Fundamentals

a female patient tells the charge nurse that she does not want a male nurse caring for her, which intervention by the charge nurse is best? 1) Explain that hospital policy does not allow nursing assignments based on the gender of the nurse. 2) Explore with the patient her beliefs and determine which might have caused her to make this statement. 3) Assure the patient that each nurse is capable of providing professional nursing care, regardless of their gender. 4) Comply with the patient's request and assign a female nurse to care for the patient.

2) Explore with the patient her beliefs and determine which might have caused her to make this statement.

The nurse is planning client education for an older adult being prepared for discharge home after hospitalization for a cardiac problem. Which nursing action addresses the most commonly deter-mined need for this age-group? 1. Suggest that he purchase an emergency in-home alert system. 2. Arrange for the client to receive meals delivered to his home daily. 3. Encourage the client to use a compartmentalized pill storage container for his daily medications. 4. Provide a written document describing the medications the client is currently pre-scribed.

3. Encourage the client to use a compartmentalized pill storage container for his daily medications.

A 72-year-old client is in a long-term care facility after having had a cerebrovascular accident. The client is noncommunicative, enteral feedings are not being absorbed, and respirations are becoming labored. Which of the stages of the GAS is the client experiencing? 1. Alarm reaction 2. Resistance stage 3. Exhaustion stage 4. Reflex pain response

3. Exhaustion stage

It appears to the nurse the client is experiencing a crisis. The nurse plans to: 1. Allow the client to work through independent problem-solving 2. Complete an in-depth evaluation of stressors and responses 3. Focus on immediate stress reduction 4. Recommend ongoing therapy

3. Focus on immediate stress reduction

in reviewing changes in the older adult, the nurse recognizes that which of the following statements related to cognitive functioning in the older client is true? 1. Delirium is usually easily distinguished from irreversible dementia. 2. Therapeutic drug intoxication is a common cause of senile dementia. 3. Reversible systemic disorders are often implicated as a cause of delirium. 4. Cognitive deterioration is an inevitable outcome of the human aging process.

3. Reversible systemic disorders are often implicated as a cause of delirium.

the nurse is concerned that the client's midsternal wound is at risk for the complication of dehiscence. which of the following is the best intervention to prevent this complication? 1. Administering antibiotics to prevent infection 2. Using appropriate sterile technique when changing the dressing 3. Keeping sterile towels and extra dressing supplies near the client's bed 4. Placing a pillow over the incision site when the client is deep breathing or coughing

4. Placing a pillow over the incision site when the client is deep breathing or coughing

of the following options, which is the greatest barrier to providing quality health care to the older-adult client? 1. Poor client compliance resulting from generalized diminished capacity 2. Inadequate health insurance coverage for the group as a whole 3. Insufficient research to provide a basis for effective geriatric health care 4. Preconceived assumptions regarding the lifestyles and attitudes of this group

4. Preconceived assumptions regarding the lifestyles and attitudes of this group

A corporate executive works 60 to 80 hours/week. The client is experiencing some physical signs of stress. The practitioner teaches the client to "include 15 minutes of biofeedback." This is an example of which of the following health promotion interventions? 1. Guided imagery 2. Regular exercise 3. Time management 4. Relaxation technique

4. Relaxation technique

You are conducting patient teaching about cholesterol levels. When discussing the patient's elevated LDL and lowered HDL levels, the patient shows an understanding of the significance of these levels by stating what? A) "Increased LDL and decreased HDL increase my risk of coronary artery disease." B) "Increased LDL has the potential to decrease my risk of heart disease." C) "The decreased HDL level will increase the amount of cholesterol moved away from the artery walls." D) "The increased LDL will decrease the amount of cholesterol deposited on the artery walls."

A) "Increased LDL and decreased HDL increase my risk of coronary artery disease."

The nurse working on a cardiac care unit is caring for a patient whose stroke volume has increased. The nurse is aware that afterload influences a patient's stroke volume. The nurse recognizes that afterload is increased when there is what? A) Arterial vasoconstriction B) Venous vasoconstriction C) Arterial vasodilation D) Venous vasodilation

A) Arterial vasoconstriction

The nursing instructor is explaining cardiac function to the senior nursing class. The instructor explains that blood is ejected into circulation as the chambers of the heart become smaller. The instructor categorizes this action of the heart as what? A) Systole B) Diastole C) Hypertension D) Ejection fraction

A) Systole

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? A) The patient is experiencing laryngeal stridor. B) The patient complains of generalized fatigue. C) The patient's bowels have not moved for 4 days. D) The patient has numbness and tingling of the lips.

A) The patient is experiencing laryngeal stridor.

A patient receives 3% NaCl solution for correction of hyponatremia. which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? A) lung sounds. B) urinary output. C) peripheral pulses. D) peripheral edema

A) lung sounds.

the nurse is admitting a patient with an infectious disease process. what question would be appropriate for a nurse to ask this patient? A. "Do you have a chronic disease, and how long have you had it?" B. "Do you have any children living in the home?" C. "What is your marital status—single, married, or divorced?" D. "Do you have any cultural or religious beliefs that will influence your care?"

A. "Do you have a chronic disease, and how long have you had it?"

A nurse is caring for an older adult client preparing for discharge to a nursing center after having hip surgery. Which of the following nursing responses is most therapeutic with a client's concern that she, will never go back home? A. "What makes you think that this transfer to the nursing center will be permanent?" B. "The reason for this transfer is only to support you while you continue to recuperate." C. "The decision to stay in the nursing center is yours to make. When you want to leave no one will stop you." D. "The nursing center is a lovely place with a wonderful staff of caring people. Just give it a chance. You may like it."

A. "What makes you think that this transfer to the nursing center will be permanent?"

a client who is in hospice care complains of increasing amounts of pain. the healthcare provider prescribes and analgesic every four hours as needed. which action should the nurse take? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli D. Offer a medication-free period so that the client can do daily activities

A. Give an around-the-clock schedule for administration of analgesics.

Eliminating disparities in the health status of people from diverse racial, ethnic, and cultural backgrounds has become one of the two most important priorities of Healthy People 2020 because populations with health disparities have A. Increased incidence of disease. B. Lower levels of morbidity. C. Lower mortality rates. D. Decreased incidence of disease.

A. Increased incidence of disease.

The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which of the following nursing actions would be appropriate given this organism? A. Instruct assistive personnel to use soap and water rather than sanitizer to clean hands. B. Place the patient on Droplet Precautions. C. Wear an N95 respirator when entering the patient room. D. Teach the patient cough etiquette.

A. Instruct assistive personnel to use soap and water rather than sanitizer to clean hands.

the nurse administers an intravenous (IV) hypertonic solution to a patient. in which direction will the fluid shift? A. Intracellular to extracellular B. Extracellular to intracellular C. Intravascular to intracellular D. Intravascular to interstitial

A. Intracellular to extracellular

a patient is experiencing chest pain while playing tennis. he has a bottle of sublingual nitroglycerin with him. which of the actions are appropriate for the patient to take at this time? (SELECT ALL THAT APPLY) A. Stop the activity and lie down or sit down. B. Call 911 immediately. C. Call 911 if the pain is not relieved after taking 1 sublingual tablet. D. Call 911 if the pain is not relieved after taking 3 sublingual tablets in 15 minutes. E. Place a tablet under the tongue. F. Place a tablet in the space between the gum and cheek. G. Take another sublingual tablet if chest pain is not relieved after 5 minutes, up to three, total. H. Take a sip of liquid to help dissolve the pill.

A. Stop the activity and lie down or sit down. D. Call 911 if the pain is not relieved after taking 3 sublingual tablets in 15 minutes. E. Place a tablet under the tongue. G. Take another sublingual tablet if chest pain is not relieved after 5 minutes, up to three, total.

the nurse is caring for a patient in the hospital. the nurse observes the nursing assistant turning off the handle faucet with his hands. what professional practice supports the need for follow-up with the nursing student? A. The nurse is responsible for providing a safe environment for the patient. B. This is a key step in the procedure for washing hands. C. Allowing the water to run is a waste of resources and money. D. Different scopes of practice allow modification of procedures.

A. The nurse is responsible for providing a safe environment for the patient.

the nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. which finding indicates the patient has met an expected outcome? A. The patient is able to ambulate in the hallway with crutches. B. The patient's level of mobility will improve. C. The nurse provides assistance while the patient is walking in the hallways. D. The patient will deny pain while walking in the hallway.

A. The patient is able to ambulate in the hallway with crutches.

The nurse is caring for a Native American who has had recent surgery. In the patient's culture, it is a sign of weakness to complain of pain. In the nurse's culture, people who are having pain ask for pain medicine. The nurse has assumed that the patient has not been having pain and does not need medication because he has not complained of pain. What is the nurse doing? A. Utilizing cultural imposition by not asking the patient about his pain B. Striving to provide culturally congruent care by allowing the patient to suffer C. Operating from an emic worldview of the patient's cultural beliefs D. Practicing discrimination by not giving the patient pain medicine

A. Utilizing cultural imposition by not asking the patient about his pain

The nurse is caring for a diabetic patient in renal failure. Which laboratory findings would the nurse expect? A. pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L B. pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L C. pH 7.3, PaCO2 47 mm Hg, HCO3- 23 mEq/L D. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L

A. pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L

The nurse assesses the patient and records the data collected. What would lead the nurse to anticipate that the patient will experience a decrease in cardiac output? A) An order for the patient to receive digoxin B) A heart rate of 54 beats per minute C) A pulse oximetry reading of 98% D) An increase in preload related to ambulation in the hall

B) A heart rate of 54 beats per minute

During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where will the nurse best palpate the PMI? A) Left midclavicular line of the chest at the level of the nipple B) Left midclavicular line of the chest wall at the fifth intercostal space C) Midline between the xiphoid process and the left nipple D) Two to three centimeters to the left of the sternum

B) Left midclavicular line of the chest wall at the fifth intercostal space

a patient is admitted for hypovolemia associated with multiple draining wounds. which assessment would be the most accurate way for the nurse to evaluate fluid balance? A) skin turgor. B) daily weight. C) presence of edema. D) hourly urine output.

B) daily weight.

Which of the following responses by an older-adult client is most reflective of a need for further education by the nurse regarding the physiological changes associated with the older adult? A. "I call a cab if I want to go out after dark." B. "I can't help worrying about becoming forgetful." C. "I have my eyes checked regularly. Can't afford to fall." D. "I really enjoy eating good vanilla ice cream, but I have cut way down."

B. "I can't help worrying about becoming forgetful."

Which of the following statements made by a family member of a client recently diagnosed with early stages of Alzheimer's disease is most reflective of an understanding of this disease process? A. "Dad has always been a fighter; he'll fight this too. He won't give up." B. "We have an appointment with his care provider to see about medication therapy." C. "Good thing we found out about this early so we can prevent this from getting worse." D. "We have a made arrangements to discuss nursing home placement for dad."

B. "We have an appointment with his care provider to see about medication therapy."

In which patient would the nurse expect to see a positive Chvostek sign? A. A 7-year-old child admitted for severe burns B. A 24-year-old adult admitted for chronic alcohol abuse C. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism D. A 75-year-old patient admitted for a broken hip related to osteoporosis

B. A 24-year-old adult admitted for chronic alcohol abuse

he nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? A. Sodium of 145 mEq/L B. Calcium of 15.5 mg/dL C. Potassium of 3.5 mEq/L D. Chloride of 100 mEq/L

B. Calcium of 15.5 mg/dL

Care that includes the nurse learning about cultural issues involved in the patient's health care belief system and enable patients and families to achieve meaningful and supportive care is known as A. Ethnocentrism. B. Culturally competent care. C. Cultural imposition. D.Culturally congruent care.

B. Culturally competent care.

A client has been recently diagnosed with Alzheimer's disease. When teaching the family about the prognosis, the nurse must explain that: A. Diet and exercise can slow the process considerably B. It usually progresses gradually with a deterioration of function C. Many individuals can be cured if the diagnosis is made early D. Few clients live more than 3 years after the diagnosis

B. It usually progresses gradually with a deterioration of function

a recent immigrant who does not speak English is alert and requires hospitalization. what is the initial action that the nurse must take to enable informed consent to be obtained? A. Ask a family member to translate what the nurse is saying. B. Request an official interpreter to explain the terms of consent. C. Notify the health care provider that the patient doesn't speak English. D. Use hand gestures and medical equipment while explaining in English.

B. Request an official interpreter to explain the terms of consent.

the nurse is caring for a patient who is susceptible to infection. which of the following nursing interventions will assist in decreasing the risk of infection? A. Teaching the patient about fall prevention B. Teaching the patient to select nutritious foods C. Teaching the patient to take a temperature D. Teaching the patient about the effects of alcohol

B. Teaching the patient to select nutritious foods

Which information obtained by the home health nurse when making a visit to an 88-year-old with mild forgetfulness is of the most concern? A. The patient's son uses a marked pillbox to set up the patient's medications weekly. B. The patient has lost 10 pounds (4.5 kg) during the last month. C. The patient is cared for by a daughter during the day and stays with a son at night. D. The patient tells the nurse that a close friend recently died.

B. The patient has lost 10 pounds (4.5 kg) during the last month.

When caring for the older adult, it is important to: A. Repeat oneself often because older adults are forgetful. B. Treat the client as an individual with a unique history of his or her own. C. Be aware that older adults are no longer interested in sex. D. Disregard the older adult's experiences because older people are too old-fashioned to be of value today.

B. Treat the client as an individual with a unique history of his or her own.

the nurse is caring for a patient on Contact Precautions. which of the following actions would be appropriate to prevent the spread of disease? A. Wear a gown, gloves, face mask, and goggles for interactions with the patient. B. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only. C. Place the patient in a room with negative airflow. D. Transport the patient quickly when going to the radiology department.

B. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only.

the nurse is caring for a patient with an incision. which of the following actions would best indicate an understanding of medical and surgical asepsis? A. Donning sterile gown and gloves to remove the wound dressing B. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing C. Donning clean goggles, gown, and gloves to dress the wound D. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing

B. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing

When caring for a patient of a different culture, it is important for the nurse to understand that A. The nurse should protect the patient from family intrusion in her health care decisions. B. Working within the established family hierarchy produces better outcomes. C. Women as primary caregivers make independent health decisions. D. Gender is not a factor when it comes to role expectations.

B. Working within the established family hierarchy produces better outcomes.

When administering a mental status examination to a patient with delirium, the nurse should A. give the examination when the patient is well-rested. B. choose a place without distracting environmental stimuli. C. reorient the patient as needed during the examination. D. medicate the patient first to reduce anxiety.

B. choose a place without distracting environmental stimuli.

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? A) K+ 3.4 mEq/L (3.4 mmol/L) B) Ca+2 7.8 mg/dL (1.95 mmol/L) C) Na+ 154 mEq/L (154 mmol/L) D) PO4-3 4.8 mg/dL (1.55 mmol/L)

C) Na+ 154 mEq/L (154 mmol/L)

The nurse is caring for a patient who does not speak English. She decides to use an interpreter to explain procedures and to answer questions that the patient may have. In performing the interview, what should the nurse do? A. Direct questions to the interpreter to ask the patient. B. Disregard the age and gender of the interpreter. C. Direct questions to the patient. D. Ask the interpreter to ask the patient for clarification at the end.

C. Direct questions to the patient.

a diabetic patient presents to the clinic for a dressing change. the wound is located on the right foot and has purulent yellow drainage. which of these intervention would be most appropriate for the nurse to provide? A. Position the patient comfortably on the stretcher. B. Explain the procedure for dressing change to the patient. C. Don gloves and other appropriate personal protective equipment. D. Review the medication list that the patient brought from home.

C. Don gloves and other appropriate personal protective equipment.

despite significant improvements in the overall health status of the U.S. population over the past few decades, disparities among ethnic and racial minorities have A. Decreased as education levels equal those of non-Hispanic whites. B. Disappeared in relation to non-Hispanic white populations. C. Remained a serious challenge locally and nationally. D. Decreased faster than anticipated.

C. Remained a serious challenge locally and nationally.

The primary reason an older adult client is more likely to develop a pressure ulcer on the elbow as compared to a middle-age adult is: A. A reduced skin elasticity is common in the older adult B. The attachment between the epidermis and dermis is weaker C. The older client has less subcutaneous padding on the elbows D. Older adults have a poor diet that increases risk for pressure ulcers

C. The older client has less subcutaneous padding on the elbows

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? A) Maintain the patient on bed rest. B) Auscultate lung sounds every 4 hours. C) Monitor for Trousseau's and Chvostek's signs. D) Encourage fluid intake up to 4000 mL every day.

D) Encourage fluid intake up to 4000 mL every day.

The student nurses are studying the conduction system of the heart. The instructor explains that the electrical conduction of the heart usually originates in the SA node. Which sequence completes the conduction? A) SA node to Bundle of HIS to AV node to Purkinje fibers B) SA node to AV node to Purkinje fibers to Bundle of HIS C) SA node to bundle of HIS to Purkinje fibers to AV node D) SA node to AV node to bundle of HIS to Purkinje fibers

D) SA node to AV node to bundle of HIS to Purkinje fibers

a patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse? A) The patient's radial pulse is 105 beats/minute. B) There is sediment and blood in the patient's urine. C) The blood pressure increases from 120/80 to 142/94. D) There are crackles audible throughout both lung fields.

D) There are crackles audible throughout both lung fields.

You are caring for an 82-year-old patient. The nurse knows that changes in cardiac structure and function occur in older adults. What is a normal change expected in the aging heart of an older adult? A) Decreased left ventricular ejection time B) Decreased connective tissue in the SA and AV nodes and bundle branches C) Thinning and flaccidity of the cardiac values D) Widening of the aorta

D) Widening of the aorta

a nurse is using a critical thinking model to provide care. which component is first that helps a nurse make clinical decisions? A. Attitude. B. Experience. C. Nursing process. D. A scientific knowledge base.

D. A scientific knowledge base.

The nurse, preparing to discharge an 81-year-old client from the hospital, recognizes that the majority of older adults: A. Require institutional care B. Have no social or family support C. Are unable to afford any medical treatment D. Are capable of taking charge of their own lives

D. Are capable of taking charge of their own lives

A nurse administers a antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistant then reports to the nurse that the patients blood pressure was low when it was taken at 0830. The nursing assistant states that she was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked and it has dropped even lower. The nurse first made an error in what phase of the nursing process? a. Planning b. Diagnosis c. Evaluation D. Assessment

D. Assessment

a 60-year-old patient is on several new medications and expresses concern that she will forget to take her pills. which of the following interventions is best in this situation? A. Teaching effective coping strategies B. Reducing the number of drugs prescribed. C. Assuring her that she will not forget once she is accustomed to the routine D. Assisting her with obtaining and learning to use a calendar or pill container.

D. Assisting her with obtaining and learning to use a calendar or pill container.

A patient is having trouble reaching the water fountain while holding on to crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing himself with two hands on the water fountain. Which critical thinking attitude is utilized in this situation? A. Humility. B. Confidence. C. Risk taking. D. Creativity.

