Intro Exam 4

A 72-year-old patient asks the nurse about using an over-the-counter antihistamine as a sleeping pill to help her get to sleep. What is the nurse's best response? A. "Antihistamines are better than prescription medications because these can cause a lot of problems." B. "Antihistamines should not be used because they can cause confusion and increase your risk of falls." C. "Antihistamines are effective sleep aids because they do not have many side effects." D. "Over-the-counter medications when combined with sleep-hygiene measures are a good plan for sleep."

B. "Antihistamines should not be used because they can cause confusion and increase your risk of falls." Older adults should avoid the use of over-the-counter antihistamines. These medications have a long duration of action in older adults and can cause confusion, constipation, urinary retention, and increased risk of falls.

Which of the following statements indicate that the new nursing graduate understands ways to remain involved professionally? Select all that apply. A. "I am thinking about joining the health committee at my church." B. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." C. "I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing." D. "Nurses do not have very much voice in legislation in Washington, DC, because of the nursing shortage." E. "I will go back to school as soon as I finish orientation."

A. "I am thinking about joining the health committee at my church." B. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." C. "I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing." Nurses need to be actively involved in their community and be aware of current issues in health care. Staying abreast of current news and public opinion through the media is essential. Nurses need to join nursing committees to be involved in decision making. Nurses have a powerful voice in the legislature.

Which statement made by the parent of a school-age child requires follow-up by the nurse? A. "I encourage evening exercise about an hour before bedtime." B. "I offer my daughter a glass of warm milk before bedtime." C. "I make sure that the room is dark and quiet at bedtime." D. "We use quiet activities such as reading a book before bedtime."

A. "I encourage evening exercise about an hour before bedtime." Best evidence related to sleep hygiene recommends avoiding exercise within 2 hours of bedtime. Exercise should be in the morning or afternoon. Encourage the parent to use quiet activities before bedtime to promote sleep.

The NAP is reviewing with the nurse how to apply a belt restraint. Which statement, if made by the NAP, indicates further teaching is necessary? A. "I should place the belt restraint around the chest or abdomen." B. "A properly applied belt restraint allows the patient to turn onto his side." C. "I should apply the belt over the patient's gown or pajamas." D. "To apply the belt restraint, I should first have the patient sit up in bed."

A. "I should place the belt restraint around the chest or abdomen." The belt restraint should be placed at the waist, not the chest or abdomen, as this restrains the center of gravity and prevents the patient from rolling off a stretcher or sitting up while on a stretcher, or from falling out of bed. Ventilation can be impaired if the belt restraint moves up over the abdomen or chest. The patient must be able to turn to a lateral position to prevent aspiration if the patient begins to vomit. The belt restraint is placed over the patient's clothes, gown, or pajamas. The NAP should remove wrinkles or creases in clothing. The patient first is in a sitting position as the belt restraint is applied.

The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? Select all that apply. A. Avoid grapefruit and grapefruit juice, which impair drug absorption. B. Increase the amount of carbohydrates for energy. C. Take a multivitamin that includes vitamin D for bone health. D. Cheese and eggs are good sources of protein. E. Limit fluids to decrease the risk of edema.

A. Avoid grapefruit and grapefruit juice, which impair drug absorption. C. Take a multivitamin that includes vitamin D for bone health. D. Cheese and eggs are good sources of protein. Cheese, eggs, and peanut butter are also useful high-protein alternatives. Vitamin D supplements are important for improving strength and balance, strengthening bone health, and preventing bone fractures and falls. Grapefruit and grapefruit juice can interfere with warfarin (Coumadin) (anticoagulant), preventing its breakdown. This would lead to an increased risk of bleeding.

A patient has been newly admitted to a medicine unit with a history of diabetes and advanced heart failure. The nurse is assessing the patient's fall risks. Which of the following is the proper order of steps for the "Timed Get-up and Go Test" (TGUGT)?1. Have patient rise from straight-back chair without using arms for support. 2. Begin timing. 3. Tell patient to walk 10 feet as quickly and safely as possible to a line you marked on the floor, turn around, walk back, and sit down. 4. Check time elapsed. 5. Look for unsteadiness in patient's gait. 6. Have patient return to chair and sit down without using arms for support. A. 3, 1, 2, 5, 6, 4 B. 2, 1, 3, 5, 6, 4 C. 1, 2, 3, 6, 5, 4 D. 1, 2, 3, 5, 6, 4

A. 3, 1, 2, 5, 6, 4 3. Tell patient to walk 10 feet as quickly and safely as possible to a line you marked on the floor, turn around, walk back, and sit down 1. Have patient rise from straight-back chair without using arms for support. 2. Begin timing. 5. Look for unsteadiness in patient's gait. 6. Have patient return to chair and sit down without using arms for support. 4. Check time elapsed. These are the correct steps for performing the TGUGT.

The nurse is inserting a small-bore nasoenteric tube before starting enteral feedings. What is the correct order of steps to perform this procedure?1. Place patient in high-Fowler's position.2. Have patient flex head toward chest.3. Assess patient's gag reflex.4. Determine length of the tube to be inserted.5. Obtain radiological confirmation of tube placement.6. Check pH of gastric aspirate for verifying placement.7. Identify patient with two identifiers. A. 7, 1, 3, 4, 2, 5, 6 B. 1, 3, 4, 7, 2, 6, 5 C. 7, 1, 3, 2, 4, 6, 5 D. 1, 7, 3, 2, 4, 5, 6

A. 7, 1, 3, 4, 2, 5, 6 This is the correct order to perform this procedure.

Which of the following patients is at greatest risk for experiencing a fall? A. A confused patient with a history of a previous fall. B. A patient who ambulates by holding onto furniture. C. A recently admitted patient. D. A patient who wears glasses to read.

A. A confused patient with a history of a previous fall. There are multiple factors that contribute to the risk of falls, including being in an unfamiliar environment (e.g., the recently admitted patient); difficulty communicating because of impaired vision, hearing, or speech; and impaired cognition. A patient who is confused and has a history of a fall is at greatest risk for experiencing a fall.

The nurse is planning tasks for the day. Which of the following patients would require repositioning at this time? (Select all that apply.) A. A patient in correct body alignment who was turned 2 hours ago. B. A patient who has been sitting in a chair for 10 minutes watching television. C. A comfortable patient with paraplegia who has been sitting in a chair for 30 minutes. D. A patient who was repositioned for comfort 30 minutes ago after being moved up in bed.

A. A patient in correct body alignment who was turned 2 hours ago. C. A comfortable patient with paraplegia who has been sitting in a chair for 30 minutes. In general, patients should be repositioned as needed and at least every 2 hours if they are in bed and every 20 to 30 minutes if they are sitting in a chair to prevent the development of pressure ulcers. A patient with paraplegia would not be able to feel discomfort from pressure.

Who may require a temporary restraint? (Select all that apply.) A. A patient who is at risk for falls when nonrestrictive measures have failed. B. A patient who is uncooperative. C. A confused patient who may interrupt prescribed therapy, such as a nasogastric tube. D. A patient who may be a risk to self or others. E. A patient who walks in his or her sleep.

A. A patient who is at risk for falls when nonrestrictive measures have failed. C. A confused patient who may interrupt prescribed therapy, such as a nasogastric tube. D. A patient who may be a risk to self or others. Patients needing temporary restraints include those at risk for falls and confused or combative patients at risk for injury or violence to self or others. In addition, restraints are used to prevent interruption of therapy such as an IV catheter, urinary or surgical drains, nasogastric tube, traction, or life support equipment. The least restrictive method should be used. Restraints should never be used as a punishment. Often, uncooperative patients can be managed with good communication skills. A bed alarm may be an appropriate safety measure for the patient who walks in his or her sleep. If alternative measures fail, then the health care provider may be contacted.

Which of the following properly applies an ethical principle to justify access to health care? Select all that apply. A. Access to health care reflects the commitment of society to principles of beneficence and justice. B. If low income compromises access to care, respect for autonomy is compromised. C. Access to health care is a privilege in the United States, not a right. D. Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics. E. Providers are exempt from fidelity to people with drug addiction because addiction reflects a lack of personal accountability. F. If a new drug is discovered that cures a disease but at great cost per patient, the principle of justice suggests that the drug should be made available to those who can afford it.

A. Access to health care reflects the commitment of society to principles of beneficence and justice. B. If low income compromises access to care, respect for autonomy is compromised. D. Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics. Justice is the ethical principle that justifies the agreement to ensure access to care for all, but it does not necessarily clarify how to resolve issues of limited resources such as money or organs available for transplant. Privilege is not an ethical principle. Nonmaleficence means "first do no harm." A lack of care because of poor access causes harm (i.e., no preventive services, no early detection, no risk reduction) and therefore is ethically troubling. The principal of fidelity implies that we agree to ensure access to care even for people whose beliefs and behaviors may differ from our own, including drug addicts.

Which of the following are appropriate measures to help the patient with dysphagia to swallow and prevent aspiration? (Select all that apply.) A. Add thickener to thin liquids. B. Place food on the unaffected side of the mouth. C. Provide the patient with a lap protector. D. Place the patient in the high-Fowler's position. E. Provide verbal coaching. F. Talk about other matters while feeding the patient.

A. Add thickener to thin liquids. B. Place food on the unaffected side of the mouth. D. Place the patient in the high-Fowler's position. E. Provide verbal coaching. Patients with dysphagia (impaired swallowing) require special precautions to prevent aspiration. Maintaining an upright position to enhance the effects of gravity is important. When feeding the patient, the nurse should place food on the unaffected side of the mouth (as in patients with hemiparesis) and observe the swallowing event closely for delays. Providing verbal coaching throughout the swallowing process can greatly help the patient swallow more effectively. Food that is the consistency of mashed potatoes is easiest for patients with dysphagia to swallow. Liquids and solids are more likely to pose a threat. In some cases, thickeners may be added to food or fluids to increase the consistency and thus allow the patient more control of the volume in the mouth. Distractions should be reduced, and therefore it is more important to keep the patient focused on swallowing when talking. The nurse may provide encouragement to increase the patient's confidence in the ability to swallow. Although a lap protector may be used, it will not influence the ability to reduce aspiration. Instead have suction equipment available.

The daughter of an elderly patient comes to visit her mother, who was recently admitted to the hospital. The daughter notices a yellow band on her mother's wrist and asks what it is for. The nurse correctly responds that it is used to identify patients who are at risk for falling and provides additional information as to what makes a patient a fall risk. What information should the nurse include? (Select all that apply.) A. Age over 65. B. New and different environment. C. Continent of urine and bowel. D. History of a fall. E. Having an IV. F. Taking muscle relaxants.

A. Age over 65. B. New and different environment. D. History of a fall. E. Having an IV. F. Taking muscle relaxants. Age over 65, being in an unfamiliar environment, and having a recent history of a fall are all risk factors for a fall. Incontinence or frequency/urgency are additional risk factors, as well as being attached to equipment. Polypharmacy and certain medications such as muscle relaxants increase one's risk for a fall.

The nurse believes that a patient who states he is in pain is "faking it" and is hoping to get "high." The nurse decides to give the patient a placebo instead of the pain medication that was ordered for the patient. The nurse is violating which principle(s) of ethics? Select all that apply. A. Autonomy B. Utilitarianism C. Beneficence D. Dilemmas E. Veracity

A. Autonomy B. Utilitarianism C. Beneficence Autonomy is the principle of respect for the individual person; the nurse does not respect someone upon whom the nurse is inflicting harm. Beneficence is providing benefit to others by promoting their welfare. In general terms, to be beneficent is to promote goodness, kindness, and charity. By taking the patient's pain medication and substituting saline, the nurse did harm, not good, for the patient. Veracity is truth-telling. The nurse misled the patient to believe he/she was receiving a dose of pain medication. Utilitarianism is the principle that assumes that an action is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. Because the patient's pain medication was taken away, the consequences were all bad. Dilemmas are not included as a principle of ethics.

