Fundamentals 1
labs for kidney/ renal disease
BUN, creatinine, GRF, Rennin, EPO
Which action by the nurse is an intervention to promote reflection?
Be physically present and actively listen when the patient speaks
After changing the intravenous tubing on a patient's primary infusion, the nurse notes air bubbles in the tubing. How would the nurse remove them?
Close the clamp, stretch the tubing downward, and flick the tubing.
A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device?
Collapse the device of air after emptying.
Which intervention assists a patient with connectedness to others?
Refer the patient to, or arrange for, the patient to engage in a support group or counseling
The nurse is caring for an Islamic patient who is recovering from a motor vehicle accident. The patient is observing Ramadan, the ninth lunar month, in which Muslims fast during daylight for 28 days. The nurse understands that a good diet is important for the patient's wounds to heal. What should the nurse do when planning the patient's diet?
Reschedule meals. Respect the cultural beliefs and assure the patient that medical needs will be taken care of. The nurse should understand the patient's cultural and spiritual beliefs and deliver health care accordingly. Muslims fast during Ramadan. Therefore, the nurse should not assume that the patient will take regular meals during Ramadan. Likewise, the treatment and medication regimen should be rescheduled according to the cultural needs of the patient. The nurse should respect the patient's culture and assure the patient that the hospital staff will provide optimal care. Asking the patient's family to ask the patient not to fast would be emotionally disturbing. Starting enteral tube feedings is also not ethical, because they would be against the patient's will. Trying to convince the patient to have meals may indicate that the nurse disrespects the patient's personal beliefs. p. 103
A single mother expresses that she feels inefficient because she is unable to balance her work and family roles. She takes care of her 5-year-old son without any support. She works as a store manager in a retail outlet. What are the role stressors that are responsible for her current state of mind? Select all that apply.
Role conflict Role overload
Which interventions should the nurse implement while caring for a patient with a disturbed body image who has undergone a modified radical mastectomy? Select all that apply.
Show acceptance of breast surgery when providing care. Ask the patient to identify personal strengths and talents. Assist the patient in developing a realistic perception of or her body. Tell the patient that her feelings are similar to feelings of other people in the same situation.
A patient is scheduled for colon resection with colostomy in 2 days. The nurse finds the patient appearing anxious and asking, "How am I going to live with a bag on my belly for the rest of my life?" Which nursing actions address the patient's self-concept and altered body image? Select all that apply.
Showing the patient a video about a healthy functioning body after a colostomy . Discussing the availability of support groups for patients with colostomies.
The nurse is teaching a group of young adults about the normal changes in role performance associated with maturation. What are the common stressors related to role performance in this stage of life? Select all that apply.
Transition from school to work setting. Physical, emotional, or cognitive deficits preventing role assumption. Death of a loved one
True or False Conflict in the workplace can impact the quality of the care provided.
True
True or False Respirations are counted immediately after taking a pulse. The resident should not know you are counting respirations.
True
True or False Restraints can increase a person's confusion or agitation
True
True or False The goal of bladder training programs is control of urination
True
True or False You are giving male perineal care. To clean the tip of the penis, start at the meatus of the urethra and work outward.
True
lab work for atherosclerosis
cholesterol; LDL/HDL, homocystine; C-Reactive protein
stage 2 PAD
claudication; muscle pain/ cramping
What are some symptoms you would expect from a pt who experiences hypoglycemia after insulin?
confusion, blurred vision, cold sweats, shaking
Which of the following would be consistent with infiltration (SATA)?
cool to the touch . swelling around site . with or without pain.
The nurse is preparing to administer several oral medications when the patient says he would like to take his pills with orange juice. What is the nurse's best response?
Establish whether the medications may be taken with orange juice.
sleep deprivation causes
irritability, cognitive impairment, memory lapses/loss, severe yawning, s/s like ADHA, impaired immune system, risk of type 2 diabetes, increased heart rate variability, decreased reaction time and accuracy, tremors, aches, growth suppression, decreased temp, risk of obesity, hallucinations
standards of care
legal guidelines for defining nursing practice and identifying the minimum acceptable nursing care
Pain threshold
level of stimulus needed to produce the perception of pain
communication-
process by which people affect one another; exchange of info, ideas, feelings; basic component of human relationships; fundamental element of nurse-client relationship
utilitarianism
proposes that the value of something is determined by its usefulness
sleep
purpose unclear; physiological and psychological restoration; maintenance of biological function; regulated by reticular activating system > regulates sleep cycle in hypothalamus
communicable disease
the infectious process transmitted from one person to another
Pharmacokinetics
the study of how meds enter the body; are absorbed and distributed into cells, tissues, or organs; alter physiological functions
pressure ulcers
tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period; tissue ischemia that leads to necrosis
treating CHF
upright position, high semi fowlers; nitrates- vasodilate coronary arteries and myocardium (dizzy feeling, hypotension); Lasix- diuretic/ urine output; oxygen- when pulse ox. under 95%; ACE inhibitors- Vasotech, Nosinopro (check BP before admin, low potassium or under 60 bpm hold); Digoxin- slows heart rate; apical pulse before admin; nausea and vomiting; toxic if stays in blood for too long; cardiac glycocide- increases contraction, slows heart rate, increases CO and oxygen in blood; decrease fluids to 1500ml; decrease salt to 2000-3000mg; test dig level, ABGs, potassium
The nurse is talking with the spouse of a patient who is having emergency surgery. Which statements, if made by the spouse, would demonstrate hope?
"I know my spouse will survive this surgery because the surgeon is one of the best in the country."
Which question would help the nurse assess the patient's spirituality? Select all that apply. One, some, or all responses may be correct.
"Whom do you feel is the closest to you?" "What do you want to achieve in your life?" "Do you attend a religious service on a regular basis?"
Which intervention should the nurse determine once the cue for spiritual care is recognized? Select all that apply. Reflection Faith Rituals Meditation Connection with others Change in environment
- Reflection - Faith Rituals - Connection with others
A pt is to receive cephalexin (Keflex) 500mg PO. The pharmacy has sent 250mg tablets. How many tablets does the nurse administer?
2 tablets
The period of heart muscle relaxation is called a. diastole b. systole c. blood pressure d. mean arterial pressure
A
Your task is to help Mrs. Morris to eat lunch. Which statement below is incorrect? a. use a spoon for safety b. serve solid foods first and then liquids c. serve the foods in order she prefers d. tell her what food and fluids are on the tray
A
Which patient would most likely require spiritual intervention related to grief?
A 30-year-old patient who underwent a mastectomy
The beginning sign of a pressure sore is: a. Coolness b. Discoloration c. Swelling d. Numbness
B
The nurse tells you to perform a procedure. Which is not true? a. The nurse must be available to answer questions and supervise b. Do whatever the nurse tells you to do c. The procedure must be in your job description d. Your state must allow nursing assistants to perform the procedure
B
You enter a residents room and the resident has a new onset bedsore. You feel you need to document this in the medical record but also have a discussion with the nurse. Where would you opt to have this discussion? a. In the patients room b. In the hallway with the family c. In private d. At the local bar
C
Your personal feelings about death a. affect the care you give b. are shared with the dying person c. do not matter while you are working d. are shared with the resident and their family
C
The BEST time to prepare for a disaster is: a. During your lunch b. When everyone has gone to bed c. During a tornado or hurricane d. Before it happens
D
Which statement about foot care is not true? a. feet are easily injured b. follow standard precautions and Blood borne Pathogen Standard c. Dirty feet and socks harbor microbes d. Cleaning toenails is easier in the morning
D
Which statement below is not a safety measure for tub baths and showers? a. clean the tub or shower before after use b. turn hot water on first, then cold c. place needed items within the person's reach d. fill the tub before the person gets in it
D
Which statement is false about coughing and deep breathing a. they are done during bedrest b. they help remove mucous c. they move air into most parts of the lungs d. they are done after surgery because the are too painful.
D
You are asked to collect a sputum specimen from your resident by the nurse. it is easier: a. After an activity b. After a meal c. Before a meal d. Upon awakening in the morning
D
True or False As a nursing assistant it is your responsibility to check IV flow rates
False
True or False Battery is threatening to touch a person's body without their consent
False
True or False Dementia is a normal part of aging
False
True or False Everyone has a bowel movement everyday
False
True or False In healthy adults, respirations should be between 24-30
False
True or False Inappropriate sexual behaviors by the resident are always on purpose
False
True or False Most residents enjoy enemas
False
True or False Nursing Assistants are responsible for starting oxygen therapy
False
True or False Pain that is described as "chronic" means it is sudden onset
False
True or False You should always make yourself at home and sit on the resident bed while feeding
False
True or False You should pick your residents daily activities and make them go
False
When administering an intradermal injection, which outcome would require the nurse to withdraw the needle and begin again?
Inability to feel resistance when injecting the medication
Which example reflects effective documentation of medication administration by a nurse?
Including the location of an injection site on the medication administration record
A 38-year-old patient who is a Jehovah's Witness is involved in a major motor vehicle accident. The patient was brought to the emergency department and was found to have lost too much blood, thus requiring a blood transfusion. Which nursing action would be taken in such a situation?
The patient should be asked to decide about the transfusion.
A patient survived a motor vehicle accident; the driver of the other car did not. The patient feels extremely guilty and says, "I am never going to touch the wheel again in my life." If the nurse intervened to improve the patient's self-esteem, what would be the most likely immediate outcome?
The patient would at least sit in the driver's seat in 3 days.
The nurse receives an order to start giving a loop diuretic to a pt to help lower his or her bp. The nurse determines the appropriate route for administering the diuretic according to:
The prescriber's orders
What is the greatest safety concern when withdrawing medication from an ampule?
Withdrawing glass particles into the syringe
The nurse is preparing to instill antibiotic eardrops in a patient who will be discharged with a prescription for the medication. The following information should be included in the patient's education plan to best ensure maximum therapeutic response when self-applying the medication:
Remain in the lateral position for at least 5 minutes after instillation.
What term describes how one thinks of oneself?
Self-concept
The nurse finds that a patient has not understood the health education provided on personal hygiene. How does the nurse ensure that the patient understands the teachings?
The nurse clarifies the information and requests a teach back.
A nurse on a medical-surgical unit is washing her hands prior to assisting with surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?
The nurse washes with her hands held higher than her elbows
The nurse is trying to assess if a patient is free from identity stressors. What would suggest that the patient has a strong identity?
The patient has been happily married for 10 years.
Where is the best injection site for blood thinners?
abdomen - because it allows the medication to be released into the the system at a steady rate
psychomotor learning
acquiring skills that require the integration of mental / muscular activity
Types of pain
acute, chronic, cancer, by inferred pathology, idiopathic
In the FICA assessment tool for evaluating spirituality, what does the letter A stand for?
address
The nurse is obtaining a spiritual history from a patient admitted with renal failure. Which factor influences a patient's spirituality? Select all that apply. One, some, or all responses may be correct.
age gender culture religon education
factors affecting bowel elimination
age, diet/fluid intake, physical activity, psychological factors, personal habits, position during defecation, pregnancy, surgery/ anesthesia, meds/laxatives/ cathartics
Factors influencing pain
age, fatigue, genes, neurological functions, social factors, spiritual factors, psychological factors, cultural factors
factors influenceing infection
age, stress, disease process, treatment/ condition that compromise the immune system
fidelity
agreement to keep promises
Pain tolerance
amount of pain a patient endures without its interference of ADLs
definition of nursing
an art and a science with limitless opportunities; client, family, and community centered; diagnosis and treatment of human response to actual and potential health problems
Pharmacological pain relief
analgesics (NSAIDS & non-opioids, opioids, adjuvants)
MD, APRN office
annual PE and screening/ preventative education
UTI treatment
antibiotic- Siproflaxin; cranberry juice for prevention
The most common mental health problem is
anxiety
stage 1 PAD
asymptomatic; Bruit may be present; toes cool to touch; slow capillary bed refill
non-maleficence
avoidance of harm/ hurt
hematuria
blood in urine; not a good sign
stage 2 ulcer
broken skin; partial thickness; blister epidermis and dermis; can ooze
stress incontinence
usually in women who didn't do kegels during labor
forms of communication
verbal, non-verbal
pruritis
chemical, allergic, physical agent; drugs, food, sweat-act on nerve fibers, releases histamine and affects itch receptors; insect bites, scabies, medication (opioid) , systemic effect
loose stool
chunks of stool
deep vein thrombosis
clots in the veins; usually in the extremities
safety guidelines in hygiene
communicate with team members; incorporate patient's priorities; move from cleanest to less clean areas; use clean gloves for contact with non-intact skin, mucous membranes, secretions, excretions, or blood; test tempo of water or solutions; use principles of body mechanics and safe patient handling; be sensitive to invasion of privacy
sterilization
complete elimination or destruction of all microorganisms including spores
health care delivery system
complex, dynamic, constantly changing; past 10-15 yrs managed care, primary care provider; services provided by a wide variety of licensed/ non-licensed staff
pulmonary emboli
complication of DVT
Water
comprises 60-70% of body weight; cell function depends on a fluid environment, you can only survive a few days without it, illness increases need for fluids
chain of infection
infectious agent/ pathogen > reservoir/ source for pathogen growth > portal of exit > mode of transportation > portal of entry > susceptible host
laryngitits
inflammation/ swelling of larynx; occurs as single problem or with resp infection; risk/irritant-smoking; dry coughing; voice changes; throat cultures to check for strep; comfort care
socioeconomic status affecting hygiene
influences type and extent of hygiene practice used
What should a nurse do first when drawing up a 10 unit of Humulin R (regular) insulin and 30 units of Humulin N (NPH) insulin in same syringe?
inject 30 U of air into Humulin N insulin
hospital and med centers
inpatient services, diagnostic and treatment services
gastric bypass
malabsorption surgery; can cause dehydration and electrolyte problems; overeating can cause dumping syndrome-food deposits into small intestines too quickly
Planning:
nurse comes up with client-centered goals; need to be measurable (client will ambulate 10 meters 3x daily for 2 wks)
Diagnosis:
nurse makes a nursing diagnosis based on assessment of patient; not a medical diagnosis
dreams
occur in NREM and REM; REM in color; important for learning, memory, and adopting to stress
varient angina/ prinz metals
occurs at rest (sort of constant)
Naloxone (Narcan)
opiate antagonist, reverses opioid induced resiratory depression
urinalysis
pH; protein; glucose; ketones; blood; specific gravity; WBCs; bacteria
myocardial infarction
pain (sudden onset, substernal, crushing/ tightness/severe; affects back, neck, jaw, arm, shoulder), dyspnea, syncope with low BP, shortness of breath, nausea, vomiting, sweating, increased heart rate, DENIAL
dysuris
pain or burning on urination
SOLER
sit close, observe, lean forward, eye contact, relax
learning
purposeful acquisition of new knowledge, attitudes, behavior, or skills
clinics
screening to comprehensive care
A patient experienced asystole because of an acute heart attack but recovered because of resuscitative measures. Which observation made by the patient suggests the patient had a near-death experience (NDE)? Select all that apply. One, some, or all responses may be correct.
seeing a bright light meeting her dead parents feeling as if she was pulled out of her body
SATA
select all that apply - just so know what is meant in the cards
Which dimension of spirituality includes "a sense of authentically connecting to one's inner self?"
self-transcendence
block and parish nursing
services based on need vs availability of reimbursement; religous involvement
A patient just gave birth to a beautiful baby. The mother says, "It's like a miracle. I don't have words to explain this feeling. My baby is perfect, like something out of this world. Thank you, God." Which feeling did the patient just experience?
transcendence
A senior nurse is talking with student nurses about spirituality. Which conceptual element is included in spirituality? Select all that apply.One, some, or all responses may be correct.
transcendence faith and hope inner strength and peace meaning and purpose in life connectedness
True or False Everyone likes to be touched
False
True or False Foley catheters treat the cause of urinary incontinence
False
True or False Acute confusion is usually permanent
False
True or False All colostomies are permanent
False
What does the nurse teach the student nurse about quality health care to prevent health disparities?
"Quality health care should be effective."
True or False Multiple sclerosis is cured with diet and medications
False
stage 5 of sleep
20-25%; REM; brainwaves speed up and dreaming occurs; increased heart rate; rapid and shallow breathing
The pt has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her?
30mL
Which needle is best for a 2.5 mL IM injection?
3mL
stage 1 of sleep
4-5%; light sleep; muscle activity slows
stage 3 of sleep
4-6%; deep sleep
The absence of breathing is called? a. apnea b. hypoxia c. orthopnea d. dyspnea
A
A rule of conduct made by the government body is called: a. A law b. Libel c. Tort d. Informed Consent
A
After urinating, the resident is assisted to: a. Wash their hands b. Get back in bed c. GIven something to drink d. Put in a diaper
A
A nurse is planning care for a group of clients who are receiving O2 therapy. Which of the following clients should the nurse plan to see first?
A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask. Therefore, the nurse should first see the client who has heart failure and is receiving 100% oxygen via a partial rebreather mask. Oxygen is a gas which can cause toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of client injury.
The spouse of a patient who is terminally ill is in spiritual distress. What other situations adversely affect the spirituality of an individual? Select all that apply.
A diagnosis of diabetes A major motor vehicle accident A near-death experience
Which finding tells the nurse that a patient may have had a positive reaction to a tuberculin test?