D. Creativity.

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that tho resuscitative effects be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts B. Transfer the client to a hospice inpatient facility C. Prepare the family for the client's impending death D. Notify the healthcare provider of the family's request

D. Notify the healthcare provider of the family's request

Which of these nursing activities is appropriate for the RN working in the eye clinic to delegate to experienced nursing assistive personnel (NAP)? a. Application of a warm compress to a patient's hordeolum b. Assessment of a patient with possible bacterial conjunctivitis c. Instruction about hand washing for a patient with herpes keratitis d. Administration of antiviral drops to a patient with a corneal ulcer

a. Application of a warm compress to a patient's hordeolum

A patient with hearing loss asks the nurse about the use of a cochlear implant. Which information will the nurse include when replying to the patient? a. Cochlear implants require training in order to receive the full benefit. b. Cochlear implants are not useful for patients with congenital deafness. c. Cochlear implants are most helpful as an early intervention for presbycusis. d. Cochlear implants improve hearing in patients with conductive hearing loss.

a. Cochlear implants require training in order to receive the full benefit.

An older adult patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids? a. Experiment with volume and hearing ability in a quiet environment initially. b. Keep the volume low on the hearing aids for the first week while adjusting to them. c. Add the second hearing aid after making the initial adjustment to the first hearing aid. d. Wear the hearing aids for about an hour a day at first, gradually increasing the time of use.

a. Experiment with volume and hearing ability in a quiet environment initially.

The nurse is caring for a 68-year-old hospitalized patient with a decreased glomerular filtration rate who is scheduled for an intravenous pyelogram (IVP). Which action will be included in the plan of care? a. Monitor the urine output after the procedure. b. Assist with monitored anesthesia care (MAC). c. Give oral contrast solution before the procedure. d. Insert a large size urinary catheter before the IVP.

a. Monitor the urine output after the procedure.

A patient who had cataract extraction and intraocular lens implantation the previous day calls the eye clinic and gives the nurse all of the following information. Which information is the priority to communicate to the health care provider? a. The patient has eye pain rated at a 5 (on a 0-10 scale). b. The patient has questions about the ordered eyedrops. c. The patient has poor depth perception when wearing an eye patch. d. The patient complains that the vision has "not improved very much."

a. The patient has eye pain rated at a 5 (on a 0-10 scale).

the nurse is instructing the student nurse regarding discharge teaching and medications. which response by the student would indicate that learning has occurred? a. "I need to be precise when teaching a patient about Zyprexa (olanzapine) and Zyrtec (cetirizine)." b. "The medications can be picked up at the pharmacy on the way out of the hospital." c. "I need to be sure to give the patient leftover medications from the medication drawer." d. "I need to remember to teach the patient to take all medications at the same time of the day."

a. "I need to be precise when teaching a patient about Zyprexa (olanzapine) and Zyrtec (cetirizine)."

a nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis a. "It is important to do breathing exercises every hour to prevent atelectasis" b. "If I develop atelectasis, I will need a chest tube to drain excess fluid" c. "Atelectasis affects only those with chronic conditions such as emphysema" d. "Hyperventilation will open up my alveoli, preventing atelectasis"

a. "It is important to do breathing exercises every hour to prevent atelectasis"

a terminally ill client shares with the nurse that he, needs to tell someone what i want when the end comes. the nurses most therapeutic response is: a. "We can talk about that now if you want to. Let me close the door and pull up a chair." b. "i imagine you would like to discuss matters with your primary care provider. I'll let him know you want to talk" c. "let me finish with my client care and we can talk as long as you need to" d. "if you haven't discussed your feelings with your family yet, I'd suggest you do that when they visit this evening"

a. "We can talk about that now if you want to. Let me close the door and pull up a chair."

upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. which question is most appropriate? a. "When was the last time you voided?" b. "Do you lose urine when you cough or sneeze?" c. "Have you noticed any change in your urination patterns?" d. "Do you have a fever or chills?"

a. "When was the last time you voided?"

A nursing student has been written up several times for being late with providing patient care and for omitting aspects of patient care and not knowing basic procedures that were taught in the skills course one term earlier. The nursing student says, "I don't understand what the big deal is. As my instructor, you are there to protect me and make sure I don't make mistakes." What is the best response from the nursing instructor? a. "You are expected to perform at the level of a professional nurse." b. "You are expected to perform at the level of a nursing student." c. "You are practicing under the license of the nurse assigned to the patient." d. "You are expected to perform at the level of a skilled nursing assistant."

a. "You are expected to perform at the level of a professional nurse."

A patient with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic? a. "Your disease doesn't send enough oxygen to your fingers." b. "Your disease affects both your lungs and your heart, and not enough blood is being pumped." c. "Your disease will be helped if you pursed-lip breathe." d. "Your disease often makes patients lose mental status."

a. "Your disease doesn't send enough oxygen to your fingers."

which of the following client statements regarding self-medication administration by an older-adult client requires follow-up teaching by the nurse? a. "i take all the pills ordered once a day at bedtime, so I'm less likely to forget them" b. "i have one pill that needs cut in half. i am going to ask the pharmacist to do that for me" c. "the pharmacist said to keep my pills away from the sunlight, so I put them inside the kitchen cabinet" d. "my daughter comes over each morning and puts my pills into a container that sorts them by the time they are due"

a. "i take all the pills ordered once a day at bedtime, so I'm less likely to forget them"

the home health nurse cares for an alert and oriented older adult patient with a history of dehydration. which instructions should the nurse give to this patient related to fluid intake? a. "increase fluids if your mouth feels dry" b. "more fluids are needed if you feel thirsty" c. "drink more fluids in the late evening hours" d. "if you feel lethargic or confused, you need more to drink"

a. "increase fluids if your mouth feels dry"

the health care provider has ordered a hypotonic intravenous (IV) solution to be administered. which IV bag will the nurse prepare? a. 0.45% sodium chloride (1/2 NS) b. 0.9% sodium chloride (NS) c. lactated ringer's (LR) d. dextrose 5% in lactated ringer's (D5LR)

a. 0.45% sodium chloride (1/2 NS)

a nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use. 1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma 2. Writes a diagnostic label of impaired gas exchange 3. Organizes data into meaningful clusters 4. Interprets information from patient 5. Writes an etiology a. 1, 3, 4, 2, 5 b. 1, 3, 4, 5, 2 c. 1, 4, 3, 5, 2 d. 1, 4, 3, 2, 5

a. 1, 3, 4, 2, 5

ordered: Diazepam 8mg IM Q4H PRN Available: Diazepam 5mg/mL Administer: a. 1.6mL b. 0.6mL c. 3.2mL d. 1.2mL

a. 1.6mL

in which order will the nurse use the nursing process steps during the clinical decision-making process? 1. evaluating goals 2. assessing patient needs 3. planning priorities of care 4. determining nursing diagnoses 5. implementing nursing interventions a. 2, 4, 3, 5, 1 b. 4, 3, 2, 1, 5 c. 1, 2, 4, 5, 3 d. 5, 1, 2, 3, 4

a. 2, 4, 3, 5, 1

a dosage of 0.8g has been ordered. the available dose is 1g in 2.5mL. how many mL are administered? a. 2mL b. 2.3mL c. 1.2mL d. 0.8mL

a. 2mL

a nurse is using the research process. place in order the sequence that the nurse will follow. 1. Analyze results. 2. Conduct the study. 3. Identify clinical problem. 4. Develop research question. 5. Determine how study will be conducted. a. 3, 4, 5, 2, 1 b. 4, 3, 5, 2, 1 c. 3, 5, 4, 2, 1 d. 4, 5, 3, 2, 1

a. 3, 4, 5, 2, 1

a patient with a fecal impaction has an order to remove stool digitally. in which order will the nurse perform the steps, starting with the first one? 1. obtain baseline vital signs 2. apply clean gloves and lubricate 3. insert index finger into the rectum 4. identify patient using two identifiers 5. place the patient on the left side in the Sims position 6. massage around the feces and work down to remove. a. 4,1,5,2,3,6 b. 1,4,2,5,3,6 c. 4,1,2,5,3,6 d. 1,4,5,2,3,6

a. 4,1,5,2,3,6

The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? a. 43-year-old with a (blood pressure (BP) of 160/92 who is complaining of chest pain b. 52-year-old with a BP of 212/90 who has intermittent claudication c. 50-year-old with a BP of 190/104 who has a creatinine of 1.7 mg/dL d. 48-year-old with a BP of 172/98 whose urine shows microalbuminuria

a. 43-year-old with a (blood pressure (BP) of 160/92 who is complaining of chest pain

A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest? a. A cup of nonfat yogurt with granola and a handful of dried apricots b. Whole wheat toast with butter and a side of bacon c. A bowl of cereal with whole milk and a banana d. Omelet with sausage, cheese, and onions

a. A cup of nonfat yogurt with granola and a handful of dried apricots

A nurse is caring for a group of patients. Which patient should the nurse see first? a. A patient with hypercapnia wearing an oxygen mask b. A patient with a chest tube ambulating with the chest tube unclamped c. A patient with thick secretions being tracheal suctioned first and then orally d. A patient with a new tracheostomy and tracheostomy obturator at bedside

a. A patient with hypercapnia wearing an oxygen mask

which of the following statements is true regarding an adverse drug reaction (ADR)? a. ADR's can be unexpected and unintended responses to medications b. ADR's are desired responses to a medication. c. ADR's are unpredictable, one of a kind response to a medication d. ADR's are preventable if proper precautions are taken

a. ADR's can be unexpected and unintended responses to medications

A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output. The patient has voided 400 mL of urine. After reporting these values to the health care provider, which order does the nurse anticipate? a. Add a potassium supplement to replace loss from output. b. Decrease the rate of intravenous fluids to 100 mL/hr. c. Administer a diuretic to prevent fluid volume excess. d. Discontinue the nasogastric suctioning.

a. Add a potassium supplement to replace loss from output.

the standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. after assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. which action will the nurse take next? a. Administer the acetaminophen. b. Notify the health care provider to obtain a verbal order. c. Direct the nursing assistive personnel to give the acetaminophen. d. Perform a pain assessment only after administering the acetaminophen.

a. Administer the acetaminophen.

When utilizing Freud's psychoanalytical/psychosocial theory, the nurse recalls that a. Adult personality is the result of resolved conflicts between sources of sexual pleasure and the mandates of reality. b. Development occurs throughout the life span and focuses on psychosocial stages. c. The genital stage precedes the phallic stage of development. d. Problems evident in adult life are due to early successes and resolution of earlier developmental stages.

a. Adult personality is the result of resolved conflicts between sources of sexual pleasure and the mandates of reality.

The nurse is caring for a patient who needs oxygen via a nasal cannula. Which task can the nurse delegate to the nursing assistive personnel? a. Applying the nasal cannula b. Adjusting the oxygen flow c. Assessing lung sounds d. Setting up the oxygen

a. Applying the nasal cannula

a newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action? a. Assign the patient to a room near the nurse's station. b. Place the patient in a room nearest to the water fountain. c. Place the patient on telemetry to monitor for peaked T waves. d. Assign the patient to a semi-private room and place an order for a low-salt diet.

a. Assign the patient to a room near the nurse's station.

Isotonic, isometric, and resistive isometric are three categories of exercise. They are classified according to the type of muscle contraction involved. Of the following exercises, which are considered isotonic? a. Bicycling, swimming, walking, jogging, dancing b. Tightening or tensing of muscles without moving body parts c. Push-ups, hip lifting, pushing feet against a footboard on the bed d. Quadriceps set exercises and contraction of the gluteal muscles

a. Bicycling, swimming, walking, jogging, dancing

the nurse is caring for a patient who is experiencing inadequate bladder emptying. to determine postvoid residual, which technique is most important for the nurse to implement? a. Bladder scanner b. Indwelling catheterization c. Straight/intermittent catheterization d. Foley catheterization

a. Bladder scanner

A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli's function will the nurse share with the patient? a. Carries out gas exchange b. Regulates tidal volume c. Produces hemoglobin d. Stores oxygen

a. Carries out gas exchange

Which nursing action should the nurse take first in order to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? a. Collect a detailed diet history. b. Provide a list of low-sodium foods. c. Help the patient make an appointment with a dietitian. d. Teach the patient about foods that are high in potassium.

a. Collect a detailed diet history.

which action indicates a nurse is using critical thinking for implementation of nursing care to patients? a. Determines whether an intervention is correct and appropriate for the given situation b. Reads over the steps and performs a procedure despite lack of clinical competency c. Establishes goals for a particular patient without assessment d. Evaluates the effectiveness of interventions

a. Determines whether an intervention is correct and appropriate for the given situation

while preparing a teaching plan, the nurse describes what the learner will be able to accomplish after the teaching session about healthy eating. which action is the nurse completing? a. Developing learning objectives b. Providing positive reinforcement c. Presenting facts and knowledge d. Implementing interpersonal communication

a. Developing learning objectives

a nurse uses evidence-based practice (EBP) to provide nursing care. what is the best rationale for the nurse's behavior? a. EBP is a guide for nurses in making clinical decisions b. EBP is based on the latest textbook information c. EBP is easily attained at the bedside d. EBP is always right for all situations

a. EBP is a guide for nurses in making clinical decisions

in caring for a patient who has a pouching for noncontinent urinary diversion, which nursing intervention is essential a. Empty the pouch when it is one-third to one-half full. b. Remove the ureteral stents after 2 days. c. Pouch the stoma with the patient sitting up. d. Dispose of used pouches in the toilet.

a. Empty the pouch when it is one-third to one-half full.

The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination? a. Experiences chest pain after eating a heavy meal b. Experiences adequate oxygen saturation during exercise c. Experiences crushing chest pain for more than 20 minutes d. Experiences tingling in the left arm that lasts throughout the morning

a. Experiences chest pain after eating a heavy meal

a nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. the patient is afebrile and dyspenic. the nurse auscultates crackles in both lung bases and sees jugular vein distention. on which transfusion complication will the nurse focus interventions? a. Fluid volume overload b. Hemolytic reaction c. Anaphylactic shock d. Septicemia

a. Fluid volume overload

Jean Piaget's cognitive developmental theory focuses on four stages of development, including a. Formal operations. b. Intimacy versus isolation. c. Latency. d. The postconventional level.

a. Formal operations.

A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? a. Grape and walnut chicken salad sandwich on whole wheat bread b. Broccoli and cheese soup with potato bread c. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing d. Turkey and mashed potatoes with brown gravy

a. Grape and walnut chicken salad sandwich on whole wheat bread

the nurse is providing discharge teaching for an older adult woman who will need dressing changes at home. the husband states that he will not be able to perform the dressing changes. what does the nurse need to arrange for? a. Home care service referrals b. Extra dressing supplies c. Cancellation of the discharge d. An order for antibiotics

a. Home care service referrals

Which coughing technique will the nurse use to help a patient clear central airways? a. Huff b. Quad c. Cascade d. Incentive spirometry

a. Huff

The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse most likely expect? a. Increased preload b. Increased heart rate c. Decreased afterload d. Decreased tissue perfusion

a. Increased preload

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at 125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium decreases to less than 128 mEq/L.

a. Infuse 5% dextrose in water at 125 mL/hr.

the nurse is calculating intake and output on a patient. the patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient's medical record? a. Intake 255; output 375 b. Intake 285; output 375 c. Intake 505; output 125 d. Intake 535; output 125

a. Intake 255; output 375

A patient has dehydration. While planning care, the nurse considers that the majority of the patient's total water volume exists in with compartment? a. Intracellular b. Extracellular c. Intravascular d. Transcellula

a. Intracellular

A patient is using laxatives three times daily to lose weight. After stopping laxative use, the patient has difficulty with constipation and wonders if laxatives should be taken again. Which information will the nurse share with the patient? a. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. b. Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis. c. Long-term use of emollient laxatives is effective for treatment of chronic constipation and may be useful in certain situations. d. Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced.

a. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur.

A patient has carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient? a. Low-carbohydrate b. Low-caffeine c. High-caffeine d. High-carbohydrate

a. Low-carbohydrate

a nurse is caring for a hospitalized patient with a urinary catheter. which nursing action best prevents the patient from acquiring an infection? a. Maintaining a closed urinary drainage system b. Inserting the catheter using strict clean technique c. Disconnecting and replacing the catheter drainage bag once per shift d. Fully inflating the catheter's balloon according to the manufacturer's recommendation

a. Maintaining a closed urinary drainage system

a patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

a. Metabolic acidosis

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next? a. Monitor ionized calcium level. b. Give oral calcium citrate tablets. c. Check parathyroid hormone level. d. Administer vitamin D supplements.

a. Monitor ionized calcium level.

A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first? a. Notify the patient's health care provider b. Obtain an order to draw a potassium level. c. Review the magnesium level on the patient's chart. d. Teach the patient about the risk of magnesium-containing antacids

a. Notify the patient's health care provider

a patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. the nurse should alert the health care provider immediately that the patient on which medication? a. Oral digoxin (Lanoxin) 0.25 mg daily b. Ibuprofen (Motrin) 400 mg every 6 hours c. Metoprolol (Lopressor) 12.5 mg orally daily d. Lantus insulin 24 U subcutaneously every evening

a. Oral digoxin (Lanoxin) 0.25 mg daily

The patient has right-sided heart failure. Which finding will the nurse expect when performing an assessment? a. Peripheral edema b. Basilar crackles c. Chest pain d. Cyanosis

a. Peripheral edema

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete immediately? a. Presence of the Chvostek's sign b. Abnormal serum potassium level c. Decreased thyroid hormone level d. Bleeding on the patient's dressing

a. Presence of the Chvostek's sign

a patient who is going to surgery has been taught how to cough and deep breathe. which evaluation method will the nurse use? a. Return demonstration b. Computer instruction c. Verbalization of steps d. Cloze test

a. Return demonstration

a confused patient is restless and continues to try to remove his oxygen and urinary catheter. what is the priority nursing diagnosis and intervention to implement for this patient? a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail. b. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter. c. Disturbed body image: Encourage patient to express concerns about body. d. Caregiver role strain: Identify resources to assist with care.

a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail.

in advancing the NG tube, which technique provides the safest outcome? a. Rotate the tube if resistance is felt. b. Advance the tube in between swallows. c. Start with the patient's head flexed. d. Check the tube placement by instilling air and auscultating over the stomach.

a. Rotate the tube if resistance is felt.

A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave? a. SA node b. AV node c. Bundle of His d. Purkinje fibers

a. SA node

The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? a. Serum creatinine of 2.8 mg/dL b. Serum potassium of 4.5 mEq/L c. Serum hemoglobin of 14.7 g/dL d. Blood glucose level of 96 mg/dL

a. Serum creatinine of 2.8 mg/dL

in assessing the spiritual health of her patients, the nurse understands that a. Spiritual beliefs change as patients grow and develop. b. Spiritual health in older adults leads to peace and acceptance of others. c. Older adults often express spirituality by focusing on themselves. d. The basis of beliefs among older people is focused on one or two factors.

a. Spiritual beliefs change as patients grow and develop.

the nurse is caring for an elderly patient admitted with nausea, vomiting, and diarrhea. upon completing the health history, which priority concern would require collaboration with social services to address the patient's health care needs? a. The electricity was turned off 2 days ago. b. The water comes from the county water supply. c. A son and family recently moved into the home. d. The home is not furnished with a microwave oven.

a. The electricity was turned off 2 days ago.

which situation will cause the nurse to intervene and follow up on the nursing assistive personnel's (NAP) behavior? a. The nursing assistive personnel is calling the older-adult patient "honey." b. The nursing assistive personnel is facing the older-adult patient when talking. c. The nursing assistive personnel cleans the older-adult patient's glasses gently. d. The nursing assistive personnel allows time for the older-adult patient to respond.

a. The nursing assistive personnel is calling the older-adult patient "honey."

the following statements are on a patient's nursing care plan. which statement will the nurse use as an outcome for a goal of care? a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. b. The patient will demonstrate increased tolerance to activity over the next month. c. The patient will understand needed dietary changes by discharge. d. The patient will demonstrate increased mobility in 2 days.

a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.

which observation by the nurse when examining a patient's auditory canal and tympanic membrane is a priority to report to the health care provider? a. The tympanum is blue-tinged. b. There is a cone of light visible. c. Cerumen is present in the auditory canal. d. The skin in the ear canal is dry and scaly.

a. The tympanum is blue-tinged.

