exam 3

9. Which action indicates the nurse is meeting a primary goal of cultural competent care for patients? a. Provides care to transgender patients b. Provides care to restore relationships c. Provides care to patients that is individualized d. Provides care to surgical patients

ANS: A Although cultural competence and patient-centered care both aim to improve health care quality, their focus is slightly different. The primary aim of cultural competence care is to reduce health disparities and increase health equity and fairness by concentrating on people of color and other marginalized groups, like transgender patients. Patient-centered care, rather than cultural competence care, provides individualized care and restores an emphasis on personal relationships; it aims to elevate quality for all patients.

18. A nurse is assessing the patient's meaning of illness. Which area of focus by the nurse is priority? a. On the way a patient reacts to disease b. On the malfunctioning of biological processes c. On the malfunctioning of psychological processes d. On the way a patient reacts to family/social interactions

ANS: A To provide culturally congruent care, you need to understand the difference between disease and illness. Illness is the way that individuals and families react to disease, whereas disease is a malfunctioning of biological or psychological processes. The way a patient interacts to family/social interactions is communication processes and family dynamics.

5. A patient has an order to receive 12.5 mg of hydrochlorothiazide. The nurse has on hand a 25 mg tablet of hydrochlorothiazide. How many tablet(s) will the nurse administer? a. 1/2 tablet b. 1 tablet c. 1 1/2 tablets d. 2 tablets

ANS: A 1/2 tablet will be given. The nurse is careful to perform nursing calculations to ensure proper medication administration. The dose ordered is 12.5. The dose on hand is 25. 12.5/25 = 1/2 tablet.

12. The nurse is planning to administer a tuberculin test with a 27-gauge, -inch needle. At which angle will the nurse insert the needle? a. 15 degree b. 30 degree c. 45 degree d. 90 degree

ANS: A A 27-gauge, -inch needle is used for intradermal injections such as a tuberculin test, which should be inserted at a 5- to 15-degree angle, just under the dermis of the skin. Placing the needle at 30 degrees, 45 degrees, or 90 degrees will place the medication too deep.

18. While preparing medications, the nurse knows one of the drug is an acidic medication. In which area does the nurse anticipate the drug will be absorbed? a. Stomach b. Mouth c. Small intestine d. Large intestine

ANS: A Acidic medications pass through the gastric mucosa rapidly. Medications that are basic are not absorbed before reaching the small intestine.

19. The nurse administers a central nervous system stimulant to a patient. Which assessment finding indicates to the nurse that an idiosyncratic event is occurring? a. Falls asleep during daily activities b. Presents with a pruritic rash c. Develops restlessness d. Experiences alertness

ANS: A An idiosyncratic event is a reaction opposite to what the effects of the medication normally are, or the patient overreacts or underreacts to the medication. Falls asleep is an opposite effect of what a central nervous system stimulant should do. A stimulant should make a patient restless and alert. A pruritic (itch) rash could indicate an allergic reaction.

6. A nurse is caring for a 35-year-old female patient who recently started taking antidepressants after repeated attempts at fertility treatment. The patient tells the nurse, "I feel happier, but my sex driveis gone." Which nursing diagnosis has the highest priority? a. Sexual dysfunction b. Ineffective coping c. Risk for self-directed violence d. Deficient knowledge about contraception

ANS: A Antidepressants have adverse effects on sexual desire and response. The nurse should be sure to educate the patient on the potential for these side effects and how to correct for them, for example, using lubricant to ease discomfort. The patient has taken steps toward effective coping by seeking therapy. The patient has not expressed a reason for the nurse to be concerned about contraceptives. The nurse should always assess for concerns about violence in a patient's life. Although some antidepressants have been related to self-directed violence, this patient focus is on becoming pregnant (fertility treatments) but sex drive is gone.

25. The nurse prepares a pain injection for a patient but had to check on another patient and asks a new nurse to give the medication. Which action by the new nurse is best? a. Do not give the medication. b. Administer the medication just this once. c. Give the medication for any pain score greater than 8. d. Avoid the issue and pretend to not hear the request.

ANS: A Because the nurse who administers the medication is responsible for any errors related to it, nurses administer only the medications they prepare. You cannot delegate preparation of medication to another person and then administer the medication to the patient. The right medication cannot be verified by the new nurse; do not violate the six rights. Do not administer the medication even one time. Do not administer the medication regardless of the pain rating. Avoiding the issue is not appropriate or safe.

23. A nurse teaches the patient about the prescribed buccal medication. Which statement by the patient indicates teaching by the nurse issuccessful? a. "I should let the medication dissolve completely." b. "I will place the medication in the same location." c. "I can only drink water, not juice, with this medication." d. "I better chew my medication first for faster distribution."

ANS: A Buccal medications should be placed in the side of the cheek and allowed to dissolve completely. Buccal medications act with the patient's saliva and mucosa. The patient should not chew or swallow the medication or take any liquids with it. The patient should rotate sides of the cheek to avoid irritating the mucosal lining

3. A 2-year-old child is ordered to have eardrops daily. Which action will the nursetake? a. Pull the auricle down and back to straighten the ear canal. b. Pull the auricle upward and outward to straighten the ear canal. c. Sit the child up for 2 to 3 minutes after instilling drops in ear canal. d. Sit the child up to insert the cotton ball into the innermost ear canal.

ANS: A Children up to 3 years of age should have the auricle pulled down and back, children 3 years of age to adults should have the auricle pulled upward and outward. Solution should be instilled 1 cm (1/2 in) above the opening of the ear canal. The patient should remain in the side-lying position 2 to 3 minutes. If a cotton ball is needed, place it into the outermost part of the ear cana

8. A patient who has had several sexual partners in the past month expresses a desire to use a contraceptive. Which contraceptive method should the nurse recommend? a. Condom b. Diaphragm c. Spermicide d. Oral contraceptive

ANS: A Condoms are both a contraceptive and a barrier against STIs and HIV; proper use will greatly reduce the risk. Spermicides, diaphragms, and oral contraceptives all protect against pregnancy; however, they are not a barrier and do not prevent bodily fluids from coming in contact with the patient during sexual intercourse.

21. A patient needs assistance in eliminating an anesthetic gaseous medication (nitrous oxide).Which action will the nurse take? a. Encourage the patient to cough and deep-breathe. b. Suction the patient's respiratory secretions. c. Suggest voiding every 2 hours. d. Increase fluid intake

ANS: A Gaseous and volatile medications are excreted through gas exchange (lungs). Deep breathing and coughing will assist in clearing the medication more quickly. It is a gaseous medication and cannot be suctioned out of the lungs. It is not excreted through the kidneys so fluids and voiding will not help.

44. A nurse is preparing to administer an antibiotic medication at 1000 to a patient but gets busyin another room. When should the nurse give the antibioticmedication? a. By 1030 b. By 1100 c. By 1130 d. By 1200

ANS: A Give time-critical scheduled medications (e.g., antibiotics, anticoagulants, insulin, anticonvulsants, and immunosuppressive agents) at the exact time ordered (within 30 minutes before or after scheduled dose). Give non-time critical scheduled medications within a range of either 1 or 2 hours of scheduled dose. 1100, 1130, and 1200 are too late.

12. The nurse is caring for an older adult patient who has no apparent family. When questionedabout family and the definition of family, the patient states, "I have no family. They're all gone." When asked, "Who prepares your meals?" the patient states, "I do, or I go out." Which approach should the nurse use for this patient? a. Family as context b. Family as patient c. Family as system d. Family as caregiver

ANS: A If only one family member receives nursing care, it is realistic and practical to use the approach "family as context." Although family nursing is based on the assumption that all people regardless of age are a member of some type of family form, the patient insists that there is no family. The nurse should investigate further. However, at this time, family as patient or as system is not appropriate. Family as caregiver is not an approach but rather is a term to describe a family member caring for another family member.

