication is being injected into your bloodstream." An intravenous medication is administered directly into the bloodstream.

A patient is to have an ophthalmic ointment applied to both eyes. Which information would the nurse provide?

"Your vision may be blurred for a while after I put the ointment in your eyes." Ophthalmic ointment creates a film over the eye, resulting in blurred vision. "I'm giving you two tissues to use to wipe extra ointment off your face; use one for each eye." A tissue is used to wipe excess ointment from the face. A separate tissue is used for each eye to prevent the spread of infection from one eye to the other.

Medication prescription: hydrochlorothiazide 25 mg PO daily Available: 50-mg tablets How many tablets should be given to the patient? (Record your answer as a decimal and include a leading zero, if applicable.) __ tablet(s)

0.5 25 mg is a half of 50 mg. 25 mg/1 dose x 1 tablet/50 mg = 0.5 tablet.

Medication prescription: digoxin 0.25 mg IV stat Available: digoxin 0.5 mg/2 mL How many milliliters should be given to the patient? __ mL

1 0.25 mg/1 dose x 2 mL/0.5 mg = 1 mL

Medication prescription: cimetidine 0.4 g PO, q6hAvailable: 400-mg tablets How many tablets should be given to the patient? __ tablet(s)

1 0.4 g = 400 mg = 1 tablet

The nurse directs a patient who needs two puffs of medication from a metered-dose inhaler to wait how many minutes between puff one and puff two? Record your answer as a whole number. __ min

1 A time gap of 1 minute allows the medication in the first puff to penetrate the lung before the second round of medication enters.

For how many minutes would a nurse monitor a patient for an immediate allergic reaction following medication administration? Record your answer as two whole numbers separated by a hyphen. __ minutes

20-30 An immediate allergic reaction occurs within 20 to 30 minutes after administration.

Which patient would the nurse recognize as having the highest risk for low health literacy?

A 25-year-old undocumented migrant worker This patient is at high risk for low health literacy. The patient may be in a minority group and in a lower socioeconomic class; in addition, the patient may have limited formal education because of status as an undocumented migrant worker.

Which patient would the nurse identify as someone who is ready to learn new information?

A patient with dilated cardiomyopathy who asked for more information on heart failure A patient who is requesting information about the disease process is showing emotional readiness, so this patient would be the best one to begin teaching.

Which factors would the nurse recognize as cues indicating that a patient is at increased risk for an adverse reaction to a medication?

Age of 71 years Older adults are at increased risk for adverse reactions to medications. History of kidney disease Because the majority of drugs are excreted through the kidneys, a history of kidney disease could indicate interference with excretion and precipitate an adverse reaction. Allergic to watermelon, cucumber, and peanuts An allergy to foods indicates the potential risk for an allergic reaction to a medication. An allergic reaction is a type of adverse reaction.

The nurse is caring for a patient who has digoxin prescribed for chronic heart failure. Which assessment data is needed before administering the digoxin?

Apical pulse Measuring the patient's apical pulse is necessary prior to administering digoxin. The nurse should count the apical pulse for 1 minute.

Which questions are answered by the medication reconciliation process?

Are any of the prescribed medications duplicates of each other? One goal of the medication reconciliation process is to identify duplication of drugs, which can lead to overdose and toxic effects. Does the patient currently need every medication that is prescribed? Medication reconciliation should be performed at each care transition. Because care transitions occur when a patient's clinical status has changed, these transitions are associated with the possibility of medications no longer being needed. Medication reconciliation can identify changes in needed medications. Are there any medications that the patient needs that are not prescribed? A purpose of medication reconciliation is to identify omissions in medications that are needed by the patient. As the patient's clinical status changes, changes occur in needed medications. Medication reconciliation at a care transition is critical to avoiding omissions in needed medications. Do any of the prescribed medications interact with one another, requiring an adjustment in dosage or a change in the medications themselves? Interactions between medications, between foods and medications, and between herbs or other supplements and medications can result in adverse effects, even death. A focus of medication reconciliation is to identify the potential for such interactions so action can be taken to prevent them.

An older, visually impaired but proudly self-sufficient adult patient has several prescribed medications to take at home. Which action would the nurse take to assist this patient in complying with the medication regimen?