The nurse is careful to monitor a patient's cardiac output. Which goal is the nurse trying to achieve? a. To determine peripheral extremity circulation b. To determine oxygenation requirements c. To determine cardiac dysrhythmias d. To determine ventilation status

a. To determine peripheral extremity circulation

the nurse receives an order to insert a Foley catheter. in obtaining a catheter of the right size, the nurse is aware that large catheters can lead to which complication? a. Urethral damage b. Bladder relaxation c. Obstruction of urinary flow d. Decreased risk for infection

a. Urethral damage

the nurse is teaching a group of newly hired nursing assistive personnel (NAP) about proper hand washing. the nurse will know that the teaching was effective if the NAP demonstrate what? Select all that apply. the NAP: a. Uses a paper towel to turn off the faucet b. Holds fingertips above the wrists while rinsing off the soap c. Removes all rings and watch before washing hands d. Cleans underneath each fingernail

a. Uses a paper towel to turn off the faucet c. Removes all rings and watch before washing hands d. Cleans underneath each fingernail

The nurse is concerned about pulmonary aspiration when providing her patient with tube feedings. The nurse should a. Verify tube placement before feeding. b. Lower the head of the bed to a supine po-sition. c. Add blue food coloring to the enteral formula. d. Run the formula over 12 hours to decrease volume.

a. Verify tube placement before feeding.

alcohol based solutions for hand hygiene can be used to combat which types of organisms? select all that apply a. Viruses b. Bacterial spores c. Yeasts d. Molds

a. Viruses c. Yeasts d. Molds

the nurse is caring for a group of patients. which patient will the nurse see first? a. a patient with D5W hanging with the blood b. a patient with type A blood receiving type O blood c. a patient with intravenous potassium chloride that is diluted d. a patient with a right mastectomy and intravenous site in the left arm

a. a patient with D5W hanging with the blood

morphine 10 mg IV every 4 to 6 hours prn is ordered for a patient with a pancreatic tumor who has a distant history of opiod abuse. after 3 days of receiving the morphine every 6 hours, the patient tells the nurse that the medication is needed more frequently to control the pain. the initial intervention by the nurse is to: a. administer the morphine every 4 hours as needed. b. consult with the doctor about initiating an appropriate weaning protocol for the morphine c. remind the patient that the previous substance abuse increases the risk for addiction. d. use alternative therapies such as heat or cold.

a. administer the morphine every 4 hours as needed.

the patient reports to the nurse of being afraid to speak up regarding a desire to end care for fear of upsetting spouse and children. which principle in the nursing code of ethics ensures that the nurse will promote the patient's cause? a. advocacy b. responsibility c. confidentiality d. accountability

a. advocacy

the nurse is preparing to apply an external catheter. which action will the nurse take? a. allow 1 to 2 inches of space between the tip of the penis and the end of the catheter b. spiral wrap the penile shaft using adhesive tape to secure the catheter c. twist the catheter before applying drainage tubing to the end of the catheter d. shave the pubic area before applying the catheter

a. allow 1 to 2 inches of space between the tip of the penis and the end of the catheter

four patients arrive at the emergency department at the same time. which patient will the nurse see first? a. an infant with temperature of 102.2 and diarrhea for 3 days b. a teenager with a sprained ankle and excessive edema c. a middle-aged adult with abdominal pain who is moaning and holding her stomach d. an older adult with nausea and vomiting for 3 days with blood pressure 112/60

a. an infant with temperature of 102.2 and diarrhea for 3 days

Which nursing intervention is the most effective in preventing hospital-acquired pneumonia in an elderly patient a. assist patient to cough, turn, and deep breath every 2 hours b. encourage patient to drink through a straw to prevent aspiration c. discontinue humidification delivery device to keep excess fluid from lungs d. monitor oxygen saturation, and frequently assess lung bases

a. assist patient to cough, turn, and deep breath every 2 hours

Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this medication when the patient reveals a history of a. asthma. b. daily alcohol use. c. peptic ulcer disease. d. myocardial infarction (MI).

a. asthma.

the nurse is evaluating the response to treatment for a patient has recently started taking furosemide (Lasix) to treat stage 2 hypertension. The information that will require the nurse to act most rapidly is a(n) a. blood potassium level of 2.0 mEq/L. b. blood glucose level of 180 mg/dl. c. BP reading of 164/96. d. dyspnea on exertion

a. blood potassium level of 2.0 mEq/L.

during the admission interview the client reports to the nurse that she is "a little allergic to penicillin." which of the following questions asked by the nurse is most likely to provide the most relevant information regarding the client's possible allergy to penicillin? a. can you describe what happens when you take penicillin b. who told you that you are allergic to penicillin c. what makes you think you are allergic to penicillin d. what do you take for an infection since you are allergic to penicillin

a. can you describe what happens when you take penicillin

the nurse at the eye clinic advises all patients to wear sunglasses that protect the eyes from the ultraviolet light because ultraviolet sunlight exposure is associated with the development of a. cataracts b. glaucoma c. anisocoria d. exophthalmos

a. cataracts

a nurse is teaching a patient about the large intestine in elimination. in which order will the nurse list the structures, starting with the first portion? a. cecum, ascending, transverse, descending, sigmoid, and rectum b. ascending, transverse, descending, sigmoid, rectum, and cecum c. cecum, sigmoid, ascending, transverse, descending, and rectum d. ascending, transverse, descending, rectum, sigmoid, and cecum

a. cecum, ascending, transverse, descending, sigmoid, and rectum

the nurse is using critical thinking skills during the first phase of the nursing process. which action indicates the nurse is in the first phase? a. completes a comprehensive database b. identifies pertinent nursing diagnosis c. intervenes based on priorities of patient care d. determines whether outcomes have been achieved

a. completes a comprehensive database

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make? a. daily alcohol intake b. intake of dietary protein c. multivitamin/mineral use d. use of over-the-counter (OTC) laxatives

a. daily alcohol intake

a patient with hypertension asks the nurse why lifestyle changes are needed when the patient has no symptoms from the high BP. the response by the nurse that is most likely to improve patient compliance with therapy is that hypertension: a. damages the blood vessels leading to risk for heart attack, stroke, and kidney failure. b. increases blood flow to the kidneys leading to increased workload for the renal system. c. may not cause any problems for some people but does cause symptoms in many others. d. is probably causing symptoms but the patient does not recognize that they are occurring.

a. damages the blood vessels leading to risk for heart attack, stroke, and kidney failure.

the nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. the patient's kidney lab results are abnormal, and the patient's oral intake has significantly decreased since previous shifts. which step of the nursing process should the nurse proceed to after this review? a. diagnosis b. planning c. implementation d. evaluation

a. diagnosis

a nurse is providing care to a patient with an indwelling catheter. which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI)? a. drapes the urinary drainage tubing with no depended loops b. washes the drainage tube toward the meatus with soap and water c. places the urinary drainage bag gently on the floor below the patient d. allows the spigot to touch the receptacle when emptying the drainage bag

a. drapes the urinary drainage tubing with no depended loops

a patient becomes infected with oral candidiasis (thrush) while receiving intravenous antibiotics to treat a systemic infection. which type of infection has the patient developed? a endogenous nosocomial b. exogenous nosocomial c. latent d. primary

a. endogenous nosocomial

the nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. which part of the diagnostic statement does the nurse need to revise? a. etiology b. nursing diagnosis c. collaborative problem d. defining characteristic

a. etiology

onset of a drug action refers to the time it takes for the drug to: a. exerts a desired effect b. take to produce and undesirable effect c. take the plasma concentration of a drug to reach the full concentration d. take the plasma concentration of a drug to reach half of its original concentration

a. exerts a desired effect

the nurse is caring for a patient who has suffered a stroke and has residual mobility problems. the patient is at risk for skin impairment. which initial interventions should the nurse select to decrease this risk? a. gentle cleaners and thorough drying of the skin b. absorbent pads and garments c. positioning with use of pillows d. therapeutic beds and mattresses

a. gentle cleaners and thorough drying of the skin

the nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency, with peripheral neuropathy and urinary incontinence. the nurse realizes that patients with these conditons a. have decreased pain sensation and increased risk of skin impairment b. are at decreased risk for developing infection due to urinary pH level c. also have decreased caloric intake, which results in accelerated wound healing d. have impaired venous return, allowing for greater circulation and less breakdown

a. have decreased pain sensation and increased risk of skin impairment

a nurse is teaching a patient about the Speak Up Initiatives. which information should the nurse include in the teaching session? a. if you still do not understand, ask again. b. ask a nurse to be your advocate or supporter. b. the nurse is the center of the health care team. d. inappropriate medical tests are the most common mistakes.

a. if you still do not understand, ask again.

a patient has fallen several time in the past week when attempting to get to the bathroom. the patient gets up 3 or 4 times a night to urinate. which recommendation by the nurse is most appropriate in correcting this urinary problem? a. limit fluid and caffeine intake before bed b. leave the bathroom light on to illuminate a pathway c. practice kegel exercises to strengthen bladder muscles d. clear the path to the bathroom of all obstacles before bedtime

a. limit fluid and caffeine intake before bed

a nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. which oxygen delivery device is most appropriate for the nurse to administer the oxygen? a. nasal cannula b. simple face mask c. non-rebreather mask d. partial non-rebreather mask

a. nasal cannula

which of these interventions would take priority and should be included in a plan of care for a patient who presents with pneumonia? a. observe the patient for decreased activity tolerance b. assume that the patient is in pain and treat accordingly c. maintain the temperature of 65 degrees F d. provide the patient with ice chips as requested

a. observe the patient for decreased activity tolerance

a nurse is taking a history on a patient who cannot speak English. which action will the nurse take? a. obtain an interpreter b. refer to a speech therapist. c. let a close family member talk. d. find a mental health nurse specialist.

a. obtain an interpreter.

the nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. which process is the nurse describing? a. osmosis b. filtration c. diffusion d. active transport

a. osmosis

a patient asks about treatment for stress urinary incontinence. which is the nurse's best response? a. perform pelvic floor exercises b. avoid voiding frequently c. drink cranberry juice d. wear an adult diaper

a. perform pelvic floor exercises

the client is to receive a medication via the buccal route. the most appropriate nursing intervention is to: a. place the medication inside the cheek b. crush the medication before administration c. offer the client a glass of orange juice after administration d. use sterile technique to administer the medication

a. place the medication inside the cheek

The standard policy on the cardiac unit states, "Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg." The nurse will need to call the health care provider about the a. postoperative patient with a BP of 116/42. b. newly admitted patient with a BP of 150/87. c. patient with left ventricular failure who has a BP of 110/70. d. patient with a myocardial infarction who has a BP of 140/86.

a. postoperative patient with a BP of 116/42.

before meeting the patient, a nurse talks to other caregivers about the patient. which phase of the helping relationship is the nurse in with this patient? a. preinteraction b. orientation c. working d. termination

a. preinteraction

the nurse is working in a clinic that is designed to provide health education and immunizations. as suck, this clinic is designed to provide. a. primary prevention b. secondary prevention c. tertiary prevention d. diagnosis and prompt intervention

a. primary prevention

A nurse wants to present information about flu immunizations to the elderly in the community. Which type of communication should the nurse use? a. public b. small group c. interpersonal d. intrapersonal

a. public

The nurse is observing a student who is preparing to perform an ear examination for a 24-year-old patient. The nurse will need to intervene if the student a. pulls the auricle of the ear down and backward. b. chooses a speculum larger than the ear canal. c. stabilizes the hand holding the otoscope on the patient's head. d. stops inserting the otoscope after observing impacted cerumen.

a. pulls the auricle of the ear down and backward

what is the terminal point in the conduction system of the heart? a. purkinje fibers b. AV node c. bundle of HIS d. nodal cells

a. purkinje fibers

a nurse is implementing an evidence-based practice project regarding infection rates. after reviewing literature, which other evidence should the nurse review? a. quality improvement data b. inductive reasoning data c. informed consent data d. biased data

a. quality improvement data

which wound bed color usually indicates normal, healthy granulation tissue? a. red b. yellow c. tan d. black

a. red

a nurse is using SOLER to facilitate active listening. which technique should the nurse use for R? a. relax b. respect c. reminisce d. reassure

a. relax

a patient is experiencing respiratory acidosis. which organ system is responsible for compensation in this patient? a. renal b. endocrine c. respiratory d. gastrointestinal

a. renal

The priority nursing diagnosis for a patient experiencing an acute attack with Meniere's disease is a. risk for falls related to dizziness. b. impaired verbal communication related to tinnitus. c. self-care deficit (bathing and dressing) related to vertigo. d. imbalanced nutrition: less than body requirements related to nausea.

a. risk for falls related to dizziness.

a nurse is describing a patient's perceived ability to successfully complete a task. which term should the nurse use to describe this attitude? a. self-efficacy b. motivation c. attentional set d. active participation

a. self efficacy

a patient has developed a decubitus ulcer. what laboratory data would be important to gather? a. serum albumin b. creatine kinase c. vitamin E d. potassium

a. serum albumin

the nurse is reviewing laboratory results. which cation will the nurse observe is the most abundant in the blood? a. sodium b. chloride c. potassium d. magnesium

a. sodium

a patient tells the nurse, "I feel that God has abandoned me. I am so angry that I can't even pray." the patient refuses to see his clergyman when he calls. which is the most appropriate nursing diagnosis for this patient a. spiritual distress b. risk for spiritual distress c. impaired religiosity d. moral distress

a. spiritual distress

a nurse is teaching about risk factors for cardiopulmonary disease. which risk factor should the nurse describe as modifiable? a. stress b. allergies c. family history d. gender

a. stress

a new nurse on the cardiac unit is taking a class in the anatomy and physiology of the heart. what does the nurse learn is the cardiac action potential? a. the cycle of depolarization and repolarization b. the time it takes from the firing of the SA node to the contraction of the ventricles c. the time between the contraction of the atria and the contraction of the ventricles d. the cycle of the firing of the AV node and the contraction of the myocardium

a. the cycle of depolarization and repolarization

when a nurse provides a medication to a client, who has the ultimate responsibility for the medication that is being administered? a. the nurse administering the medication b. the client taking the medication c. the physician prescribing the medication d. the pharmacist dispensing the medication

a. the nurse administering the medication

a patient had a stroke and must use a cane for support. a nurse is preparing to teach the patient about the cane. which learning objective/outcome is most appropriate for the nurse to include in the teaching plan? a. the patient will walk to the bathroom and back to bed using a cane b. the patient will understand the importance of using a cane c. the patient will know the correct use of a cane d. the patient will learn how to use a cane

a. the patient will walk to the bathroom and back to bed using a cane

The nurse has received the laboratory results for a patient who developed chest pain 2 hours ago and may be having a myocardial infarction. The most important laboratory result to review will be a. troponins T and I. b. creatine kinase-MB (CK-MB) c. LDL cholesterol. d. myoglobin

a. troponins T and I.

bacteria are necessary for human health and well-being. a. true b. false

a. true

spirituality occurs over time and involves the accumulation of life experiences and understanding. a. true b. false

a. true

which of the following interventions is most likely to minimize the cause of a pressure ulcer on the left buttock of a client who is comatose? a. turn and position the client at least every 2 hours b. use a lift sheet when moving the client up in the bed c. change wet, soiled clothing as promptly as it is detected d. keep the head of the client's bed elevated to less than 30 degrees

a. turn and position the client at least every 2 hours

a patient is aphasic, and the nurse notices that the patient's hands shake intermittently. which nursing action is most appropriate to facilitate communication? a. use a picture board. b. use pen and paper c. use an interpreter d. use a hearing aid

a. use a picture board

which of the following nursing activities is of highest priority for maintaining medical asepsis? a. washing hands b. donning gloves c. applying sterile drapes d. wearing a gown

a. washing hands

The nurse is beginning a sleep assessment on a patient. Which of the following would be the most appropriate question to ask? a. "What is going on?" b. "How are you sleeping?" c. "Are you taking any medications?" d. "What did you have for dinner last night?"

b. "How are you sleeping?"

A patient has received a nursing diagnosis of sleep deprivation. Which of the following statements by the patient would indicate that outcomes are being met? a. "I wake up only once a night to go the bathroom." b. "I feel rested when I wake up in the morning." c. "I go to sleep within 30 minutes of lying down." d. "I only take a 20-minute nap during the day."

b. "I feel rested when I wake up in the morning."

A nurse receives an order from a health care provider to administer Vicodin ES, which contains 750 mg acetaminophen and 7.5 mg hydrocodone, to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurse's best next action? a. Give the Vicodin ES to the patient immediately because the patient is experiencing severe pain. b. Ask the health care provider to verify the dosage and frequency of the medication. c. Ask the health care provider for an order for a nonsteroidal antiinflammatory drug (NSAID). d. Ask the health care provider for an order to play music for the patient, in addition to providing the pain medication.

b. Ask the health care provider to verify the dosage and frequency of the medication.

The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority? a. Call the rapid response team. b. Ask the patient to rate and describe the pain. c. Raise the head of the bed. d. Administer pain relief medications

b. Ask the patient to rate and describe the pain.

The nurse notes that nursing assistive personnel (NAP) perform all the following actions when caring for a patient with Ménière's disease who is experiencing an acute attack. Which action by NAP indicates that the nurse should intervene immediately? a. NAP raise the side rails on the bed. b. NAP turn on the patient's television. c. NAP turn the patient to the right side. d. NAP place an emesis basin at the bedside.

b. NAP turn on the patient's television.

Which topic will the nurse plan to include when teaching the patient with herpes simplex keratitis of the left eye about management of the infection? a. How to apply an occlusive dressing to the affected eye b. Need for frequent hand washing and avoiding touching the eyes c. Application of antibiotic drops to the left eye several times daily d. Use of corticosteroid ophthalmic ointment to decrease inflammation

b. Need for frequent hand washing and avoiding touching the eyes

When the nurse is admitting a 78-year-old patient, the patient repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take? a. Overenunciate while speaking. b. Speak normally but more slowly. c. Increase the volume when speaking. d. Use more facial expressions when talking.

b. Speak normally but more slowly.

The charge nurse observes a newly hired nurse performing all of the following interventions for a patient who has just arrived in the postanesthesia care unit after having right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene? a. The nurse leaves the eye shield in place. b. The nurse encourages the patient to cough. c. The nurse elevates the patient's head to 45 degrees. d. The nurse applies corticosteroid drops to the right eye.

b. The nurse encourages the patient to cough.

A patient who had a motor vehicle accident 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). How does the nurse know that the patient is experiencing effective pain management with the PCA? a. The patient is sleeping and is difficult to arouse. b. The patient rates pain at an acceptable level of 3 on a 0 to 10 scale. c. Sufficient medication is left in the PCA syringe. d. The patient presses the control button to deliver pain medication.

b. The patient rates pain at an acceptable level of 3 on a 0 to 10 scale.

To evaluate the effectiveness of the prescribed bifocals for a patient with myopia and presbyopia, the nurse in the eye clinic will check the patient for a. strength of the eye muscles. b. both near and distant vision. c. cloudiness in the eye lenses. d. intraocular pressure changes.

b. both near and distant vision.