A hard, raised area 15 mm or greater in diameter
When you're teaching a pt how to prepare mixed insulin what is a key thing to remember about the procedures (ie the order to draw)
ALWAYS draw regular insulin first then modified insulin (N R R N)
A federal insurance plan providing benefits for older persons and some younger persons with disabilities is called: a. Medicaid b. Medicare c. Blue Cross/ Blue Shield d. Coventry
B
A microbe that is harmful and causes infection is called: a. reservoir b.pathogen c. a non- pathogen d. host
B
A resident uses crutches to walk. Which does not promote safety? a. a physical therapist measures and fits the person with crutches b. comfortable bedroom slippers won c. clothes fit well d. crutch tips are attached to the end of crutches
B
When is a patient at a higher risk for a medication administration error?
During a care transition point, such as transfer to another unit
UTI causes
E. coli, young and old women at risk; uncircumcised men (smegma); frequent sexual intercourse/ unprotected/ multiple partners; poor hygiene; HAI; med/surg related
A nurse is caring for a client who has an NG tube for intermittent feedings. Which of the following actions should the nurse take?
Elevate the client's head of bed 45° before the feeding.
Which of the following statements made by a nurse is most reflective of the proper understanding of the role that unlicensed ancillary staff may play regarding the insertion of a rectal suppository?
Be sure to let me know if she reports any rectal pain.
Which term best describes the type of elements that people in Western cultures believe cause illness?
Biomedical
Which term best describes the type of elements that people in Western cultures believe cause illness? 4. Imbalance between humans and nature
Biomedical Most Western cultures believe that illnesses have biomedical causes. Beliefs that illnesses are caused by supernatural or medicoreligious causes, or by an imbalance between humans and nature, are more common in non-Western cultures. p. 106
A document about personal choices regarding life support when death is likely is a. a durable healthcare power of attorney b. a Do Not Resuscitate Order c. a living will d. Hospice Care
C
A safety device used to transfer a dependent resident from the bed to chair is called: a. posey vest b. hand roll c. transfer/gait belt d. foot board
C
During which step of the nursing process is care provided? a. Assessment b. Evaluation c. Implementation d. Planning
C
The provider has ordered that a patient be given 1000 mL of IV normal saline to run over 12 hours. What is the first step in the calculation of the rate of infusion?
Calculate the hourly volume of normal saline the patient should receive.
What is the most important step the nurse can take to ensure that the patient is getting the correct medication?
Compare the medication label with the MAR three times.
The nurse says to the patient when her family arrives, "Let me give you privacy." What is being promoted by the nurse?
Connectedness to others
True or False A married couple is admitted to a nursing facility. They should be assigned to separate rooms.
False
What can the nurse do to minimize the discomfort of a subcutaneous injection?
Cover the injection site with gauze pad after withdrawing the needle.
A resident continues to ask you the same question over and over again each time you come into the room. You should: a. Tell the person you are tired of answering the same question b. Yell at the resident c. Report the behavior d. Be patient
D
An assisted living facility provides all of the following except: a. Housing b. Personal care c. Social activities d. 24 hour skilled nursing care
D
You promote quality of life by: a. Delegating tasks to your coworkers b. Making sure you bring your resident chocolate and Starbucks c. Doing everything for the patient, they don't need to lift a finger d. Speaking to individuals in a respectful manner
D
True or False Always use medical terms when you talk to the patient or resident.
False
True or False An oral temperature is the best route for a patient on oxygen
False
Which site is least desirable for 3 mL IM injections
Deltoid
A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?
Encourage the client to express his thoughts about death and dying
A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?
Evaluate pedal pulses
Which nursing intervention is most important in ensuring safe infusion of a medication delivered by IV piggyback through a saline lock?
Flush the saline lock with sodium chloride solution before initiating the infusion.
A patient diagnosed with major depressive disorder has long-term low self-esteem related to negative view of the self. Which action would be the most appropriate cognitive intervention by the nurse?
Focus on identifying strengths and accomplishments.
How can the nurse best minimize the patient's risk for infection when administering an IV bolus of an analgesic?
Follow aseptic technique during the entire process.
What would the nurse do to remove air trapped in a syringe before withdrawing the syringe from the vial?
Position the tip of the needle in the vial's airspace, and tap the barrel of the syringe.
Biomedical Theory
Postulates that microorganisms are responsible for specific disease conditions.
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal stimuli, has no respirations, and is pulses. Which of the following actions should the nurse take first?
Start chest compressions. The nurse should apply the safety and risk reduction priority-setting framework when caring for this client.
treatment for PAD
Statins- help metabolize cholesterol; Crestor, Lipitor- muscle pain, leg pain, cramping, diarrhea
The nurse cares for a family of four, offering routine medical care throughout the year. Which member of the family does the nurse expect to exhibit the highest levels of self-esteem?
The 8-year-old boy
justice
being fair
treatment for hypoventillation
if narcotic based, reduce/ discontinue; stroke- high fowlers/ oxygen; other meds to increase breathing
causes of obesity
corticosteroids, estrogen, antidepression meds, overeating, unconscious eating, physical inactivity, genetics, Pretnezone
Retirement usually results in: a. Physical changes from aging b. Financial security c. Less Free Time d. Typically a lower income
d
A patient is suffering from spiritual distress. Of which patient feeling would the nurse be aware? Select all that apply. One, some, or all responses may be correct
doubt loneliness loss of faith
xerosis
dry skin; becomes reddish; low humidity; frequent washing
incontinence
inability to control passage of feces or gas through rectum
cognitive learning
includes all intelectual behavior/ requires thinking
uremic syndrome
increase in nitrogenous wastes in the blood
labs for obesity
electrolyte/sodium/potassium, blood glucose, triglycerides, hemoglobin, serum albumin
disinfection
eliminates many or all microorganisms with exception of spores from inaminate objects
ethic of care
emphasizes the importance of understanding relationships, especially as they are revealed in narratives
arteriosclerosis
hardening of arteries
asymptomatic infection
when the infection does not cause any signs or symptoms, making the diagnosis difficult
symptomatic infection
when the infection has signs and symptoms like fever, cough, etc
Laws that deal with relationships between people are called? a. Criminal lwas b. Torts c. Responsibilities d. Civil laws
D
Oral hygiene: a. is only done once daily b. is not important for the unconscious person c. causes pyorrhea d. prevents mouth odor and infection
D
Padding side rails on a bed serves a purpose. The purpose is: a. Restrain the patient b. Have somewhere to put the call button c. Keep the client warm d. Protect your client from possible injury
D
Phantom pain is a. suddenly felt b. constant and severe c. felt at the site of tissue damage and in nearby areas d. is felt in the body part which is no longer there
D
Stiffness or rigidity of skeletal muscles that occurs after death is called: a. DNR b. peristalsis c. postmortem d. rigor mortis
D
The apical pulse is located? Choose One. a. in the neck b. at the wrist c. in the second finger d. below the left nipple
D
The following are risk factors for coronary artery disease. Which risk factor can not be changed a. lack of exercise b. smoking c. being overweight d. your mother and father both had heart attacks at 40 and 48
D
To prevent shampoo from getting into your residents eyes, you should: a. Use a hand held nozzle b. Use dry shampoo c. Rinse the hair throughly d. Use a washcloth to cover the eyes
D
What type of specimen is collected for a basic routine urinalysis: a. random urine specimen b. 24 hour urine specimen c. a clean cath urine specimen d. a midstream specimen
D
When changing an unsterile dressing, the nurse aide should wash hands: a. before the procedure b. after the procedure c. before and after the procedure d. before, after the removal of the soiled dressing, and after the procedure
D
Which is not a rule for collecting specimen? a. use a clean container for each specimen b. use the correct container c. label the container accurately d. collect the specimen as soon as you have it
D
Which of following medical problems frequently develop in residents with diabetes? a. kidney failure b. stroke c. decreased vision d. all of the above
D
Which of the following changes in the skin growth should be reported immediately to the nurse. a. change in color b.bleeding c. change in size d. all of the above
D
Which patient statement supports a nursing diagnosis of spiritual distress related to a diagnosis of chronic illness?
"I feel like I have nothing to live for anymore."
Which statement best illustrates the nurse's understanding of the role of NAP in documenting medication administration?
"Let me know if she says her nausea is getting worse."
A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?
"There are times I should use soap and water rather than alcohol based hand rub to clean my hands."
While assessing a patient of a different culture, the nurse wants to know the patient's perception of the etiology of the disease. Which is the most appropriate question asked by the nurse using a patient's explanatory model?
"What do you call your problem?"
Morbid Obesity
100% over weight for height
The normal body temperature range for the rectal site is: a. 98.6 to 100.6 degrees F b. 96.6 to 98.6 degrees F c. 97.6 to 99.6 degrees F d. 99.6 to 101 degrees F
A
When preparing to administer heparin or insulin subcutaneously, which site is preferred?
Abdomen
What is the most appropriate way for the nurse to split an unscored tablet?
Ask the pharmacy if it is appropriate to split the pill and if so, ask them to split and repackage it with the adjusted dose given on the label.
Which action will the nurse take to minimize a patient's risk for injury when applying a gauze dressing to an infusion site?
Avoid encircling the arm with tape
Frequent urination at night is: a. dysuria b. nocturia c. urinary urgency d. polyuria
B
Which is more correct measure of urinary output? a. 30 oz b. 300ml or cc c. 2 cups d. 1 gallon
B
Which of the following stages of dying is usually the final stage for the client? a. Anger b. Acceptance c. Bargaining d. Depression
B
A tube inserted into the stomach through a surgically create opening is called: a. a gastrostomy tube b. a jejunostomy tube c. a PEG tube d. a nasogastric tube
C
Development is a. an involuntary movement b. a skill that must be completed c. changes in mental, emotional, and social function d. the physical changes that can be measured and that occur in steady, orderly manner
C
Difficulty swallowing may be associated with: a. Congestive Heart Failure b. Parkinson's Disease c. Stroke d. Multiple Sclerosis
C
Direct Questions are used to: a. show the person you care about them b. make sure you understand what was said c. focus on specific information d. allow the person time to think
C
Exercises that move each muscle and joint care called? a. Rotation b. Adduction c. Range of Motion d. Abduction
C
Hemoptysis is: a. mucous from the respiratory tract b. a black tarry stoll c. bloody stool d. infection
C
It is 4:00pm. In a 24- hour clock, how do you record time? a. 2400 b.4000 c.1600 d.0004
C
Looking at things from another's point of view is called: a. Politeness b. Work ethic c. Empathy d. Courtesy
C
Which of the following would not be a cause of constipation? a. medications b. decreased fluid intake c. high fiber diet d. inactivity
C
When preparing an intramuscular injection, what can the nurse do to reduce the patient's risk for infection?
Clean the injection site with an alcohol swab.
What might the nurse do to improve a patient's cooperation during the removal of an IV access device?
Describe the entire procedure to the patient.
Which action would the nurse take if an IV insertion site appeared red, warm, and swollen?
Discontinue the infusion.
A patient is suffering from spiritual distress. Of which patient feeling would the nurse be aware? Select all that apply.
Doubt Loneliness Loss of faith
swine flu
H1N1; person to person transmission; touching infected surfaces; nose/throat culture; vaccine
In assessing a patient for self-concept and self-esteem, on what components should the nurse focus? Select all that apply.
Identity Body image Role performance
A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment.
Inspect, Auscultate, Percuss, Palpate
Which process is involved in the ETHNIC mnemonic communication technique?
Intervention
Which action will best minimize the patient's risk for vein injury when removing an IV access device from a patient's arm?
Keep the hub parallel to the skin
What will the nurse do after opening a multidose vial and withdrawing a dose of medication from it?
Label the vial with the date it was opened and your initials.
A patient is a Jehovah's Witness and does not want a blood transfusion, but her health care provider told her she would risk her life without it. Which diagnosis is appropriate for this patient?
Moral distress
The nurse is incorporating the patient's religious dietary preferences into the care plan. What step of the LEARN mnemonic is the nurse applying?
Negotiate
The senior nurse observes that a newly appointed nurse is having trouble relating to a patient from a different culture. What advice can the senior nurse give this nurse to enhance cultural competency?
Obtain sufficient knowledge about a patient's cultures and beliefs.
Which is a patient-centered goal regarding spirituality?
Patient will report the ability to pray after counsel by the hospital chaplain.
While assessing a patient with a psychiatric disorder, the nurse seeks the patient's point of view. Which process of the RESPECT mnemonic is the nurse employing?
Rapport
Which is an example of a health practice to heal an illness under Hindusim?
Removing external toxins through fasting
How can the nurse ensure that a patient's IV tubing will not tug on the infusion catheter after a transparent dressing is applied to an infusion site on the arm?
Secure the tubing in two different locations on the arm.
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?
The client reports severe pain
What is the primary goal of patient-centered care?
To provide individualized care and restore an emphasis on personal relationships
The nurse should question an order to insert a suppository into the rectum of a patient experiencing: term-479
Watery diarrhea.
allocating scares resources
a key issue in discussions about access to care
body image affecting hygiene
a person's subjective concept of his/her body appearance
atherosclerosis
affects intima of arteries; plaque froms and narrows lumen of arteries; pain when tissues don't get oxygen
developmental stage in hygiene
affects the patient's ability to preform hygiene care
slough
dead tissue; yellowish, brownish; makes wound unstageable; has to be debritied
Basal metabolic rate (BMR)
energy needed to maintain life
stage 3 ulcer
epidermis, dermis, and subQ tissue; oozing, signs of infection; full thickness loss
stage 1 ulcer
intact skin; red/irritation; unblanchable
Match the religion with the correct belief.
listening, seeing, and peace are central to life - Native American Rebirth occurs until a person reaches nirvana - Buddhism The trinity is the Father, Son, and Holy Spirit as one - Christianity Life is a gift from God and is precious - Judaism Higher powers do not exist - atheist
stage 3 PAD
rest pain
As the nurse is giving a patient his medications, he remarks, "I've never seen this blue pill before." What is the nurse's correct response?
"Don't take it. Let me double-check the doctor's order to make sure this is the correct medication for you."
A patient suffers from situational low self-esteem following the death of her pet dog. What are the appropriate questions for the nurse to ask during assessment of her self-esteem?
"How do you feel about yourself?"
Which statement by a patient with end-stage cancer indicates the need for spiritual intervention?
"I would like to ask my pastor about a final blessing."
What should you do if a pt develops s/s of an allergy or has adverse side effects to a medication?
- assess pt - document and add allergy to chart - call provider
stage 2 of sleep
45-55%; breathing and heart rate slow
You must check the MSDS a. before using a hazardous substance b. after cleaning up a leak or spill c. at the beginning of the shift d. at the end of the shift
A
You're preparing an injection from a liquid vial. You have the MAR what else do you need? (SATA) A. syringe B. needle for withdrawal C. needle for injection D. filter needle E. alcohol swabs F. diluent
A. syringe B. needle for withdrawal C. needle for injection E. alcohol swabs
A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first?
Assessment
Your resident is in back lying position. This is called: a. prone b. supine c. High Fowlers d. dorsal recumbent position
B
The process of becoming "unclean" is called: a. asepsis b. disinfection c. contamination d. immunity
C
Your resident is wealthy. He offers you a "little gift" in the form of cash for providing expert care. You should: a. Accept and say nothing b. Accept like a tip and share it with your coworkers c. Refuse graciously d. Look to see if anyone is listening or watching
C
Which action minimizes the patient's risk for injury when inserting a venous access device into the arm?
Checking for a radial pulse once the tourniquet has been applied.
Which action must the nurse take for the patient to accept spiritual care?
Create an environment of compassion and care.
Catastrophic reactions involve a. false beliefs b. restless behavior c. seeing something that is not there d. extreme responses
D
Inflammation of the mouth is called: a. aphasia b. metastasis c. benign d. stomatitis
D
Which of the word below best describes of apetite: a. gavage b. regurgitation c. dysphagia d. anorexia
D
When the nurse has a prejudice against a particular culture, which type of behavior is likely to result?
Discrimination
avian flu
H5N1; bird to human trough droppings, saliva, blood; stayed in Asia
What does illness in the Native American culture represent?
Imbalance
Which religion's health practices include a preference for same-gender caregivers?
Islam
What factor is the nurse least likely to associate with health disparities among marginalized groups?
Self-care
A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft contender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority?
Temperature
True or False Sodium causes the body to retain water
True
consent
a signed form required for all routine treatment, hazardous procedures, and some other treatments; provisions made for deaf, illiterate, and foreign language clients
A patient states he does not believe in the existence of God. Which belief does this statement indicate about the patient?
atheist
deontology
defines actions as right or wrong
ability to learn
developmental / physical ability
ESRD
irreversible damage to kidney tissue
A Roman Catholic patient with diabetes receives a meal tray on the Friday before Easter. Which food does the nurse offer to replace?
spaghetti with meat sauce
school health
support educational success by enhancing health
nephrostomy
urinary diversion; bypasses the ureters, bladder, urethra; used in patient with kidney stones, cancer, ureter problem, any GU problem
nocturia
voiding at night; early sign of hypertension; pressure on bladder during pregnancy
Measurements for obesity
waist size, BMI, ideal weight for height
medication interactions
when one med modifies the action of another
Which instruction might the nurse give to NAP regarding the care of a patient with an IV site dressing?
"Be sure to notify me if the patient reports that the IV site is painful or swollen."
