Intro to Nursing - Exam 1 Concepts - Chapters 15-20, 28-30, 39, 47
The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. The nurse would recommend which of the following menus? A. Cream of broccoli soup with whole wheat crackers and tapioca for dessert B. Hamburger on soft roll with a side salad and an apple for dessert C. Low-fat turkey chili with sour cream and fresh pears for dessert D. Chicken salad on toast with tomato and lettuce and honey bun for dessert
Answer: A. The dairy and broccoli in the soup, the whole grain crackers, plus the tapioca are all great sources of calcium.
A clinic nurse assesses a patient who reports a loss of appetite and a 15-pound weight loss since 2 months ago. The patient is 5 feet 10 inches tall and weighs 135 pounds (61.2 kg). She shows signs of depression and does not have a good understanding of foods to eat for proper nutrition. The nurse makes the nursing diagnosis of imbalanced nutrition: less than body requirements related to reduced intake of food. For the goal of, "Patient will return to baseline weight in 3 months," which of the following outcomes would be appropriate? (Select all that apply.) A. Patient will discuss source of depression by next clinic visit. B. Patient will achieve a calorie intake of 2400 daily in 2 weeks. C. Patient will report improvement in appetite in 1 week. D. Patient will identify food protein sources.
11. Answer: B, C. With the related factor of reduced intake of food, the outcomes should focus on behaviors that reflect an increase in intake. Thus achieving an increase in calories and an improved appetite for food would be appropriate. The patient's depression probably contributes to the loss of appetite, but being able to discuss the source of depression is not an outcome for improving her baseline weight. Being able to identify protein sources would improve any knowledge deficit the patient might have but would not help her gain weight.
During the review of systems in a nursing history, a nurse learns that the patient has been coughing mucus. Which of the following nursing assessments would be best for the nurse to use to confirm a lung problem? (Select all that apply.) A. Family report B. Chest x-ray film C. Physical examination with auscultation of the lungs D. Medical record summary of x-ray film findings
12. Answer: C, D. The family cannot provide information to reveal that the cough is a lung problem. A chest x-ray film is not a nursing assessment; if a previous chest x-ray film had been performed, the nurse could review that report to confirm a lung problem.
The nurse writes an expected-outcome statement in measurable terms. An example is: A. Patient will be pain free. B. Patient will have less pain. C. Patient will take pain medication every 4 hours. D. Patient will report pain acuity less than 4 on a scale of 0 to 10.
7. Answer: D. Answer D is measurable because it is the only outcome statement that allows the nurse to obtain an actual measure of the patient's pain. Answer A is a goal, answer B is written vaguely, and answer C is an intervention.
The nurse teaches a patient about cranial nerves to help explain why the patient's right side of the mouth droops instead of moving up into a smile. What nerve does the nurse explain to the patient? A. VII — Facial B. V — Trigeminal C. XII — Hypoglossal D. XI— Spinal accessory
Answer: A. The facial nerve innervates the sensory and motor functions of the face above the brow, the cheeks, and the chin and controls face symmetry and smile.
Which of the following should the nurse report to the healthcare provider? A. An athlete with a blood pressure of 110/70. B. An elderly male with a temperature of 96.8°F (36°C). C. A newborn with a respiratory rate of 40. D. An adult patient with a heart rate of 55.
Answer: D. An adult's heart rate should be 60-100. A rate of 55 is bradycardic. A blood pressure of 110/70 is within normal range, An elderly person will have a lower body temperature and 96.8°F is acceptable. A newborn will have an expected respiratory rate of 30-50.
You are helping a female patient bathe. As you are about to perform perineal care, the patient says, "I can finish my bath." The patient has discomfort and burning in the perineal area. What action do you need to take initially? A. Explain to the patient that, because of her symptoms, you need to observe the perineal area. B. Insist that you are supposed to complete the care. C. Honor the patient's request to complete her own perineal care to avoid any embarrassment. D. Ask the patient if a family member can complete the care instead.
Answer A: The symptoms of burning and discomfort indicate a problem. It is your responsibility to perform an assessment to note any vaginal or urethral discharge, skin irritation, and odors. It is not safe to let embarrassment cause you to overlook hygiene needs and the diagnosis of problems. Providing information and patient teaching often encourages patient cooperation.
The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The patient reports she is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse asks her to clarify the type of trouble. The patient explains she can't concentrate or even solve simple problems. The nurse records the results of the assessment, describing the patient as having ineffective coping. This is an example of: A. Diagnostic reasoning. B. Competency. C. Inference. D. Problem solving.
Answer: A In this example the nurse collects information about the patient, sees patterns in the data collected, and makes a nursing diagnosis. This is an example of the diagnostic process.
A healthy 30-year-old male arrives at the clinic for a physical because he will be living in a third-world country for the next 2 to 5 years, and he wants to make sure he is healthy. The nurse is responsible for collecting his vital signs. Which of these can be delegated to NAP? (Select all that apply.) A. Temperature. B. Pulse. C. Respiration. D. BP. Correct E. Pulse oximetry.
Answer: A, B, C, D, E. All of the vital signs can be delegated since the patient comes to the clinic healthy and without physical complaints.
Put the following steps for removal of protective barriers after leaving an isolation room in order: A. Untie top, then bottom mask strings and remove from face. B. Untie waist and neck strings of gown. Allow gown to fall from shoulders and discard. Remove gown, rolling it onto itself without touching the contaminated side. C. Remove gloves. D. Remove eyewear or goggles. E. Perform hand hygiene.
Answer: A, B, C, D, E. This sequence ensures that the risk of contamination to other surfaces or health care personnel is minimized.
Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.) A. Patient's weight B. Patient's level of cooperation C. Patient's ability to assist D. Presence of medical equipment E. 24-hour calorie intake
Answer: A, B, C, D.
A nurse on a cancer unit is reviewing and revising the written plan of care for a patient who has the nursing diagnosis of nausea. Place the following steps in their proper order: A. The nurse revises approaches in the plan for controlling environmental factors that worsen nausea. B. The nurse enters data in the assessment column showing new information about the patient's nausea. C. The nurse adds the current date to show that the diagnosis of nausea is still relevant. D. The nurse decides to use the patient's self-report of appetite and fluid intake as evaluation measures.
Answer: A, B, C, D. These steps follow the sequence needed for modifying an existing care plan.
A small group of nursing students is giving a teaching presentation on the principles of surgical asepsis. Which of the following standards are appropriate to include in the presentation? (Select all that apply.) A. A sterile barrier that has been permeated by moisture must be considered contaminated. B. A sterile object or field out of the range of vision or an object held below a person's waist is considered contaminated. C. A sterile field or object cannot become contaminated by air. D. If there is any doubt about an item's sterility, the item is considered to be unsterile. E. All items used within a sterile field must be sterile.
Answer: A, B, D, E. A sterile surface that comes in contact with moisture must be considered contaminated. A sterile object or field out of the range of vision or an object held below a person's waist is considered contaminated. A sterile object or field becomes contaminated by prolonged exposure to air; stay organized, and complete any procedure as soon as possible. If there is any doubt about an item's sterility, the item is considered to be unsterile. All items used within a sterile field must be sterile.
Which of the following are symptoms of latex allergy? (Select all that apply.) A. Skin redness. B. Itching. C. Purulent drainage. D. Edema. E. Difficulty breathing. F. Elevated temperature.
Answer: A, B, D, E. Symptoms of latex allergy may vary in degree and may include redness and itching, hives, localized swelling, itchy or runny eyes and nose, coughing, rash, wheezing, bronchospasm, difficulty breathing, laryngeal edema, diarrhea, nausea, hypotension, tachycardia, and respiratory or cardiac arrest. Purulent drainage and elevated temperature may indicate infection.
A 56-year-old patient with diabetes admitted for community acquired pneumonia has a temperature of 38.2°C (100.8°F) via the temporal artery. Which additional assessment data are needed in planning interventions for the patient's infection? (Select all that apply.) A. Heart rate B. Presence of diaphoresis C. Smoking history D. Respiratory rate E. Recent bowel movement F. Blood pressure in right arm G. Patient's normal temperature H. Blood pressure in distal extremity
Answer: A, B, D, G. You need to determine the patient's usual temperature to evaluate the degree of temperature elevation. Heart rate and respiratory rate increase with temperature. The presence of diaphoresis may contribute to fluid volume deficit from hyperthermia.
As a nurse prepares to provide morning care and treatments, it is important to question a patient about a latex allergy before which intervention? (Select all that apply.) A. Applying adhesive tape to anchor a nasogastric tube B. Inserting a rubber Foley catheter into the patient's bladder C. Providing oral hygiene using a standard toothbrush and toothpaste D. Giving an injection using plastic syringes with rubbercoated plungers E. Applying a transparent wound dressing
Answer: A, B, D.
Review the following list of nursing diagnoses and identify those stated incorrectly. (Select all that apply.) A. Acute pain related to lumbar disk repair B. Sleep deprivation related to difficulty falling asleep C. Constipation related to inadequate intake of liquids D. Potential nausea related to nasogastric tube insertion
Answer: A, B, D.
What technique(s) best encourage(s) a patient to tell his or her full story? (Select all that apply.) A. Active listening B. Back channeling C. Validating D. Use of open-ended questions E. Use of closed-ended questions
Answer: A, B, D. Active listening allows the patient to speak and shows the nurse's respect for what he or she has to say. Back channeling reinforces interest in what the patient has to say and shows the nurse's desire to hear the full story. Using open-ended questions encourages the patient to tell his or her story and actively describe his or her health status. Validation simply confirms accuracy of data collected. Closed-ended questions do not encourage storytelling.
When is it acceptable to use antiseptic hand rub rather than soap and water? (Select all that apply.) A. After adjusting a nasal cannula on a patient. B. After removing gloves after changing a wound dressing. C. When the nurse's hands are cracked from frequent hand hygiene. D. After moving patient's belongings on the bedside table. E. After the patient develops a skin tear and blood is on the nurse's hand. F. When the patient has been diagnosed with C. difficile.
Answer: A, B, D. When hands are visibly dirty or contaminated with proteinaceous material or visibly soiled with blood or other body fluids, you need to wash your hands with soap and water. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands, such as after contact with inanimate objects (including medical equipment) in the immediate vicinity of a patient and after removing gloves. If repeated use of soaps or antiseptics have caused dermatitis or cracked skin, the nurse should rinse and dry hands thoroughly after using soap and water and avoid excessive amounts of soap or antiseptic. A hand lotion or barrier cream may be applied after hand hygiene. Hands should be washed with soap and water if a patient has C. difficile. Alcohol-based hand rubs are not effective against C. difficile spores.
A nurse is starting on the evening shift and is assigned to care for a patient with a diagnosis of impaired skin integrity related to pressure and moisture on the skin. The patient is 72 years old and had a stroke. The patient weighs 250 pounds and is difficult to turn. As the nurse makes decisions about how to implement skin care for the patient, which of the following actions does the nurse implement? (Select all that apply.) A. Review the set of all possible nursing interventions for the patient's problem B. Review all possible consequences associated with each possible nursing action C. Consider own level of competency D. Determine the probability of all possible consequences
Answer: A, B, D. When making decisions about implementation, reviewing all possible interventions and consequences and determining the probability of consequences are necessary steps. The nurse is responsible for having the necessary knowledge and clinical competency to perform an intervention, but this is not part of the decision making involved.
The nurse is planning to teach the student nurse how to assess the hydration status of an older adult. Which techniques are appropriate for this situation? (Select all that apply.) A. Inspect the lips and mucous membranes to determine if they are moist. B. Pinch the skin on the back of the hand to see if the skin tents. C. Check the patient's pulse and blood pressure. D. Weigh the patient daily.
Answer: A, B.
The nurse manager is reviewing the use of standard precautions with the staff. Which of the following should be included in the review? (Select all that apply.) A. Standard precautions are used to protect you from potential contact with blood and body fluids. B. Standard precautions should be observed in every patient encounter. C. Standard precautions refer only to the use of gloves; not to the use of masks, eye protection, or gowns, as these refer to other types of precautions. D. To follow standard precautions, you must wear sterile gloves. E. Standard precautions are utilized once the type of infection is identified.
Answer: A, B. Standard precautions are used to protect you from potential contact with blood and body fluids and should be observed in every patient encounter. Besides gloving, standard precautions include the use of masks, eye protection, and gowns when there is a risk of being splattered with infectious materials. Surgical asepsis (sterile technique) requires the use of sterile gloves. Clean gloves may be worn when following standard precautions. Any patient may be a source of infection and should be treated as such rather than waiting until a pathogen is identified.
Under which circumstance(s) should hand washing be repeated? (Select all that apply.) A. Hands touch the sink during hand washing. B. Areas under fingernails remain soiled. C. Cracked areas are noted on the nurse's hands. D. Hands are free of visible soiling. E. Hands are lowered below waist level.
Answer: A, B. The inside of the sink is a contaminated area. If the hands touch the sink during hand washing, the hand washing procedure should be repeated. If the hands or areas under fingernails remain soiled, repeat hand washing with soap and water. If the nurse's hands are cracked, rinse and dry hands thoroughly. Hand washing does not require repeating as this would only dry out the skin more. Hands lowered below the waist do not require repeated hand washing as this skill is utilizing clean technique, not sterile technique.
During a patient's routine annual physical, she tells you that she has noted that her heart feels like it's " racing, " usually in the later morning, early afternoon, or just before she goes to bed. Her radial pulse rate is 68 beats/min and regular; her blood pressure is 134/82 mm Hg. What additional information is helpful in evaluating the patient's racing heart? (Select all that apply.) A. Dietary habits B. Medication list C. Exercise regimen D. Age, weight, and height
Answer: A, B. Dietary habits may include caffeine fluids and foods that stimulate heart rate. Medication list may include pharmacological agents that increase or decrease heart rate.
Which of the following patients is at most risk for tachypnea? (Select all that apply.) A. Patient just admitted with four rib fractures B. Woman who is 9 months' pregnant C. Adult who has consumed alcoholic beverages D. Adolescent awaking from sleep
Answer: A, B. Rib fractures would cause splinting and pain to increase respiratory rate. Pregnancy impedes diaphragmatic excursion, causing shallow, frequent breaths.
Identify why a child's respirations might be shallow. A. She is in acute pain. B. She was running around in the waiting room with her sibling before her name was called. C. Her parents are smokers and her lungs are negatively affected by the secondhand smoke. D. She is anxious about seeing the doctor.
Answer: A. Acute pain alters the rate and rhythm of respirations, and breaths become shallow. If she were running around in the waiting room with her sibling before her name was called, it would result in deep breaths. If her parents are smokers and her lungs are negatively affected by the secondhand smoke, it would result in increased breaths per minute. Respirations increase in rate and depth as a result of stimulation by the sympathetic nervous system.
Unmet and partially met goals require the nurse to do which of the following? (Select all that apply.) A. Redefine priorities B. Continue intervention C. Discontinue care plan D. Gather assessment data on a different nursing diagnosis E. Compare the patient's response with that of another patient
Answer: A, B. When you determine that a goal has not been met or has been met only partially, intervention must continue; and the fact that the health problem still exists suggests that priorities may need to be redefined. You do not discontinue a plan unless a goal has been achieved. Evaluation never involves comparing a patient's data with that of another patient. A patient may develop new diagnoses at any time, but assessment of a new diagnosis does not address goals for an existing diagnosis.
Which of the following situations may affect a patient's vital signs? (Select all that apply.) A. Time of day. B. Occupation. C. Moving from lying to standing position. D. Pain rated as a 7 on 0-10 pain scale. E. Isolation precautions.
Answer: A, C, D. Factors that may alter vital signs include time of day, stress (emotional and physical), temperature alterations/weather conditions, exercise/activity, emotions, medication, postural changes, acute pain, smoking, disease/injury status, noise, food/liquid consumption, and odors. The person's occupation and isolation precautions do not alter vital signs. If a person's job requires an activity that increases exertion or stress, the activity affects vital signs, not the occupation.
When should you perform hand hygiene? (Select all that apply.) A. Before applying gloves to insert an IV. B. After documenting in the patient's electronic medical record. C. After moving a patient up in bed. D. Before assessing a patient's vital signs. E. Before touching clean linens.
Answer: A, C, D. You should perform hand hygiene before putting on sterile gloves and before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices. You should perform hand hygiene after contact with a patient's intact skin (e.g., after assessing a patient's vital signs or moving a patient in bed). Unless the hands are visibly soiled, it is unnecessary to perform hand hygiene after documentation. If you touch an object that is not visibly soiled, such as clean linens, hand washing is unnecessary at that time.
A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. What does the nurse need to determine before setting the goal of "patient will self-administer insulin?" (Select all that apply.) A. Goal within reach of the patient B. The nurse's own competency in teaching about insulin C. The patient's cognitive function D. Availability of family members to assist
Answer: A, C, D. A goal must be realistic and one that the patient has cognitive and sociocultural potential to reach. The nurse's competency does not influence the patient's goal. However, it may mean that the nurse must consult with a diabetes educator or a more qualified nurse before beginning instruction.
Which of the following statements correctly describe the evaluation process? (Select all that apply.) A. Evaluation is an ongoing process. B. Evaluation usually reveals obvious changes in patients. C. Evaluation involves making clinical decisions. D. Evaluation requires the use of assessment skills.
Answer: A, C, D. Evaluation often reveals changes that are not obvious. Changes are often subtle and occur over a period of time.