Arrange for the medications to be put in a weekly pill organizer. Pills can be organized by the day for a week at a time in a multisection container. Empty sections serve as a reminder that medications have been taken already to help prevent duplication of doses. This is a good first choice to promote adherence to a medication regimen.

In response to a hypothesis of Lack of Knowledge of Medication Regime, the nurse teaches the patient about a newly prescribed medication, specifically the name, dose, route of administration, time, frequency, and special instructions. Which method would the nurse use to evaluate the effectiveness of the teaching?

Ask the patient to explain the use of the new medication, giving its name, dose, route, frequency, expected effects, and management of side and adverse effects of the new medication. Asking the patient to explain the information taught about the new medication objectively evaluates the patient's mastery of the information. This is the method of evaluation the nurse would use.

A 56-year-old male is undergoing emergency surgery for a ruptured appendix. The nurse gives his wife the registration paperwork and asks her to complete the forms. Which action by the spouse could be indicative of a health literacy issue?

Asks the nurse to read the forms because she "forgot her glasses and can't read the small print" Making an excuse and asking the nurse to read the forms could be an indication of a health literacy issue. Waits for their daughter to arrive to complete the paperwork Waiting for her daughter to arrive to complete the paperwork could be an indication of a health literacy issue. Returns the paperwork only partially completed Partially completing paperwork could indicate health literacy issues because she was most likely unable to understand the forms.

Which actions would the nurse implement during auscultation of the cardiovascular system?

Assess rate and rhythm The nurse listens for the rate and rhythm of the apical pulse. Use both sides of stethoscope The nurse uses both sides of the stethoscope to assess for both low- and high-pitched sounds.

Which component of the gastrointestinal assessment does the nurse evaluate using the diaphragm of the stethoscope?

Bowel sounds The nurse utilizes the diaphragm of the stethoscope to listen to bowel sounds in all four quadrants of the abdomen.

Which examples illustrate formal teaching in health care?

CPR certification taught to a pediatrician's office staff A CPR certification class is an example of formal teaching in health care; it is structured, goal-oriented, and scheduled at a certain time. Infant parenting class at the local hospital An infant parenting class is an example of formal teaching in health care; it is structured, goal-oriented, and scheduled at a certain time. Teaching the patient and family signs of a wound infection during the discharge process The educational component of the discharge process would be considered formal teaching. Discharge teaching is scheduled, structured, and goal-oriented.

When the nurse identifies clubbing of a patient's nails, which type of medical condition would the nurse suspect as the cause?

Cardiac Clubbing is a condition in which there is enlargement of the ends of one or more fingers or toes and is associated with decreased peripheral perfusion due to cardiac or respiratory problems.

Which cue is an example of physiologic evidence indicating that a patient newly diagnosed with diabetes may not have understood the discharge education clearly?

Consistently elevated blood glucose levels Physiologic evidence of the effectiveness of the educational process can be observed and measured. Such evidence can include elevated blood glucose levels.

Which nerve does the nurse examine by evaluating eye movements and pupillary reflexes?

Cranial nerve Cranial nerve assessment involves the eyes, upper nasal passages, pons, and medulla oblongata. Cranial nerves are assessed through evaluation of eye movements and pupillary reflex.

Which elements should be performed after light palpation of all quadrants of the abdomen in the adult patient?

Deep palpation of all quadrants Deep palpation is the element of the abdominal assessment that should be performed after light palpation of all quadrants; deep palpation should be done last because it is the maneuver most likely to cause discomfort or pain.

Which characteristic is the nurse assessing when placing thumbs on either side of the spine during the respiratory system assessment?

Depth of respirations Depth of respirations is assessed by placing the thumbs on either side of the spine and noting thumb movement.

When would the nurse assess the patient's health literacy?

During each patient interaction Assessing the patient's health literacy should be done during every patient interaction. By observing behaviors and conversing with the patient, the nurse can see subtle cues that may indicate low literacy or low health literacy.

A newly admitted patient tells the nurse "I can't swallow medicines; they all need to be crushed." Based on this statement, the nurse would contact the health care provider about a prescription for which form of medication?

Enteric-coated tablet Enteric-coated tablets are coated to prevent dissolution in the acidic environment of the stomach. They dissolve in the intestine, thereby preventing the drug from irritating the stomach lining or preventing the drug from being digested by gastric enzymes. If the medication is crushed, the protective coating is destroyed.

