Multidimensional Care 1 Exam 1
While working with both patients and coworkers, a nurse needs to use a concept referred to as ____________________, or the distance or personal space that people place between themselves and others.
Proxemics
Safety measures for fall
a. Do one thing at a time. b. Change positions slowly to avoid dizziness. c. Be sure pathways are well lit. d. Have your eyes checked at least once a year. e. Wear shoes with non-skid soles. f. Avoid clutter
What are the risk factors for people with narcolepsy?
a. Driving, working, or operating machinery
Examples of folk medicine
a. Eating soup and resting when getting a cold b. Placing ointments c. Having a folk healer (North America, a professional healthcare provider is considered a folk healer) d. Circumcision after male birth e. Washing the death before burial f. Drinking teas
How do we prevent falls at home?
a. Exercise regularly b. Take your time c. Lighten loads- brighten paths d. use caution on stairs e. minimize bathroom hazards f. Childproof the home g. Don't trip yourself up
What aids might you need when interviewing?
a. Glasses, hearing aids
What is the universal choking sign?
a. Grasping the neck between the thumb and index finger b. clutching the neck with both hands
What does bathing promote?
a. Hygiene and circulation
A nurse who provides holistic nursing care is said to be ____________________ competent.
culturally
Output
elimination • Emesis (vomit)=Oral, Bleeding, Urine, Feces = Diarrhea • Solid feces are counted per how many • Example: Patient had 1 solid BMs at 1300 • Liquid stools will be measured using mLs.
Mormons follow a strict
health code, known as the Word of Wisdom
Soy Herbal Uses
high cholesterol, high blood pressure, heart disease, diabetes, symptoms of menopause, premenstrual syndrome (PMS), stomach pain & infant acute diarrhea
Folk Medicine
ii. Beliefs and practices an individual performs when ill than conventional medicine. iii. Passed down by generations to generations
Hypothermia Preventions
ii. Cover the pt with blankets iii. Use heating devices iv. Increase room temp v. Infuse warm solutions vi. Remove wet clothing
How do we prevent falls at home for Older adults
ii. Use beds that are low to the floor iii. Keep a cordless phone near by iv. ask doctor to review medicines v. get treatment for postural hypotension and cardiovascular disorders
Hyperthermia Preventions
ii. Wear lightweight, loose-fitting clothing. iii. Avoid excessive sun exposure. iv. Stay indoors with fans or air conditioning when outside v. temperatures are elevated. vi. Limit consumption of alcohol and caffeine. vii. Apply sunscreen of at least 30 SPF. viii. If overheated, take a cool water shower or bath.
Water Pollution (Community Safety)
inadequate or untreated human, industries or agriculture waste reaches the water.
Socialization
learning how to become a member of a society or a group.
What is socialization?
learning how to become a member of a society or a group.
Scientific belief
Hospitals, clinics, medications, etc.
Scald injury
Hot water, steam, grease, cigarettes. The first 3 are the most common burn injuries in children younger than 3.
Respiratory distress interventions
iii. Position the client for maximum ventilation (Fowler's or semi-Fowler's position). iv. Complete a focused respiratory assessment. v. Promote deep breathing, and use supplemental oxygen as prescribed. vi. Stay with the client, and provide emotional support to decrease anxiety. vii. Promote airway clearance by encouraging coughing and oral/oropharyngeal suctioning if necessary.
Bradycardia pulse rate
less than 60 bpm
Mormons believe in
life before and after death; thus, death repre- sents the passage into another life phrase
Hypoxia is a
low oxygen level in the blood, which leads to symptoms that may affect the client's basic care and comfort needs.
Air Pollution (Community Safety)
outdoor or indoor. Outdoor - car, factories, power plants.Indoors - carbon monoxide, mites, smoke, mold, rodent, pets, noise.
A nurse explains to a patient's family that there are six vital signs monitored on all patients: blood pressure, temperature, pulse, respirations, pain, and ____________________.
oxygen saturation
What are Centers for Medicare & Medicaid Services (CMS)? And what do they ensure?
part of the Department of Health and Human Services (HHS) that provides multiple services to the U.S. communities. Ex. Medicare, Medicaid, Affordable Care Act, Statistical Information for healthcare delivery. Ensure proper quality of care is provided and not overcharged.