A female patient with a suspected urinary tract infection (UTI) is to provide a clean-catch urine specimen for culture and sensitivity testing. To obtain the specimen, the nurse will a. have the patient empty the bladder completely, then obtain the next urine specimen that the patient is able to void. b. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup. c. insert a short sterile "mini" catheter attached to a collecting container into the urethra and bladder to obtain the specimen. d. clean the area around the meatus with a povidone-iodine (Betadine) swab, and then have the patient void into a sterile container.

b. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup.

An Orthodox Jewish Rabbi has been pronounced dead. The nursing assistant respectfully asks family members to leave the room and go home as postmortem care is provided. Which of the following statements from the supervising nurse reflects correct knowledge of Jewish culture? a. "I wish they would go home because we have work to do here." b. "Family members stay with the body until burial the next day." c. "I should have called a male colleague to handle the body." d. "I thought they would quietly leave after praying and touching the Rabbi's head."

b. "Family members stay with the body until burial the next day."

A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask first? a. "Did you take any acetaminophen (Tylenol) today?" b. "Have you been consistently taking your medications?" c. "Have there been any recent stressful events in your life?" d. "Have you recently taken any antihistamine medications?"

b. "Have you been consistently taking your medications?"

a patient says, "you are the worst nurse i have ever had." which response by the nurse is most assertive? a. "If I were you, I'd feel grateful for a nurse like me." b. "I feel uncomfortable hearing that statement." c. "How can you say that when I have been checking on you regularly?" d. "You shouldn't say things like that, it is not right."

b. "I feel uncomfortable hearing that statement."

an outcome for an older adult patient living alone is to be free from falls. which of these statements by a patient indicates that teaching on safety concerns has been effective? a. "I'll leave my throw rugs in place so that my feet won't touch the cold tile." b. "I'll take my time getting up from the bed or chair." c. "I should wear my favorite smooth bottom socks to protect my feet when walking around." d. "I will have my son dim the lighting outside to decrease the glare in my eyes."

b. "I'll take my time getting up from the bed or chair."

while recovering from a severe illness, a hospitalized patient wants to change a living will, which was signed 9 months ago. which response by the nurse is most appropriate? a. "Check with your admitting health care provider whether a copy is on your chart." b. "Let me check with someone here in the hospital who can assist you." c. "you are not allowed to ever change a living will after signing it." d. "Your living will can be changed only once each calendar year."

b. "Let me check with someone here in the hospital who can assist you."

a patient has just received a diagnosis of cancer. which statement by the nurse demonstrates empathy? a. "Tomorrow will be better." b. "This must be hard news to hear." c. "What's your biggest fear about this diagnosis?" d. "I believe you can overcome this because I've seen how strong you are."

b. "This must be hard news to hear."

The nurse is doing discharge teaching with a patient who has coronary artery disease. The patient asks why he has to take an aspirin every day if he doesn't have any pain. What would be the nurse's best response? a. "taking an aspirin every day is an easy way to prevent plaque build up in the arteries." b. "an aspirin a day is a common nonprescription medication that improves outcomes in patients with CAD" c. "taking an aspirin every day really isn't necessary. it just makes some patients feel like they are doing something to help themselves" d. "an aspirin a day is an easy way to help yourself feel better"

b. "an aspirin a day is a common nonprescription medication that improves outcomes in patients with CAD"

Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a patient with stage 1 hypertension who has a history of diabetes mellitus? a. 102/60 mm Hg b. 128/76 mm Hg c. 139/90 mm Hg d. 136/82 mm Hg

b. 128/76 mm Hg

A nurse is teaching staff about the conduction of the heart. In which order will the nurse present the conduction cycle, starting with the first structure? 1. Bundle of His 2. Purkinje network 3. Intraatrial pathways 4. Sinoatrial (SA) node 5. Atrioventricular (AV) node a. 5, 4, 3, 2, 1 b. 4, 3, 5, 1, 2 c. 4, 5, 3, 1, 2 d. 5, 3, 4, 2, 1

b. 4, 3, 5, 1, 2

the staff is having a hard time getting an older-adult patient to communicate. which technique should the nurse suggest the staff use? a.Try changing topics often. b. Allow the patient to reminisce. c. Ask the patient for explanations. d. involve only the patient in conversations

b. Allow the patient to reminisce.

A confused older-adult patient is wearing thick glasses and a hearing aid. Which intervention is the priority to facilitate communication? a. focus on tasks to be completed. b. allow time for the patient to respond. c. limit conversations with the patient. d. use gestures and other nonverbal cues.

b. Allow time for the patient to respond.

a patient with heart failure is learning to reduce salt in the diet. when will be the best time for the nurse to address this topic? a. At bedtime, when the patient is relaxed b. At lunchtime while the nurse is preparing the food tray c. At bath time, when the nurse is cleaning the patient d. At medication time, when the nurse is administering patient medication

b. At lunchtime while the nurse is preparing the food tray

the nurse questions health care provider's decision to not tell the patient about cancer diagnosis. which ethical principle is the nurse trying to uphold for the patient? a. Consequentialism b. Autonomy c. Fidelity d. Justice

b. Autonomy

Which assessment finding for a patient who is receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider? a. Blood glucose level of 175 mg/dL b. Blood potassium level of 3.0 mEq/L c. Most recent blood pressure (BP) reading of 168/94 mm Hg d. Orthostatic systolic BP decrease of 12 mm Hg

b. Blood potassium level of 3.0 mEq/L

The home health nurse recommends that a patient with respiratory problems install a carbon monoxide detector in the home. What is the rationale for the nurse's action? a. Carbon monoxide detectors are required by law in the home. b. Carbon monoxide tightly binds to hemoglobin, causing hypoxia. c. Carbon monoxide signals the cerebral cortex to cease ventilations. d. Carbon monoxide combines with oxygen in the body and produces a deadly

b. Carbon monoxide tightly binds to hemoglobin, causing hypoxia.

A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first? a. Obtain the baseline weight. b. Check the patient's blood pressure. c. Draw blood for serum electrolyte levels. d. Ask about any extremity numbness or tingling.

b. Check the patient's blood pressure.

The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. To prevent this, the nurse a. Irrigates the tube with 60 mL of water af-ter all medications are given. b. Checks with the pharmacy to find out if liquid forms of the medications are avail-able. c. Instills nonliquid medications without di-luting. d. Mixes all medications together to decrease the number of administrations.

b. Checks with the pharmacy to find out if liquid forms of the medications are avail-able.

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. This nurse should a. Notify the physician to recommend a psychological evaluation. b. Consider cultural differences during this assessment. c. Ask the patient to make eye contact to determine her affect. d. Continue with the interview and document that the patient is depressed.

b. Consider cultural differences during this assessment.

The nurse needs to closely monitor the oxygen status of an older-adult patient undergoing anesthesia because of which age-related change? a. Thinner heart valves cause lipid accumulation and fibrosis. b. Diminished respiratory muscle strength may cause poor chest expansion. c. Alterations in mental status prevent patients' awareness of ineffective breathing. d. An increased number of pacemaker cells make proper anesthesia induction

b. Diminished respiratory muscle strength may cause poor chest expansion.

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a. Pallor b. Edema c. Confusion d. Restlessness

b. Edema

The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient? a. Inform the patient of the importance of finishing the entire dose of antibiotics. b. Encourage the patient to stay up-to-date on all vaccinations. c. Schedule patient to get annual tuberculosis skin testing. d. Create an exercise routine to run 45 minutes every day.

b. Encourage the patient to stay up-to-date on all vaccinations.

The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What should the nurse do to decrease the patient's anxiety? a. Tell the patient to close his eyes. b. Explain the procedure. c. Turn on the television. d. Ask the family to leave the room.

b. Explain the procedure.

A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? a. Explain to the patient that nothing else has been ordered. b. Explore other options for pain relief. c. Offer to notify the health care provider after morning rounds are completed. d. Discuss the surgical procedure and reason for the pain.

b. Explore other options for pain relief.

a patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? a. Discontinue the nasogastric suction. b. Give the patient the PRN IV morphine sulfate 4 mg. c. Notify the health care provider about the ABG results. d. Teach the patient how to take slow, deep breaths when anxious.

b. Give the patient the PRN IV morphine sulfate 4 mg.

Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient? a. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. b. Have the patient sit in a chair with the feet flat on the floor. c. Assist the patient to the supine position for BP measurements. d. Obtain two BP readings in the dominant arm and average the results.

b. Have the patient sit in a chair with the feet flat on the floor.

the nurse is admitting an older patient from a nursing home. during the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. this pressure ulcer would be staged as stage: a. I b. II c. III d. IV

b. II

While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. Which action will the nurse take first? a. Press the emergency response button. b. Insert a spare tracheostomy with the obturator. c. Manually occlude the tracheostomy with sterile gauze. d. Place a face mask delivering 100% oxygen over the nose and mouth.

b. Insert a spare tracheostomy with the obturator.

The patient with cardiovascular disease must be taught how to reduce the risk of cardiovascular disease by balancing calorie intake with exercise to maintain a healthy body weight. In addition to this, the nurse instructs the patient to a. Eat fish at least 5 times per week. b. Limit saturated fat to less than 7%. c. Limit cholesterol to less than 200 mg/day. d. Avoid high-fiber foods.

b. Limit saturated fat to less than 7%.

The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take? a. Set suction regulator at 150 to 200 mm Hg. b. Limit the length of suctioning to 10 seconds. c. Apply suction while gently rotating and inserting the catheter. d. Liberally lubricate the end of the suction catheter with a water-soluble solution.

b. Limit the length of suctioning to 10 seconds.

an elderly patient presents to the hospital with a history of falls, confusion, and stroke. the nurse determines that the patient is at high risk for falls. which of the following interventions is most appropriate for the nurse to take? a. Place the patient in restraints. b. Lock beds and wheelchairs when transferring. c. Place a bath mat outside the tub. d. Silence fall alert alarm upon request of family.

b. Lock beds and wheelchairs when transferring.

the nurse is preparing to test a patient for postvoid residual with a bladder scan. which action will the nurse take? a. Measure bladder before the patient voids. b. Measure bladder within 10 minutes after the patient voids. c. Measure bladder with head of bed raised to 60 degrees. d. Measure bladder with head of bed raised to 90 degrees.

b. Measure bladder within 10 minutes after the patient voids.

which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Administer IV antibiotics through the implantable port. b. Monitor the IV sites for redness, swelling, or tenderness. c. Remove the patient's nontunneled subclavian central venous catheter. d. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.

b. Monitor the IV sites for redness, swelling, or tenderness.

The nurse obtains the following information from a patient newly diagnosed with prehypertension. Which finding is most important to address with the patient? a. Low dietary fiber intake b. No regular aerobic exercise c. Weight 5 pounds above ideal weight d. Drinks a beer with dinner on most nights

b. No regular aerobic exercise

during the initial home visit, a home health nurse lets the patient know that the visits are expected to end in about a month. which phase of the helping relationship is the nurse in with this patient? a. Preinteraction b. Orientation c. Working d. Termination

b. Orientation

The nurse is developing an exercise plan for someone diagnosed with congestive heart failure and exercise intolerance. In doing so, the nurse should a. Plan for 20 minutes of continuous aerobic activity and increase as tolerated. b. Perform 6-minute walks at the patient's pace at least 2 times a day. c. Instruct the patient that he should not take his beta blocker medication on exercise days. d. Encourage a high-calorie diet to plan for extra calorie expenditure

b. Perform 6-minute walks at the patient's pace at least 2 times a day.

The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP a. Teaching a patient scheduled for exercise electrocardiography about the procedure b. Placing electrodes in the correct position for a patient who is to receive ECG monitoring c. Checking the catheter insertion site for a patient who is recovering from a coronary angiogram d. Monitoring a patient who has just returned to the unit after a transesophageal echo-cardiogramhe nu

b. Placing electrodes in the correct position for a patient who is to receive ECG monitoring

Knowing that protein is required for tissue growth, maintenance, and repair, the nurse must understand that for optimal tissue healing to occur, the patient must be in a. Negative nitrogen balance. b. Positive nitrogen balance. c. Total dependence on protein for kcal pro-duction. d. Neutral nitrogen balance.

b. Positive nitrogen balance.

The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility, which intervention is most important for the nurse to complete? a. Encourage the patient to sit up in the chair. b. Provide analgesic medication as ordered. c. Explain the risks of immobility to the patient. d. Turn the patient every 3 hours while in bed.

b. Provide analgesic medication as ordered.

A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action should the nurse take first? a. Inform the patient about the reasons for a possible change in drug dosage. b. Question the patient about whether the medication is actually being taken. c. Inform the patient that multiple drugs are often needed to treat hypertension. d. Question the patient regarding any lifestyle changes made to help control BP.

b. Question the patient about whether the medication is actually being taken.

A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority? a. Pulse b. Respirations c. Temperature d. Blood pressure

b. Respirations

the nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. at 1400, the nurse notices that the dressing is saturated and leaking. what is the nurse's next action? a. Wait and change the dressing at 1800 as ordered. b. Revise the plan of care and change the dressing now. c. Reassess the dressing and the wound in 2 hours. d. Discontinue the plan of care for wound care.

b. Revise the plan of care and change the dressing now.

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse? a. Arterial blood pH is 7.32. b. Serum calcium is 18 mg/dL. c. Serum potassium is 5.1 mEq/L. d. Arterial oxygen saturation is 91%.

b. Serum calcium is 18 mg/dL.

the nurse and the patient have the same religious affiliation. because of this, the nurse a. Can assume that they have the same spiritual beliefs. b. Should not impose her personal values on the patient. c. Must use an assessment tool to assess the patient's beliefs. d. Can skip the spiritual belief assessment.

b. Should not impose her personal values on the patient.

which action indicates a registered nurse is being responsible for making clinical decisions? a. Applies clear textbook solutions to patients' problems b. Takes immediate action when a patient's condition worsens c. Uses only traditional methods of providing care to patients d. Formulates standardized care plans solely for groups of patients

b. Takes immediate action when a patient's condition worsens

the nurse has had three patients die during the past 2 days. which approach is most appropriate to manage the nurse's sadness? a. Telling the next patients why the nurse is sad b. Talking with a colleague or writing in a journal c. Exercising vigorously rather than sleeping d. Avoiding friends until the nurse feels better

b. Talking with a colleague or writing in a journal

Conjoined twins are in the neonatal department of the community hospital until transfer to the closest medical center. A photographer from the local newspaper gets off the elevator on the neonatal floor and wants to take pictures of the infants. What initial action should the nurse take? a. Escort the cameraman to the neonatal unit while a few pictures are taken quietly. b. Tell the cameraman where the hospital's public relations department is located. c. Ask the cameraman to wait while permission is obtained from the physician. d. Ask the cameraman how the pictures are to be used in the local newspaper.

b. Tell the cameraman where the hospital's public relations department is located

In planning a physical activity program for a patient, the nurse must understand that a. Isotonic exercises cause contraction without changing muscle length. b. The best program includes a combination of exercises. c. Isometric contraction involves the movement of body parts. d. Resistive isometric exercises can lead to bone wasting

b. The best program includes a combination of exercises.

the nurse is observing a family member changing a dressing for a patient in the home health environment. which of these observations would indicate that the family member has a correct understanding of how to manage contaminated dressings? a. The family member removes gloves and gathers items for disposal. b. The family member places the used dressings in a plastic bag. c. The family member saves part of the dressing because it is clean. d. The family member wraps the used dressing in toilet tissue before placing in the trash.

b. The family member places the used dressings in a plastic bag.

A nurse works full-time on the oncology unit at the hospital and works part-time on weekends giving immunizations at the local pharmacy. While giving an injection on a weekend, the nurse caused injury to the patient's arm and is now being sued. How will the hospital's malpractice insurance provide coverage for this nurse? a. It will provide coverage as long as the nurse followed all procedures, protocols, and policies correctly. b. The hospital's malpractice insurance covers this nurse only during the time the nurse is working at the hospital. c. As long as the nurse has never been sued before this incident, the hospital's malpractice insurance will cover the nurse. d. The hospital's malpractice insurance will provide approximately 50% of the coverage the nurse will need.

b. The hospital's malpractice insurance covers this nurse only during the time the nurse is working at the hospital.

when assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately? a. The bibasilar breath sounds are decreased. b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The patient reports feeling "sick to my stomach."

b. The patellar and triceps reflexes are absent.

Which nursing observation would indicate that the patient was at risk for pressure ulcer formation? a. The patient ate two thirds of breakfast. b. The patient has fecal incontinence. c. The patient has a raised red rash on the right shin. d. The patient's capillary refill is less than 2 seconds.

b. The patient has fecal incontinence.

the nurse has placed a patient on high-risk alert for falls. which of the following observations by the nurse would indicate that the patient has an understanding of this alert? a. The patient removes the high alert armband to bathe. b. The patient wears the red nonslip footwear. c. The call light is kept on the bedside table. d. The patient insists on taking a "water" pill on home schedule in the evening.

b. The patient wears the red nonslip footwear.

