Cumulative Final Exam NUR215

PLISSIT Assessment of Sexuality

(P)-Permission to discuss sexuality issues (LI)-Limited Information related to sexual health problems being experienced (SS)-Specific Suggestions—only when the nurse is clear about the problem (IT)-Intensive Therapy—referral to professional with advanced training if necessary

Who falls under having an intimacy versus isolation self concept developmental task?

(Young adult to mid 40's) -Has stable, positive feelings about self -Affiliation versus love -Experiences successful role transitions and increased responsibilities

Bowel Diversions

-Temporary or permanent stoma -Ileostomy -Colostomy

What are aspiration precautions?

-high fowlers -no straws -chin tuck when swallowing -gather history (any disease related concerns? MS, Parkinson's, myasthenia gravis)

Stomachs 3 functions

1) temporary storage 2) mixing food and digestive juices into chyme 3)Regulates emptying of its contents with the small intestine

You are caring for a patient in an intensive care unit (ICU) who has pulled out his own IV line. You have tried restraint alternatives. Which of the following would you assess to determine appropriateness or reason to physically restrain the patient? (Select all that apply.) 1. Health care provider's order 2. Patient's current behavior 3. Current medications 4. Health literacy 5. Presence of fever 6. Serum electrolytes 7. Age

1. Health care provider's order 2. Patient's current behavior 3. Current medications 5. Presence of fever 6. Serum electrolytes

HIV infection process

1. Primary infection stage: lasts about a month, flulike symptoms 2. Clinical latency phase: 6 wees to 3 months after infection HIV antibodies appear 3. Last stage: AIDs happens when a person begins to show symptoms of the disease -serious and fatal as immune damage progresses, symptoms of malaise, body aches, fever, skin, rash, lymphadenopathy develop.

Put the following steps for removal of protective barriers after leaving an isolation room in order. 1. Remove and dispose of gloves. 2. Perform hand hygiene. 3. Remove eyewear or goggles. 4. Untie bottom and then top mask strings and remove from face. 5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side.

1. Remove and dispose of gloves. 3. Remove eyewear or goggles. 5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side. 4. Untie bottom and then top mask strings and remove from face. 2. Perform hand hygiene.

Conduction of the heart

1. Sinoatrial node 2. Atrial ventricle node 3. Bundle of His 4. Purkinje fibers P wave-atrial depolarization (0.12 to 0.20 secs) Atria contracting QRS Complex-ventricular depolarization (0.06 to 0.1 sec) electical impulse traveled through ventricles T wave-Ventricular repolarization ( 0.12 to 0.42 sec)

Match the patient fall risks on the left with the correct risk factor category on the right. A. Intrinsic risk B. Extrinsic risk ___1. A 42-year-old patient who is recovering from anesthesia refuses assistance with walking to the bathroom. ___2. A 60-year-old patient with a history of falling in the last 6 months. ___3. A patient's walking path has spilled fruit juice on the floor. ___4. A 68-year-old patient recovering from a colon resection uses an IV pole to walk. ___5. Patient is unable to identify own fall risks. ___6. The physical therapist has not yet fitted a 62-year-old patient for a prescribed walker.

1A. Intrinsic risk 2A. Intrinsic risk 3B. Extrinsic risk 4B. Extrinsic risk 5A. Intrinsic risk 6B. Extrinsic risk

A belt restraint is applied to a person in bed. How does the nursing student place patient in belt restraint? A. Remove wrinkles or creases in clothing. B. Have patient sit in bed C. Apply belt over clothes, gown, or pajamas. D. Ensure that straps secured to bedframe are snug so belt does not slide to sides of bed E. Have patient roll to side and avoid applying belt too tightly. F. Help patient lie down in bed.

1B. Have patient sit in bed 2C. Apply belt over clothes, gown, or pajamas. 3A. Remove wrinkles or creases in clothing. 4F. Help patient lie down in bed. 5E. Have patient roll to side and avoid applying belt too tightly. 6D. Ensure that straps secured to bedframe are snug so belt does not slide to sides of bed Belt restraint is good option for: -Confused or impulsive patients who are continually trying to get out of bed after repeated redirection (unsafe to get up) Prevents patient from rolling off stretcher or bed, or sitting up while on stretcher or bed. (p. 444)

Match the fall prevention intervention on the left with the scientific rationale on the right. ___1. Prioritize nurse call system responses to patients at high risk. ___2. Place patient in a wheelchair with wedge cushion. ___3. Establish elimination schedule with bedside commode. ___4. Use a low bed for patient. ___5. Provide a hip protector. ___6. Place nonskid floor mat on floor next to bed. A. Maintains comfort and makes exit difficult B. Makes it difficult for patients with lower extremity weakness to stand C. Reduces slipping when walking D. Reduces fall impact E. Ensures rapid response for help F. Reduces chance of patient trying to get out of bed on own

1E. Ensures rapid response for help 2A. Maintains comfort and makes exit difficult 3F. Reduces chance of patient trying to get out of bed on own 4B. Makes it difficult for patients with lower extremity weakness to stand 5D. Reduces fall impact 6C. Reduces slipping when walking

You complete a fall risk assessment on your assigned patient, who is 45 years old and has a history of cocaine use and liver failure. His laboratory results show an elevated prothrombin time. You determine that the patient is at high risk for falling. Which of the following measures are targeted to his fall risk status? (Select all that apply.) 1. Using skid-proof footwear 2. Scheduling any oral medications at least 2 hours before bedtime 3. Placing a low bed in room 4. Placing the nurse call system within patient's reach 5. Using a bed exit alarm 6. Providing patient with a protective head helmet when in chair or walking

2. Scheduling any oral medications at least 2 hours before bedtime 3. Placing a low bed in room 5. Using a bed exit alarm 6. Providing patient with a protective head helmet when in chair or walking (Sherpath q)

How old is a person according to Erikson that has a self concept developmental task of initiative versus guilt?

3-5 Years Highly imaginative Identifies with gender Enhanced self awareness

A nurse who recently graduated from nursing school is providing discharge instructions to a patient who suffered a myocardial infarction (MI). The nurse knows that sexual issues are common after an MI but feels uncomfortable bringing up this topic. What is the best way for the nurse to handle this situation? (Select all that apply) 1. Instruct the patient to discuss any sexual concerns with his or her partner after discharge. 2. Avoid discussing the topic unless the patient brings it up. 3. Ask a more experienced nurse to cover this with the patient and learn from the example. 4. Plan to attend conferences or training soon on how to discuss such issues. 5. Encourage the patient to discuss any personal concerns with the cardiologist.

3. Ask a more experienced nurse to cover this with the patient and learn from the example. 4. Plan to attend conferences or training soon on how to discuss such issues. (p. 760, potter)

A nurse enters the hospital room of a patient who had a total knee replacement the day before and is sitting in a chair. The nurse is preparing to return the patient to bed. Which of the following pose potential safety risks? (Select all that apply.) 1. A current safety inspection sticker is on the IV fluid pump. 2. A walker is positioned near the patient's bedside. 3. The hospital bed is in the high position. 4. There is no gait belt at the bedside. 5. The overbed table with the patient's glasses is positioned against the wall opposite the end of the bed.

3. The hospital bed is in the high position. 4. There is no gait belt at the bedside. 5. The overbed table with the patient's glasses is positioned against the wall opposite the end of the bed.

Chlamydia

A bacterial infection that affects the reproductive organs of both males and females Few symptons 3 million affected by fluids from infected site Cause: Pelvic Inflammatory disease Ectopic pregnancy Infertility

How would you Don and Doff for Contact Isolation precautions? A. Don: First put gown on Then put on your gloves Doff: First take off your gloves Then remove gown and throw in trash B. Don: First put on your gloves Then put gown on Doff: First remove gown and throw in trash Then take off gloves

A. Don: First put gown on Then put on your gloves Doff: First take off your gloves Then remove gown and throw in trash

How would you Don and Doff for Protective Isolation precautions? A. Don: First put mask on Then put on your gloves Doff: First take off your gloves Then remove mask and throw in trash B. Don: First put gloves on Then put on your mask Doff: First take off your mask Then remove gloves and throw in trash

A. Don: Mask Gloves Doff: Gloves Mask -Highly susceptible to infection because of an underlying condition or treatment. -Uses positive airflow with HEPA Filter Ex: Kidney Transplant pt. The patient wears a mask when leaving the hospital room during transportation to x-ray.