A nurse is working with a nursing assistive personnel (NAP) on a busy oncology unit. The nurse has instructed the NAP on the tasks that need to be performed, including getting patient A out of bed, collecting a urine specimen from patient B, and checking vital signs on patient C, who is scheduled to go home. Which of the following represent(s) successful delegation? (Select all that apply.) A. A nurse explains to the NAP the approach to use in getting the patient up and why the patient has activity limitations. B. A nurse is asked by a patient to help her to the bathroom; the nurse leaves the room and directs the NAP to assist the patient instead. C. The nurse sees the NAP preparing to help a patient out of bed, goes to assist, and thanks the NAP for her efforts to get the patient up early. D. The nurse is in patient B's room to check an intravenous (IV) line and collects the urine specimen while in the room. E. The nurse offers support to the NAP when needed but allows her to complete patient care tasks without constant oversight.
Answer: A, C, D. Successful delegation is represented by good communication, showing respect, and showing initiative. The example in option 2 shows a lack of initiative on the part of the nurse.
Which steps does the nurse follow when he or she is asked to perform an unfamiliar procedure? (Select all that apply.) A. Seeks necessary knowledge B. Reassesses the patient's condition C. Collects all necessary equipment D. Delegates the procedure to a more experienced staff member E. Considers all possible consequences of the procedure
Answer: A, C, E. You require additional knowledge and skills in situations in which you are less experienced. When you are asked to administer a new procedure with which you are unfamiliar, follow the three choices: A, C, and E. Collecting necessary equipment and considering potential consequences is needed for any procedure.
A patient who is cognitively impaired and has dementia requires hygiene care. The patient often displays aggressive behavior such as screaming and hitting during the bath. Which techniques make the bathing experience less stressful for both the nurse and the patient? (Select all that apply.) A. Allow the patient to perform as much of the care as possible. B. Start by washing the face. C. Try an alternative to traditional bathing such as the "bag bath." D. Use restraints to prevent the patient from injuring self or the nurse.
Answer: A, C.
A nurse identifies several interventions to resolve the patient's nursing diagnosis of impaired skin integrity. Which of the following are written in error? (Select all that apply.) A. Turn the patient regularly from side to back to side. B. Provide perineal care, using Dove soap and water, every shift and after each episode of urinary incontinence. C. Apply a pressure-relief device to bed. D. Apply transparent dressing to sacral pressure ulcer.
Answer: A, C. Answers A and C do not provide specific guidelines for the frequency or type of intervention. Answers B and D identify specific intervention methods.
When are sterile gloves necessary? When performing a sterile procedure. If blood or body fluids are present. If the patient is placed on isolation. When performing postmortem care.
Answer: A. Sterile gloves or a no-touch technique should be used when performing any sterile procedure.
A nurse who is working on a surgical unit is caring for four different patients. Patient A will be discharged home and is in need of instruction about wound care. Patients B and C have returned from the operating room within an hour of each other, and both require vital signs and monitoring of their intravenous (IV) lines. Patient D is resting following a visit by physical therapy. Which of the following activities by the nurse represent(s) use of clinical decision making for groups of patients? (Select all that apply.) A. Consider how to involve patient A in deciding whether to involve the family caregiver in wound care instruction. B. Think about past experience with patients who develop postoperative complications. C. Decide which activities can be combined for patients B and C. D. Carefully gather any assessment information and identify patient problems.
Answer: A, C. Considering how to involve patients in decisions and how to combine nursing activities to be more organized and allow for resolving more than one problem at a time are examples of clinical decision making for groups of patients. Answer 2 is an example of reflection, an approach to strengthen critical thinking skills. Answer 4 is part of the process of diagnostic reasoning, which should be applied to each patient.
A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just entered the hospital with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The nurse's knowledge about this patient results in which of the following assessment approaches at this time? (Select all that apply.) A. A problem-focused approach B. A structured comprehensive approach C. Using multiple visits to gather a complete database D. Focusing on the functional health pattern of role-relationship
Answer: A, C. The nurse should use a focused approach initially to determine the patient's respiratory status. However, to gather an admission assessment, multiple visits are needed because of the patient's age and level of physical distress. A structured comprehensive approach is not appropriate for this acute situation. Eventually the nurse will want to assess the patient's role-relationship health pattern because of his wife's death. But it is not appropriate at this time.
Which of the following patients are at risk for developing an infection? (Select all that apply.) A. A patient receiving chemotherapy. Correct B. A patient who has an early discharge from the hospital. C. A patient in a private room. D. A patient with an IV. Correct E. A patient receiving broad spectrum antibiotics. Correct F. A patient with a chronic respiratory disease receiving steroid therapy.
Answer: A, D, E, F. Risk factors for healthcare-associated infection include crowding within a healthcare facility and the patient's length of stay. In addition, infection is more likely to develop in persons with chronic illness or compromised immunity. In all settings, patients may have procedures or treatments that lower their resistance to infections. For example, patients' immune systems may be altered after receiving chemotherapy or broad spectrum antibiotics; therefore, they are more susceptible to infections, even from their own normal flora. In addition, invasive procedures, such as the insertion of intravenous or urinary catheters, disrupt the body's natural defense barriers.
A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting a problem? (Select all that apply.) A. The skin around the wound is tender to touch. B. Fluid intake for 8 hours is 800 mL. C. Patient has a heart rate of 78 and regular. D. Patient has drainage from surgical wound. E. Body temperature is 101° F (38.3° C). F. Patient asks, "I'm worried that I won't return to work when I planned."
Answer: A, D, E. These form a pattern of a problem with wound healing. Answer 2 is a normal finding. Answer 6 may suggest a problem, but more cues are needed to see a pattern that would allow the nurse to clearly identify the problem.
A male nurse is caring for a 32-year-old female Muslim patient who has an indwelling Foley catheter. After introducing himself to the patient, the nurse learns that the patient does not want him to help her with personal hygiene care. Which of the following is(are) appropriate actions? (Select all that apply.) A. Finding a female nurse to help the patient B. Convincing the patient that he will work quickly and provide as much privacy as possible C. Skipping hygiene care for the day except for the parts that the patient can complete independently D. Asking the patient if she prefers a family member assist with the care
Answer: A, D.
The nurse is teaching a patient with poor arterial circulation about checking blood flow in the legs. Which information should the nurse include? (Select all that apply.) A. A normal pulse on the top of the foot indicates adequate blood flow to the foot. B. To locate the dorsalis pedis pulse, take the fingers and palpate behind the knee C. When there is poor arterial blood flow, the leg is generally warm to the touch. D. Loss of hair on the lower leg indicates a long-term problem with arterial blood flow.
Answer: A, D.
Which of the following are examples of data validation? (Select all that apply.) A. The nurse assesses the patient's heart rate and compares the value with the last value entered in the medical record. B. The nurse asks the patient if he is having pain and then asks the patient to rate the severity. C. The nurse observes a patient reading a teaching booklet and asks the patient if he has questions about its content. D. The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement. E. The nurse asks the patient to describe a symptom by saying, "Go on."
Answer: A, D.
Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) A. Anxiety related to fear of dying B. Fatigue related to chronic emphysema C. Need for mouth care related to inflamed mucosa D. Risk for infection
Answer: A, D. Answer A is stated correctly, with the related factor being the patient's response to a health problem. Answer D, risk for infection, is a risk factor for an at-risk diagnosis. In all cases the related factor or risk factor is a condition for which the nurse can implement preventive measures. Answer B is incorrect since chronic emphysema is a medical diagnosis. Answer C is not a NANDA-I-approved nursing diagnosis.
A 15-year-old male patient is hypothermic. Which temperature reflects hypothermia? A. 95° F (35°C). B. 99° F (37.2°C). C. 101° F (38.3°C). D. 110° F (43.3°C).
Answer: A. 95° F (35°C) indicates a hypothermic temperature. 99° F (37.2°C) would be a "normal" temperature for someone his age. 101° F (38.3°C) would be considered a fever for someone his age. 110° F (43.3°C) indicates the opposite physiologic situation to hypothermia, namely heatstroke.
One evaluation measure of creating and maintaining a sterile field involves monitoring the patient for developing signs and symptoms of localized or systemic infection. Which of the following is cause for concern? A. Temperature of 102.5° F. B. Incisional area light pink in color. C. White blood cell count at 6500 per mm3. D. Absence of purulent drainage.
Answer: A. An elevation in temperature is an indication of systemic infection. An incision may appear pink in color. Cause for concern would be if the incision had redness, edema, and/or tenderness. An elevated WBC above 10,000 per mm3 would indicate infection. Purulent drainage (e.g., yellow, green, or brown) is an indication of localized infection, as is a foul odor from the site.
The nurse is planning a staff education conference about abdominal assessment. Which point is important for the nurse to include? A. The aorta can be felt using deep palpation in the upper abdomen near the midline. B. The patient should be sitting to best determine the contour and shape of the abdomen. C. Always wear gloves when palpating the skin on the patient's abdomen. D. Avoid palpating the abdomen if the patient reports any discomfort or feelings of fullness.
Answer: A. Complete abdominal assessment includes inspection, followed by auscultation, palpation, and percussion (if warranted). Anatomically the aorta is located in the upper abdomen and can be palpated on an average-sized patient. The assessment should be performed when the patient is supine so all assessment techniques can be included. Unless there is an open wound or other abdominal drainage, the aorta should be palpated without gloves to be able to assess skin texture, temperature, and any unusual pulsations. Palpation should be performed routinely, but leave areas of discomfort or pain until last.
Which patient is at high risk for for the pulse oximetry alarm to sound? A. A patient with a continuous pulse oximetry reading of 84%. B. A patient who is receiving oxygen via face mask. C. A patient who has an intermittent pulse oximetry reading of 95%. D. A patient with a heart rate of 64 beats per minute.
Answer: A. Continuous pulse oximetry alarms activate if oxygen saturation falls below 85% and/or the probe falls off.
A patient has a diagnosis of Clostridium difficile. What is most important for the nurse to convey to the NAP regarding this patient's care? A. To wash hands with soap and water before and after caring for the patient. B. To use an alcohol-based hand rub after removing gloves. C. To wear an N-95 mask when in the patient's room. D. To avoid caring for other patients with C. difficile to prevent cross contamination.
Answer: A. If patient is being treated for C. difficille infection clean hands with soap and water. Alcohol-based hand rubs are not effective against the spores of C. difficile. Standard and contact precautions are used for patients with C. difficile. An N-95 mask would be unnecessary. Cross contamination of C. difficile will not occur if both patients already have C. difficile.
The nurse is preparing to insert a urinary catheter. To perform this procedure, the nurse will use: A. Surgical asepsis (sterile technique). B. Medical asepsis (clean technique). C. Droplet precautions. D. Standard precautions.
Answer: A. Inserting a urinary catheter requires sterile technique (surgical asepsis) to prevent the introduction of any microorganisms into the urinary bladder during the procedure. Medical asepsis (clean technique) is used to reduce the number or transmission of microorganisms and includes hand hygiene, wearing clean disposable gloves, etc. Droplet precautions are a type of standard precaution in which the recommended barrier method includes the use of a mask. Standard precautions refers to wearing PPE when there is potential contact with blood or body fluids. It does not specifically warrant sterile technique.
Which of the following actions would best help prevent skin breakdown in a patient who is incontinent of stools and very weak and drowsy? A. Checking frequently for soiling B. Washing the perineal area with strong soap and water C. Placing the call light within easy reach D. Keeping a pad under the patient
Answer: A. Loose stool contains digestive enzymes that irritate the skin and need to be cleaned from the skin as soon as possible after soiling to prevent skin breakdown.
The nurse is teaching a patient how to perform a testicular self-examination. Which statement by the nurse is correct? A. "The testes are normally round and feel smooth and rubbery." B. "The best time to do a testicular self-examination is before your bath or shower." C. "Perform a testicular self-examination weekly to detect signs of testicular cancer." D. "Since you are over 40 years old, you are in the highest risk group for testicular cancer."
Answer: A. Men ages 18 to 24 are in the group at most risk for testicular cancer. Teaching should include normal anatomy. A testicular examination should be planned monthly during a shower since the soap and water ease movement of the fingertips over the skin.
It is 7 a.m. and the nurse takes the vital signs of a post-operative patient and finds his blood pressure is elevated. Which of the following could explain the cause for an alteration in B/P? A. The patient complains of pain at a 9 on a 0-10 pain scale. B. The patient has been NPO since midnight. C. The patient has a temperature of 99.0°F rectally. D. The cool environment of the surgical suite.
Answer: A. Pain is the likely cause of the increase in the patient's blood pressure. Although dehydration can cause a decrease in blood pressure, the patient has only been restricted of oral fluids, and likely had an IV during surgery to maintain fluid balance. Furthermore, the patient has only been NPO for 7 hours. Environmental temperature may affect a patient's temperature and pulse. A rectal temperature of 99.0°F correlates with an oral temperature of 98.1°F, which is within normal limits. Body temperature can affect pulse and respiratory rate.
The nurse is validating the NAP's skill with respiratory rate assessment. Which of the following actions, if made by the NAP, indicates that further instruction is needed? A. When a patient inhales a breath, the NAP counts that as one, and when the patient exhales the breath, the NAP counts that as two. B. When the patient's respiratory rate is irregular, the NAP counts the patient's respirations for 1 full minute. C. When the patient's respiratory rate is less than 12 or greater than 20, the NAP counts the patient's respirations for 1 full minute. D. After taking the patient's pulse, the NAP continues to hold the patient's wrist, moving the arm across the patient's chest, and focuses on the patient's breathing.
Answer: A. Respiratory rate is equivalent to the number of respiratory cycles (one inspiration and one expiration) per minute. The NAP should assess the patient's respiratory rate for 1 full minute if the patient's respiratory rhythm is irregular, less than 12, or greater than 20.
Why are the hands rinsed with the fingertips held lower than the wrist? A. Water flows from the least to the most contaminated area, rinsing microorganisms into the sink. B. To keep the sleeves from getting wet. C. It is necessary to ensure that all surfaces of the hands, including under the nails, are cleansed. D. To loosen and remove dirt and bacteria.
Answer: A. The hands and forearms are kept lower than the elbows, and the fingertips are kept lower than the wrists during washing to promote the flow of water from the least to the most contaminated area, rinsing microorganisms into the sink. Use of an adequate amount of detergent and vigorous lathering and rubbing of the hands together for an appropriate length of time (15 seconds) ensures that all surfaces of the hands and fingers are covered and cleansed. Friction and rubbing mechanically loosen and remove dirt and transient bacteria.
The patient has a history of a left mastectomy. Where should the nurse take the patient's blood pressure? A. In the right arm B. In the left arm C. In the right leg D. In the left leg.
Answer: A. The nurse should take the patient's blood pressure in the opposite arm of the mastectomy, in this case, the right arm. If the patient had a shunt for dialysis, this should be avoided also.
A patient was brought to the emergency department following a motor vehicle accident. He appears drowsy, but will arouse to his name being called. He is bleeding profusely from an injury to his leg. What would the nurse expect his vital signs to be? A. 97.8°F (36.5°C), 110, 24, 80/40 B. 98.6°F (37°C), 84, 20, 120/80 C. 99.0°F (37.2°C), 88, 16, 130/80 D. 100.4°F (38°C), 76, 24, 140/90
Answer: A. The nurse would expect vital signs to be reflective of hypovolemic shock: tachycardic, tachypneic, and hypotensive.
A patient complains of feeling excessively tired. Which statement, if made by the NAP, indicates further instruction is necessary? A "I will turn the continuous pulse oximetry alarms off at night so you can sleep without interruption." B. "I can give you a back massage to help you relax." C. "What kind of nighttime ritual helps you go to sleep?" D. "If the finger clip is bothering you, I can attach a probe to your ear." E. "I will notify the nurse and the two of you can determine whether you need your sleeping medication."
Answer: A. The oximeter alarms should remain on for continuous pulse oximetry. Further inquiry may assist the staff in meeting the patient's need for sleep.
The nurse is caring for four individuals. Which patient would be most at-risk for infection? A. The patient who is receiving immunosuppressive medication. B. The patient who is unable to shower without assistance. C. The patient with a history of a latex allergy. D. The patient who exercises daily in a swimming pool.
Answer: A. The patient receiving immunosuppressive medication would have an impaired or delayed response to antigens and would be at increased risk for infection. This would include such medications as steroids and chemotherapeutic drugs. Contact sports places a patient at-risk for certain infections. Hypoallergenic (latex-free) gloves can be used with patients who have an allergy to latex. Requiring assistance to bathe does not place the person at-risk for infection. The patient may still receive hygienic care.
Which of the following vital signs are expected for the adult patient who is experiencing cyanosis? A. Temp 98.6° F (37 °C), P-102, R-28, BP 98/50, O2 sat 85%. Correct B. Temp 97.9° F (36.6 °C), P-80, R-18, BP 140/90, O2 sat 95%. C. Temp 98.2° F (36.8 °C), P-64, R-16, BP 120/80, O2 sat 96%. D. Temp 97.5° F (36.4 °C), P-76, R-20, BP 110/70, O2 sat 95%.
Answer: A. The patient with cyanosis would most likely have an oxygen saturation below the normal limits of 95% to 100%. The respiratory rate and the heart rate may also be elevated as the body attempts to compensate for a decrease in oxygen. A decreased blood pressure may be evident in the person who is experiencing hypovolemic shock. An elevated blood pressure reading is not an expected finding associated with cyanosis; rather, a decreased oxygen saturation reading would be expected.
The NAP is preparing to measure a patient's vital signs. The patient reports having eaten a bowl of warm soup. The NAP asks the RN what he should do. What is the best response? A. "Ask the patient not to eat, drink, or smoke for 15 minutes and then assess the patient's oral temperature." B. "Since the soup was not hot, go ahead and take the patient's temperature." C. "Change to the red thermometer probe and take the patient's temperature rectally." D. "Take the patient's temperature using the axillary route and when you record the reading, add 1°F."