A nurse is educating parents to look for clues in teenagers for possible substance abuse. Which environmental and psychosocial clues should the nurse include? Select all that apply. A. Blood spots on clothing B. Long-sleeved shirts in warm weather C. Changes in relationships D. Wearing dark glasses indoors E. Increased computer use

A. Blood spots on clothing B. Long-sleeved shirts in warm weather C. Changes in relationships D. Wearing dark glasses indoors Environmental clues include the presence of drug-oriented magazines, beer and liquor bottles, drug paraphernalia and blood spots on clothing, and the continual wearing of long-sleeved shirts in hot weather and dark glasses indoors. Psychosocial clues include failing grades, change in dress, increased absenteeism from school, isolation, increased aggressiveness, and changes in interpersonal relationships.

A nurse in a home setting is assessing a 79-year-old male patient's risk for malnutrition. The nurse suspects malnutrition when reviewing which laboratory results? Select all that apply. A. Body mass index (BMI) of 17 B. Waist-to-hip ratio of 1.0 C. Weight loss of 6% since last month's visit D. Prealbumin level of 16 mg/dL E. Hematocrit level of 50% F. Hemoglobin level of 8.2 g/dL

A. Body mass index (BMI) of 17 C. Weight loss of 6% since last month's visit' F. Hemoglobin level of 8.2 g/dL A BMI of 18.5 to 24.9 is normal, and this patient's BMI is below normal; a major weight loss is defined as more than a 2% weight change over 1 week; and the expected hemoglobin level for a man is 14 to 18 g/dL. The patient's values may also indicate dehydration. The expected level for prealbumin is 15 to 36 mg/dL. A hematocrit level of 50% is within normal limits.

Which of the following are appropriate safety measures for the use of a wheelchair? (Select all that apply.) A. Brakes on both wheels are locked when the patient is being transferred into the wheelchair. B. Brakes on the side nearest the bed are locked when the patient is being transferred into the wheelchair. C. Keep footplates lowered for transfer into the wheelchair. D. Back the wheelchair into and out of an elevator. E. Seat patient in wheelchair with buttocks against back of seat.

A. Brakes on both wheels are locked when the patient is being transferred into the wheelchair. D. Back the wheelchair into and out of an elevator. To keep the chair steady and secure, the brakes on both wheels must be locked securely when a patient is transferred into or out of a wheelchair. The footplates should be raised before the transfer so that they are not a trip hazard and should be lowered, placing the patient's feet on them, after the patient is seated so that the patient's feet will be supported with movement of the wheelchair. The wheelchair should be backed into and out of an elevator, with rear large wheels first. This makes a smoother ride and prevents smaller wheels from catching in the crack between the elevator and the floor. The patient should be seated with buttocks well back in the seat, and a seat belt or wedge cushion may be used if available to protect the patient from sliding out of the chair.

The nurse walking down the hospital corridor glances into the patient's room and sees the patient's feet and legs sticking out from the bathroom entrance. The nurse immediately goes into the room and determines that the patient has fallen. What actions should be taken? (Select all that apply.) A. Call for assistance. B. Assess for injury. C. Notify the health care provider. D. Avoid moving the patient until the health care provider arrives. E. Assess the situation for precipitous factors (e.g., hypotension, slippery footwear, etc.). F. Apply a restraint after returning the patient to bed. G. Fill out an agency occurrence or sentinel event report.

A. Call for assistance. B. Assess for injury. C. Notify the health care provider. E. Assess the situation for precipitous factors (e.g., hypotension, slippery footwear, etc.). G. Fill out an agency occurrence or sentinel event report. The nurse should first call for assistance and assess the patient for injury. The nurse should stay with the patient until assistance arrives to help lift the patient to the bed or to a wheelchair. The health care provider should be notified. The patient may be moved to a bed or wheelchair before the health care provider arrives. The nurse should note pertinent events related to the fall and resultant treatment in the patient's medical record. The agency's incident reporting policy should be followed. The nurse will reassess the patient and environment to determine if the fall could have been prevented. The nurse may then reinforce identified risks with the patient and review safety measures needed to prevent a fall. The use of restraints requires a health care provider's order.

You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. Which is the best nursing action to take first? A. Call the nursing supervisor to discuss the situation B. Discuss the problem with a colleague C. Leave the nursing unit and go home D. Say nothing and begin your work

A. Call the nursing supervisor to discuss the situation Alerting the nursing supervisor as a representative of the hospital administration is the first step in providing notice that a problem may exist related to insufficient staffing. This notice serves to share the burden of knowledge of the staffing inequity issues that may create an unsafe patient situation for the hospital and nursing staff.

To promote safety, the nurse manager sensitive to point-of-care (sharp-end) and systems-level (blunt-end) exemplars works closely with administrators to address which organizational system exemplar? A. Care coordination B. Communication C. Diagnostic workup D. Fall prevention

A. Care coordination The most common safety issues at the blunt end include documentation/electronic records, team systems, environmental systems, error reporting/analysis systems, and regulatory systems. Each of the other options is classified as a point-of-care, sharp-end exemplar.

A nurse is evaluating a patient who is in soft wrist restraints. Which of the following activities does the nurse perform? Select all that apply. A. Check the patient's peripheral pulse in the restrained extremity B. Evaluate the patient's need for toileting C. Offer the patient fluids if appropriate D. Release both limbs at the same time to perform range of motion (ROM) E. Inspect the skin under each restraint

A. Check the patient's peripheral pulse in the restrained extremity B. Evaluate the patient's need for toileting C. Offer the patient fluids if appropriate E. Inspect the skin under each restraint The nurse should evaluate patient for signs of injury every 15 minutes e.g., circulation, vital signs, ROM, physical and psychological status, and readiness for discontinuation. The nurse should evaluate patient's need for toileting, nutrition and fluids, hygiene, and elimination and release restraint at least every 2 hours but should do it one limb at a time.

Match the examples with the professional nursing code of ethics: A. You see an open medical record on the computer and close it so no one else can read the record without proper access. B. You administer a once-a-day cardiac medication at the wrong time, but nobody sees it. However, you contact the primary care provider and your head nurse and follow agency procedure. C. A patient at the end of life wants to go home to die, but the family wants every care possible. The nurse contacts the primary care provider about the patient's request. D. You tell your patient that you will return in 30 minutes to give him his next pain medication.

A. Confidentiality B. Accountability C. Advocacy D. Responsibility

The nurse is developing a teaching plan of general health for an adolescent who will be entering college. The nurse should discuss which modifiable factors that could affect the student's sleep pattern? Select all that apply. A. Coping strategies B. Study habits C. Diet D. Social concerns E. Age

A. Coping strategies B. Study habits C. Diet D. Social concerns Assessment of sleep is critical as a component of health and well-being assessment in every person. Changes in daily routine, stress, diet, social concerns, and anything that affects daily functioning, routine, or affect can be accompanied by a sleep problem of some type. Thorough assessment of sleep quality can be complex for a variety of reasons. Age is not a modifiable factor affecting sleep quality.

A patient has severe rheumatoid arthritis affecting her hands. What measures can be taken to facilitate optimum nutrition? (Select all that apply.) A. Determine the patient's food preferences. B. Provide the patient with finger foods such as raisins, nuts, grapes, and cheese cubes. C. Identify the food location on the plate as if it were a clock. D. Provide adaptive utensils (e.g., large handles). E. Attach a plate guard to the plate.

A. Determine the patient's food preferences. D. Provide adaptive utensils (e.g., large handles). E. Attach a plate guard to the plate. Determining the patient's food preferences promotes the patient's appetite, regardless of physical ability. Providing adaptive utensils can enable the patient to remain independent in eating. Large-handled utensils facilitate a patient with a poor grasp. A plate guard enables a patient to push the food up against the plate guard so as to fill the fork or spoon. Finger foods that are small may be more difficult for a patient with a poor hand grasp to obtain. A patient with visual impairment may benefit from having the location of food identified on the plate as if it were a clock.

The nurse checks the patient's extremity restraints hourly. What is the nurse looking for specific to this type of restraint? (Select all that apply.) A. Distal pulses. B. Temperature of the skin distal to the restraint. C. Whether the patient wants the restraints released. D. Proper placement of the restraint. E. The character of respirations. F. Sensation of the distal part of the extremity. G. The patient's blood pressure. H. Color of skin distal to the restraint.

A. Distal pulses. B. Temperature of the skin distal to the restraint. D. Proper placement of the restraint. F. Sensation of the distal part of the extremity. H. Color of skin distal to the restraint. The restraint should be checked at least every hour or according to agency policy for proper placement, and the patient should be evaluated for pulse, temperature, color, and sensation of the distal part of the extremities. The restraints should be released every 2 hours. If the patient is violent or noncompliant, remove one restraint at a time or have staff assistance. With regard to extremity restraints, routine assessment of the patient's blood pressure or character of respirations is unnecessary unless the patient's condition indicates otherwise.

You are conducting an education class at a local senior center on safe-driving tips for seniors. Which of the following should you include? Select all that apply. A. Drive shorter distances B. Drive only during daylight hours C. Use the side and rearview mirrors carefully D. Keep a window rolled down while driving if has trouble hearing E. Look behind toward the blind spot F. Stop driving at age 75

A. Drive shorter distances B. Drive only during daylight hours C. Use the side and rearview mirrors carefully D. Keep a window rolled down while driving if has trouble hearing E. Look behind toward the blind spot Educate patients regarding safe driving tips (e.g., driving shorter distances or only in daylight, using side and rearview mirrors carefully, and looking behind them toward their "blind spot" before changing lanes). If hearing is a problem, encourage the patient to keep a window rolled down while driving or reduce the volume of the radio or CD player. Counseling is often necessary to help older patients make the decision of when to stop driving.

The ethics of care suggests that ethical dilemmas can best be solved by attention to relationships. How does this differ from other ethical practices? Select all that apply. A. Ethics of care pays attention to the environment in which caring occurs. B. Ethics of care pays attention to the stories of the people involved in the ethical issue. C. Ethics of care is used only in nursing practice. D. Ethics of care focuses only on the code of ethics for nurses E. Ethics of care focuses only on understanding relationships.

A. Ethics of care pays attention to the environment in which caring occurs. B. Ethics of care pays attention to the stories of the people involved in the ethical issue. E. Ethics of care focuses only on understanding relationships. Ethic of care focuses on environmental issues affecting care, the narratives of the patients and health care providers, and understanding relationships.

A patient is admitted to a medical unit with pneumonia. She is able to ambulate on her own to the bathroom. What safety precautions should be taken for this patient? (Select all that apply.) A. Explain the use of the call light. B. Keep the bed in the low, locked position. C. Keep all side rails up when patient is in bed. D. Place a bedside commode near bed with back to wall. E. Ensure that the pathway to the bathroom is clear. F. Keep patient's personal items on the overbed table.

A. Explain the use of the call light. B. Keep the bed in the low, locked position. E. Ensure that the pathway to the bathroom is clear. F. Keep patient's personal items on the overbed table. To promote safety for a recently admitted patient who is able to ambulate, the nurse should explain the use of the call light, keeping it in an accessible location for the patient. Keep the bed in a low, locked position. Keep the pathway clear to reduce the likelihood of the patient falling over objects or bumping into them. Side rails may be considered a restraint device when used to prevent the ambulatory patient from getting out of bed. The nurse may ask the patient if she would like to have one side rail up. The patient is ambulatory; therefore, offering a bedside commode would be unnecessary. Necessary items such as eyeglasses should be placed within the patient's easy reach, such as on the overbed table. This facilitates independence and self-care and prevents falls that occur when a patient reaches too far.