How would you Don and Doff for Droplet Isolation precautions? A. Don: Mask (if splash, add face shield) Gloves Doff Gloves Mask with face shield B. Don: Gloves Mask (if splash, add face shield) Doff: Mask with face shield Gloves

A. Don: Mask (if splash, add face shield) Gloves Doff Gloves Mask with face shield Diseases w/ large droplets (greater than 5 microns) expelled into the air and by being within 3 feet of a patient. Ex. pt with influenza

How would you Don and Doff for Airborne isolation precautions? A. Don: First put on N95 Respirator Then put on your gloves Doff: First take off your gloves Then take off your N95 Respirator B. Don: First put on gloves then put on N95 Respirator Doff: First take off N95 Respirator Then take off your gloves

A. Don: First put on N95 Respirator Then put on your gloves Doff: First take off your gloves Then take off your N95 Respirator *Smaller droplets, which remain in the air for longer periods of time. Use negative airflow with HEPA filter Ex. Pt with tuberculosis

A nurse has admitted a patient to the rehabilitation unit with left-side hemiparesis from a stroke. Which response would the nurse provide to the patient that reflects the implementation of universal fall precautions? (Select all that apply) A. " Can you show me how to use the call light?." B. "When you need your cane to get up, call me." C. "What personal items can I place on your bedside table?" D. "I am going to put some elastic stockings that go above your knees." E. "Your doctor has decreased the dose of your antihypertensive medication."

A. "Can you show me how to use the call light?." C. "What personal items can I place on your bedside table?" (p. 416 Potter)

A registered nurse (RN) is teaching a patient about preventative measures for electrical shocks. Which statement by the patient indicates the need for further teaching? A. "Use extension cords at all times." B. "Do not operate unfamiliar equipment." C. "Keep electrical items away from water." D. "Grasp the plug, not the cord, while unplugging."

A. "Use extension cords at all times." Meant to be used only as temporary power sources (p. 430, Potter)

Which stage of pressure injury can be dressed with a transparent or hydrocolloid dressing? A. 1 B. 2 C. 3 D. 4

A. 1 Stage 1 pressure injury is intact and can be dressed with hydrocolloid dressings p. 1348, potter

During an infection control surveillance study, the nurse review medical records and identifies that which person is at increased risk for an airborne infection? (Select all that apply) A. A neonate B. A 78 yr old that is hospitalized C. A 45 yr old undergoing an outpatient procedure D. A high school student E. A resident of an assisted living facility

A. A neonate B. A 78 yr old that is hospitalized E. A resident of an assisted living facility (p. 459)

Which patient is at an increased risk of developing a healthcare associated-infection (HAI)? Select all that apply A. A patient who underwent bronchoscopy B. A patient who receives broad-spectrum antibiotics C. A patient who has an in dwelling urinary catheter D. A patient who suffers from diabetes mellitus E. A patient who has a fever

A. A patient who underwent bronchoscopy B. A patient who receives broad-spectrum antibiotics C. A patient who has an in dwelling urinary catheter (Serves as a port of entry for microorganisms) D. A patient who suffers from diabetes mellitus (suppresses body's immunity and increases risk of HAI)

A patient comes in with disseminated herpes zoster and you as a future nurse would need to put this patient in what kind of isolation room? A. Airborne precautions B. Contact precautions C. Droplet precautions D. Standard precautions

A. Airborne precautions -Negative-pressure airflow (HEPA filtration) -N95 respirator

What is a cause of diarrhea? (Select all that apply) A. Antibiotic use B. Lack of exercise C. C diff D. Reduced fluid intake E. Surgeries of the lower GI tract

A. Antibiotic use C. C diff E. Surgeries of the lower GI tract p. 1279-1280, potter

A patient presents to the emergency department with severe injuries. The nurse notices that the wound on the abdomen is so deep that the liver has been eviscerated. Which prompt action does the nurse take? (Select all that apply) A. Assess the patient for symptoms of shock B. Administer oral antibiotics to prevent infection C. Contact the surgical team for emergency surgery D. Places sterile gauze soaked in saline over the wound E. Keep the wound open to examine the extent of the injury

A. Assess the patient for symptoms of shock C. Contact the surgical team for emergency surgery D. Places sterile gauze soaked in saline over the wound p. 1327, potter

What is considered an Iatrogenic infection? A. Bronchoscopy procedure B. Treatment with broad-spectrum antibiotics C. Not following infection control preventions D. Microorganisms in the mouth

A. Bronchoscopy procedure B. Treatment with broad-spectrum antibiotics C. Not following infection control preventions TYPE OF HAI: Iatrogenic infections : Type of HAI caused by an invasive diagnostic or therapeutic (p. 457)

Which health promotion strategy would be classified as passive? A. Clean water laws B. Exercise programs C. Wearing seat belts D. Nutrition programs

A. Clean water laws (P. 426, Potter)

The nurse questions which item is listed in a chart that compares home oxygen delivery systems? A. Compressed oxygen is an appropriate choice for patients who travel frequently

A. Compressed oxygen is an appropriate choice for patients who travel frequently (Large tank that is heavy and is suitable ONLY for stationary use) p. 1006, potter

What are signs of dysphagia? ( Select all that apply) A. Coughing during eating B. Change in voice C. Uncoordinated speech D. Gag reflect abnormal E. Delayed swallowing F. Regurgitation G. Laughing uncontrollably

A. Coughing during eating B. Change in voice C. Uncoordinated speech D. Gag reflect abnormal E. Delayed swallowing F. Regurgitation

Which questions would the nurse ask a patient to assess for the presence of infection? Select all that apply A. Do you have a cough that produces sputum? B. Do you have any pain or burning during urination? C. What medications are you currently taking? D. What recent diagnostic testing have you undergone? E. Have you had any recent cuts or lacerations?

A. Do you have a cough that produces sputum? B. Do you have any pain or burning during urination? Wrong E. This would be if you are inspecting for Risk of infection (p. 460)

What happens in the lungs when a patient has COPD? (Select all that apply) A. Elastic recoil is lost (in lungs) B. Breathing is harder C. Use of accessory muscles D. Could have hypoxemia and hypercapnia due to air trapping causing low oxygenation

A. Elastic recoil is lost (in lungs) B. Breathing is harder C. Use of accessory muscles D. Could have hypoxemia and hypercapnia due to air trapping causing low oxygenation

Decreased levels of which hormone may result in painful sexual intercourse? A. Estrogen B. Testosterone C. Growth hormonE D. Follicle-stimulating hormone (FSH)

A. Estrogen p. 745, potter

Which precaution would the nurse take to avoid environmental risks at a healthcare agency? A. Follow proper hand hygiene B. Follow standard isolation procedures C. Be aware of location of material safety data sheets D. Use IV pumps E. Perform safety checks on equipment

A. Follow proper hand hygiene B. Follow standard isolation procedures C. Be aware of location of material safety data sheets (p. 428-430 Potter)

When identifying an appropriate outcome for a 15 yr old girl, which primary developmental task of adolescence would the nurse consider? A. Forming a sense of identity B. Creating intimate relationships C. Separating from parents and living independently D. Achieving positive self-esteem through experimentation

A. Forming a sense of identity (Adolescents are focused on establishing their identities outside of their family and should be supported in meeting this developmental task) p. 728-729, potter

A patient has an inability to understand language or communicate orally. Which type of aphasia is the patient experiencing? A. Global B. Receptive C. Expressive D. Perception

A. Global Aphasia Inability to understand language or communicate orally is a global aphasia Perception aphasia is not a type of aphasia p. 1397, potter

Which event in life can alter the self concept of a person significantly? Select all that apply A. Having a child B. Losing a sibling C. Being promoted at work D. Taking an examination at school E. Being diagnosed with a chronic illness

A. Having a child B. Losing a sibling C. Being promoted at work E. Being diagnosed with a chronic illness p. 725, 729, potter

A nurse is providing community education about how the sexual response changes with age. What statement made by one of the adults indicates a need for further teaching? A. Health problems such as diabetes, copd, and hypertension have little effect on sexual functioning and desire. B. It usually takes longer for male and female to orgasm C. Mot of the normal changes in function are related to alteration in circulation and hormone levels D. Many medications can interfere with sexual function.