A determination or judgment about a person or group based on an irrational suspicion or hatred of a particular group, race, sexual orientation, or religion is known as ____________________.
prejudice
What is the American Nurses Association (ANA)?
premier organization representing the nursing workforce in the U.S. and territories.
What type of environment is best when interviewing?
quiet environment
The mother of a 9 year old boy becomes concerned when he will not stop crying or clinging to her. A nurse explains to the mother that the child may be showing signs of ____________________, or a returning to earlier behaviors that may occur in school age children when they feel insecure and threatened by treatments.
regression
Rhythm of pulse
regular or irregular
rhythm of pulse
regular or irregular
Working phase
the bulk of the therapeutic communication; the active part of the relationship ● Nurse communicates caring, the patient expresses thoughts and feelings, and mutual respect is maintained
Grunting is caused when
the child exhales against a partially closed glottis in an attempt to keep the bronchioles open and prevent closure of the alveoli.
Regulation or thermoregulation is determined using
the client's temperature.
Dominant culture
the group that has the most authority or power to control values and rewards or punish behaviors ○ Usually but not always the largest group
Promote & prevent shearing injuries?
use lift and not drawsheet
quality of pulse
strong, weak or bounding
Acculturation
An individual assumes the characteristics of a culture they just immigrated too.
If a fire occurs call a
"Code Red" or "Code yellow" depending on the institution process. Stay safe and evacuate if needed. Use RACE or PASS
What are the physiological consequences for electrolyte deficit?
-Cardiac dysrhythmias (<K+) -Muscle weakness (< K+) -Mental Status Change (< Na+) -Generalized Weakness (< Na+)
What are common code names for fire?
"Mr. Red," "Dr. Red," and "code red" are common
Determine clients Respiratory effort
(nasal flaring; use of accessory muscles, and body positioning)
Bag Bath:
Modification of the towel bath, in which you use 8 to 10 washcloths instead of a towel and bath blanket.
Examples of self actualization
(e.g., extent to which goals are achieved, role performance, Personal growth, reaching one's highest potential)
Examples of physiological needs
(e.g., oxygen, water, food, air, water, shelter, sleep and rest, elimination, activity, temperature regulation)
Pathogenic causes
(foodborne, Water-borne, or vector-borne illnesses)
Back injury (Occupational safety)
- 52% nurse report back pain - Causes include transferring, repositioning, changing bed linens, & weighing patients - Preventative measures includes, using sage handling equipment, report hazards, incidents and injuries
Therapeutic Responses & Techniques
- Active Listening - Cultural competence - Don't interrupt - Veracity - Fidelity - Establishing Trust - Being Assertive - Restating, Clarifying, and Validating Messages - Interpreting Body Language and Sharing Observations - Exploring Issues - Using Silence - Summarizing the Conversation
Radiation injury (Occupational safety)
- Avoid excess radiation - Use protective equipment - TIME: limit time of exposure - DISTANCE: only perform care of patient near the patient when its essential - SHIELDING: wear protective shielding
What would be the proper follow up for cultures that refuse medication?
- Documentation why they refused - Never Force - Explain/Educate to the patient why you are giving them the medication - Try to find alternatives
herbal supplements & their usage
- Ginko Biloba: Depression, memory - Ginseng: depression, antioxidant and anti-inflammatory effects - Kava: Depression, anxiety - Echinacea: common cold; Reduce inflammation, control blood sugar, lowers BP - Chamomile: calming and soothing properties. - Goldenseal: Stimulates immune system and bile secretion - Melatonin: sleep - Saw palmetto: increase testosterone levels, improve prostate health, reduce inflammation, prevent hair loss, and enhance urinary tract function - Feverfew: fevers, migraine headaches, rheumatoid arthritis, stomach aches, toothaches, insect bites, infertility, and problems with menstruation and labor during childbirth. Aloe: Reduce skin itching& inflammation, constipation and psoriasis
Peripheral pulses (Normal, bradycardia, tachycardia)
- Normal= 60-100 beats per minute o Bradycardia = beats below 60/min o Tachycardia= beats higher than 100/min
Examples of never events
- air embolism - wrong transfusion - Labor Death - Wrong site surgery - falls - trauma or injuries -DVT or PE after knee surgery - CAUTIs - CLABSIs - HAPIs, etc.