45. The nurse is administering medications to several patients. Which action should the nursetake? a. Advise a patient after a corticosteroid inhaler treatment to rinse mouth with water. b. Administer an intravenous medication through tubing that is infusing blood. c. Pinch up the deltoid muscle of an adult patient receiving a vaccination. d. Aspirate before administering a subcutaneous injection in the abdomen

ANS: A If the patient uses a corticosteroid, have him or her rinse the mouth out with water or salt water or brush teeth after inhalation to reduce risk of fungal infection. Piercing a blood vessel during a subcutaneous injection is very rare. Therefore, aspiration is not necessary when administering subcutaneous injections. When giving immunizations to adults: to avoid injection into subcutaneous tissue, spread the skin of the selected vaccine administration site taut between the thumb and forefinger, isolating the muscle. Never administer IV medications through tubing that is infusing blood, blood products, or parenteral nutrition solutions

20. An order is written for phenytoin 500 mg IM q3-4h prn for pain. The nurse recognizes that treatment of pain is not a standard therapeutic indication for this drug. The nurse believes thatthe health care provider meant to write hydromorphone. What should the nurse do? a. Call the health care provider to clarify the order. b. Give the patient hydromorphone, as it was meant to be written. c. Administer the medication and monitor the patient frequently. d. Refuse to give the medication and notify the nurse supervisor.

ANS: A If there is any question about a medication order because it is incomplete, illegible, vague, or not understood, contact the health care provider before administering the medication. The nurse cannot change the order without the prescriber's consent; this is out of the nurse's scope of practice. Ultimately, the nurse can be held responsible for administering an incorrect medication. If the prescriber is unwilling to change the order and does not justify the order in a reasonable and evidence-based manner, the nurse may refuse to give the medication and notify the supervisor

24. What is the nurse's priority action to protect a patient from medication error? a. Reading medication labels at least 3 times before administering b. Administering as many of the medications as possible at one time c. Asking anxious family members to leave the room before giving a medication d. Checking the patient's room number against the medication administration record

ANS: A One step to take to prevent medication errors is to read labels at least 3 times before administering the medication. The nurse should address the family's concerns about medications before administering them. Do not discount their anxieties. The medication administration record should be checked against the patient's hospital identification band; a room number is not an acceptable identifier. Medications should be given when scheduled, and medications with special assessment indications should be separated. Giving medications at one time can cause the patient to aspirate.

28. A patient who is being discharged today is going home with an inhaler. The patient is to administer 2 puffs of the inhaler twice daily. The inhaler contains 200 puffs. When should thenurse appropriately advise the patient to refill themedication? a. 6 weeks from the start of using the inhaler b. As soon as the patient leaves the hospital c. When the inhaler is half empty. d. 50 days after discharge

ANS: A Six weeks will be about the time the inhaler will need to be refilled. The inhaler should last the patient 50 days (2 puffs× 2/twice daily = 4; 200/4 = 50); the nurse should advise the patient to refill the prescription when there are 7 to 10 days of medication remaining. Refilling it as soon as the patient leaves the hospital or when the inhaler is half empty is too early. If the patient waits 50 days, the patient will run out of medication before it can be refilled.

1. A nurse is caring for a 15-year-old who in the past 6 months has had multiple male and female sexual partners. Which response by the nurse will be most effective? a. "Sexually transmitted infections and unwanted pregnancy are a real risk. Let's discuss what you think is t method for protecting yourself." b. "Having sexual interaction with both males and females places you at higher risk for STIs. To protect you you need to decide which orientation you are." c. "Your current friends are leading you to make poor choices. You should find new friends to hang out wit d. "I think it's best to notify your parents. They know what's best for you and can help make sure you practi sex."

ANS: A Some adolescents participate in risky behaviors. The nurse should acknowledge this feeling to the patient and offer education and alternatives, while giving the patient the autonomy to make his or her own decisions. Adolescents who engage in sexual risk behaviors experience negative health outcomes such as STIs and unintended pregnancy. In addition, the pattern of risk-taking behavior tends to be established and continue throughout life. The nurse should not force the patient to make a choice of orientation and should not pass judgment on a patient's sexual orientation or social network; this would make the patient feel defensive and would eliminate the trust in the relationship. Involving parents is not the first line of action; parents should be notified only if the child is in a life or death situation.

22. A nurse has withdrawn a narcotic from the medication dispenser and must waste a portion of the medication. What should the nurse do? a. Have another nurse witness the wasted medication. b. Return the wasted medication to the medication dispenser. c. Place the wasted portion of the medication in the sharps container. d. Exit the medication room to call the health care provider to request an order that matches the dosages.

ANS: A The nurse should follow Nurse Practice Acts and safe narcotic administration guidelines by having a nurse witness the "wasted" medication. The nurse cannot return the wasted medication to the medication dispenser. Wasted portions of medications are not placed in sharps containers. The nurse should not leave the narcotic unattended and call the health care provider to obtain matching dosages; the nurse is expected to obtain the correct dose

12. A nurse is designing a form for lesbian, gay, bisexual, and transgender (LGBT) patients. Which design should the nurse use? a. Use partnered rather than married. b. Use mother rather than father. c. Use parents rather than guardian. d. Use wife/husband rather than significant other

ANS: A Include LGBT-inclusive language on forms and assessments to facilitate disclosure, knowing that disclosure is a choice impacted by many factors. For example, provide options such as "partnered" under relationship status. For parents, use parent/guardian, instead of mother/father. Use neutral and inclusive language when talking with patients (e.g., partner or significant other), listening and reflecting patient's choice. Remember that some LGBT patients are also legally married

34. A nurse is caring for a patient who is receiving pain medication through a saline lock. After obtaining a good blood return when the nurse is flushing the patient's peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm and tender to the touch. What is the nurse's initial action? a. Do not administer the pain medication. b. Administer the pain medication slowly. c. Apply a warm compress to the site. d. Apply a cool compress to the site.

ANS: A The patient has phlebitis; the initial nursing action is do not administer the medication. The medication should not be given slowly. A cool or warm compress may be used later depending upon protocol, but it is not the first action.

13. The nurse closely monitors an older adult for signs of medication toxicity. Which physiological change is the reason for the nurse's action? a. Reduced glomerular filtration b. Reduced esophageal stricture c. Increased gastric motility d. Increased liver mass

ANS: A The reduced glomerular filtration rate delays excretion, increasing chance for toxicity. In older adults, gastric motility and liver mass decrease. Esophageal stricture is not a physiological change associated with normal aging.

16. A nurse is interviewing a woman who uses a diaphragm. Which information from the patient will require the nurse to follow up? a. "I have lost 12 pounds on this diet." b. "I use the diaphragm to prevent pregnancy." c. "I use a contraceptive cream with my diaphragm." d. "I know this provides a barrier over the cervical opening."

ANS: A The woman needs to be refitted after a significant change in weight (10-pound gain or loss) or pregnancy. The diaphragm is a round, rubber dome that has a flexible spring around the edge. It is used with a contraceptive cream or jelly and is inserted in the vagina so it provides a contraceptive barrier over the cervical opening.

35. The nurse is preparing to administer medications to two patients with the same last name.After the administration, the nurse realizes that did not check the identification of the patient before administering medication. Which action should the nurse complete first? a. Return to the room to check and assess the patient. b. Administer the antidote to the patient immediately. c. Alert the charge nurse that a medication error has occurred. d. Complete proper documentation of the medication error in the patient's chart.

ANS: A When an error occurs, the patient's safety and well-being are the top priorities. You first assess and examine the patient's condition and notify the health care provider of the incident as soon as possible. The nurse's first priority is to establish the safety of the patient by assessing the patient. Second, notify the charge nurse and the health care provider. Administer antidote if required. Finally, the nurse needs to complete proper documentation

6. A nurse is beginning to use patient-centered care and cultural competence to improve nursing care. Which step should the nurse take first? a. Assessing own biases and attitude b. Learning about the world view of others c. Understanding organizational forces d. Developing cultural skills

ANS: A Becoming more aware of your biases and attitudes about human behavior is the first step in providing patient-centered care, leading to culturally competent care. It is helpful to think about cultural competence as a lifelong process of learning about others and also about yourself. Learning about the world view, developing cultural skills, and understanding organizational forces are not the first steps.