A. Health problems such as diabetes, copd, and hypertension have little effect on sexual functioning and desire. (p. 760, potter)

Which reason would justify the use of restraints on a disoriented person? (Select all that apply) A. Helps reduce the risk of patient injury from falls B. Prevents the patient from removing Intravenous (IV) Infusion lines and/or their trachea C. Helps control the patient D. Helps reduce the risk of injury to others by the patient E. Minimizes the need for supervision of the patient

A. Helps reduce the risk of patient injury from falls B. Prevents the patient from removing Intravenous (IV) Infusion lines and/or their trachea D. Helps reduce the risk of injury to others by the patient (p. 412-413)

Which condition is defined as a hypersensitivity to tactile stimuli? A. Hyperesthesia B. Peripheral neuropathy C. Macular degeneration D. Carpal tunnel syndrome

A. Hyperesthesia

Which factor will the nurse observe in a 38 yr old patient who is in the intimacy versus isolation developmental stage of self concept? A. Increased responsibilities B. Examination of attitudes and values C. Changes in appearance and physical endurance D. Need for the provision of a legacy for the next generation

A. Increased responsibilities (Young adult to mid 40's have increased responsibilities of caring for children and older adults, and said to be living in the "sandwich generation") p. 726, potter

A patient reports passing black and tarry stools. The nurse identifies that the patient should be evaluated for which conditions? (Select all that apply) A. Iron ingestion B. Ingestion of beets C. Gastrointestinal bleeding D. Spastic constipation D. Malabsorption of fat

A. Iron ingestion C. Gastrointestinal bleeding P. 1284, potter

Which characteristic of a stage 2 pressure injury is the nurse likely to find during a wound assessment? A. It has a reddish-pink wound bed without slough B. The subcutaneous fat is visible C. It may include undermining and tunneling D. The wound extends to muscle and bone

A. It has a reddish-pink wound bed without slough P. 1321, potter

Which protection barrier is specified for use with a patient that has varicella (chickenpox)? (Select all that apply) A. Mask B. Gloves C. Face shield D. Gown E. Goggles F. N95 respirator

A. Mask B. Gloves F. N95 respirator Airborne precautions : Negative airflow with HEPA filter. Diseases: TB, measles, Rubella, Varicella (chicken pox), Disseminate herpes zoster (p. 469)

A decrease in which feature is a risk factor for developing pathological fractures in patients with immobility? (Select all that apply) A. Metabolism B. Urinary output C. Tissue catabolism D. Calcium regulation E. Urine concentration

A. Metabolism D. Calcium regulation P. 875, potter

What is considered an exogenous infection? A. Microorganisms in rotten milk B. Microorganisms on the skin C. Microorganisms coming from soil D. Microorganisms inside the ear

A. Microorganisms in rotten milk contains Aspergillus. C. Microorganisms coming from soil contains Clostridium tetani TYPE OF HAI: Exogenous Infection: Microorganisms found outside the individual, such as Salmonella, Clostridium tetani, and Aspergillus. They do not exist as normal floras.

The nurse is caring for a patient with. Malabsorption syndrome. Which change in bowel elimination is the patient likely to report? (Select all that apply) A. Pale stools B. Black, tarry stools C. Clay-colored stools D. Increase flatulence E. Oily stools

A. Pale stools E. Oily stools Malabsorption syndrome means unable to absorb fat. p 1284, potter

What is considered an exogenous infection? A. Patient receives broad-spectrum antibiotics B. Microorganisms in the mouth C. Microorganisms under finger nails D. Microorganisms in water

A. Patient receives broad-spectrum antibiotics B. Microorganisms in the mouth could be enterococci TYPE OF HAI: Endogenous infection Patient's flora becomes altered and an overgrowth occurs (e.g., staphylococci, enterococci, yeasts, and streptococci). (p. 457)

Which patient would be at a high risk of hypothermia? (Select all that apply) A. Patients who have angina B. Patients who are homeless C. Patients who have Kidney disorders D. Patients who have taken drugs or alcohol in excess E. Patients who are exposed to carbon monoxide

A. Patients who have angina (vascular issue) B. Patients who are homeless D. Patients who have taken drugs or alcohol in excess (p. 406 Potter)

When assessing a 45 yr old patient's sensory status, which assessment finding does the nurse consider a normal part of aging? A. Presbyopia and the need for glasses for reading B. Reduced taste discrimination C. Reduced sensitivity to orders D. Impaired balance and coordination

A. Presbyopia and the need for glasses for reading

Which of these statements are true regarding disinfection and cleaning? (Select all that apply.) A. Proper cleaning requires mechanical removal of all soil from an object or area. B. Routine environmental cleaning is an example of medical asepsis. C. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. D. Cleaning in a direction from the least to the most contaminated area helps reduce infections. E. Disinfecting and sterilizing medical devices and equipment involve the same procedures

A. Proper cleaning requires mechanical removal of all soil from an object or area. B. Routine environmental cleaning is an example of medical asepsis. D. Cleaning in a direction from the least to the most contaminated area helps reduce infections.

A patient is being provided artificial respiration through ventilators in an intensive care unit when a fire erupts on the unit. Which action would the nurse perform in this situation? A. Provide manual respiration through a bag-valve mask device B. Make arrangements to move the patient along with ventilators C. Remove ventilator support and wait until the fire is under control D. Make arrangements to provide oxygen until the fire is control

A. Provide manual respiration through a bag-valve mask device Remember ABC's first! (p. 434)

Healthcare organizations focus on patient-centered safety by focusing on what aspect? (Select all that apply) A. Providing current reliable technology B. Making decisions regarding healthcare C. Engagement in performance-improvement endeavors D. Anticipating necessary assessments for treatment E. Integrating evidence-based practice into procedures F. Cultivating a safe work environment

A. Providing current reliable technology C. Engagement in performance-improvement endeavors E. Integrating evidence-based practice into procedures F. Cultivating a safe work environment (p. 408-409 Potter)

Match the intervention for promoting child safety on the left with the correct developmental stage on the right. A. School-age child B. Preschooler 1. Teach children proper bicycle and skateboard safety. 2. Teach children how to cross streets and walk in parking lots. 3. Teach children proper techniques for specific sports. 4. Teach children not to operate electric toothbrushes while unsupervised. 5. Teach children not to talk to or go with a stranger. 6. Teach children not to eat items found in the grass.

A. School -age children : teach children.. 1. Proper bicycle and skateboard safety. 2. Cross streets and walk in parking lots. 3. Proper techniques for specific sports. B: Preschooler: teach children.... 4. Not to operate electric toothbrushes while unsupervised. 5. Not to talk to or go with a stranger. 6. Not to eat items found in the grass.

Which parameter would be measured to determine the protein deficiency in the patient with a wound? Select all that apply A. Serum albumin B. Serum transferrin C. Serum prealbumin D. Hemoglobin levels E. Serum creative levels

A. Serum albumin B. Serum transferrin C. Serum prealbumin Lab facts: A. Indicates protein deficiency and malnutriotn B. Indicates protein status in the body C. Indicates nutritional status (what has been metabolized) p. 1330, potter

A 54 yr old women being treated for breast cancer tells the nurse that she has no interest in sex since her surgery 2 months ago. The nurse is aware that: (Select all that apply) A. Sexual issues can occur in a woman this age. B. Women experience sexual dysfunction more frequently than men C. HSDD occurs in women over 65 yrs of age D. Medical conditions such as cancer often contribute to HSDD E. Disturbances in self concept affect sexual functioning.

A. Sexual issues can occur in a woman this age. B. Women experience sexual dysfunction more frequently than men D. Medical conditions such as cancer often contribute to HSDD E. Disturbances in self concept affect sexual functioning. (p. 760, potter)

Which element influences the achievement of identity of a person? (Select all that apply) A. Sexuality B. Gender C. Ethnicity D. Place of birth E. Physical appearance

A. Sexuality B. Gender C. Ethnicity Think of what influences identity p. 726, potter

The nurse is the aching health promotion tips to an elderly patient with presbycusis. Which nursing action ensures effective communication? (Select all that apply) A. Speaking slowly and articulating sentences clearly B. Speaking in a high pitched voice with the patient C. Avoid eating while communicating with the patient D. Sitting at the same level while communicating with the patient E. Repeating the main points while walking away from the patient's room

A. Speaking slowly and articulating sentences clearly C. Avoid eating while communicating with the patient D. Sitting at the same level while communicating with the patient presbycusis is a hearing disorder in elderly p. 1405, potter

The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on the nurses' part would contribute to reducing health care-acquired infections? (Select all that apply.) A. Teaching correct handwashing to assigned patients B. Using correct procedures in starting and caring for an intravenous infusion C. Providing perineal care to a patient with an indwelling urinary catheter D. Isolating a patient on antibiotics who has been having loose stool for 24 hours E. Decreasing a patient's environmental stimuli to decrease nausea

A. Teaching correct handwashing to assigned patients B. Using correct procedures in starting and caring for an intravenous infusion C. Providing perineal care to a patient with an indwelling urinary catheter

What outcome would the nurse include when preparing a plan of care for a patient with a risk of falling? A. The patient remains injury free for 1 month. B. The patient will perform strengthening exercises. C. The patient identifies risk factors that contribute to their falls D. The patient and family education for fall prevention has been scheduled

A. The patient remains injury free for 1 month. (p. 423-424)

Which event that occurred during a sterile aseptic procedure indicates potential contamination? (Select all that apply) A. The sterile field was lower than the nurse's waist B. The package was slightly damp on the bottom C. The nurse avoided touching the edges of the field D. An instrument was out of the nurse's line of sight E. The sterile syringe tip touched the nurse's clean glove

A. The sterile field was lower than the nurse's waist B. The package was slightly damp on the bottom D. An instrument was out of the nurse's line of sight E. The sterile syringe tip touched the nurse's clean glove (485-489, Potter)

The nurse is caring for a patient who is immobile. Which cardiovascular change does the nurse expect to observe in the patient? (Select all that apply) A. Thrombus formation B. Orthostatic hypotension C. Increased cardiac output D. Increased cardiac workload E. Increased circulating fluid volume

A. Thrombus formation B. Orthostatic hypotension E. Increased circulating fluid volume p. 878-879

An adolescent who is pregnant for the first time is at her initial prenatal visit states she does not have an STI and no symptoms of one either. The nurse informs the patient that she will be screening her for STI's. What response is appropriate? (Select all that apply) A. Untreated STIs can cause serious complications in pregnancy, so we routinely screen pregnant women. B. Bacterial STI's do not usually cause symptoms, or you could have an asymptomatic viral STI C. Chlamydia screening is recommended for all sexually active women up to age 25 even if asymptomatic. D. There is no need then to screen for infection since you are not having any problems or symptoms. E. People between 15 and 24 are often asymptomatic and have the highest incidence of STI's.