Answer: A. The temperature of food or liquid could impair the accuracy of the reading. The NAP should ask the patient not to eat, drink, or smoke for 15 minutes and then assess the oral temperature. Taking a rectal temperature can be needlessly embarrassing and uncomfortable for the patient. Although the axillary route could be used, it is less accurate than the oral route. Furthermore, when recording an axillary temperature reading, the site is documented, but the reading itself is unchanged.
Your newborn patient's temperature has been rising rapidly and the baby has been crying. Which of the following thermometers would be the best to use in measuring this patient's temperature? A. Temporal artery B. Tympanic C. Chemical dot D. Rectal electronic
Answer: A. The temporal artery thermometer reflects rapid change in core temperature and can be used on newborns. The tympanic membrane sensor is unable to accurately measure core temperature changes during and after exercise. Chemical dot thermometers are inappropriate for use when there is a sudden and/or variable rise in temperature. It would be unnecessary to use a rectal thermometer and could cause bowel perforation if inserted too far on a newborn.
The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics? A. Risk for aspiration B. Acute confusion C. Readiness for enhanced coping D. Sedentary lifestyle
Answer: A. A risk diagnosis does not have defining characteristics, but instead risk factors. Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem.
Which of the following is the most effective way to break the chain of infection? A. Hand hygiene B. Wearing gloves C. Placing patients in isolation D. Providing private rooms for patients
Answer: A. Hands become contaminated through contact with the patient's environment. Clean hands interrupt the transmission of microorganisms.
The licensed practice nurse (LPN) provides you with the change-of-shift vital signs on four of your patients. Which patient do you need to assess first? A. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% B. 54-year-old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72 C. 63-year-old man with venous ulcers from diabetes, temperature 37.3°C (99.1°F), HR 84 D. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62
Answer: A. Oxygen saturation is low, indicating a problem with ventilation or diffusion, which is related to the respiratory rate.
Your ungloved hands come in contact with the drainage from your patient's wound. What is the correct method to clean your hands? A. Wash them with soap and water. B. Use an alcohol-based hand cleaner. C. Rinse them and use the alcohol-based hand cleaner. D. Wipe them with a paper towel.
Answer: A. Physically removing wound drainage is most effectively accomplished by washing with soap and water.
A patient who visits the allergy clinic tells the nurse practitioner that he is not getting relief from shortness of breath when he uses his inhaler. The nurse decides to ask the patient to explain how he uses the inhaler, when he should take a dose of medication, and what he does when he gets no relief. On the basis of Gordon's functional health patterns, which pattern does the nurse assess? A. Health perception-health management pattern B. Value-belief pattern C. Cognitive-perceptual pattern D. Coping-stress tolerance pattern
Answer: A. The nurse assesses the patient's understanding of his therapy and level of adherence. She also assesses his health practices.
The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? A. Appearance and behavior B. Measurement of vital signs C. Observing specific body systems D. Conducting a detailed health history
Answer: A. The nurse inspects appearance and behavior first as part of the nursing assessment. As the patient enters the room, the nurse can observe his or her appearance and behavior, noting any unusual choice of clothing or hygiene or any signs of confusion, anxiety, or happiness.
The nurse is working in a busy emergency room. On entering station 1, the nurse dons a pair of clean disposable gloves. The nurse sees that the patient has a gunshot wound to the chest, and is concerned there may be splattering of infectious materials. The nurse applies goggles, a mask, and a gown. What is this called? A. Following standard precautions. B. Using medical asepsis. C. Using surgical asepsis. D. Infection control to prevent a healthcare-acquired infection.
Answer: A. The nurse is demonstrating the use of standard precautions. Standard precautions are used to protect the nurse from potential contact with blood and body fluids. Because there is a risk of being splattered with infectious materials, the nurse should use gloves, mask, eye protection, and a gown. Standard precautions should become a routine part of her practice and thus be observed in every patient encounter. Medical asepsis (or clean technique), includes procedures used to reduce the number of and prevent the spread of microorganisms. Surgical asepsis (or sterile technique), includes procedures used to eliminate all microorganisms from an area. Healthcare-acquired infections are those that develop as a result of a stay or visit in a health care facility and that were absent at the time of admission.
During a home health visit the nurse prepares to instruct a patient in how to perform range-of-motion (ROM) exercises for an injured shoulder. The nurse verifies that the patient took an analgesic 30 minutes before arrival at the patient's home. After discussing the purpose for the exercises and demonstrating each one, the nurse has the patient perform them. After two attempts with only the second of three exercises, the patient stops and says, "This hurts too much. I don't see why I have to do this so many times." The nurse applies the critical thinking attitude of integrity in which of the following actions?" A. "I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let's go a bit more slowly and try to relax." B. "I see that you're uncomfortable. I'll call your doctor to decide the next step." C. "Show me exactly where your pain is and rate it for me on a scale of 0 to 10." D. "Is anything else bothering you? Other than the pain, is there any other reason you might not want to do the exercises?"
Answer: A. The nurse reviews the position of requiring exercises to restore function and decides to try a different approach to proceed, which is an example of integrity. In answer B the nurse does not reinforce the importance of exercises, which is likely the standard of care for this type of patient. In answer C the nurse is interpreting further to determine if any other physical problems are developing. In answer D the nurse is showing curiosity, attempting to learn if any other underlying problems exist.
A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid in the intravenous (IV) line, and the patient asking to be turned. Which of the following does the nurse perform first? A. Reconnect the drainage tubing B. Inspect the condition of the IV dressing C. Improve the patient's comfort and turn onto her side. D. Obtain the next IV fluid bag from the medication room
Answer: A. The priority is to reconnect the drainage tube. This can be done quickly and prevents fluid loss and reduces risk of infection spreading up into the tube. Next the nurse turns the patient for comfort. With 100 mL of fluid remaining, the nurse has time to perform these tasks. The nurse can inspect the IV dressing last, after going to obtain the next IV fluid bag.
Before consulting with a physician about a patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill? A. Cognitive B. Interpersonal C. Psychomotor D. Consultative
Answer: A. Thinking and anticipating how to approach implementation involve a cognitive implementation skill. The nurse considers the rationale for an intervention and evidence in nursing science that supports that intervention or alternatives.
Immobilized patients are at risk for impaired skin integrity. Which of the following interventions would reduce this risk? (Select all that apply.) A. Repositioning patient every 1 to 2 hours while awake B. Using an objective, valid scale to assess patient's risk for pressure ulcer development C. Using a device to relieve pressure when patient is seated in chair D. Teaching patient how to shift weight at regular intervals while sitting in a chair E. A good rule is: the higher the risk for skin breakdown, the shorter the interval between position changes
Answer: B, C, D, E.
Your patient wears full dentures. His usual denture care includes taking the teeth out once a day to brush. He wears the dentures overnight. You are concerned that he might be at risk for developing denture-induced stomatitis. Which points do you include in a teaching plan for denture care? (Select all that apply.) A. Remove dentures overnight once a week while they soak in a cleansing bath. B. Do not wear damaged or poorly fitting dentures. C. Observe mouth for reddened areas under the dentures and small red sores on the roof of the mouth. D. See dentist regularly. E. Rinse dentures after meals. F. Clean dentures every night with cleanser, rinsing well before replacing in mouth at bedtime.
Answer: B, C, D, E.
An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment you note that the patient cannot tolerate lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.) A. B/P = 128/84 B. Respirations 26 per minute on room air C. HR 114 D. Crackles heard on auscultation E. Pain reported as 3 on scale of 0 to 10 after medication
Answer: B, C, D.
The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. The patient has recurrent redness in the perineal area, and there is concern that he is developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. She calls the ostomy and wound care specialist and asks that he visit the patient to recommend skin care measures. Which of the following describe the nurse's actions? (Select all that apply.) A. The application of the skin barrier is a dependent care measure. B. The call to the ostomy and wound care specialist is an indirect care measure. C. The cleansing of the skin is a direct care measure. D. The application of the skin barrier is a direct care measure.
Answer: B, C, D. The call to the ostomy and wound care specialist is an indirect care measure involving collaborative care. Cleansing the skin is an independent direct care measure. Applying the skin barrier is an independent nursing measure involving direct care.
The nurse cared for a 14-year-old with renal failure who died near the end of the work shift. The health care team tried for 45 minutes to resuscitate the child with no success. The family was devastated by the loss, and, when the nurse tried to talk with them, the mother said, "You can't make me feel better; you don't know what it's like to lose a child." Which of the following examples of journal entries might best help the nurse reflect and think about this clinical experience? (Select all that apply.) A. Data entry of time of day, who was present, and condition of the child B. Description of the efforts to restore the child's blood pressure, what was used, and questions about the child's response C. The meaning the experience had for the nurse with respect to her understanding of dealing with a patient's death D. A description of what the nurse said to the mother, the mother's response, and how the nurse might approach the situation differently in the future
Answer: B, C, D. The nurse can reflect on the effects of the treatment and what was difficult or confusing about the outcome. The nurse reviews the meaning of the experience to help improve understanding of personal comfort and competence in dealing with death and how to respond in the future. The nurse reflects on the communication approach used with the mother to consider if it was appropriate.
The NAP tells you that the patient's pulse oximetry is 85% on room air. What nursing action(s) should you take? (Select all that apply.) A. Start oxygen at 2 liters per minute by nasal cannula. B. Reassess pulse oximetry. C. Place the patient in the high-Fowler's position. D. Have the NAP take the patient's vital signs. E. Assess the patient's respiratory and cardiac status.
Answer: B, C, E. The first action you should take is to reassess the patient's pulse oximetry, making sure the probe is intact and correctly positioned. You may place the patient in the high-Fowler's position to promote optimal ventilation. Observe the patient for signs of decreased oxygenation such as anxiety, restlessness, tachycardia, etc. Assess the patient's complete respiratory status (i.e., auscultate lung sounds). Assess the patient for signs of altered cardiac output (cool skin, decreased blood pressure, etc.). If the patient is unstable, you should assess the patient's vital signs rather than delegating this task to NAP. You may prepare to initiate oxygen therapy, but a physician's order is required for implementation. If the patient's pulse oximetry remains below acceptable parameters, obtain additional assessment data (i.e., vital signs, cardiopulmonary assessment) and notify the physician. The physician will determine whether arterial blood gases are necessary.
The nurse in a geriatric clinic collects the following information from an 82-year-old patient and her daughter, the family caregiver. The daughter explains that the patient is "always getting lost." The patient sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, "I just don't know what to do because I worry she will fall or hurt herself." The daughter states that, when she took her mother to the store, they became separated, and the mother couldn't find the front entrance. The daughter works part time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern? (Select all that apply.) A. Daughter's concern of mother's risk for injury B. Pacing C. Patient getting lost easily D. Daughter working part time E. Getting up frequently
Answer: B, C, E. Pacing, getting lost, and hyperactivity are a cluster of defining characteristics that point to the diagnostic label of wandering.
A home care nurse is preparing the home for a patient who is discharged to home following a left-sided stroke. The patient is cooperative and can ambulate with a quad-cane. Which of the following must be corrected or removed for the patient's safety? (Select all that apply.) A. The rubber mat in the walk-in shower B. The three-legged stool on wheels in the kitchen C. The braided throw rugs in the entry hallway and between the bedroom and bathroom D. The night-lights in the hallways, bedroom, and bathroom E. The cordless phone next to the patient's bed
Answer: B, C.
A patient who is receiving chemotherapy has inflamed gums and oral mucosa and painful sores in the mouth. Which of the following oral care actions are appropriate? (Select all that apply.) A. Decreasing frequency of oral hygiene B. Applying water-soluble moisturizing gel on the oral mucosa C. Encouraging intake of soft foods D. Using commercial mouthwash
Answer: B, C.
In which of the following patients would the nurse expect to find a decrease in pulse rate? (Select all that apply.) A. A newborn. B. A patient returning from OR after having a hip replacement. C. A patient who received morphine for severe cancer pain. D. A student who is getting ready to take a final exam. E. A patient who had a bleeding episode.
Answer: B, C. Having general anesthesia or receiving an opioid analgesic may decrease the pulse rate. A newborn has a higher pulse rate than an adult. Sympathetic stimulation such as anxiety will increase the pulse rate. Having a decreased fluid volume will increase the pulse rate as the heart attempts to compensate to maintain cardiac output.
You are supposed to take your patient's vital signs preoperatively and record them on the patient's record as part of the patient's preparation for surgery. Why is it necessary to take vital signs preoperatively? (Select all that apply.) A. To see if the patient is "feeling funny." B. To provide a set of vital signs to use for comparison during and after surgery. C. To make sure the patient is not experiencing any complications such as a high fever that may contraindicate surgery or require intervention at this time. D. To provide the patient with reassurance that he or she is being cared for by a competent staff.
Answer: B, C. The patient who is going to surgery is going to experience a change in condition and an invasive procedure. Vital signs are necessary so that the operative team has a baseline for comparison as well as to rule out any complications before the beginning of the surgical event. Providing reassurance to the patient can be done verbally.
Which of the following are examples of collaborative problems? (Select all that apply.) A. Nausea B. Hemorrhage C. Wound infection D. Fear
Answer: B, C. Hemorrhage and wound infection are collaborative problems, actual or potential physiological complications. Nurses typically monitor for these to detect changes in a patient's status. Nausea and fear are both NANDA-I approved nursing diagnoses. (Collaborative Problem: Physiological complication that requires the nurse to use nursing- and health care provider-prescribed interventions to maximize patient outcomes.)
A 58-year-old patient with nerve deafness has come to his doctor's office for a routine examination. The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient? (Select all that apply.) A. Maintain a neutral facial expression B. Lean forward when interacting with the patient C. Acknowledge the patient's answers through head nodding D. Limit direct eye contact
Answer: B, C. Leaning forward shows that the nurse is aware and attending to what the patient is saying. The use of head nodding regulates the interaction and makes it easier for the patient to know the nurse's responses to his comments. A neutral expression does not express warmth or immediacy, which is needed to establish a positive relationship. Good eye contact communicates the nurse's interest in what the patient has to say.
A nurse is assigned to a patient who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment the nurse anticipates the need to monitor the patient's abdominal dressing, intravenous (IV) infusion, and function of drainage tubes. The patient is in pain, reporting 6 on a scale of 0 to 10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the patient. The nurse establishes priorities first for which of the following situations? (Select all that apply.) A. The family comes to visit the patient. B. The patient expresses concern about pain control. C. The patient's vital signs change, showing a drop in blood pressure. D. The charge nurse approaches the nurse and requests a report at end of shift.
Answer: B, C. Pain control is a priority, because it is severe and affects the patient's ability to rest after surgery and be able to perform necessary activities. A change in vital signs is a priority, and the change could be related to the patient's pain. However, because of the nature of surgery, the nurse has to reassess for any bleeding, which lowers blood pressure. Attending to the family is important to lend the patient needed support, but it is not the initial priority. Finally the nurse must attend to urgent patient needs before completing a report.
In which of the following examples is a nurse applying critical thinking attitudes when preparing to insert an intravenous (IV) catheter? (Select all that apply.) A. Following the procedural guideline for IV insertion B. Seeking necessary knowledge about the steps of the procedure from a more experienced nurse C. Showing confidence in performing the correct IV insertion technique D.Being sure that the IV dressing covers the IV site completely
Answer: B, C. Seeking necessary knowledge about the steps of the procedure shows humility. The nurse recognizes that she needs clarification from a senior colleague. Another example of a critical thinking attitude is confidence. In this case confidently inserting an IV line allows the nurse to convey expertise and a sense of calm, leading the patient to trust the nurse. Following policy and procedure is an example of following standards of care, not of a critical thinking attitude. Making sure that the dressing is covered is a step in following good standards of IV care but is not a critical thinking attitude.
A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of risk for impaired skin integrity. Which of the following goals are appropriate for the patient? (Select all that apply.) A. Patient will be turned every 2 hours within 24 hours. B. Patient will have normal bowel function within 72 hours. C. Patient's skin will remain intact through discharge. D. Patient's skin condition will improve by discharge.
Answer: B, C. The skin remaining intact is an appropriate goal for the patient's at-risk diagnosis. Answer 2 is also appropriate since it indicates removal of a risk factor. Answer 1 is an intervention; answer 4 is a poorly written goal that is not measurable.
A 56-year-old female patient has been admitted with a diagnosis of pneumonia. Which information should be provided to the NAP delegated to take her temperature? (Select all that apply.) A. The patient's age. B. The type of temperature required. C. The patient's diagnosis. D. The frequency for taking or monitoring the temperature. E. What changes to report immediately to the nurse.
Answer: B, D, E. It is more important that the temperature be done on time by the correct route, with the correct equipment, and that identified changes be reported as requested.
A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant tells you his admitting vital signs. Which measurement should you reassess? (Select all that apply.) A. Right arm BP: 120/80 B. Radial pulse rate: 72 and irregular C. Temporal temperature: 37.4°C (99.3°F) D. Respiratory rate: 28 E. Oxygen saturation: 99%
Answer: B, D, E. An irregular pulse may be the result of a complication of heart disease and requires the assessment of the apical rate. A respiratory rate of 28 is abnormal, yet the oxygen saturation is normal. Both oxygen saturation and respiratory rate would be expected to be outside of the acceptable range.
The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72. Which of the following data form a cluster, showing a relevant pattern? (Select all that apply.) A. Vital sign results B. Abdominal distention C. Age of patient D. Change in bowel elimination pattern E. Abdominal pain F. No past history of hospitalization
Answer: B, D, E. The presence of abdominal pain, distention, and a change in bowel elimination pattern forms a cluster, suggesting an elimination problem.