13. A nurse is assessing population groups for the risk of suicide requiring medical attention. Which group should the nurse monitor most closely? a. Young bisexuals b. Young caucasians c. Asian Americans d. African-Americans

ANS: A Gay, lesbian, and bisexual young people have a significantly increased risk for depression, anxiety, suicide attempts, and substance use disorders, being 4 times as likely as their straight peers to make suicide attempts that require medical attention. Caucasian youth, Asian Americans, and AfricanAmericans are not as likely to attempt suicide resulting in medical attention

9. A nurse is caring for a patient from a motor vehicle accident. Which action by the unlicensed assistive personnel will cause the nurse to intervene? a. Tells the family not to leave the bedside b. Offers the family a sandwich c. Gives the family a blanket d. Sits with the family

ANS: A The action of telling the family not to leave is inappropriate and should be corrected. Sometimes telling the family that you will stay with their loved one while they are gone is all they need to feel comfortable in leaving. Offering a sandwich, giving a blanket, and sitting with the family are appropriate and do not require the nurse to intervene. When the victim of trauma is hospitalized, take time to make sure that the family is comfortable. You can bring them something to eat or drink, give them a blanket, or encourage them to get a meal.

17. A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful in the role of providing culturally congruent care? a. Provides care that fits the patient's valued life patterns and set of meanings b. Provides care that is based on meanings generated by predetermined criteria c. Provides care that makes the nurse the leader in determining what is needed d. Provides care that is the same as the values of the professional health care system

ANS: A The goal of transcultural nursing is to provide culturally congruent care, or care that fits the person's life patterns, values, and system of meaning. Patterns and meanings are generated from people themselves, rather than from predetermined criteria. Discovering patients' cultural values, beliefs, and practices as they relate to nursing and health care requires you to assume the role of learner (not become the leader) and to partner with your patients and their families to determine what is neededto provide meaningful and beneficial nursing care. Culturally congruent care is sometimes different from the values and meanings of the professional health care system.

3. A nurse is assessing the health care disparities among population groups. Which area is the nurse monitoring? a. Accessibility of health care services b. Outcomes of health conditions c. Prevalence of complications d. Incidence of diseases

ANS: A While health disparities are the differences among populations in the incidence, prevalence, and outcomes of health conditions, diseases and related complications, health care disparities are differences among populations in the availability, accessibility, and quality of health care services (e.g. screening, diagnostic, treatment, management, and rehabilitation) aimed at prevention, treatment, and management of diseases and their complications.

7. A nurse is assessing a child that lives in a car with family members who presents to the emergency department. Which area should the nurse assess closely? a. Ears b. Eyes c. Head d. Hands

ANS: A Children of homeless families are often in fair or poor health and have higher rates of asthma, ear infections, stomach problems, and mental illness. Eyes, head, and hands are not as important as the ear

1. A nurse is assessing threats concerning the family. Which areas will the nurse include in the assessment? (Select all that apply.) a. Homelessness b. Domestic violence c. Presence of illness d. Changing economic status e. Rise of homosexual families

ANS: A, B, C, D Social scientists have identified five trends as threats facing the family. These include (1) Changing economic status, (2) homelessness, (3) domestic violence, (4) the presence of acute or chronic illness or trauma, and (5) end-of-life care. Homosexual families are not a threat facing the family; in fact, many homosexual couples now define their relationship in family terms.

2. A nurse is assessing the realms of family life. Which processes will the nurse assess? (Select all that apply.) a. Developmental b. Interactive c. Integrity d. Coping e. Life

ANS: A, B, C, D The five realms of family life that should be assessed include: developmental, interactive, integrity, coping, and health, not life.

1. A nurse is using Campinha-Bacote's model of cultural competency. Which areas will the nurse focus on to become competent? (Select all that apply.) a. Cultural skills b. Cultural desire c. Cultural transition d. Cultural knowledge e. Cultural encounters

ANS: A, B, D, E Campinha-Bacote's model of cultural competency has five interrelated components: cultural awareness; cultural knowledge; cultural skills; cultural encounters; and cultural desire. Cultural transition is not a component of this model.

2. A nurse is using the RESPECT mnemonic to establish rapport, the "R" in RESPECT. Which actions should the nurse take? (Select all that apply.) a. Connect on a social level. b. Help the patient overcome barriers. c. Consciously attempt to suspend judgment. d. Stress that they will be working together to address problems. e. Know limitations in addressing medical issues across cultures.

ANS: A, C The "R" in RESPECT stands for rapport and includes the following behaviors: connect on a social level; seek the patient's point of view; and consciously attempt to suspend judgment. The "S" stands for support and includes the behavior of helping the patient overcome barriers. The "P" stands for partnership and includes the following behaviors: be flexible with regard to issues of control and stress that you will be working together to address medical problems. The "C" stands for cultural competence and includes the behavior of knowing your limitations in addressing medical issues across cultures

9. The nurse is preparing to administer an injection into the deltoid muscle of an adult patient. Which needle size and length will the nurse choose? a. 18 gauge × 1 1/2 inch b. 23 gauge × 1/2 inch c. 25 gauge × 1 inch d. 27 gauge × 5/8 inch

ANS: C For an intramuscular injection into an adult deltoid muscle, a 25-gauge, 1-inch needle is recommended. An 18-gauge needle is too big. While a 23-gauge needle can be used, a 1/2-inch needle is too small. A 27-gauge, 5/8 -inch needle is used for intradermal.

2. Which methods will the nurse use to administer an intravenous (IV) medication thatis incompatible with the patient's IV fluid? (Select all that apply.) a. Start another IV site. b. Administer slowly with the IV fluid. c. Do not give the medication and chart. d. Flush with 10 mL of sterile water before and after administration. e. Flush with 10 mL of normal saline before and after administration.

ANS: A, D, E When IV medication is incompatible with IV fluids, stop the IV fluids, clamp the IV line above the injection site, flush with 10 mL of normal saline or sterile water, give the IV bolus over the appropriate amount of time, flush with another 10 mL of normal saline or sterile water at the same rate as the medication was administered, and restart the IV fluids at the prescribed rate. Do not administer the drug slowly with the IV; this is contraindicated when incompatibility exist. Not giving the medication and charting is inappropriate; this is not a prudent or safe action by the nurs

7. A nurse is performing a cultural assessment using the ETHNIC mnemonic for communication. Which area will the nurse assess for the "H"? a. Health b. Healers c. History d. Homeland

ANS: B The "H" in ETHNIC stands for healers: Has the patient sought advice from alternative health practitioners? While health, history, and homeland are important, they are not components of "H."

11. A nurse is using core measures to reduce health disparities. Which group should the nurse focus on to cause the most improvement in core measures? a. Caucasians b. Poor people c. Alaska Natives d. American Indians

ANS: B To improve results, the nurse should focus on the highest disparity. Poor people received worse care than high-income people for about 60% of core measures. American Indians and Alaska Natives received worse care than Caucasians for about 30% of core measures.

7. A patient is receiving vancomycin. Which function is the priority for the nurses to assess? a. Vision b. Hearing c. Heart tones d. Bowel sounds

ANS: B A side effect of vancomycin is ototoxicity—hearing. It does not affect vision, heart tones, or bowel sounds.

31. Which patient using an inhaler would benefit most from using a spacer? a. A 15 year old with a repaired cleft palate who is alert b. A 25 year old with limited coordination of the extremities c. A 50 year old with hearing impairment who uses a hearing aid d. A 72 year old with left-sided hemiparesis using a dry powder inhaler

ANS: B A spacer is indicated for a patient who has difficulty coordinating the steps, like patients with limited mobility/coordination. An alert adolescent with a repaired cleft palate would not need a spacer. Hearing impairment may make teaching the patient to use the inhaler difficult, but it does not indicate the need for a spacer. Although a patient with left-sided hemiparesis could have coordination problems, a patient using a dry powder inhaler does not require the use of spacers.