A patient has a fractured femur that is placed in skeletal traction with a fresh plaster cast applied. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to document this because one of the nurse's other patients experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation? Select all that apply. A. Failure to document a change in assessment data B. Failure to provide discharge instructions C. Failure to follow the six rights of medication administration D. Failure to use proper medical equipment ordered for patient monitoring E. Failure to notify a health care provider about a change in the patient's condition

A. Failure to document a change in assessment data E. Failure to notify a health care provider about a change in the patient's condition The failure to document a change in assessment data and the failure to notify a health care provider about a change in patient status reflect a breach of duty to the patient.

When designing a plan for pain management for a postoperative patient, the nurse assesses that the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient's priority is met. Which principle is used to encourage the nurse to monitor the patient's response to the pain? A. Fidelity B. Beneficence C. Nonmaleficence D. Respect for autonomy

A. Fidelity Fidelity means keeping promises. Keeping the promise in this case includes not just tending to the clinical need but evaluating the effectiveness of the interventions.

The nurse should teach a patient about the dangers of excessive drowsiness when prescribed a combination of which medications? Select all that apply. A. Gabapentin (Neurontin) B. Fluoxetine (Prozac) C. Diphenhydramine (Benadryl) D. Lorazepam (Ativan) E. Zolpidem (Ambien) F. Pseudoephedrine (Sudafed)

A. Gabapentin (Neurontin) B. Fluoxetine (Prozac) C. Diphenhydramine (Benadryl) D. Lorazepam (Ativan) E. Zolpidem (Ambien) Common pharmacological agents used for sleep disorders, to aid in sleeping, include: Neurontin (anticonvulsant), Prozac (antidepressant), Benadryl (antihistamine), Ativan (benzodiazepine), and Ambien (benzodiazepine receptor-like agent). Sudafed is commonly prescribed for congestion and is more likely to act as a stimulant.

Which sleep-hygiene actions at bedtime can the nurse delegate to the nursing assistant? Select all that apply. A. Giving the patient a backrub B. Turning on quiet music C. Dimming the lights in the patient's room D. Giving a patient a cup of coffee E. Monitoring for the effect of the sleeping medication that was given

A. Giving the patient a backrub B. Turning on quiet music C. Dimming the lights in the patient's room Giving the patient a backrub, turning on quiet music, and dimming the lights are all appropriate sleep-hygiene measures. These activities are within the scope of practice for the nursing assistant. Coffee, tea, cola, and chocolate act as stimulants, causing a person to stay awake or awaken throughout the night and should not be ingested before bedtime. Monitoring medication effect is a registered nurse activity.

The school nurse is teaching health-promoting behaviors that improve sleep to a group of high-school students. Which points should be included in the education? Select all that apply. A. Go to bed at the same time each night. B. Study in your bedroom to have a quiet place. C. Turn on the television to help you fall asleep. D. Avoid drinking coffee or soda before bedtime. E. Turn off your cell phone at bedtime.

A. Go to bed at the same time each night. D. Avoid drinking coffee or soda before bedtime. E. Turn off your cell phone at bedtime. Going to bed at the same time each night, avoiding drinking coffee and soda before bedtime, and turning off electronic devices are effective sleep-hygiene practices for adolescents. Use of electronic devices is a main cause of sleep disruption in adolescents.

If a patient has dysphagia (difficulty swallowing), which of the following foods found on the patient's tray may be cause for concern or require further intervention? (Select all that apply.) A. Grape juice. B. Oatmeal. C. Sausage patty. D. Toast with butter. E. Scrambled eggs.

A. Grape juice. C. Sausage patty. D. Toast with butter. A patient with dysphagia should have thickener added to thin liquids such as grape juice to create the consistency of mashed potatoes. Thin liquids such as water and fruit juice are difficult to control in the mouth and are more easily aspirated. A patient with dysphagia should have foods that require little chewing (i.e., pureed foods), and if this is tolerated, then the patient may advance to foods that require more chewing and to thinner liquids.

A patient who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What would the nurse do first? A. Have the patient perform a Valsalva procedure B. Clamp the intravenous (IV) tubing to prevent more air from entering the line C. Have the patient take a deep breath and hold it D. Notify the health care provider immediately

A. Have the patient perform a Valsalva procedure Turn the patient on his or her left side to prevent air from entering the left side of the heart. Then have the patient perform a Valsalva maneuver (holding the breath and "bearing down").

The nurse is caring for an elderly person who has suffered a stroke and now has left-sided weakness and dysphagia. The nurse is being careful to prevent the patient from aspirating by taking which of the following measures? (Select all that apply.) A. Having the patient maintain an upright position for 30 to 60 minutes after eating. B. Placing the food on the patient's left side of the mouth. C. Placing the food in the middle of the tongue toward the back of the mouth. D. Having the patient tilt her head forward slightly when swallowing. E. Placing several tablespoons of food in the patient's mouth following it with liquid prior to having the patient swallow.

A. Having the patient maintain an upright position for 30 to 60 minutes after eating. D. Having the patient tilt her head forward slightly when swallowing. To help avoid aspiration or regurgitation, a patient with dysphagia should be maintained in an upright position for 30 to 60 minutes after eating. One-half to 1 teaspoon of food should be placed on the unaffected side (in this case, the right side) of the mouth, and the patient's head should be flexed slightly forward. Liquids and bites of food should be alternated.

What is your role as a nurse during a fire? Select all that apply. A. Help to evacuate patients B. Shut off medical gases C. Use a fire extinguisher D. Single carry patients out E. Direct ambulatory patients

A. Help to evacuate patients B. Shut off medical gases C. Use a fire extinguisher E. Direct ambulatory patients Direct all ambulatory patients to walk by themselves to a safe area. If you have to carry a patient, do so correctly (e.g., two-man carry). After a fire is reported and patients are out of danger, nurses and other personnel take measures to contain or extinguish it such as closing doors and windows, placing wet towels along the base of doors, turning off sources of oxygen and electrical equipment, and using a fire extinguisher.

What should the nurse do prior to applying physical restraints? A. Initially, provide a restraint-free environment. B. Warn the patient that restraints will be used if he or she does not cooperate. C. Move the patient to a room without a roommate and away from the nurses' station. D. Wait until the patient has actually fallen.

A. Initially, provide a restraint-free environment. The standard of care for institutionalized older adults is avoidance of mechanical restraints except as needed under exceptional circumstances and only after all other reasonable alternatives have been tried. Creating fear in the patient and stating restraints will be used as a punishment can be considered assault. The patient should be provided with the least restrictive environment, and close monitoring would be wise. Restraints are to be used only after all other reasonable alternatives have been tried. If the nurse waits until the patient has actually fallen, the patient could sustain an injury. Although restraints are to be used only after all other reasonable alternatives have been tried, it is unreasonable to wait until the patient sustains a fall.

A combative patient comes in to the emergency room and is swinging his fists at the nurses. With the assistance of security, the charge nurse places wrist restraints on the patient. What would be a priority action at this time? A. Notify the health care provider for follow-up evaluation. B. Tie the restraints to the bedside rail or frame of the wheelchair. C. Tie the restraint straps in a knot so the patient does not get loose. D. Assess, but avoid removing the restraints every 2 hours because the patient is violent.

A. Notify the health care provider for follow-up evaluation. When a restraint is used for violent or self-destructive behavior, a licensed health care provider must evaluate the patient in person within 1 hour of the initiation of restraints and orders obtained. Restraints should be tied to the movable frame of the bed so if the position of the head of bed is changed, the patient's extremity will not be compromised. Restraints should never be tied to the side rail. Restraints should be secured with a quick-release tie in case of an emergency. The restraints should be released every 2 hours. If the patient is violent or noncompliant, remove one restraint at a time or have staff assistance.

The nurse is getting a patient with right-sided weakness up in a chair. On what side of the bed should the nurse place the chair? A. On the patient's left side. B. On the patient's weak side. C. It doesn't matter because you are assisting the patient. D. Whichever side the patient prefers.

A. On the patient's left side. To facilitate balance and movement, the chair or wheelchair should be positioned so that the move will be toward the patient's stronger side.

The nurse is providing an in-service on patient safety and reducing the risk of patient falls. What information should the nurse include in this discussion? (Select all that apply.) A. Organize a predictable daily routine that alternates activity and rest for the patient. B. Respond promptly to a patient's call light. C. Wait to toilet high fall risk patients until after they have been medicated for pain. D. Place soft cotton socks on patient's feet whenever getting them out of bed. E. Keep the bed in a low, locked position.

A. Organize a predictable daily routine that alternates activity and rest for the patient. B. Respond promptly to a patient's call light. E. Keep the bed in a low, locked position. Reducing the risk of falls includes measures of providing a restraint-free environment, such as keeping the patient's daily routine predictable with alternate periods of activity and rest, teaching the patient how to use the call light and responding to it promptly, and encouraging family members or a sitter to stay with the patient, especially at night. Other safety measures include backing a wheelchair in and out of the elevator and keeping the bed in a low, locked position. Patients should be toileted before receiving pain medication as the medication could cause sedation. Nonskid footwear should be provided.

A nurse knows that the people most at risk for accidental hypothermia are: Select all that apply. A. People who are homeless. B. People with respiratory conditions. C. People with cardiovascular conditions. D. The very old. E. People with kidney disorders.

A. People who are homeless. C. People with cardiovascular conditions. D. The very old. Exposure to severe cold for prolonged periods causes frostbite and accidental hypothermia. Older adults, the young, patients with cardiovascular conditions, patients who have ingested drugs or alcohol in excess, and people who are homeless are at high risk for hypothermia.

The nurse has applied extremity restraints on a patient. What should the nurse assess on a regular basis? (Select all that apply.) A. Skin integrity and range of motion. B. Pulse and temperature of restrained body part. C. Ability of patient to breathe without restriction. D. Readiness for discontinuation of restraint. E. Presence of visitors at patient's bedside. F. That IV catheter remains uninterrupted.

A. Skin integrity and range of motion. B. Pulse and temperature of restrained body part. D. Readiness for discontinuation of restraint. F. That IV catheter remains uninterrupted. Evaluate the patient's condition for signs of injury every 15 minutes. Assess proper placement of restraint, including skin integrity, pulses, temperature, color, and sensation of the restrained body part. It is not necessary with an extremity restraint to assess patient's breathing. Use judgment and consider the patient's condition and the type of restraint when selecting physical assessment measures (e.g., circulation, nutrition and hydration, ROM in extremities, hygiene and elimination, physical and psychological status, and readiness for discontinuation). Observe IV catheters, urinary catheters, and drainage tubes to determine that they are positioned correctly and that therapy remains uninterrupted.

A patient has been recently admitted to the hospital. What indications, if observed, may suggest that the patient has dysphagia (difficulty swallowing)? (Select all that apply.) A. Persistent drooling. B. Drowsiness. C. Change in voice after swallowing. D. Wet, gurgly voice. E. Loss of appetite

A. Persistent drooling. C. Change in voice after swallowing. D. Wet, gurgly voice. The nurse should assess the patient for difficulty swallowing. The presence of drooling, problems with speech, and a wet, gurgly voice indicate difficulty with muscle control and may put the patient at risk for aspiration. Loss of appetite does not indicate difficulty swallowing. Although the nurse should ensure that the patient is fully awake before feeding, drowsiness does not indicate dysphagia.

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: A. Place a bed alarm device on the bed. B. Place the patient in a belt restraint. C. Provide one-on-one observation of the patient. D. Apply wrist restraints.

A. Place a bed alarm device on the bed. Consider and implement alternatives as appropriate before the use of a restraint. A bed alarm is an alternative that the nurse implements independently.