Needle stick (Occupational safety)
-26% of nurses even with osha regulation - Increased risk when (stress, +12hr shifts, low skill level, lack of protective devices)
Physiological tier consists of (Maslow Hierarchy of needs)
-Air-Food - Nutrition -Water - Temperature regulation - Elimination -Rest - Sleep effects -Sex - Physical Activity - mobility assessment - Blood flow (perfusion) is necessary to meet other basic needs
Non therapeutic responses & Techniques
-Asking Too Many Questions - Asking Why - Fire-Hosing Information - Changing the Subject Inappropriately - Failing to Probe - Offering Advice - Providing False Reassurance - Stereotyping - Using Patronizing Language
What are the physiological consequences for electrolyte excess?
-Cardiac Dysrhythmias -Muscle Spasms -Kidney stones (nephrolithiasis)
Maintenance for respiratory illnesses
-Determine the underlying cause -Requires Immediate Attention (emergent) -Administer oxygen-Monitor pulse oximetry. -Medications will be needed (antihistamine, decongestants, glucocorticoids, bronchodilators, mucolytics, & antimicrobials) -Reposition patient in Semi-Fowlers -Teach about deep breathing (use an incentive spirometer) -Coughing exercise -Deep Breathing Techniques
Maintenance for sensory disabilities
-Encourage compliance with medication treatments -Use corrective devices -Complete visual impairment will need resources (guide dogs and learn braille language) -Complete hear impairment will need resources (closed-captions, assistance hearing devices, and learn sign language)
Communication with visual impaired patients
-Guide dogs -Braille -Auditory communication -Assisted devices such as walking sticks
What are the physiological consequences for fluid excess?
-Hypertension -Strong & Bounding peripheral pulses -Edema
What are the physiological consequences for fluid deficit?
-Hypotension -Tachycardia -Weak peripheral pulses -Dehydration -Reduced kidney function -Decrease urine output (less than 30mL/hr)
Prevention for sensory disabilities
-Interventions will be primary (prevent) and secondary (maintain) interventions. -Encourage the use of protective devices to minimize risk (ex. Safety goggles, ear plugs, etc) -Perform annual screening diagnosis.
Maintenance regarding nutrition
-Monitor for signs and symptoms of fluid and electrolyte imbalances -Assess skin -Urine incontinence: Teach the patient about bladder training, the patient might need an intermittent catheter or a Foley catheter -Diarrhea: provide fluid-balanced, administered medications as needed, keep accurate track of I&O. If severe diarrhea, keep patient NPO but provide IV fluids -Constipation: Encourage a high-fiber diet, use medications as needed, increase activity, increase fluid intake.
Prevention for sexual illnesses
-Perform STI screening and physical examination -Determine patients' self-knowledge -Educate about risk factors and protection
Prevention for respiratory illnesses
-Proper hand washing to avoid respiratory illness. -Smoking Cessation (prevents COPD and emphysema) -Teach about exposure to TB or FLU -Vaccinations (prevents flu, pneumonia, etc.) -Turn, Cough and use deep breath techniques.
Prevention regarding nutrition
-Proper nutrition and hydration -Diet high in fiber (reduces the risk of colon cancer) -Exercise
What are the steps to validate the message by using therapeutic communication?
-Restating: using your own words to summarize the message -Clarifying: ensure you have decoded the message correctly -Validate: confirms you have made the correct interpretation
Maintenance for sexual illnesses
-Will depend on the cause -Determine the root-cause -Referred to correct healthcare provider
What are some education points to teach parents with school age children on how to prevent injuries at home?
....
Strength of pulse
0 = absent 1+ = thready or weak 2+ = normal 3+ = strong 4+ = bounding
Self-Actualization tier consists of? (Maslow Hierarchy of needs)
1. Achieving one's full potential 2. Extent to which goals are achieved 3. Role performance
Units
1 TBS=15mL 1oz=30mL 1mg=1000mcg
Name the pain scales
1-10 FACES FLACC CRIES
NCLEX STYLE:What nursing intervention can give a patient a sense of control regarding personal safety? Select all that apply. 1. Inform the patient why an identification band should be worn. 2.Instruct the patient how to lock the wheels on a wheel chair. 3. Keep the patient's bed in the lowest position. 4. Teach the patient how to use the call bell. 5.Orient the patient to the environment.