10. A nurse is preparing a community class about sexually transmitted infections. Which primary group will the nurse focus on for this class? a. Bisexual women b. Men who have sex with men c. Youths between the ages of 24 and 27 d. Pregnant women and their partners

ANS: B About 20 million people in the United States are diagnosed with an STI each year, with the highest incidence occurring in men who have sex with men, bisexual men, and youths between the ages of 15 and 24. While bisexual women, youths between the ages of 24 and 27, and pregnant women and their partners are important, they are not the primary groups affected by STI

3. Which patient is most in need of a nurse's referral to adoption services? a. A woman considering abortion for an unwanted pregnancy b. An infertile couple religiously opposed to artificial insemination c. A woman who suffered miscarriage during her first pregnancy d. An infertile couple who has been attempting conception for 3 months

ANS: B Adoption is an option for someone with infertility, especially if infertility treatments are unavailable owing to religious or financial constraints. A patient who wishes to have an elective abortion may be educated about all the possibilities, but the nurse should approach the patient in a nonjudgmental manner and should accept the patient's decision. When a patient has recently miscarried, the nurse should assess the patient's feelings about the loss and should address any concerns the patient may have about fertility. Infertility is the inability to conceive after 1 year of unprotected intercourse; therefore, talking about adoption after one miscarriage or after only 3 months of attempting conception would be too soon

26. A patient is at risk for aspiration. Which nursing action is most appropriate? a. Give the patient a straw to control the flow of liquids. b. Have the patient self-administer the medication. c. Thin out liquids so they are easier to swallow. d. Turn the head toward the stronger side.

ANS: B Aspiration occurs when food, fluid, or medication intended for GI administration inadvertently enters the respiratory tract. To minimize aspiration risk, allow the patient, if capable, to self-administer medication. Patients should also hold their own cup to control how quickly they take in fluid. Some patients at risk for aspiration may require thickened liquids; thinning liquids does not decrease aspiration risk. Patients at risk for aspiration should not be given straws because use of a straw decreases the control the patient has over volume intake. Turning the head toward the weaker side helps the medication move down the stronger side of the esophagus.

43. A nurse is performing the three accuracy checks before administering an oral liquid medication to a patient. When will the nurse perform the second accuracy check? a. At the patient's bedside b. Before going to the patient's room c. When checking the medication order d. When selecting medication from the unit-dose drawer

ANS: B Before going to the patient's room, compare the patient's name and name of medication on the label of prepared drugs with MAR for the second accuracy check. Selecting the correct medication from the stock supply, unit-dose drawer, or automated dispensing system (ADS) is the first check. The third accuracy check is comparing names of medications on labels with MAR at the patient's bedside. Checking the orders is not one of the three accuracy checks but should be done if there is any confusion about an order.

11. The nurse is leading a seminar about menopause and age-related changes. Which response from a group member indicates the nurse needs to follow up? a. "Hormones of sexual regulation decrease with aging." b. "Orgasms are no longer achievable after menopause." c. "The excitement phase is prolonged as we age." d. "As men age, their erection may be less firm."

ANS: B Believing that orgasms are no long achievable requires follow-up to correct this misconception. Orgasms are achievable at any age; however, it may take longer with aging. All other statements indicate that the patient does have an understanding of age-related changes and needs no follow-up. Both genders experience a reduced availability of sex hormones. The excitement phase prolongs in both men and women. Men often have erections that are less firm and shorter acting.

11. The nurse is giving an IM injection. Upon aspiration, the nurse notices blood return in the syringe. What should the nurse do? a. Administer the injection at a slower rate. b. Withdraw the needle and prepare the injection again. c. Pull the needle back slightly and inject the medication. d. Give the injection and hold pressure over the site for 3 minutes.

ANS: B Blood return upon aspiration indicates improper placement, and the injection should not be given. Instead withdraw the needle, dispose of the syringe and needle properly, and prepare the medication again. Administering the medication into a blood vessel could have dangerous adverse effects, and the medication will be absorbed faster than intended owing to increased blood flow. Holdingpressure is not an appropriate intervention. Pulling back the needle slightly does not guarantee proper placement of the needle and medication administration.

39. A nurse is attempting to administer an oral medication to a child, but the child refuses to take the medication. A parent is in the room. Which statement by the nurse to the parent is best? a. "Please hold your child's arms down, so I can give the full dose." b. "I will prepare the medication for you and observe if you would like to try to administer the medication." c. "Let's turn the lights off and give your child a moment to fall asleep before administering the medication d. "Since your child loves applesauce, let's add the medication to it, so your child doesn't resist."

ANS: B Children often have difficulties taking medication, but it can be less traumatic for the child if the parent administers the medication and the nurse supervises. Another nurse should help restrain a child if needed; the parent acts as a comforter, not a restrainer. Holding down the child is not thebest option because it may further upset the child. Never administer an oral medication to a sleeping child. Don't mix medications into the child's favorite foods, because the child might start to refuse the food.

14. The nurse is providing discharge teaching for an older-adult patient who will need tube feedings at home. The spouse is the only source of care and states "I will not be able to perform thefeedings due to arthritis." Which action should the nurse take? a. Obtain extra feeding supplies. b. Arrange for home care. c. Cancel the discharge. d. Teach the spouse.

ANS: B Discharge planning with a family involves an accurate assessment of what will be needed for care at the time of discharge, along with any shortcomings in the home setting. If no one can do the feedings properly, the nurse will need to arrange for a home care service referral. Extra feeding supplies will not help the situation if the spouse cannot use them. Canceling the discharge is not an option. Teaching the spouse will not be effective since the spouse is unable to perform the feeding.

1. A nurse is teaching a patient about medications. Which statement from the patient indicates teaching is effective? a. "My parenteral medication must be taken with food." b. "I will rotate the sites in my left leg when I give my insulin." c. "Once I start feeling better, I will stop taking my antibiotic." d. "If I am 30 minutes late taking my medication, I should skip that dose."

ANS: B For daily insulin, rotate site within anatomical area. Rotating injections within the same body part (instrasite rotation) provides greater consistency in absorption of medication. Parenteral medication absorption is not affected by the timing of meals. Taking a medication 30 minutes late is within the 60-minute window of the time medications should be taken. Medications are usually stopped based on the provider's orders except in extenuating circumstances. With some medications, such as antibiotics, it is crucial that the full course of medication is taken to avoid relapse of infection.

nurse administer to be absorbed the quickest? a. Acetaminophen 650 mg PO b. Hydromorphone 4 mg IV c. Ketorolac 8 mg IM d. Morphine 6 mg SQ

ANS: B IV is the fastest route for absorption owing to the increase in blood flow. The richer the blood supply to the site of administration, the faster a medication is absorbed. Medications administered intravenously enter the bloodstream and act immediately, whereas those given in other routes take time to enter the bloodstream and have an effect. Oral, subcutaneous (SQ), and intramuscular (IM) are others ways to deliver medication but with less blood flow, slowing absorption.

9. A woman who has been in a monogamous relationship for the past 6 months presents to clinicwith herpes on her labia. The patient is distraught because her partner must have cheated on her.Which response by the nurse is mosteffective in establishing an open rapport with apatient? a. Share a story. b. Inform the patient that all encounters are confidential. c. Encourage the patient to break up with her partner for cheating. d. Tell the patient that she must be honest about every sexual experience she has had

ANS: B If open communication is to be established with the patient, the patient must know that she can trust health care team members. By telling the patient that all encounters are confidential, the nurse establishes trust. Sharing a story brings the focus to the nurse, inhibiting open rapport. The nurse does not tell the patient what to do, because that should be the patient's decision. Forcing the patient to confide by sharing every sexual encounter may hinder a trusting relationship.

42. A nurse is administering oral medications to patients. Which action will the nurse take? a. Remove the medication from the wrapper, and place it in a cup labeled with the patient's information. b. Place all of the patient's medications in the same cup, except medications with assessments. c. Crush enteric-coated medication, and place it in a medication cup with water. d. Measure liquid medication by bringing liquid medication cup to eye level

ANS: B Placing medications that require preadministration assessment in a separate cup serves as a reminder to check before the medication is given, making it easier for the nurse to withhold medication if necessary. Medications should not be removed from their package until they are in the patient's room because this makes identification of the pill easier and reduces contamination. When measuring a liquid, the nurse should use the meniscus level to measure; make sure it is at eye level on a hard surface like a countertop. Enteric coated medications should not be crushed.