At 12 noon the emergency department nurse hears that an explosion has occurred in a local manufacturing plant. Which action does the nurse take first? A. Prepare for an influx of patients B. Contact the American Red Cross C. Determine how to resume normal operations D. Evacuate patients per the disaster plan

A. Prepare for an influx of patients The emergency department nurse needs to prepare for the potential influx of patients first. Staff need to be aware of the disaster plan. Patients may need to be evaluated but not initially. The American Red Cross is not contacted initially. Determination of how to resume normal operations is part of the disaster plan and is determined before an actual event.

A nursing instructor asks what may cause orthostatic hypotension. The nursing student correctly replies: (Select all that apply.) A. Prolonged bed rest. B. Hypovolemia. C. Low body weight. D. Antihypertensives. E. Room temperature

A. Prolonged bed rest. B. Hypovolemia. D. Antihypertensives. Orthostatic hypotension may be related to bed rest, hypovolemia and certain medications such as sedatives, hypnotics, analgesics, antihypertensives, antiemetics, antihistamines, diuretics, and antianxiety agents. Body weight and room temperature are unrelated to the occurrence of orthostatic hypotension.

Appropriate approaches used by the long-term care nurse to provide education for a 73 year old who has just been diagnosed with diabetes include which of the following? Select all that apply. A. Schedule a visit by another resident who is diabetic. B. Demonstrate food choices using food photographs. C. Avoid discussion of the patient's favorite foods. D. Remind the patient that a lot of damage has already occurred. E. Encourage the patient's family to participate in teaching sessions. F. Ask the patient about past experiences with lifestyle changes.

A. Schedule a visit by another resident who is diabetic. B. Demonstrate food choices using food photographs. E. Encourage the patient's family to participate in teaching sessions. F. Ask the patient about past experiences with lifestyle changes. Strategies to promote learning in older adults include peer teaching, visual aids, family participation, and relating new learning to past experiences. Discussion of the patient's favorite foods is needed to determine how old favorites can be adapted to the new diet. Reminders about the damage already done will indicate that the changes are not worth the effort.

The nurse is developing a plan for a patient who was diagnosed with narcolepsy. Which interventions should the nurse include on the plan? Select all that apply. A. Take brief, 20-minute naps during the day. B. Drink a glass of wine with dinner. C. Eat the large meal at lunch rather than dinner. D. Establish a regular exercise program. E. Teach the patient about the side effects of modafinil (Provigil).

A. Take brief, 20-minute naps during the day. D. Establish a regular exercise program. E. Teach the patient about the side effects of modafinil (Provigil). Taking short naps, no longer than 20 minutes, during the day and regular exercise are management strategies that help reduce the feeling of sleepiness. Modafinil is a stimulant used to treat narcolepsy; therefore it is important for patients to understand its side effects.

Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse? Select all that apply. A. Taking or selling controlled substances B. Refusing to provide health care information to a patient's child C. Reporting suspected abuse and neglect of children D. Applying physical restraints without a written physician's order E. Completing an occurrence report on the unit

A. Taking or selling controlled substances D. Applying physical restraints without a written physician's order The inappropriate use of controlled substances is prohibited by every Nurse Practice Act. A physical restraint can be applied only on the written order of a health care provider on the basis of The Joint Commission and Medicare guidelines.

The nurse is educating the patient and his family about the parenteral nutrition. Which aspect related to this form of nutrition would be appropriate to include? Select all that apply. A. The purpose of the fat emulsion in parenteral nutrition is to prevent a deficiency in essential fatty acids. B. We can give you parenteral nutrition through your peripheral intravenous line to prevent further infection. C. The fat emulsion will help control hyperglycemia during periods of stress. D. The parenteral nutrition will help your wounds heal. E. Since we just started the parenteral nutrition, we will only infuse it at 50% of your daily needs for the next 6 hours.

A. The purpose of the fat emulsion in parenteral nutrition is to prevent a deficiency in essential fatty acids. C. The fat emulsion will help control hyperglycemia during periods of stress. D. The parenteral nutrition will help your wounds heal. Sometimes adding intravenous fat emulsions to parenteral nutrition supports the patient's need for supplemental kilocalories, prevents essential fatty acid deficiencies, and helps control hyperglycemia during periods of stress. Parenteral nutrition is administered at 50% of the patient's daily needs for the first 24 hours to assess how he or she is tolerating the infusion.

Resolution of an ethical dilemma involves discussion with the patient, the patient's family, and participants from all health care disciplines. Which of the following best describes the role of the nurse in the resolution of ethical dilemmas? A. To articulate the nurse's unique point of view, including knowledge based on clinical and psychosocial observations. B. To study the literature on current research about the possible clinical interventions available for the patient in question. C. To hold a point of view but realize that respect for the authority of administrators and physicians takes precedence over personal opinion. D. To allow the patient and the physician to resolve the dilemma on the basis of ethical principles without regard to personally held values or opinions.

A. To articulate the nurse's unique point of view, including knowledge based on clinical and psychosocial observations. A nurse's point of view is essential to full discussion of ethical issues because of the nature of the relationship that nurses develop with patients and the intensity and intimacy of contact with the patient and family.

Which of the following can be delegated? (Select all that apply.) A. Transfer from bed to chair. B. Determining a dependent patient's risk for aspiration. C. Completing a fall risk assessment tool. D. Applying restraints. E. Moving a patient with an acute spinal cord injury up in bed.

A. Transfer from bed to chair. D. Applying restraints. The skills of safe and effective transfer from bed to chair can be delegated to NAP who have successfully demonstrated good body mechanics and safe transfer techniques for patients involved. The assessment of a patient's risk for aspiration and determination of positioning cannot be delegated. Assessment for risk of fall or injury requires the critical thinking and knowledge application unique to the nurse and should never be delegated. Application of restraints may be delegated to NAP. However, assessment of when restraints are needed and the appropriate type to use requires the critical thinking and knowledge application unique to the nurse and should never be delegated. The nurse should assist and supervise when moving patients who are transferred for the first time after prolonged bed rest, extensive surgery, critical illness, or spinal cord trauma.

The nurse is caring for a patient diagnosed with peptic ulcer disease (PUD). The patient was prescribed the proton pump inhibitor Prevacid (lansoprazole). Which of the following supplements may be prescribed to prevent deficiency? A. Vitamin B12 B. Vitamin C C. Vitamin D D. Omega-3 fatty acids

A. Vitamin B12 Vitamin B12 deficiency can occur as a result of the reduced gastric acidity associated with use of proton pump inhibitors, and supplementation is often warranted. Vitamin C deficiency is not a known deficiency associated with medications. Vitamin D deficiency may occur in patients who take cholesterol medication, and this link is currently being investigated. Omega-3 fatty acids may be used as monotherapy or in conjunction with cholesterol medication for patients with hyperlipidemia.

A 28-year-old married woman received word that she is pregnant. Sadly, the patient is not able to carry the pregnancy because she suffers from long QT syndrome, which causes an abnormality of the heart, meaning any rush of adrenaline could prove fatal. The pregnant patient states, "I want to have this baby." The nurse realizes that this is a conflict that involves the which ethical principle? of A. utilitarianism. B. deontology. C. autonomy. D. veracity.

A. utilitarianism. Utilitarianism is an approach that is rooted in the assumption that an action or practice is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. An attempt is made to determine which actions will lead to the greatest ratio of benefit to harm for all persons involved in the dilemma. Veracity is telling the truth in personal communication as a moral and ethical requirement. Deontology is an approach that is rooted in the assumption that an action or practice is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. Autonomy is the principle of respect for the individual person. All persons have unconditional intrinsic value. People are self-determining agents who are entitled to decide their own destiny.

A couple who is caring for their aging parents are concerned about factors that put them at risk for falls. Which factors are most likely to contribute to an increase in falls in the elderly? Select all that apply. A.Inadequate lighting B. Throw rugs C. Multiple medications D. Doorway thresholds E. Cords covered by carpets F. Staircases with handrails

A.Inadequate lighting B. Throw rugs C. Multiple medications D. Doorway thresholds E. Cords covered by carpets Falls most often occur while transferring from beds, chairs, and toilets; getting into or out of bathtubs; tripping over items such as cords covered by rugs or carpets, carpet edges, or doorway thresholds; slipping on wet surfaces; and descending stairs. Multiple medications also contribute to fall risk.

What are some examples of "verbal coaching" that can be used when feeding the adult dependent patient who has difficulty swallowing? (Select all that apply.) A. "Green beans are very nutritious." B. "Open your mouth." C. "Let's turn on the television and see what's cooking on the Food Network." D. "Raise your tongue to the roof of your mouth." E. "Close your mouth and swallow."

B. "Open your mouth." D. "Raise your tongue to the roof of your mouth." E. "Close your mouth and swallow." Verbal coaching may consist of something like the following: "Open your mouth. Feel the food in your mouth. Chew and taste the food. Raise your tongue to the roof of your mouth. Think about swallowing. Close your mouth and swallow. Swallow again. Cough to clear the airway." It is important to respect the patient's dignity and to keep the patient focused on the task at hand. Distractions should be minimized.

Which statement made by a mother being discharged to home with her newborn infant indicates that she understands the discharge teaching related to best sleep practices? A. "I'll give the baby a bottle to help her fall asleep." B. "We'll place the baby on her back to sleep." C. "We put the baby's stuffed animals in the crib to make her feel safe." D. "I know the baby will not need to be fed until morning."

B. "We'll place the baby on her back to sleep." This is based on the current evidence that shows that parents need to place an infant on his or her back to prevent suffocation. Bottles, stuffed animals, and pillows should not be placed in the bed with an infant.

Ethical dilemmas often arise over a conflict of opinion. Reliance on a predictable series of steps can help people in conflict find common ground. All of the following actions can help resolve conflict. What is the best order of these actions in order to promote the resolution of an ethical dilemma? 1. List the actions that could be taken to resolve the dilemma. 2. Agree on a statement of the problem or dilemma that you are trying to resolve. 3. Agree on a plan to evaluate the action over time. 4. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma. 5. Take time to clarify values and distinguish between facts and opinions—your own and those of others involved. 6. Negotiate a plan. A. 4, 5, 2, 6, 1, 3 B. 4, 5, 2, 1, 6, 3 C. 5, 4, 2, 1, 3, 6 D. 4, 5, 1, 2, 3, 6

B. 4, 5, 2, 1, 6, 3 This is the correct order to determine the dilemma and influencing factors. This process provides opportunities for the nurse and health care team to reflect on personal values and then identify the exact nature of the ethical problem, design a plan, and evaluate the success of the plan.

A nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline that the nurse will follow? A. A living will allows an appointed person to make health care decisions when the patient is in an incapacitated state. B. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state. C. The patient cannot make changes in the advance directive once admitted to the hospital. D. A durable power of attorney for health care is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

B. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state. A living will does not assign another individual to make decisions for the patient. A durable power of attorney for health care is active when the patient is incapacitated or cognitively impaired. A cognitively intact patient may change an advance directive at any time.

The nurse is assessing a group of patients to determine their risk of vitamin D deficiency. Which of the following patients has the highest risk for vitamin D deficiency? A. A Caucasian female who is 39 weeks gestation B. An African-American female who is breastfeeding C. An Asian female diagnosed with hypoglycemia D. A Hispanic female who has a BMI of 24.1

B. An African-American female who is breastfeeding Vitamin D deficiency is more frequently found among persons of African heritage and has increased in prevalence, especially among the infants of breastfeeding African-American mothers. Caucasian females do not share these risk factors. There is no known risk of hypoglycemia and vitamin D deficiency; however, diabetes increases the risk for vitamin D deficiency. There is no known risk of vitamin D deficiency in normal-weight females of Hispanic heritage; however, obesity is a risk factor.