The patient reports an allergy to latex. What alterations should be made in the patient's care? (Select all that apply.) A. Have a nurse who is also allergic to latex provide the patient's care. B. Use latex-free or synthetic gloves when gloves are necessary. C. Avoid wearing gloves unless absolutely necessary and only for short periods of time. D. Remove items that contain latex in the care of the patient. E. Avoid use of alcohol-based hand rubs. F. Determine whether syringes, IV tubing, catheters contain latex.
Answer: B, D, F. For individuals at high risk or with suspected sensitivity to latex, it is important to choose latex-free or synthetic gloves and to inspect the contents of all sterile kits for items that contain latex (e.g., an indwelling catheter).
The nurse is caring for a patient who has reduced sensation in both feet. Which of the following should the nurse do? (Select all that apply.) A. Avoid cleaning the feet until an order from the health care provider is received. B. Wash the feet with lukewarm water and then dry well. C. Apply moisturizing lotion to the feet, especially between the toes. D. File the toenails straight across.
Answer: B, D.
An elderly patient is admitted for back surgery. She is now retired but her previous occupation was as a registered nurse. She reports that she is also allergic to morphine and penicillin. She has a history of five laminectomies (back surgeries) resulting from scoliosis as a child. She has three children who visit her. She requires a cane to ambulate. Which factors would be considered high-risk factors for latex allergy? (Select all that apply.) A. Her age. B. History of multiple surgeries as a child. C. Allergy to morphine and penicillin. D. Occupation. E. Use of a cane.
Answer: B, D. High-risk factors for a latex allergy include a history of spina bifida, congenital or urogenital defects, indwelling catheter, placement or repeated catheterizations, adverse reactions during surgery or dental procedures, use of condom catheters, multiple childhood surgeries, food allergies (papaya, avocado, banana, peach, kiwi, tomato), and high latex exposure (e.g., housekeepers, food handlers, health care workers). This patient has the risk factors of a history of multiple surgeries and her previous occupation as a registered nurse, where she was often in contact with latex. These factors placed her at high exposure to latex in her past. Her age, known allergies, and the use of a cane are unrelated to a risk for latex allergy.
Which of the following outcome statements for the goal, "Patient will achieve a gain of 10 lbs (4.5 kg) in body weight in a month" are worded incorrectly? (Select all that apply.) A. Patient will eat at least three fourths of each meal by 1 week. B. Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week. C. Patient will eat foods with high-calorie content by 1 week. D. Give patient liquid supplements 3 times a day.
Answer: B, D. Answer B is not singular, and answer D is an intervention.
A nurse caring for a patient with pneumonia sits the patient up in bed and suctions the patient's airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water. Which of the following would be appropriate evaluative criteria used by the nurse? (Select all that apply.) A. Patient drinks contents of water glass. B. Patient's lungs are clear to auscultation in bases. C. Patient reports abdominal pain on scale of 0 to 10. D. Patient's rate and depth of breathing are normal with head of bed elevated.
Answer: B, D. The criteria of clear lung sounds and rate and depth of breathing are evaluative criteria for determining if the patient's airway is clear. Drinking the contents of the water glass is a completed intervention. The patient's report of pain is assessment data.
A patient comes to a medical clinic with the diagnosis of asthma. The nurse practitioner decides that the patient's obesity adds to the difficulty of breathing; the patient is 5 feet 7 inches tall and weighs 200 pounds (90.7 kg). Based on the nursing diagnosis of imbalanced nutrition: more than body requirements, the practitioner plans to place the patient on a therapeutic diet. Which of the following are evaluative measures for determining if the patient achieves the goal of a desired weight loss? (Select all that apply.) A. The patient eats 2000 calories a day. B. The patient is weighed during each clinic visit. C. The patient discusses factors that increase the risk of an asthma attack. D. The patient's food diary that tracks intake of daily meals is reviewed.
Answer: B, D. Weighing the patient during each clinic visit and reviewing a food diary indicate whether weight loss is occurring and if the patient is eating the proper foods designed to reduce his or her weight.
You ask the nursing assistive personnel (NAP) to clean a patient who has been incontinent of urine. Several minutes later you pass the open door of the room and see the NAP changing the patient's gown and linen. Which of the following requires your immediate attention? A. Room temperature is overly warm. B. Room door is open to the hallway. C. Television volume is too loud. D. Strong odor of urine is detected.
Answer: B. This violates the patient's privacy. Although attention to the room temperature, noise level, and odor is required, the immediate concern is with privacy.
You are washing your hands in a sink with hand faucets. You first turn on the water and regulate the temperature to warm. You increase the water pressure to create a strong spray. You wet your hands, apply 1 teaspoon (5 mL) of soap, and rub your hands together vigorously, creating lather. You interlace your fingers and rub the palms and backs of the hands with a circular motion at least five times each. You keep your hands positioned with fingertips down and rinse the hands and wrists thoroughly. You turn off the faucet. You dry your hands with a paper towel. Which step(s) are incorrect? (Select all that apply.) A. The temperature of the water. B. The force of the water. C. The amount of soap used. D. The technique used in lathering. E. The position of your hands. F. The method used to turn off the faucet.
Answer: B, F. The temperature of the water should be warm. Water that is too hot can cause injury to the hands, promoting cracks in the skin. The force of the water (a strong spray) is likely to cause splashing water against the uniform. Microorganisms travel and grow in moisture, so getting the uniform wet should be avoided. You should use 3 to 5 mL of detergent. You correctly lathered your hands. The position of your hands with fingertips down is correct. The faucet should be turned off with a new, clean paper towel, usually done after drying the hands.
A nurse is preparing a medication for subcutaneous administration. As the nurse recaps the needle using the scoop method, the nurse accidentally touches the table with the uncovered needle. What is the nurse's best action? A. Discard the needle, syringe, and medication and start over. B. Discard the needle and replace with a new one before administration. C. Wipe the needle with an alcohol swab and recap for use. D. Transfer the medication to a new syringe.
Answer: B.
The nurse is adding a dry sterile gauze dressing to the sterile field. The dressing bounces on the surface and lands on the outer 1-inch border of the sterile field. What action is appropriate at this time? A. The nurse discards the entire sterile field, all items upon it, and starts over. B. The nurse opens another sterile gauze dressing and adds it to the sterile field, but does not use the first one. C. Once sterile gloves are applied, the nurse moves the sterile gauze dressing to the center of the sterile field. D. The nurse continues with the procedure adding supplies to the sterile field and using each of them as needed.
Answer: B.
While assessing the adult patient's lungs, the nurse identifies the following assessment findings. Which finding should be reported to the health care provider? A. Respiratory rate: 14 B. Pain reported when palpating posterior lower thorax C. Thorax rising and falling symmetrically for right and left lungs D. Vesicular breath sounds heard with auscultation of peripheral lung fields
Answer: B. Any areas of tenderness or pain over the posterior thorax could indicate injury such as a broken rib or disturbance of the integumentary system. Further palpation should be avoided until more assessment data are collected, either through further health history or diagnostic testing. All other findings are normal.
A nurse assists a patient with a Foley catheter to ambulate down the hall. The nurse holds the catheter bag above the level of the patient's bladder. What link in the chain of infection is the nurse breaking by doing so? A. Portal of exit. B. Portal of entry. C. Reservoir. D. Host susceptibility.
Answer: B. By not allowing the urine from the bedside drainage bag to re-enter the bladder, the nurse is breaking the chain of infection at the portal of entry. Emptying the bedside drainage bag may be an example of controlling the reservoir. Host susceptibility has to do with issues such as age, nutritional status, medical treatments, immunizations, etc.
The nurse should routinely auscultate the apical pulse with the bell side of the stethoscope, and use the diaphragm side to identify heart murmurs. A. True. B. False.
Answer: B. For routine auscultation of the apical pulse, you should rely on the diaphragm side of the chest piece because it is designed to pick up higher-pitched heart sounds like that of the apical pulse.The bell side of the stethoscope should be used to assess heart sounds to identify murmurs.
Which of the following patients would be considered hypertensive after having two or more consistent readings of these values? A. An African-American patient with a systolic BP of 100. B. A football player with a diastolic BP of 94. C. An elderly patient with a systolic BP of 88. D. A pregnant woman with a diastolic BP of 67.
Answer: B. Hypertensive patients typically have a systolic blood pressure greater than 140 and a diastolic blood pressure greater than 90. Hypotensive patients have a SBP of less than 90 mm Hg. Although African-Americans and the elderly are more likely to have hypertension, race and age alone do not determine who would be hypertensive.
Why do you take BP in both arms on a "new" patient? A. To practice your technique. B. To ensure that you obtain an accurate BP reading. C. Because there is always a difference in dominant and nondominant hands, and it is good to know what that is. D. To assess for a pulse deficit.
Answer: B. If readings are different by more than 5 mm Hg, additional readings are necessary. Report the differences to a health care provider. Although practice is a good idea, it is better to practice with your friends and family. The primary reason for taking pressure in both arms is to assess for differences between arms. A pulse deficit is a measure of differences in apical and radial pulse, not differences in BP.
For which patient should you avoid using a leg pressure cuff (thigh cuff) to assess BP? A. A patient without arms. B. A patient with a deep vein thrombosis (blood clot, usually in the lower extremities). C. A patient with a history of a CVA (stroke). D. A patient who has an arteriovenous shunt located in the forearm for hemodialysis.
Answer: B. Leg pressure cuffs should be avoided on patients with deep vein thrombosis.
Which of the following vital signs recorded for an older adult would be considered acceptable (within normal limits)? A. Temp 96.8° F (36 °C), P-60, R-18, BP 160/90, O2 sat 93%. B. Temp 97.0° F (36.1 °C), P-60, R-16, BP 116/78, O2 sat 95%. C. Temp 98.6 °F (37 °C), P-56, R-20, BP 120/80, O2 sat 91%. D. Temp 98.0 °F (36.7 °C), P-76, R-22, BP 110/70, O2 sat 88%.
Answer: B. Normal values for an older adult are: average body temperature approximately 36° C (96.8° F), heart rate 60 to 100 beats per minute, respiratory rate 12 to 20 breaths per minute, average BP less than 120 over 80, and pulse oximetry 95% to 100%. A BP greater than 140 over 90 may be an indication of hypertension.
You are taking a patient's BP by using the one-step method. Which of the following is an incorrect step in the sequence for performing this procedure? A. Perform hand hygiene. Select the appropriate-size cuff. With the patient sitting, place the forearm at heart level, palm up. Provide privacy and explain the procedure. B. Expose the arm and apply the cuff around the upper arm. Palpate for a brachial pulse. Place the stethoscope in your ears and place the diaphragm over the site of the brachial pulse. C. Pump the cuff to 20 mm Hg above the patient's normal diastolic pressure. Release the valve quickly. Observe the needle fall. Identify the onset of the first Korotkoff sound in mm Hg. D. Listen for the last Korotkoff sound in mm Hg. Completely deflate the cuff and remove it from the patient's arm. Make the patient comfortable. Perform hand hygiene. Document the result.
Answer: B. Pumping the cuff to 20 mm Hg above the patient's normal diastolic pressure is an incorrect step in the sequence. The cuff should be pumped 30 mm Hg above the patient's normal systolic pressure, and the valve should be released slowly, not quickly.
A nurse is teaching infection control to a group of daycare workers. Which of the following should the nurse include in the instruction? A. Washing hands with soap and water is the only effective means for stopping the spread of germs. B. Immunizations help protect children from being susceptible hosts. C. Large containers of hand sanitizer should be made available for use when there is visible soiling. D. Toys are typically the reservoir of pathogen growth.
Answer: B. Receiving immunizations helps prevent being a susceptible host. Alcohol-based hand rubs are also effective for reducing microorganisms. Hand washing should be used when there is visible soiling. Smaller containers of hand sanitizer are preferred as microorganisms may begin to reside in larger containers. Toys are typically the vehicle for transmission in the chain of infection.
The student nurse is unsure of the BP measurement. What should the student nurse do first? A. Repeat the measurement on the same arm within 30 seconds. B. Measure the BP in the other arm. C. Get the RN to assess the BP. D. Determine whether the patient has had his or her BP medication.
Answer: B. Repeating a BP too quickly will result in a false high diastolic reading. Wait 1 to 2 minutes to repeat a measurement, or measure the pressure in the opposite arm.
A nurse caring for a male patient observes the nursing assistive personnel (NAP) performing perineal care. Which of the following observed actions indicates a need for further teaching for the NAP? The NAP: A. Used clean gloves. B. Did not retract the foreskin before cleansing. C. Used the clean portion of washcloth for each cleansing wipe. D. Used a circular motion to cleanse from urinary meatus outward.
Answer: B. Secretions collect beneath the foreskin and can promote bacterial growth if not removed.
The nurse is teaching a young female patient to practice good skin health. Which information is important for the nurse to include? A. Avoid sunbathing between 3 PM and 7 PM. B. Oral contraceptives and antiinflammatories make the skin more sensitive to the sun. C. Call the health care provider for the presence of a mole on an arm or leg that appears uniformly brown. D. Wear sunscreen with an SPF of 30 or greater if using a sunlamp or tanning parlor.
Answer: B. Some medications such as oral contraceptives or antiinflammatory medications may increase the skin's sensitivity to ultraviolet (UV) rays. Skin self-care and self-evaluation practices include avoiding the sun when UV rays are strongest (10 AM to 4 PM). In addition, good skin practices indicate that skin protection should be used when using a tanning bed or sunlamp. Moles that are uniformly brown are not a cause of concern.
Who would you expect to have the lowest body temperature? A. A 16-year-old who ran 1 mile. B. An 80-year-old who walked half a mile. C. A toddler who is febrile. D. A child playing softball.
Answer: B. The 80-year-old would have a lower starting temperature and therefore, would most likely have the lowest body temperature although it may take longer to return to baseline after exercise. To be febrile means to have a fever. The toddler would fail to have the lowest body temperature. A 16-year-old will have a higher starting body temperature, and exercise will increase the body temperature further. A child will have a higher starting temperature and exercise will increase the body temperature further.
A patient of any age can develop a contracture of a joint when: A. The adductors muscles are weakened as a result of immobility. B. The muscle fibers become shortened because of disuse. C. The calcium-to-phosphorus ratio becomes disrupted. D. There is a deficiency in vitamin D.
Answer: B. The adductor muscles are stronger than the abductor muscles; when patients are immobile and the joint is not exercised through their ROM, the adductor muscle fibers shorten, resulting in the contracture of that joint, which is usually permanent.
What is the best nursing practice to reduce the potential transmission of microorganisms within the health care setting? A. Bagging all linen. B. Performing hand hygiene. C. Keeping catheter bags empty. D. Wearing gloves.
Answer: B. The best practice to prevent the transmission of microorganisms for all caregivers is performing hand hygiene before and after patient contact.
To apply sterile gloves, To apply sterile gloves, the nurse applied the first glove on the right hand. Where should the nurse pick up the remaining glove? A. At the top edge of the cuff. B. Underneath the second glove's cuff. C. Anywhere, because the entire glove is sterile. D. You should pick it up with your ungloved hand.
Answer: B. The fingers of the gloved hand should be slid underneath the cuff of the second glove, avoiding touching any exposed areas. The cuff protects the gloved fingers. If the nurse picks up the glove at the top edge of the cuff, it will be very likely that the gloved hand will touch exposed skin at the wrist when pulling the glove over the fingers of the second hand. Picking up the second glove anywhere may make pulling the glove on over the fingers and hand more difficult and increase the risk of touching exposed skin with the sterile gloved hand. It would be very difficult to apply a glove with only one hand and highly likely to result in contamination.
What is the normal pulse range for an adult? A. 120 to 160 beats per minute. B. 90 to 140 beats per minute. C. 60 to 100 beats per minute. D. 50 to 80 beats per minute.
Answer: C. The normal pulse range for an adult is 60 to 100 beats per minute. The the pulse rate of a newborn is 120 to 160 beats per minute. The pulse rate of a 2-year-old is 90 to 140 beats per minute.
The nursing instructor is asking the nursing students to share their knowledge regarding sterile gloving. Which statement, if made by a student, would require correction? A. "Be sure to select appropriate size gloves. Gloves that are too small can tear more easily." B. "Once sterile gloves are applied, the inside of the glove is still considered sterile." C. "Be sure to select appropriate size gloves. Gloves that are too large can impede your ability to pick up items and perform your task." D. "If you touch a nonsterile item with your sterile gloved hands, you should remove the gloves and obtain a new pair."
Answer: B. The inside of sterile gloves is considered nonsterile once it touches the skin. Gloves that are too small may tear more easily and gloves that are too large may impeded your ability to pick up items and perform tasks. If you touch a nonsterile item with your sterile gloved hands, you should remove the now contaminated gloves and obtain a new pair.
Which is an outcome for a patient diagnosed with osteoporosis? A. Maintain serum level of calcium. B. Maintain independence with activities of daily living (ADLs). C. Reduce supplemental sources of vitamin D. D. Reverse bone loss through dietary manipulation.
Answer: B. The main goal is to maintain independence in ADLs once osteoporosis is diagnosed. It is best to identify individuals at risk and work toward preventing the disease.
If a 52-year-old patient has a normal temperature, what range should the patient's temperature fall within? A. 37-39 °C (98.6-102.2 °F) B. 96.8-100.4 °F (36-38 °C) C. 35-36 °C (95-96.8 °F) D. 96.8-98.6 °F (36-37 °C)
Answer: B. The normal temperature range for an adult is 96.8° F to 100.4° F or 36° C to 38° C. The normal temperature range for a newborn is 95.9° F to 99.5° F. Nursing judgment should be used to determine whether further assessment is indicated regarding an individual patient's temperature, even if it is within the identified range of normal for most people. For example, a patient recovering from a stroke with a feeding tube and a temperature of 99.0° should be assessed further as this may be an initial indication of aspiration.