Which student nurse statement regarding cultural competence indicates a need for further teaching?
"Culturally competent organizations manage the dynamics of homogeny."
Which statement made by a patient with cancer reflects positive thoughts about personal health?
"I have the ability to get well quickly."
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?
"I keep having nightmares about my upcoming surgery."
While measuring the vital signs of a Muslim patient, the nurse observes that the patient is anxious. Which statement by the nurse indicates a good understanding of transcultural nursing?
"I know modesty is very important for you. Is there any way I can make you comfortable?"
Following a bilateral mastectomy, a 50-year-old patient refuses to eat, discourages visitors, and pays little attention to her appearance. One morning the nurse enters the room to see the patient with her hair combed and makeup applied. Which statement is the best response from the nurse?
"I see that you've combed your hair and put on makeup." When the nurse uses a matter-of-fact approach and acknowledges a change in the patient's behavior or appearance, it allows the patient to establish its meaning.
Which response might the nurse give to NAP who reports that the alarm is sounding on a patient's electronic infusion device? D. "Turn off the alarm."
"I'll check the IV site and pump."
Which statement might the nurse make to NAP when caring for a patient who is prescribed an intradermal injection?
"Immediately report any patient complaints of itching or dyspnea."
The nurse is providing care to patient who states, "I practice the Chinese religion of Confucianism." Which question should the nurse include when conducting a spiritual assessment for this patient?
"Is acupuncture a treatment you want to explore?"
Which question does the nurse ask a patient to assess the beliefs and practices of the patient?
"What do you do to keep yourself well?"
Which question should the nurse ask a patient with low self-esteem in order to assess the nature of the problem?
"What do you like about your appearance?"
Normal range for BP
100/60-140-90
stage 4 of sleep
12-15%; very deep sleep; rhythmic breathing
The nurse is assessing a patient by asking, "How does this problem affect you and how has it affected your life and your family"? Which type of nursing assessment question is the nurse asking?
4 Bicultural ecology and health risks Bicultural ecology and health risk questions involve inquiring about a problem and its effect on life and the family. Ethnohistory questions refer to ethnic background and history. Socioeconomic status questions deal with income and means of living. Caring beliefs and practices questions deal with self care and care provided to and by family members. p. 107
How many interrelated components are present in Campinha-Bacote's model of cultural competency?
5
A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the following abdominal assessments should the nurse expect?
Absent bowel sounds with distention
Which of the following technique(s) is/are best for minimizing a patient's risk for injury when inserting a venous access device?
All of the above
The nurse recognizes that the patient would benefit from reflection. Which action promotes reflection?
Allow time and opportunity for self-disclosure by the patient
Which body image stressors would likely damage the self-concept of an individual? Select all that apply.
Alopecia due to chemotherapy Amputation of the foot
Which action would the nurse perform to best ensure effective insertion of a venous access device into a patient's arm?
Anchor the vein by placing a thumb 1 to 2 inches below the site.
When applying a dressing to an infusion site on a patient's left forearm, what will the nurse do to ensure proper maintenance of the tubing?
Apply the dressing proximal to the tubing and catheter hub connector.
Which action by the nurse would reduce his or her exposure to blood borne pathogens while administering fluids to a patient by mini-infusion pump?
Applying clean gloves
A nurse accidentallly gives a pt a med at the wrong time. The nurse's first priority is to:
Assess the pt for adverse effects
Large rings are dangerous because: a. They can fall off and can be lost b. They can scratch the resident c. They can damage equipment d. patients can pull them off your finger
B
Which life event is commonly celebrated in most religions?
Birth and death
The spread of cancer to other body parts is called: a. gangrene b. Benign tumor c. metastasis d. malignant tumor
C
The word ACUTE when used to define illness means: a. an illness for which there is no reasonable expectation of recovery b. an ongoing illness for which there is no cure c. a sudden onset to an illness d. an illness that is gradual
C
What can the nurse do to help protect the patient from infiltration of IV medication?
Check the IV site for placement before and after the infusion.
A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?
Check the client's perineum. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. The priority nursing action is for the nurse to collect more data by assessing the area of irritation.
Anxiety is a. false belief b. feelings and emotions c. a persistent thought or idea d. a vague, uneasy feeling in response to stress
D
Which action would the nurse take to address the "F" portion of the FICA assessment tool during an assessment of a patient's spiritual needs?
Determine the patient's belief in a higher power.
A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?
Determine whether the client is able to breathe.
True or False Restraints are safe and are always used to prevent falls
False
True or False The healthy adult produces about 1500ml urine per day
False
A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching?
Granulation tissue fills the wound during healing.
The nurse determines that a patient is experiencing repeated failures, having conflicts, with others, and is more dependent on his or her parents. Which component of self-concept is affected in the patient?
Identity
Which is least appropriate when communicating with a non-English-speaking patient who has complete hearing loss?
Informing the patient that language assistance services are provided at a low cost
The nurse is inserting an over-the-needle catheter into a newly admitted patient. What will the nurse do after confirming blood return?
Lower the catheter until it is flush with the skin.
Which action would the nurse take to diminish tissue irritation when administering a subcutaneous injection to a patient of average size?
Make sure the volume of the medication is less than 2 mL.
The nurse asks you to give Mrs. Jones a milk and molasses enema. Should you give the enema?
No
While preparing a patient's oral medication dispensed from an automatic system, the nurse realizes that the pill dispensed is twice the required dose. What is the nurse's best response?
Notify the pharmacy to determine if the accurate dose is available
If a pt who is receiving IV fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects:
Phlebitis
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?
Place the bladder of the cuff over the posterior aspect of the thigh
Which type of spiritual practice connection occurs when the nurse states, "This must be a difficult time for you. What are you thinking?"
Reflection
A patient states, "My religion does not permit me to bathe todays." Which nursing action would be most appropriate?
Request clarification of the patient's beliefs and adapt a plan for bathing accordingly
Which action by the nurse ensures patient safety when administering an intramuscular injection?
Rotating injection sites
The nurse asks the patient, "How do you feel about yourself?" What is the nurse assessing?
Self-esteem
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature?
Temporal
Which response best describes why a patient would use reflection in spirituality?
To find meaning prior to a life-changing event
Why is it most important for nurses to know the patient's end-of-life religious and spiritual preferences for a patient receiving hospice care?
To have compassion for various patient beliefs
What is the goal of culturally congruent care?
To provide care to fit a patient's own values, beliefs, and traditions
A nurse is administering eardrops to an 8 y/o pt with an ear infection. How does the nurse pull the pts ear when administering the medication?
Upward and outward
Which site is most commonly used for intramuscular injections?
Ventrogluteal
As the nurse is at the bedside preparing to administer a new medication, the patient mentions that he is allergic to the drug. What will the nurse do first?
Withhold the medication
A nurse is administering meds to a 4 y/o pt. After he/she explains which meds are being given, the mother states, "I don't remember my child having that med before." What is the nurse's next action?
Withhold the meds and verify the med orders
peripheral artery disease
caused by atherosclerosis; usually lower extremities; deprives lower extremities of oxygen; cramps and muscle pain with activity
quality of life
central to discussions about futile care, cancer therapy, physician assisted suicide, DNR
myocardial ischemia
chest pain, aching, associated with activity, pain leaves when patient rests
need for nurse to teach client
clarify info given by doc or other health care providers; has to be complete, accurate, and relevant; should be based on patient's needs and learning ability
Behavioral responses to pain
clenching teeth, holding painful part, bent posture, grimaces, cries or moans, restlessness, frequent requests of the nurse; confused patient may not show reaction
Patient Controlled Analgesia (PCA)
client has control with minimum risk of overdose; system designed to deliver no more than specific number of doses
treatment for atherosclerosis
decreased cholesterol intake; smoking cessation; blood work; exercise
narcolepsy
falling asleep at inappropriate times
primary care in community
health professionals, community members, govt
eschar
necrotic/black; surgically removed
the nursing shortage
produces difficult working conditions and affects client outcomes
unstable angina
spontaneous pain
hand hygiene
the most important technique used in preventing and controlling transmission of infection
The registered nurse is admitting a patient of French heritage to the hospital. Which question asked by the nurse indicates that the nurse is stereotyping the patient?
"Do you bathe and use deodorant more than one time a week?" Nurses need to avoid stereotypes or unwarranted generalizations about any particular group that prevents further assessment of the individual's unique characteristics. p. 106
Which of the following statements made by a nurse is most reflective of the proper understanding of the role that unlicensed ancillary staff may play regarding the instillation of eye medications?
"Her vision may be temporarily impaired, so please help her to the bathroom."
During a spiritual assessment, which question asked by the nurse assesses connectedness?
"How do you feel after you've prayed?"
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make?
"I am going to listen to your abdomen." The nurse should auscultate the client's abdomen to determine the presence of bowel sounds before clear liquids can be administered.
What statements made by the patient indicate that the patient's self-concept is improving following treatment? Select all that apply.
"I am pretty comfortable with my crutches." "It is easier to administer insulin than I had imagined." "Physical therapy is going well. I'm going to be on my feet soon."
The nurse is caring for an elderly patient who has diarrhea, and the nurse suspects that the patient has a biomedical perspective of illness. Which statement by the patient helped the nurse to reach this conclusion?
"I am sick because of unhygienic surroundings."
The nurse is caring for a patient newly diagnosed with cancer. Which statement made by the patient is an example of faith?
"I am sure this has happened to me for a reason and someday I will understand why."
Which statements made by an older-adult woman whose husband recently died mostindicates the need for follow-up by the nurse?
"I have been unable to talk with my children lately."
Normal range for respirations
12-20
Normal range for pulse
60-100
Which technique is most accurate in identifying an appropriate vein site for IV catheter insertion into the arm?
Apply a tourniquet to the selected arm 4 to 6 inches above.
The nurse is caring for a patient who os refusing an important treatment based on religious beliefs. Which is the best action for the nurse to take?
Ask the patient how they need to incorporate their beliefs into their care.
Name on major contraindication to shaving a male resident with a straight razor ___________________.
Blood Thinner
When you assist a person to ambulate/walk, what should would do first: a. Apply braces to the legs b. Get crutches, cane or walker c. Apply a gait belt d. Get the patients glasses
C
What is the best way for the nurse to ensure that a patient receives the correct dose of a medication?
Compare the prescriber's order with the medication administration record before dispensing the medication
When preparing to administer a new medication, what would the nurse do first to ensure the patient's safety?
Compare the written order with the medication administration record (MAR).
What can happen is constipation is not relieved? a. Enema b. Diarrhea c. Incontinence d. Fecal Impaction
D
When removing soiled linens, you must wear: a. A gown b. Face Mask c. Eye Protection d. Gloves
D
Which action might the nurse take when drawing up medication from an ampule?
Hold the ampule upside down while inserting the filter needle.
A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take?
Hold the linens away from the body and clothing.
A patient is hospitalized with heart failure states that she sees her illness as an opportunity and a challenge. Despite her illness, she is still able to see that life is worth living. Of which concept is this an example?
Hope
What does the "I" stand for in the FICA Spiritual Assessment Framework?
Importance of faith
Who can the nurse contact to provide spiritual care in the absence of a personal spiritual advisor identified by the patient?
Interfaith chaplain
What concept of intersectionality addresses the fact that some groups have limited access to certain facets of society such as the labor market?
Marginalization
Which concept of intersectionality refers to limited access to certain facets of society?
Marginalization
What is the nurse's first step in preparing to administer a prescribed medication using an automated medication dispensing system?
Review the medication administration record (MAR)
How would the nurse prepare insulin to ensure its efficacy?
Roll the vial of insulin suspension between the palms prior to drawing up the medication.
Religious leaders and families participate in making medical decisions mostly in which system of beliefs?
Sikhism
For which manifestation would the nurse look when assessing an altered self-concept in a patient? Select all that apply. One, some, or all responses may be correct.
Slumped postureoverly apologetichesitant speechavoidance of eye contact
Which concept of intersectionality involves unequal access to resources and services?
Social inequality
Buddhist's believe that life is suffering. Which concept is represented by this?
The four noble truths
The nurse is examining a patient who just had a spontaneous abortion. What observations suggest to the nurse that the patient has good self-esteem post incident and is coping well? Select all that apply.
The patient's husband stays by her side and holds her hand. The patient seems depressed but is asking the health care provider about conceiving again.
True or False HIV medications can make you very sick
True
True or False The enema tubing is usually inserted 6 inches into the adult rectum
True
True or False Trochanter rolls prevent the hips from turning inward
True
Which step to protect the patient from infection is of special concern when preparing a mini-infusion pump to deliver an analgesic?
Use an antiseptic swab to wipe the proximal injection port on the primary tubing.
What is the nurse's first response when a patient requests another dose of narcotic pain medication before it is time for the next dose?
Working with the patient to find alternative nonpharmacologic means of pain management
stage 4 ulcer
full thickness loss; can see organs/ bones; very painful
parasomnias
night terrors, sleep walking/talking/eating/driving, bed wetting
The nurse is performing a cultural assessment of a patient. Which question by the nurse reflects a focused question?
"Is there someone with whom you want us to talk about your care?"
The nurse is conducting a health interview for a patient. Which assessment question is an example of an open-ended question? Select all that apply. One, some, or all responses may be correct.
"What do you think caused your illness?" "How do you want us to help you with your problem?"
In order to incorporate spirituality into the plan of care, which questions, based on the HOPE framework; will the nurse ask an end-of-life patient? Select all that apply. "How do you personally practice spirituality?" "Can you tell me how important your faith is to you?" "I see you're crying. Would you like me to call the chaplain?" "Do you want me to call your family?" "Why do you believe in God?"
- "How do you personally practice spirituality?" - "I see you're crying. Would you like me to call the chaplain?"
A pt is taking albuterol through a pressurized metered-dose inhaler (pMDI) that contains a total of 200 puffs. The pt takes 2 puffs every 4 hrs. How many days will the pMDI last?
16
In which religion is Karma considered a strong belief?
Buddhism
Men often times have difficulty urinating because: a. kidneys atrophy b. bladder increases in size c. prostate gland enlarges d. urethra loses tone
C
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?
Confirm unresponsiveness
Communication that uses written/spoken word is: a. nonverbal b. focusing c. body language d. verbal communication
D
Infestation of the body with lice is called: a. dandruff b. pediculosis corporis c. pediculosis pubis d. pediculosis capitis
D
Which of the following is an important function of the skin: a. prevents pressure on the subcutaneous tissue b. provides support to the internal organs c. first line defense against infection d. all of the above
D
Which temperature is considered MOST accurate? a. Oral b. Axillary (A) c. Temporal d. Rectal (R)
D
The nurse is caring for a pregnant woman who is in labor. When the nurse asks the woman if she wants her husband to be near when she is delivering, the patient strongly objects. People of which cultures are likely to react in this way?
Hindus Muslims Religious beliefs sometimes prohibit the presence of males, including husbands, from the delivery room. This often occurs among devout Muslims, Hindus, and Orthodox Jews. People from Mexico, the Philippines, and Roman Catholics are comfortable with the husband staying with them during childbirth. p. 103
What is the most common reason for elective cosmetic surgery?
Improve self-image
What is the most important action the nurse can take to protect the patient when administering a narcotic analgesic by IV bolus?
Injecting the medication at the prescribed rate
A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from stretcher to the bed?
Lock the wheels on the bed and stretcher
The nurse is preparing to administer several oral medications when the patient states, I'd really like to take these pills with orange juice. The most appropriate response to this request is for the nurse to:
Establish whether the medications may be taken with orange juice.
The nurse is preparing to discharge a patient after providing instructions regarding the self administration of a topical medication. The nurse should best follow up this intervention before discharge by:
Evaluating the patient's ability to apply the medication.
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?
Exert pressure on the bony prominences when holding the eyelids open. The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye.
After seeing a pt, the physician gives a nursing student a verbal order for a new med. The nursing student first needs to:
Explain to the physician that the order needs to be given to a RN
The nurse questions a Jehovah's Witness patient about his faith belief system and whether or not members of his faith community need to be involved in his care. Which spiritual assessment framework is being used for this patient?
FICA
In which site would it be inappropriate to administer an intradermal injection?
Right deltoid of a high school softball pitcher
Which process/communication/belief describes moving beyond the present and into the future?
Transcendence
When preparing to administer medication via the intramuscular route, the nurse should avoid which of the following sites?
Vastus lateralis muscle of a patient with burns to both thighs
The nurse calculates that the patient is to receive 125 mL of IV normal saline per hour. After programming the infusion pump to deliver at that rate, how would the nurse ensure accurate fluid administration?
First verify that the fluid is dripping, and then check the level of fluid remaining in the container every hour.
A 55-year-old male patient underwent a colostomy. Earlier he underwent coronary artery bypass graft (CABG) surgery. The nurse finds the patient depressed and weeping. The patient expresses that he is fed up with his poor health. He feels that he has become a burden on his family because he can't work now. The nurse finds that the patient's body language is suggestive of altered self-concept. Which behaviors suggest low self-esteem? Select all that apply.
Frequent crying Hesitant speech Avoidance of eye contact Behaviors that are suggestive of altered self-esteem include frequent crying, hesitant speech, avoiding eye contact, slumped posture, and an unkempt appearance. Normal speech and maintaining good eye contact are suggestive of a normal and positive self-esteem.
Which events in life can alter the self-concept of a person significantly? Select all that apply.