The nurse is bathing a patient and notices movement in the patient's hair. The nurse should a. Ignore the movement and continue. b. Use gloves or a tongue blade to inspect the hair. c. Examine the hair without gloves to make picking lice easier. d. Shave the hair off of the patient's head.

b. Use gloves or a tongue blade to inspect the hair.

a female patient is having difficulty voiding in a bedpan but states that her bladder feels full. to stimulate micturition, which nursing intervention should the nurse try first? a. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient's progress. b. Utilizing the power of suggestion by turning on the faucet and letting the water run. c. Obtaining an order for a Foley catheter. d. Administering diuretic medication.

b. Utilizing the power of suggestion by turning on the faucet and letting the water run.

a nurse is determining if teaching is effective. which finding best indicates learning has occurred? a. a nurse presents information about diabetes. b. a patient demonstrates how to inject insulin. c. a family member listens to a lecture on diabetes. d. a primary care provider hands a diabetes pamphlet to the patient.

b. a patient demonstrates how to inject insulin.

a nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. which assessment finding will the nurse expect? a. dry mucous membranes b. abdominal distention c. distended neck veins d. flushed skin

b. abdominal distention

if a patient takes an oral medication on an empty stomach, the expected effect is that the drug will be: a. affected by the enzyme in the colon b. absorbed more rapidly c. neutralized by pancreatic enzymes d. absorbed more slowly

b. absorbed more rapidly

which nursing diagnosis will the nurse document in the patient's care plan that is NANDA-I approved? a. sore throat b. acute pain c. sleep apnea d. heart failure

b. acute pain

The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance a. suctioning respiratory secretions several times every hour b. administering humidified oxygen through a tracheostomy collar c. instilling normal saline into the tracheostomy to thin secretions before suctioning d. deflating the tracheostomy cuff before allowing the patient to cough up secretions

b. administering humidified oxygen through a tracheostomy collar

a patient is admitted to the hospital with tuberculosis. which precautions must the nurse institute when caring for this patient? a. droplet transmission b. airborne transmission c. direct contact d. indirect contact

b. airborne transmission

during the initial dose of 500 mg of aztreonam IV to a client with a urinary tract infection, the client reports having difficulty breathing. the nurse quickly identifies this as a symptom of a(n): a. therapeutic effect b. anaphylactic reaction c. idiosyncratic reaction d. medication interaction

b. anaphylactic reaction

the home health nurse is teaching a patient and family about hand hygiene in the home. the nurse is sure to emphasize washing hands before a. and after shaking hands b. and after treatments c. opening the refrigerator d. and after using a computer

b. and after treatments

A patient who has been taking antihypertensive drugs for a few months complains of having a persistent dry cough. The nurse knows that this cough is an adverse effect of which class of antihypertensive drugs? a. Beta-blockers b. angiotensin-converting enzyme (ACE) inhibitors c. angiotensin-receptor blockers (ARBs) d. calcium channel blockers

b. angiotensin-converting enzyme (ACE) inhibitors

the nurse identifies that a patient has received Mylanta (simethicone) instead of the prescribed Pepto-Bismol (bismuth subsalicylate) for the problem of indigestion. the nurse's next intervention is to: a. do nothing, no harm has occurred b. assess and monitor the patient c. notify the physician, treat and document d. complete an incident report

b. assess and monitor the patient

a staff member verbalizes satisfaction in working on a particular nursing unit because of the freedom of choice and responsibility for the choices. this nurse highly values which element of shared decision making? a. authority b. autonomy c. responsibility d. accountability

b. autonomy

how does the blood flow through the heart? a. blood flows from the body into the left atrium, through the tricuspid valve to the right ventricle, then to the lungs to the right atrium. from the right atrium blood goes through the mitral valve and into the left ventricle, through the aortic valve to the aorta and out to the body. b. blood flows from the body into the right atrium through the tricuspid valve to the right ventricle, then to the lungs to the left atrium. from the left atrium, blood goes through the mitral valve and into the left ventricle, through the aortic valve to the aorta and out to the body c. blood flows from the body into the right atrium through the mitral valve to the right ventricle, then to the lungs to the left atrium. from the left atrium, blood goes through the tricuspid valve and into the left ventricle, through aortic valve to the aorta and out to the body d. blood flows from the body into the left atrium, through the mitral valve to the right ventricle, then to the lungs to the right atrium. from the right atrium blood goes through the tricuspid valve and into the left ventricle, through aortic valve to the aorta and out to the body.

b. blood flows from the body into the right atrium through the tricuspid valve to the right ventricle, then to the lungs to the left atrium. from the left atrium, blood goes through the mitral valve and into the left ventricle, through the aortic valve to the aorta and out to the body

When auscultating over the patient's abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a a. thrill. b. bruit. c. murmur. d. normal finding

b. bruit.

the nurse, upon reviewing the history, discovers the patient has dysuria. which assessment finding is consistent with dysuria? a. blood in the urine b. burning upon urination c. immediate, strong desire to void d. awakes from sleep due to urge to void

b. burning upon urination

a patient is to receive an angiotensin-converting enzyme (ACE) inhibitor as part of his treatment for hypertension. during the assessment, the nurse notes that the patient has a severe liver dysfunction. which ACE inhibitor would be best for this patient? a. quinapril, because it is a prodrug b. captopril, because it is not a prodrug c. fosinopril, because it can be dosed only once a day d. enalapril, because it is also available in parenteral form

b. captopril, because it is not a prodrug

a patient learns that a normal adult heartbeat is 60 to 100 beats/min after a teaching session with a nurse. in which domain dd learning take place? a. kinesthetic b. cognitive c. affective d. psychomotor

b. cognitive

in conducting a research study, the nurse researcher guarantees the subject no information will be reported in any manner that will identify the subject and only the research team will have access to the information. which concept is the nurse researcher fulfilling? a. bias b. confidentiality c. informed consent d. the research process

b. confidentiality

which of these assessments of an older adult, who has a urinary tract infection, requires an immediate nursing intervention? a. temperature of 97.6 F b. confusion c. death of a spouse 3 months ago d. presbycusis

b. confusion

the physician has written admission orders, and the nurse is transcribing them. the nurse is having difficulty transcribing one order because of the physician's handwriting. which of the following is the best action to take at this time? the nurse should: a. ask a colleague what the order says b. contact the physician to clarify the order c. wait until the physician makes rounds again to clarify the order d. ask the patient what medications he takes at home

b. contact the physician to clarify the order

the nurse observes that the patient's calcium is elevated. when check the phosphate level, what does the nurse expect to see? a. increased b. decreased c. equal to calcium d. no change in phosphate

b. decreased

the most common affective or mood disorder of old age is: a. dementia b. depression c. delirium d. Alzheimers

b. depression

proper documentation regarding the assessment of a pressure ulcer must include which of the following information concerning the wound? (Select all that apply) a. presence of anorexia b. depth of damage c. length and width d. presence of drainage e. description of drainage f. condition of surrounding tissue

b. depth of damage c. length and width d. presence of drainage e. description of drainage f. condition of surrounding tissue

a patient is seen at a clinic for repeated hordeolum of the eyes during the last 6 months. to help prevent further infection, the nurse advises the patient to A patient is seen at a clinic for repeated hordeolum of the eyes during the last 6 months. To help prevent further infection, the nurse advises the patient to a. apply cold compresses at the first sign of recurrence. b. discard all open or used cosmetics used near the eyes. c. wash the scalp and eyebrows with an antiseborrheic shampoo. d. be evaluated for the presence of sexually transmitted diseases (STDs).

b. discard all open or used cosmetics used near the eyes.

the nurse has been monitoring a patients progress on a new drug regimen since the first dose and documenting signs of possible adverse effects. this example illustrates which phase of the nursing process? a. planning b. evaluation c. implementation d. nursing diagnosis

b. evaluation

the infection control nurse is reviewing data for the medical-surgical unit. the nurse notices a spike in postoperative infections on this unit and categorizes this type of health care-associated infection as what type of infection? a. iatrogenic b. exogenous c. endogenous d. nosocomial

b. exogenous

the nurse is removing personal protective equipment (PPE). which item should be removed first? a. gown b. gloves c. face shield d. hair covering

b. gloves

a nursing assistive personnel (NAP) reports seeing a reddened area on the patient's hip while bathing the patient. which action should the nurse take first? a. request a wound nurse consult b. go to the patient's room to assess the patient's skin c. document the finding per the NAP's report d. ask the NAP to apply a dressing over the reddened area

b. go to the patient's room to assess the patient's skin

the nurse is assessing the integrity of the ventrogluteal injection site. the nurse finds the site by locating the: a. middle third of the lateral thigh b. greater trochanter, anterior iliac spine, and iliac crest c. greater trochanter, posterior iliac spine, and iliac crest d. acromion process and axilla

b. greater trochanter, anterior iliac spine, and iliac crest

if a client makes a comment implying that a particular medication seems unusual in any way, the nurse's responsibility is to a. convince the patient to take it because the nurse was careful to obtain the correct medication b. hold the medication until the nurse has double checked the order, the medication, the patient, and is positive all are correct c. have another nurse give the medication to reassure the patient that the medication is correct d. skip this dose and assess the patient for confusion

b. hold the medication until the nurse has double checked the order, the medication, the patient, and is positive all are correct

when assessing patients for the possible health impact of stressors, the most important information to obtain is: a. the importance of religious influences for the patient b. how long the patient has been exposed to the stressor c. medications that the patient is taking to control anxiety d. any family history of stress-related physical illnesses

b. how long the patient has been exposed to the stressor

a nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. which nursing diagnosis is priority? a. risk for skin breakdown b. impaired gas exchange c. activity intolerance d. risk for infection

b. impaired gas exchange

according to the World Health Organization, what is the best definition for "health"? a. simply the absence of disease b. involving the total person and environment c. strictly personal in nature d. status of pathological state

b. involving the total person and environment

after withdrawing the first does of a medication from a multidose vial, the vial: a. is left in the patient's room for the next dose b. is initialed, dated, and timed c. is placed in the refrigerator d. is discarded in the sharps container.

b. is initialed, dated, and timed

the nurse is caring for a group of medical-surgical patients. the patient most at risk for developing an infection is the patient who a. is in observation for chest pain b. is recovering from a right total hip arthroplasty c. has been admitted with dehydration d. has been admitted for stabilization of atrial fibrillation

b. is recovering from a right total hip arthroplasty

a nurse is teaching a patient about the urinary system. in which order will the nurse present the structures, following the flow of urine? a. kidney, urethra, bladder, ureters b. kidney, ureters, bladder, urethra c. bladder, kidney, ureters, urethra d. bladder, kidney, urethra, ureters

b. kidney, ureters, bladder, urethra

the patient is admitted with chronic back pain. the nurse who is caring for this patient should a. focus on finding quick remedies for the back pain b. look at how pain influences the patient's ability to function c. realize that the patient's only goal is relief of the back pain d. help the patient realize that there is little hope of relief from chronic pain

b. look at how pain influences the patient's ability to function

a patient is admitted for bowel obstruction and has had a nasogastric tube set to low intermittent suction to the past 3 days. which arterial blood gas values will the nurse expect to observe? a. respiratory alkalosis b. metabolic alkalosis c. metabolic acidosis d. respiratory acidosis

b. metabolic alkalosis

when caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray? a. grape juice b. milk carton c. mixed green salad d. fried chicken breast

b. milk carton

the nurse ask a patient where the pain is, and the patient responds by pointing to the area of pain. which form of communication did the patient use? a. verbal b. nonverbal c. intonation d. vocabulary

b. nonverbal

a nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. which area should the nurse address first? a. anxiety b. not eating c. mental health d. not seeing family members

b. not eating

the patient is taking phenazopyridine. when assessing the urine, what will the nurse expect? a. red color b. orange color c. dark amber color d. intense yellow color

b. orange color

which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis? a. pH 7.60, PaCO2 40 mm Hg, HCO3- 30 mEq/L b. pH 7.53, PaCO2 30 mm Hg, HCO3- 24 mEq/L c. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L d. pH 7.25, PaCO2 48 mm Hg, HCO3- 23 mEq/L

b. pH 7.53, PaCO2 30 mm Hg, HCO3- 24 mEq/L

A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse a. presses on the skin over the tibia for 10 seconds to check for edema. b. palpates both carotid arteries simultaneously to compare pulse quality. c. documents a murmur heard along the right sternal border as a pulmonic murmur. d. places the patient in the left lateral posi-tion to check for the point of maximal impulse.he nurse and unc

b. palpates both carotid arteries simultaneously to compare pulse quality.

a nurse is sitting at the patient's bedside taking a nursing history. which zone of person space is the nurse using? a. socio-consultative b. personal c. intimate d. public

b. personal

a nurse is assessing a patient. which assessment finding should cause the nurse to further assess for extracellular fluid volume deficit? a. moist mucous membranes b. postural hypotension c. supple skin turgor d. pitting edema

b. postural hypotension

a nurse is administering a diuretic to a patient and teaching the patient about foods to increase. which food choices by the patient will best indicate successful teaching? a. milk and cheese b. potatoes and fresh fruit c. canned soups and vegetables d. whole grains and dark green leafy vegetables

b. potatoes and fresh fruit

the structure that is responsible for returning oxygenated blood to the heart is the a. pulmonary artery b. pulmonary vein c. superior vena cava d. inferior vena cava

b. pulmonary vein

the nurse is planning discharge for an alert, homless 70-year-old with a chronic foot infection. the most appropriate intervention by the nurse is to: a. teach the patient how to assess and care for the foot infection b. refer to social services for further assessment of patient needs c. schedule the patient to return to outpatient services for foot care d. give the patient written information about shelters and meal sites

b. refer to social services for further assessment of patient needs

the medical-surgical acute care patient has received a nursing diagnosis of impaired skin integrity. the nurse consults a: a. respiratory therapist b. registered dietitian c. chaplain d. case manager

b. registered dietitian

a 2-year-old child is brought to the emergency department after ingesting a medication that causes respiratory depression. for which acid-base imbalance will the nurse most closely monitor this child? a. respiratory alkalosis b. respiratory acidosis c. metabolic acidosis d. metabolic alkalosis

b. respiratory acidosis

the nurse has become aware of missing narcotics in the patient care area. which ethical principle obligates the nurse to report the missing medications? a. advocacy b. responsibility c. confidentiality d. accountability

b. responsibility

blood flows from the body to the a. left atrium b. right atrium c. left ventricle d. right ventricle

b. right atrium

a nurse is trying to help a patient begin to accept the chronic nature of diabetes. which teaching technique should the nurse use to enhance learning? a. lecture b. role play c. demonstration d. question and answer sessions

b. role play

which type of wound closes by primary intention? a. second-degree burn b. surgical incision c. traumatic wound d. pressure ulcer

b. surgical incision

a homeless adult patient presents to the emergency department. the nurse obtains the following vital signs: temperature 94.8 F, blood pressure 100/56, apical pulse 56, respiratory rate 12. which of the vital signs should be addressed immediately? a. respiratory rate b. temperature c. apical pulse d. blood pressure

b. temperature

a nurse is administering a blood transfusion. which assessment finding will the nurse report immediately? a. blood pressure 110/60 b. temperature 101.3F c. poor skin turgor and pallor d. heart rate of 100 beats/min

b. temperature 101.3F

the nurse is caring for a hospitalized patient. which of the following behaviors alerts the nurse to consider the need for restraint? a. the patient refuses to call for help to go to the bathroom b. the patient continues to remove the nasogastric tube c. the patient gets confused regarding the time at night d. the patient does not sleep and continues to ask for items

b. the patient continues to remove the nasogastric tube

which patient is at most risk for experiencing difficult grieving? a. the middle-aged woman whose grandmother died of advanced Parkinson's disease b. the young adult with three small children whose wife died suddenly in an accident c. the middle-aged person whose spouse suffered a slow, painful death d. the older adult whose spouse died of complications of chronic renal disease

b. the young adult with three small children whose wife died suddenly in an accident

when providing postmortem care, the nurse places dentures in the mouth and closes the eyes and mouth of the patient within 2 to 4 hours after death. why is the timing of the action so important? a. to prevent blood from settling in the head, neck, and shoulders b. to perform these actions more easily before rigor mortis develops c. to set the mouth in a natural position for viewing by the family d. to prevent discoloration caused by blood settling in the facial area

b. to perform these actions more easily before rigor mortis develops

the name tylenol is known as this medication's: a. chemical name b. trade name c. generic name d. united states pharmacopeia

b. trade name

an older-adult patient is wearing a hearing aid. which technique will the nurse use to facilitate communication? a. chew gum b. turn off the television c. speak clearly and loudly d. use at least 14-point print

b. turn off the television

the nurse is caring for a patient with a nursing diagnosis of risk for infection. aware of the need for standard precautions, the nurse is careful to a. teach the patient about good nutrition b. wear eyewear when emptying a urinary drainage bag c. avoid contact with intact skin without wearing gloves d. don gloves when wearing artificial nails

b. wear eyewear when emptying a urinary

the patient had a colostomy placed 1 week ago. when approached by the nurse, the patient and his wife refuse to talk about it and refuse to be taught about how to care for it. the nurses realizes that the patient and his wife are in which stage of adjustment? a. shock b. withdrawal c. acceptance d. rehabilitation

b. withdrawal

A nurse is supervising a student who is caring for a patient with chronic pain. Which statement by the student indicates an understanding of pain management? a. "This patient says her pain is a 5, but she is not acting like it. I am not going to give her any pain medication." b. "The patient is sleeping, so I pushed her PCA button for her." c. "I need to reassess the patient's pain 1 hour after administering oral pain medication." d. "It wasn't time for the patient's medication, so when she requested it, I gave her a placebo."

c. "I need to reassess the patient's pain 1 hour after administering oral pain medication."

A nurse is providing medication education to a patient who just started taking ibuprofen, a nonselective nonsteroidal antiinflammatory drug (NSAID). Which statement made by the nurse best indicates how ibuprofen works? a. "Ibuprofen helps to remove factors that cause or stimulate pain." b. "Ibuprofen reduces anxiety, which will help you better cope with your pain." c. "Ibuprofen helps to decrease the production of prostaglandins." d. "Ibuprofen binds with opiate receptors to reduce your pain."

c. "Ibuprofen helps to decrease the production of prostaglandins."

A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eyedrops cause eye burning and visual blurriness for a short time after administration. The best response to the patient's statement is a. "These are normal side effects of the drug, which should become less noticeable with time." b. "If you occlude the puncta after you administer the drops, it will help relieve these side effects." c. "The drops are uncomfortable, but it is very important for you to use them as prescribed to retain your vision." d. "These symptoms are caused by glaucoma and may indicate a need for an increased dosage of the eyedrops."

c. "The drops are uncomfortable, but it is very important for you to use them as prescribed to retain your vision."

A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with Vicodin (5/325). What important patient education does the nurse provide? a. "Be sure to eat a meal high in fat before taking the medication, to avoid a stomach ulcer." b. "Narcotics can be addictive, so do not take them unless you are in severe pain." c. "You need to drink plenty of fluids and eat a diet high in fiber." d. "As your pain severity lessens, you will begin to give yourself once-daily intramuscular injections."

c. "You need to drink plenty of fluids and eat a diet high in fiber."

Which of the following would be most important for the nurse to monitor in a patient who has obstructive sleep apnea? a. Gastrointestinal function b. Circulatory status c. Respiratory status d. Neurological function

c. Respiratory status

The home health nurse observes a patient taking these actions when self-administering eardrops. Which patient action indicates a need for more teaching? a. The patient leaves the ear wick in place while administering the drops. b. The patient lies down before and for 2 minutes after administering the drops. c. The patient gets the eardrops out of the refrigerator just before administering the drops. d. The patient holds the tip of the dropper 1 cm above the ear while administering the drops.

c. The patient gets the eardrops out of the refrigerator just before administering the drops.

When performing an eye examination, the nurse will assess for accommodation by: a. covering one eye for 1 minute and noting the pupil reaction when the cover is removed. b. shining a light into the patient's eye and watching the pupil response in the opposite eye. c. observing the pupils when the patient focuses on a distant object and then on a close object. d. touching the patient's pupil with a small piece of sterile cotton and watching for a blink reaction.

c. observing the pupils when the patient focuses on a distant object and then on a close object.

A patient with external otitis has an ear wick placed and a new prescription for antibiotic otic drops. After the nurse provides patient teaching, which patient statement indicates that more instruction is needed? a. "I may use aspirin or acetaminophen (Tylenol) for pain relief." b. "I should apply the eardrops to the cotton wick in my ear canal." c. "I should clean my ear canal daily with a cotton-tipped applicator." d. "I may use warm compresses to the outside of my ear for comfort."

c. "I should clean my ear canal daily with a cotton-tipped applicator."

a nurse attends a seminar on teaching/learning. which statement indicates the nurse has a good understanding of teaching/learning? a. "teaching and learning can be separated." b. " learning an interactive process that promotes teaching." c. "teaching is most effective when it responds to the learner's needs." d. "learning consists of a conscious, deliberate set of actions designed to help the teacher."

c. "teaching is most effective when it responds to the learner's needs."

a female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area. during the health history, which of these questions should the nurse prioritize? a. "when was the last time you visited the physician?" b. "has this condition affected your eating habits?" c. "what medications are you currently taking?" d. "are you able to sleep at night?"

c. "what medications are you currently taking?"

the patient's son requests to view documentation in the medical record. what is the nurse's best response to this question? a. "I'll be happy to get that for you" b. "you are not allowed to look at it" c. "you will need your mother's permission" d. "i cannot let you see that chat without the doctor's order"

c. "you will need your mother's permission"

8mg= ? grams a. 800 b. 8000 c. 0.008 d. 0.08

c. 0.008

when preparing an adult patient for an enema, the nurse undertands that the tube or nozzle should be inserted how far? a. 1 to 1 1/2 inches b. 2 to 3 inches c. 3 to 4 inches d. 4 to 5 inches

c. 3 to 4 inches

a nurse is teaching a patient about hypertension. in which order from first to last will the nurse implement the steps of the teaching process? 1. Set mutual goals for knowledge of hypertension. 2. Teach what the patient wants to know about hypertension. 3. Assess what the patient already knows about hypertension. 4. Evaluate the outcomes of patient education for hypertension. a. 1, 3, 2, 4 b. 2, 3, 1, 4 c. 3, 1, 2, 4 d. 3, 2, 1, 4

c. 3, 1, 2, 4

A nurse is teaching the patient with mitral valve problems about the valves in the heart. Starting on the right side of the heart, describe the sequence of the blood flow through these valves. 1. Mitral 2. Aortic 3. Tricuspid 4. Pulmonic a. 1, 3, 2, 4 b. 4, 3, 2, 1 c. 3, 4, 1, 2 d. 2, 4, 1, 3

c. 3, 4, 1, 2

on the basis of the nurse's assessment of kidney function for an adult patient, which finding is normal? a. 10 mL/hr b. 20 mL/hr c. 30 mL/hr d. 100 mL/hr

c. 30 mL/hr

A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step? 1. Insert catheter. 2. Apply suction and remove. 3. Have patient deep breathe. 4. Encourage patient to cough. 5. Attach catheter to suction system. 6. Rinse catheter and connecting tubing. a. 1, 2, 3, 4, 5, 6 b. 4, 5, 1, 2, 3, 6 c. 5, 3, 1, 2, 4, 6 d. 3, 1, 2, 5, 4, 6

c. 5, 3, 1, 2, 4, 6

a client is nauseated, has been vomitting for seceral hours, and needs to receive an antiemetic (antinausea) medication. the nurse recognizes that which of the following is accurate? a. An enteric-coated medication should be given. b. Medication will not be absorbed as easily because of the nausea. c. A parenteral route is the route of choice. d. A rectal suppository must be administered.

c. A parenteral route is the route of choice.