Whenever there is an alteration in the radial pulse rate, rhythm, or amplitude, the nurse should consider: A. Checking the carotid pulse. B. Using a stethoscope and assessing the quality of the apical pulse as well as the rate. C. Counting the pulse again for 30 seconds and multiplying the results by two. D. Checking the radial pulse on the opposite side.
Answer: B. The nurse should assess the quality and rate of the apical pulse. The rate should be counted over a full minute to ensure greater accuracy. The pulse on the opposite side should also be assessed to see if the alteration is happening bilaterally, in addition to assessing the apical pulse.
The patient at greatest risk for developing multiple adverse effects of immobility is a: A. 1-year-old child with a hernia repair. B. 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA). C. 51-year-old woman following a thyroidectomy. D. 38-year-old woman undergoing a hysterectomy.
Answer: B. The older the patient and the greater the period of immobility, which can be significant following a hemorrhagic stroke, the greater is the number of systems that can be affected by the immobility.
A patient was diagnosed with a urinary tract infection. The patient has been drinking fruit juice and has increased his intake of fluids but has failed to take his antibiotic as prescribed because it caused gastric upset. Three days later, the patient presents to the clinic with fever, malaise, nausea, and vomiting. What might you suspect? A. The patient probably has the flu. B. The patient may now have a systemic infection. C. The patient is displaying signs of a localized infection. D. The patient is experiencing an allergic response to his medication.
Answer: B. The patient is displaying generalized symptoms that indicate a systemic infection. Symptoms of a localized infection such as the urinary tract may include pain, burning from edematous membranes, and frequency of urination. Because the patient failed to be treated as prescribed, you might suspect that the patient's urinary tract infection has ascended to the kidney, producing more systemic symptoms of infection. Gastrointestinal (GI) disturbance may be a side effect of the antibiotic. An allergic response would be more likely suspected if the patient developed a rash, hives, urticaria, or difficulty breathing.
The nurse is assisting a patient with rheumatoid arthritis to bathe at the sink. During the bath the patient states that she is tired. The nurse notices the patient is breathing rapidly and the pulse is rapid. What is the nurse's best response? A. Finish the bath quickly B. Help the patient return to bed C. Leave the patient alone to rest in the chair at the sink for a few minutes D. Instruct the patient to take deep breaths and try to relax
Answer: B. The report of fatigue and rapid respirations and pulse indicates that the patient is not tolerating the activity and needs to rest. Leaving the patient alone at the sink is not safe.
The nurse is reviewing with the surgical technician how to prepare a sterile field. Which of the following is incorrect and should not be included in the review? A. Keep your intended work surface above waist level. B. Place the drape so the top half of the drape is over the top half of the work surface. C. You may grasp the outer one-inch border of the drape without wearing sterile gloves. D. Place sterile items onto the sterile field at an angle.
Answer: B. The sterile drape should be placed in a direction so the bottom half of the drape is over the top half of the intended work surface. This prevents the nurse from reaching over the sterile drape once it is on the table surface. The sterile field should be at or above waist level. There is a 1-inch border around any sterile drape or wrap that is considered contaminated. To avoid reaching over the sterile field, sterile items should be placed at an angle onto the sterile field.
The NAP reports to the nurse a 65-year-old patient's blood pressure is 160/98. The initial response of the nurse is to: A. Ask the NAP if the patient received their anti-hypertensive medication this a.m. B. Assess the patient's blood pressure. C. Instruct the NAP to obtain a full set of vital signs. D. Document this as a normal finding in an elderly adult.
Answer: B. This is out of normal range. If there is a question regarding a patient's vital signs or a suspected change in the patient's condition that may require further assessment, the nurse should take the patient's vital signs rather than delegating the task.
The nursing diagnosis readiness for enhanced communication is an example of a(n): A. Risk nursing diagnosis. B. Actual nursing diagnosis. C. Health promotion nursing diagnosis D. Wellness nursing diagnosis.
Answer: C. A patient's readiness for enhanced communication is an example of a health-promotion diagnosis because it implies the patient's motivation and desire to strengthen his health.
A nurse from home health is talking with a nurse who works on an acute medical division within a hospital. The home health nurse is making a consultation. Which of the following statements describes the unique difference between a nursing care plan from a hospital versus one for home care? A. The goals of care will always be more long term. B. The patient and family need to be able to independently provide most of the health care. C. The patient's goals need to be mutually set with family members who will care for him or her. D. The expected outcomes need to address what can be influenced by interventions.
Answer: B. A community-based health care setting such as home health must work with patients and their families to set goals and outcomes that ultimately lead to a plan that allows them to provide the majority of care themselves. Answer 1 is not the case; goals will be short term and long term, depending on the patient's condition. Answer C is true for any health care setting. Answer D is an error; the outcomes allow you to direct your evaluation of care.
What is the priority concern when providing oral hygiene for a patient who is unconscious? A. Thoroughly brushing all tooth and oral surfaces B. Preventing aspiration C. Controlling mouth odor D. Applying local antiseptic such as chlorhexidine
Answer: B. Although thorough and effective cleaning is needed, measures to prevent aspiration of oral secretions and/or cleaning agents into the lungs take priority since aspiration can lead to lower respiratory infections.
A patient is being discharged after abdominal surgery. The abdominal incision is healing well with no signs of redness or irritation. Following instruction, the patient has demonstrated effective care of the incision, including cleansing the wound and applying dressings correctly to the nurse. These behaviors are an example of: A. Evaluative measure. B. Expected outcome. C. Reassessment. D. Standard of care.
Answer: B. An expected outcome is an end result that is measureable, desirable, observable, and translates into observable patient behaviors. It is a measure that tells you if the educational interventions led to successful goal achievement, the patient's self-care of the wound. An evaluative measure would be the process of observing the patient. Reassessment is a behavior performed by the nurse. The type of wound cleanser and dressings would be a standard of care.
The nurse reviews a patient's medical record and sees that tube feedings are to begin after a feeding tube is inserted. In recent past experiences the nurse has seen patients on the unit develop diarrhea from tube feedings. The nurse consults with the dietitian and physician to determine the initial rate that will be ordered for the feeding to lessen the chance of diarrhea. This is an example of what type of direct care measure? A. Preventive B. Controlling for an adverse reaction C. Consulting D. Counseling
Answer: B. Anticipating the need to start the feeding at a slower rate is an example of controlling for an adverse reaction, which in this case would be a harmful or unintended effect (diarrhea) of therapeutic intervention.
A patient was hospitalized for surgical repair of a fractured hip. Her discharge was delayed because she developed a fever and respiratory distress. A chest x-ray confirmed left lower lobe pneumonia. Which type of infection best describes what this patient has? A. An iatrogenic infection. B. A healthcare-associated infection C. A systemic infection. D. A local infection.
Answer: B. Healthcare-associated infections are those that develop as a result of a stay or visit in a healthcare facility and that were absent at the time of admission. An iatrogenic infection is a type of healthcare-associated infection resulting from a diagnostic or therapeutic procedure. An example of a systemic infection would be developing an infection at the site of her hip surgery (local) that then spread to her bloodstream (systemic). An example of a local infection would be the patient developing an infection at the site of her hip surgery (local).
When a nurse is performing surgical hand asepsis, the nurse must keep hands: A. Below elbows. B. Above elbows. C. At a 45-degree angle. D. In a comfortable position.
Answer: B. Keeping hands above the elbows when performing a surgical scrub prevents contaminated water from contact with hands.
What is the best method to sterilize a straight urinary catheter and suction tube in the home setting? A. Use an autoclave. B. Use boiling water. C. Use ethylene oxide gas. D. Use chemicals for disinfection.
Answer: B. The best sterilizer in a home setting is boiling water.
A nurse checks a patient's intravenous (IV) line in his right arm and sees inflammation where the catheter enters the skin. She uses her finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of what type of assessment? A. Agenda setting B. Problem-focused C. Objective D. Use of a structured database format
Answer: B. The nurse saw the inflammation and gathered additional information to determine if a problem existed with the IV site. The data were not all objective; the patient's report of tenderness is subjective. Setting an agenda is an interview technique. The nurse was not using a structured format for her assessment.
A 55-year-old widowed patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intravenous (IV) line is infusing in the right antecubital fossa, and pneumatic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. What sites do you instruct the nursing assistant to use for obtaining the patient's blood pressure and temperature? A Right antecubital and tympanic membrane B. Right popliteal and right axillae C. Left antecubital and oral D. Left popliteal and temporal artery
Answer: B. The only extremity that does not have a compromised artery to auscultate is the right lower leg after the sequential device is removed. The tympanic membrane and temporal artery are affected by facial surgery and oxygen mask.
A patient had hip surgery 16 hours ago. During the previous shift the patient had 40 mL of drainage in the surgical drainage collection device for an 8-hour period. The nurse refers to the written plan of care, noting that the health care provider is to be notified when drainage in the device exceeds 100 mL for the day. On entering the room, the nurse looks at the device and carefully notes the amount of drainage currently in it. This is an example of: A. Planning. B. Evaluation. C. Intervention. D. Diagnosis.
Answer: B. The patient's baseline for wound drainage was 40 mL, representing the initial assessment of the patient's wound condition. In this example the nurse is evaluating to determine if there is a change in the amount of drainage, which indicates the progress of wound healing.
A nurse checks a physician's order and notes that a new medication was ordered. The nurse is unfamiliar with the medication. A nurse colleague explains that the medication is an anticoagulant used for postoperative patients with risk for blood clots. The nurse's best action before giving the medication is to: A. Have the nurse colleague check the dose with her before giving the medication. B. Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, and the potential side effects. C. Ask the nurse colleague to administer the medication to her patient. D. Administer the medication as prescribed and on time.
Answer: B. When a nurse performs a new or unfamiliar procedure, such as giving a new medication, it is important to assess personal competency and determine if new knowledge or assistance is needed. The nurse's best action is to check with the pharmacist about the medication. Having another nurse check the dosage is appropriate if the nurse is still uncertain about the medication. Once the nurse feels prepared, the medication is administered as prescribed. You never ask a colleague to give a medication to a patient to whom you are assigned.
If an infectious disease can be transmitted directly from one person to another, it is a: A. Susceptible host. B. Communicable disease. C. Port of entry to a host. D. Port of exit from the reservoir.
Answer: B. When an infectious disease can be transmitted directly from one person to another, it is termed a communicable disease. No vector is necessary for transmission.
A patient is recovering from surgery for removal of an ovarian tumor. It is 1 day after her surgery. Because she has an abdominal incision and dressing and a history of diabetes, the nurse has selected a nursing diagnosis of risk for infection. Which of the following is an appropriate goal statement for the diagnosis? A. Patient will remain afebrile to discharge. B. Patient's wound will remain free of infection by discharge. C. Patient will receive ordered antibiotic on time over next 3 days. D. Patient's abdominal incision will be covered with a sterile dressing for 2 days.
Answer: B. When selecting an at-risk diagnosis, the goal is to avoid or prevent the condition at risk, in this case infection. Answer 1 is a potential outcome measure for the goal. Answers 3 and 4 are interventions.
A patient on a surgical unit develops sudden shortness of breath and a drop in blood pressure. The staff respond, but the patient dies 30 minutes later. The manager on the nursing unit calls the staff involved in the emergency response together. The staff discusses what occurred over the 30-minute time frame, the actions taken, and whether other steps should have been implemented. The nurses in this situation are: A. Problem solving. B. Showing humility. C. Conducting reflective practice. D. Exercising responsibility.
Answer: C Reflective practice is a conscious process of thinking, analyzing, and learning from previous work situations. The staff may discuss problems that occurred, but in this case they are reflecting on them to learn for future patient situations.
During the implementation step of the nursing process, a nurse reviews and revises the nursing plan of care. Place the following steps of review and revision in the correct order: A. Review the care plan. B. Decide if the nursing interventions remain appropriate. C. Reassess the patient. D. Compare assessment findings to validate existing nursing diagnoses.
Answer: C, A, D, B. After reassessing a patient, the nurse reviews the care plan and compares assessment data to validate the nursing diagnoses and determine whether the nursing interventions remain the most appropriate for the clinical situation. If the patient's status has changed and the nursing diagnosis and related nursing interventions are no longer appropriate, the nurse modifies the nursing care plan.
Which of the following are symptoms of a systemic infection? (Select all that apply.) A. Redness. B. Edema. C. Fatigue. D. Fever. E. Pain or tenderness. F. Lack of appetite.
Answer: C, D, F. Systemic infections cause more generalized symptoms than local infection. They usually result in fever, fatigue, and malaise. Lymph nodes that drain the area of infection often become enlarged, swollen, and tender during palpation. Systemic infections commonly cause a loss of appetite, nausea, and vomiting. Redness and swelling caused by inflammation are signs of a local infection. Infected drainage at a local infection site may be yellow, green, or brown depending on the pathogen. The patient may complain of tightness and pain caused by edema. Gentle palpation of a localized infected area usually results in some degree of tenderness.
A nurse has worked on an oncology unit for 3 years. One patient has become visibly weaker and states, "I feel funny." The nurse knows how patients often have behavior changes before developing sepsis when they have cancer. The nurse asks the patient questions to assess thinking skills and notices the patient shivering. The nurse goes to the phone, calls the physician, and begins the conversation by saying, "I believe that your patient is developing sepsis. I want to report symptoms I'm seeing." What examples of critical thinking concepts does the nurse show? (Select all that apply.) A. Experience B. Ethical C. Analyticity D. Self-confidence E. Risk taking
Answer: C, D. Among critical thinking concepts, the nurse shows analyticity (analyzing information, gathering additional findings, and sensing a problem), and self-confidence (calling the physician, which shows trust in his own reasoning). The nurse's experience would have influenced the familiarity of patient symptoms, but in this text experience is considered a component of the critical thinking model and not a concept. Acting ethically is a critical thinking standard.
In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply.) A. The nurse who listens to lung sounds after a patient reports "difficulty breathing" B. The nurse who considers conflicting cues in deciding which diagnostic label to choose C. The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema D. The nurse who identifies a diagnosis on the basis of a single defining characteristic
Answer: C, D. In answer C the nurse fails to validate her assessment findings of edema, either by using a scale to measure the severity or by asking a colleague to validate her findings. In answer 4 the nurse prematurely closes clustering, which can lead to an inaccurate diagnosis. In answer 1 the nurse validates findings to make an accurate diagnosis. In answer 2 the nurse interprets cue clusters to make an accurate diagnosis.
When does implementation begin as the fourth step of the nursing process? A. During the assessment phase B. Immediately in some critical situations C. After the care plan has been developed D. After there is mutual goal setting between nurse and patient
Answer: C. Implementation begins after the nurse has developed the plan of care. Even in emergent situations a nurse assesses a situation quickly, considers options, and then implements nursing measures. Goal setting is part of planning.
The nurse checks the intravenous (IV) solution that is infusing into the patient's left arm. The IV solution of 9% NS is infusing at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site was changed as scheduled per standard of care. While in the room, the nurse inspects the condition of the dressing and notes the date on the dressing label. In what ways did the nurse evaluate the IV intervention? (Select all that apply.) A. Checked the IV infusion location in left arm B. Checked the type of IV solution C. Confirmed from nurses' notes the time of dressing change and checked label D. Inspected the condition of the IV dressing
Answer: C, D. The evaluation of interventions examines two factors: the appropriateness of the interventions selected (whether the IV dressing was changed as the standard of care requires) and the correct application of the intervention (whether the dressing was in place and secure). Answer 1 is an evaluation measure, and answer 2 is an assessment step to ensure that correct fluid is infusing.
What type of interview techniques does the nurse use when asking these questions, "Do you have pain or cramping?" "Does the pain get worse when you walk?" (Select all that apply.) A. Active listening B. Open-ended questioning C. Closed-ended questioning D. Problem-oriented questioning
Answer: C, D. The nurse's technique is to ask a closed-ended question using a problem oriented approach. The patient gives a specific answer to broaden the nurse's knowledge about the character of his pain.
A 15-year-old male has come to the health care provider's office because he does not feel well after football practice. He looks sheepish when you ask him about drug and alcohol use but is unwilling to explain why. His temperature is 102°F (38.9°C). This is a: A. Normal temperature for a person his age. B. Low temperature for a person his age. C. High temperature for a person his age. D. Likely due to alcohol intake.
Answer: C. A normal temperature range is 96.8°F to 100.4°F (36° C to 38° C). Exercise, warm environment, and dehydration may account for the temperature elevation.
During bathing your patient experiences shortness of breath and labored breathing with a respiratory rate of 30. The bed is in a flat position. You change the bed position to: A. Trendelenburg's. B. Reverse Trendelenburg's. C. Fowler's. D. Semi-Fowler's.
Answer: C. Fowler's upright sitting position facilitates breathing by allowing for full expansion of the chest and lungs. Although reverse Trendelenburg's position raises the head of the bed, it is a straight tilt position and is not likely as comfortable as the more supported Fowler's position.
The nurse recognizes that her older-adult patient needs additional teaching about skin care when the older adult says, "I should: A. Bathe twice a week. B. Rinse well after using soap. C. Use hot water for bathing. D. Drink plenty of fluids.
Answer: C. Hot water dries the skin by removing natural oils more quickly.
How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast? A. Supine with both arms overhead with palms upward B. Sitting with hands clasped just above the umbilicus C. Supine with the right arm abducted and hand under the head and neck D. Lying on the right side, adducting the right arm on the side of the body
Answer: C. Lying on the back allows breast tissue to relax; raising the arm over the patient's head causes the breast tissue to flatten, and palpation can more accurately locate any nodules or tumors, especially cancerous tumors that are fixed against the chest wall.