A. Untreated STIs can cause serious complications in pregnancy, so we routinely screen pregnant women. C. Chlamydia screening is recommended for all sexually active women up to age 25 even if asymptomatic. E. People between 15 and 24 are often asymptomatic and have the highest incidence of STI's. (p. 760, potter)

The medical records of an older adult reveals a stroke affecting the right hemisphere of the brain. Which assessment finding would the nurse expect to find? (Select all that apply) A. Visual-spatial alteration such as loss of half of a visual field B. Loss of sensation and motor function on the right side of the body C. I attention and neglect, especially to the left side D. Cloudy or opaque areas in part of the lens or the entire lens E. Difficulty with speech

A. Visual-spatial alteration such as loss of half of a visual field C. I attention and neglect, especially to the left side p. 1391, potter

What is the key function of the GI System?

Absorbs high volumes of fluid and electrolyte balance

trust-versus-mistrust stage

According to Erikson Birth to 18 months -Largely depending on how well their needs are met by their caregivers -Distinguishes self from environment

Who falls under having a generativity versus self absorption self concept developmental task?

Adult: mid 40's to mid 60's Able to acceot changes in appearance and physical endurance Reasses life goals Shows contentment with aging

A client develops sudden onset of bronchiolar constriction, edema of pharynx and larynx, and shortness of breath following administration of a medication. What type of allergic reaction is the client experiencing?

Anaphylactic reaction

The nurse would monitor for which complication if an endotracheal tube cuff is under inflated?

Aspiration It allows secretions to enter the trachea and permits vocalization -Adding more air is also important to prevent aspiration p. 1019, potter

A nurse accidentally gives a client a medication at the wrong time. The nurse's first priority is to:

Assess the client for adverse effects

What self concept developmental task begins to communicate likes and dislikes, has self control and independence in thoughts and actions, and appreciates body appearance and function?

Autonomy versus shame and doubt 18 months to 3 years

How would you Don and Doff for Standard Precaution precautions? A. Don: Gloves Goggles (if a risk for splash) Doff: Googles (if worn) Gloves B. Don: Goggles (if a risk for splash) Gloves Doff: Googles (if worn) Gloves

B. Don: Goggles (if a risk for splash) Gloves Doff: Googles (if worn) Gloves

The nurse understands that an immobile patient is at high risk for thrombus formation. Which factor may contribute to this risk? (Select all that apply) A. Alteration in body weight B. Alteration of slowing of blood flow C. Damage to the wall of the blood vessels D. Alteration in the patients nutritional status E. Alteration of constituents in the blood

B. Alteration of slowing of blood flow C. Damage to the wall of the blood vessels E. Alteration of constituents in the blood p. 879, potter

Which type of transmission-based precautions requires gowns and gloves? A. Droplet precautions B. Contact precautions C. Airborne precautions D. Protective environment precautions

B. Contact precautions Disease: C diff, VRE, MRSA, Shigella, Herpes Simplex, Scabies (p. 469)

Which infection control practice would the nurse implement for a patient who is hospitalized for treatment of an infection with a multi-drug resistant organism? A. Use of N95 respirators B. Contact precautions C. HEPA filtration D. Droplet precautions

B. Contact precautions Ex. C diff, staphlococcus aureus, shigella , and other enteric pathogens, major wound infections, herpes, scabies, varicella zoster

What is the major cause of hospital associated infections? A. Serving bland food at the hospital that cools down before entering the room B. Contaminated respiratory therapy equipment C. Repeated catheter irrigations D. Improper technique during administration of multiple blood productsts (or urine specimens collection) E. Washing hands for 1 minute with soap and water

B. Contaminated respiratory therapy equipment C. Repeated catheter irrigations D. Improper technique during administration of multiple blood products (or urine specimens collection) ALL HAI Infections majorly caused by: Improperly performing hand hygiene increases patient risk for all types of health care-associated infections.

A patient is diagnosed with meningitis. Which type of isolation precaution is most appropriate for this patient? A. Reverse isolation B. Droplet Precautions C. Standard Precautions D. Contact Precautions

B. Droplet Precautions

The nurse is caring for a patient who is at risk for falls because of improper gait. Which measure would the nurse take to ensure patient safety? (Select all that apply) A. Apply restraints B. Ensure that the patient wears rubber soled slippers C. Encourage the patient to use crutches or walkers after ensuring correct use D. Remove excess furniture from the path E. Advise family members to accompany the patient when the nurse is not present

B. Ensure that the patient wears rubber soled slippers C. Encourage the patient to use crutches or walkers after ensuring correct use D. Remove excess furniture from the path Wrong: E. It is the nurse's responsibility to take care of the patient (p. 432)

When do you assess a patient with soft extremity restraints? A. Every 15 mins B. Every 2 hours C. Every 1 hours D. Every 4 hours

B. Every 2 hours (Evaluate pts need for toileting, nutrition and fluids, and hygiene) (p. 446)

Which chief factor determines the self-concept of an individual? (Select all that apply) A. Age B. Identity C. Body image D. Gender E. Role performance

B. I dentity C. Body image E. Role performance p. 726

According to Erickson, which is a primary developmental task of a 9 yr old patient? A. Communication of likes and dislikes B. Increased self-esteem with mastery of a new skill C. Acceptance of body changes D. Distinguishing self from environment.

B. Increased self-esteem with mastery of a new skill (According to Erickson primary developmental task, during 6 to 12 yrs, its a primary to increase self-esteem) p. 726, potter

Which of the following actions by the nurse demonstrate the practice of core principles of surgical asepsis? (Select all that apply.) A. The front and sides of the sterile gown are considered sterile from the waist up. B. Keep the sterile field in view at all times. C. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. D. Only health care personnel within the sterile field must wear personal protective equipment. E. After cleansing the hands with antiseptic rub, apply clean disposable gloves.

B. Keep the sterile field in view at all times. C. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated.

Which mode of action of emollient laxatives? A. Increasing pressure in the bowel B. Lowering the surface tension of feces C. Causing local irritation to the intestinal mucosa D. Inhibiting the reabsorption of water in the large intestines

B. Lowering the surface tension of feces

The healthcare provider perscribes methyl cellulose to a pt with chronic constipation. Which instruction provided by the nurse will help prevent complications? A. Do not use the medication on a regular basis B. Mix the powder with 250 mL of water or juice and swallow it quickly C. Report to the healthcare provider if you do not pass stools within 8 to 10 hours of taking the medication D. Stop taking the medication if you notice increased gas formation and flatus when you first start taking it

B. Mix the powder with 250 mL of water or juice and swallow it quickly Methyl cellulose (laxative) is a bulk forming stool softener that absorbs water and increases solid intestinal bulk. Available in powder form and drug of choice for constipation P. 1295, potter

What is the best overall rule for avoiding accidents with equipment in the hospital setting? A. Always lock the wheels on movable equipment B. Never operate equipment without prior instruction C. Always unplug equipment when moving equipment D. Never use equipment without a person to assist you

B. Never operate equipment without prior instruction

Equipment-related accidents result from an electrical hazard or malfunction, disrepair, or misuse of equipment by... A. Improper application of external devices (eg. IV, indwelling catheter, oxygen tubing) B. Operating equipment with adequate instruction material C. Replacing fault equipment and tagging it, and taking it out of service and reporting it. D. Chemicals found in some medications (e.g., chemotherapy) E. Assess the room for any potential electrical hazards at the bedside F. Using programmed infusion pumps with free flow protection

B. Operating equipment with adequate instruction material. C. Replacing fault equipment and tagging it, and taking it out of service and reporting it. E. Assess the room for any potential electrical hazards at the bedside F. Using programmed infusion pumps with free flow protection.