Which part of the eye would the nurse palpate gently to assess for nodules or pain?

Eyelid The eyelids should be gently palpated to feel for nodules and pain.

Which abilities are required for a person to be considered as having higher health literacy?

Filling out a health questionnaire A higher health literacy requires general literacy, which includes the ability to fill out a health questionnaire. Solving simple mathematical equations A higher health literacy requires the ability to solve simple mathematical equations, also known as numeric literacy. Reading discharge instructions A higher health literacy requires general literacy, which includes the ability to read and understand discharge instructions. Following medication instructions A higher health literacy includes having enough knowledge about one's health to be able to follow medication instructions.

For which patient would providing a weekly medication organizer be an appropriate intervention?

Forgetful patient A weekly organizer allows medications to be placed in compartments according to when they are to be taken. It allows people who forget whether medications were taken to check by looking to see if the compartment for the day/time in question is empty.

To which aspect does the abbreviation STAT refer when used in a prescription for a medication?

Frequency/time of administration STAT is the abbreviation for "immediately" and refers to the time of administration

The nurse looks up an unfamiliar medication when preparing to administer it. The reference indicates the medication is on the Institute for Safe Medication Practices (ISMP) high-alert list. Which action would the nurse take?

Have a second nurse verify the dosage. Dosages of high-alert drugs should be verified by a second nurse as a precaution against error.

Which nursing action would best ensure patient understanding of how to perform a dressing change in the home environment?

Have the patient demonstrate a correct dressing change before discharge. Having the patient demonstrate the dressing change will ensure patient understanding of the correct procedure. This method allows the nurse to evaluate the patient's performance of the dressing change before home discharge.

Which method would be most effective when teaching a patient recently diagnosed with diabetes to check blood glucose levels?

Have the patient perform the step-by-step instructions with guidance from the nurse. Having the patient perform the skill is one of the best ways to teach. People retain almost 80% of material during hands-on learning sessions, according to estimates.

Forgetfulness, poor vision, and arthritic hands are relevant cues related to which hypothesis?

Impaired Ability to Manage Medication Regime Forgetfulness puts the patient at risk for not taking medications as scheduled. Poor vision can result in errors in reading medication labels. Arthritic hands can interfere with opening medication containers. All of these factors impair a patient's ability to manage the medication regime as prescribed.

Which outcomes have been associated with increased health literacy?

Improved health outcomes Improved health outcomes (e.g., fewer admissions to the hospital) have been associated with increased health literacy. Increased clarity about future decisions related to illness Increased clarity regarding illness-related decisions has been associated with higher health literacy. Improved medication adherence Increased health literacy has been shown to correlate with improved medication adherence. Increased adherence to treatment plan Increased adherence to treatment plans (e.g., showing up for scheduled outpatient appointments) has been associated with increased health literacy.

Which focused assessment would the nurse perform when caring for a patient with a prescription for a medication administered by transdermal patch?

Inspect the patient's skin for cracks and lesions. Inspecting the patient's skin for cracks and lesions is necessary, because a transdermal patch is a form of topical medication applied to the patient's skin.

Which assessment technique would the nurse use during the neurologic assessment?

Inspection The nurse uses the assessment techniques of inspection and palpation during a neurologic examination.

Which strategies can the nurse use to increase the effectiveness of the education process?

Involve family members in the teaching process. It is important for family members to participate in patient education to facilitate patient-centered care. Cover only two to three key points at a time. The nurse should limit information to two to three key topics to avoid overwhelming the patient. Review previous information before starting new material. Reviewing previously taught information before advancing to new material confirms that the patient retained knowledge. Encourage the patient to ask questions. Encouraging questions allows for an interactive learning process and confirms understanding of material.

To promote a positive learning experience for a 75-year-old patient, which environmental concerns would the nurse address?

Keep the patient's door closed. Keeping the patient's door closed ensures privacy, and it should be done to promote a positive learning environment. Ask the patient about room temperature preference. Confirming the patient's preference of room temperature promotes a positive learning environment. Ensure adequate lighting. Ensuring adequate lighting promotes a positive learning environment for all patients but especially older adult patients.

Patient education in the hospital setting can be challenging due to which factors?