13. A mother brings her 12-year-old daughter into a clinic and inquires about getting a human papillomavirus (HPV) vaccine that day. Which information will the nurse share with the motherand daughter about the HPV vaccine? a. Protects against human immunodeficiency virus (HIV) b. Protects against cervical cancer c. Protects against chlamydia d. Protects against pregnancy

ANS: B The HPV vaccine is effective against the four most common types of HPVs that can cause cervical cancer. It is not effective against HIV, chlamydia, or pregnancy.

2. A nurse is caring for a patient who expresses a desire to have an elective abortion. The nurse's religious and ethical values are strongly opposed. How should the nurse best handle the situation? a. Attempt to educate the patient about the consequences of abortion. b. Refer the patient to a family planning center or another health professional. c. Continue to care for the patient, and limit conversation as much as possible. d. Inform the patient that, because of immoral issues, another nurse will have to care for her.

ANS: B The nurse must be aware of personal beliefs and values and is not required to participate in counseling or procedures that compromise those values. However, the patient is entitled to nonjudgmental care and should be referred to someone who can create a trusting environment. The nurse should not care for a patient if the quality of care could be jeopardized. The nurse should not attempt to push personal values onto a patient. The nurse also should not create tension by informing the patient that he or she does not have the same morals; this could cause the patient to feel guilty or defensive when receiving care from any health care professional.

36. The nurse is caring for two patients with the same last name. In this situation which right of medication administration is the priority to reduce the chance of an error? a. Right medication b. Right patient c. Right dose d. Right route

ANS: B The nurse should ask the patient to verify identity and should check the patient's ID bracelet against the medication record to ensure right patient. Acceptable patient identifiers include the patient's name, an identification number assigned by a health care facility, or a telephone number. Do not use the patient's room number as an identifier. To identify a patient correctly in an acute care setting, compare the patient identifiers on the MAR with the patient's identification bracelet while at the patient's bedside. Right medication, right dose, and right route are equally as important, but in this situation, right patient is the priority (two patients with the same last name).

37. A patient prefers not to take the daily allergy pill this morning because it causes drowsiness throughout the day. Which response by the nurse is best? a. "The physician ordered it; therefore, you must take your medication every morning at the same time whe you're drowsy or not." b. "Let's see if we can change the time you take your pill to 9 PM, so the drowsiness occurs when you woul normally be sleeping." c. "You can skip this medication on days when you need to be awake and alert." d. "Try to get as much done as you can before you take your pill, so you can sleep in the afternoon."

ANS: B The nurse should use knowledge about the medication to educate the patient about potential response to medications. Then the medication schedule can be altered based on that knowledge. It is the patient's right to refuse medication; however, the nurse should educate the patient on the importance and effects of the medication. Asking a patient to fit a schedule around a medication is unreasonable and will decrease compliance. The nurse should be supportive and should offer solutions to manage medication effects.

8. A health care provider orders lorazepam (Ativan) 1 mg orally 2 times a day. The dose available is 0.5 mg per tablet. How many tablet(s) will the nurse administer for each dose? a. 1 b. 2 c. 3 d. 4

ANS: B The nurse will give 2 tablets. It will take 2 tablets (0.5) to equal 1 mg OR ordered dose (1) over dose on hand (0.5). 1/0.5 = 2 tablets.

14. A parent asks about the human papillomavirus (HPV) vaccine. Which information will the nurse include in the teaching session? a. It is recommended for girls 6 to 9 years old. b. It is recommended for females ages 11 to 26. c. It is recommended that booster injections be given. d. It is recommended to receive four required injections.

ANS: B The vaccine is safe for girls as young as 9 years old and is recommended for females ages 11 to 26 if they have not already completed the three required injections. Booster doses currently are not recommended. The vaccine is most effective if administered before sexual activity or exposure.

6. The patient is to receive phenytoin (Dilantin) at 0900. When will be the ideal time for the nurse to schedule a trough level? a. 0800 b. 0830 c. 0900 d. 0930

ANS: B Trough levels are generally drawn 30 minutes before the drug is administered. If the medication is administered at 0900, the trough should be drawn at 0830

10. A nurse is using the family as context approach to provide care to a patient. What should the nurse do next? a. Assess family patterns versus individual characteristics. b. Assess how much the family provides the patient's basic needs. c. Use "family as patient" and "family as context" approaches simultaneously. d. Plan care to meet not only the patient's needs but those of the family as well

ANS: B When the nurse views the family as context, the primary focus is on the health and development of an individual member existing within a specific environment (i.e., the patient's family). Although the focus is on the individual's health status, the nurse assesses how much the family provides the individual's basic needs. Family patterns are in the realm of "family as patient" approach. Often, the nurse will use the two simultaneously (family as context and family as patient) with the approach of "family as system." "Family as patient" involves planning to meet the needs of the patient and those of the family as well.

15. A nurse is teaching patients about health care information. Which patient will the nurse assess closely for health literacy? a. A patient 35 years old b. A patient 68 years old c. A patient with a college degree d. A patient with a high-school diploma

ANS: B About 9 out of 10 people in the United States experience challenges in using health care information. Patients who are especially vulnerable are the elderly (age 65+), immigrants, persons with low incomes, persons who do not have a high-school diploma or GED, and persons with chronic mental and/or physical health conditions. A 35-year-old patient and patients with high-school and college education are not identified in the vulnerable populations.

14. A nurse is assessing a patient's ethno history. Which question should the nurse ask? a. What language do you speak at home? b. How different is your life here from back home? c. Which caregivers do you seek when you are sick? d. How different is what we do from what your family does when you are sick?

ANS: B An ethnohistory question is the following: How different is your life here from back home? Caring beliefs and practice questions include the following: Which caregivers do you seek when you are sick and How different is what we do from what your family does when you are sick? The language and communication is the following: What language do you speak at home?

4. A nurse is providing care to a patient from a different culture. Which action by the nurse indicates cultural competence? a. Communicates effectively in a multicultural context b. Functions effectively in a multicultural context c. Visits a foreign country d. Speaks a different language

ANS: B Cultural competence refers to a developmental process that evolves over time that impacts ability to effectively function in the multicultural context. Communicates effectively and speaking a different language indicates linguistic competence. Visiting a foreign country does not indicate cultural competence

8. The nurse is caring for a patient of Hispanic descent who speaks no English. The nurse is working with an interpreter. Which action should the nurse take? a. Use long sentences when talking. b. Look at the patient when talking. c. Use breaks in sentences when talking. d. Look at only nonverbal behaviors when talking.

ANS: B Direct your questions to the patient. Look at the patient, instead of looking at the interpreter. Pace your speech by using short sentences, but do not break your sentences. Observe the patient's nonverbal and verbal behaviors.

E 1. A nurse is assessing the family unit to determine the family's ability to adapt to the change of a member having surgery. Which area is the nurse monitoring? a. Family durability b. Family resiliency c. Family diversity d. Family forms

ANS: B Family resiliency is the ability of the family to cope with expected and unexpected stressors; it's the families' ability to adapt to changes. Family diversity is the uniqueness of each family unit. Every person within a family unit has specific needs, strengths, and important developmental considerations. Family durability is a system of support and structure within a family that extends beyond the walls of the household. Family forms are patterns of people considered by family members to be included in the family.

3. A nurse is using the explanatory model to determine the etiology of an illness. Which questions should the nurse ask? (Select all that apply.) a. How should your sickness be treated? b. What do you call your problem? c. How does this illness work inside your body? d. What do you fear most about your sickness? e. What name does it have?