Which component is included in the PLISSIT model of assessment? A. Palliation B. Permission C. Limited information D. Specific suggestions E. Intravenous therapy

B. Permission C. Limited information D. Specific suggestions PLISST P: Permission from pt to discuss sexual activity L: limited info regarding sexual health problems SS: Specific suggestions made when the nurse is clear about a problem

What are risks associated with the development of infections or health care-associated infections in older patients are... A. Planned weight loss B. Poor nutrition C. Lack of exercise D. Social support E. Low serum albumin levels

B. Poor nutrition C. Lack of exercise E. Low serum albumin levels Also.. * Unplanned weight loss * Poor social support -Meticulous hand hygiene practices -Use of chlorhexidine washes for bathing and personal hygiene care Help prevent HAI (p. 457)

Which safety precaution would be followed by a patient infected with Hep A? A. Avoid needle sharing B. Practicing hand hygiene C. Use a walker or cane D. Perform ROM exercises

B. Practicing hand hygiene Prevents pathogen transmission to others (p. 411, Potter)

When planning nursing care for an 85 yr old patient, which basic need is most important to be met? A. Assurance of sexual intimacy B. Preservation of self-esteem C. Expanded socialization D. Increase in monthly income

B. Preservation of self-esteem (A focus of Erikson's developmental task of an 85 yr old is the need to feel positive about life and its meaning.) p. 726

During an assessment, the nurse finds that a patient is able to express words but is unable to understand questions. Which condition is the probably reason for this? A. Global aphasia B. Receptive aphasia C. Expressive aphasia D. A hearing impairment

B. Receptive aphasia This is receptive or sensory aphasia. Pt can express words, but unable to understand questions. P. 1397, potter

Which disease requires contact precautions? A. Measles B. Scabies C. Diptheria D. Pertussis

B. Scabies Spreads through skin contact

Which term describes how one thinks of oneself? A. Self awareness B. Self concept C. Self esteem D. Self expression

B. Self concept p. 724, potter

Which element of self concept is the nurse assessing when asked the patient, " How do you feel about yourself?" A. Identify B. Self-esteem C. Body Image D. Role performance

B. Self-esteem (P. 728, potter)

What is a soft extremity (ankle or wrist) restraint made from? A. Leather and cotton B. Soft quilted material or sheepskin with foam padding. C. t shirt type material D. Gauze

B. Soft quilted material or sheepskin with foam padding.

The RN is overseeing a nursing student who is caring for a patient who has impaired circulation distal to an elastic bandage. Which action by the nursing student requires correction? A. Releasing the bandage B. Taking a wound culture C. Palpating the extremity distal to the bandage D. Reapplying the bandage in the same area with less pressure

B. Taking a wound culture Only necessary if actual infection is suspected does not relieve impaired circulation p. 1382, potter

he nurse assesses the following data from a patient with diabetes mellitus who is 4 days postoperative for repair of an abdominal aortic aneurysm. Which assessment finding is of greatest concern for the nurse? A. Vesicular breath sounds in the lung bases B. Temperature 38.5oC (101.4o F) C. Incision pain rating of 6 out of 10 D Blood glucose of 164 mg/dL

B. Temperature 38.5o C (101.4o F)

A patient is diagnosed with a multidrug-resistant organism (MDRO) in his surgical wound and asks the nurse what this means. What is the nurse's best response? (Select all that apply.) A. There is more than one organism in the wound that is causing the infection. B. The antibiotics the patient has received are not strong enough to kill the organism. C. The patient will need more than one type of antibiotic to kill the organism. D. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively. E There are no longer any antibiotic options available to treat the patient's infection.

B. The antibiotics the patient has received are not strong enough to kill the organism. D. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively.

A patient is diagnosed with a multidrug-resistant organism (MDRO) in his surgical wound and asks the nurse what this means. What is the nurse's best response? (Select all that apply.) A. There is more than one organism in the wound that is causing the infection. B. The antibiotics the patient has received are not strong enough to kill the organism. C. The patient will need more than one type of antibiotic to kill the organism. D. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively. E. There are no longer any antibiotic options available to treat the patient's infection.

B. The antibiotics the patient has received are not strong enough to kill the organism. D. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively.

Which statement by the nursing student regarding the use of physical restraints indicates effective learning? (Select all that apply) A. Restraints are ordered prn B. They reduce the risk of patient injury from falls C. Restraints are used as alternatives for electronic devices D. They prevent interruption of therapy, such as traction E. Restraints prevent the removal of life support equipment by confused patients

B. They reduce the risk of patient injury from falls D. They prevent interruption of therapy, such as traction E. Restraints prevent the removal of life support equipment by confused patients

Which infection control precaution would the nurse take to prevent the spread of influenza? Select all that apply A. Wearing gloves while reviewing the medical report B. Wearing a surgical mask (and gown) w/in 3 feet of the patient C. Wearing a sterile gown while entering the patient's room D. Maintaining proper hand hygiene during the assessment and wearing gloves E. Placing the patient in an airborne infection isolation room.

B. Wearing a surgical mask (and gown) w/in 3 feet of the patient D. Maintaining proper hand hygiene during the assessment and wearing gloves! (p. 469) Influenza- droplet precautions Diseases: Grp A strep, Rhinovirus, Neisseria, meningitis, mycoplasma pneumonia, diphthermia, adenovirus

partial bed bath

Bath in which body parts that might cause the patient discomfort if left unbathed (i.e., face, hands, axillary areas, back, and perineum) are washed in bed.

What is biotransformation and where does it occur?

Biotransformation (metabolism) changes medications into less active forms or inactive forms by the action of enzymes. This occurs primarily in the liver, but also takes place in the kidneys, lungs, bowel, and blood

Factors that influence hygiene

Body image Socioeconomic status health beliefs motivations cultural variables

A long term care facility encourages nurse to assess patients at risk of developing pressure injuries based on six sub scales. What tool is used for risk of assessment of pressure injury development?

Braden scale p. 1329, potter

Normal assessment findings of a stoma

Brick red moist great circulation

Which cause of death is classified as an environmental event on the National Quality Forum (NQF) list? A. Physical assault in the healthcare setting B. Contaminated drugs in the healthcare agency C. A fall while in the healthcare agency D. Spinal manipulative therapy in the healthcare agency

C. A fall while in the healthcare agency (p. 415, Potter)

How is a self concept stressor defined? A. The inability of an individual to distinguish self-concept from self-esteem B. An individual's belief that establishes a feeling of unworthiness C. A real or perceived change that threatens a person's identify, body image, or role performance D. The inability of an individual to reach an age-appropriate developmental stage

C. A real or perceived change that threatens a person's identify, body image, or role performance p. 728, potter

At 10:00am a patient was restrained after physically assaulting another patient on the unit. Which monitoring parameter will the nurse incorporate into the care plan? A. Assess the patients vital signs at 10:30am B. Renew the prescription for restraints at 12:00pm C. Assess the patients psychological status at 10:15am D. Request the doctor to come see the patient at 12:00pm

C. Assess the patients psychological status at 10:15am (Violent-need to assess every 15 mins) (p. 433)

Which strategy does the nurse use when communicating with a hearing-impaired patient? (Select all that apply) A. Speak loudly toward the patient's ear B. Avoid sitting at the same level as the patient C. Avoid eating or chewing while speaking D. Use a normal tone of voice and normal inflections of speech E. Use written information to enhance the spoken word

C. Avoid eating or chewing while speaking D. Use a normal tone of voice and normal inflections of speech E. Use written information to enhance the spoken word

Which sign is an early indication of pressure that resolves without tissue loss if the pressure is eliminated? A. Pallor or molting B. Dark red or purple discoloration C. Blanchable erythema D. Nonblanchable erythema

C. Blanchable erythema P. 1320, potter

The registered nurse is teaching a nursing student about safety for equipment-related accidents. Which statement by the nursing student indicates the need for further teaching. A. Free flow protection devices should be used B. Place a tag on faulty equipment C. Check equipment for safety regularly and often D. Healthcare workers must follow HIPPA to ensure patient privacy

C. Check equipment for safety regularly and often. This is not the nurses job, only the IT's at the hospital.

Which precaution is necessary to help prevent healthcare-associated infections? (Select all that apply) A. Frequently irrigate urinary catheters B. Insert drug additives to IV fluids C. Ensure a closed urinary catheter drainage system D. Change the IV access if inflamed E. Use aseptic technique when suctioning the airway

C. Ensure a closed urinary catheter drainage system(Helps prevent infection) D. Change the IV access if inflamed (Inflammation leads to infection) E. Use aseptic technique when suctioning the airway (microorganisms in the airway can be introduced)

The nurse is taking care of two patients with hearing impairments. Which precaution would the nurse take while communicating with these patients? (Select all that apply) A. Speak loudly when talking B. When not understood, repeat the statement and conversation C. Ensure that the patients keep their eyeglasses clean. D. Use written information to enhance or supplement spoken communication E. Keep the patient's hands free to allow communication through hand gestures.