Having a child Losing a child Being promoted at work Being diagnosed with a chronic illness Having a child changes the role of a person to a parent and affects a person's self-concept. Losing a child brings shock and depression, which negatively influence the self-concept. Being promoted at work boosts an individual's self-concept. A diagnosis of a chronic illness may reduce the self-esteem of the patient considerably. Events such as taking an exam would not influence an individual's self-concept.
Assessment:
collecting vital signs, pain levels, other signs/ symptoms
psych facilities
focus on clients with emotional / behavioral problems
nursing centers
focus on health promotion/ health education, disease prevention, chronic disease management, support for self-care and caregivers
new philosophy of health care
manage health; wellness and prevention
transpersonal communication
persons spiritual domain; higher power; prayer, meditation, guided reflexion
Virchow's triad
stasis-immobility, bed ridden, car/plane/ train travel vessel wall injury, fracture, trauma hypercoagulability- altered coagulation (birth control, hormone therapy, smokers, dehydration)
A 62-year-old male patient has just been told he has a terminal illness. Which statement indicates that the patient is spiritually distressed because of the diagnosis of terminal illness?
"I have nothing to live for now."
The nurse is performing a cultural assessment of a patient. Which question of the nurse reflects a focused question?
"Is there someone with whom you want us to talk about your care?" Asking the patient if there is someone with whom he or she would like the health care team to discuss his or her care is an example of a focused question. Asking the patient what he or she does to keep him- or herself well assesses the patient's beliefs and practices. Asking the patient with whom he or she lives assesses the patient's social organization. Asking the patient what he or she thinks the reason is for an illness is an open-ended question. p. 107
Which instruction might the nurse give to NAP when caring for a patient whose IV access device is to be removed?
"Let me know if you notice any bleeding on the site dressing."
Which instruction might the nurse give to NAP regarding the care of a patient with a venous access device?
"Let me know if you notice that the dressing has become damp."
A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?
"What do you think caused the onset of your pain?" The nurse is using an open-ended question that allows the client to respond with a wide range of information by using more than one or two words.
The nurse is carrying out an assessment of a Chinese patient with pain in the abdomen. Which question by the nurse is open-ended?
"What do you think of your problem?" Open-ended questions allow the patient to express feelings or to elaborate more on the situation. Open-ended questions do not limit the patient's response to either "yes" or "no" or a short answer. In this scenario, asking what the patient thinks about the problem is an open-ended question. Asking about the location, severity, or duration of the pain are closed-ended questions. p. 107
Nurses are likely to refer chaplains to which care areas? Select all that apply. Oncology units Intensive care Emergency department Hospice Critical care unit
- Oncology units - Intensive care - Hospice - Critical care unit
Which is an actual nursing diagnostic label related to spirituality? Select all that apply.
- Spiritual Distress - Decisional Conflict - Moral Distress
how to process an ethical dilemma
1. ask if this is an ethical dilemma 2. gather all relevant info 3. clarify values 4. verbalize problem 5. identify possible courses of action 6. negotiate a plan 7. evaluate plan
When will a patient's blood glucose levels be most affected by a short-acting insulin injection, such as Humulin-R?
In 2 to 3 hours
To prevent hypoglycemia and enhance efficacy, it is appropriate to give rapid-acting insulin how many minutes before the next meal?
5 to 15 minutes
A patient is prescribed 1000 mL of IV normal saline to run over 8 hours. The initial fluid is hung at 0800. How many milliliters of fluid will have infused by 1200?
500 mL
Normal range for temperature
96.8-100.4
hyperventillation (kussmaul)
>40 RR; over-breathing, decreased CO2 leads to alkaline; panic attack, stress/anxiety, fever/infection, intense exercise
Normal range for pulse ox.
>95%
An infection of the bladder is called: a. cystitis b. pyelonephritis c. renal calculi d. dialysis
A
An older persons ability to sense pain is: a. Decreased b. Increased c. The same as every other adult d. the same as a baby
A
An uncircumcised male resident needs perineal care. Which of the following statements is true? a. the foreskin should be retracted. After cleaning, the foreskin is returned to its natural position. b. you should perform the procedures as if the resident were circumcised c. the labia are separated Downward strokes from front to back are used the area d. there is no difference
A
Bath water temperature should be at what temperature: a. 110- 115 degrees F b. 110- 120 degrees F c. 105 degrees F d. 105- 109 degrees F
A
Blood vessels that carry blow away from the heart are called: a. arteries b. veins c. venulee d. capillaries
A
When caring for a patient who is suffering from a serious illness, the nurse encourages the patient to follow his or her spiritual practices. How does spirituality help in healing? Select all that apply. One, some, or all responses may be correct.
Increases the pain threshold of the patient. Decreases stress and increases the immune response. Reduces perception of pain and anxiety.
Why is it important to label the gauze dressing covering the site of an intravenous access device with the date, time, and nurse's initials?
Informs the nurse and other staff when the next dressing change is due
The nurse receives an order to infuse 1000 mL of D5W at 125 mL continuously. Which of the following actions by the nurse indicates correct interpretation of this order?
Infusing D5W at a rate of 125 mL/hour until the health care provider changes the order
How can the nurse prevent negative pressure from building up in the vial when preparing an injection?
Inject an amount of air into the vial equivalent to the volume of medication to be withdrawn.
When preparing an injection that contains both short- and intermediate-acting insulins, what is the first step the nurse would take to ensure the effectiveness of the injection?
Insert air into the intermediate-acting insulin.
What will the nurse do to prevent possible complications after removing an IV access device in a patient on anticoagulant therapy?
Apply firm pressure to the site with sterile gauze for 10 minutes.
If the nurse does not see blood return when aspirating the saline lock in preparation for an IV bolus medication, what is the next step?
Assess the site for swelling or coolness while flushing the saline lock with normal saline.
The NAP reports to the nurse that a patient's intravenous access device dressing is wet. What would the nurse do first?
Assess the site.
Which statement describes cultural skill according to Campinha-Bacote's model of cultural competency?
Assessing social, cultural, and biophysical factors before initiating the treatment.
When the nurse asks about religious preference, the patient states, "I do not believe that God exists." Which religion will the nurse record as the patient's religious preference?
Atheist
A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss?
Attempt to increase the client's self-motivation
The nurse is teaching the proper technique for using an inhaler to a 12-year-old patient who suffers from asthma; the nurse is also teaching exercises to improve the breathing process. What should the nurse focus on to avoid development of an altered self-concept? Select all that apply.
Awareness of limitations Awareness of strengths Acceptance of changes in physical endurance Providing reinforcement for mastery of a new skill
Mr. Edwards is on strict bedrest. Which of the following statements is correct? a. he has a contracture b. good body alignment is important c. he can get up to use the bathroom only d. he has orthostatic hypotension
B
Mr. Kline is bedbound. How often should reposition him? a. at least every hour b. at least every two hours c. at least every four hours d. at least every shift
B
Mr. Poole's blood pressure measure remains above 150/100 mmHg. This is called. a. tachycardia b. hypertension c. hypotension d. anxiety
B
When preparing an injection of mixed insulin that includes 12 units of NPH and 5 units of regular insulin, how does the nurse initially confirm the proper dosage in the syringe?
By noting when 5 units of clear insulin is visible in the syringe
Muscle Atrophy is: a. the abnormal shortening of a muscle b. bending backward c. the decrease in size or wasting away of a muscle d. excessive straightening of a body part
C
Rectal temperatures are taken: a. a person has a diarrhea b. a person has had rectal surgery c. the person has trauma to their face d. the person has a heart problem
C
The call bell or signal light should ALWAYS be: a. on the bedrail b. attached to the pillow c. within the patients reach d. on the arm of the chair
C
The goal of the healthcare team is to: a. Carry out the MDs orders b. Develop plans of care for residents c. Provide quality care d. Complain about the workload
C
Those persons who provide basic nursing care under the supervision of a registered nurse or a licensed practical nurse are: a. Licensed practical nurse b. Case managers c. Assistive personnel d. The "health care team"
C
What is the besy way to promote the resident independence in bathing a resident who has had a stroke? a. Limit the client to washing her hands b. Leave the client alone and assume the client will do as much as she can c. Encourage the client to do as much as possible and assist as needed d. Give the client a complete bed bath only if requested
C
You enter a patients room and the resident states they are in pain. What should you do? a. ignore the clients statements b. tell the clients to suck it up the pain will go away c. report it to the nurse d. tell the client they will feel better if they just get out the bed
C
You go to check on a resident and the gown is soiled. The next action should be: a. clean the patient and put the soiled gown back on b. leave the patient dirty and change the gown c. clean the patient and put on a clean gown d. walk out of the room
C
Your patient has left sided weakness, how do you put on their shirt? a. Clients choice b. Right sleeve c. Left sleeve d. Both sleeve together
C
The patient has requested a PRN medication for nausea. Which of the following should the nurse do first?
Check to see when the medication was given last and make sure the time interval is up
Which type of cultural competency recognizes biases, prejudices, and assumptions about other people?
Cultural awareness
How is cultural competence different from patient-centered care? Select all that apply. One, some, or all responses may be correct.
Cultural competence aims to increase health equity. Cultural competence emphasizes reducing disparities. Cultural competence concentrates on disadvantaged groups.
An official record of persons who have completed a Nursing Assistant training and competency evaluation programs. a. OBRA b. Civil law c. Protected nursing assistants records d. Nursing Assistant Registry
D
Before leaving on for lunch, you need to: a. Use the bathroom and wash your hands b. Turn off the computer c. Call home and check on your children d. Tell the nurse
D
Before putting your patients feet on the floor for ambulation, you want to ensure: a. They wear whatever they want b. Slippers c. Cowboy boots d. Non skid footwear
D
HIV can be spread by a. sneezing coughing b. insects c. holding hands and hugging d. unprotected anal, vaginal or oral sex as well as blood exposure to unbroken skin
D
In your role as a nursing assistant, you are able to: a. You can take verbal orders over the phone from doctors b. Give medications c. Insert a foley in the patients vagina or penis d. Report changes in the residents condition to the nurse
D
Increased signs, symptoms and behaviors of Alzheimers Disease during the hours of darkness is called a. night time fatigue b. sleep deprivation c. delirium d. sundowning
D
Information that you can see, hear, feel or smell is called: a. Assessment b. Observation c. Objective data d. Subjective data
D
Your resident wears dentures. What should you check the dentures for when providing oral care? a. bleeding gums b. irritation or watch patches in the mouth c. dryness and cracks in the oral mucousa d. rough, sharp or chipped areas
D
You are giving mouth care to an unconscious resident. You must be especially careful to prevent the resident from: a. Talking during the procedure b. Biting down on the toothbrush c. Eating the toothpaste d. Aspirating fluid
D.
The nurse is preparing to administer insulin to a patient. Which of the following actions will best ensure the patient's safety?
Determining the patient's current blood glucose level
How can the nurse ensure that medication from a single-dose vial is used appropriately?
Discard the vial and any remaining medication in the vial directly after use.
Which belief would an agnostic person profess? Select all that apply. One, some, or all responses may be correct.
Discovering meaning in what he or she do or how he or she lives. Not finding ultimate meaning for the way things are. Believing that people bring meaning to what they do.
Which nursing action demonstrates appropriate spiritual care for a school-age child whose parent is terminally ill?
Discussing with the child the permanence of the child-parent relationship and that the illness is not caused by anything the child did.
A nurse is replacing the surgical dressing on a client who had abdominal surgery. Which of the following actions should the nurse take?
Don clean gloves to remove the old dressing.
The nurse is planning care and treatment of a patient with a below-the-knee amputation who currently has very low self-esteem. What interventions should the nurse include to improve the self-concept of the patient when outlining the care plan? Select all that apply.
Enroll the patient in a class that will teach ambulation with assistive devices. Involve the patient in planning the schedule and extent of physical therapy. Schedule a prosthetic expert to talk to the patient.
True or False It is best practice to cut toenails with scissors
False
True or False Medical diagnosis and the nursing diagnosis are always the same
False
A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?
Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back
A patient is diagnosed with a diabetic ulcer with gangrene to his foot. The health care provider advises surgery, but the patient refuses because removal of a body part is not permitted according to his or her religion. Which concept justifies this scenario?
Iceberg analogy
Based on knowledge of the developmental tasks of Erikson's industry-versus-inferiority stage, the nurse emphasizes proper technique for use of an inhaler with a 10-year-old boy. Why does the nurse do this?
It increases the patient's self-esteem with the mastery of a new skill.
The self-concept of an individual is influenced by various environmental, social, and psychological factors. How is a self-concept stressor defined?
It is a real or perceived change that threatens a person's identity and body image.
Which task might the nurse delegate to NAP caring for a patient receiving IV medication via mini-infusion pump?
Notifying the nurse if the pump alarm sounds
The patient refuses the scheduled dose of an antibiotic, saying that the medication makes him feel nauseated. What it the nurse's best response?
Notifying the prescriber of the patient's reason for refusing the medication
Who makes the most referrals to a hospital chaplain?
Nurses
A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?
Obtain client information
How can the nurse best ensure the patient's safety when preparing insulin for administration?
Obtain the patient's current blood glucose level.
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?
Obtaining cotton balls for the tracheostomy care
The nurse is assessing an Asian patient in a day care center. The nurse is developing a transcultural care plan for the patient who identifies both with his native culture and the American culture. Which components should the nurse incorporate in order to provide culturally congruent care? Select all that apply.
Obtaining knowledge of the patient's health beliefs. Self-examining the nurse's own culture. Being open and accepting of cultural differences.
A 20-year-old patient is diagnosed with an eating disorder. Which nursing intervention would be best to address self-esteem?
Offer independent decision-making opportunities.
What are the familial factors that contribute to the development of high self-esteem? Select all that apply.
Parental support Social support Positive communication
To insure proper needle insertion, during the administration of heparin via the subcutaneous route to a patient whose body mass is above the normal range, the nurse should:
Pinch up the skin at the site with your thumb and forefinger.
How might the nurse safely administer an extended-release capsule to a patient with dysphagia?
Place the capsule in a spoonful of the patient's applesauce.
The nurse is administering a time-released capsule to a patient with a history of dysphagia after a cerebral vascular accident. To minimize the risk of injury to the patient, the nurse should:
Place the capsule in a spoonful of the patient's applesauce.
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use?
Place the wheelchair at a 45 degree angle to the bed
How does the nurse ensure that he or she meets the goals related to self-concept alterations in an acute care setting? Select all that apply.
Plan for the patient's discharge to home. Make referrals to other health care professionals. Schedule routine follow-up appointments.
Which of the following statements made by a nurse is most reflective of the proper understanding of the role that unlicensed ancillary staff may play regarding the application of topical medications?
Please apply that moisturizing lotion to the patient's elbows.
What factors should the nurse look for when assessing the emotional development of a 15-year-old patient? Select all that apply.
Positive feelings of self Maturation Goals for the future Acceptance of bodily changes
Which precaution should the nurse observe to ensure patient safety when using an automated medication dispensing system?
Prepare medications for one patient at a time
A nurse is changing the dressing for a client who is 3 days postop following a cholecystectomy. The nurse observes, yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?
Purulent exudate
The nurse is performing a spiritual assessment on a patient admitted for trauma following an auto accident. What should the nurse include in the spiritual assessment?
Questions about the patient's specific preferences
The nurse wants to assess health literacy in a group of patients. Which measure does the nurse use to evaluate word recognition?
Rapid Estimate of Adult Literacy in Medicine (REALM) Rapid Estimate of Adult Literacy in Medicine (REALM) is one of the health literacy measurements that used to assess word recognition. C-LARA is a communication technique used during cultural assessment. The Test of Functional Health Literacy in Adults (TOFHLA) is used to measure reading skills and numeracy of patients. Culturally and Linguistically Appropriate Standards (CLAS) is an organization that advances health equity, improves quality, and helps eliminate health disparities. p. 100
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?
Remove the restraints one at a time
A nurse is planning care for a client who is confused and requires a prescription for wrist restrains. Which of the following interventions should the nurse include in the plan of care?
Renew the prescription for the use of restrains within 24 hr. The nurse should plan to renew the prescription for the restraints within 24 hr, and only after the provider has evaluated the client.
A patient states, "My religion does not permit me to bathe today." Which nursing action would be mostappropriate?
Request clarification of the patient's beliefs and adapt a plan for bathing accordingly.
Which nursing action(s) are most effective to assist a typical adult male patient to make health care decisions related to spirituality?
Researching and providing factual information
The nurse consistently observes that the positioning of a confused patient's arm has a direct effect on the flow rate of the IV solution. What might the nurse do to ensure infusion of the patient's IV fluid at a consistent rate?
Restart the IV in another location less affected by the patient's positioning.
The nurse is caring for a Korean woman who has just delivered her first baby. Which soup should the nurse anticipate the family to provide as the first meal to the woman?
Seaweed Soup Koreans believe that seaweed soup should be given to a woman immediately postpartum because it cleans the blood and helps healing and lactation. Tomato, sweet corn, and hot garlic soups can be given later but are not specifically part of the Korean culture. p. 106
What elements influence the achievement of identity in a person? Select all that apply.
Sexuality Gender Ethnicity
A pt is receiving an IV push med. If the drug infiltrates into the upper tissues, the nurse
Stops the administration of the meds and follows agency policy
What stressors is a patient likely to experience in an acute care setting? Select all that apply.