ANS: B, C, E The questions for etiology include "What do you call your problem?" and "What name does it have?" Recommended treatment is asked by the question "How should your sickness be treated?" Pathophysiology is asked by the question "How does this illness work inside your body?" The course of illness is asked by the question "What do you fear most about your sickness?"

5. An 18-year-old male patient informs the nurse that he isn't sure if he is homosexual because heis attracted to both genders. Which response by the nurse will help establish a trustingrelationship? a. "Don't worry. It's just a phase you will grow out of." b. "Those are abnormal impulses. You should seek therapy." c. "At your age, it is normal to be curious about both genders." d. "Having questions about sexuality is normal but if these sexual activities make you feel bad you should s

ANS: C Adolescents have questions about sexuality. The patient will feel most comfortable discussing his sexual concerns further if the nurse establishes that it is normal to ask questions about sexuality. The nurse can then discuss in greater detail. Although it is normal for young adults to be curious about sexuality, the nurse should use caution in giving advice on taking sexual action. The nurse should promote safe sex practices. Telling the patient not to worry dismisses his concern. Telling the patient that he is abnormal might offend the patient and prevent him from establishing an open relationship

4. The nurse is caring for a patient who recently had unprotected sex with a partner who has HIV. Which response by the nurse is best? a. "You should have your blood drawn today to see if you were infected." b. "If you have the virus, you will have flu-like symptoms in 6 months." c. "Highly active antiretroviral therapy has been shown effective in slowing the disease process." d. "I will set you up with a support group to help you cope with dying within the next 10 years."

ANS: C Highly active retroviral therapy increases the survival time of a person with HIV or AIDS. HIV antibodies will not show up in blood work for 6 weeks to 3 months. The infection stage of HIV lasts for about a month after the virus is contracted; during that time, the patient may experience flu-like symptoms. A support group may be beneficial for a patient who contracts HIV; however, it is unknown whether the patient has contracted HIV, and antiretroviral therapy has helped people live beyond the 10 years expected if HIV goes untreated.

15. A patient is to receive a proton pump inhibitor through a nasogastric (NG) feeding tube. Whichis the mostimportant nursing action to ensure effective absorption? a. Thoroughly shake the medication before administering. b. Position patient in the supine position for 30 minutes to 1 hour. c. Hold feeding for at least 30 minutes after medication administration. d. Flush tube with 10 to 15 mL of water, after all medications are administered.

ANS: C If a medication needs to be given on an empty stomach or is not compatible with the feeding (e.g., phenytoin, carbamazepine [Tegretol], warfarin [Coumadin], fluoroquinolones, proton pump inhibitors), hold the feeding for at least 30 minutes before or 30 minutes after medication administration. Thoroughly shaking the medication mixes the medication before administration but does not affect absorption. Flushing the tube after all medications should be 30 to 60 mL of water; 15 to 30 mL of water is used for flushing between medications. Patients with NG tubes should never be positioned supine but instead should be positioned at least to a 30-degree angle to prevent aspiration, provided no contraindication condition is known

10. When the nurse administers an IM corticosteroid injection, the nurse aspirates. What is the rationale for the nurse aspirating? a. Prevent the patient from choking. b. Increase the force of the injection. c. Ensure proper placement of the needle. d. Reduce the discomfort of the injection.

ANS: C The purpose of aspiration is to ensure that the needle is in the muscle and not in the vascular system. Blood return upon aspiration indicates improper placement, and the injection should not be given. While a patient can aspirate fluid and food into the lungs, this is not related to the reason for why a nurse pulls back the syringe plunger after inserting the needle (aspirates) before injecting the medication. Reducing discomfort and prolonging absorption time are not reasons for aspirating medications.

15. A nursing student is providing education to a group of older adults who are in an independent living retirement village. Which statement made by the nursing student requires the nurse to intervene? a. "Avoiding alcohol use will enhance your sexual functioning." b. "You need to tell your partner how you feel about sex and any fears you may have." c. "You do not need to worry about getting a sexually transmitted infection at this point in your life." d. "Using pillows and taking pain medication if needed before having sexual intercourse often help allev

ANS: C Research indicates many older adults are more sexuality active than previously thought and engage in high-risk sexual encounters, resulting in a steady increase HIV and STI rates over the past 12 years. Therefore, the nurse needs to intervene when the student tells the older adults that they are not at risk for developing an STI. Avoiding the use of alcohol; using pillows; taking pain medications before having intercourse if needed; and communicating thoughts, fears, and feelings about sex all enhance sexual functioning.

2. A nurse is preparing to administer an injection to a patient. Which statement made by the patientis an indication for the nurse to use the Z-track method? a. "I am allergic to many medications." b. "I'm really afraid that a big needle will hurt." c. "The last shot like that turned my skin colors." d. "My legs are too obese for the needle to go through."

ANS: C The Z-track is indicated when the medication being administered has the potential to irritate sensitive tissues. It is recommended that, when administering IM injections, the Z-track method be used to minimize local skin irritation by sealing the medication in muscle tissue. The Z-track method is not meant to reduce discomfort from the procedure. If a patient is allergic to a medication, it should not be administered. If a patient has additional subcutaneous tissue to go through, a needle of a different size may be selected.

7. A nurse is using the PLISSIT model when caring for a patient with dyspareunia from diminished vaginal secretions. The nurse suggests using water-soluble lubricants. Which component ofPLISSIT is the nurse using? a. P b. LI c. SS d. IT

ANS: C The nurse is using the specific suggestions (SS). The PLISSIT model is as follows: Permission to discuss sexuality issues Limited Information related to sexual health problems being experienced Specific Suggestions—only when the nurse is clear about the problem Intensive Therapy—referral to professional with advanced training if necessary

2. A nurse reviews the current trends affecting the family. Which trend will the nursefind? a. Mothers are staying at home. b. Adolescent mothers usually live on their own. c. More grandparents are raising their grandchildren. d. Teenage fathers usually have stronger support systems

ANS: C More grandparents are raising their grandchildren. The majority of women work outside the home, and about 60% of mothers are in the workforce. The majority of adolescent mothers continue to live with their families. Teenage fathers usually have poorer support systems and fewer resources to teach them how to parent

33. The supervising nurse is observing several different nurses. Which action will cause the supervising nurse to intervene? a. A nurse administers a vaccine without aspirating. b. A nurse gives an IV medication through a 22-gauge IV needle without blood return. c. A nurse draws up the NPH insulin first when mixing a short-acting and intermediate-acting insulin. d. A nurse calls the health care provider for a patient with nasogastric suction and orders for oral meds.

ANS: C The supervising nurse must intervene with the nurse who is drawing up the NPH insulin first; if regular and intermediate-acting (NPH) insulin is ordered, prepare the regular insulin first to prevent the regular insulin from becoming contaminated with the intermediate-acting insulin. All the other actions are appropriate and do not need follow-up. The CDC no longer recommends aspiration when administering immunizations to reduce discomfort. In some cases, especially with a smaller gauge (22) IV needle, blood return is not aspirated, even if the IV is patent. If the IV site shows no signs of infiltration and IV fluid is infusing without difficulty, proceed with IV push slowly. Oral meds are contraindicated in patients with nasogastric suction.

40. An older-adult patient needs an IM injection of antibiotic. Which site is best for the nurse to use? a. Deltoid b. Dorsal gluteal c. Ventrogluteal d. Vastus lateralis

ANS: C The ventrogluteal site is the preferred and safest site for all adults, children, and infants. While the vastus lateralis is a large muscle that could be used it is not the preferred and safest. The dorsal gluteal site is a location for a subcutaneous injection, and this patient requires an IM injection. The deltoid is easily accessible, but this muscle is not well developed and is not the preferred site.