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Start the prescribed PRN oxygen at 2 to 4 L/min. c. Administer the prescribed normal saline bolus and insulin. d. Encourage the patient to take deep, slow breaths with guided imagery.

c. Administer the prescribed normal saline bolus and insulin.

the patient has contracted a urinary tract infection while in the hospital. which of these actions would most likely increase the risk of a patient contracting a urinary tract infection (UTI)? a. Emptying the urinary drainage bag once a shift b. Reusing the patient's graduated receptacle to empty the drainage bag c. Allowing the drainage bag port to touch the graduated receptacle d. Providing perineal hygiene at least once a shift

c. Allowing the drainage bag port to touch the graduated receptacle

During a follow-up visit, a woman is describing new onset of marital discord with her terminally ill spouse. Using the Kübler-Ross behavioral theory, the nurse recognizes that the spouse is in which stage of dying? a. Denial b. Bargaining c. Anger d. Depression

c. Anger

the nurse is caring for a patient in the perioperative area for several hours. the surgical mask the nurse is wearing becomes moist. the nurse's best next step is to a. Change the mask when relieved. b. Air-dry the mask while at lunch, and reapply. c. Ask for relief, step out of the surgical area, and apply a new mask. d. Not change the mask, if the nurse is comfortable.

c. Ask for relief, step out of the surgical area, and apply a new mask.

Which action should the nurse take when administering the initial dose of oral labetalol (Normodyne) to a patient with hypertension? a. Encourage the use of hard candy to prevent dry mouth. b. Instruct the patient to ask for help if heart palpitations occur. c. Ask the patient to request assistance when getting out of bed. d. Teach the patient that headaches may occur with this medication.

c. Ask the patient to request assistance when getting out of bed.

A patient is experiencing oliguria. Which action should the nurse perform first? a. Increase the patient's intravenous fluid rate. b. Encourage the patient to drink caffeinated beverages. c. Assess for bladder distention. d. Request an order for diuretics.

c. Assess for bladder distention.

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter? a. Notify the health care provider. b. Offer reassurance to the patient. c. Auscultate the patient's breath sounds. d. Give the prescribed PRN morphine sulfate IV.

c. Auscultate the patient's breath sounds.

The health care model that utilizes Maslow's hierarchy as its base is the? a. Health Belief b. Health Promotion c. Basic Human Needs d. Holistic Health

c. Basic Human Needs

A nurse is caring for a patient who is taking warfarin (Coumadin) and discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient? a. Increased cholesterol level b. Distended jugular vein c. Bleeding d. Angina

c. Bleeding

The nurse suspects the patient has increased afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition? a. Pulse oximeter b. Oxygen cannula c. Blood pressure cuff d. Yank auer suction tip catheter

c. Blood pressure cuff

A patient has a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia? a. Superior vena cava b. Pulmonary artery c. Coronary artery d. Carotid artery

c. Coronary artery

to increase quality and years of healthy life, healthy people 2020 focuses on four areas. one of those areas is a. Allowing people to continue current behaviors to reduce the stress of change. b. Focusing only on individual health changes that will lead to better communities. c. Creating social and physical environments that promote good health. d. Focusing on illness treatment to provide fast recuperation.

c. Creating social and physical environments that promote good health.

A patient's heart rate increased from 94 to 164 beats/min. What will the nurse expect? a. Increase in diastolic filling time b. Decrease in hemoglobin level c. Decrease in cardiac output d. Increase in stroke volume

c. Decrease in cardiac output

the long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. which assessment finding indicates that the patient's condition has improved? a. Hematocrit 28% b. Absence of skin tenting c. Decreased peripheral edema d. Blood pressure 110/72 mm Hg

c. Decreased peripheral edema

The patient has been diagnosed with cardiovascular disease and placed on a low-fat diet. The patient asks the nurse, "How much fat should I have? I guess the less fat, the better." The nurse needs to explain that a. Fats have no significance in health and the incidence of disease. b. All fats come from external sources so can be easily controlled. c. Deficiencies occur when fat intake falls below 10% of daily nutrition. d. Vegetable fats are the major source of saturated fats and should be avoided.

c. Deficiencies occur when fat intake falls below 10% of daily nutrition.

a nurse is preparing to teach a patient about smoking cessation. which factors should the nurse assess to determine a patient's ability to learn? a. Sociocultural background and motivation b. Stage of grieving and overall physical health c. Developmental capabilities and physical capabilities d. Psychosocial adaptation to illness and active participation

c. Developmental capabilities and physical capabilities

To decrease the risk for future hearing loss, which action should the nurse who is working with college students at the on-campus health clinic implement? a. Arrange to include otoscopic examinations for all patients. b. Administer influenza immunizations to all students at the clinic. c. Discuss the importance of limiting exposure to amplified music. d. Perform tympanometry on all patients between the ages of 18 to 24.

c. Discuss the importance of limiting exposure to amplified music.

the nurse preceptor recognizes the new nurse's ability to determine patient safety risks when which behavior is observed? a. Checking patient identification once every shift b. Multitasking by gathering two patients' medications c. Disposing of used needles in a red needle container d. Raising all four side rails per family request

c. Disposing of used needles in a red needle container

while the nurse is taking a patient history, the nurse discovers that the patient has a type of diabetes that results from a head injury and does not require insulin. Which dietary change should the nurse share with the patient? a. Reduce the quantity of carbohydrates ingested to lower blood sugar. b. Include a serving of dairy in each meal to elevate calcium levels. c. Drink plenty of fluids throughout the day to stay hydrated. d. Avoid food high in acid to avoid metabolic acidosis.

c. Drink plenty of fluids throughout the day to stay hydrated.

the nurse is caring for a patient with a pressure ulcer on the left hip. the ulcer is black. the nurse recognizes that the next step in caring for this patient includes a. Monitoring of the wound. b. Irrigation of the wound. c. Débridement of the wound. d. Management of drainage.

c. Débridement of the wound.

it is essential for family members to realize that a family's beliefs, values, and practices strongly influence the health-promoting behaviors of its members, and to understand that a. American families are part of the same culture with the same values and beliefs. b. Economic status has little effect on a family's ability to access adequate health care. c. Family environment in early life has a strong influence on later health practices. d. All families place a high value on good health and health practices.

c. Family environment in early life has a strong influence on later health practices.

The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. The most likely cause of the diarrhea would be a. Clostridium difficile. b. Antibiotic therapy. c. Formula intolerance. d. Bacterial contamination.

c. Formula intolerance.

A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation? a. Anxiety over illness b. Decreased drive to breathe c. Increased metabolic demands d. Infection destroying lung tissues

c. Increased metabolic demands

While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record? a. Atrial fibrillation b. Myocardial ischemia c. Left-sided heart failure d. Right-sided heart failure

c. Left-sided heart failure

a nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. the patient complains of "just blowing up" and has peripheral edema and shortness of breath. which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill

c. Mental status

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping b. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes d. Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates

c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes

which method of data collection will the nurse use to establish a patient's database? a. Reviewing the current literature to determine evidence-based nursing actions b. Checking orders for diagnostic and laboratory tests c. Performing a physical examination d. Ordering medications

c. Performing a physical examination

when assessing a patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility, the nurse learns that the patient has had several episodes of wandering away from home. which nursing action will the nurse include in the plan of care? a. Ask the patient why the wandering episodes have occurred. b. Reorient the patient to the new living situation several times daily. c. Place the patient in a room close to the nurses' station. d.Have the family bring in familiar items from the patient's home.

c. Place the patient in a room close to the nurses' station.

a nurse is evaluating a nursing assistive personnel's (NAP) care for a patient with an indwelling catheter. which action by the NAP will cause the nurse to intervene? a. Emptying the drainage bag when half full b. Kinking the catheter tubing to obtain a urine specimen c. Placing the drainage bag on the side rail of the patient's bed d. Securing the catheter tubing to the patient's thigh

c. Placing the drainage bag on the side rail of the patient's bed

The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a meal plan that includes increased a. Fat. b. Carbohydrates. c. Protein. d. Vitamin E.

c. Protein.

after assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient's headache. which action by the nurse is priority for this patient? a. Eliminate headache from the nursing care plan. b. Direct the nursing assistive personnel to ask if the headache is relieved. c. Reassess the patient's pain level in 30 minutes. d. Revise the plan of care.

c. Reassess the patient's pain level in 30 minutes.

the nurse finds it difficult to care for a patient whose advance directive states that no extraordinary resuscitation measures should be taken. which step may help the nurse to find resolution in this assignment? a. Call for an ethical committee consult. b. Decline the assignment on religious grounds. c. Scrutinize her own personal values. d. Convince the family to challenge the directive.

c. Scrutinize her own personal values.

a nurse is reviewing urinary laboratory results. which finding will cause the nurse to follow up? a. Protein level of 2 mg/100 mL b. Urine output of 80 mL/hr c. Specific gravity of 1.036 d. pH of 6.4

c. Specific gravity of 1.036

An older patient has been diagnosed with possible white coat hypertension. Which action will the nurse plan to take next? a. Schedule the patient for regular blood pressure (BP) checks in the clinic. b. Instruct the patient about the need to decrease stress levels. c. Tell the patient how to self-monitor and record BPs at home. d. Inform the patient that ambulatory blood pressure monitoring will be needed.

c. Tell the patient how to self-monitor and record BPs at home.

Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be most important to report to the health care provider before the MRI? a. The patient has an allergy to shellfish. b. The patient has a history of atherosclerosis. c. The patient has a permanent ventricular pacemaker. d. The patient took all the prescribed cardiac medications today.

c. The patient has a permanent ventricular pacemaker.

a charge nurse is reviewing outcome statements using the SMART approach. which patient outcome statement will the charge nurse praise to the new nurse? a. The patient will ambulate in hallways. b. The nurse will monitor the patient's heart rhythm continuously this shift. c. The patient will feed self at all mealtimes today without reports of shortness of breath. d. The nurse will administer pain medication every 4 hours to keep the patient free from discomfort.

c. The patient will feed self at all mealtimes today without reports of shortness of breath.

a smiling patient angrily states, "I will not cough and deep breathe." how will the nurse interpret this finding? a. The patient's denotative meaning is wrong. b. The patient's personal space was violated. c. The patient's affect is inappropriate. d. The patient's vocabulary is poor.

c. The patient's affect is inappropriate.

the patient has been diagnosed with diabetes for the past 12 years. when admitted, the patient is unkempt and is in need of a bath and foot care. when questioned about his hygiene habits, the patient tells the nurse that baths are taken once a week where he comes from, although he takes a sponge bath every other day. to provide ultimate care for this patient, the nurse understands that a. Personal preferences determine hygiene practices and are unchangeable. b. Patients who appear unkempt place little importance on hygiene practices. c. The patient's illness may require teaching of new hygiene practices. d. All cultures value cleanliness with the same degree of importance.

c. The patient's illness may require teaching of new hygiene practices.

which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? a. Lightheadedness when standing up b. Weak quadriceps muscles c. Tingling of the extremities with possible tetany d. Decreased deep tendon reflexes

c. Tingling of the extremities with possible tetany

when the nurse visits a hospice patient, the patient has a respiratory rate of 8 breaths/minute and complains of severe pain. which action is best for the nurse to take? a. Inform the patient that increasing the morphine will cause the respiratory drive to fail. b. Tell the patient that additional morphine can be administered when the respirations are 12. c. Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief. d. Administer a nonopioid analgesic, such as a nonsteroidal anti-inflammatory drug (NSAID), to improve patient pain control.

c. Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief.

A confused patient with a urinary catheter, nasogastric tube, and intravenous line keeps touching these needed items for care. The nurse has tried to explain to the patient that he should not touch these lines, but the patient continues. What is the best action by the nurse at this time? a. Apply restraints loosely on the patient's dominant wrist. b.Notify the health care provider that restraints are needed immediately to maintain the patient's safety. c. Try other approaches to prevent the patient from touching these care items. d. Allow the patient to pull out lines to prove that the patient needs to be restrained.

c. Try other approaches to prevent the patient from touching these care items.

A new nurse notes that the health care unit keeps a listing of patient names in a closed book behind the front desk of the nursing station so patients can be located easily. What action is most appropriate for the nurse to take? a. Move the book to the upper ledge of the nursing station for easier access. b. Talk with the nurse manager about the listing being a violation of the Health Insurance Portability and Accountability Act (HIPAA). c. Use the book as needed while keeping it away from individuals not involved in patient care. d. Ask the nurse manager to move the book to a more secluded area.

c. Use the book as needed while keeping it away from individuals not involved in patient care.

which information from a patient's urinalysis requires that the nurse notify the health care provider? a. pH 6.2 b. trace protein c. WBC 20 to 26/hpf d. specific gravity 1.021

c. WBC 20 to 26/hpf

which of the following behaviors indicates the highest potential for spreading infections among clients? the nurse: a. Disinfects dirty hands with antibacterial soap b. Allows alcohol-based rub to dry for 10 seconds c. Washes hands primarily after leaving each room d. Uses cold water for medical asepsis

c. Washes hands primarily after leaving each room

the health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. which is the most effective nursing intervention for monitoring both of these patients? a. Assess the patients for edema in extremities. b. Ask the patients to record their intake and output. c. Weigh the patients every morning before breakfast. d. Measure the patients' blood pressures every 4 hours.

c. Weigh the patients every morning before breakfast.

in which situation would using standard precautions be adequate? select all that apply a. While interviewing a client with a productive cough b. While helping a client to perform his own hygiene care c. While aiding a client to ambulate after surgery d. While inserting a peripheral intravenous catheter

c. While aiding a client to ambulate after surgery d. While inserting a peripheral intravenous catheter

At present, the most reliable method for verification of placement of small-bore feeding tubes is a. Auscultation. b. Aspiration of contents. c. X-ray. d. pH testing.

c. X-ray.

the nurse will anticipate inserting a Coude catheter for which patient? a. an 8-year old male undergoing anesthesia for a tonsillectomy b. a 24-year old female who is going into labor c. a 56-year old male admitted for bladder irrigation d. an 86- year old female admitted for a urinary tract infection

c. a 56-year old male admitted for bladder irrigation

which assessment finding will cause the nurse to begin teaching a patient because the patient is ready to learn? a. a patient has the ability to grasp and apply the elastic bandage b. a patient has sufficient upper body strength to move from a bed to a wheelchair c. a patient with a below-the-knee amputation is motivated about how to walk with assistive devices d. a patient has normal eyesight to identify the markings on a syringe and coordination to handle a syringe.

c. a patient with a below-the-knee amputation is motivated about how to walk with assistive devices

which patient will the nurse assess most closely for an ileus? a. a patient with a fecal impaction b. a patient with chronic cathartic abuse c. a patient with surgery for bowel disease and anesthesia d. a patient with suppression of hydrochloric acid from medication

c. a patient with surgery for bowel disease and anesthesia

which action should the nurse take to best develop critical thinking skills? a. study 3 hours more each night b. attend all inservice opportunities c. actively participate in clinical experiences d. interview staff nurses about their nursing experiences

c. actively participate in clinical experiences

the nurse is planning care for a group of patients. which task will the nurse assign to the nursing assistive personnel (NAP)? a. performing the first postoperative pouch change b. maintaining a nasogastric tube c. administering an enema d. digitally removing stool

c. administering an enema

the nurse is caring for a dying patient. which intervention is considered futile? a. giving pain medication for pain b. providing oral care every 5 hours c. administering the influenza vaccine d. supporting lower extremities with pillows

c. administering the influenza vaccine

a client is nauseated, has been vomiting for several hours, and needs to receive an antiemetic (anti-nausea) medication. the patient has an infusing IV and a foley catheter. the best route for administration is? a. an enteric-coated medication b. an IM injection c. and IV injection d. a rectal suppository

c. and IV injection

when assessing a patient who is receiving a loop diuretic, the nurse looks for manifestations of potassium deficiency, which would include which of the following? (SELECT ALL THAT APPLY) a. dyspnea b. constipation c. anorexia d. muscle weakness e. mental confusion f. lethargy

c. anorexia d. muscle weakness e. mental confusion f. lethargy

a nurse auscultates heart sounds. when the nurse hears S2, which valves is the nurse hearing close a. aortic and mitral b. mitral and tricuspid c. aortic and pulmonic d. mitral and pulmonic

c. aortic and pulmonic

the nurse is caring for patients with ostomies. in which ostomy location will the nurse expect very liquid stool to be present? a. sigmoid b. transverse c. ascending d. descending

c. ascending

a nurse is in the hallway assisting a patient to ambulate and hears an alarm sound. what is the best next step for the nurse to take? a. seek out the source of the alarm b. wait to see if the alarm discontinues c. ask another nurse to check on the alarm d. continue ambulating the patient

c. ask another nurse to check on the alarm

a nurse is caring for a male patient with urinary retention. which action should the nurse take first? a. limit fluid intake b. insert a urinary catheter c. assist to a standing position d. ask for a diuretic medication

c. assist to a standing position

A patient with chronic otitis media is scheduled for a tympanoplasty. Before surgery, the nurse teaches the patient that postoperative expectations include a. keeping the head elevated. b. the need for prolonged bed rest. c. avoidance of coughing or blowing the nose. d. continuous antibiotic irrigation of the ear canal.

c. avoidance of coughing or blowing the nose.