1. Although wearing an identification band will provide for patient safety, it does not give the patient a sense of control. • 2. This information allows the patient to ensure that the wheels of a wheel chair are locked. 3. Keeping the patient's bed in the lowest position will not give the patient a sense of control. • 4. The ability to call for help when needed gives the patient a sense of control. • 5. Having an understanding of the environment (e.g., how to use a call bell, how to raise and lower the bed, and how to use the side rails when turning or transferring) gives the patient a sense of control.
Esteem tier consists of? (Maslow Hierarchy of needs)
1. Feeling of accomplishment 2. Body image 3. Pride in achievements 4. Admiration from others
Nursing Interventions to achieve physiological needs
1. Helping patient to eat dinner 2.Changing a patients oxygen tank 3.Ensure patient is getting enough rest
Love/Belonging tier consists of? (Maslow Hierarchy of needs)
1. Intimate relationship 2. Friends 3. Social supports
Examples of Complementary and alternative therapy (CAM)
1. Pet Therapy 2. Massages 3. Biofeedback 4. Exercise & Fitness 5. Nutritional Supplements 6. Health-Focused TV 7. Music Therapy 8. Acupuncture 9. Acupressure 10. Disease Management 11. Aromatherapy
Safety and security tier consists of? (Maslow Hierarchy of needs)
1. Protection from physical harm 2. Adequate shelter 3. Freedom from fear and anxiety 4. Safe from falls 5. Treatment 6. Side effects 7. The need for psychological security
3 Major Health Beliefs
1. Scientific 2. Magico-Religious 3. Holistic
Normal Resp Values
12-20 breaths per minute
Normal BP values
120/80
Personal distance
18 inches to 4 feet
Personal Distance
18 inches to 4 feet.
Oral care should be done every ___ hours?
2
Remove patient restraints every?
2 hours
A patient complains of left sided chest pain radiating to the left shoulder. Using the SOAPIER method, a nurse should chart this complaint under the initial A) S. B) O. C) A. D) P.
A) S.
A nurse explains to a terminally ill patient's family members that they should expect their loved one to experience five stages of grief. Place the five stages in the typical order in which grief is experienced (1 5). (Enter the number of each step in the proper sequence, do not use commas). 1. Anger 2. Acceptance 3. Denial 4. Depression 5. Bargaining
3. Denial 1. Anger 5.Bargaining 4.Depression 2.Acceptance
Social distance
4 to 12 feet
Social Distance
4 to 12 feet. It is used in more formal interaction or when communicating with a group of individuals at the same time.
width of the cuff should be
40% of the arm circumference
Normal Pulse Values
60 to 100 beats per minute
cuff size the length needs to be
80% of the arm circumference
Normal Temp
96.4 to 99.5 degrees Fahrenheit
Intimate distance
<18 inches
Public Distance
> 12 feet. This distance requires loud and clear enunciation for communication.
Public distance
>12 feet
A nurse is caring for a Jewish patient who adheres to Jewish dietary law. The nurse recognizes that the most appropriate kosher dietary choice to offer to this patient is A) Salmon. B) Clam chowder. C) Grilled shrimp. D) Pulled pork.
A) Salmon.
Empathy
A desire to understand and be sensitive to the feelings and situation of another person. Put yourself in the client's place, mentally and emotionally.
Assimilation
A new member learn and take essential values, beliefs and behaviors of the dominant culture gradually.
A nurse recognizes that macronutrients include which of the following? Select all that apply. A) Fats B) Protein C) Vitamins D) Carbohydrates E) Water
A) Fats B) Protein D) Carbohydrates E) Water
A nurse is caring for a patient who just fell from the bed onto the floor. The nurse should write a(n) A) Emergency record. B) Incident report. C) Progress report. D) Grievance report.
B) Incident report.
A nurse is instructing a student nurse about the best methods to use when teaching a kinesthetic learner. The student nurse demonstrates understanding when stating: A) "A kinesthetic learner learns best by doing." B) "A kinesthetic learner learns best by seeing." C) "A kinesthetic learner learns best by reading." D) "A kinesthetic learner learns best by watching."