The three elements of nursing competency described in the Quality and Safety for Nurses (QSEN) initiative are knowledge, skill, and which other element? A. Accountability B. Attitude C. Education D. Value

B. Attitude The Robert Wood Johnson Foundation funded the national initiative called Quality and Safety for Nurses (QSEN), which builds on the work of the Institute of Medicine (IOM), defines safety, and outlines the necessary elements of knowledge, skill, and attitude to demonstrate safety in one's practice. Accountability is a critical aspect of a culture of safety; recognizing and acknowledging one's actions is a trademark of professional behavior, but accountability is not considered one of the three major elements of QSEN.

The nurse incorporates which priority nursing intervention into a plan of care to promote sleep for a hospitalized patient? A. Have patient follow hospital routines. B. Avoid waking patient for nonessential tasks. C. Give prescribed sleeping medications at dinner. D. Turn television on low to late-night programming.

B. Avoid waking patient for nonessential tasks. Avoiding awakening patient for nonessential tasks promoted sleep. Cluster activities and allow the patient time to sleep. Do not perform tasks such as laboratory draws and bathing during the night unless absolutely essential. Patients should try to follow home routines related to sleep habits. The other tasks do not promote sleep.

Why are most health care agencies no longer using vest (jacket) restraints? A. Because they are difficult to apply and remove. B. Because they have been associated with fatal injuries. C. Because they are less cost effective than other restraints. D. Because patients are able to get out of them more easily.

B. Because they have been associated with fatal injuries. Most patient deaths from use of restraints have resulted from strangulation from a vest or jacket restraint. For this reason, numerous facilities have stopped using vest restraints. Jacket or vest restraints are not difficult to apply or remove.

A child's immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and society, outweigh the temporary discomforts. Which principle is involved in this situation? A. Fidelity B. Beneficence C. Nonmaleficence D. Respect for autonomy

B. Beneficence Beneficence means "doing well" by taking positive actions. It implies that the best interest of the patient (and society) outweighs self-interest.

A homeless man presents to the emergency room with hypothermia. He tells the nurse that he is positive for human immunodeficiency virus (HIV) and sought revenge by deliberately having sex with his mate, who does not know of his HIV status. This patient is violating which ethical principle? A. Veracity B. Beneficence C. Nonmaleficence D. Autonomy

B. Beneficence Nonmaleficence means to abstain from injuring others and to help others further their own well-being by removing harm and eliminating threats. The patient is definitely violating this principle through his actions. Veracity is telling the truth in personal communication. Beneficence is promoting goodness, kindness, and charity. Autonomy is the principle of respect for the individual person. This concept maintains that all persons have unconditional intrinsic value.

A patient is receiving total parenteral nutrition (TPN). What is the primary intervention the nurse should follow to prevent a central line infection? A. Institute isolation precautions B. Clean the central line port through which the TPN is infusing with alcohol C. Change the TPN tubing every 24 hours D. Monitor glucose levels to watch and assess for glucose intolerance

B. Clean the central line port through which the TPN is infusing with alcohol Use either alcohol or an alcoholic solution of chlorhexidine gluconate to clean the injection port or catheter hub 15 seconds before and after each time it is used to reduce the risk of a central line infection.

Which of the following concepts would a nurse think has the strongest link to safety? Select all that apply. A. Cognition B. Communication C. Quality D. Regulation E. Teamwork

B. Communication C. Quality D. Regulation E. Teamwork Communication, quality, regulation, and teamwork are the concepts with the strongest links to safety and include processes that are essential for the nurse to consider related to safety. Safety refers to the prevention of injuries or freedom from accidents. Quality and safety are interrelated, overlapping concepts, and it is difficult to achieve outcomes in one without working on the other. Regulation refers to the mandates that have been credited with many of the improvements in health care systems, such as those from the Joint Commission, and to the oversight for the safety of the public provided by state boards of nursing. Teamwork and the ability of health care professionals to work together account for as much as 70% of health care errors. Cognition dependent on an optimally functioning brain could affect vigilance but would not be considered a concept that has one of the strongest links to safety.

It can be difficult to agree on a common definition of the word quality when it comes to quality of life. Why? Select all that apply. A. Average income varies in different regions of the country. B. Community values influence definitions of quality, and they are subject to change over time. C. Individual experiences influence perceptions of quality in different ways, making consensus difficult. D. The value of elements such as cognitive skills, ability to perform meaningful work, and relationship to family is difficult to quantify using objective measures. E. Statistical analysis is difficult to apply when the outcome cannot be quantified. F. Whether or not a person has a job is an objective measure, but it does not play a role in understanding quality of life.

B. Community values influence definitions of quality, and they are subject to change over time. C. Individual experiences influence perceptions of quality in different ways, making consensus difficult. D. The value of elements such as cognitive skills, ability to perform meaningful work, and relationship to family is difficult to quantify using objective measures. E. Statistical analysis is difficult to apply when the outcome cannot be quantified. A person's average income and whether the person is employed are incorrect answers because income level is not necessarily a determining factor in measuring quality of life, but the ability to do meaningful work usually does influence the definition.

Parents of a newborn tell the nurse they are exhausted when they wake up in the mornings. What should the nurse suspect as the most likely cause of the parent's fatigue? A. Possible thyroid disorder B. Disrupted sleep pattern C. Iron deficiency anemia D. Recent changes in diet

B. Disrupted sleep pattern A newborn does not have established, regular sleep patterns. Therefore, parents of newborns experience sleep pattern disturbances. While the nurse should assess for all possible causes of fatigue and obtain a history of any current concerns, sleep deprivation is the most common etiology in this situation.

A hospitalized elderly patient is disoriented to time and place, and the NAP reports the patient has been pulling at the indwelling catheter. The nurse replaced the Foley catheter an hour ago after the patient pulled it out. After a focused assessment of the patient, the nurse determines the use of restraints is appropriate. Which action should the nurse take next? A. Apply restraints immediately to prevent disruption of the Foley catheter. B. Have the NAP stay with the patient and call the health care provider. C. Call the patient's family and obtain consent for restraints to be applied. D. Have the NAP apply restraints and assess application 1 hour later.

B. Have the NAP stay with the patient and call the health care provider. A health care provider's order is required for the use of restraints prior to application unless it is an emergency situation because of violent or aggressive behavior that presents immediate danger. The information from the nursing assessment is the foundation of the request for the health care provider's order. Restraint alternatives should be tried first, and if ineffective, restraints may be required. Although facility policy may indicate that family members should be notified, this would be done after the health care provider's order is obtained and the patient's safety secured. In long-term care, consent by the family is required for the application of restraints, but this patient was not in a long-term care setting.

A patient and her husband used in vitro fertilization to become pregnant. The unused sperm were frozen so the couple could have more children later. They bore a little girl who was diagnosed with leukemia when she was 5 years old. The child now needs a bone marrow transplant (BMT). The best chance of a match for the BMT is a sibling. The couple would like to use the sperm to have another child so that they can increase the likelihood of a match. The nurse realizes that the unborn child poses an ethical dilemma involving which principle? A. Beneficence B. Human dignity C. Justice D. Veracity

B. Human dignity Human dignity is the inherent worth and uniqueness of a person. Human rights are the basic rights of each individual. Beneficence is defined as promoting goodness, kindness, and charity. In ethical terms, beneficence means to provide benefit to others by promoting their welfare. Justice involves upholding moral and legal principles. Veracity is truth-telling.

The application of utilitarianism does not always resolve an ethical dilemma. Which of the following statements best explains why? A. Utilitarianism refers to usefulness and therefore eliminates the need to talk about spiritual values. B. In a diverse community it can be difficult to find agreement on a definition of usefulness, the focus of utilitarianism. C. Even when agreement about a definition of usefulness exists in a community, laws prohibit an application of utilitarianism. D. Difficult ethical decisions cannot be resolved by talking about the usefulness of a procedure.

B. In a diverse community it can be difficult to find agreement on a definition of usefulness, the focus of utilitarianism. In increasingly diverse communities, ideas of usefulness have become equally diverse.

What is the purpose of a gait belt? A. It keeps patients from ambulating too fast by holding onto them. B. It provides a means to steady a patient at the center of gravity. C. It measures the distance a patient has ambulated by counting steps. D. It identifies patients who are at risk for a fall and require assistance. E. It is a type of restraint used as a safety measure.

B. It provides a means to steady a patient at the center of gravity. A gait belt is used to transfer a patient safely or as a safety measure to steady a patient who has poor balance. NAP or nurses may use a gait belt.

An elderly patient was recently admitted to a medical unit with severe fluid and electrolyte imbalance. His family states that he has periods of confusion. What are some practical precautions the nurse can take to ensure the patient's safety without having to use restraints? (Select all that apply.) A. Use a security camera to monitor the patient while in bed. B. Make staff assignments for patients in adjacent rooms. C. Activate the bed alarm when the patient is in bed. D. Perform nurse toilet and turn or comfort and safety rounds hourly. E. Administer IV fluids to reverse fluid imbalance.

B. Make staff assignments for patients in adjacent rooms. C. Activate the bed alarm when the patient is in bed. D. Perform nurse toilet and turn or comfort and safety rounds hourly. You may use a bed alarm to alert staff of the patient getting up without assistance. Having assigned patients in close proximity facilitates the ability of staff to monitor and respond quickly to their assigned patients. Hourly rounding will enable the nurse to meet patient needs and avoid the patient getting up without assistance. Although some health care agencies may have rooms equipped with security cameras and have the staff to monitor them, it is unlikely in most settings. The infusion of fluids is determined by a health care provider and will not necessarily quickly reverse confusion.

A patient with left-sided weakness needs to be transferred to a wheelchair. On which side of the bed should the nurse place the wheelchair? A. On the patient's weak (affected) side. B. On the patient's strong (unaffected) side. C. Either side of the bed. D. Whichever side the patient prefers.

B. On the patient's strong (unaffected) side. During transfer, position the wheelchair on the same side of bed as patient's strong or unaffected side. This will best enable the patient to transfer safely and maximize the patient's ability.

The nurse would delegate which of the following to nursing assistive personnel (NAP)? Select all that apply. A. Repositioning and retaping a patient's nasogastric tube B. Performing glucose monitoring every 6 hours on a patient C. Documenting PO intake on a patient who is on a calorie count for 72 hours D. Administering enteral feeding bolus after tube placement has been verified E. Hanging a new bag of enteral feeding

B. Performing glucose monitoring every 6 hours on a patient C. Documenting PO intake on a patient who is on a calorie count for 72 hours The skills of measuring blood glucose level after skin puncture (capillary puncture) and writing down the amount the patient ate can be delegated to NAP. The nurse needs to administer enteral feeding because of the risk of aspiration. The nasogastric tube should never be repositioned by the NAP for risk of causing injury to the patient.

The nurse sees the nursing assistive personnel (NAP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention? A. Fastening tube to the gown with new tape B. Placing patient supine while giving a bath C. Hanging a new container of enteral feeding D. Ambulating patient with enteral feedings still infusing

B. Placing patient supine while giving a bath A patient receiving continuous enteral feedings should never be placed supine because it increases the risk for pulmonary aspiration. If the nurse needs to lay the patient in the supine position, the feedings should be stopped and restarted when the head of the bed is at 45 degrees.

A nurse is caring for a patient who recently had coronary bypass surgery and now is on the postoperative unit. Which are legal sources of standards of care that the nurse uses to deliver safe health care? Select all that apply. A. Information provided by the head nurse B. Policies and procedures of the employing hospital C. State Nurse Practice Act D. Regulations identified in The Joint Commission manual E. The American Nurses Association standards of nursing practice

B. Policies and procedures of the employing hospital C. State Nurse Practice Act D. Regulations identified in The Joint Commission manual E. The American Nurses Association standards of nursing practice All of these sources govern the legal standards of care and are individualized by state and agency. Policies and procedures of employing agencies and standards set by statutes, accrediting agencies, and professional organizations describe the minimum requirements for safe care.