C. Ensure that the patients keep their eyeglasses clean. D. Use written information to enhance or supplement spoken communication E. Keep the patient's hands free to allow communication through hand gestures. P. 1405, potter

After obtaining negative results for screening for falls, a patient reports to the nurse that they have fallen once over the past 12 months. Which action is appropriate for the nurse to take next? A. Periodically assess the patient B. Conduct a physical examination C. Evaluate the gait and balance of the patient D. Initiate a multicomponent intervention to address identified risks and prevent falls.

C. Evaluate the gait and balance of the patient (p. 422)

Based on the Centers for Disease Control and Prevention's guidelines, which information would the nurse include in a hand hygiene teaching session for healthcare workers? A. Proper hand hygiene is most effective way to kill microorganisms B. Antimicrobial soaps are most effective for standard hand washing by healthcare workers than alcohol-based products. C. Hand washing is defined as the vigorous, brief rubbing together of all surfaces of lathered hands followed by rinsing under a stream of warm water for 15 seconds. D. Ethanol-based antiseptics containing 50% alcohol appear the be the most effective against common pathogens found on hands.

C. Hand washing is defined as the vigorous, brief rubbing together of all surfaces of lathered hands followed by rinsing under a stream of warm water for 15 seconds. -Hand washing does not kill microorganisms. -Ethanol soaps contain 60 to 90% alcohol -Alcohol based products are more effective for standard hand washing (Only if non soiled) than Antimicrobial soaps

The nurse notices an increased amount of red-colored fluid from the drain in a postoperative patient who had undergone abdominal surgery 2 days ago. The nurse inspects the incision site and notices some swelling and warmth over the incision. The patient is otherwise a febrile and has stable vital signs. Which condition are these findings indicative of? A. Infection B. Evisceration C. Hemorrhage D. Full thickness repair

C. Hemorrhage Increased amount of red darainage from the surgical drain indicates hemorrhage or internal bleeding from underlying tissues. P.1327, potter

A patient experiences chronic constipation but has no other symptoms. Which medication would the nurse anticipate the health care provider to prescribe to provide relief for the condition? A. Castor oil B. Magnesium citrate C. Polycarbophil D. Docusate sodium

C. Polycarbophil this is the drug of choice for chronic constipation for pts who are hemodynamically stable. It is a bulk forming substance It is for acute emptying of the bowel for acute constipation p. 1295, potter

An elderly patient reports to the nurse,, "I have a difficult time clearly seeing objects that are close to me. However, i can see objects at a distance." Which diagnosis does the nurse anticipate in the patient? A. Cataracts B. Glaucoma C. Presbyopia D. Macular degeneration

C. Presbyopia a gradual decline in the ability of the lens to focus on close objects indicates presbyopia.

Which aspect is the primary contraceptive action of an Intrauterine device (IUD)? A. Prevents ovulation B. Acts as a physical barrier C. Prevents fertilization D. Kills sperm cells

C. Prevents fertilization P. 749, potter

Which type of oxygen mask is contraindicated for patients who retain carbon dioxide? A. Venturi mask B. Nasal cannula C. Simple face mask D. Partial rebreather

C. Simple face mask Contraindicated to patients who have CO2 retention because retention can be worsened, leading to decreased LOC. -Simple face mask can cause retention of CO2 -Only used for short periods of oxygenation such as patient transport. p. 1005, potter

Which type of enema should be used with caution specifically in pregnant women and older adults? A. Medicated enema B. Normal saline C. Soap suds enema D. Tap water enema E. Oil-retention enema

C. Soap suds enema Causes electrolyte imbalance or damage to intestinal mucosa in pregnant women and older adults p. 1295, potter

A 16 yr old female tells the school nurse that she does not need the HPV vaccine since her partner uses condoms. The best response by the nurse to this statement is" A. "Latex condoms are the most effective way to eliminate the risk of HPV transmission. B. Your parents may not want you to receive the HPV vaccine since it has been shown to increase sexual risk taking and sexual activity. C. The HPV-9-valent vaccine is recommended for males and females even if they use condoms because it targets the specific viruses that cause cancer and genital warts. D. You are past the recommended age to receive the vaccine/

C. The HPV-9-valent vaccine is recommended for males and females even if they use condoms because it targets the specific viruses that cause cancer and genital warts.

On assessing your patient's sacral pressure injury, you note that the tissue over the sacrum is dark, red, hard, and adherent to the wound edge. Which stage would be applied to this patient's pressure injury? A. Stage 2 B. Stage 4 C. Unstageable D. Suspected deep tissue damage

C. Unstageable Need to examine the depth of the tissue involvement. This is explaining necrotic tissue, the depth cannot be determined p. 1322, potter

The nurse is having difficulty reading a physician's order for a medication. He or she knows that the physician is very busy and does not like to be called. What is the most appropriate next step for the nurse to take?

Call the physician to have the order clarified.

The nurse monitors for which complication when performing tracheostomy suctioning?

Changes in blood pressure either hypotensive or hypertensive p. 997, potter

Which condition could cause infertility in a female patient?

Chlamydia p. 750, potter

What do you do if a patient is at risk for aspiration?

Consult with Speech Therapist Notify the Doctor

Bag bath/travel bath

Contains several soft, nonwoven cotton cloths that are premoistened in a solution of no-rinse surfactant cleanser and emollient. The bag bath offers an alternative because of the ease of use, reduced time bathing, and patient comfort.

The registered nurse is teaching the nursing student about poisons. Which statement by the student nurse indicates effective in learning? (Select all that apply) A. "Poisons mostly affect the liver." B. "Household cleaning solutions do not cause poisoning." C. "Older adults are at risk of accidental poisoning at home." D. "A poison control center is the best resource for treating accidental poisoning." E. "Emergency treatment is necessary when a poisonous substance comes into contact with the skin."

D. "A poison control center is the best resource for treating accidental poisoning." E. "Emergency treatment is necessary when a poisonous substance comes into contact with the skin." (p. 410 Potter)

The registered nurse is teaching a nursing student about procedure-related accidents. Which statement made by the nursing student indicates a need for further teaching? A. "Surgical asepsis for dressing can prevent infections." B. "Proper use of equipment reduces the risk of injuries." C. "Distractions contribute to procedure-related accidents." D. "Accidents are mainly caused by misuse of equipment."

D. "Accidents are mainly caused by misuse of equipment." = Actually procedure-related accidents happen from healthcare providers from medication and fluid administration errors! (p. 414, 416 Potter)

Who should you verify medications calculations with and why? A. The Nurse Assistant, to ensure accuracy. B. The pharmacy, because only the pharmacist knows accurate calculations. C. The patient, because they are a math teacher. D. Another Nurse, to ensure accuracy.

D. Another Nurse, to ensure accuracy.

When repositions an immobile patient, the nurse notices redness over a bony prominence. Which condition is indicated when a reddened area blanches on fingertip touch? A. A local skin infection requiring antibiotics B. Sensitive skin that requires special bed linen C. A stage 3 pressure injury needing the appropriate dressing D. Blanching hypermedia, indicating the attempt by the body to overcome the ischemic episode.

D. Blanching hypermedia, indicating the attempt by the body to overcome the ischemic episode. This is the first sign of bed sores. P. 13230, potter

Which type of laxative acts by causing the stool to absorb water and swell? A. Emollient B. Stimulant C. Lubricant D. Bulk forming

D. Bulk forming Stimulates the muscles in the gut to squeeze feces out P. 1295, potter

What change can be observed upon exposure to severe heat? (Select all that apply) A. Irregular heartbeat B. Cognitive impairment C. Decreased oxygenation D. Changes in electrolyte balance E. Rise in core body temperature

D. Changes in electrolyte balance E. Rise in core body temperature = These result in heatstroke or heat exhaustion (p. 409 Potter)

Which bacterial STI is most commonly reported in the United States? A. Syphillis B. Gonorrhea C. Genital herpes D. Chlamydia

D. Chlamydia P. 750, potter

The nurse plans care for a 70 yr old with the knowledge that the patient is primarily focused on which developmental task? A. Intimacy versus isolation B. Autonomy versus shame and doubt C. Generativity versus self-absorption D. Integrity versus despair

D. Integrity versus despair (Mid-late 60's focuses on feeling positive about life and its meaning and providing a legacy for the next generation) p. 726, potter

On assessment, the nurse finds that the patient has blurred vision, loss of central vision, and distraction of vertical lines. Which visual deficient is likely to be found in the patient? A. Cataracts B. Glaucoma C. Presbyopia D. Macular degeneration

D. Macular degeneration Blurred vision, loss of central vision, and distortion of vertical lines are symptoms of macular degeneration p. 1391, potter

A patient is admitted to the emergency department after the ingestion of a poison. Which type of cathartic would the nurse anticipate being prescribed to the patient? A. Bisacodyl B. Castor oil C. Docusate calcium D. Magnesium citrate

D. Magnesium citrate Fasting acting cathartic Bisacodyl and castor oil appropriate for bowel prep for diagnostics

When communicating with a patient who has expressive aphasia, which strategy is priority for the nurse? A. Asking open-ended questions B. Understanding that the patient will be uncooperative C. Coaching the patient to respond D. Offering pictures or a communication board so the patient can point