While planning morning care, which of the following patients would receive the highest priority to receive his or her bath first? A. A patient who just returned to the nursing unit from surgery and is experiencing pain at a level of 7 on a scale of 0 to 10 B. A patient who prefers a bath in the evening when his wife visits and can help him C. A patient who is experiencing frequent incontinent diarrheal stools D. A patient who has just returned from diagnostic testing and complains of being very fatigued
Answer: C. Patients who have body fluids, excretions, secretions, or wastes on the skin require immediate hygiene care. Hygiene care can be delayed for patients with pain or fatigue until these symptoms are controlled as long as there is no compelling reason such as drainage. Allowing patients to make choices involves them in care and gives them control.
The nurse is teaching a young mother to palpate her 8-year-old child to quickly evaluate if the child has a fever. Which information is important for the nurse to include? A. Place the palm of the hand on the child's back. B. Lightly touch the child's forehead with the fingertips. C. Place the back of your hand against the child's forehead and then on the back of the neck. D. Use the pads of your fingers and press against the child's neck and over the thorax.
Answer: C. Temperature is best evaluated by palpating the skin with the dorsum or back of the hand. It is best to select two areas to compare to allow you to detect a change in body surface temperature.
The nurse is observing the NAP perform hand washing. During which step should the nurse intervene and provide further instruction? A. The NAP pushes his wristwatch and long uniform sleeves above the wrists. Standing in front of the sink, the NAP keeps his hands and uniform away from the sink surface. B. The NAP turns on the water and regulates the flow of water so that the temperature is warm and the force of the spray will not cause splashing. C. The NAP wets his hands and wrists thoroughly under the running water and keeps his hands and forearms higher than the elbows during washing. D. The NAP applies 3 to 5 mL of detergent and rubs the hands together vigorously, lathering thoroughly. The NAP performs hand hygiene for at least 15 seconds, interlacing the fingers and rubbing the palms and back of hands with a circular motion at least five times each. E. The nurse rinses the hands and wrists thoroughly, dries the hands and uses a dry paper towel to turn off the hand faucet.
Answer: C. The hands and forearms should be kept lower than the elbows during washing. Water flows from the least to the most contaminated area, rinsing microorganisms into the sink.
Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher? A. The patient is 5 feet 6 inches and weighs 120 lbs. B. The patient speaks and understands English. C. The patient received an injection of morphine 30 minutes ago for pain. D. You feel comfortable handling a patient of his size and with his level of cooperation.
Answer: C. The morphine injection would change the patient's ability to safely follow directions and participate in the transfer; therefore additional help would be needed to safely transfer the patient from the bed to the stretcher.
Which of the following patients would require follow-up? A. A child with a respiratory rate of 24 breaths per minute. B. An adolescent with a respiratory rate of 16 breaths per minute. C. An adult with a respiratory rate of 10 breaths per minute. D. A newborn with a respiratory rate of 40 breaths per minute.
Answer: C. The normal respiratory rate for a newborn is 35 to 40 breaths per minute. The normal respiratory rate of a child is 20 to 30 breaths per minute. The normal respiratory rate for a teenager is 16 to 20 breaths per minute. The normal respiratory rate for an adult is 12 to 20 breaths per minute. A rate of 10 would require follow-up.
The nurse asks a patient, "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a patient-centered interview? A. Setting the stage B. Gathering information about the patient's chief concerns C. Collecting the assessment D. Termination
Answer: C. The nurse is focusing on the patient's nutritional status and asking specific questions to assess his diet history.
Which patient would it be appropriate for the nurse to delegate vital signs? A. New admission to the hospital. B. Patient transferred from ICU. C. Elderly nursing home resident. D. Patient with recent complaint of headache.
Answer: C. The nurse may delegate routine vital signs of stable patients. Obtaining a baseline upon admission or transfer patient should be completed by the nurse. If a patient has a change in condition, such as a headache which could be reflective of hypertension, the nurse should assess the patient's vital signs.
The NAP reports to the nurse the patient's respirations are 32 and the patient is complaining of shortness of breath. What is the best nursing action at this time? A. Request the NAP obtain the patient's pulse oximetry and report the reading to the nurse. B. Ask the NAP to obtain a full set of vital signs. C. Assess the patient yourself, including the pulse oximetry reading. D. Notify the health care provider.
Answer: C. The nurse should assess the patient. NAP can obtain a pulse oximetry reading if the patient is stable and after the NAP's skill with the oximeter is validated.
The patient reports having a sore throat, coughing, and sneezing. While performing a focused assessment, which finding supports the patient's reported symptoms related to upper respiratory infection? A. Buccal mucosa is moist and dark pink. B. Respiratory rate is 18, rhythm is even. C. Retropharyngeal lymph nodes are enlarged and firm. D. Inspection with a tongue depressor on the posterior tongue causes gagging.
Answer: C. The retropharyngeal nodes are located posteriorly to the throat and are enlarged when an infection is located in the throat or pharynx.
A patient has her call bell on and looks frightened when you enter the room. She has been on bed rest for 3 days following a fractured femur. She says, "It hurts when I try to breathe, and I can't catch my breath." Your first action is to: A. Call the health care provider to report this change in condition. B. Give the patient a paper bag to breathe into to decrease her anxiety. C. Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen. D. Explain that this is normal after such trauma and administer the ordered pain medication.
Answer: C. These are signs of possible pulmonary emboli, which can be life threatening. You must assess your patient, be prepared to start oxygen, and have someone call the surgeon while you stay with the patient to continue to monitor her status.
Which of the following is a correct description of glove removal? A. You pull the gloves off by the fingertips and discard them in a proper receptacle. B. You grasp the inside of one glove with the other gloved hand, pull the glove off, and discard it in a proper receptacle. The remaining glove is removed by placing the fingers of the bare hand outside the cuff, pulling the glove off, and discarding it in a proper receptacle. C. You grasp the outside of one cuff with the other gloved hand and pull the glove off, turning it inside out, and place it in gloved hand. Take fingers of bare hand and tuck inside remaining glove cuff against the skin. Peel glove off inside out and over the previously removed glove. Discard both gloves in receptacle. D. You slide the gloved fingers of the dominant hand under the inside cuff of the nondominant hand and pull the glove off and discard. Then you slide the fingers of the nondominant hand under the cuff of the dominant hand and pull the glove off and discard.
Answer: C. You should grasp the outside of one cuff with the other gloved hand and pull the glove off, turning it inside out, and place it in gloved hand. Take fingers of bare hand and tuck inside remaining glove cuff against the skin. Peel glove off inside out and over the previously removed glove. Discard both gloves in receptacle. The outside of the glove should never touch the skin surface and the fingers should never touch a contaminated glove.
The nurse has prepared a sterile field and have added the necessary sterile items to the field. The nurse has applied sterile gloves and is waiting to assist the health care provider in performing a surgical procedure. The nurse keeps the sterile field in view and holds her hands down at her side, away from her clothing. While waiting, the nurse instructs the patient to avoid touching the sterile field and for the need to lie still. Which action made by the nurse is incorrect? A. The patient teaching. B. Failing to cover up the sterile field with a sterile drape while waiting. C. Holding gloved hands at her side. D. All actions are appropriate.
Answer: C. You should keep your hands between waist and shoulder level. A sterile object (e.g., sterile gloves) held below waist level is contaminated. You should communicate with the patient, instructing the patient to avoid touching the work surface or equipment during the procedure and to remain still. This helps avoid accidental contamination of the sterile field and supplies. It is recommended to avoid placing a sterile drape over a sterile field because it is difficult to remove the drape without contamination of the field. It is better to prepare the field immediately before the procedure and keep it in view to prevent unobserved contamination.
The nurse enters a patient's room, and the patient asks if he can get out of bed and transfer to a chair. The nurse takes precautions to use safe patient handling techniques and transfers the patient. This is an example of which physical care technique? A. Meeting the patient's expressed wishes B. Indirect care measure C. Protecting a patient from injury D. Staying organized when implementing a procedure
Answer: C. A common method for administering physical care techniques appropriately includes protecting you and your patients from injury, which involves safe patient handling. Transferring a patient is a direct care measure. Organization is an aspect of physical care but not an example of this nurse's action. Although meeting patient needs is important, it is not a physical care technique.
A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3 days and he vomited twice yesterday. Which of the following responses by the nurse is an example of probing? A. So you've had an upset stomach and began vomiting—correct? B. Have you taken anything for your stomach? C. Is anything else bothering you? D. Have you taken any medication for your vomiting?
Answer: C. A probing question encourages a full description without trying to control the direction of the patient's story. It requires further open-ended statements. Answer 1 is an example of summarizing findings. Answers 2 and 4 are examples of closed-ended questions that control the patient's response and do not ensure a full objective view from the patient.
The patient is assessed for range of joint movement. He or she is unable to move the right arm above the shoulder. How should the nurse document this finding? A. Patient was not able to flex arm at shoulder. B. Extension of right arm is limited. C. Patient's abduction of right arm was limited to 100 degrees. D. Internal rotation of right arm is limited to less than 90 degrees.
Answer: C. Abduction of the arm includes raising the arm away from the side and above the shoulder.
A nursing student is talking with one of the staff nurses who works on a surgical unit. The student's care plan is to include nursing-sensitive outcomes for the nursing diagnosis of acute pain. A nursing-sensitive outcome suitable for this diagnosis would be: A. Patient will achieve pain relief by discharge. B. Patient will be free of a surgical wound infection by discharge. C. Patient will report reduced pain severity in 2 days. D. Patient will describe purpose of pain medicine by discharge.
Answer: C. An example of a nursing-sensitive outcome is one that is influenced and sensitive to nursing interventions. Such is the case with "reduction in pain severity." Answer 1 is a goal. Answer 2 is a medical outcome. Answer 4 is an outcome for a knowledge problem but not for the diagnosis of acute pain.
A nurse is talking with a patient who is visiting a neighborhood health clinic. The patient came to the clinic for repeated symptoms of a sinus infection. During their discussion the nurse checks the patient's medical record and realizes that he is due for a tetanus shot. Administering the shot is an example of what type of preventive intervention? A. Tertiary B. Direct care C. Primary D. Secondary
Answer: C. An immunization is an example of a primary prevention aimed at health promotion.
Which outcome allows you to measure a patient's response to care more precisely? A. The patient's wound will appear normal within 3 days. B. The patient's wound will have less drainage within 72 hours. C. The patient's wound will reduce in size to less than 4 cm (1 ½ inches) by day 4. D. The patient's wound will heal without redness or drainage by day 4.
Answer: C. An outcome must have terms describing quality, quantity, frequency, length, or weight to allow for precise measurement. Answer C identifies a specific wound size, which indicates a degree of healing. Answers A and B are vague and not measurable. Answer D has more than one outcome.
A nurse caring for a patient with pneumonia sits the patient up in bed and suctions his airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water. Which of the following is an evaluative measure used by the nurse? A. Suctioning the airway B. Sitting patient up in bed C. Auscultating lung sounds D. Patient describing type of discomfort
Answer: C. Auscultation was the measure used to determine if the suctioning of the airway was effective. Suctioning and sitting the patient up are interventions. The nurse did not ask the patient or evaluate the nature of the pain.
While preparing to do a sterile dressing change, a nurse accidentally sneezes over the sterile field that is on the over-the-bed table. Which of the following principles of surgical asepsis, if any, has the nurse violated? A. When a sterile field comes in contact with a wet surface, the sterile field is contaminated by capillary action. B. Fluid flows in the direction of gravity. C. A sterile field becomes contaminated by prolonged exposure to air. D. None of the principles were violated.
Answer: C. Avoid activities that create air currents, such as sneezing. When you sneeze, microorganisms travel through the air by droplets, contaminating the sterile field.
A nurse is preparing for change-of-shift rounds with the nurse who is assuming care for his patients. Which of the following statements or actions by the nurse are characteristics of ineffective handoff communication? A. This patient is anxious about his pain after surgery; you need to review the information I gave him about how to use a patient-controlled analgesia (PCA) pump this evening. B. The nurse refers to the electronic care plan in the electronic health record (EHR) to review interventions for the patient's care. C. During walking rounds the nurse talks about the problem the patient care technicians created by not ambulating the patient. D. The nurse gives her patient a pain medication before report so there is likely to be no interruption during rounding.
Answer: C. Creating a culture of blame does not support questioning, which is needed for good handoff communication. Answer A is patient centered and thus appropriate, answer B ensures that essential information is included, and answer D allows the nurse to be organized and uninterrupted during rounds.
A patient's surgical wound has become swollen, red, and tender. You note that the patient has a new fever and leukocytosis. What is the best immediate intervention? A. Notify the health care provider and use surgical technique to change the dressing. B. Reassure the patient and recheck the wound later. C. Notify the health care provider and support the patient's fluid and nutritional needs. D. Alert the patient and caregivers to the presence of an infection to ensure care after discharge.
Answer: C. Early intervention can reduce the risk of sepsis caused by the progression of the infection. Fever depletes body fluid stores, resulting in an increased risk of dehydration, and providing proper nutrition promotes healing.
The nurse has redressed a patient's wound and now plans to administer a medication to the patient. Which is the correct infection control procedure? A. Leave the gloves on to administer the medication. B. Remove gloves and administer the medication. C. Remove gloves and perform hand hygiene before administering the medication. D. Leave the medication on the bedside table to avoid having to remove gloves before leaving the patient's room.
Answer: C. Gloves need to be changed, and hand hygiene performed to prevent transfer of microorganisms from one source (wound) to another (nurse's hands).
A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in: A. Data collection. B. Data clustering. C. Data interpretation. D. Making a diagnostic statement.
Answer: C. In the review of data, the nurse compares defining characteristics for the two nursing diagnoses and selects one based on the interpretation of data. Making a diagnostic statement is incorrect because the nurse has not included a related factor.
A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. Which of the following patient care goals are long term? A. Patient will explain relationship of insulin to blood glucose control. B. Patient will self-administer insulin. C. Patient will achieve glucose control. D. Patient will describe steps for preparing insulin in a syringe.
Answer: C. It will take time for the patient who is medically unstable to achieve glucose control. Answers 1 and 2 are short term and should be met before discharge. Answer 4 is not a goal but an outcome statement for the goal in answer 2.
A patient has been transferred to your unit from the respiratory intensive care unit, where he has been for the past 2 weeks recovering from pneumonia. He is receiving oxygen via 4 L nasal cannula. His respiratory rate is 26 breaths/min, and his oxygen saturation is 92%. In planning his care, which information is most helpful in determining your priority nursing interventions? A. Activity order B. Medication list C. Baseline vital signs D. Patient's perception of dyspnea
Answer: C. Knowledge of baseline vital signs is needed to prioritize care.
As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. Your best reply is: A. Nail polish attracts microorganisms and contaminates the finger sensor. B. Nail polish increases oxygen saturation. C. Nail polish interferes with sensor function. D. Nail polish creates excessive heat in sensor probe.
Answer: C. Nail polish reduces light transmission and can alter oxygen saturation measurement.
A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? A. Provide a dark, quiet room to calm the patient. B. Reduce the level of precautions to keep the patient from becoming angry. C. Explain the reasons for isolation procedures and provide meaningful stimulation. D. Limit family and other caregiver visits to reduce the risk of spreading the infection.
Answer: C. Patients on isolation precautions may interpret the needed restrictions as a sign of rejection by the health care worker.
Which of the following patients is most at risk for tachycardia? A. A healthy professional tennis player B. A patient admitted with hypothermia C. A patient with a fever of 39.4°C (103°F) D. A 90-year-old male taking beta blockers
Answer: C. Patients with a fever have a high heart rate. A healthy athlete has a low heart rate because of conditioning. Hypothermia slows the heart. Beta-blockers reduce heart rate.
A nurse is orienting a new graduate nurse to the unit. The graduate nurse asks, "Why do we have standing orders for cases when patients develop life-threatening arrhythmias? Is not each patient's situation unique?" What is the nurse's best answer? A. Standing orders are used to meet our physician's preferences. B. Standing orders ensure that we are familiar with evidence-based guidelines for care of arrhythmias. C. Standing orders allow us to respond quickly and safely to a rapidly changing clinical situation. D. Standing orders minimize the documentation we have to provide.
Answer: C. Standing orders are preprinted documents containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. They are common in critical care settings and other specialized practice settings in which patients' needs change rapidly and require immediate attention.
The following blood pressures, taken 6 months apart, were recorded from patients screened by the nurse at the assisted living facility. Which patient should be referred to the healthcare provider for hypertension evaluation? A. 120/80, 118/78, 124/82 B. 128/84, 124/86, 128/88 C. 148/82, 148/78, 134/86 D. 154/78, 118/76, 126/84
Answer: C. The definition of hypertension requires two elevated blood pressure measurements in a row. Answers 1, 2, and 4 describe prehypertension.
The nurse makes the following statement during a change of shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, but I don't think it's that severe. You know that back patients often have chronic pain. He seems fine when talking with his family. Have you cared for him before?" What does the nurse's conclusion suggest? A. The nurse is making an accurate clinical inference. B. The nurse has gathered cues to identify a potential problem area. C. The nurse has allowed stereotyping to influence her assessment. D. The nurse wants to validate her information with the other nurse.
Answer: C. The nurse is applying a stereotype about patients with back pain. An accurate clinical inference would not include the nurse's opinion. The cues suggest that the patient has acute pain, which the nurse is rejecting. Validation would involve having another nurse also assess the patient for pain.
The nurse asks a patient how she feels about her impending surgery for breast cancer. Before the discussion the nurse reviewed the description of loss and grief and therapeutic communication principles in his textbook. The critical thinking component involved in the nurse's review of the literature is: A. Experience. B. Problem solving. C. Knowledge application. D. Clinical decision making.
Answer: C. The nurse reviewed knowledge that pertained to the patient's clinical situation, allowing him to apply critical thinking in the patient's care.