when focusing on older adults, the nurse must be aware that a. elder abuse happens in lower socioeconomic classes only b. elders have the same social networks as younger people c. caregivers may be spouses or middle-aged children d. caregiver stress is minimal when caring for a parent

c. caregivers may be spouses or middle-aged children

the nurse is caring for a patient who has an indwelling urinary catheter. which intervention is most important to include in this patient's plan of care? a. maintaining tension on the tubing b. emptying the urinary collection bag every 24 hours c. cleaning in a circular motion from the meatus down the catheter d. keeping the drainage bag on the bed or attached to the side rails

c. cleaning in a circular motion from the meatus down the catheter

when developing the plan of a care for an older adult who is hospitalized for an acute illness, the nurse should: a. use a standardized geriatric nursing care plan b. plan for likely long-term-care transfer to allow additional time for recovery c. consider the preadmission functional abilities when setting patient goals d. minimize activity during hospitalization

c. consider the preadmission functional abilities when setting patient goals

which action should the nurse take when using critical thinking to make clinical decisions? a. make decisions based on intuition b. accept on established way to provide care c. consider what is important in a given situation d. read and follow the health care provider's orders

c. consider what is important in a given situation

the nurse is to give a patient medication for pain. the order reads, "Morphine Sulfate 20 mg. intravenously (IV) q 2 hr prn pain." the drug book states the normal dose is 2-10 mg. the nurse should: a. administer the ordered amount of the drug b. check with the charge nurse to see if it is safe to give the ordered amount c. contact the physician concerning the written order d. hold the medication and check on your other patients

c. contact the physician concerning the written order

the nurse is documenting administration of a medication that is to be given at 0600, 1400, and 2200. the medication that reflects this administration schedule is a. morphine sulfate 1 mg q4h prn b. inderal 10 mg PO bid c. diazepam 5 mg PO tid d. keflex 500 mg PO q6h

c. diazepam 5 mg PO tid

which of the following is the proper documentation related to dosing ordered for digoxin? a. digoxin .125 mg b. digoxin .1250 mg c. digoxin 0.125 mg d. digoxin 0.1250 mg

c. digoxin 0.125 mg

the family is a central institution in American society; however, the concept, structure, and functioning of the family unit continue to change over time. the uniqueness of each family is referred to as family a. durability b. resiliency c. diversity d. forms

c. diversity

which noninvasive test would provide information about ejection fraction? a. cardiac catheterization b. MRI c. echocardiogram d. EKG

c. echocardiogram

a nurse is teaching a culturally diverse patient with a learning disability about nutritional needs. what must the nurse do first before starting the teaching session? a. obtain pictures of food. b. get an interpreter. c. establish a rapport. d. refer to a dietitian.

c. establish a rapport.

what is the best suggestion a nurse could make to a family member requesting help in selecting a local nursing center? a. suggest choosing a nursing center that is as sanitary as possible. the closer the center is to the hospital standards, the better b. have family members evaluate nursing home staff according to their ability to get tasks done efficiently c. explain that it is probably best for the family to visit the center and inspect it personally d. make sure that nursing home staff members get patients out of bed every day for the entire day

c. explain that it is probably best for the family to visit the center and inspect it personally

in providing perineal care to a female patient, the nurse should wash a. upward from rectum to pubic area b. from back to front c. from pubic area to rectum d. in a circular motion

c. from pubic area to rectum

what is the most frequent cause of the spread of infection among institutionalized patients? a. airborne microbes from other patients b. contact with contaminated equipment c. hands of healthcare workers d. exposure from family members

c. hands of healthcare workers

the nurse suspects that elder abuse may be occurring when a confused and agitated 76-year-old patient with a broken arm is brought to the emergency department by a family member. which of these actions should the nurse take first? a. notify an elder protective services agency about the possible abuse b. make a referral for a home assessment visit by the home health nurse c. have the family member stay in the waiting area while the patient is assessed d. ask the patient how the injury occurred and observe the family member's reaction

c. have the family member stay in the waiting area while the patient is assessed

the nurse observes edema in a patient who has venous congestion from right heart failure. which type of pressure facilitated the formation of the patient's edema? a. osmotic b. oncotic c. hydrostatic d. concentration

c. hydrostatic

a patient has a bacterial infection in left lower leg. which nursing diagnosis will the nurse add to the patient's care plan? a. infection b. risk for infection c. impaired skin integrity d. staphylococcal leg infection

c. impaired skin integrity

a nurse is providing nursing care to patients after completing care plan from nursing diagnoses. in which step of the nursing process is the nurse? a. assessment b. planning c. implementation d. evaluation

c. implementation

which nutritional instruction is a priority for the nurse to advise a patient about with an ileostomy? a. keep fiber low b. eat large meals c. increase fluid intake d. chew food thoroughly

c. increase fluid intake

a patient develops a localized heat and erythema over an area on the lower leg. these findings are indicative of which secondary defense against infection? a. phagocytosis b. complement cascade c. inflammation d. immunity

c. inflammation

the patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. the nurse then auscultates an apical pulse and asks the patient whether there is any history of heart problems. the nurse is utilizing which critical thinking skill? a. evaluation b. explanation c. interpretation d. self-regulation

c. interpretation

the nurse is caring for a patient with a healing stage III pressure ulcer. the wound is clean and granulating. which of the following orders would the nurse question? a. use a low-air-loss therapy unit b. consult a dietitian c. irrigate with hydrogen peroxide d. utilize hydrogel dressing

c. irrigate with hydrogen peroxide

a hospice nurse who has become very close to a terminally ill patient and family is present in the home when the patient dies. the family members are crying softly, and the nurse feels like crying. the nurse recognizes that: a. personal expression of sorrow and loss is appropriate to share with peers rather than burdening the patients family b. the family should be allowed to grieve together at this time and the nurses presence will be felt as invasive to the family c. it is acceptable and healthy to cry with the family during this phase of the grief process d. it would be unprofessional to cry at this time when the family's feelings need to be addressed

c. it is acceptable and healthy to cry with the family during this phase of the grief process

The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to a. remove the electrodes when taking a shower or tub bath. b. exercise more than usual while the monitor is in place. c. keep a diary of daily activities while the monitor is worn. d. connect the recorder to a telephone transmitter once daily.

c. keep a diary of daily activities while the monitor is worn.

the nurse notes that urine does not flow after a female patient is catherized. the nurse believes that the catheter has bee placed into the vagina. which action should the nurse take? a. remove the catheter and reinsert it b. irrigate the catheter with saline c. leave the catheter in place and insert another one d. insert the catheter 9 to 10 inches farther into the patient to verify that it is in the vagina

c. leave the catheter in place and insert another one

the advantage of transdermal patches are the: a. fast onset b. short peak c. long duration d. increased half life

c. long duration

the client is ordered to have daily eye drops administered in both eyes. eye drops should be instilled on the: a. cornea b. outer canthus c. lower conjunctival sac d. opening of the lacrimal duct

c. lower conjunctival sac

the client has rheumatoid arthritis and has limited mobility because of arthritis discomfort. which of the following is the best intervention for maintaining the clients skin integrity? a. position the client up in a chair for 4-hour intervals b. keep the head of the bed in high-Fowler's position c. maintain a schedule of turning and positioning at minimum every 2 hours d. encourage the client to perform pelvic muscle training exercises several times a day

c. maintain a schedule of turning and positioning at minimum every 2 hours

when care is provided for a patient with an NG tube in place, which intervention is safest for the nurse to implement? a. tape the tube up and around the ear on the side of insertion b. secure the tubing to the bed by the patient's head c. mark the tube where it exits the nose d. change the tubing daily

c. mark the tube where it exits the nose

the nurse is administering medications to a patient who is in liver failure due to end-stage cirrhosis. the nurse is aware that the patients with liver failure would most likely have problems with which pharmacokinetic phase? a. absorption b. distribution c. metabolism d. excretion

c. metabolism

a patient has been admitted to the hospital numerous times. the nurses asks the patient to share a personal story about the care that has been received. which interaction is the nurse using? a. nonjudgmental b. socializing c. narrative d. SBAR

c. narrative

A patient with a pneumothorax had a chest tube inserted and was placed on low constant suction. Which finding requires immediate action by the nurse? a. 50 mL of blood gushes into the drainage device after the patient coughs b. the patient complains of pain at the chest tube insertion site that increase with movement c. no bubbling is present in the suction control chamber of the drainage device d. yellow purulent discharge is seen leaking out from around the dressing site

c. no bubbling is present in the suction control chamber of the drainage device

the nurse is assessing a patient whose 24-hours output is 2400 mL. which finding reflects the nurse's understanding of urine output? a. increased output b. decreased output c. normal output d. balanced output

c. normal output

the nurse is caring for a patient who had a colostomy placed 5 days earlier. the nurse notes that the stoma is red and moist. which action should the nurse take? a. notify the physician immediately b. apply pressure c. note the condition of the stoma in her notes d. change the appliance pouch

c. note the condition of the stoma in her notes

when reviewing pharmacology terms for a group of newly graduated nurses, the nurse explains that a drugs half-life is the time it takes for a. the drug to elicit half of its therapeutic response. b. one half of the original amount of a drug to reach the target cells. c. one half of the original amount of a drug to be removed from the body d. one half of the original amount of a drug to be absorbed into the circulation.

c. one half of the original amount of a drug to be removed from the body

the time it takes for a drug concentration to reach a therapeutic level in the blood is known as: a. peak action b. duration of action c. onset of action d. half-lfe

c. onset of action

the nurse is assessing that a patient has a severe fecal impaction. which action taken by the nurse addresses this problem? a. administering laxatives b. providing high-fiber diet c. performing digital removal d. administering an enema

c. performing digital removal

the nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. which step will the nurse take next in the nursing process? a. assessment b. diagnosis c. planning d. implementation

c. planning

the client is brought into the emergency department with a fishing hook imbedded in the hand. the nurse correctly documents the clients wound as a(n): a. contusion wound b. abrasion wound c. puncture wound d. laceration wound

c. puncture wound

the nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. which action will the nurse take first? a. offer calcium-rich foods b. administer diuretic c. raise head of bed d. increase fluids

c. raise head of bed

the nurse enters the patient's room and notices a small fire in the headlight about the patient's bed. immediately, the nurse assigns a nursing diagnosis of risk for injury with a goal for the patient to be safe. which of the following actions should the nurse take first? a. activate the alarm b. extinguish the fire c. remove the patient d. confine the fire

c. remove the patient

the nurse is preparing to catheterize a patient who has a urostomy and uses a two-piece puch system. the nurse should take which action? a. place the patient in a semi-recumbent position b. remove both pieces of the pouch system c. remove the pouch and leave the barrier attached d. use sterile gloves to remove the system

c. remove the pouch and leave the barrier attached

a nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan? a. stimulate the patient's appetite to eat. b. deliver antibiotics to fight off infection c. replace fluid, electrolytes, and nutrients d. provide medication to raise blood pressure

c. replace fluid, electrolytes, and nutrients

the nurse is gathering data on a patient. which data will the nurse report as objective data? a. states "doesn't feel good" b. reports headache c. respirations 16 d. nauseated

c. respirations 16

a nurse is teaching a health class about the heart. which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart? a. right ventricle, left ventricle, left atrium b. left atrium, right ventricle, left ventricle c. right ventricle, left atrium, left ventricle d. left atrium, left ventricle, right ventricle

c. right ventricle, left atrium, left ventricle

the nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. which finding indicates goal achievement? a. urine output increases to 150mL/hr b. systolic and diastolic blood pressure decreases c. serum sodium concentration returns to normal d. large amounts of emesis and diarrhea decrease

c. serum sodium concentration returns to normal

The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short-term goal that the patient could achieve a. running 30 minutes every morning b. stopping smoking immediately c. sleeping on 2-3 pillows at night d. limiting the diet to 1500 calories a day

c. sleeping on 2-3 pillows at night

the nurse is caring for a patient who had a colostomy placed yesterday. the nurse should report which assessment finding immediately? a. stoma is protruding from the abdomen b. stoma is flush with the skin c. stoma is purple d. stoma is moist

c. stoma is purple

a patient has heart failure and cardiac output is decreased. which formula can the nurse use to calculate cardiac output? a. myocardial contractility x myocardial blood flow b. ventricular filling time/diastolic filling time c. stroke volume x heart rate d. preload/afterload

c. stroke volume x heart rate

when auscultating the heart, the S2 sound ("dub") is caused by: a. the tricuspid and aortic valves closing b. the mitral and tricuspid valves closing c. the aortic and pulmonary valves closing d. the aortic and mitral valves closing

c. the aortic and pulmonary valves closing

during the admission assessment, the nurse assess the patient for fall risk. which of the following has the greatest potential to increase the patient's risk for falls? a. the patient is 59 years of age b. the patient walks 2 miles a day c. the pateint takes Benadryl (diphenhydramine) for allergies d. the patient has recently became widowed

c. the pateint takes Benadryl (diphenhydramine) for allergies

the nurse is discussing with a patient's physician the need for restraint. the nurse indicates that alternatives have been utilized. what behaviors would indicate that the alternatives are working? a. the patient continues to get up from the chair at the nurses' station b. the patient apologizes for being "such a bother." c. the patient folds three washcloths over and over d. the sitter leaves the patient alone to go to lunch

c. the patient folds three washcloths over and over

A patient is seen in the ophthalmology clinic and diagnosed with recurrent staphylococcal and seborrheic blepharitis. The nurse will plan to teach the patient about a. saline irrigation of the eyes. b. surgical removal of the lesion. c. using baby shampoo to clean the lids. d. the use of cool compresses to the eyes.

c. using baby shampoo to clean the lids.

when evaluating the health care team member's ability to apply a condom catheter, it is most important for the nurse to provide further instruction for which intervention? a. clipping of hair at the base of the penis b. applying skin prep to the penis before catheter placement c. using regular adhesive tape to hold the catheter in place d. leaving 1 to 2 inches of space between the tip of the penis and then end of the catheter

c. using regular adhesive tape to hold the catheter in place

the nurse agrees with regulations for mandatory immunizations of children. the nurse believes that immunizations prevent diseases as well as prevent spread of the disease to others. which ethical framework is the nurse using? a. deontology b. ethics of care c. utilitarianism d. feminist ethics

c. utilitarianism

there are factors that influence the musculoskeletal system associated with aging. the nurse recognizes that with age: a. men have the greatest incidence of osteoporosis b. muscle fibers increase in size and become tighter c. weight-bearing exercise reduces the loss of bone mass d. muscle strength does not diminish as much as muscle mass

c. weight-bearing exercise reduces the loss of bone mass

the nurse knows that four categories of risk have been identified in the health care environment. which of the following provides the best examples of those risks? a. tile floors, cold food, scratchy linen, and noisy alarms b. carpeted floors, ice machine empty, unlocked supply cabinet c. wet floors, pinching fingers in door, failure to use lift for patient, and alarms not functioning properly d. dirty floors, hallways blocked, medication room locked, and alarms set

c. wet floors, pinching fingers in door, failure to use lift for patient, and alarms not functioning properly

a nurse and patient work on strategies to reduce weight. which phase of the helping relationship is the nurse in with this patient? a. preinteraction. b. orientation. c. working. d. termination

c. working

A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower legs, which is causing the patient to have a decreased ability to feel pain in the lower extremities. The nurse is providing education to the patient to prevent injury to the feet. The nurse tells the patient to always wear shoes or slippers when walking. Which of the following statements made by the nurse best explains the rationale for this instruction? a. "Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet." b. "Shoes provide nonpharmacological pain relief to people with diabetes and peripheral neuropathy." c. "Since you cannot feel pain as much in your feet, you need to open your neurological gates to allow pain sensations to come through. Wearing shoes helps to open those gates, which protects your feet." d. "You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."

d. "You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."

Which of the following is the best way for the nurse to manage pain for a patient with chronic pain from arthritis? a. Administer pain medication before any activity. b. Provide intravascular bolus as needed for breakthrough pain. c. Give medications around-the-clock. d. Administer pain medication only when nonpharmacological measures have failed.

d. Administer pain medication only when nonpharmacological measures have failed.

Which priority teaching will the nurse implement for a patient who has just been diagnosed with viral conjunctivitis? a. Explain the purpose of antiviral eyedrops. b. Show how to perform eye irrigation safely. c. Instruct about how to insert soft contact lenses. d. Demonstrate appropriate hand-washing technique.

d. Demonstrate appropriate hand-washing technique.

The patient presents to the clinic with reports of irritability, being sleepy during the day, not being able to fall asleep, and being tired. Select the most appropriate nursing diagnosis. a. Anxiety b. Fatigue c. Sleep deprivation d. Insomnia

d. Insomnia

Which action will the nurse include in the plan of care for a patient who has vestibular disease? a. Check Rinne and Weber tests. b. Face the patient when speaking. c. Enunciate clearly when speaking. d. Monitor the patient's ability to ambulate safely.

d. Monitor the patient's ability to ambulate safely.

Which assessment finding in a patient who was struck in the right eye with a baseball is a priority for the nurse to communicate to the health care provider in the emergency department? a. The patient complains of a right-sided headache. b. The sclerae on the right eye have broken blood vessels. c. The area around the right eye is bruised and tender to the touch. d. The patient complains of "a curtain" blocking part of the visual field.

d. The patient complains of "a curtain" blocking part of the visual field.

The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first? a. The patient who needs to take a scheduled dose of maintenance pain medication b. The patient who needs to be premedicated before walking c. The patient with a PCA running who needs to have the syringe replaced d. The patient who is experiencing 8/10 pain and has a STAT order for pain medication

d. The patient who is experiencing 8/10 pain and has a STAT order for pain medication

A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." What type of pain does the nurse document that the patient is having at this time? a. Superficial pain b. Idiopathic pain c. Chronic pain d. Visceral pain

d. Visceral pain

The nurse is educating a student nurse on caring for a patient with a chest tube. The nurse knows that teaching has been effective when the student states a. "I should strip the drains on the chest tube every hour to promote drainage" b. "If the chest tube becomes dislodged, the first thing I should do is notify the physician" c. "I should clamp the chest tube when giving the patient a bed bath" d. "I should report if I see continuous bubbling in the water-seal chamber"

d. "I should report if I see continuous bubbling in the water-seal chamber"

when making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. which therapeutic response is most appropriate? a. "You will be okay. Your surgeon will talk to you in the morning." b. "Why can't you sleep? You have the best surgeon in the hospital." c. "Don't worry. The surgeon ordered a sleeping pill to help you sleep." d. "It must be difficult not to know what the surgeon will find. What can I do to help?"

d. "It must be difficult not to know what the surgeon will find. What can I do to help?"