38. A nurse is preparing to administer a medication from a vial. In which order will thenurse perform the steps, starting with the first step? 1. Invert the vial. 2. Fill the syringe with medication. 3. Inject air into the airspace of the vial. 4. Clean with alcohol swab and allow to dry. 5. Pull back on the plunger the amount to be drawn up. 6. Tap the side of the syringe barrel to remove air bubbles. a. 4, 1, 5, 3, 6, 2 b. 1, 4, 5, 3, 2, 6 c. 4, 5, 3, 1, 2, 6 d. 1, 4, 5, 3, 6, 2

ANS: C When preparing medication from a vial, the steps are as follows: Firmly and briskly wipe the surface of the rubber seal with an alcohol swab and allow to dry; pull back on the plunger to draw an amount of air into the syringe equal to the volume of medication to be aspirated from the vial; inject air into the airspace of the vial; invert the vial while keeping firm hold on the syringe and plunger; fill the syringe with medication; and tap the side of the syringe barrel carefully to dislodge any air bubbles.

13. The nurse is caring for an older adult patient at home who requires teaching for dressing changes. The spouse and adult child are also involved in changing the dressing. Which statement by thenurse will most likely elicit a positive response from the patient and family? a. "You're doing that all wrong. Let me show you how to do it." b . "I don't know who showed you how to change a dressing, but you're not doing it right. Let me show you c . "You're hesitant about changing the dressing like I was before I was shown an easier way; would you lik d . "I used to change the dressing the same way you are doing it: the wrong way. I'll show you the right way

ANS: C When the nurse is confident and skillful instead of coming across as an authority on the subject, the patient's/family's defenses will be down, making the patient/family more willing to listen without feeling embarrassed. Respectful communication is necessary. Saying that you're doing it wrong, you're not doing it right, or the wrong way is not respectful or necessary.

11. The nurse is caring for a patient in hospice. The nurse notes that the patient is getting adequate care, but the spouse is not sleeping well. The nurse also assesses the need for better familynutrition and meals assistance. The nurse discusses these needs with the patient and family and develops a plan of care with them using community resources. Which approach is the nurseusing? a. Family as context b. Family as patient c. Family as system d. Family as caregiver

ANS: C When you care for the family as a system, you are caring for each family member (family as context) and the family unit (family as patient), using all available environmental, social, psychological, and community resources. In family as context, the primary focus is on the health of an individual member. In family as patient, family processes and relationships are the primary focus. Family as caregiver is not an approach to family-focused nursing but is a term used to describe a family member caring for another family member

10. The nurse is caring for a Chinese patient using the Teach-Back technique. Which action by the nurse indicates successful implementation of thistechnique? a. Asks, "Does this make sense?" b. Asks, "Do you think you can do this at home?" c. Asks, "What will you tell your spouse about changing the dressing?" d. Asks, "Would you tell me if you don't understand something so we can go over it?

ANS: C The Teach-Back technique asks open-ended questions, like what will you tell your spouse about changing the dressing, to verify a patient's understanding. When using the Teach-Back technique do not ask a patient, "Do you understand?" or "Do you have any questions?" Does this make sense and do you think you can do this at home are closed-ended questions. Would you tell me if you don't understand something so we can go over it is not verifying a patient's understanding about the teaching.

8. The nurse is interviewing a patient who is being admitted to the hospital. The patient's familywent home before the nurse's interview. The nurse asks the patient, "Who decides when to come to the hospital?" What is the rationale for the nurse's action? a. To assess the family form b. To assess the family function c. To assess the family structure d. To assess the family generalization

ANS: C To assess the family structure, the nurse asks questions that determine the power structure and patterning of roles and tasks (e.g., "Who decides where to go on vacation?"). When focusing on family form, the nurse should begin the family assessment by determining the patient's definition of family. Family function is the ability of the family to provide emotional support and to cope with health problems or situations. The question asked by the nurse will not assess that. Nurses do not assess family generalization.

4. A nurse cares for the family's as well as the patient's needs using available resources. Which approach is the nurse using? a. Family as context b. Family as patient c. Family as system d. Family as caregivers

ANS: C When you care for the family as a system, you are caring for each family member (family as context) and the family unit (family as patient), using all available environmental, social, psychological, and community resources. When you view the family as context, the primary focus is on the health and development of an individual member existing within a specific environment (i.e., the patient's family). When you view the family as patient, the family processes and relationships (e.g., parenting or family caregiving) are the primary focuses of nursing care. There is no approach for family as caregivers; rather it is a term to describe family members caring for other family members usually at home

6. A nurse is working with a patient. When the nurse asks about family members, the patientstates that it includes my spouse, children, and aunt and uncle. How will the nurse describe this typeof family? a. Nuclear b. Blended c. Extended d. Alternative

ANS: C The extended family includes relatives (aunts, uncles, grandparents, and cousins) in addition to the nuclear family. The nuclear family consists of husband and wife (and perhaps one or more children). The blended family is formed when parents bring unrelated children from prior adoptive or foster parenting relationships into a new, joint living situation. Relationships include multi-adult households, "skip-generation" families (grandparents caring for grandchildren), communal groups with children, "nonfamilies" (adults living alone), cohabitating partners, and homosexual couples.

1. A nurse is following safety principles to reduce the risk of needlestick injury. Which actions will the nurse take? (Select all that apply.) a. Recap the needle after giving an injection. b. Remove needle and dispose in sharps box. c. Never force needles into the sharps disposal. d. Use clearly marked sharps disposal containers. e. Use needleless devices whenever possible.

ANS: C, D, E Needles should not be forced into the box. Clearly mark receptacles to warn of danger. Using needleless systems when possible will further reduce the risk of needlestick injury. To prevent the risk of needlesticks, the nurse should never recap needles. The syringe and sheath are disposed of together in a receptacle

16. A health care provider prescribes aspirin 650 mg every 4 hours PO when febrile. For which patient will this order be appropriate? a. 7 year old with a bleeding disorder b. 21 year old with a sprained ankle c. 35 year old with a severe headache from hypertension d. 62 year old with a high fever from an infection

ANS: D Aspirin is an analgesic, an antipyretic, and an anti-inflammatory medication. The provider wrote the medication to be given for a fever (febrile). Fevers are common in infections. If a child is bleeding, aspirin would be contraindicated; aspirin increases the likelihood of bleeding. Although it can be used for inflammatory problems (sprained ankle) and pain/analgesia (severe headache), this is not how the order was written

4. A patient has an order to receive 0.3 mL of U-500 insulin. Which syringe will the nurse obtain to administer the medication? a. 3-mL syringe b. U-100 syringe c. Needleless syringe d. Tuberculin syringe

ANS: D Because there is no syringe currently designed to prepare U-500 insulin, many medication errors result with this kind of insulin. To prevent errors, ensure that the order for U-500 specifies units and volume (e.g., 150 units, 0.3 mL of U-500 insulin), and use tuberculin syringes to draw up the doses. A 3 mL and U-100 can result in inaccurate dosing. A needleless syringe will not be acceptable in this situation

30. Which patient does the nurse most closely monitor for an unintended synergistic effect? a. The 4 year old who has mistakenly taken a half bottle of vitamins b. The 35 year old who has ingested meth mixed with several household chemicals c. The 50 year old who is prescribed a second blood pressure medication d. The 72 year old who is seeing four different specialists

ANS: D The 72 year old seeing four different providers is likely to experience polypharmacy. Polypharmacy places the patient at risk for unintended mixing of medications that potentiate each other. When two medications have a synergistic effect, their combined effect is greater than the effect of the medications when given separately. The child taking too much of a medication by mistake could experience overdose or toxicity. The 50 year old is prescribed two different blood pressure medications for their synergistic effect, but this is a desired, intended event. A patient taking meth and mixing chemicals can be toxic.

32. The prescriber wrote for a 40-kg child to receive 25 mg of medication 4 times a day. The therapeutic range is 5 to 10 mg/kg/day. What is the nurse's priority? a. Change the dose to one that is within range. b. Administer the medication because it is within the therapeutic range. c. Notify the health care provider that the prescribed dose is in the toxic range. d. Notify the health care provider that the prescribed dose is below the therapeutic range.

ANS: D The dosage range is 200 to 400 mg a day (5 × 40 = 200 and 10 × 40 = 400). The prescribed dose is 100 mg/day (4 ×25 = 100), which is below therapeutic range. The nurse should notify the health care provider first and ask for clarification on the order. The dose is not above the therapeutic range and is not at a toxic level. The nurse should never alter an order without the prescriber's approval and consent.