A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7°C (101.6°F) (0400), 36.6°C (97.9°F) (0800), 36.9°C (98.4°F) (1200), 37.6°C (99.6°F) (1600), and 38.3°C (100.9°F) (2000). How would you describe this pattern of temperature measurements? A. Usual range of circadian rhythm measurements B. Sustained fever pattern C. Intermittent fever pattern D. Resolving fever pattern
Answer: C. The pattern returns to acceptable levels at least once in 24 hours interspersed with fever spikes.
A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? A. It keeps an incontinent patient's skin dry. B. It can get caught in the linens or equipment. C. It obstructs the normal flushing action of urine flow. D. It allows the patient to remain hydrated without having to urinate.
Answer: C. The presence of a catheter in the urethra breaches the natural defenses of the body. Reflux of microorganisms up the catheter lumen from the drainage bag or backflow of urine in the tubing increases the risk of infection.
Identify the interval when a patient progresses from nonspecific signs to manifesting signs and symptoms specific to a type of infection. A. Illness stage B. Convalescence C. Prodromal stage D. Incubation period
Answer: C. The prodromal stage is the interval between entrance of a pathogen into the body and appearance of first symptoms.
A nurse has been working on a surgical unit for 3 weeks. A patient requires a Foley catheter to be inserted, so the nurse reads the procedure manual for the institution to review how to insert it. The level of critical thinking the nurse is using is: A. Commitment. B. Scientific method. C. Basic critical thinking. D. Complex critical thinking.
Answer: C. This is an example of basic critical thinking, in which the nurse trusts that experts have the right answers for how to insert the Foley catheter and thus goes to the procedure manual. Thinking is concrete and based on a set of rules or principles.
A patient is being discharged today. In preparation the nurse removes the intravenous (IV) line from the right arm and documents that the site was "clean and dry with no signs of redness or tenderness." On discharge the nurse reviews the care plan for goals met. Which of the following goals can be evaluated with what you know about this patient? A. Patient expresses acceptance of health status by day of discharge. B. Patient's surgical wound will remain free of infection. C. Patient's IV site will remain free of phlebitis. D. Patient understands when to call physician to report possible complications.
Answer: C. To achieve the goal of preventing phlebitis the nurse evaluates for signs of phlebitis, which include redness or inflammation. The outcome for this goal would be stated as, "IV site will show no signs of inflammation to discharge."
A patient has been given an opioid analgesic (e.g., morphine) for pain relief. Why does the nurse assess the patient's respiratory rate before administering the next dose? A. To see if the patient's complaints of pain are supported physiologically. B. To reduce the addiction potential to pain medication. C. Opioid analgesics may depress rate and depth of respirations, although this is a rare adverse event. D. To provide the patient with a sense of security regarding his/her respiratory status and as a result, reduce anxiety.
Answer: C. To prevent further respiratory depression, the nurse should determine the patient's respiratory rate prior to administering another dose of a narcotic. The morphine should be held if the patient's respiratory rate (in an adult) is below 10 breaths per minute. Assessing the patient's respiratory rate is unrelated to addiction. Narcotics can depress respirations.
The surgical unit has initiated the use of a pain-rating scale to assess patients' pain severity during their postoperative recovery. The registered nurse (RN) looks at the pain flow sheet to see the pain scores recorded for a patient over the last 24 hours. Use of the pain scale is an example of which intellectual standard? A. Deep B. Relevant C. Consistent D. Significant
Answer: C. Use of the same pain scale for assessing pain acuity is an example of being consistent.
A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a very slow radial pulse of 44. What is your priority intervention? A. Request that the nursing assistant repeat the pulse check B. Call for a stat electrocardiogram (ECG) C. Assess the patient's apical pulse and evidence of a pulse deficit D. Prepare to administer cardiac-stimulating medications
Answer: C. Your priority is to assess the patient first. The nurse cannot delegate vital signs to an unstable patient. Therefore first you determine if the patient has a pulse deficit. Answers 2 and 4 require notification of the health care provider and occur after you assess the patient.
While assessing a patient, the nurse observes that the patient's intravenous (IV) line is not infusing at the ordered rate. The nurse assesses the patient for pain at the IV site, checks the flow regulator on the tubing, looks to see if the patient is lying on the tubing, checks the point of connection between the tubing and the IV catheter, and then checks the condition of the site where the intravenous catheter enters the patient's skin. After the nurse readjusts the flow rate, the infusion begins at the correct rate. This is an example of: A. Inference. B.Diagnostic reasoning. C. Competency. D. Problem solving.
Answer: D This is an example of problem solving. The nurse collects information and tries options until she is able to find a solution to the slowed infusion rate. The focus is on solving the problem with the patient's IV and not on solving the patient's health problem; thus this is not the diagnostic reasoning process.
The nurse is assessing a patient who returned 3 hours ago from a cardiac catheterization, during which the large catheter was inserted into the patient's femoral artery in the right groin. Which assessment finding would require immediate follow-up? A. Palpation of a femoral pulse with a heart rate of 76 B. Auscultation of a heart murmur over the left thorax C. Identification of mild bruising at the catheter insertion site D. Palpation of a right dorsalis pedis pulse with strength of +1
Answer: D. A weak pulse may indicate disruption of arterial flow and should be reported immediately. Mild bruising is normal, but if it increases in size, the femoral artery may be leaking, requiring further follow-up with the health care provider. Other findings are within normal limits and do not require notification.
The nurse plans to assess the patient's abstract reasoning. Which task should the nurse ask the patient to perform? A. "Tell me where you are." B. "What can you tell me about your illness?" C. "Repeat these numbers back to me: 7...5...8." D. "What does this mean: 'A stitch in time saves nine? ' "
Answer: D. Abstract reasoning requires cognitive functioning and the ability to identify relationships between concepts.
For which patient would a tympanic thermometer be the preferred thermometer to use? A. A marathon runner who developed weakness during the race. B. A newborn in the intensive care unit that requires continuous temperature monitoring. C. A child who had tubes surgically placed in the ears. D. A tachypneic patient who is receiving oxygen by nasal cannula.
Answer: D. An advantage to the tympanic thermometer is that it can be used for tachypneic patients. The tympanic thermometer is contraindicated in patients who have had surgery of the ear or tympanic membrane and does not accurately measure core temperature after exercise. A continuous measurement cannot be obtained with the tympanic thermometer.
The nurse is preparing to set up a sterile field for a patient who is going to have a sterile dressing change. Which of the following assessment measures would be unnecessary at this time? A. The nurse reviews documentation to see what supplies will be needed. B. The nurse asks the patient to rate his pain on a pain scale. C. The nurse asks the patient if he needs to use the bathroom. D. The nurse asks the patient if he has ambulated in the hall today.
Answer: D. Assessing the patient's mobility is unnecessary at this time. The nurse should anticipate the number and variety of supplies needed to avoid having to leave a sterile field to obtain more supplies. Premedication may be required if pain level is sufficiently severe. You should anticipate the patient's needs so that the patient can relax and avoid any unnecessary movement that might disrupt the procedure and/or the sterile field.
Two nurses are having a discussion at the nurses' station. One nurse is a new graduate who added, "Patient needs improved bowel function related to constipation" to a patient's care plan. The nurse's colleague, the charge nurse says, "I think your diagnosis is possibly worded incorrectly. Let's go over it together." A correctly worded diagnostic statement is: A. Need for improved bowel function related to change in diet. B. Patient needs improved bowel function related to alteration in elimination. C. Constipation related to inadequate fluid intake. D. Constipation related to hard infrequent stools.
Answer: D. Constipation related to inadequate fluid intake is an accurate NANDA-I approved nursing diagnosis with an appropriate etiology. Need for improved bowel function related to change in diet is a goal with an etiologic factor. Patient needs improved bowel function related to alteration in elimination is a goal with a diagnostic statement. Constipation related to hard infrequent stools is a nursing diagnostic label with a clinical sign.
The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to: A. Prevent varicose veins. B. Prevent muscular atrophy. C. Ensure joint mobility and prevent contractures. D. Promote venous return to the heart.
Answer: D. Elastic stockings maintain external pressure on the lower extremities and assist in promoting venous return to the heart. This increase in venous return helps reduce the stasis of blood and in turn reduces the risk for deep vein thrombosis (DVT) formation in the lower extremities.
How can the nurse best obtain an accurate measurement of a patient's respiratory rate? A. Inform the patient when monitoring his or her respirations. B. Assess the respirations while the patient is talking. C. Auscultate the lung sounds, asking the patient to take a deep breath in through the nose and exhale slowly through the mouth. D. Continue to act as though taking the patient's pulse while discretely observing the rise and fall of the patient's chest.
Answer: D. If the patient is aware that the nurse is monitoring his or her respirations, the patient will most likely alter the breathing pattern. It is best to discretely observe the rise and fall of the patient's chest. Assessing the patient's respirations while they are talking may make it more difficult to assess and may affect the rate. Auscultation will enable the nurse to identify lung sounds, but having the patient take deep breaths would affect the accuracy of the rate.
When assessing the respiratory rate, the nurse has difficulty seeing the patient's chest rise and fall with inspiration and expiration. What is the nurse's best action? A. Have someone else assess the patient's respiratory rate. B. Remove the patient's gown so you have better visualization of the patient's chest for assessment. C. Document the inability to visualize inspiration and expiration. D. While holding the patient's wrist, move the patient's arm over the chest or abdomen, then feel the rise and fall of inspiration and expiration and assess the rate.
Answer: D. If unable to visualize respirations, the nurse should discreetly feel the patient's respirations. The nurse should first attempt to hold the patient's wrist and move it over the patient's chest or abdomen, feel the rise and fall of inspiration and expiration, and assess the rate. The nurse needs to obtain the patient's respiratory rate. Documenting inability to visualize respirations may imply the patient is deceased or that the nurse is incompetent.
A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements made by a woman in the audience reflects a need for further education? A. "I usually go swimming with my family at the YMCA 3 times a week." B. "I need to ask my doctor if I should have a bone mineral density check this year." C. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." D. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill. "
Answer: D. Just because a multivitamin has calcium in it does not mean that the woman is receiving enough to meet her needs. She must know her requirement and make the decision based on that rather than on the value for calcium on the label.
An older adult who was in a car accident and fractured his femur has been immobilized for 5 days. Which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the first time? A. Chronic pain B. Impaired skin integrity C. Risk for ineffective cerebral tissue perfusion D. Risk for activity intolerance
Answer: D. Patients on bed rest are at risk for activity intolerance, which increases patients' risk for falling.
An NAP asks what an example would be of using standard precautions. The nurse is correct to respond: A. Placing an "isolation precautions" sign on the patient's door to alert any visitors. B. Wearing gloves and a mask whenever it is known a patient has a communicable illness. C. Collecting a sputum specimen to determine if an infection is present. D. Wearing clean gloves when emptying a bedpan.
Answer: D. Standard precautions are used whenever there is a potential for contact with blood or body fluids. All patients should be treated as though they may be communicable, rather than only using precautions with patients who have identified illnesses. Emptying a bedpan requires standard precautions and the use of PPE as there is a potential for contact with body fluids.
Who would the nurse expect to have the highest body temperature reading? A. An elderly African-American male. B. A teenager playing video games. C. A preterm baby who is sleeping. D. An adult female who is walking.
Answer: D. The adult female who is exercising would be expected to have the highest body temperature. Playing video games is a more sedentary activity. A preterm baby lacks subcutaneous fat to maintain warmth. An elderly person is more likely to have a decreased body temperature. African-Americans are more likely to have a higher blood pressure reading, not body temperature measurement.
A nurse is obtaining a patient's medical history when he states, "I am HIV positive because I shared needles with a friend who is also HIV positive." The friend would be considered: A. The susceptible host. B. The vehicle or route of transmission. C. The infectious agent. D. The reservoir.
Answer: D. The friend would be the reservoir for pathogen growth. The needle is the mode of transmission. The HIV virus would be the infectious agent or pathogen. The patient is the susceptible host.
The nurse changes the dressing of your first patient with methicillin-resistant Staphylococcus aureus of the wound. The nurse discards the gloves and goes into the next room, where the nurse suctions a second patient's airway. According to the chain of infection, the mode of transmission is: A. Methicillin-resistant Staphylococcus aureus. B. The first patient. C. The first patient's wound. D. The nurse. E. The second patient's respiratory tract F. The second patient.
Answer: D. The nurse failed to perform hand hygiene after removing the gloves and before having contact with the second patient. The nurse's hands are the mode of transmission.
A nurse teaching a family member caregiver how to bathe the patient explains the importance of using long strokes on the patient's extremities, moving from distal to proximal. Which explanation does the nurse include? Long strokes moving from distal to proximal are used to: A. Decrease the chance of infection. B. Help remove dry, flaky skin. C. Prevent skin trauma. D. Stimulate venous return.
Answer: D. The pressure from long, smooth strokes moving from distal to proximal areas presses on the veins, which promotes venous return.
A patient with left-sided weakness asks his nurse, "Why are you walking on my left side? I can hold on to you better with my right hand." What would be your best therapeutic response? A. "Walking on your left side lets me use my right hand to hold on to your arm. In case you start to fall, I can still hold you." B. "Would you like me to walk on your right side so you feel more secure?" C. "Either side is appropriate, but I prefer the left side. If you like, I can have another nurse walk with you who will hold you on the right side." D. "By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint.
Answer: D. Walking on the affected (weak side) side and holding the patient around the waist or using a gait belt gives you better control if the patient starts to fall. If you were holding the patient's arm as he was falling, you might dislocate his shoulder.
A patient had a left-sided cerebrovascular accident 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The patient is receiving enteral feedings through a small-bore nasogastric (NG) tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately? A. Pale yellow urine B. Unilateral neglect C. Slight movement noted on the R side D. Coffee ground-like aspirate from the feeding tube
Answer: D. When patients are receiving medications such as heparin or enoxaparin (Lovenox), you must assess for signs of bleeding. These include overt signs such as bleeding from their gums or covert signs, which can be detected by testing their stool or observing their aspirate from NG tubes for coffee ground-like matter. These are signs of bleeding in the gastrointestinal tract.
The nurse is assessing the character of a patient's migraine headache and asks, "Do you feel nauseated when you have a headache?" The patient's response is "yes." In this case the finding of nausea is which of the following? A. An objective finding B. A clinical inference C. A validation D. A concomitant symptom
Answer: D. A concomitant symptom is a symptom that occurs along with a primary symptom. The finding is subjective based on patient self-report. There is no clinical inference since the nurse is not trying to find the meaning of the findings. The patient is reporting nausea, but there is no validation or confirmation with another source.
A patient has limited mobility as a result of a recent knee replacement. The nurse identifies that he has altered balance and assists him in ambulation. The patient uses a walker presently as part of his therapy. The nurse notes how far the patient is able to walk and then assists him back to his room. Which of the following is an evaluative measure? A. Uses walker during ambulation B. Presence of altered balance C. Limited mobility in lower extremities D. Observation of distance patient is able to walk
Answer: D. An evaluative measure determines a patient's response to therapy, in this case how well the patient is able to ambulate (distance walked).
A patient has the nursing diagnosis of nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? A. Provide frequent mouth care. B. Maintain intravenous (IV) infusion at 100 mL/hr. C. Administer prochlorperazine (Compazine) via rectal suppository. D. Consult with dietitian on initial foods to offer patient. E. Control aversive odors or unpleasant visual stimulation that triggers nausea.
Answer: D. Answers A and E are independent interventions, and answers B and C are dependent interventions.
Which of the following is unique to the commitment level of critical thinking? A. Weighs benefits and risks when making a decision. B. Analyzes and examine choices more independently. C. Concrete thinking. D. Anticipates when to make choices without others' assistance.
Answer: D. Anticipating when to make choices during decision making is unique to the commitment level of critical thinking. Thinking concretely is basic critical thinking. Analyzing and examining choices and weighing benefits and risks are characteristic of complex critical thinking.
A family member is providing care to a loved one who has an infected leg wound. What would you instruct the family member to do after providing care and handling contaminated equipment or organic material? A. Wear gloves before eating or handling food. B. Place any soiled materials into a bag and double bag it. C. Have the family member check with the doctor about need for immunization. D. Perform hand hygiene after care and/or handling contaminated equipment or material.
Answer: D. Clean hands interrupt the transmission of microorganisms from family members.
The nurse is applying sterile gloves. Which series of steps would require correction? A. Perform hand hygiene. Examine glove package to determine if it is dry and intact. Open sterile gloves by carefully separating and peeling open the adhered package edges. Identify right and left glove. B. With thumb and first two fingers of nondominant hand, grasp edge of the cuff of the glove for the dominant hand. Touch only inside surface of the glove and pull the glove over the dominant hand, carefully working the thumb and fingers into the correct spaces. Gently let go of the cuff while preventing it from rolling up the wrist. C. Slide the fingers of the gloved hand underneath the second glove's cuff. Pull the glove over the fingers of the nondominant hand. Avoid touching exposed areas with the gloved hands. D. Hold gloved hands at sides of body, below waist level, until beginning the sterile procedure.
Answer: D. Fingers of the gloved hands should be interlocked and held away from the body, above waist level, until beginning the procedure. Hand hygiene should be performed before applying gloves. The glove package should be examined because a torn or wet package is contaminated. The package is opened by separating and peeling the adhered package edges. With thumb and first two fingers of nondominant hand, grasp edge of the cuff of the glove for the dominant hand. Touch only inside surface of the glove and pull the glove over the dominant hand, carefully working the thumb and fingers into the correct spaces. Gently let go of the cuff while preventing it from rolling up the wrist. Slide the fingers of the gloved hand underneath the second glove's cuff. Pull the glove over the fingers of the nondominant hand. Avoid touching exposed areas with the gloved hands.