D. Offering pictures or a communication board so the patient can point Expressive aphasia: Understand questions but have difficulty expressing an answer. p. 1405, potter

The nurse caring for a patient with a history of grand mal seizures witness the patient begin to have a seizure in bed. Which immediate intervention will the nurse implement? A. Place the bed in the lowest position B. Restrain the patient's legs C. Place a backboard under the patient D. Place a pad/pillow under the patients head E. Insert a bite block into the patient's mouth F. Position patient on their side

D. Place a pad/pillow under the patients head. Decreases risk of injury (p. 433, Potter) Sherpath question

A 65 yr old patient reports to the nurse an increased difficulty with balance and an inability to determine the position of an object. The nurse finds that the patient has decreased sensitivity to pain and pressure. These are symptoms if which condition? A. Aphasia B. Presbyopia C. Peripheral neuropathy D. Proprioceptive changes

D. Proprioceptive changes Increased difficulty with balance, inability to avoid obstacles, decrease sensitivity to pain and pressure are all proprioceptive changes that occur in adults at the age of 60 and later. P. 1392, potter

Which agent is osmotic and is used to treat constipation? A. Polycarbophil B. Casanthranol C. Docusate potassium D. Sodium phosphate

D. Sodium phosphate p. 1295, potter

The nurse is caring for a visually impaired elderly patient. Which nursing intervention is useful for enhancing the vision of the patient and for promoting functional ability? A. The use of telescopic lens eyeglasses B. The use of a pocket magnifier C. The use of sunglasses while outside D. The use of warm, incandescent lighting

D. The use of warm, incandescent lighting Incandescent lighting provides less glare, is brighter, and helps patients to see paths clearly. p. 1403, potter

Stool Upper GI Bleed

Dark, tarry, black, sticky Treatment: endoscopy

Which characteristic would be indicative of abnormal healing of a primary wound?

Drainage for more than 3 days after closure p. 1324, potter

Abnormal assessment of stoma

Dry, grey, purple or blue stoma

Which terminology would the nurse chart to document the patient saying, "It's hard for me to breathe, and I feel short-winded all the time"?

Dyspnea Dyspnea is a subjective P. 982, potter

Which safety precaution would be taken for the patient with muscle weakness while walking? A. Side rails B. Crutches C. Wheelchair D. Belt restraint E. Rubber soled shoes

E. Rubber soled shoes

Diagnostic exams for altered bowel elimination

Hemoglobin Hematocrit Nurses can do Guaita test

Which sexually transmitted infection cannot be cured?

Herpes Human papilloma virus infection

ultrasound imaging (sonography)

High-frequency sound waves echo off the body's tissues and are used to visualize structures/ picture of GI tract

tap water enema (type of cleansing enema)

Hypotonic Enema. After infusion into the colon, tap water escapes from the bowel lumen into interstitial spaces. (*Do not repeat because water toxicity or circulatory overload will develop)

The nurse suspects which condition when a patient's assessment findings include increased blood pressure, tachycardia, dizziness, a decreased level of consciousness, and the need to sit in high Fowler position?

Hypoxia Hypovolemia is low bp, and low hr

What age and title (according to Erikson) is a person who has a self concept developmental task that accepts body changes, is becoming sexually mature, establishes goals for the future and feels positive about expanded sense of self ?

Identity versus role confusion 12-19 years

When caring for a patient postoperatively, which nursing intervention prevents atelectasis?

Incentive spirometry

colonic transit study

Indirect Visualization • The patient swallows a capsule containing radiopaque markers. • The patient maintains their normal diet and fluid intake for 5 days and refrains from medications that affect bowel function. On the fifth day x-ray film examination is performed.

What age and title (according to Erikson) is a person who has a self concept developmental task that engages in tasks and activities and increases self esteem and new skill mastery?

Industry versus inferiority (6 to 12 years old )

Most formed stool is present in which portion of the digestive tract?

Large Intestines (Cecum)

Colostomy are located where?

Large intestines Stool more formed located in descending colon

endoscopy

Lighted fiber optic tube direct visualization of upper GI Tract Clear diet the day before

colonoscopy

Lighted fiber optic tube for direct visual examination of the inner surface of the entire colon (Lrg intestines) from the rectum to the cecum bowel prep beforehand

How to prevent medication errors

Minimize verbal or telephone orders Repeat order to prescriber Spell drug name aloud No interruptions Prepare meds 1 pt at a time Be well rested Double check calculations

The nurse is caring for a bedridden patient. The nurse understands that immobility results in many metabolic changes. Which metabolic change maybe found in this patient?

Negative nitrogen balance Decreased basal metabolic rate (BMR) Decreased appetite and slowing of peristalsis p. 878, potter

Conditions that increase risk for aspiration

Neuromuscular problems Head, neck, and upper GI tract issues

Which info would the nurse share with the patient about normal mechanism of respiration?

Normal breathing is quiet and accomplished with minimal effort Ventilation is the process of air moving in and out of the lungs The diaphragm is the major inspiratory muscle of respiration (P. 972)

digital removal of fecal impaction

Nurse should insert a lubricated gloved finger in advance it along the rectal wall when digitally evacuating stool Placed patient in side lying position with knees flexed Contra indicated for administering bisacodyl

Metabolism of Medications

Once reached site of action, metabolizes into less active or inactive form that is easier to excrete

When caring for a stable patient with a well-established tracheostomy tube, which actin is safe for the nurse to delegate to the assistive personnel (AP)?

Perform oral suctioning Only after pt has been assessed by the RN and is stable, the nurse can delegate p. 1008, potter

gender identity

Persons private view of being male or female

According to the Braden scale for predicting pressure injury risk, which factors most puts the patient at risk of developing a pressure injury?

Poor nutrition P. 1328

continent ileostomy

Pouch from sm. Intestion Drained with large catheter Rarely performed

ileoanal pouch anastomosis

Pouch is a reservoir for wastes that are eliminated from the anus. For treatment of ulcerative colitis or familial adenoppolyposis (FAP)

Define side effects

Predicable and avoidable adverse effect produced at a therapeutic dose

large intestine

Primary organ of water absorption and bowel elimination

Which role does vitamin A play in wound healing?

Promotes wound closure p. 1330, potter

Which parameter would the nurse monitor in a patient who has developed hypoxia as a result of sever anemia?

Pulse rate, respiratory rate, skin color change

What are the three medication administration checks?

Read labels 3x: 1. After removing from pixxis (or storage draw) 2. Before you enter pts room 3. Before giving the med to the pt

normal sensation

Reception: stimulation of a receptor such as light, touch, or sound Perception: integration and interpretation of stimuli Reaction: only the most important stimuli will elicit a reaction

Stool Lower GI Bleed

Red blood in stool Treatment: Colonscopy through anus

While assessing a patient who experienced a mild allergic reaction, the nurse observes swelling and a clear, watery discharge from the nose. Upon nasal mucosal biopsy, the nurse finds inflammation of the mucous membranes. Which allergic reaction should the nurse suspect in the client?

Rhinitis

The nurse identifies that which lung sound indicates the need for suctioning in a patient with an artificial airway?

Rhonchi p. 998, potter

The nurse is caring for a patient who has been immobile for a month because of quadriplegia. What risk would the nurse be prepared for?

Risk of developing atelectasis Risk of developing hypostatic pneumonia Risk of ineffective coughing

Patient risk factrs for STI's

Risky behaviors including substance use, low rates of condom use and multiple partners

Role strain vs role conflict

Role strain - when you can't carry out all obligations of a status, tensions within one status. Causes individual to be pulled many directions by one status Role conflict- one role interferes with another; conflict/tension between two or more different statuses,

What reasons do nurses assess one's gait and posture?

Romberg test: balance during neuro test Posture: assess how they sit in a chair and position to determine fall risk and ROM

normal saline enema (type of cleansing enema)

Safest due to equal osmotic pressure Isotonic Volume stimulates peristalsis

where is the ileostomy placed

Sm intestines Stool is watery not formed yet

A client is receiving an intravenous (IV) push medication. If the drug infiltrates into the outer tissues, the nurse:

Stop the IV infusion and follow company policy.

ileus (paralytic ileus)

Surgery with direct manipulation of the bowel temporarily stops peristalsis. Lasts about 24 to 48 hours If pt remains inactive or is unable to eat after surgery, return of normal bowel elimination is further delayed

Which sexual disease is caused by bacteria?