Lack of patient readiness to learn Patients who are unwilling or not ready to learn can increase the difficulty of providing quality patient education in the hospital setting. Sedation related to medications Sedation or pain medications can decrease the effectiveness of patient education because the patient may be too sleepy to remember what was taught. Lack of skill required for patient teaching Sometimes patient education can be difficult because the nurse may lack the skill and adequate training to provide the necessary patient education.

During the breast and genital examination, which findings would the nurse document and report to the health care provider?

Lesions on the genitalia Lesions, growths, and masses on the genitalia can indicate systemic problems and should be documented and reported. Presence of hemorrhoids The presence of hemorrhoids can cause rectal bleeding, which is an unexpected finding that the nurse should document and report. Unusual odor or discharge Unusual odor or discharge is a sign of infection and should be documented and reported. Excoriation of the breast tissue Rashes, lesions, or excoriation of the breast tissue could be indicative of breast cancer, and the nurse should document and report the findings.

Which factor is cued by gathering information about a patient's prior exposure to a medication that is being prescribed?

Likelihood of side and adverse effects Information about prior use of the medication and its effects cues to the likelihood of side effects and the risk for an adverse effect from a new exposure to the medication.

The nurse would contact the health care provider for clarification for which medication prescription?

Lisinopril 5 mg PO qd When a prescription contains an abbreviation found on The Joint Commission's "Do Not Use" list, the prescription needs to be clarified with the health care provider. The abbreviation "qd" is on the "Do Not Use" list.

Which techniques would the nurse utilize to auscultate the patient's chest during the respiratory assessment?

Listen for a full respiratory cycle. At each auscultation site, the nurse listens for a full respiratory cycle (inspiration and expiration). Use a systematic pattern. The breath sounds in each of the lobes of the lungs are auscultated using a systematic pattern. Listen for unexpected sounds. The nurse listens to each lobe for airflow and any unexpected sounds.

Which characteristic is an advantage of a transdermal patch?

Long-term continuous administration Transdermal patches provide slow, continuous absorption over a period of hours or days.

Which action would the nurse take as part of the procedure for administering a vaginal suppository?

Lubricate the applicator with a water-soluble gel. The nurse lubricates the applicator or suppository with a water-soluble gel before administering a vaginal suppository.

When examining the head and its associated structures, which unexpected findings would the nurse document?

Lumps The presence of lumps is an unexpected finding that should be documented by the nurse. Edema Edema is an unexpected finding that the nurse would document. Lesions The existence of lesions is an unexpected finding that the nurse would document. Discoloration Discoloration is an unexpected finding that the nurse should document.

Which potential findings would the nurse assess during the palpation phase of the musculoskeletal examination?

Masses The nurse assesses for masses during the palpation phase of the musculoskeletal examination. Masses are indicative of musculoskeletal problems. Crepitus Crepitus is a crackling or popping sound, and the nurse assesses for this during the palpation phase of a musculoskeletal examination. Tenderness The nurse assesses for tenderness during the palpation phase of the musculoskeletal examination.

Which aspects does the nurse assess while palpating the chest during the respiratory system assessment?

Masses The nurse palpates to assess for masses or tenderness. Skin moisture The nurse palpates to assess for skin moisture and temperature.

Patient reluctance to share information is a major obstacle to which process?

Medication reconciliation Medication reconciliation requires patients to list the amount and frequency of all prescription drugs, over-the-counter drugs, herbal preparations, vitamins or other supplements, and illicit drugs taken. Patients are often reluctant to disclose complete information about all drugs taken, regardless of type or source.

Which actions apply to the administration of an intradermal injection?

Monitoring the skin for a wheal The nurse monitors for a wheal because this indicates the intradermal injection was administered correctly. Inserting the needle into the skin with the bevel up The needle is inserted into the skin with the bevel up when administering an intradermal injection. Applying outward traction to the skin around the site The nurse applies outward traction to the skin around the site when administering an intradermal injection.

Which medication would the nurse plan to give without first clarifying the prescription with the health care provider?

Naltrexone hydrochloride 50 mg PO daily This is a complete prescription (drug name, dose, route, frequency) and does not contain any unacceptable abbreviations, symbols, or dose designations.

As a general rule, which information should be given to a patient when a drug is being administered?