The nurse is caring for a patient with pneumonia who has severe malnutrition. The nurse recognizes that, because of the nutritional status, the patient is at increased risk for: Select all that apply. A. Heart disease. B. Sepsis. C. Pleural effusion. D. Cardiac arrhythmias. E. Diarrhea.

B. Sepsis. C. Pleural effusion. D. Cardiac arrhythmias. Patients who are malnourished on admission are at greater risk of life-threatening complications such as arrhythmia, pleural effusions, sepsis, or hemorrhage during hospitalization.

The nurse is providing health teaching for a patient using herbal compounds such as kava for sleep. Which points need to be included? Select all that apply. A. Can cause urinary retention B. Should not be used indefinitely C. May have toxic effects on the liver D. May cause diarrhea and anxiety E. Are not regulated by the U.S. Food and Drug Administration (FDA)

B. Should not be used indefinitely C. May have toxic effects on the liver E. Are not regulated by the U.S. Food and Drug Administration (FDA) Herbal products help promote sleep. These products need to be used cautiously because they are not regulated by the U.S. Food and Drug Administration. They should not be used long term and can interact with prescribed medications. Kava needs to be used cautiously because it can be toxic to the liver.

A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits? A. Family member B. Surgeon C. Nurse D. Nurse manager

B. Surgeon The person performing the procedure is responsible for informing the patient about the procedure and its risks, benefits, and possible complications.

Which patients are at high risk for nutritional deficits? Select all that apply. A. The divorced computer programmer who eats precooked food from the local restaurant B. The middle-age female with celiac disease who does not follow her gluten-free diet C. The 45-year-old patient with type II diabetes who monitors her carbohydrate intake and exercises regularly D. The 25-year-old patient with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements E. The 65-year-old patient with gallbladder disease whose electrolyte, albumin, and protein levels are normal

B. The middle-age female with celiac disease who does not follow her gluten-free diet D. The 25-year-old patient with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements Patients suffering from celiac disease or Crohn's disease need to take vitamin and iron supplements regularly because they have a deficit resulting from malabsorption.

A nurse is sued for negligence due to failure to monitor a patient appropriately after a procedure. Which of the following statements are correct about this lawsuit? Select all that apply. A. The nurse does not need any representation. B. The patient must prove injury, damage, or loss occurred. C. The person filing the lawsuit has to show a compensable damage, such as lost wages, occurred. D. The patient must prove that a breach in the prevailing standard of care caused an injury. E. The burden of proof is always the responsibility of the nurse.

B. The patient must prove injury, damage, or loss occurred. C. The person filing the lawsuit has to show a compensable damage, such as lost wages, occurred. D. The patient must prove that a breach in the prevailing standard of care caused an injury. The patient as plaintiff must prove that the defendant nurse had a duty, breached the duty, and because of this breach caused the patient injury or damage.

A person of Northern heritage is at an increased risk for which of the following? Select all that apply. A. Vitamin C deficiency B. Type 1 diabetes C. Celiac disease D. Type 2 diabetes E. Hypertension F. Metabolic syndrome

B. Type 1 diabetes C. Celiac disease Type 1 diabetes and Celiac disease are more common in Northern heritage. African Americans and Hispanics are at increased risk for Type 2 diabetes, hypertension, and metabolic syndrome. Vitamin C deficiency is not a common deficiency related to heritage or ethnicity.

A newly admitted client was found wandering the hallways for the past two nights. The most appropriate nursing intervention to prevent a fall for this client would include: A. Raise all four side rails when darkness falls B. Use an electronic bed monitoring device C. Place the client in a room close to the nursing station D. Use a loose-fitting vest-type jacket restraint.

B. Use an electronic bed monitoring device

The nurse is caring for a patient who is having a seizure. Which of the following measures will protect the patient and the nurse from injury? Select all that apply. A. If patient is standing, attempt to get him or her back in bed. B. With patient on floor, clear surrounding area of furniture or equipment. C. If possible, keep patient lying supine. D. Do not restrain patient; hold limbs loosely if they are flailing. E. Never force apart a patient's clenched teeth.

B. With patient on floor, clear surrounding area of furniture or equipment. D. Do not restrain patient; hold limbs loosely if they are flailing. E. Never force apart a patient's clenched teeth. During a seizure, if a patient is standing, guide to floor. Do not try to place in bed. Do not position the patient supine; instead turn patient onto one side with head tilted slightly. When patient is on the floor, remove any furniture or objects that he or she could strike during tonic and clonic activity. Never force apart a patient's clenched teeth; you might be bitten. Do not restrain patient; hold limbs loosely if they are flailing. A postictal phase follows the seizure, during which the patient has amnesia or confusion and falls into a deep sleep.

A patient suffers from sleep pattern disturbance. To promote adequate sleep, the most important nursing intervention is: A. administering a sleep aid B. synchronizing the medication, treatment, and vital signs schedule C. encouraging the patient to exercise immediately before sleep D. discussing with the patient the benefits of beginning a long-term nighttime medication regimen

B. synchronizing the medication, treatment, and vital signs schedule

A patient complains to the nurse that he is unable to sleep well since he has been diagnosed with gastroesophageal reflux disease (GERD). What is the nurse's best response? A. "You should be able to rest if you eat a larger meal before bedtime." B. "You should sleep in a recliner in the lowest position every night to reduce symptoms." C. "A pillow wedge may help you sleep more comfortably while in bed." D. "Drinking at least 8-12 ounces at bedtime should help you sleep through the night."

C. "A pillow wedge may help you sleep more comfortably while in bed." Gastroesophageal reflux disease is a condition in which stomach acid rises up into the esophagus and causes irritation that is commonly referred to as "heartburn." Patients are often advised to sleep at a minimum 30-degree incline to reduce abdominal pressure and stomach acid entry into the esophagus. Patients diagnosed with GERD should consume small, frequent meals during the day. A large meal at night stimulates the secretion of stomach acid and increased intra-abdominal pressure. While sleeping in a recliner is commonly recommended to reduce stomach acid irritation, the recliner should not be placed in the lowest reclining position. This position defeats the purpose of sleeping at a slight inclination. Drinking a large amount of fluid at bedtime could lead to nocturia which interrupts sleep patterns.

Which statement made by an older adult best demonstrates understanding of taking a sleep medication? A. "I'll take the sleep medicine for 4 or 5 weeks until my sleep problems disappear." B. "Sleep medicines won't cause any sleep problems once I stop taking them." C. "I'll talk to my health care provider before I use an over-the-counter sleep medication." D. "I'll contact my health care provider if I feel extremely sleepy in the mornings."

C. "I'll talk to my health care provider before I use an over-the-counter sleep medication." The statement, "I'll talk to my health care provider before I use an over-the-counter sleep medication" shows an understanding of the risks of over-the-counter sleep medications. The use of nonprescription sleep medications is not advisable. Over the long term these drugs lead to further sleep disruption even when they initially seemed effective. Caution older adults about using over-the-counter antihistamines because of their long duration of action that can cause confusion, constipation, urinary retention, and increased risk of falls.

The nurse is taking a sleep history from a patient. Which statement made by the patient needs further follow-up? A. "I feel refreshed when I wake up in the morning." B. "I use soft music at night to help me relax." C. "It takes me about 45 to 60 minutes to fall asleep." D. "I take the pain medication for my leg pain about 30 minutes before I go to bed."

C. "It takes me about 45 to 60 minutes to fall asleep." Good sleep-hygiene practices indicate that individuals should fall asleep within 30 minutes of going to bed. Taking 45 to 60 minutes to fall asleep indicates a potential sleep problem and requires follow-up on sleep-hygiene practices. If an individual does not fall asleep within 30 minutes, encourage him or her to get out of bed and do a quiet activity until he or she feels sleepy.

You are caring for a patient who frequently tries to remove his intravenous catheter and feeding tube. You have an order from the health care provider to apply a wrist restraint. What is the correct order for applying a wrist restraint?1. Be sure that patient is comfortable with arm in anatomic alignment. 2. Wrap wrist with soft part of restraint toward skin and secure snugly.3. Identify patient using two identifiers.4. Introduce self and ask patient about his feelings of being restrained.5. Assess condition of skin where restraint will be placed. A. 4, 3, 5, 1, 2 B. 4, 3, 1, 5, 2 C. 3, 4, 1, 5, 2 D. 3, 4, 5, 1, 2

C. 3, 4, 1, 5, 2 3. Identify patient using two identifiers 4. Introduce self and ask patient about his feelings of being restrained 1. Be sure that patient is comfortable with arm in anatomic alignment 5. Assess condition of skin where restraint will be placed 2. Wrap wrist with soft part of restraint toward skin and secure snugly These are the correct steps for applying a wrist restraint.

Which of the following patients should be allowed to lie back down? A. A patient who was just transferred to a chair and states she was more comfortable in bed. Health care provider's orders are to be up in chair twice daily. B. A patient whose blood pressure was 120/80 prior to transfer and is now 112/78. C. A patient who complains of feeling dizzy and slightly nauseous when sitting on the bedside. D. A patient whose blood pressure was 110/70 prior to transfer and is now 125/80.

C. A patient who complains of feeling dizzy and slightly nauseous when sitting on the bedside. A drop in blood pressure of approximately 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure with symptoms of dizziness, pallor, or fainting indicates orthostatic hypotension. This patient's blood pressure changed within a normal range. A patient with orders to be up in chair needs to be encouraged to stay up in the chair in order to improve endurance.

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? Select all that apply. A. Contact the nursing supervisor. B. Restrict the family's visiting privileges. C. Ask the family to stay with the patient if possible. D. Inform the family of the risks associated with side-rail use. E. Thank the family for being conscientious and put the four rails up. F. Discuss alternatives that are appropriate for this patient with the family.

C. Ask the family to stay with the patient if possible. D. Inform the family of the risks associated with side-rail use. F. Discuss alternatives that are appropriate for this patient with the family. The family is concerned about ensuring a safe environment for their loved one. The nurse should discuss their concerns, the risk of using restraints related to using four side rails, and safer alternatives such as the presence of a family member. If the family still insists on use of four side rails, you could contact the nursing supervisor to further discuss the situation with them. This is not a reason to restrict visitation; but, although you should appreciate their concern, the use of four side rails should be avoided.

The patient's blood glucose level is 330 mg/dL. What is the priority nursing intervention? A. Recheck by performing another blood glucose test. B. Call the primary health care provider. C. Check the medical record to see if there is a medication order for abnormal glucose levels. D. Monitor and recheck in 2 hours.

C. Check the medical record to see if there is a medication order for abnormal glucose levels. Check the medical record to see if there is a medication order for deviations in glucose level; if not, notify the health care provider. As the nurse you want to get the patient's blood sugar as close to normal as possible.

A home health nurse notices significant bruising on a 2-year-old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take? A. Document her findings and treat the patient B. Instruct the mother on safe handling of a 2-year-old child C. Contact a child abuse hotline D. Discuss this story with a colleague

C. Contact a child abuse hotline Nurses are mandated reporters of suspected child abuse. These assessment findings possibly indicate child abuse.

A hospitalized patient has repeatedly refused her meals. What should the nurse do? (Select all that apply.) A. Offer to feed patient. B. Administer vitamins with minerals to the patient. C. Determine the patient's food preferences. D. Apply more seasonings to foods. E. Determine whether the patient is in pain.