Stress related to diagnostic tests and results. Stress related to an altered body image. Stress related to lifestyle modifications. Stressors affecting a patient in an acute care setting are fear and anxiety related to diagnostic tests and their results. There is also potential fear and stress about a disturbed body image due to surgery or other physical condition. The patient also experiences the stress of adapting to an altered lifestyle because of the medical or physical condition. The patient may not be greatly affected by what the family thinks about his or her condition. Stress related to socialization is more common in elderly patients.
The nurse is preparing to insert a venous access device into a newly admitted 75-year-old patient. Which vein is not an inappropriate choice for IV insertion in this patient?
Superficial dorsal vein
As the nurse is administering medication to a patient, the patient states, "I've never seen that pill before." What is the nurse's most appropriate response?
Tell the patient that you will review the physician's order to clarify any discrepancies.
The nurse is assessing a patient who lost his fingers in an accident with a meat mincer. What patient behavior is suggestive of an altered self-concept? Select all that apply.
The patient does not make eye contact while talking. The patient still cannot believe he was so careless. The patient states that he wants to be left alone.
A patient who is spiritually distressed comes for a follow-up. What observations by the nurse indicate positive outcomes in the patient? Select all that apply.
The patient expresses increased hope of becoming healthy. The patient's relationship with his partner is satisfactory. The patient is compliant with his medication regimen.
A nurse is preparing to administer an IM injection to a client who is overweight. Which of the following sites should the nurse select for injection?
The side hip between the iliac crest and anterior iliac spine. This site is the preferred site for intramuscular injections for an adult client.
Which statement is true regarding the goal of core measures?
They help reduce mortality, complications, and inpatient readmissions.
True or False Before using your stethoscope on a resident you should wipe the earpieces and diaphragm with antiseptic wipes.
True
True or False Even with residents of nursing facilities, use of condoms will prevent STDs.
True
True or False Follow Standard Precautions and the Bloodborne Pathogen Standard when giving oral care
True
True or False I will document appropriately, date, time, event and not leave anything out!
True
True or False Listen and use silence when dealing with an angry person
True
True or False Taking an apical pulse requires a stethoscope and some sort of clock
True
How will the nurse minimize the risk for infection when changing a patient's IV catheter site dressing?
Use aseptic technique throughout the process.
Which action will the nurse take to minimize a patient's risk for injury when applying a dressing to an infusion site?
Use aseptic technique throughout the process.
The nurse is preparing to instill eardrops for the treatment of an ear infection. To best minimize the risk of injury to the patient as a result of the instillation, the nurse should:
Warm the eardrops to room temperature before instillation.
A nurse is preparing to withdraw medication from an open multidose vial. After confirming that the vial contains the appropriate medication and checking the expiration date, what would the nurse do next?
Wipe the rubber seal of the vial with an alcohol swab.
The nurse is preparing to withdraw medication for an opened multidose vial. After confirming that the vial contains the appropriate medication and checking the expiration date, the nurse should:
Wipe the rubber seal of the vial with an alcohol swab.
professional nursing code of ethics
a set of guiding principles that all members of a profession accept; helps professional groups settle questions about practice or behavior; includes responsibility, accountability, and confidentiality
left sided failure
blood backing up into lungs; shortness of breath; impaired gas exchange; hypertrophied left ventricle wall; coughing up blood; orthopnea; exertional dyspnea; cyanosis of extremities; paroxymal nocturnal dyspnea
ICU
close monitoring; 1:2 staffing; equipped with most advanced technology; staff educated in critical care principles/ techniques
autonomy
commitment to include clients in decisions
hypoventillation
decreased ability to remove CO2 from body; pH below 7.35; RR below 12; emphysema/ CVA; hypoxic
A nurse is preparing an IV infusion prior to initiating an IV. The nurse removes the protective sheath covering the tubing insertion spike and accidentally touches the spike. What is the nurse's next action?
discard the IV tubing and obtain new ones
Proteins
essential from growth, maintenance, and repair of body tissue; amino acids; complete and complementary; nitrogen balance
Vitamins
essential to normal metabolism; fat soluble(A,D, K,E) can be stored in body except D; water soluble(C and B complex) cannot be stored in body; obtained from fruits, milk, veggies, fish, cereal, grains, nuts, sunlight
social patterns affecting hygiene
ethnic, social, and family influences on hygiene patterns
polyuria
excessive urine; sign of diabetes or hormone issue
feminine ethics
focuses on the inequality between people
Implementing:
following through with plan that was developed for the patient
UTI s/s
frequency/ urgency; burning pain when voiding; hematuria; fever; chills; nausea; vomiting; pyelonenephritis; malaise
Latrogenic HAI
from a procedure in a hospital
Exogenous HAI
from microorganisms outside the individual ( Salmonella)
purpose of teaching
gaining new knowledge, change attitudes, adopt new behaviors, preform new skills,
Evaluation:
goal was met, partially met, not met; how effective the plan was for the patient and what should be changed for the patient
Which belief does an atheist profess?
god does not exist
NSAIDS & non-opiates
has analgesic/ antipyretic effects; available OTC; used for moderate to mild pain; blocks pain impulses by inhibiting prostaglandin synthesis; lethal when overdosed; do not take with alcohol; do not take if liver dysfunction, possible liver failure
treatment for hyperventillation
have patient hold one nostril; try to reduce patient;s stress/panic; purse-lipped breathing
changes in pattern affecting sleep
illness (cardiac, resp, pain), RLS; food before bed; change in daily pattern
Obese
increased weight for height by 10% or more
4 stages of infection
incubation period, prodromal stage, illness stage, convalescence
Minerals
inorganic elements essential as catalysts in biochemical reactions; obtained in milk, eggs, meats, grains; maintains acid/base balance, osmotic pressure, oxygen transport
teaching
interactive process that promotes learning
evidence based practice
interventions nurses do that are based on evidence
futile care
interventions unlikely to produce benefit for the client
infection
invasion of a susceptible host by pathogens or microorganisms. resulting in disease
bariatrics-
lap band reduction; gastric bypass
Carbohydrates
main source of energy; glucose needed for brain, skeletal muscles, production of RBC/WBC, all functions of renal medulla; obtained from grains, fruits, veggies, milk, sugar, honey
old philosophy of health care
manage illness; disease management
physical condition in hygiene
may lack physical energy / dexterity to preform self-care
stage 4 PAD
necrosis/ gangrene; loss of oxygen to toes > toes fall off/ need to be removed
Which dietary practice is followed by a Hindu patient?
not eating any meat
kidney/ renal disease
not enough RBCs; anemia; metabolizes calcium and Vitamin D; ADL intolerance; risk for hyper/hypotension, anemia, soft bones, and fractures; caused by diabetes; patient has to out out at least 30mls per hour
colonization
occurs when a microorganism invades the host but doesn't cause infection
Opioids
pain relivers that contain opium or chemically related to opium; ordered for moderate to severe pain such as post-op, chronic non-cancer, or cancer; depresses respiratory center, causes constipation, itching, altered mental status
stable angina
predictable
An emergency department nurse is caring for a patient who was severely injured in a car accident. The patient's family is in the waiting room. They are crying softly. The nurse sits down next to the family, takes the mother's hand, and says, "I can only imagine how you're feeling. What can I do to help you feel more at peace right now?" Which concept is the nurse demonstrating in this example?
presence
Free Radical Theory
presence of free radicals produced through normal respiration and metabolism cause damage to existing cells, some believe this can be reversed through consumption of vitamins and other products
impaction
result of unrelieved constipation; leaky drainage
factors that affect med absorption
route of administration; ability to dissolve; blood flow to site of administration; body surface area; lipid solubility of medication
The nurse notices failure of flow in drip chamber with roller clamp open and an absence of swelling at insertion site. What should you do? (SATA)
should determine patency by aspirating for blood E. check for kink in IV line.
peritoneal dialysis
shunt placed in peritoneum; diasolate poured in peritoneum, about 1hr later diasolate, nitrogenous waste, fluid, electrolytes removed
tamaflu
stops flu virus multiplication; increases risk for self injury; take within 48 hr of onset
beneficence
taking positive actions to help others
Medication absorption
the passage of medication molecules into the blood from the site of administration
Fats
triglycerides and fatty acids; saturated or unsaturated; monounsaturated or polyunsaturated fatty acids; essential or nonessential
Erikson's 8 stages of development
trust vs mistrust autonomy vs shame and doubt initiative vs guilt industry vs inferiority identity vs identity confusion intimacy vs isolation generativity vs stagnation integrity vs despair
causes of urinary incontinence
urethral obstruction, surgical trauma, alterations in sensory/ motor innervation, medication side effects, anxiety
Which statement or question best illustrates the nurse's understanding of the role of NAP in using medication dispensing systems?
"Let me know if she complains of any nausea."
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?
"Tell me what I can do to help you overcome your fear of giving yourself injections."
Ms. Schnieder has an order for NPO after midnight. This means: a. fluids are restricted b. accurate records are kept of oral intake c. she can eat whatever she wants or drink whatever she wants d. she is encouraged to drink a variety of fluids
A
The role of the ombudsman is: a. Work with the nursing home to protect the clients rights b. Control the nursing home budget c. Prepare classes that nurses aides take to learn hygiene d. Run a group of nursing homes
A
The type of bone that bears weight of the body is called: a. long bone b. flat bone c. irregular bone d. short bone
A
Your resident is "comatose" you should assume: a. They can hear b. They can see c. They can touch d. They can speak
A
Self-esteem stressors vary with developmental stages. In children, what are the stressors that affect self-esteem and self-worth? Select all that apply.
An inability to meet parents' expectations Sibling rivalry In children, the inability to meet the expectations of parents and sibling rivalry issues can decrease the level of self-esteem and self-worth. An unsuccessful relationship is a stressor that affects the self-esteem of an adult. The late onset of education has a limited, if any, effect on a child's self-esteem. The loss of a companion or a spouse can affect self-concept in an older adult.
The nurse is teaching a 10-year-old patient about personal hygiene. What observation would indicate that the child has not reached an age-appropriate developmental stage?
An inability to understand and master brushing technique. As per Erikson's developmental stages, a 10-year-old child should be able to understand and reinforce information provided and master new skills, such as the basic hygiene tasks the nurse discusses. A person starts to accept age-related body changes and begins to establish goals in adolescence, but may not do so as young as 10 years of age. The assessment of life goals is not expected until adulthood. Setting goals for the future, such as deciding which school to attend or what career to pursue, is a developmental behavior for children 12 to 20 years old.
When preparing to administer an injection of insulin, the nurse recognizes that which of the following areas is not an appropriate injection site?
Area within 2 inches of the umbilicus
What is the best way for the nurse to ensure that the patient does not receive the wrong dose because of a calculation error?
Ask another registered nurse to verify the calculation.
Which action can the nurse take to minimize the patient's risk for infection when applying new tubing to a primary IV infusion?
Both selections A and C are appropriate to minimize the patient's risk for infection
Which statement complies with The Joint Commission's (JCAHO) requirements to incorporate spiritual health into the patient's care? Select all that apply.
- "Do you have family in the area?" - "Is there anyone that you would like to call?" - "Do you belong to a faith community?"
When preparing an injection of mixed insulin that includes 12 units of NPH and 5 Units of Regular insulin, the nurse initially confirms proper dosage when:
5 units of clear insulin are visible in the syringe.
You are caring for Mr. Gomez. He requested to be shaved. Which statement is false? a. report nicks or cuts to the nurse at once b. shave away from the direction of hair growth c. soften the skin before shaving d. hold the skin taut as necessary
B
What is the term for a device used to take the place of a missing body part? a. Pronation b. External rotation c. Amputation d. Prosthesis
D
What is the meaning of spirituality?
Expression of significant and purpose in life
The nurse wants to include spiritual care when planning care for a sick patient. Which action would the nurse allow? Select all that apply. One, some, or all responses may be correct.
Family members to plan a prayer session Slow, religious music Time for religious readings
A nurse is preparing to anchor with tape the catheter tuber for a male client who has a new inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter?
Lower abdomen The nurse should secure with tape the client's indwelling urinary catheter to the lower abdomen or the upper aspect of the thigh to eliminate the penoscrotal angle and prevent tissue injury.
When preparing to administer medication via the subcutaneous route, the nurse should avoid which of the following sites?
Right deltoid of a high school softball pitcher
Which of the following statements is accurate regarding insulin administration?
Vials of insulin must be inspected before each use for changes in appearance.
What would the nurse do to assess a patient's risk for embolus when removing a venous access device?
Visualize the tip of the IV device.
A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet?
Vitamin C and zinc
affective learning
expression of feelings and acceptance of attitude, opinion, values
reflex incontinence
on urge to go; it just comes out
Which statement made by a Native American patient recovering from chemotherapy treatment indicates the diagnosis of Readiness for Enhanced Religiosity?
"It is important for me to make dietary choices according to the tribal beliefs of my community."
Painful or difficult urination is called a. dysuria b. micturition c. urinary urgency d. oliguria
A
A nurse takes a med to a pt, and the pt tells them to take it away because she is not going to take it. What is the nurse's next action?
Ask the pts reason for refusal
The loss of urine in response to a sudden, urgent need to void is called: a. mixed incontinence b. functional incontience c. overflow incontinence d. urge incontinence
B
When performing perineal care, you should clean the: a. labia b. urethra to the anal area c. anal area to the urethra d. buttocks to the urethra
B
A patient underwent six cycles of chemotherapy for her cancer. She lost all of her hair due to drug effects. She is very worried and says, "My children may find me ugly. I will not be able to tolerate that." What stressor is most affecting her self-concept?
Body Image
What is the similarity between patient-centered care and cultural competence?
Both improve health care quality.
A 30-year-old patient suffering from osteoarthritis is unable to move without using a splint and lives with her mother. The patient no longer has a job. The patient refuses to meet anyone and feels worthless. What factors are responsible for this change in self-concept? Select all that apply.
Chronic illness Dependency on others Physical impairment Loss of job identity
A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?
Face the client when speaking.
What are two characteristics of spirituality?
Faith and hope
How can the nurse increase a patient's self-awareness? Select all that apply.
Help the patient define his or her problems clearly. Allow the patient to openly explore thoughts and feelings. Reframe the patient's thoughts and feelings in a more positive way. Helping a patient define his or her problems, allowing the patient to explore his or her feelings, and reframing the patient's thoughts and feelings in a more positive way are techniques designed to promote self-awareness and a positive self-concept. Having a family member assume more responsibility does not help a patient achieve self-awareness; instead it is important to encourage a patient to assume more self-responsibility.
A patient states that he would like to go to church every week, but due to immobility limitations, is unable. Which diagnosis is correct for this patient?
Impaired Religiosity
What are three types of spiritual practices?
Reflection, relationship, and faith rituals
Which statement is true regarding spirituality?
Spirituality has five overlapping constructs.
functional incontinence
can't make it to the bathroom in time; every 1/2 hr or 1 hr bring patient to bathroom/ put on schedule
granulation tissue
healing tissue; looks beefy
diarrhea
liquid stool; associated with disorders affecting digestion, absorption, and secretion in GI tract
s/s of PAD
red, inflammed, shortness of breath, coughing, increased heart rate, sweating, anxious feeling
uriticaria
reddish, whitish, plaques edematous; usually show up on torso; usually caused by drugs, histamine, bed linen detergent
Endogenous HAI
when patient's normal flora becomes altered (C.diff)
You are measuring vital signs on a resident. What do you report to the nurse immediately? a. the apical pulse b. any vital sign that is changed from a prior reading c. when you took the measurement d. vital signs within the normal range
B
To use reagent strips correctly, you should: a. ask the nurse b. check the plan of care c. check your assignment flow sheet d. read and follow manufactures
D
A pt is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe med administration for the discharge nurse?
Ensure that the home care agency is aware of meds and health teaching needs
True or False Nursing Assistants supervise other Nursing Assistants
False
True or False The plan of care for a resident tells you when to apply and remove heat/ice
False
True or False The towel bar is the best place for the resident to hold on for support when the resident gets in or out of tub.
False
The nurse is outlining a plan of care for a 9-year-old patient. What primary developmental task for this patient should the nurse consider?
Mastery of new skill
The nurse is planning care to meet the spirituality needs of a patient. How should the nurse involve the chaplain with this patient's care?
Nurses should make chaplaincy referrals when a patient demonstrates or verbalizes a need for spiritual care.
Under supervision of the registered nurse, a nursing student is caring for a patient from different cultural background. Which action performed by the student nurse indicates the need for further teaching on transcultural nursing?
Offering generalized opinions during the assessment of the patient's world view.
A 20-year-old woman who lives with her parents gives birth to a baby. Around the same time, her parents adopt a 5-year-old child. The young woman is overwhelmed and has difficulty balancing her role as a mother with her role as a sister. What kind of role performance stressor does the woman experience?
Role conflict Role conflict happens when a person has to assume two or more inconsistent roles. This new mother is trying to cope with the physical and psychological burdens of raising a child and is stressed by the addition of a new relationship with a young sibling, creating role conflicts. Role ambiguity occurs when a person is confused and not sure of his or her role. Role strain results from role conflict and role ambiguity. When a person has more responsibilities within a role than she can manage, she experiences role overload.
A patient was diagnosed with cervical cancer and underwent a hysterectomy. During assessment in the recovery room, the patient tells the nurse, "I don't believe in God anymore. I can't believe I can never have a child. Why me? I can never be the same person again." Which concept does this reaction suggest?