Name of the drug The patient is told the name of the drug being administered. Patients have a right to be involved in their care, and knowledge of medications taken can aid in the prevention of medication errors and provide a foundation for discharge teaching. Why the drug has been prescribed Patients are told why the drug has been prescribed when it is administered to reinforce knowledge of the health problem and its treatment. Expected side effects Patients are told about expected side effects to decrease anxiety if they occur and to allow for implementation of any safety precautions or mitigation measures.

Which actions are taken when a patient refuses a medication?

Notify the health care provider. The health care provider must be notified because the refusal requires consideration of any changes needed in the medical plan of care. Inquire why the patient is refusing. The patient should be asked why the medication is being refused because the reason may indicate a need for additional explanation or a significant new patient need. Explain the consequences of refusal with teach-back. The patient has a right to refuse treatment, but this must be an informed decision. Therefore the consequences of refusal must be explained and a teach-back performed to verify understanding. Document the circumstances of the situation and the actions taken. The circumstances of the refusal, the reason given for it, the fact that an explanation of consequences with teach-back was given, and the fact the health care provider was notified are all documented.

A patient has a prescription for 2.5 mL of a liquid medication to be administered orally. In accordance with best practice guidelines, which device would the nurse use when preparing this medication?

Oral syringe calibrated in metric only Best practice guidelines specify the use of an oral syringe calibrated in metric only and labeled FOR ORAL USE ONLY to prevent accidental injection of an oral formulation of a medication or administration of a wrong dose as a result of confusing two systems of measurement.

Which physical assessment findings related to the musculoskeletal system would the nurse report to the health care provider?

Pain Pain is an unexpected finding that should be reported to the health care provider. Lesions Lesions are unexpected findings that the nurse should report to the health care provider. Abnormal posture or gait Abnormal posture or gait is an unexpected finding that should be reported to the health care provider.

Which assessment techniques would the nurse use during the abdominal assessment?

Palpation The nurse palpates the abdomen in each quadrant, starting with light pressure and then using deeper pressure. The nurse also palpates the bladder area. A palpable, firm bladder suggests that it is distended with urine. Inspection The nurse inspects the abdomen for discoloration, bruising, edema, lesions, stretch marks, and scarring. Bulges, distention, or protruding masses are also noted. Auscultation The nurse uses the diaphragm of the stethoscope to auscultate bowel sounds in all four quadrants of the abdomen.

The nurse is providing patient education to the parents of an infant born with tetralogy of Fallot. The infant is currently stable, and surgery is planned for 3 days from now. Which teaching approach would be best for this situation?

Participating Participating is the approach used when both the patient and the nurse are involved in the learning process, and it would be the most appropriate in this situation. The parents are free to interrupt and ask questions as the nurse provides the medical information.

Which cue suggests a hypothesis of Risk for Adverse Medication Interaction?

Patient denies regular use of any prescription medications but acknowledges use of different herbal preparations, a varied assortment of nonprescription medications, and an occasional stomach or pain pill from her sister's medicine cabinet. Taking medications prescribed for someone else and using a mixture of medications and supplements without a health care provider's guidance can result in an adverse drug interaction.

Match the health literacy assessment tool to its description.

Patient determines which two of three words are more closely related - Short Assessment of Health Literacy Patient's ability to pronounce seven common medical words is assessed - Rapid Estimate of Adult Literacy in Medicine Patient is asked a series of questions specific to a nutritional label - Newest Vital Sign Tests reading comprehension and numeracy related to medical information - Test of Functional Health Literacy in Adults

Which patient information would the nurse recognize as a relevant cue indicating the need for monitoring following an intramuscular injection?

Patient is 78 years old. With advancing age, there is a greater risk for bleeding following an intramuscular injection, so it is important to reassess the site for bleeding.

Which factors would the nurse recognize as cues that oral administration might not be appropriate for a patient?

Patient must lie flat. Swallowing anything other than saliva can be difficult when lying flat. Depending on the patient and the medication form and amount to be swallowed, oral administration may not be appropriate. Patient has difficulty swallowing. Depending on the degree of difficulty swallowing and the formulation and amount of medication to be taken, the oral route of medication administration may not be appropriate. Patient reports feeling nauseated. Patient report of nausea is a cue that oral administration of medications may not be appropriate for the patient because of the risk for associated vomiting.