C. Determine the patient's food preferences. E. Determine whether the patient is in pain. The nurse should first try to identify and resolve possible problems while retaining the patient's independence. Determine whether the patient has other food preferences, cultural influences, or religious restrictions. Determine whether different times of the day are better. Determine whether discomfort or anxiety should be treated before eating. Determine whether the patient is mentally incapable of cooperating. If the problem cannot be resolved, the health care provider may be notified for further orders. Offering to feed the patient may be demeaning. The nurse may ask whether the patient would like seasonings added but should avoid adding them unless instructed. Administering vitamins with minerals would require a health care provider's order.

A nurse is determining which type of restraint to apply to a toddler who recently had facial surgery and is pulling at her sutures and oxygen tubing and rubbing her face. Which type of restraint would likely be the least restrictive and most effective? A. Mitten restraint. B. Extremity restraint. C. Elbow restraint. D. Belt restraint.

C. Elbow restraint. Elbow restraints are used to prevent a patient (usually a child) from reaching the head and face area to pull at stitches and tubes or scratch at skin irritations. A belt restraint secures a patient in bed or on a stretcher. An extremity/limb restraint (wrist or ankle) may be used to immobilize one or all extremities. A mitten restraint is a thumbless mitten device to restrain a patient's hands. It is used to prevent the use of fingers to scratch the skin, remove dressings, or dislodge equipment, yet allows more movement than a wrist restraint.

The nurse is developing a plan of care for a patient experiencing obstructive sleep apnea (OSA). Which intervention is appropriate to include on the plan? A. Instruct the patient to sleep in a supine position. B. Have patient limit fluid intake 2 hours before bedtime. C. Elevate the head of the bed to sleep. D. Encourage patient to take an over-the-counter sleep aid.

C. Elevate the head of the bed to sleep. Lifestyle changes and modifications of sleep habits should be included on a plan of care for a patient with OSA. Individuals should sleep with the head of the bed elevated and use a side or prone position. Other modifications include good sleep-hygiene practices, alcohol modification, smoking cessation, and weight reduction.

Which ethical term matches this statement: "A problem for which in order to do something right you have to do something wrong"? A. Justice B. Veracity C. Ethical dilemma D. Fidelity

C. Ethical dilemma An ethical dilemma involves a problem for which in order to do something right you have to do something wrong. Justice involves upholding moral and legal principles. Veracity means telling the truth as a moral and ethical requirement. Fidelity is the principle that requires a person to act in ways that are loyal. In the role of a nurse, such action includes keeping promises, doing what is expected of you, performing your duties, and being trustworthy.

A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nurse manager because this action is a violation of which act? A. Patient Protection and Affordable Care Act (PPACA) B. Patient Self-Determination Act (PSDA) C. Health Insurance Portability and Accountability Act (HIPAA) D. Emergency Medical Treatment and Active Labor Act

C. Health Insurance Portability and Accountability Act (HIPAA) The Privacy Rule of the HIPAA requires that patient information be protected from unnecessary publication.

In an agency with a culture of safety, when an error or patient safety issue is identified, the individual who reports the problem knows which information? A. Is disciplined according to established protocols B. Must communicate the problem to the patient C. Near misses in health care are used to improve care. D. Shares details to locate the individual at fault

C. Near misses in health care are used to improve care. In an agency with a culture of safety, a nurse knows that near misses are used to improve care. Individual people are not punished for flawed systems, and there are no protocols for discipline. Consequences are individualized to improve the system and minimize the opportunity for future problems. Telling the patient is part of the transparency and the sharing and disclosure among stakeholders but is generally the responsibility of the risk management staff, not the staff nurse. Through a strategy such as root cause analysis, the reasons for errors in medication administration can be identified and strategies developed to minimize future occurrences, not to point a finger at a certain person.

The ANA code of nursing ethics articulates that the nurse "promotes, advocates for, and strives to protect the health, safety, and rights of the patient." This includes the protection of patient privacy. On the basis of this principle, if you participate in a public online social network such as Facebook, could you post images of a patient's x-ray film if you obscured or deleted all patient identifiers? A. Yes, because patient privacy would not be violated since patient identifiers were removed B. Yes, because respect for autonomy implies that you have the autonomy to decide what constitutes privacy C. No, because, even though patient identifiers are removed, someone could identify the patient on the basis of other comments that you make online about his or her condition and your place of work D. No, because the principle of justice requires you to allocate resources fairly

C. No, because, even though patient identifiers are removed, someone could identify the patient on the basis of other comments that you make online about his or her condition and your place of work Information such as comments and photos on social media is widely distributed and becomes a risk for violation of privacy. People often inadvertently give "clues" or hints to the identity of a person, or people accessing your site could know your actual assignment or put "two and two" together.

In most ethical dilemmas in health care, the solution to the dilemma requires negotiation among members of the health care team. Why is the nurse's point of view valuable? A. Nurses understand the principle of autonomy to guide respect for a patient's self-worth. B. Nurses have a scope of practice that encourages their presence during ethical discussions. C. Nurses develop a relationship with the patient that is unique among all professional health care providers. D. The nurse's code of ethics recommends that a nurse be present at any ethical discussion about patient care.

C. Nurses develop a relationship with the patient that is unique among all professional health care providers. A fundamental goal of this chapter is to promote and nurture the value of the nursing voice in ethical discourse.

In the change of shift report, the nurse was told a patient requires "minimal assistance with meals." What should the nurse expect to do for the patient at mealtime? (Select all that apply.) A. Place the meal tray in the room, leave the room, and return in 30 minutes to remove the tray. B. Feed the patient. C. Open packages and cartons. D. Assist the patient to an upright position. E. Ask the patient if he or she needs the nurse to cut up the food or butter the bread. F. Document the intake.

C. Open packages and cartons. D. Assist the patient to an upright position. F. Document the intake. The patient requires some assistance but is able to feed himself or herself. The nurse should position the patient appropriately for safe eating and assist the patient with setting up the meal tray: open packages, cut up food, apply seasonings/condiments, butter bread, and place a napkin. If appropriate, the nurse may place adaptive utensils on the tray and instruct the patient in their use. The patient should be encouraged to remain as independent as possible in self-feeding. A patient who is able to eat without assistance may have the correct tray left to be picked up when the patient is finished. Whether the patient is independent or requires assistance, the nurse should document the intake.

The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patients' medical diagnoses on the message board. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)? A.Discussing patient conditions in the nursing report room at the change of shift B. Allowing nursing students to review patient charts before caring for patients to whom they are assigned C. Posting medical information about the patient on a message board in the patient's room D. Releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared

C. Posting medical information about the patient on a message board in the patient's room Posting the medical condition of a patient on a message board in the patient's room is not necessary for the patient's treatment. Doing so can result in this information being accessed by people who are not involved in the patient's treatment.

The patient reports episodes of sleepwalking to the nurse. Through understanding of the sleep cycle, the nurse recognizes that sleepwalking occurs during which sleep phase? A. Rapid eye movement (REM) sleep B. Stage 1 non rapid eye movement (NREM) sleep C. Stage 4 NREM sleep D. Transition period from NREM to REM sleep

C. Stage 4 NREM sleep Stage 4 NREM sleep is the deepest stage of sleep. It is difficult to rouse the sleeper in this stage. During this stage sleepwalking and enuresis (bed-wetting) sometimes occur.

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. His wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. Which factors increase his fall risk at this time? Select all that apply. A. Smokes a pack a day B. Used a cane to walk at home C. Takes antihypertensive and diuretics D. History of recent fall E. Neglect, spatial and perceptual abilities, impulsive F. Requires assistance with activity, unsteady gait G. IV line, urinary catheter

C. Takes antihypertensive and diuretics D. History of recent fall E. Neglect, spatial and perceptual abilities, impulsive F. Requires assistance with activity, unsteady gait G. IV line, urinary catheter Smoking is not a risk factor for falls. Use of the cane at home is not a current risk factor for falls. Risk is determined by his current status.

A nurse stops to help in an emergency at the scene of an accident. The injured party files a suit, and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation? A. The nurse's automobile insurance B. The nurse's homeowner's insurance C. The Good Samaritan law, which grants immunity from suit if there is no gross negligence D. The Patient Care Partnership, which may grant immunity from suit if the injured party consents

C. The Good Samaritan law, which grants immunity from suit if there is no gross negligence The Good Samaritan law holds the health care provider immune from liability as long as he or she functions within the scope of his or her expertise.

Which of the following would be a correct action of the NAP in regard to the application of restraints? A. The NAP removes the restraints every 24 hours for an hour to perform ROM. B. The NAP may apply restraints to patients if the NAP determines it is necessary. C. The NAP removes one restraint at a time for a patient who has violent behavior. D. The NAP keeps the patient's bed at a working height while the patient is in restraints.

C. The NAP removes one restraint at a time for a patient who has violent behavior. If the patient is violent or noncompliant, restraints should be removed one at a time, or staff assistance should be available while removing restraints. Restraints should be removed according to agency policy, but at least every 2 hours. An order is required for continuation of restraints every 24 hours. Application of restraints may be delegated to NAP. However, assessment of when restraints are needed and the appropriate type to use requires the critical thinking and knowledge application unique to the nurse and should never be delegated. The bed should be kept in the lowest position. If the patient falls when the bed is in the lowest position, this will reduce the chance of injury.

A nurse floats to a busy surgical unit and administers a wrong medication to a client. This error can be classified as: A. a poisoning accident B. an equipment-related accident C. a procedure-related accident D. an accident related to time management

C. a procedure-related accident

A 4-year-old pediatric patient resists going to sleep. To assist this patient, the best action to take would be: A. adding a daytime nap B. allowing the child to sleep longer in the morning C. maintaining the child's home sleep routine D. offering the child a bedtime snack

C. maintaining the child's home sleep routine

The nursing assessment of a 78-year-old woman reveals orthostatic hypotension, weakness on the left side, and fear of falling. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? A. Activity Intolerance B. Impaired Bed Mobility C. Acute Pain D. Risk for Falls

D. Risk for Falls For adults age 65 and older, orthostatic hypotension, fear of falling, and weakness on one side are risks for the nursing diagnosis of Risk for Falls.

During rounds on the night shift, you note that a patient stops breathing for 1 to 2 minutes several times during the shift. This condition is known as A. Cataplexy. B. Insomnia. C. Narcolepsy. D. Sleep apnea.

D. Sleep apnea.

Which statement made by the patient indicates a need for further teaching on sleep hygiene? A. "I'm going to do my exercises before I eat dinner." B. "I'm going to go to bed every night at about the same time." C. "I set my alarm to get up at the same time every morning." D. "I moved my computer to the bedroom so I could work before I go to sleep."

D. "I moved my computer to the bedroom so I could work before I go to sleep." This statement requires further teaching. Good sleep-hygiene practices state that the bedroom should only be used for sleeping. Work and study should not be done in the bedroom.

Which statement by a mother in the pediatric clinic requires further assessment by the nurse? A. "My 13 month old goes to bed around 7 pm and wakes up at 10 am." B. "My 2 year old sleeps about 9 hours at night and still takes a nap." C. "My 9-year-old daughter sleep 10 hours a night, sometimes 11 hours." D. "My 16 year old finishes homework late at night but wakes up at 6 am every day."

D. "My 16 year old finishes homework late at night but wakes up at 6 am every day." General recommendations for sleep amounts vary with age as follows: Infants: 14-16 hours each dayToddlers: 9-10 hours at night plus 2-3 hours of daytime napsSchool-age children: 9-11 hoursTeenagers: 9 hours Adults: 7-9 hoursThe teenager in this question does not appear to be getting 9 hours of sleep. The nurse should further assess for any abnormal findings related to sleep pattern in this patient.