Spiritual distress because of loss of purpose in life
Which statement is true about religion?
Spirituality is often expressed through religion
What can the nurse do to ensure proper site selection for subcutaneous insulin injection?
Systematically rotate sites within the same anatomical location or area.
The registered nurse is teaching a patient of a different cultural background the procedure to self-administer insulin. After teaching, the nurse asks the patient to self-administer insulin. Which type of technique does the nurse use in this situation?
Teach-back
True or False Pain subjective and different for each individual
True
True or False Use of narcotic pain medications can cause constipation
True
Which of the following nursing actions will reduce the risk of "wrong route" when administering a medication?
Using an oral dosing syringe when administering oral liquid medication
roles of nurse
caregiver, advocate, educator, communicator, manager, autonomy and accountability
management of obesity
decreased food intake, increased physical activity
hypoxia
decreased tissue oxygenation; restlessness, anxiety, confusion, increased heart rate and RR
personal preferences affecting hygiene
dictates personal hygiene practices for individual patients
JCAHO's ethical standards
mandate that health care institutions provide multidisciplinary ethics committees or similar structures to write guidelines and policies, provides education, counselling, and support for staff on ethical issues
What should you do if dry medication requires reconstitution doesn't go into solution (clumping)?
mix until all dry medication is mixed into the solution
A nurse is caring for a client who is in terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?
Sit and hold the client's hand
elements of communication
referent sender; message, receiver, channels, feedback, interpersonal
lap band reduction
removable, premanent life cange; can cause dehydration, electrolyte problem, backup into esophagus, blockage
small group communication
small number of people meet; committees; group meetings
Which statement or question best illustrates the nurse's understanding of the role of NAP in medication administration?
"Let me know if she complains of any nausea."
Which intervention promotes connectedness with others for a patient who seems more quiet than usual? Select all that apply. Be physically present and actively listen when the patient speaks Assess and promote supportive social contacts Allow time and opportunity for self-disclosure by the patient Integrate the family into spiritual practices, as appropriate Refer the patient to a support group or for counseling
- Assess and promote supportive social contacts - Integrate the family into spiritual practices, as appropriate - Refer the patient to a support group or for counseling
You come into a room and find a patient having a seizure. You should: a. leave and find help b. remove any object the patient may hit c. restrain the patient's movements d. raise the foot of the bed
B
What Act did Congress pass in 1987, to protect the quality of life, health and safety of nursing home residents? a. MedicareAct of 1987 b. Patients Bill of Rights c. EMTALA d. Omnibus Budget Reconciliation Act
D
True of False Accidents or errors in giving care should be reported to the nurse at the end of the shift.
False
The nurse determines that a patient is experiencing repeated failures, having conflicts with others, and is more dependent on his or her parents. Which component of self-concept is affected in the patient?
Identity Identity is defined as an internal sense of individuality, wholeness, and consistency of a person in different situations. The experiences of repeated failures, conflicts with others, and dependency on parents disturb the internal sense of individuality and consistency of an individual. Therefore, identity is affected in the patient. Self-esteem is an individual's overall feeling of self-worth or the emotional appraisal of self. Body image is the physical appearance, structure, and function of the person. The individual has significant roles throughout life. Failure in meeting role expectations results in deficits.
Which is a health-promotion nursing diagnosis related to spiritual health?
Readiness for Enhanced Religiosity
The nurse has provided a patient with a prn oral analgesic that may be repeated as needed every 6 to 8 hours. What is the most appropriate follow-up action to ensure appropriate pain management?
Reassess the patient's pain in 30 to 40 minutes.
What would the nurse do to ensure the correct administration of gravity drip IV fluid after changing the tubing on a patient's primary infusion?
Recheck the drip rate by counting the drops for 1 full minute
Which action minimizes the risk of introducing glass particles into the syringe when drawing medication from an ampule?
Using a filter needle or straw to draw the medication from the ampule
Anesthetics
depresses CNS from consciousness to unconsciousness; loss of responsiveness to sensory stimuli including pain; muscle, skeletal, and visceral smooth muscle relaxation; general or local
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?
"Sit on the toilet 30 minutes after eating a meal."
A patient with lung cancer states he has not prayed in years because he never thought it would do any good, but now wants to start going to church. Which goals are appropriate goals for this patient? Select all that apply. Patient will report the ability to pray after counsel by the hospital chaplain. Patient will attend religious services within two weeks of discharge. Patient will speak with a spiritual counselor within one week of admission. Patient will consult with the family members about his desire to go to church. Patient will start praying in one day.
- Patient will report the ability to pray after counsel by the hospital chaplain. - Patient will attend religious services within two weeks of discharge. - Patient will speak with a spiritual counselor within one week of admission.
Which nursing care pattern focuses on tasks and jobs? a. Functional nursing b. Team nursing c. Primary nursing d. Care management
A
Your resident has an ileostomy. Which statement is fake? a. the ostomy pouch must fit well b. food skin care is needed c. the entire large intestine has been removed d. the stool is formed
D
True or False The nursing progress never ends
True
occupational health
health promotion, accident or illness prevention
meds are excreted through:
kidney, liver, bowel, lungs, exocrine glands
A tearful parent of a 10-year-old boy diagnosed with cancer is in the hospital lobby. The nurse comforts the parent, who says that life would be meaningless without the child. Which trait is the parent exhibiting?
spiritual distress
constipation
stool gets lodged in the intestines; a symptom not a disease
A Japanese patient is admitted to the hospital after a fall. The patient doesn't understand English. Which should the nurse do to promote communication? 1. Use sign language. 2. Provide language assistance to the patient. 3. Ask a nurse who speaks Japanese to take over. 4. Check the patient physically and start treatment of the disorder. 5. Try to learn Japanese.
2, 3 Whenever a patient faces language barriers, the nurse should make language assistance available to the patient. This service is free for all patients. A patient may ask a family member to interpret instead of a translator. Nurses who know the patient's language may be asked to take over to help provide better care. Sign language is unreliable for assessment of the patient. Checking the patient physically and starting treatment without communication is inappropriate and can violate patient rights. Learning a new language is a time-consuming process and will not help this patient. pp. 104, 108
What does not promote effective listening? a. sitting back in the chair with your arms crossed b. making eye contact c. facing the person d. asking appropriate questions
A
When taking an oral temperature with a glass thermometer. The thermometer must be left in place: a. 15 seconds b. 3 minutes c. 45 seconds d. 8 minutes
B
True or False Axillary temperatures are more reliable than oral temperatures.
False
True or False If your resident starts to fall, move out of the way so you don't get hurt
False
Which action would the nurse take when mixing intermediate- and long-acting insulins together in one syringe?
Prepare two injections.
True or False To brush ones hair start at the scalp and brush toward the hair ends
True
The largest art of the brain and the center of thought and intelligence is: a. midbrain b. brainstem c. cerebellum d. cerebellum
D
True or False Unless otherwise ordered, take vital signs with the resident standing
False
In planning nursing care for an 85-year-old male, what is the most important, basic need that must be met?
Preservation of self-esteem
Which are elements of the SPIRIT framework of spiritual assessment? Select all that apply. Spiritual belief system Personal spirituality Importance of faith Regular practice of faith Terminal-events planning
- Spiritual belief system - Personal spirituality - Terminal-events planning
Mrs Jansen is dying. She is very very sad, She cries a lot. She rings her call bell at 2 a.m. and asks for the priest. You should: a. Ask her why she wants to see the patient b. Tell her to go back to sleep c. Tell her you will ask the nurse to call the priest in the morning d. Report her request to the nurse
D
True or False If you call the resident by name and the respond. You know it is them.
False
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?
Screening groups of older adults in nursing care facilities for early influenza manifestations
True or False A flowsheet is only used by RNS and used to record frequent measurements or observations.
True
oliguria
patient has some form of renal failure; not producing as much urine as regular patient; strict I&Os
Which statement or question best illustrates the nurse's understanding of the role of NAP in administering oral medications?
Please make sure the patient has plenty of fresh water to take with her pills."
The nurse has provided a patient with a prn oral analgesic that may be repeated as needed every 6 to 8 hours. The most appropriate follow-up action to ensure appropriate pain management is to:
Re-assess the patient's pain in 30 to 40 minutes.
An older adult is receiving hospice care. Which nursing intervention(s) help(s) the patient cope with feelings related to death and dying? Select all that apply.
Teaching the patient how to use guided imagery. Encouraging the family to visit the patient frequently. Helping the patient put significant photographs in a scrapbook for the family
Which action by the nurse helps to ensure patient safety when administering IV fluids by gravity to very young children? A. Using microdrip tubing for the infusion B. Using macrodrip tubing for the infusion C. Using a volume-control device for the infusion D. Not infusing more than 25 mL/hour of IV fluids
Using a volume-control device for the infusion
insomnia
more than 45 min to fall asleep/ trouble staying asleep
health beliefs and motivation
motivation is the key factor in hygiene
When treating a patient who is Muslim, which factor would the nurse keep in mind? Select all that apply. One, some, or all responses may be correct.
muslims do not eat pork during ramadan, muslims ea only after sunset
intrapersonal communication
occurs within, self verbalization, self awareness, self talk, guided imagery
interpersonal communication
one on one interaction; most frequently used; exchange of idea, problem solving, decision making
cultural variables in hygiene
people from diverse cultures practice different hygiene rituals
motivation to learn
person's desire/ willingness to learn
Values
personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior
The nurse knows to monitor the pts IV site for signs of phlebitis. Why is it important to discontinue the IV site if phlebitis is evident?
phlebitis can be dangerous because blood clots can occur.
treatment for pulmonary emboli
prevention- anticoagulant therapy; thrombolytic therapy; surgery to remove thrombus
learning environment
privacy, room temperature, lighting, noise, furniture, ventilation
cardiac panel
sodium, LDL/HDL, potassium, ABG, CKMB, triponin, C-Reactive, protein
definition of health
state of complete physical, mental, and social well being not merely the absence of disease or infirmity
treatment for MI
stent angioplasty or balloon; thrombolytic therapy- breaks clot apart; M-morphine, O-oxygen, N-nitrates, A-aspirin
public communication
with an audience; speaking at conferences; leading class
What is the best way to protect a patient from an IV site injury when giving an antibiotic medication by piggyback?
Assess the IV site before initiating the IV piggyback medication.
A 43-year-old female patient has come into the clinic for her annual physical examination. The patient has chronic arthritis, states that she feels incompetent doing simple tasks, and that she is a burden to others. Which techniques would the nurse perform to assess for low self-esteem? Select all that apply.
Observe patient's behavior. Ask patient to explain thoughts and feelings about self. Note clues about both stressful and supportive relationships.
Which factor is familial and contributes to the development of high self-esteem? Select all that apply. One, some, or all responses may be correct.
Parental support Social support Positive communication
Which description is true about role performance?
The way an individual perceives his or her ability to responsibly carry out significant roles
factors influencing communication process
developmental level, gender, values/ perception, personal space, territoriality, roles/ relationships, environment, congruence
Which nursing action is most important in demonstrating concern for the various cultural differences surrounding illness and death?
Asking about patient preferences and accommodating those requests as much as possible
The nurse is using an interpreter to communicate with a patient who does not speak English. Which action by the nurse may hamper the communication between the nurse and the patient?
Asking the patient's family members to serve as interpreters
Which action by the nurse helps to ensure that the medication is delivered into the muscle when administering an intramuscular injection?
Aspirating for blood return before injection medication
After assessing a patient's immediate complaint, the nurse asks a patient, "What other problems do you have?" What is the nurse trying to assess by posing this question to the patient?4. Sexual orientation and gender identity
Bicultural ecology and health risks Asking the patient about the other problems helps to assess bicultural ecology and health risks. Asking the patient about employment status and sources of income helps to assess the patient's socioeconomic status. Asking the patient about home care management helps to assess caring beliefs and practices. Asking the patient about gender, current relationship status, and current sexual partner helps to assess the patient's sexual orientation and gender identity. p. 107
What is the definition of cultural awareness in Campinha-Bacote's model of cultural competency?
It is the in-depth self-examination of one's own background, recognizing biases, prejudices, and assumptions about other people.
What might the nurse do to minimize the risk for injury in a patient receiving IV therapy?
Regulate the flow rate of the infusion.
right sided failure
lower extremity edema; dependent edema; HTN; daily weights; increased peripheral venous pressure; distended jugular veins; cyanosis of extremities; asites, GI distress
What should you do if you insert the angle of the needle of ID too deep?
withdraw needle, change needle, and try in new area
The nurse enters the room of a patient who is crying after receiving news of a life-threatening illness. Which question posed by the nurse may provide comfort?
"Would you like me to pray with you?"
Which statement is true regarding culturally congruent care?
Culturally congruent care sometimes diverges from the values of the professional health care system. Culturally congruent care sometimes diverges from the values and meanings of the professional health care system. Patterns of life and systems of meaning are generated by people themselves. Culturally congruent care bridges gaps to provide supportive care for all patients, not only patients from certain cultures. Transcultural nursing provides culturally congruent care, or care that fits a person's life patterns, values, and the system of meaning. p. 103
The following statements are about restraint use. Which is false? a. the least restrictive method is used b. restraints require a doctors order c. restraints can cause serious harm d. restraints are used to discipline a person who is uncooperative with care
D
The surgical replacement of a joint is called: a. open reduction b. healing fracture c. osteoporosis d. arthroplasty
D
To prevent aspiration when providing oral care to the unconscious person, you should a. place a kidney basin under the persons chin b. clean the mouth using sponge swabs moistened with a cleaning agent c. explain the procedure to the persons and provide for privacy d. position the resident in a side-lying position with the head turned to the side.
D
Which patient safety issue is specific to administration of medication by IV bolus?
Determining that the medication is compatible with the IV solution
True or False Reporting and recording are done before you give the patient care
False
The nurse is instilling a medication into the ear of an elderly patient with an ear infection. To best maximize the distribution of the medication after instillation, the nurse should instruct the patient to:
Instill the medication after gently pulling the ear up and back.
Which goal is appropriate for a patient with a nursing diagnosis of Readiness for Enhanced Religiosity?
Patient will contact estranged family members to arrange for a combined meeting with a spiritual counselor within two weeks.
Which action by a nurse is most important in protecting the safety of patients and staff when using an automated medication dispensing system?
Refusing to share his or her individual security log-in code for the dispensing system
Which altered self-concept might be observed in a patient who has psychosis?
Relying on others for making decisions and going to extreme lengths to obtain support
A depressed patient is crying and verbalizes feelings of low self-esteem and self-worth such as, "I'm such a failure—I can't do anything right." What would be the best nursing intervention?
Remain with the patient until he or she stops crying.
Which statement is true regarding parish nursing? Select all that apply. Parish nursing was designated as a specialty area of practice by the ANA in 2007. The Reverend Dr. Granger-Westberg's work in the mid-1980s was the stimulus for Parish nursing. Parish nurses act in roles such as health advisers, advocates, and liaison to faith and community resources Holistic care focusing on the mind, body, and spirit is provided by parish nurses Many faith traditions exclude parish nursing as part of their recognized spiritual communities.
- The Reverend Dr. Granger-Westberg's work in the mid-1980s was the stimulus for Parish nursing. - Parish nurses act in roles such as health advisers, advocates, and liaison to faith and community resources - Holistic care focusing on the mind, body, and spirit is provided by parish nurses
When transferring a resident to a wheelchair: a. The brakes must be locked b. Hold the handgrips c. Put your foot on the back of the wheels to hold in place d. Stand on the footplates
A
Your patient's roommate has just died, how can you BEST help the client with the loss? a. Discourage individual activity b. Encourage the client talk c. Convince the client its no big loss. The roommate was a complainer d. Leave the client alone
B
To residents share a room. One family wants to take pictures of the two residents together. A persons picture taken without permission is called: a. Assault b. Malpractice c. Negligence d. Invasion of Privacy
D
What are the most obvious indications of hearing impairment? a. resident speaks loudly b. resident leans forward to hear c. resident turns or cups their better ear toward the speaker
D
True or False Stroke is leading cause of disability in adults
False
What is the nurse's best response after noticing that the route of administration has been omitted from a medication order?
Immediately notify the prescriber to request that the order be completed.
You are giving your resident a back massage. Which statement is false. a. Warm the lotion before applying it b. the massage should last about 1 minute c. use firm strokes d. always keep your hands in contact with his skin
B
You walk into check on your resident. They are in the bed, sweaty, seem really "out of sorts", and clutching their chest. You suspect: a. Stroke b. Heart attack c. TIA d. COPD
B
True or False The blood pressure cuff works best if applied over clothing
False
What is the best way to prevent infection and conserve resources when terminating an IV piggyback medication infusion in a patient who also has a primary fluid infusion?
Leave both the piggyback tubing and the bag attached to the primary line Y-site port until the next scheduled dose.
A nurse is caring for an older client who has dysphagia following a CVA. Which of the following actions should the nurse take when assisting the client at mealtime?
Offer the client tart or sour foods first. The client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing.
Which spirituality-related goal written by a student suggests the student needs additional teaching?
Patient will start going to church daily after discharge and will report back to the nurse.
The nurse is using the "Teach Back" technique to evaluate a patient after teaching about medication adherence. Which question by the nurse is appropriate to verify the patient's understanding?