Syphillis Chlamydia Gonorrhea p. 749, potter

Changes and interventions due to immobility in Metabolic system

System Changes: Decreased metabolic rate Endocrine metabolism Calcium reasbsorption Function of GI Interventions: Assess always Monitor lab work High protein High calorie diet Vit B & C supplements

Changes and interventions due to immobility in Integumentary System

System changes: Pressure injuries Interventions: Assess skin/ pressure points Reposition every 2 hrs Provide barrier cream (skincare) Hydrocolloid patches

Changes and interventions due to immobility in Elimination (bowels and urinary) System

System changes: Urinary stasis Renal calculi Infection Constipation/impaction Urinary retention Interventions: Assess for UTI and dehydration Adequate hydration High fiber diet Toileting schedule

Changes and interventions due to immobility in Respiratory system

Systemic changes: Atelectasis (lung collapse) Hypostatic pneumonia (inflammed lungs) Interventions: Assess always Coughing and deep breathing Incentive spirometer (cough before breathing in) Assist in mobilizing secretions

Changes and interventions due to immobility in Musculoskeletal system

Systemic changes: Muscle effects Muscular atrophy/weakness Interventions: Assess motility Provide passive ROM Encourage active ROM Identify fall risks

Changes and interventions due to immobility in Cardiovascular system

Systemic changes: Orthostatic hypotension Increased cardiac workload Thrombus formation Interventions: Assess for VTE Assess for DVT progress from bed to chair ambulation SCD's TED hose leg exercises

end colostomy

Temporary or permanent. Stoma at proximal end of bowel. Distal end is either removed (permanent) or sewn closed in abdominal cavity (temporary). Rectum either removed or left intake

Esophagus

The bolus of food travels down the esophagus with the aid of peristalsis Prevents air from entering the esophagus Prevents food from refluxing into the throat

Expressive aphasia (Broca's)

The inability to produce language ( despite being able to understand language)

When addressing orthopnea with a patient, which topic would the nurse discuss?

The need to sleep in a recliner chair to breathe easier Orthopnea is an abnormal condition -pts use multiple pillows when reclining or sits forward with arms elevated to breathe easier p. 982, potter

Which characteristic of the skin and surrounding tissues of the sacral area help the nurse to classify a wound as a stage 1 pressure injury?

The skin is warm and edematous The area is cooler than the adjacent tissue localized, unglanceable erythema is present

For which reason would the water seal chamber of a chest tube have continuous bubbling during both inspiration and expiration?

There is a leak in the system p. 1032, potter

Which statement is true regarding oxygen concentrations that are used for home oxygen delivery?

They require electricity to work - do not have to be resupplied - cheaper than liquid oxygen p. 1034, potter

loop colostomy

This is temporary in the transverse colon or ileum Two openings: Proximal ends fecal effluent Distal drains mucus

Which risk is associated with bulk-forming enema?

This type of enema is not recommended in patient with large fluids intake that is contraindicated p. 1295, potter

Why does a nurse place a patient with a chest tube in a high Fowler position?

To promote drainage promotes drainage of fluids from the chest from conditions like hemothorax, and emphysema. P. 1032, potter

True or False Digestion begins in the mouth ?

True

Common (MDROs) Multi-drug resistance organisms such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), and C. difficile cause of colonization and HAI. True or False:

True! Use Contact Precautions in addition to Standard Precautions when caring for patients with MDROs. • Use thorough hand hygiene before entering and leaving the room of a patient in isolation.

What is an allergic reaction?

Unpredictable response to meds (an exaggerated immune response)

What stage of a pressure injury has black wound tissue?

Unstageable pressure injury Black tissue is known as Escher. It obscures the depth of the wound therefore Unstageable. p. 1322

Which oxygen system is a high flow delivery device?

Venturi mask delivers 24 to 50% fraction of inspired oxygen (FiO2)

Which nutrient is an antioxidant that promotes wound healing?

Vitamin C

Which type of physical sign is often seen in adult victims of sexual abuse?

Vomiting or abdominal tenderness p. 747, potter

While performing hygiene, which nursing action reduces skin inflammation and promotes circulation?

Washing the feet in warm water p. 962-965, potter

role ambiguity

When role expectations are not clearly understood. Makes people stressed and confused Common in adolescents and employment situations

CT scan (virtual colonoscopy)

X ray, many angles under scanner Oral contract drink w/ test bowel prep

HPV (human papilloma virus)

a group of viruses that can cause genital warts in males and females and can cause cervical cancer in females Asymptomatic Vaccines available to young adolescents (11 or 12 yrs old)

sexual orientation

a person's sexual identity in relation to the gender to which they are attracted; the fact of being heterosexual, homosexual, or bisexual.

The colon has three functions:

absorption, secretion, and elimination -Rebsorbs Lrg volume of H20 (up to 1.5L) and sodium and chloride

complete bed bath

bath administered to totally dependent patient in bed

hormonal contraceptives

birth control pill, depo injection, subdermal skin patches, IUD's, Implants, rings Does not prevent STI's

HIV

bloodborne pathogen present in most body fluids of infected individuals Primary route: Contaminated IV needles, anal and or vaginal intercourse, oral-genital sex, and transfusion of blood/ blood products

barrier contraceptive methods

condoms, diaphragm, cervical cap Prevents STI's and pregnancy (not 100% though!)

soapsuds enema (Type of cleansing enema)

creates intestinal irritation to stimulate peristalsis, only pure castile soap is safe Do not use on pregnant women or older adults. Causes electrolyte imbalance and damage to intensional mucosa

sensory deficit

deficit in the normal function of sensory reception and perception

dysphagia

difficulty swallowing

small intestine function

digestion and absorption

STI's that are curable

gonorrhea, chlamydia, syphillis and pelvic inflammatory disease are caused by bacteria and are usually curable with antibiotics

role overload

having more work to accomplish than time permits Ex: "Sandwich generation": trying to care for older family member and own family and maintain a career

Primary intention wound healing

healing of a wound across a surgically closed incision Ex. Hematoma

aphasia

inability to speak, interpret, or understand language Ex. Stoke, TBI

global aphasia

inability to understand language or communicate orally

sensory/receptive aphasia

inability to understand written or spoken language

oil retention enema

lubricate the stool and intestinal mucosa, easing defecation (making it softer due to oil absorption) given in small amts

anorectal manometry

measures the pressure activity of internal and external and sphincters and reflexes during rectal distention, relaxation during straining, and rectal sensation X-ray No Prep

Who falls under having an integrity versus despair self concept developmental task?

mid late 60's to death Feels positive about life and its meaning interested in providing a legacy for the next generation

sigmoid colostomy

more formed stool temporary frequent liquid stools

Dehiscence

partial or total separation of wound layers

cleansing enema

promote the complete evacuation of feces from the colon

Evisceration

protrusion of viscera through an incision

carminative enema

provide relief from gaseous distention

hypertonic solution enema (type of cleansing enema)

pulls fluid out of interstitial space. The colon fills with fluid and the resultant distention promotes defecation. Patients unable to tolerate large volumes of fluid benefit most from this type of enema. These enemas are contraindicated for dehydrated patients and young infants. Fleet enema (120 to 180 ml) is the most commonly used of this type of enema.

gender roles

sets of behavioral norms assumed to accompany one's status as male or female

Medicated enema (Kayexalate)

solution with drugs to reduce bacteria or remove potassium

Barium swallow test

specialized x-ray: fluoroscopic procedure (x ray film using opaque) that demonstrates the patient's ability to swallow. Pt contrast medium visualization of structures of lower GI; check motility Clear liquid diet, laxative day before

Large intestine Cecum

stool least formed

hemorrhoids

swollen, twisted, varicose veins in the rectal region

What is a bowel diversion?

temporary or permanent artificial opening in the abdominal wall

sexual identity

the recognition, or internalization, of a biological sex category

What is pharmacokinetics?

the study of drug movement throughout the body -It starts with how the med enters the body -Reach their site of action -Metabolize -Exit body Use for timing of medication Selecting route of administration Evaluating pts response to med

antegrade continence enema (ACE)

the surgeon creates a continence valve with an opening on to the abdomen in the intestine so the patient or caregiver can insert a tube and give himself or herself an enema that comes out through the anus. Uses' s child's appendix or Cecum to create valve

What is adverse effects?

undesired, unintended, and often unpredictable responses to medication Immediate or develop over time Priority intervention: Stop giving meds immediately if intolerable

secondary intention wound healing

when a wound is allowed to remain open and heal by granulation, epithelialization, and contraction - used for dirty wounds, o/w abscess can form

Tertiary intention wound healing

when a wound is allowed to remain open for a time and then closed, allowing for debridement and other wound care - to reduce bacterial counts prior to closure

What improves oxygenation in patients with COPD?

• Respiratory muscle training • Pursed breathing • Deep breathing and coughing (every 2 hrs) • Diaphragmatic breathing • Home oxygen therapy • Oxygen via nasal cannula: 2 to 4L of oxygen flow OR Venturi Mask • Okay for SPO2% to be 88-92 % (normal for COPD pts) Not good: Higher O2 results in hypoventilation

Common meds taken for constipation

• Stool softners laxatives • cathartics -stronger, rapid • Suppository • enemas