The nurse is contacting the health care provider about a patient's sleep problem. What is the correct order for the steps for SBAR? 1. Mrs. Dodd, 46 years old, was admitted 3 days ago following a motor vehicle accident. She is in balanced skeletal traction for a fractured left femur. She is having difficulty falling asleep. 2. "Dr. Smithson, this is Pam, the nurse caring for Mrs. Dodd. I'm calling because Mrs. Dodd is having difficulty sleeping." 3. "I'm calling to ask if you would order a hypnotic such as zolpidem (Ambien) to use on a prn basis." 4. Mrs. Dodd is taking her pain medication every 4 hours as ordered and rates her pain as 2 out of 10. Last night she was still awake at 0100. She states that she is comfortable but just can't fall asleep. Her vital signs are BP 124/76, P 78, R 12 and T 37.1° C (98.8° F). A. 2, 1, 3, 4 B. 1, 2, 3, 4 C. 2, 1, 4, 3 D. 1, 2, 4, 3

D. 1, 2, 4, 3 SBAR is Situation, Background, Assessment, and Recommendation. This is the correct sequence of steps in SBAR for the patient and sleep problem.

What are the correct steps to resolve an ethical dilemma on a clinical unit? Place the steps in correct order. 1. Clarify values. 2. Ask the question, Is this an ethical dilemma? 3. Verbalize the problem. 4. Gather information. 5. Identify course of action. 6. Evaluate the plan. 7. Negotiate a plan. A. 2, 4, 1, 5, 3, 7. 6 B. 2, 4, 3, 1, 5, 6, 7 C. 4, 1, 2, 3, 5, 7, 6 D. 2, 4, 1, 3, 5, 7, 6

D. 2, 4, 1, 3, 5, 7, 6 In resolving an ethical dilemma, it first must be determined that an ethical dilemma exists. Then a systematic approach is needed to gather information, clarify values, verbalize the exact problem, identify a plan, negotiate elements of the plan, and evaluate the plan.

The patient for whom you are caring needs a liver transplant to survive. This patient has been out of work for several months and doesn't have health insurance or enough cash. Even though several ethical principles are at work in this case, what are the principles from highest to lowest priority? 1. Accountability: You as the nurse are accountable for the wellbeing of this patient. 2. Respect for autonomy: This patient's autonomy will be violated if he does not receive the liver transplant. 3. Ethics of care: The caring thing that a nurse could provide this patient is resources for a liver transplant. 4. Justice: The greatest question in this situation is how to determine the just distribution of resources. A. 4, 1, 3, 2 B. 2, 4, 3, 1 D. 4, 2, 3, 1 D. 4, 3, 2, 1

D. 4, 2, 3, 1 Understanding the concept of justice helps to enrich the conversation about how to act and lifts the conversation above and beyond the circumstances of the patient. If justice is compromised, respect for autonomy will be hard to maintain. The nurse will be able to care for the patient, but unfortunately her commitment to care does not give her the power to resolve the difficult issue of limited resources. Other concepts are valid but not as relevant to the case.

A patient is admitted to a medical unit. The patient is fearful of hospitals. The nurse carefully assesses the patient to determine the exact fears and then establishes interventions designed to reduce these fears. In this setting how is the nurse practicing patient advocacy? A. Seeking out the nursing supervisor to talk with the patient B. Documenting patient fears in the medical record in a timely manner C. Working to change the hospital environment D. Assessing the patient's point of view and preparing to articulate it

D. Assessing the patient's point of view and preparing to articulate it Assessing the patient's point of view and preparing to articulate it best reflects the concept of advocacy because it is standing up for the patient and having his or her views and wishes heard.

You are the night shift nurse caring for a newly admitted patient who appears to be confused. The family asks to see the patient's medical record. What is the priority nursing action? A. Give the family the record B. Discuss the issues that concern the family with them C. Call the nursing supervisor D. Determine from the medical record if the family has been granted permission by the patient to access his or her medical information

D. Determine from the medical record if the family has been granted permission by the patient to access his or her medical information Family members do not have the right to private personal health information without the consent of the patient. Confidentiality protects private patient information once it has been disclosed in health care settings.

A patient's gastric residual volume was 250 mL at 0800 and 350 mL at 1200. What is the appropriate nursing action? A. Assess bowel sounds B. Raise the head of the bed to at least 45 degrees C. Position the patient on his or her right side to promote stomach emptying D. Do not reinstall aspirate and hold the feeding until you talk to the primary care provider

D. Do not reinstall aspirate and hold the feeding until you talk to the primary care provider Do not administer feeding when a single gastric residual volume exceeds 500 mL or when two consecutive measurements (taken 1 hour apart) each exceed 250 mL because of the potential for aspiration.

A homeless man enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the City Hospital for care. This action is most likely a violation of which of the following laws? A. Health Insurance Portability and Accountability Act (HIPAA) B. Americans with Disabilities Act (ADA) C. Patient Self-Determination Act (PSDA) D. Emergency Medical Treatment and Active Labor Act (EMTALA) without triage completed

D. Emergency Medical Treatment and Active Labor Act (EMTALA) without triage completed The EMTALA requires that an emergency situation needs to be established and that the patient needs to be stabilized before a transfer is appropriate.

Which statement made by a patient of a 2-month-old infant requires further education? A. I'll continue to use formula for the baby until he is a least a year old. B. I'll make sure that I purchase iron-fortified formula. C. I'll start feeding the baby cereal at 4 months. D. I'm going to alternate formula with whole milk starting next month.

D. I'm going to alternate formula with whole milk starting next month. Infants should not have regular cow's milk during the first year of life. It is too concentrated for the infant's kidneys to manage. There is also an increased risk for developing milk-product allergies.

A woman has severe life-threatening injuries and is hemorrhaging following a car accident. The health care provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurse's responsibility? A. Obtain a court order to give the blood B. Coerce the husband into giving the blood C. Call security and have the husband removed from the hospital D. More information is needed about the wife's preference and if the husband has her medical power of attorney

D. More information is needed about the wife's preference and if the husband has her medical power of attorney Adult patients such as those with specific religious objection are able to refuse treatment for personal religious reasons, but there need to be clear directions on who can make the decision.

The nurse evaluates which laboratory values to assess a patient's potential for wound healing? A. Fluid status B. Potassium C. Lipids D. Nitrogen balance

D. Nitrogen balance Nitrogen balance is important to determining serum protein status. A negative nitrogen balance is present when catabolic states exist. When a patient has a decreased protein level, he or she is at risk for delayed wound healing.

The nurse is administering a benzodiazepine sleep aid to an older adult. What should be the priority assessment for the patient? A. Incontinence B. Nausea and vomiting C. Bradycardia D. Respiratory depression

D. Respiratory depression Benzodiazepines in older adults should be used on a short-term, limited basis. Respiratory depression is an adverse effect of benzodiazepines in older adults. Other adverse effects for which to assess include next-day sedation, amnesia, rebound insomnia, and impaired motor functioning and coordination.

The nurse manager is reviewing the use of restraints during an in-service with the staff. Which of the following is inaccurate information that should not be included in the discussion? A. Attach the restraint to the movable part of the bed frame. B. When all side rails are raised, this may be considered a form of physical restraint. C. Two fingers should be able to fit underneath the restraint. D. Restraints provide a reliable method to prevent falls without serious complications.

D. Restraints provide a reliable method to prevent falls without serious complications. The use of restraints is associated with serious complications, including pressure ulcers, constipation, urinary and fecal incontinence, and pneumonia. In some cases, restricted breathing or circulation has resulted in death. Loss of self-esteem and a sense of humiliation, fear, and anger are additional serious concerns. Side rails may be considered a restraint device when used to prevent the ambulatory patient from getting out of bed. Check agency policy. Using two fingers to check the fit of a restraint guarantees safe application and prevents neurovascular compromise. Restraints should not be attached to the bedside rails but should be attached to the portion of the bed frame that will move when the head of the bed is raised or lowered to prevent patient injury.

The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? A. Suction her mouth and throat B. Turn her on their side C. Put on oxygen at 2-L nasal cannula D. Stop feeding her and place on NPO

D. Stop feeding her and place on NPO Stop feeding and place patient on NPO. If choking persists, suction airway. Notify health care provider.

The patient begins to cough and choke while the nurse is feeding him. What should the nurse do? A. Notify the health care provider immediately. B. Give the patient some water. C. Allow the patient to rest. D. Suction the airway as necessary.

D. Suction the airway as necessary. The nurse should first use suction equipment if necessary to clear food from the airway and position the patient in the high-Fowler's position or, if unable to do so, position the patient on the patient's side. If choking occurs repeatedly, stop feeding the patient and notify the health care provider. Provide oxygen if the patient's color has failed to return to normal. Offering the patient water may only increase choking, because thin liquids such as water and fruit juice are difficult to control in the mouth and are more easily aspirated. As a preventive measure, the nurse should allow the patient to rest throughout feeding.

The nurse and NAP are applying extremity restraints to a patient. Which action, if made by the NAP, would require correction? A. The NAP inserted two fingers under the secured restraint. B. The NAP used a quick-release tie on the movable bed frame. C. The NAP first placed the patient in functional alignment. D. The NAP attached the restraint to the side rail of the bed.

D. The NAP attached the restraint to the side rail of the bed. The NAP should be able to insert two fingers under the secured restraint to make sure it is not too tight that it would interfere with circulation and cause neurovascular injury. Using a quick-release tie is an appropriate action of the NAP because it allows for quick release of the restraint in an emergency. The patient should be placed in functional alignment to prevent strain of joints and discomfort. The patient could be injured if the restraint is secured to the side rail and it is lowered. Restraints should be attached to the bed frame, which moves when the head of the bed is raised or lowered, so that the straps will remain at the correct tension without restricting circulation.

A parent calls the pediatrician's office to ask about directions for using a car seat. Which of the following is the most correct set of instructions the nurse gives to this parent? A. Only infants and toddlers need to ride in the back seat. B. All toddlers can move to a forward facing car seat when they reach age 2. C. Toddlers must reach age 2 and the height/weight requirement before they ride forward facing. D. Toddlers must reach age 2 or the height or weight requirement before they ride forward facing.

D. Toddlers must reach age 2 or the height or weight requirement before they ride forward facing. The American Academy of Pediatrics (2011a) recommends that all infants and toddlers ride in the back seat with a rear-facing-only seat and rear-facing convertible seat until they are 2 years of age or they reach the highest weight or height allowed by the manufacturer of the car safety seat.

A student nurse receives an order for diazepam to be given intravenously. Diazepam tablets are available. The student nurse crushes a tablet and mixes it with sterile water for injection. The instructor notes that the solution is cloudy and asks to see the medication vial. When the student produces the vial of sterile water for injection and the instructor stops the medication from being given, what type of error is prevented? A. Communication error B. Diagnostic error C. Preventive error D. Treatment error

D. Treatment error The nurse avoided a treatment error; she was prevented from giving the wrong type of medication. Diazepam (Valium) for intravenous administration is clear and comes prepared in a vial labeled for intravenous administration. According to Leape, treatment errors occur in the performance of an operation, procedure, or test; in administering a treatment; in the dose or method of administering a drug; or in an avoidable delay in treatment or in responding to an abnormal test. A communication error results from a failure to communicate. Diagnostic errors are the result of a delay in diagnosis, a failure to employ indicated tests, the use of outmoded tests, or a failure to act on results of monitoring or testing. Preventive errors occur when there is a failure to provide prophylactic treatment when monitoring is inadequate, or when follow-up of treatment is inadequate.

A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request discontinuing parenteral nutrition? A. When 25% of the patient's nutritional needs are met by the tube feedings B. When bowel sounds return C. When central line has been in for 10 days D. When 75% of the patient's nutritional needs are met by the tube feedings

D. When 75% of the patient's nutritional needs are met by the tube feedings When meeting 75% of nutritional needs by enteral feedings or reliable dietary intake, it is usually safe to discontinue PN therapy.