Which is the most likely means of transmitting infection between patients? A. Exposure to another patient's cough B. Sharing equipment among patients C. Disposing of soiled linen in a shared linen bag D. Contact with a health care worker's hands
Answer: D. Hands become contaminated through contact with the patient and the environment and serve as an effective vector of transmission.
A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic statement, best described as: A. Identifying the clinical sign instead of an etiology. B. Identifying a diagnosis based on prejudicial judgment. C. Identifying the diagnostic study rather than a problem caused by the diagnostic study. D. Identifying the medical diagnosis instead of the patient's response to the diagnosis.
Answer: D. In this example intestinal colitis is a medical diagnosis and thus an incorrect diagnostic statement.
A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 pounds. Her vital signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8°C (98.2°F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy? A. Temperature: 37°C (98.6°F) B. Radial pulse: 112 C. Respiratory rate: 24 D. Oxygen saturation: 96% E. Blood pressure: 134/78
Answer: D. Oxygen therapy increases oxygen saturation. Temperature is not affected by the oxygen. There is no change in heart rate. Administering oxygen should decrease the respiratory rate. The decline in blood pressure is unlikely to be caused by oxygen.
When a nurse properly positions a patient and administers an enema solution at the correct rate for the patient's tolerance, this is an example of what type of implementation skill? A. Interpersonal B. Cognitive C. Collaborative D. Psychomotor
Answer: D. Psychomotor skills require the integration of cognitive and motor activities to ensure safe intervention.
The nurse wears a gown when: A. The patient's hygiene is poor. B. The nurse is assisting with medication administration. C. The patient has acquired immunodeficiency syndrome (AIDS) or hepatitis. D. Blood or body fluids may get on the nurse's clothing from a task that he or she plans to perform.
Answer: D. The gown serves as a barrier between the patient's blood and/or body fluid and potential contact with the caregiver's skin.
A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? A. Value-belief pattern B. Cognitive-perceptual pattern C. Coping-stress-tolerance pattern D. Health perception-health management pattern
Answer: D. The nurse is attempting to learn about the patient's self-report of health practices, clinic appointments, and exercise plan designed to improve his health.
In which of the following examples is the nurse not applying critical thinking skills in practice? A. The nurse considers personnel experience in performing intravenous (IV) line insertion and ways to improve performance. B. The nurse uses a fall risk inventory scale to determine a patient's fall risk. C. The nurse observes a change in a patient's behavior and considers which problem is likely developing. D. The nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care.
Answer: D. The nurse is explaining how to provide care on the basis of knowledge. Option 1 is self-regulation through reflection. Option 2 is evaluation, using a criteria-based screening scale. Option 3 is inference, in which the nurse looks for a relationship in findings.
A goal specifies the expected behavior or response that indicates: A. The specific nursing action was completed. B. The validation of the nurse's physical assessment. C. The nurse has made the correct nursing diagnoses. D. Resolution of a nursing diagnosis or maintenance of a healthy state.
Answer: D. The success in meeting a goal is reflected in achieving expected outcomes—the physiological responses or behaviors that indicate that a nursing diagnosis has been resolved and the patient's health is improving.
Setting a time frame for outcomes of care serves which of the following purposes? A. Indicates which outcome has priority B. Indicates the time it takes to complete an intervention C. Indicates how long a nurse is scheduled to care for a patient D. Indicates when the patient is expected to respond in the desired manner
Answer: D. The time frame indicates when you expect a response to your nursing interventions. Time frames help to organize priorities but do not indicate which problem is most important. Time frames for outcomes are not used to gauge the time it takes to complete interventions, and they are unrelated to a nurse's work schedule.
A patient returns to your postoperative unit following surgery for right shoulder rotator cuff repair. The licensed practical nurse (LPN) reports that she had difficulty obtaining the patient's heart rate from his right radial pulse. What is your best response? A. Assess the patient's apical pulse to obtain the heart rate. B. Obtain the heart rate from right and left radial sites. C. Obtain the heart rate using the oximeter probe. D. Perform a complete assessment of all pulses.
Answer: D. When an LPN reports that one pulse is difficult to obtain, first you need to assess the patient yourself and compare the quality of all pulses.
The evaluation process includes interpretation of findings as one of its five elements. Which of the following is an example of interpretation? A. Evaluating the patient's response to selected nursing interventions B. Selecting an observable or measurable state or behavior that reflects goal achievement C. Reviewing the patient's nursing diagnoses and establishing goals and outcome statements D. Matching the results of evaluative measures with expected outcomes to determine patient's status
Answer: D. When interpreting findings, you compare the patient's behavioral responses and physiological signs and symptoms that you expect to see with those actually seen from your evaluation.
You observe a nursing student taking a blood pressure (BP) on a patient. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. The student used a BP cuff that was too narrow for the patient. Which of the following BP readings made by the student is most likely caused by the incorrect choice of BP cuff? A. 96/40 mm Hg B. 110/66 mm Hg C. 130/70 mm Hg D. 156/82 mm Hg
Answer: D. When you use a blood pressure cuff that is too narrow or short, your patient will most likely have a BP reading that is higher than it really is; you will get a false-high reading.
The nurse is having great difficulty hearing any sound when taking a patient's BP. What can the nurse do to increase the ability to auscultate the reading? (Select all that apply.) A. Reduce environmental noise. B. Make sure the stethoscope does not touch the patient's clothing or BP cuff. C. Keep stethoscope tubing still to avoid extraneous sound. D. Ensure the chest piece is rotated to the diaphragm side. E. Ensure the bladder of the cuff is centered 1 inch (2.5 cm) above the brachial artery. F. Use a different stethoscope with longer tubing for conduction of sound. G. Be sure to use the bell side of the stethoscope.
Answers: A, B, C, D, E. Turn off the TV or close the door to the patient's room to help reduce environmental noise. Focus on listening for the Korotkoff sounds. If the stethoscope rubs against the patient's clothing or the blood pressure cuff, it can produce crackling noises and interfere with hearing the Korotkoff sounds. Movement of the stethoscope tubing can create popping noises that would interfere with auscultation of the Korotkoff sounds. If the stethoscope chest piece is rotated incorrectly, it will be quiet. Centering the bladder of the cuff 1 inch above the location of where the brachial pulse is palpated will facilitate auscultation. A stethoscope with shorter tubing produces better sound. Typically the diaphragm is used to assess BP. The bell of the stethoscope is used for auscultating low-pitched heart sounds and some vascular sounds.
Identify the factors that may have an effect on an 82-year-old patient's temperature: (Select all that apply.) A. Drinking a cold glass of water. B. Participation in strenuous physical therapy exercises. C. Infection. D. Room temperature. E. Patient's height.
Answers: A, B, C, D. The average body temperature of older adults is lower (96.8 °F). Cold water and a cool room temperature would lower temperature. A warm room would raise temperature. Exercise and an infection would raise temperature. Height is not a factor that would affect body temperature.
The nurse is preparing a sterile field. Which of the following would be considered contamination of the field? (Select all that apply.) Some of the sterile normal saline spills onto the sterile barrier. A. Non-sterile items are added to the sterile field. B. The nurse prepares the sterile field and leaves the room to get more sterile supplies. C. The nurse prepares the sterile field immediately before the procedure. D. When a sterile item falls off the sterile field, the nurse opens a new sterile item.
Answers: A, B, C. If the sterile barrier becomes wet (strikethrough), it is considered contaminated. Only sterile items should be added to a sterile field. The nurse should keep the sterile field in view to prevent unobserved contamination. A sterile field is established immediately before the procedure because there is a direct relationship between the time the sterile field is opened and the presence of airborne contaminants. If a sterile item falls off the sterile field, the nurse should open a new sterile item and add it to the field, unless the field was contaminated.
The nurse is reviewing with the surgical technician how to prepare a sterile field. Which of the following should be included in the discussion? (Select all that apply.) A. When preparing a sterile field, unwrap the commercial tray by beginning with the outermost flap and unfolding it in the direction away from the sterile kit toward the top of what will be the sterile field. B. If there is any question or doubt of an item's sterility, the item is considered to be nonsterile. C. When using a sterile barrier, touch only the outer 2 inches (5 cm) of the border, as this is considered nonsterile. D. When using a sterile drape, position the bottom half of the sterile drape over the top of the intended sterile field. E. When pouring a solution, if some spills onto the sterile barrier, cover the spill with sterile gauze.
Answers: A, B, D. You should open the outermost flap away from the body, keeping the arm outstretched and away from the sterile field. Whenever there is any question or doubt of an item's sterility, the item is considered to be nonsterile, and new supplies should be obtained. When using a sterile drape, hold the drape at the corners and position the bottom half over the top half of intended work surface. Then allow top half of drape to be placed over bottom half of work surface.
The patient's BP reading is 150/50. For this patient, 50 is representative of: (Select all that apply.) A. The systolic pressure. B. The diastolic pressure. Correct C. The ventricles during contraction. D. The ventricles during relaxation. E. The pulse deficit. F. The pulse pressure.
Answers: B, D. The top number (100) represents the systolic pressure. The bottom number (50) represents the diastolic pressure. Systolic pressure is the ventricular pressure during contraction. Diastolic pressure is the ventricular pressure during relaxation. The pulse deficit is the difference between the apical and radial pulse rates. The difference between systolic and diastolic pressure is the pulse pressure. For a BP of 150 over 50, the pulse pressure is 100.
Which of the following actions, if made by the NAP, would require intervention and further instruction by the nurse? (Select all that apply.) A. The NAP inserts the red-tipped electronic thermometer probe into the patient's mouth after applying a probe cover. B. The NAP wipes the single-use chemical dot thermometer and places it back in the patient's drawer for future use. C. The NAP waits until a tone sounds to read the tympanic thermometer. D. The NAP uses a blue-tipped electronic probe for assessing a patient's axillary temperature. E. The NAP pulls the pinna up, back, and out in an adult when inserting the tympanic thermometer.
Answers: A, B. The electronic thermometers are differentiated by the probe cover tips: blue for oral or axillary, red for rectal. Even though a probe cover is applied, a red-tipped probe should not be placed into a patient's mouth. The single-use chemical dot thermometer is plastic and can only be used once. All electronic thermometers (oral, axillary, rectal) and the tympanic thermometer have a tone that sounds when the measurement is complete. Pull the pinna up, back, and out in an adult when inserting the tympanic thermometer.
A new quality assurance program has been instituted on the unit because of a higher than average infection rate. Which of the following could be factors responsible for this increase? (Select all that apply.) A. Nurse A wears artificial nails. B. Nurse B performs hand hygiene between patients. C. Nurse C wears rings on her fingers. D. Nurse D has fingernails less than ¼ inch long. E. Nurse E has open cuts on her hand. F. Nurse F has chipped nail polish.
Answers: A, C, E, F. Healthcare workers who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails. Microorganisms tend to colonize under rings. Open cuts may harbor increased numbers of microorganisms and should be covered. Chipped nail polish may support the growth of larger numbers of organisms on fingernails. Hand hygiene should be performed before providing patient care, and fingernails should be kept less than ¼ inch in length.
Which of the following patients would need frequent assessment of their temperature? (Select all that apply.) A. A patient receiving a blood transfusion for chronic anemia. B. An elderly patient who needs assistance with feeding and dressing. C. A 43-year-old female who has undergone a hysterectomy. D. A child who is small for his age. A 19-year-old with a white blood count of 15,000/mm3.
Answers: A, C, E. Certain conditions place patients at risk for temperature alterations and may require more frequent assessment. Patients at risk may include those receiving a blood product infusion, those who are of a postoperative status, and those with a white blood cell count below 5,000 or above 12,000/mm3.
Which of the following may increase both rate and depth of respiration? (Select all that apply.) A. Walking 1 mile briskly. B. Having a pain level rating at 7 on a scale of 0-10. C. Feeling anxious when taking a test. D. Smoking a cigarette. E. Taking an opioid to relieve pain. F. Having an addiction problem with amphetamines/cocaine. G. Using a bronchodilator prior to exercise. H. Incurring a head injury from a motor vehicle accident.
Answers: A, C, F. Exercise, anxiety, and amphetamines/cocaine increase both respiratory rate and depth. Respiratory rate may increase when the patient is in pain, but breathing becomes shallow. Smoking also increases the respiratory rate, but depth is unaffected. Opioids may depress both respiratory rate and depth. It is clinically significant when both rate and depth are affected. Bronchodilators decrease the respiratory rate. Damage to the brain stem impairs the respiratory center and slows the rate and rhythm.
What is the nursing intervention if your patient is taking more than 20 breaths per minute? (Select all that apply.) A. Count again for a full 60 seconds (1 minute). B. Tell the patient that you are counting breaths so the patient will slow the rate of breathing. C. Assess physiologic factors that may be causing the patient to breathe so fast. D Administer a bronchodilator that will decrease the respiratory rate.
Answers: A, C. If the patient has a respiratory rate greater than 20 breaths per minute, you should count the respiratory rate again over a full minute and assess for factors causing the patient's elevated respiratory rate. Administering a bronchodilator would require a physician's order and may not treat the cause (e.g., pain could be the cause of the increased rate). You should attempt to assess the patient's respiratory rate inconspicuously to prevent the patient from altering the rate of breathing.
The nurse decides to collect the patient's temperature orally using an electronic thermometer. Choose the equipment to be used. (Select all that apply.) A. Blue probe electronic thermometer. B. Red probe electronic thermometer. C. Chemical oral thermometer. D. Chemical external thermometer. E. Tympanic thermometer. F. Thermometer cover. G. Lubricant. H. Watch with second hand. I. Patient data recording sheet and a pen. J. Tissue.
Answers: A, F, I. To take an oral temperature electronically, you will need a blue probe electronic thermometer. A thermometer cover is used to reduce the transmission of microorganisms. A watch is necessary to measure the length of time for reading the chemical dot thermometer. The patient data recording sheet and a pen are necessary for documenting the result. Disposable gloves are used for personal protection from body fluids. A red probe electronic thermometer, chemical external thermometer, or tympanic thermometer is inappropriate for taking an oral temperature. Lubricant and a tissue are used for taking a rectal temperature.
The NAP reports to the nurse that the patient's pulse oximetry is 88%. What action(s) should the nurse take? (Select all that apply.) A. None should be taken because this is a normal value. B. Verify the reading by taking the patient's pulse oximetry. C. Assist the patient to a high-Fowler's position. D. Assist the patient to a fully supine position. E. Be prepared to administer oxygen. F. Perform a cardiopulmonary assessment. G. Notify the health care provider.
Answers: B, C, E, F, G. The nurse should first retake the patient's pulse oximetry to verify the finding. The nurse should place the patient in a high-Fowler's position for maximum chest expansion and be prepared to administer oxygen. The nurse should obtain vital signs, perform a cardiopulmonary assessment, and notify the health care provider for further orders. Below 90% is considered abnormal. A semi-Fowler's or high-Fowler's position is preferred over a supine position.
The nurse is preparing a sterile field. The nurse opens the sterile commercial kti by pulling the outermost flap towards his body, followed by opening the remainaing flaps. The nurse touches only the outer edge of the sterile field with his hands. The nurse adds sterile items to the sterile field by placing them on the field at an angle and never allowing the wrapper to touch the field. The nurse pours normal saline form a previously opened bottle in the patient's room into a sterile receptacle without splashing. Which action(s) in preparing a sterile field did the nurse perform incorrectly? (Select all that apply.) A. The nurse correctly prepared the sterile fields. B. Opening the outermost flap. C. Touching the outer edge of the sterile field. D. Adding sterile items to the field. E. Pouring a sterile solution.
Answers: B, E.
The task of pulse assessment could be delegated to the NAP for which of the following patients? (Select all that apply.) A. An apical pulse of a patient who is going to receive digoxin (Lanoxin). B. A radial pulse on a patient with a 1200 mL fluid restriction. C. A radial pulse of a patient in the emergency room with chest pain. D. A femoral pulse following a lower leg amputation. E. The temporal pulse of a child.
Answers: B, E. The skill of pulse measurement can be delegated to NAP unless the patient is considered unstable or you are evaluating a response to a treatment or medication. The pulse of a patient on a fluid restriction may be delegated to NAP, as well as the temporal pulse of a child, provided the NAP knows how to locate this pulse site.
Which of the following patients would be at risk for having an alteration in peripheral pulse? (Select all that apply.) A. A 76-year-old with Type 1 diabetes who is otherwise healthy. B. A patient who was just informed of a diagnosis of cancer. C. A patient with peripheral vascular disease. D. A patient who is receiving bolus IV fluids. E. A patient with Alzheimer's disease.
Answers: C, D. Certain conditions place patients at risk for pulse alterations. This may include a person with cardiovascular disease, a patient who is experiencing anxiety, and a patient who received a sudden infusion of IV fluids. Uncomplicated diabetes and Alzheimer's disease fail to directly relate to pulse alteration.
The NAP reports that the patient's temperature is 39° C (102.2 °F). Which of the following are appropriate nursing actions? (Select all that apply.) A. Place the patient's feet in a tub of cool water with ice. B. Apply a hyperthermia blanket as ordered. C. Remove the patient's blankets. D. Limit the patient's fluid intake. E. Administer an antipyretic to the patient as ordered.
Answers: C, E. Although the task of temperature assessment may be delegated, it is the nurse's responsibility to determine the accuracy of the measurement and to assess for further indication of infection. Fluids should be increased to 3 L daily (unless contraindicated). The nurse should administer an antipyretic as ordered and reassess the temperature in 30 minutes and every 4 hours until the temperature has stabilized within normal limits. A cool wet wash cloth may be provided, but the patient should not be excessively chilled, such as with ice. Cooling the temperature in the room will aid in reducing the temperature, and reducing the amount of external covering will promote heat loss. A hyperthermia blanket is used to raise body temperature.