"Please review what we talked about. How will you make it work at home?" The "Teach Back" technique helps the nurse confirm whether the patient has understood the teaching or not. When using the teach-back technique, the nurse should ask open-ended questions such as asking the patient to review the information and explain how he or she will make it work at home. This question will help the nurse to verify the patient's understanding. The nurse should not ask the patient whether he or she understood the teaching, whether he or she has any questions, or about the usefulness of the provided information, because these are unlikely to elicit detailed answers that reflect the patient's understanding. pp. 100, 111
Which questions should the nurse ask a patient to assess bicultural ecology and health risks while performing cultural assessment? Select all that apply.
"What is the cause your illness?" "What other illnesses do you have?" "How do you treat this illness at home?"
When making an occupied bed, the nursing assistant should: a. raise the side rail on the unattended side b. lower both side rails before changing the bed c. help the client to sit in a chair while the bed is made d. put the dirty sheets on the floor
A
Your resident has a history of a stroke with residual weakness, you are asked to ambulate them. You should: a. Assist on weak side b. Assist on strong side c. Put them in a wheelchair d. Stand in front of them like you are a walker
A
After requesting a narcotic pain medication, the patient refuses it after the nurse prepares the injection. What is the nurse's best initial response?
Ask the patient the reason for his refusal
A patient with a history of nighttime confusion is to receive several oral medications at bedtime. What is the best way for the nurse to ensure that the patient has swallowed the medication?
Ask the patient to open his mouth after swallowing each tablet.
The patient who has a history of nighttime confusion is to receive several oral medications at bedtime. To best ensure that the patient has swallowed the medication, the nurse should:
Ask the patient to open his mouth after swallowing the tablets.
The nurse is adminstering a sustained-release capsule to a new pt. The pt insists that he can't swallow pills. What is the nurse's best next course of action?
Ask the prescriber to change the order
True or False Women in nursing homes are not interested in shaving their underarms and legs
False
True or False The most serious risk of restraint use is death
True
True or False The skin is the body's first line of defense against disease
True
True or False When transferring a patient, the weak side moves first
True
True or False When using a fracture pan, the larger end is placed under the buttocks
True
The patient is to receive both Lantus® (insulin glargine) and regular insulin. To ensure the proper action of the insulins, what would the nurse do when preparing these two types of insulin for administration?
Prepare the insulins in two syringes for separate injections.
In cases in which a patient is experiencing stress and anxiety, which meditation techniques would the nurse teach the patient to help healing? Select all that apply. One, some, or all responses may be correct.
Teach the patient to sit with his or her back straight and breathe slowly. Identify a quiet room in the home that has minimal interruptions. Provide a printed teaching guide that explains how to meditate.
chenye-strokes
irregular breathing; altering rapid/apnea episodes; near death breathing pattern
When preparing an injection with medication contained in an ampule, the nurse can best minimize the risk of infection for the patient by:
Preserving the sterility of the needle during the
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?
Second intercostal space to the right of the sternum
Which of the following statements is false: a. OBRA requires activity programs for nursing home residents b. Activities are important for physical and emotional health c. personal choice is protected d. Each resident by law to participate in at least two activities daily
D
A patient has a large facial scar after the removal of a tumor of the buccal mucosa. The patient is extremely depressed due to this facial disfiguration. Which nursing actions would be helpful in motivating the patient? Select all that apply.
Examine the scar and assuring the patient that it is healing well. Tell the patient about a good plastic surgeon who can improve the appearance of the scar. State that the scar does not look as bad as anticipated.
A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?
Explain the procedure to the client. This framework assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety
True or False Urinary urgency is the loss of bladder control
False
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?
Identify the client using two identifiers
A nurse is administering a cleaning enema to a client who is schedule for diagnostic procedure. Which of the following actions should the nurse take?
Insert the tip of the tubing 8 cm (3.1 in). The nurse should insert the tip of the tubing 7 to 10 cm (3 to 4 in) along the rectal wall to prevent dislodging of the tube during the procedure and injury to the rectal mucosa.
Which information is not necessary for the nurse to include when documenting the use of an electronic infusion device (EID) for an intravenous infusion?
Patient's pulse and heart rate
True or False A resident can have a diagnosis of constipation and still stool
True
sleep apnea
lack of airflow through mouth/nose >10sec during sleep; airway collapses, blocking airflow to lungs
When preparing to insert a venous access device, how can the nurse encourage patient compliance with the procedure?
Assess the patient's understanding of the placement of the device.
While changing a patient's hospital gown, the extension set on the IV infusion becomes disconnected and ends up on the bed linens. What would the nurse do?
Change the extension set tubing.
To best minimize the patient's risk of injury when delivering a medication via intramuscular injection, the nurse realizes that the:
Plunger should be pulled back after the needle is inserted into the muscle.
How does the nurse minimize the risk of patient infection when preparing medication from an ampule?
Preserving the sterility of the needle while preparing the medication
The nurse is preparing to mix short- and intermediate-acting insulins to administer to a patient. Which action best preserves the insulin's effectiveness?
Refraining from injecting the intermediate-acting insulin into the short-acting vial
urinary incontinence
can be temporary; affects everyone especially elderly
source of laws
legal guidelines that come from statutory, regulatory, and common law
Which is required in the delivery of culturally congruent care?
Acquiring specific knowledge, skills, and attitudes Specific knowledge, skills, and attitudes are required in the delivery of culturally congruent care. pp. 103, 107
The nurse is preparing to administer a prescribed medication via the subcutaneous route. To best ensure patient safety, the nurse should:
Observe the six rights of medication administration
True or False Giving your opinion, positive or negative, promotes effective communication
True
John is a new nursing tech who also happens to be a diabetic. He says he knows how to prepare insulin injections and offers to help you prepare insulin injections for a diabetic pt on the floor. Which of the following are correct responses to John? (SATA)
licensing guidelines only allow nurses to prepare injections. you review side effects of insulin w/ John and ask him to report to you immediately if he observes any of thoses signs.
causes of atherosclerosis
lifestyle; HTN; smoking; diabetes; genetic
You go to check on Mrs. Jones, she is very agitated. Your task is to give her a bed bath, When you walk in the room, she tells you "Get out of here. I do not want a bed bath". What should you do? a. Speak loudly because maybe Mrs. Jones didn't hear or understand you. b. Run c. Tell the client they have no choice, shut up and lets get cleaned up d. Talk calmly, slowly, reassure the client. Do not force them. Report the refusal to the nurse.
D
A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?
Montgomery straps Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely
A 50-year-old female patient is admitted to the hospital for surgical management of breast cancer. The patient is now at home after a successful operation. During a home visit, the patient breaks down and expresses that she is overburdened with responsibilities. She takes care of her 8-month-old granddaughter as well as her 80-year-old mother who has Alzheimer's disease. What stressors is the patient facing? Select all that apply.
Role conflict Role overload
A nursing student takes a pts antibiotic to the pts room.The pt asks the nursing student what it is and why he should take it. Which information does the nursing student include when replying to the pt?
The student provides the name of the medication and a description of its desired effects
True or False Persons with foley catheters are at high risk for urinary infection
True
The nurse prepares a diet plan for a Hindu patient. Which action would the nurse perform to plan the patient's diet appropriately? Select all that apply. One, some, or all responses may be correct.
Determine whether the patient consumes non-vegetarian food. Ask if the patient is observing a fast. Ask if the patient has any particular food preferences. Ask the patient to talk to the dietitian about preferences.
What is the goal of transcultural nursing?
To provide care to fit with a patient's own values, beliefs, and traditions The goal of transcultural nursing is to provide care to fit with the patient's own values, beliefs, and traditions. Cultural awareness is required to recognize biases, prejudices, and assumptions about other people. Cultural skill helps to assess social, cultural, and biophysical factors that influence patient treatment and care. Cultural desire involves the motivation to learn from others, accept the role as a learner, and be open to and accepting of cultural differences. p. 103
True or False Proper positioning prevents pressure ulcers and contractures
True
True or False Rectal temperatures are not taken if your resident has heart disease. Why?
True
Which concept related to spiritual health is a patient experiencing when she states that she knows her husband loves her even when he cannot be by her side?
faith
Which instruction reflects the nurse's correct understanding of the role of NAP in caring for a patient receiving an IV antibiotic medication by piggyback?
"Let me know immediately if the patient complains of pain at the IV site."
Which statement might a nurse make to NAP when caring for a patient prescribed an IV bolus of analgesic medication?
"Let me know immediately if the patient complains of pain at the insertion site."
Which instruction would the nurse give to NAP when caring for a patient who is receiving IV fluids?
"Let me know when the IV bag is almost empty."
Which instruction to NAP reflects the nurse's correct understanding of the NAP's role in caring for a patient receiving IV fluids by gravity drip?
"Let me know when you notice that the IV bag contains less than 100 mL."
Which instruction might the nurse give to NAP regarding the care of a patient with an intravenous access device?
"Let me know when you notice that the IV bag contains less than 100 milliliters."
The nurse is using the "Teach Back" technique to evaluate a patient after teaching about medication adherence. Which question by the nurse is appropriate to verify the patient's understanding?
"Please review what we talked about. How will you make it work at home?"
The nurse is educating the student nurse on the legal and ethical responsibilities of providing spiritual care. Which statement made by a student nurse signifies the need for additional training?
"Religious beliefs have no place in health care."
The nurse is caring for a 50-year-old Hindu Asian male patient who is hospitalized following an incidence of high blood pressure. The nurse understands the ethnicity of the patient and asks questions as part of the cultural assessment. Which questions would help gather information about bicultural ecology and health risks? 1. "What other problems do you have?" 2. "Tell me why you left your homeland." 3. "How do you treat this problem at home?" 4. "How strongly does your culture influence you?" 5. "How has the problem affected you and your family?"
1, 3, & 5 Culturally oriented questions help the nurse learn about a patient's values, beliefs, and practices and help to properly evaluate the care plan. Questions about other problems, how the patient is treating the problem at home, and how the problem affects the patient and the family help the nurse to assess bicultural ecology and health risk. Asking the patient about reasons for leaving the homeland and influences of the patient's culture would provide the nurse with ethnohistory but would not help determine bicultural ecology and health risks. Test-Taking Tip: Read the question carefully! Notice that this question asks about bicultural ecology AND health risks. All three correct answers focus on health problems. p. 107
Which measures taken by the health care organizations would create an inclusive environment for patients belonging to the lesbian, gay, bisexual, transgender (LGBT) community? 1. Identify on the basis of their appearance 2. Make sure that they have access to unisex bathrooms 3. Ensure that gender-inclusive language is used while talking 4. Avoid enquiring about their gender to avoid discomfort 5.Ensure that gender-inclusive information is asked in the hospital forms
2, 3 Patients belonging to the LGBT community may differ in appearance from the conventional male and female appearance and may feel uncomfortable using gender-specific restrooms. Therefore, the health care organizations should ensure that patients belonging to the LGBT community have access to unisex restrooms. Health care professionals should use neutral language while talking to patients, such as partner or a significant other instead of husband and wife, because LGBT patients may also be married. Health care organizations should not encourage identification of patients on the basis of their physical appearance, because the assumptions made may be wrong. Health care organizations should ensure that patients are asked about gender, because presumptions may cause errors in treatment. All the forms used in the hospital should have an LGBT query section to facilitate disclosure.�� �� Test-Taking Tip: The patients belonging to LGBT community may have an altered appearance and a conservative attitude. Answer the above question by keeping these tips in mind. p. 105
The nurse is learning about the impact of different cultures on nursing. Which are benefits of culturally congruent care? 1. It will help the nurse to interact with different people in their language. 2. It will help the nurse to interpret the needs of the patient who belongs to a different culture. 3. It will help the nurse to identify the similarities and differences of various patients across different cultures. 4. It will help the nurse to deliver the specific kind of health care that is expected from patients who belong to a different culture. 5. It will help the nurse to deliver different remedies for an illness as practiced in the patient's culture.
2, 3, 4 Culturally congruent nursing refers to a comparative study of cultures to understand similarities and differences across human groups. It helps the nurse to identify the needs of a patient who belongs to a different culture. Culturally congruent nursing can help the nurse to identify the similarities and differences in various patients across different cultures. It also helps the nurse to meet the health care expectations of patients who belong to different cultures. Culturally congruent nursing does not help the nurse to interact with people in different languages. The nurse does not deliver remedies common in different cultures. p. 103
The provider orders that a patient be given 1000 mL of IV normal saline to run over 10 hours. The drop factor of the selected tubing is 15. What is the correct rate of infusion in drops per minute?
25 drops/minute
Which needle would be most appropriate for the nurse to use when giving a subcutaneous injection to a patient of average height and weight?
25-gauge, ⅜-inch
hemodialysis
3 days out of week, 3-4 hr long process; blood circulated through the machine and nitrogenous waste, fluid, electrolytes removed; BP before and after treatment; weight before and after; can be used for drug overdose
You are unsure of a vital sign measurement taken by you. You must: a. promptly ask the nurse to take it again b. ask another nursing assistant to check it for you c. report what you think d. wait an hour and then try again
A
anuria
irreversible renal disease; need kidney transplant or dialysis; not producing urine; increased phosphorus in system
A patient who was cured of cancer is diagnosed with relapse of the disease. The primary health care provider recommends that the patient consume foods rich in antioxidants and drink plenty of water. Which step of the C-LARA mnemonic is the primary health care provider performing?
Add The step "add" in the C-LARA mnemonic refers to providing the patient and/or the caregivers with additional information that may help them. It may also include educating the patient. The primary health care provider is educating the patient regarding the inclusion of antioxidants and plenty of water in his or her diet. The step "affirm" in the mnemonic means expression of a feeling or a perspective that strengthens the patient's concern. If the primary health care provider responds to a question posed by the patient, then he or she is performing the "respond" step. The "calm down" step is used to relax the patient, wherein the patient is encouraged to stay calm and the pulse rate is determined. p. 109
The nurse is caring for an 80-year-old patient. What factors influence this particular patient's current self-concept? Select all that apply.
Adjustment to a role change Adjustment to the loss of a spouse An 80-year-old patient's self-concept is likely to be altered by changes in the role in the family and by the loss of the spouse. Living conditions do not influence self-concept at this age. Sexual intimacy is generally not desired at this age, because the production of sexual hormones lowers. The behavior of relatives providing care is not a significant factor for altering self-concept at this age.
The nurse has to examine a patient and administer an intravenous medication that is not a life-saving drug. The patient is a devout Muslim. When the nurse goes to administer the medication the nurse finds that patient is getting ready for namaz (prayers). The nurse understands that the patient prays at certain times, as specified in his culture. What should the nurse do in this scenario?
Allow the patient to pray and come back later to administer the medication. The nurse should respect the patient's religious beliefs. Muslims offer namaz, or prayers, at specific times of the day. The nurse should let the patient complete the prayers and then administer the medication. It would be inappropriate to administer the drugs while the patient is praying because that would show disrespect to the patient. It would be inappropriate for the nurse to ask the patient to delay prayer, because his culture dictates that he pray at specific times. The nurse should not refer to responsibilities with other patients. p. 104
The nurse is concerned that a confused patient's erratic movements may compromise the IV insertion site. Which action can the nurse take to protect the patient and the site from injury?
Apply an IV site-protection device over the site, such as House UltraDressing.
The nurse is preparing to discharge a patient after providing instructions regarding the self administration of an antibiotic ear medication. The nurse should assess the patient specifically for the ability to:
Appropriately handle the medication applicator.
The nurse at an outpatient clinic asks a Chinese American patient with newly diagnosed hypertension if he is limiting sodium intake as directed. The patient nods his head but does not make eye contact with the nurse. What should the nurse do next?
Ask the patient how much salt he is consuming each day. In Asian cultures spoken messages often have little to do with their meanings. The nurse should clarify how much salt the patient is consuming in his diet. p. 107
Mrs. Cooper is on isolation precautions. Which is false? a. say hello from the doorway every 15 minutes b. spend as little time as you can in her room c. provide her with hobby materials d. treat her with respect, kindness and dignity
B
Spreading rumors or talking about the private matters of others is: a. Harassment b. Gossip c. Loads of fun d. Confidentiality
B
Standard Precautions apply to: a. the health care team b. everyone c. nursing center residents d. persons only with infections
B
You are doing a dressing change on a resident. You notice that the dressing has a red/yellow body fluid on it. The dressing is called: a. Gross b. Biohazards waste c. Bloody pus d. use droplet precautions
B
Where does digestion begin? a. stomach b. esophagus c. mouth d. intestines
C
Which of the following vital signs should you report to the nurse immediately. a. 37.1, 78, 16, 118/64 b. 36.9 (r), 90, 20, 138/70 c. 36.4 (a), 158, 22, 90/46 d. 36.6, 100, 16, 120/88
C
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 is using chlorhexidine to prepare the site before inserting a venous access device into the median cubital vein of a 60-year-old patient. Which action is correct?
Cleanse the area by first swabbing horizontally, then vertically with the applicator for about 30 seconds.
After assessing a 2-year-old child, the nurse observes that the child is in the psychosocial development stage of autonomy versus shame and doubt, according to Erikson's theory of self-concept. Which developmental tasks does the nurse observe in the child? Select all that apply.