A female nursing student in the final term of nursing school is overheard by a nursing faculty member telling another student that she got to insert a nasogastric tube in the emergency department while she was working as a nursing assistant. What advice is best for the nursing faculty member to give to the nursing student? a. "Just be careful when you are doing new procedures and make sure you are following directions by the nurse." b. "Review your procedures before you go to work, so you will be prepared to do them if you have a chance." c. "The nurse should not have allowed you to insert the nasogastric tube because something bad could have happened." d. "You are not allowed to perform any procedures other than those in your job description even with the nurse's permission."

d. "You are not allowed to perform any procedures other than those in your job description even with the nurse's permission."

during the end-of-shift report the nurse notes that the client had been very nervous and preoccupied during the evening and that no family visited. to determine the amount of anxiety that the client is experiencing, the nurse should respond: a. "Would you like for me to call a family member to come and support you?" b. "Would you like to go down the hall and talk with another client who had the same surgery?" c. "How serious do you think your illness is?" d. "You seem worried about something. Would it help to talk about it?"

d. "You seem worried about something. Would it help to talk about it?"

the nurse is caring for a patient supported with a ventilator who has been unresponsive since arrival via ambulance 8 days ago. the patient has not been identified, and no family members have been found. the nurse is concerned about the plan of care regarding maintenance or withdrawal of life support measures. place the steps the nurse will use to resolve this ethical dilemma in the correct order. 1. The nurse identifies possible solutions or actions to resolve the dilemma. 2. The nurse reviews the medical record, including entries by all health care disciplines, to gather information relevant to this patient's situation. 3. Health care providers use negotiation to redefine the patient's plan of care. 4. The nurse evaluates the plan and revises it with input from other health care providers as necessary. 5. The nurse arranges a meeting with health care team members to clarify opinions, values, and facts. 6. The nurse states the problem a. 6,1,2,5,4,3 b. 5,6,2,3,4,1 c. 1,2,5,4,3,6 d. 2,5,6,1,3,4

d. 2, 5, 6, 1, 3, 4

you administer percocet, an oral narcotic for pain in you patient after surgery. according to the Davis Drug Guide the onset of this medication is 15 minutes, the peak is 60 minutes, and the duration is 4-6 hours. the BEST time to reassess your patient's response to this medication is: a. 15 minutes b. 60 minutes c. 2 hours d. 4 hours e. 6 hours

d. 4 hours

the instructor is teaching the beginning nursing class how to calculate pulse pressure. if the patient's systolic pressure was 122 mm Hg and the diastolic pressure was 75 mm Hg, what would the pulse pressure be? a. 57 b. 60 c. 54 d. 47

d. 47

the patient has a catheter that must be irrigated. the nurse is using a needleless closed irrigation technique. in which order will the nurse perform the steps, starting with the first one? 1. clean injection port 2. inject prescribed solution 3. twist needleless syringe into port 4. remove clamp and allow to drain 5. clamp catheter just below specimen port 6. draw up prescribed amount of sterile solution ordered a. 3,2,6,1,5,4 b. 5,6,1,2,3,4 c. 1,5,6,3,2,4 d. 6,5,1,3,2,4

d. 6,5,1,3,2,4

In determining kcal expenditure, the nurse knows that carbohydrates and proteins provide 4 kcal of energy per gram ingested. The nurse also knows that fats provide _____ kcal per gram. a. 3 b. 4 c. 6 d. 9

d. 9

the client is to receive an IM injection. the nurse recognizes that the angle of inejection that is used for an intramuscular injection is: a. 15 degrees b. 30 degrees c. 45 degrees d. 90 degrees

d. 90 degrees

The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method? a. A 5-year-old with excessive drooling from epiglottitis b. A 5-year-old with an asthma attack following severe allergies c. A 24-year-old with a right pneumothorax following a motor vehicle accident d. A 24-year-old with acute respiratory distress syndrome requiring mechanical

d. A 24-year-old with acute respiratory distress syndrome requiring mechanical

The nurse is admitting a patient to the hospital. The patient states that he is a very spiritual person but does not practice any specific religion. The nurse understands that these statements a. Are contradictory. b. Indicate a strong religious affiliation. c. Indicate a lack of faith. d. Are reasonable.

d. Are reasonable.

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Suggest that the patient avoid orange juice with meals. d. Ask the health care provider to order a basic metabolic panel.

d. Ask the health care provider to order a basic metabolic panel.

a patient has just been diagnosed with hypertension and has been started on captopril (capoten). which information is important to include when teaching the patient about this medication? a. Check blood pressure (BP) in both arms before taking the medication. b. Increase fluid intake if dryness of the mouth is a problem. c. Include high-potassium foods such as bananas in the diet. d. Change position slowly to help prevent dizziness and falls.

d. Change position slowly to help prevent dizziness and falls.

The nurse cares for a terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be most appropriate? a. death-rattle respirations b. agonal breathing c. apneustic breathing d. Cheyne-Stokes respiration

d. Cheyne-Stokes respiration

a nurse is teaching a patient's family member about permanent tube feedings at home. which purpose of patient education is the nurse meeting? a. Health promotion b. Illness prevention c. Restoration of health d. Coping with impaired functions

d. Coping with impaired functions

The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia? a. Elevated blood pressure b. Increased pulse rate c. Restlessness d. Cyanosis

d. Cyanosis

The patient has been in bed for several days and needs to be ambulated. Before ambulation, the nurse a. Removes the gait belt to allow for unrestricted movement. b. Has the patient get up from bed before he has a chance to get dizzy. c. Has the patient look down to watch his feet to prevent tripping. d. Dangles the patient on the side of the bed.

d. Dangles the patient on the side of the bed.

The nurse is teaching about the process of exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process? a. Ventilation b. Surfactant c. Perfusion d. Diffusion

d. Diffusion

In measuring the effectiveness of nutritional interventions, the nurse should a. Expect results to occur rapidly. b. Not be concerned with physical measures such as weight. c. Expect to maintain a course of action regardless of changes in condition. d. Evaluate outcomes according to the patient's expectations and goals.

d. Evaluate outcomes according to the patient's expectations and goals.

an older adult patient in no acute distress reports being less able to taste and smell. what is the nurse's best response to this information? a. Notify the physician immediately to rule out cranial nerve damage. b. Perform testing on the vestibulocochlear nerve and a hearing test. c. Schedule the patient for an appointment at a smell and taste disorders clinic. d. Explain to the patient that diminished senses are normal findings.

d. Explain to the patient that diminished senses are normal findings.

the nurse values autonomy above all other principles. which patient assignment will the nurse find most difficult to accept? a. Teenager in labor who requests epidural anesthesia b. Middle-aged father of three with an advance directive declining life support c. Elderly patient who requires dialysis d. Family elder who is making the decisions for a young female member

d. Family elder who is making the decisions for a young female member

a nurse must make an ethical decision concerning vulnerable patient populations. which philosophy of health care ethics would be particularly useful for this nurse? a. Teleology b. Deontology c. Utilitarianism d. Feminist ethics

d. Feminist ethics

The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider? a. Increased anterior-posterior diameter of the chest b. Accessory muscle used for breathing c. Clubbing of the fingers d. Hemoptysis

d. Hemoptysis

Which information should the nurse include when teaching a patient with newly diagnosed hypertension? a. Increasing physical activity will control blood pressure (BP) for most patients. b. Most patients are able to control BP through dietary changes. c. Annual BP checks are needed to monitor treatment effectiveness. d. Hypertension is usually asymptomatic until target organ damage occurs.

d. Hypertension is usually asymptomatic until target organ damage occurs.

a nurse develops a diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. which nursing diagnosis did the nurse write? a. Ineffective breathing pattern related to pneumonia b. Risk for infection related to chest x-ray procedure c. Risk for deficient fluid volume related to dehydration d. Impaired gas exchange related to alveolar-capillary membrane changes

d. Impaired gas exchange related to alveolar-capillary membrane changes

Some proteins are manufactured in the body, but others are not. Those that must be obtained through diet are known as a. Amino acids. b. Dispensable amino acids. c. Triglycerides. d. Indispensable amino acids.

d. Indispensable amino acids.

A patient has inadequate stroke volume related to decreased preload. Which treatment does the nurse prepare to administer? a. Diuretics b. Vasodilators c. Chest physiotherapy d. Intravenous (IV) fluids

d. Intravenous (IV) fluids

A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning? a. Pulse 75 b. Pulse 80 c. Oxygen saturation 91% d. Oxygen saturation 88%

d. Oxygen saturation 88%

an active lifestyle is important for maintaining and promoting health. in developing an exercise program, the nurse understands that a. Physical exercise is contraindicated for patients with chronic illnesses. b. Regular physical activity is beneficial only for the body part that is exercised. c. Physical exercise has no effect on psychological well-being. d. Physical activity enhances functioning of all body systems.

d. Physical activity enhances functioning of all body systems.

the nurse administers the intramuscular medication of iron by the Z-track method. the medication was administered by this method to: a. Provide faster absorption of the medication b. Reduce discomfort from the needle c. Provide more even absorption of the drug d. Prevent the drug from irritating sensitive tissue

d. Prevent the drug from irritating sensitive tissue

the nurse is caring for a patient with Clostridium difficile. which nursing action will have the greatest impact in preventing the spread of the bacteria? a. Monthly in-services about contact precautions b. Placing all contaminated items in biohazard bags c. Mandatory cultures on all patients d. Proper hand hygiene techniques

d. Proper hand hygiene techniques

Upon auscultation of the patient's chest, the nurse hears a whooshing sound at the fifth intercostal space. The nurse recognizes that this sound is a. The beginning of the systolic phase. b. The opening of the aortic valve. c. S3, the third heart sound. d. Regurgitation of the mitral valve.

d. Regurgitation of the mitral valve.

a patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

d. Respiratory alkalosis

a nurse's goal is to provide teaching for restoration of health. which situation indicates the nurse is meeting this goal? a. Teaching a family member to provide passive range of motion for a stroke patient b. Teaching a woman who recently had a hysterectomy about possible adoption c. Teaching expectant parents about changes in childbearing women d. Teaching a teenager with a broken leg how to use crutches

d. Teaching a teenager with a broken leg how to use crutches

After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective? a. The patient avoids eating nuts or nut butters. b. The patient restricts intake of chicken and fish. c. The patient has two cups of coffee in the morning. d. The patient has a glass of low-fat milk with each meal.

d. The patient has a glass of low-fat milk with each meal.

a family is grieving after leaning of a family member's accidental death. the transplant coordinator requests to talk with the family about possible organ and tissue donation. the nurse recognizes that a. All religions allow for organ donation. b. Life support must be removed before organ and tissue retrieval occurs. c. The best time for organ and tissue donation is immediately after the autopsy. d. The transplant coordinator is working in accordance with federal law.

d. The transplant coordinator is working in accordance with federal law.

Which action will be included in the plan of care when the nurse is caring for a patient who is receiving nicardipine (Cardene) to treat a hypertensive emergency? a. Keep the patient NPO to prevent aspiration caused by nausea and possible vomiting. b. Organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night. c. Assist the patient up in the chair for meals to avoid complications associated with immobility. d. Use an automated noninvasive blood pressure machine to obtain frequent blood pressure (BP) measurements.

d. Use an automated noninvasive blood pressure machine to obtain frequent blood pressure (BP) measurements.

a nurse is prioritizing care for four patients. which patient should the nurse see first? a. a patient needing teaching about medications b. a patient with a healed abdominal incision c. a patient with a slight temperature d. a patient with difficulty breathing

d. a patient with difficulty breathing

a staff nurse delegates a task to a nursing assistive personnel (NAP), knowing that the NAP has never performed the task before. as a result, the patient is injured, and the nurse defensively states that the NAP should have known how to perform such a simple task. which element of the decision-making process is the nurse lacking? a. authority b. autonomy c. responsibility d. accountability

d. accountability

a long-term care patient with moderate dementia develops increased restlessness and agitation. the nurse's initial action should be to a. reorient the patient to time, place, and person b. administer the PRN dose of lorazepam (Ativan) c. have a nursing assistant stay with the patient to ensure safety d. assess for factors that might be causing discomfort

d. assess for factors that might be causing discomfort

in the event of a medication error, the nurses first responsibility is to: a. contact the physician b. fill out an incident report c. notify their supervisor d. assess the client's safety

d. assess the client's safety

a nurse is reviewing results from a urine specimen. what will the nurse expect to see in a patient with a urinary tract infection? a. casts b. protein c. crystals d. bacteria

d. bacteria

the nurse is caring for a patient with hyperkalemia. which body system assessment is the priority? a. gastrointestinal b. neurological c. respiratory d. cardiac

d. cardiac

a newly hired experienced nurse is preparing to change a patient's abdominal dressing and hasn't done it before at this hospital. which action by the nurse is best? a. have another nurse do it so the correct method can be viewed. b. change the dressing using the method taught in nursing school. c. ask the patient how the dressing change has been recently done. d. check the policy and procedure manual for the facility's method.

d. check the policy and procedure manual for the facility's method.

which nursing diagnosis is appropriate for a patient who has just received a prescription for a new medication? a. noncompliance related to a new drug therapy b. ineffective health maintenance related to new drug therapy c. lack of knowledge regarding newly prescribed drug therapy d. deficient knowledge related to newly prescribed drug therapy

d. deficient knowledge related to newly prescribed drug therapy

when admitting an 88-year-old patient to the hospital, the nurse should plan to a. speak slowly and loudly while facing the patient. b. obtain a detailed medical history from the patient c. interview the patient before the physical assessment d. determine whether the patient uses glasses or hearing aides

d. determine whether the patient uses glasses or hearing aides

A 56-year-old patient who has no previous history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that a. a BP recheck should be scheduled in a few weeks. b. dietary sodium and fat content should be decreased. c. there is an immediate danger of a stroke and hospitalization will be required. d. diagnosis of a possible cause, treatment, and ongoing monitoring will be needed.

d. diagnosis of a possible cause, treatment, and ongoing monitoring will be needed.

the nurse is administering an injection at the ventrogluteal site. on aspiration, the nurse assess that there is blood in the syringe. the initial intervention: a. inject the medication b. pull the needle back slightly and inject the medication c. move the skin to the side and inject the medication slowly d. discontinue the injection and prepare the medication again

d. discontinue the injection and prepare the medication again

after administering an intradermal (ID) injection for a skin test, the nurse notices a small bleb at the injection site. the proper action would be to: a. apply heat b. massage the area c. report the complication of the bleb to the physician d. do nothing

d. do nothing

the nurse is teaching a health class about the gastrointestinal tract. the nurse will explain that which portion of the digestive tract absorbs most of the nutrients? a. ileum b. cecum c. stomach d. duodenum

d. duodenum

the palliative team's primary obligation to a patient in severe pain includes which of the following? a. supporting the patient's nurse in her grief b. providing postmortem care for the patient c. teaching the patient the stages of grief d. enhancing the patient's quality of life

d. enhancing the patient's quality of life

the leading cause of injury and preventable source of mortality and morbidity in older adults is a. presbycusis b. car accidents c. pneumonia d. falls

d. falls

a nurse is teaching a patient with a risk for hypertension how to take a blood pressure. which action by the nurse is the priority? a. assess laboratory results for high cholesterol and other data. b. identify that teaching is the same as the nursing process. c. perform nursing care therapies to address hypertension d. focus on the patient's learning needs and objectives.

d. focus on the patient's learning needs and objectives.

a nurse is standing beside the patient's bed Nurse: how are you doing? Patient: I don't feel good. Which element will the nurse identify as feedback? a. nurse b. patient. c. how are you doing d. i don't feel good.

d. i don't feel good.

the nurse prepares to administer a tablet to a client who has difficulty swallowing pills. the safest intervention is to crush the tablet and mix it with food. the best approach is to mix the crushed medication: a. in a large amount of food to mask the taste b. with the client's favorite food c. with grapefruit juice d. in a very small amount of food.

d. in a very small amount of food.

which documentation is most complete in describing a wound? a. wound appears to be healing well. dressing dry and intact b. wound well approximated with minimal drainage c. drainage size of quarter; wound pink; two sterile 4x4's applied d. incisional edges approximated without redness or drainage; two 4x4's applied

d. incisional edges approximated without redness or drainage; two 4x4's applied

a nurse is teaching a patient who has low health literacy about COPD while giving COPD medications. which technique is most appropriate for the nurse to use. a. use complex analogies to describe COPD b. ask for feedback to assess understanding of COPD at the end of the session. c. offer pamphlets about COPD written at the eight grade level with large type. d. include the most important information on COPD at the beginning of the session.

d. include the most important information on COPD at the beginning of the session.

the client requires support, and an abdominal binder is ordered. the nurse correctly implements the use of a binder by: a. using it as a replacement for underlying dressings b. keeping it loose for client comfort c. having the client sit or stand when it is applied d. making sure the client has adequate ventilatory capacity

d. making sure the client has adequate ventilatory capacity

the patient has a calculated body mass index (BMI) of 34. this would classify the patient as a. unclassifiable b. normal weight c. overweight d. obese

d. obese

to assure effectiveness, when should the nurse stop rubbing antiseptic hand solution over all surfaces of the hands? a. when fingers feel sticky b. after 5 to 10 seconds c. when leaving the client's room d. once fingers and hands feel dry

d. once fingers and hands feel dry

the nurse needs to administer insulin subcutaneously to an obese patient. the proper technique for this injection should include: a. inserting the needle at a 5- to 15-degree angle until resistance is felt b. using the Z-track method c. spreading the skin tightly over the injection site, inserting the needle, then releasing the skin d. pinching the skin at the injection site and inserting the needle to below the tissue fold.

d. pinching the skin at the injection site and inserting the needle to below the tissue fold.

a patient has been admitted and placed on fall precautions. the nurse explains to the patient that interventions for the precautions include a. encouraging visitors in the early evening b. placing all four side rails in the "up" position c. checking on the patient once a shift d. placing a high risk for falls armband on the patient

d. placing a high risk for falls armband on the patient

a nurse is teaching a group of healthy adults about the benefits of flu immunizations. which type of patient education is the nurse providing? a. health analogies. b. restoration of health c. coping with impaired functions d. promotion of health and illness prevention

d. promotion of health and illness prevention

which action should the nurse take first during the initial phase of implementation? a. determine patient outcome and goals b. prioritize patient's nursing diagnoses c. evaluate interventions d. reassess the patient

d. reassess the patient

the nurse is caring for a patient with a urinary catheter. after the nurse empties the collection bag and disposes of the urine, the next step is to: a. use alcohol-based gel on hands b. wash hands with soap and water c. remove eye protection and dispose of in garbage d. remove gloves and dispose of in garbage

d. remove gloves and dispose of in garbage

the patient is confused, is trying to get pout of bed, and is pulling at the intravenous infusion tubing. these data would help to support a nursing diagnosis of: a. risk for poisoning b. knowledge deficit c. impaired home maintenance d. risk for injury

d. risk for injury

a nurse teaches a patient with heart failure healthy food choices. the patient states that eating yogurt is better than eating cake. which element represents feedback? a. the nurse b. the patient c. the nurse teaching about healthy food choices d. the patient stating that eating yogurt is better than eating cake

d. the patient stating that eating yogurt is better than eating cake

which learning objective/outcome has the highest priority for a patient with life-threatening, severe food allergies that require an EpiPen (epinephrine)? a. the patient will identify the main ingredients in several foods b. the patient will list the side effects of epinephrine c. the patient will learn about food labels d. the patient will administer epniephrine

d. the patient will administer epniephrine

a nurse uses SBAR when providing a hands-off report to the oncoming shift. what is the rationale for the nurse's action? a. to promote autonomy b. to use common courtesy c. to establish trustworthiness d. to standardize communication

d. to standardize communication

the nurse is caring for a patient who has an ostomy. the nurse notices that the effluent ranges from a thick liquid to a semi-formed stool. the nurse recognizes that this is indicative of which location? a. descending colon b. ileal portion of the small intestine c. sigmoid colon d. transverse or ascending colon

d. transverse or ascending colon

a patient is experiencing chest pain and needs to take a sublingual form of nitroglycerin. the nurse would instruct the patient to place the tablet: a. on a non-hairy area on the chest b. at the back of the throat for easy swallowing c. in the space between the cheek and gum inside the mouth d. under the tongue

d. under the tongue

the nurse has received a telephone order for a narcotic medication. it is to be administered to a client experiencing severe pain related to metastatic cancer of the bone. the initial intervention related to the order is to: a. prepare and administer the medication to the client b. properly sign for the narcotic analgesic in the narcotic records c. notify the client that an order for a narcotic pain medication has been received d. write, sign and document read back the order in the appropriate location in the client's chart

d. write, sign and document read back the order in the appropriate location in the client's chart

In teaching a patient with hypertension about controlling the condition, the nurse recognizes that a.all patients with elevated BP require medication. b.obese persons must achieve a normal weight to lower BP. c.it is not necessary to limit salt in the diet if taking a diuretic. d.lifestyle modifications are indicated for all persons with elevated BP.

d.lifestyle modifications are indicated for all persons with elevated BP.