Which expected outcome would the nurse select for a soon-to-be-discharged patient who has a transdermal patch prescribed for the first time?

Patient will demonstrate correct removal of used patch and application of replacement patch prior to discharge. Demonstration of correct technique indicates knowledge of the procedure and the ability to perform it.

Which aspect of cardiovascular function does the nurse assess when inspecting the skin and lower extremities?

Peripheral perfusion The skin and lower extremities are inspected for evidence of peripheral perfusion.

Which domain of learning is addressed when the nurse teaches a patient to take a pulse and then has the patient demonstrate the skill?

Psychomotor Learners who gain knowledge in the psychomotor domain use physical movement, or motor skills, during the teachable moment.

When administering an otic medication to an adult, which action would the nurse take to facilitate the spread of the medication to the entire ear canal?

Pull up and back on the pinna. Pulling up and back on the pinna of an adult patient straightens the ear canal, allowing the medication to more easily run down into it.

Which findings would the nurse recognize as abnormal during assessment of the male genitalia?

Rashes Rashes can be indicative of contact dermatitis, psoriasis, or genital herpes, and other conditions. Lesions Lesions of the male genitalia can indicate infection. Masses Masses are assessed during the palpation phase of an assessment of the male genitalia. Discharge Discharge is assessed during the inspection phase and may indicate testicular torsion or other genitalia-related problems.

A patient presents with a chart listing the dose, route, frequency, and reason for use of prescribed medications, along with a list of related questions. The patient asks the nurse to review the chart for accuracy and answer the questions. Which nursing diagnosis is appropriate for this patient?

Ready to Learn The patient developing a chart and formulating questions that the nurse is asked to review and answer is a cue that the patient is ready to learn.

Which additional body system would the nurse evaluate when assessing the cardiovascular and peripheral vascular systems?

Respiratory The heart and lungs share a common circulatory system, such that a problem affecting the cardiovascular system can also affect the respiratory system.

Which action allows the nurse to focus questions about the musculoskeletal system during the health history interview?

Review of health records The review of health records provides information on any preexisting musculoskeletal problems. This knowledge assists the nurse in focusing questions during the health history interview and review of systems.

In which order would the nurse perform an assessment of the integumentary system.

Review the patient's medical records for preexisting issues with skin, hair, or nails. Interview the patient to complete the general survey, health history, and review of systems. Complete physical examination of the skin, hair, and nails.

The nurse instructs a patient for whom a transdermal patch has been prescribed to rotate sites of application. For which hypothesis is this instruction an intervention?

Risk for impaired tissue integrity There are risks for tissue damage from the transdermal adhesive and for skin irritation from medication contained in the patch. Rotating sites allows any irritation to heal before another patch is placed over the same area.

Which nerve does the nurse assess when applying dull and sharp stimuli to different areas of the body?

Sensory nerve Sensory nerve information is assessed through the use of dull and sharp stimuli to check for normal reactions from such stimuli.

Which part of the nose would the nurse palpate to assess for swelling, drainage, and tenderness?

Sinuses The nurse palpates the sinuses to assess for swelling, drainage, and tenderness during the physical examination of the nose.

Which environmental factors are important to consider before providing patient education?

Space Ample space is needed, especially when teaching skills, performing demonstrations, or teaching to a group (instead of just an individual). Privacy It is important to choose a setting that ensures patient privacy to maintain patient confidentiality as much as possible. Noise A quiet setting is necessary to limit distractions and noise and to give the patient the best opportunity to focus on the material. Comfort The physical comfort of the patient is important. Adequate lighting and a comfortable room temperature are two indicators.

Which descriptors are accurate for an appropriately written patient education goal?

Specific Educational goals should be specific. Patient-centered Educational goals should be tailored toward the patient, and they should include the input of the patient and caregivers. Measurable Educational goals should be easily measurable to discern whether the goal was achieved. Individualized Educational goals for a patient should be individualized and created specifically for the patient.

Which components would the nurse assess during palpation of the skin?

Swelling Swelling should be assessed during the palpation phase of the examination. Skin texture Skin texture should be assessed during the palpation phase of the examination Skin temperature Skin temperature should be assessed during the palpation phase of the examination.