Communication of likes and dislikes Appreciation of body appearance and function Increased independence in thoughts and actions Children between the ages of 1 and 3 years of age are in the psychosocial development stage of autonomy versus shame and doubt. During this stage, children begin to communicate likes and dislikes that promote the development of self-concept. The positive appreciation of body appearance and function increases the self-esteem and self-concept. Children from 1 to 3 years of age gain independence in actions and thoughts due to self-exploration. This also promotes development of self-concept due to increased autonomy. Children between 1 and 3 years of age cannot understand feedback given by peers and teachers. Children from 3 to 6 years of age have increased language skills, including the identification of feelings.
The nurse is explaining the concept of being culturally competent to another nurse. Which are components of cultural competence?
Cultural awareness Cultural knowledge Cultural skills Cultural encounters Cultural desire Cultural difference Cultural competence consists of five components: cultural awareness, cultural knowledge, cultural skills, cultural encounters, and cultural desires. Cultural awareness refers to an in-depth self-examination of one's beliefs to help recognize biases, prejudices, and assumptions. Cultural knowledge involves obtaining adequate information about cultural groups. Cultural skills allow a person to assess social, cultural, and biophysical factors that affect treatment and care of patients. Cultural encounters involve engaging in cross-cultural interactions that provide information about other cultures. Cultural desire refers to the motivation and commitment to build on cultural similarities. Cultural difference is not a component of cultural competence. pp. 104-105
The nurse, while caring for a patient of a different cultural background, learns about their cultural practices that affect health. The nurse uses these facts to plan the patient's care for better acceptance. Which component of Campinha-Bacote's model of cultural competency is reflected in this scenario?
Cultural encounter Campinha-Bacote's model of cultural competency includes interrelated components. Cultural encounter involves the cross-cultural interactions between the nurse and the patient that provide opportunities to learn about other cultures and develop effective intercultural communication. Cultural skill is the ability to assess the social, cultural, and biophysical factors that influence patient treatment and care. Cultural desire is the motivation and commitment to care for a patient. Cultural knowledge is the knowledge of diverse groups, including the values, health beliefs, care practices, worldview, and bicultural ecology commonly found within each group. pp. 104, 105
The most common cause of COPD/emphysema is: a. Pollution b. Family History c. Asthma d. Smoking
D
When logrolling a resident, you must: a. make sure the bed is in Fowlers position b. make sure the bed is in the lowest position c. make sure that both bed rails are up d. turn the person as a unit, in alignment, with one motion
D
Which of the following measures will not help prevent urinary tract infection? a. encouraging the resident to do pelvic muscle exercises b. having the resident wear cotton underwear c. keeping the perineal area clean and dry d. promoting fluid intake as directed
D
As the nurse prepares to administer oral acetaminophen, the patient refuses to accept the drug because it doesn't look like the Tylenol she takes at home. After verifying that the medication and dosage are correct, what is the nurse's best response?
Explaining that drugs often come in different physical forms, depending on the manufacturer
True or False Residents do not feel safe if you tell them what you are doing
False
True or False The bed should be placed in low with the call bell in reach when providing patient care.
False
True or False Traction is removed when you make the persons bed
False
True or False Urinals when full should be placed on the overbed table
False
True or False You can never refuse to perform a delegated task.
False
True or False You shouldn't tell the nurse if you are unable to hear a blood oxygen
False
True or False A back massage is safe for everyone
False
True or False A malignant tumor grows slowly and does not invade healthy tissue
False
True or False Everyone who works at an agency as the right to read the patient.residents records
False
True or False Hematuria means blood in the stool
False
True or False When residents are sick they are hungrier
False
When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will flow properly?
Hang the piggyback medication higher than the primary fluid.
What is the importance of core measures?
Help reduce mortality, complications, and inpatient readmissions Core measures help to reduce mortality, complications, and inpatient readmissions. Cultural awareness helps to recognize prejudices, and assumptions about other people. Culturally congruent care helps to provide care to fit with patients' own values, beliefs, and traditions. Cultural skills help to assess social, cultural, and biophysical factors that influence patient treatment and care. p. 111
What are the chief factors that determine the self-concept of an individual? Select all that apply.
Identity Body image Role performance
While reviewing a new medication order, the nurse notes that the frequency of administration has been omitted. What is the nurse's best response?
Immediately contacting the prescriber to complete the order
How might the nurse prepare a patient to anticipate some discomfort when inserting a venous access device?
Instruct the patient to expect a sharp, quick stick.
The nurse has medicated a patient with a laxative in the form of a rectal suppository. Which of the following nursing actions best minimizes the patient's risk for injury as the medication produces the desired affect?
Instructing the patient to use the call bell for assistance to the bathroom
The nurse attends to an Asian male patient at a clinic, who is joined by his family. The nurse finds that the patient speaks a different language and determines that he needs an interpreter. A male interpreter is appointed, as preferred by the patient. How should nurses communicate with this patient?
Introduce themselves to the interpreter. Observe the patient's nonverbal and verbal behaviors. Ask the interpreter to ask the patient for feedback and clarification. Nurses should use transcommunication skills to effectively provide care for this patient. Even if the interpreter is present, the nurses should introduce themselves to the patient. Observing the patient's nonverbal and verbal behaviors helps in communication. Requesting that the interpreter ask the patient for feedback at regular intervals helps to assess the clinical and cultural data in detail. As a rule, nurses should direct questions to the patient. As the primary caregivers, the nurses should first introduce themselves and then the interpreter. p. 110
A 55-year-old male patient underwent a colostomy. Earlier he underwent coronary artery bypass graft (CABG) surgery. The nurse finds the patient depressed and weeping. The patient expresses that he is fed up with his poor health. He feels that he has become a burden on his family because he can't work now. The nurse concludes that the patient is experiencing role performance issues. Which statement is true about role performance?
It is the way an individual perceives his or her ability to responsibly carry out significant roles. Role performance is the way in which an individual perceives his or her ability to carry out significant roles responsibly. Self-esteem is an individual's holistic feeling of self-worth or emotional appraisal. Body image involves ideas and views of an individual related to the body including physical appearance, structure, or function. Role conflict is a conflict a person experiences when he or she has to perform two or more mutually exclusive responsibilities.
A Haitian patient is admitted to the hospital for arthritic pain. During the nursing assessment, the nurse learns that the patient is using a therapy called cupping for palliation of pain along with traditional Western medicine. Cupping involves placing heated cups on the skin. Which is the most appropriate action by the nurse?
Learn about this therapy and avoid imposing one's own beliefs.
The senior nurse observes that a newly appointed American nurse is having trouble relating to a patient from a different culture. What advice can the senior nurse give this nurse to enhance cultural competency?
Obtain sufficient knowledge about a patient's cultures and beliefs. It is extremely important for the nurse to be culturally competent. The nurse should try to obtain knowledge about various cultures and cultural practices prevalent in the population, because this will help the nurse understand the patients better and provide better care. The nurse already has medical and nursing knowledge. It is not mandatory for nurses to know foreign languages, although that may be helpful in the long term. Knowledge about languages and dialects is not sufficient; the nurse should learn about and respect the culture. pp. 103-104
The nurse attends to an Asian male patient at a clinic, who is joined by his family. The nurse is developing a transcultural care plan that identifies both with the patient's native and American culture. Which nursing actions are required for providing culturally congruent care?
Obtain the patient's health beliefs. Self-examine the nurse's own culture. Assess cultural and biophysical factors that influence treatments. The patient who identifies with both his native and American culture has obtained biculturalism. The goal of transcultural nursing is culturally congruent care. Obtaining the patient's health beliefs and self-examination of one's own culture help in delivering culturally congruent care. The nurse should also develop the skills of assessing cultural and biophysical factors that influence treatments and care for the patient. It is important to engage in cross-cultural learning. Working in another culture and learning about cultural differences is beneficial for the patient's health, but the practice should not be limited to the patient's culture. p. 103
An adult woman is recovering from a mastectomy for breast cancer and is frequently tearful when left alone. On what should the nurse's approach be based?
Patients need support in dealing with the loss of a body part
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse wth inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?
Pericardial friction rub
What can the nurse do to minimize the patient's risk for injury when delivering an intramuscular injection?
Pull back on the plunger after inserting the needle.
A patient is scheduled for colostomy in 2 days. The nurse finds the patient very anxious, stressed, and states, "How am I going to live with a poop bag for the rest of my life?" What nursing actions would influence the patient's self-concept and prepare her for an altered body image? Select all that apply.
Showing the patient a video about a healthy functioning body after a colostomy. Introducing the patient to other patients who have colostomies. Informing the patient with a practical and realistic approach, such as by showing her a video on her future condition, may help her prepare for the outcomes. The patient may have a better sense of well-being if she interacts with other people with the same problem. Showing the bag and where it is fitted would have no effect on the patient's self-concept. Teaching the patient relaxation exercises would be helpful in reducing the patient's anxiety, but it would not positively affect the self-concept of the patient. It is the nurse's duty to help prepare the patient for surgery psychologically, so the problem should not be reported to the health care provider.
What should you do if you don't have enough medication in syringe while withdrawing from an ampule and expelling air/excess medication?
Start over b/c each batch of medication is different
What is the most important nursing intervention to ensure the patient's safety when initiating infusion of an analgesic by mini-infusion pump?
Staying with the patient during the first few minutes of the infusion
Which entity affirms the importance of spirituality and spiritual well-being with regard to improved patient outcomes?
The Joint Commission
When developing an appropriate outcome for a 15-year-old girl, what primary developmental task of adolescence should the nurse consider?
The ability to form a sense of identity
To minimize the risk of skin irritation when delivering a medication via the subcutaneous route, the nurse realizes that:
The amount of medication should not exceed 1 ml in volume. - Book does say can go to 1.5mL but to 1 mL is better
How can the nurse determine that the needle tip for an intradermal injection is in the dermis?
The bulge of the needle tip will be visible through the skin.
How would the infusion of IV fluids be affected if the tubing were unintentionally dislodged from the chamber of the control mechanism of the electronic infusion device (EID)?
The flow of fluid would stop.
For what should the nurse look when assessing an altered self-concept in a patient? Select all that apply.
The patient has a slumped posture. The patient is overly apologetic. The patient uses hesitant speech. The patient avoids eye contact.
The nurse is assigned to care for a patient who has low self-esteem after undergoing a right leg amputation. The goal for the patient is that the patient's self-esteem will improve in 2 weeks. What are the expected outcomes to achieve the goal? Select all that apply.
The patient will verbalize acceptance of the prosthetic leg. The patient will interact in a social setting. The patient will talk about his or her feelings Expected outcomes for a patient with low self-esteem include nonverbal behaviors that indicate positive self-esteem. The expected outcomes include the patient verbalizing acceptance of the use of the prosthetic leg, having social interactions, and making eye contact. The patient will talk about his or her feelings. Ambiguous outcomes such as "become less depressed" don't provide the patient with small, manageable goals.
what does mobility mean?
allows ability to move freely about; musculoskeletal and nervous systems working together to make movement; decreases risk for injury
What precautions do you take to minimize risk of IM medication entering blood vessel?
aspirate before injecting meds
A patient is diagnosed with end-stage renal disease. The patient tells the nurse, "I know I am going to be all right, and I will be healthy again. I believe in God, and He will make things right. My spouse and I have yet to tour the world." Which kind of spiritual belief does this patient exhibit?
hope
Client comes into the clinic for an ID skin test. What questions should you ask the pt? (SATA)
have you ever had a tb skin test in the past? will you be able to return to the clinic in 72 hrs for the test results to be read? what medications are you taking? including OTC are you right or left handed?
What are the positive effects of spirituality on an individual? Select all that apply.
health behaviors. quality of life. lifestyle.
A patient hospitalized with heart failure states that she sees her illness as an opportunity and a challenge. Despite her illness, she is still able to see that life is worth living. Of which concept is this an example?
hope
A nurse is chaining the dressings for a client recovering from appendectomy following a rupture appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?
A halo of erythema on the surrounding skin. The nurse should report to the provider when the client has a ring of erythema (redness) on the surrounding skin, which might indicate underlying infection.
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client?
Donate autologous blood before the surgery
A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?
"I should expect my heart rate to take longer to return to normal after excessive as I get older."
A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP
"Using a cuff that is too small will result in an inaccurately high reading."
The nurse is caring for an 87-year-old patient. What factor most directly influences this patient's current self-concept?
Adjustment to role change, loss of loved ones, and physical energy
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
Administe analgesics to the child on a routine schedule throughout the day and night.
A 50-year-old female patient with breast cancer is admitted to the hospital for surgical management. On the second postoperative day, the nurse finds the patient crying. She tells the nurse that she had agreed to take care of her 8-month-old granddaughter but knows she will be unable to do so. The patient also expresses concern about her looks and that she feels worthless. Which aspects of the patient's self-concept are affected? Select all that apply.
Body image Self-esteem Role performance
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?
Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart
A nurse is planning care for an adult client who has FVE. Which of the following intervention should the nurse plan to include to monitor the client's weight?
Weigh the client on arising. The nurse should weigh the client on arising each day, after voiding, and before breakfast.
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?
Carefully remove the gloves and follow with hand hygiene
A nurse is caring for a client who post and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first?
Check to determine if the catheter tubing is kinked.
A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?
Drop the eye medication into the lower conjunctival sac.
The nurse plans her nursing care with the knowledge that old age is primarily focused on which of Erikson's stages of growth and development?
Ego integrity versus despair
A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching?
Hold breath for 5 seconds after goal volume is reached. The nurse should instruct the client to hold her breath for 3 to 5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps to prevent the risk of atelectasis and pneumonia.
A nurse is caring for a toddler at a well-child visit when the mother calls the nurse, "Help! My baby is chocking on his food." Which of the following findings indicates the toddler has an airway obstruction?
Inability of the toddler to cry or speak
A nurse is preparing a client who is scheduled for hysterectomy for transport to the operating room when the client states she no longer wants to have surgery. Which of the following actions should the nurse take?
Notify the provider about the client's decision
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?
Perform hand hygiene
A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?
Pinch the NG tube while removing the tube. The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents.
A nurse is helping a client change his hospital gown. The client has an IV infusion on a infusion pump. Which of the following actions should the nurse take first?
Remove the sleeve of the gown from the arm without the IV line.
A nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?
Taut skin around the IV catheter site that is cool to the touch. The client who has taut skin around the IV catheter site that is cool to touch might have an infiltrated IV site.
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make?
"What worries you about being without your teeth?"
A nurse is collecting a urine specimen for C&S for a client who has UTI. The client has an indwelling urinary catheter in place. Which of the following action should the nurse take?
Clamp the tubing below the collection port. The nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup.
A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching?
Cleanse the skin around the stoma with warm water.
A nurse is planning care for a client who has a prescription for collection of sputum specimen for C&S. Which of the following actions should the nurse take when obtaining the specimen?
Collect the specimen upon arising in the morning.
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?
Discontinue the machine, and measure the blood pressure manually every 15 min.
Which factor will the nurse observe in the 22-year-old patient with low self-esteem who is in the intimacy-versus-isolation stage of psychosocial development, according to Erikson's theory of self-concept?
Increased responsibilities
A 50-year-old female patient is admitted to the hospital for surgical management of breast cancer. On the second postoperative day, the nurse finds the patient crying. She tells the nurse that she had agreed to take care of her 8-month-old granddaughter, but knows she will be unable to do so. The patient also expresses concern about her looks and that she feels worthless. Identify the stressor that influenced the patient's self-esteem.
Mastectomy
A nurse is planning to collect a stool specimen for ova and parasites form a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?
Place the stool specimen collection container in a biohazard bag.
A nurse is performing suctioning for a client who has tracheostomy. Which of the following actions should the nurse take?
Pull suction catheter back 1 cm (0.5 in) if the client starts coughing. The nurse should pull the suction catheter back 1 cm (0.5 in) when the client starts to cough, or resistance is met. This will remove the catheter from the mucosal wall of the trachea prior to suctioning.
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?
Raise the level of the bed
A person tries to meet the strenuous demands of employment while taking care of a family of six and manages to fulfill the responsibilities with great difficulty. What kind of role performance stressor is affecting this person?
Role overload
Due to a shortage of staff, the nurse has been on duty for both morning and night shifts for the last 2 days. Which role performance is the nurse experiencing?
Role overload
A 55-year-old male patient recently underwent a colostomy. Prior to the colostomy, the patient underwent coronary artery bypass graft (CABG) surgery. The nurse finds the patient depressed and weeping. The patient expresses that he is fed up with his poor health. He feels that he has become a burden on his family because he can't work now. Which factors are responsible for lowering the patient's self-esteem? Select all that apply.
The colostomy Dependency on others A physical deficit preventing role assumption
Several staff members complain about a patient's constant questions such as "Should I have a cup of coffee or a cup of tea" and "Should I take a shower now or wait until later?" Which interpretation of the patient's behavior helps the nurses provide optimal care?
The inability to make decisions reflects a self-concept issue.
A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?
The involvement of the client in planning the change
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?
The signature on the preoperative consent form is the client's
A nurse is applying antiembolitic stockings for a client who has a history of DVT. Which of the following actions should the nurse take when applying the stockings?
Turn the stocking inside out up to the heel before applying.
A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of fall?
Use a gait belt during ambulation. The nurse should use a gait belt to keep the client's center of gravity midline and decrease the risk of a fall.
A nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first?
Use the pain scale to determine the client's pain level.
A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?
Wipes the labia minora in an anteroposterior direction