27. A patient refuses medication. Which is the nurse's first action? a. Educate the patient about the importance of the medication. b. Discreetly hide the medication in the patient's favorite gelatin. c. Agree with the patient's decision and document it in the chart. d. Explore with the patient reasons for not wanting to take the medication.

ANS: D The first response is to explore reasons the patient does not want the medication. After the assessment, the nurse can decide what to do next. Educating is important, but it is not the first action. Ultimately, the patient does have the right to refuse the medication; however, the nurse should first try to find out reasons for the refusal and provide education if needed based upon the assessment findings. Hiding medication and deceiving a patient into taking a medication is unethical and violates right to autonomy

12. A patient who had a colostomy placed 1 month ago is feeling depressed and does not want to participate in sexual activities anymore. The patient is afraid that the partner does not want sex. The patient is afraid the ostomy is physically unattractive. Which initial nursing interventionwill be most effective in helping this patient resume sexual activity? a. Inform the patient about a support group for people with colostomies. b. Reassure the patient that lots of people resume sex the same week the colostomy is placed. c. Teach the patient about intimate activities that can be done to incorporate the ostomy. d. Discuss ways to adapt to new body image so the patient will be comfortable in resuming intimacy

ANS: D The nurse should first address the patient's need to be comfortable with his or her own body image; once the patient's issues related to body image are resolved, intimacy may follow. Reassuring the patient that others manage to have sexual intercourse with an ostomy may help to decrease anxiety but may have the unintended effect of making the patient feel abnormal because he or she has not yet resumed sexual activity. Support groups may be helpful for the patient, but this is not the most effective initial intervention a nurse can provide; this may be helpful later. The patient is worried about the ostomy; incorporating it into intimate activities is insensitive and can even be damaging to the stoma

29. The supervising nurse is watching nurses prepare medications. Which action by one of the nurses will the supervising nurse stop immediately? a. Rolls insulin vial between hands b. Administers a dose of correction insulin c. Draws up glargine (Lantus) in a syringe by itself d. Prepares NPH insulin to be given intravenously (IV)

ANS: D The only insulin that can be given IV is regular. NPH cannot be given IV and must be stopped. All the rest demonstrate correct practice. Insulin is supposed to be rolled, not shaken. Glargine is supposed to be given by itself; it cannot be mixed with another medication. Correction insulin, also known as sliding-scale insulin, provides a dose of insulin based on the patient's blood glucose level. The term correction insulin is preferred because it indicates that small doses of rapid- or short-acting insulins are needed to correct a patient's elevated blood sugar.

14. A registered nurse interprets that a scribbled medication order reads 25 mg. The nurse administers 25 mg of the medication to a patient and then discovers that the dose wasincorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error? a. Health care provider b. Pharmacist c. Hospital d. Nurse

ANS: D Ultimately, the person administering the medication is responsible for ensuring that it is correct. The nurse administered the medication, so in this case it is the nurse. Accept full accountability and responsibility for all actions surrounding the administration of medications. Do not assume that a medication that is ordered for a patient is the correct medication or the correct dose. This is the importance of verifying the six rights of medication administration. The ultimate responsibility and accountability are with the nurse, not the health care provider, pharmacist, or hospital

41. A nurse is preparing an intravenous IV piggyback infusion. In which order will the nurse perform the steps, starting with the first one? 1. Compare the label of the medication with the medication administration record at thepatient's bedside. 2. Connect the tubing of the piggyback infusion to the appropriate connector on the upper Y-port. 3. Hang the piggyback medication bag above the level of the primary fluid bag. 4. Clean the main IV line port with an antiseptic swab. 5. Connect the infusion tubing to the medication bag. 6. Regulate flow. a. 5, 2, 1, 4, 3, 6 b. 5, 2, 1, 3, 4, 6 c. 1, 5, 4, 3, 2, 6 d. 1, 5, 3, 4, 2, 6

ANS: D When preparing and administering IV piggybacks, use the following steps: Compare the label of medication with the medication administration record at the patient's bedside; connect the infusion tubing to the medication bag; hang the piggyback medication bag above the level of the primary fluid bag; clean the main IV line port with an antiseptic swab; connect the tubing of the piggyback infusion to the appropriate connector on the upper Y-port; and regulate flow

3. A spouse brings the children in to visit their mother in the hospital. The nurse asks how the family is doing. The husband states, "None of her jobs are getting done, and I don't do those jobs, so the house and the kids are falling apart." How will the nurse interpret thisfinding? a. The family structure is resilient. b. The family structure is flexible. c. The family structure is hardy. d. The family structure is rigid.

ANS: D A rigid structure specifically dictates who is able to accomplish different tasks and also limits the number of persons outside the immediate family allowed to assume these tasks. Resiliency helps to evaluate healthy responses when individuals and families are experiencing stressful events. An extremely flexible structure also presents problems for the family. There is sometimes an absence of stability that would otherwise lead to automatic action during a crisis or rapid change. Hardiness is the internal strength and durability of the family unit characterized by a sense of control over the outcome of life and an active, rather than passive, orientation in adapting to stressful events.

16. A nurse works at a hospital that uses equity-focused quality improvement. Which strategy isthe hospital using? a. Document staff satisfaction. b. Focus on the family. c. Implement change on a grand scale. d. Reduce disparities

ANS: D Organizations can implement equity-focused quality improvement by recognizing disparities and committing to reducing them. Staff diversity is a priority for equity-focused quality improvement, not staff satisfaction. While the family is important, the focus is on the patients. Organizations should start by implementing a change on a small scale (pilot testing), learning from each test, and refining the intervention through performance improvement cycles (e.g., plan, do, study, and act)

5. A nurse is caring for a patient who needs constant care in the home setting and for whom most of the care is provided by the patient's family. Which action should the nurse take to help relieve stress? a. Encourage the caregiver to do as much as possible. b. Focus primarily on the patient. c. Point out weaknesses. d. Provide education.

ANS: D Providing education to the family and caregiver helps relieve some of the stress of caregiving. Help the family focus on their strengths instead of on problems and weaknesses. While caregivers desire to care for the loved one, they often feel extreme pressure to do everything; therefore, encouraging the caregiver to do more will add stress. Focusing primarily on the patient will not be beneficial; the entire family is the patient.

5. The nurse learns about cultural issues involved in the patient's health care belief system and enables patients and families to achieve meaningful and supportive care. Which concept is thenurse demonstrating? a. Marginalized groups b. Health care disparity c. Transcultural nursing d. Culturally congruent care

ANS: D The nurse is demonstrating culturally congruent care. Culturally congruent care, or care that fits a person's life patterns, values, and system of meaning, provides meaningful and beneficial nursing care. Marginalized groups are populations left out or excluded. Health care disparities are differences among populations in the availability, accessibility, and quality of health care services (e.g. screening, diagnostic, treatment, management, and rehabilitation) aimed at prevention, treatment,and management of diseases and their complications. Transcultural nursing is a comparative study of cultures in order to understand their similarities (culture that is universal) and the differences among them (culture that is specific to particular groups).

1. A nurse is working at a health fair screening people for liver cancer. Which population group should the nurse monitor most closely for liver cancer? a. Hispanic b. Asian Americans c. Non-Hispanic Caucasians d. Non-Hispanic African-Americans

b. Asian Americans While Asian Americans generally have lower cancer rates than the non-Hispanic Caucasian population, they also have the highest incidence rates of liver cancer for both sexes compared with Hispanic, non-Hispanic Caucasians, or non-Hispanic African-Americans.

2. A nurse is caring for an immigrant with low income. Which information should the nurse consider when planning care for this patient? a. There is a decreased frequency of morbidity. b. There is an increased incidence of disease. c. There is an increased level of health. d. There is a decreased mortality rate.

Populations with health disparities (immigrant with low income) have a significantly increased incidence of disease or increased morbidity and mortality when compared with the general population. Although Americans' health overall has improved during the past few decades, the health of members of marginalized groups has actually declined.