Which outcomes are often associated with low health literacy?

Taking prescribed medications incorrectly Outcomes associated with low health literacy include medication errors. Often patients do not take medications correctly because they cannot read or they misunderstand instructions. Missing follow-up appointments Low health literacy can lead to missed follow-up appointments because patients misunderstand instructions or because they are unable to read directions to get to appointments. Higher health care costs Low health literacy can lead to poor adherence to outpatient treatment plans. This in turn leads to increased health care costs associated with more hospital admissions, more medications, and greater frequency of outpatient appointments. Poor adherence with treatment plans Poor adherence to treatment plans often correlates with low health literacy because of misunderstood instructions and lack of knowledge about the disease process.

Which scenario would be the best example of an informal educational interaction with a parent while the infant is hospitalized?

Teaching about the side effects of diuretics to the parent when administering intravenous (IV) medication to the infant Teaching about the side effects of diuretics when administering the IV medication to the infant would be an excellent example of providing educational information to a parent in an informal way.

A patient in the emergency department with known supraventricular tachycardia starts experiencing shortness of breath and is no longer tolerating the dysrhythmia. Which teaching approach is most likely to be used when informing the patient about the need for cardioversion?

Telling The telling approach is used when there is limited time for teaching, and specific information needs to be delivered. Because the patient's condition was deteriorating, the telling approach is most appropriate.

The nurse is generating educational goals for her patients. Which patient educational goal is written correctly?

The patient will administer the correct dose of insulin after obtaining a blood glucose level. A goal stating that the patient will administer the correct dose of insulin after obtaining a blood glucose level is written appropriately because it is patient-centered, specific, individualized, and measurable. Note that the goal is measurable because it states that the patient administered the correct dos

Which technique would the nurse use to palpate the breast tissue?

Two to three fingers The entire breast tissue should be palpated using two to three fingers.

Which actions indicate proficiency in health literacy?

Understanding which websites are appropriate to use for health information Knowing which websites offer credible health information is an important aspect of health literacy. Understanding benefits of Medicare programs Ability to understand benefits of complex health insurance programs such as Medicare would indicate proficiency in health literacy. Being able to call and schedule follow-up appointments Being capable of calling and scheduling follow-up appointments would show health literacy proficiency. Navigating a smartphone to input a medication list into an app Being able to navigate a smartphone or computer to access health information and services demonstrates health literacy. In addition, knowing the dosages of medication also shows health literacy proficiency.

The abdominal and gastrointestinal organs are assessed during the evaluation of which body systems?

Urinary The urinary system is assessed during an evaluation of the abdominal and gastrointestinal organs because it involves intake and elimination and affects the gastrointestinal system. Digestive The digestive system is assessed during an evaluation of the abdominal and gastrointestinal organs because its malfunction will produce further problems in the gastrointestinal system.

A diagram of which injection site would be most helpful when teaching a patient how to use of an EpiPen?

Vastus lateralis EpiPens are used to inject epinephrine into the vastus lateralis, which is both safe and easy to access.

Which factors are most important in the educational assessment of an older adult patient?

Visual impairment Older adults can have difficulty reading labels due to visual changes that naturally occur with the aging process, such as cataracts or macular degeneration. Hearing limitations Older adults often have hearing difficulties associated with the aging process, and they should be specifically assessed for any hearing concerns. Cognitive ability Older adults are more likely to have cognitive impairments, which can affect their ability to understand presented information. They should be assessed for cognitive ability. Emotional concerns Older adults are at risk for depression, especially if they have received a new diagnosis that will affect their quality of life. It is important to address an older patient's mental health during the educational assessment.

Which patient behaviors could indicate low health literacy?

Wants to wait for family before signing consent form Patients who refuse to sign consent forms until other family members are present may indicate that they lack the capability to read the consent forms. Has laboratory results that do not support the patient's prescribed treatment plan Patients whose laboratory levels do not support the treatment plans may indicate they have low health literacy because they could be having difficulty following the discharge instructions. Refers to medications by the color of the pill Patients who refer to their medications by color instead of by name could have low health literacy and could be unable to read the names on the medication bottles. Frequently misses follow-up appointments Patients who frequently miss follow-up appointments may have low health literacy due to inability to read follow-up instructions, such as appointment times and office locations.