A) "A kinesthetic learner learns best by doing."
A patient admitted with hypertension asks the nurse what causes blood pressure to elevate. The nurse replies: A) "A long history of smoking can raise the blood pressure over time." B) "Blood pressure often is elevated in Asian races." C) "Blood pressure can increase by getting in excess of 6 to 8 hours of sleep every night." D) "We're not sure what factors are involved in raising blood pressure."
A) "A long history of smoking can raise the blood pressure over time."
A patient is considering moving to an assisted living facility. When providing education about assisted living facilities, the nurse states: A) "An assisted living facility provides a homelike atmosphere." B) "An assisted living facility provides a hospital like atmosphere." C) "Your physician will make daily visits while you're at an assisted living facility." D) "You should move to an assisted living facility when you can no longer care for yourself."
A) "An assisted living facility provides a homelike atmosphere."
An instructor is explaining various types of infections. A student demonstrates understanding by saying: A) "An infection that is acquired while the patient is being cared for in a health care setting is known as a health care associated infection." B) "If a person has an infection in just one area of the body, it is described as a primary infection." C) "If a second infection is caused by a different pathogen, it becomes a systemic infection." D) "If an infection spreads from the lungs to other organs, it becomes a secondary infection."
A) "An infection that is acquired while the patient is being cared for in a health care setting is known as a health care associated infection."
A nursing instructor recognizes that further teaching is needed if a nursing student states: A) "Client centered care fosters a feeling of dependence." B) "Client centered care is often seen in a rehabilitation setting." C) "Client centered care empowers the patient to manage his or her care." D) "Client centered care empowers the patient to take control of his or her care."
A) "Client centered care fosters a feeling of dependence."
A nurse correctly explains to a patient with a sprained wrist that cold therapy will relieve pain better than would heat by stating: A) "Cold therapy decreases swelling and pressure on nearby nerves, which helps decrease pain." B) "Heat therapy decreases swelling by constricting vessels and nerves, which can increase discomfort." C) "Heat therapy decreases pain by increasing oxygen and nutrients to the injured area." D) "Cold therapy increases the inflammatory process, which speeds healing and decreases discomfort."
A) "Cold therapy decreases swelling and pressure on nearby nerves, which helps decrease pain."
A patient with congestive heart failure (CHF) presents to the emergency department with muscle spasms in the lower back. Which of the following would not be an appropriate application of heat? A) Forced air warming blanket B) Commercial heat pack C) Hot compress D) Heat therapy can never be used safely in a patient with CHF.
A) Forced air warming blanket
A nurse is caring for a patient who is newly diagnosed with diabetes mellitus type B. The patient requires teaching about antidiabetic medications, including when to take them, what effects are expected, and negative side effects to report if they occur. When formulating a nursing diagnosis for this patient, the nurse selects A) "Deficient knowledge." B) "Diabetes knowledge deficit." C) "Risk for deficient knowledge." D) "Readiness for enhanced knowledge."
A) "Deficient knowledge."
A nurse is educating a student nurse about documentation. The nurse recognizes that additional teaching is required when the student nurse states: A) "Documentation serves as a temporary part of the medical record." B) "Documentation is one of the most important tasks that I'll perform in nursing." C) "Documentation is the act of charting pertinent information related to a patient." D) "Documentation is evidence of what transpired during an event requiring medical care."
A) "Documentation serves as a temporary part of the medical record."
A nurse educates a nursing student about effective patient care. The nurse recognizes that additional instruction is needed when the nursing student states: A) "For patient care to be effective, it must be delivered periodically." B) "For patient care to be effective, it must be delivered continuously." C) "For patient care to be effective, it must be evaluated continuously." D) "For patient care to be effective, it must be delivered systematically."
A) "For patient care to be effective, it must be delivered periodically."
A nurse educator is teaching a group of new graduate nurses about how to correctly apply restraints. The nurse educator recognizes that further instruction is warranted when a new graduate nurse states: A) "I should never use restraints on a patient." B) "I should tie restraints in a quick release knot." C) "I should not use restraints for the convenience of the staff." D) "I should be able to insert three fingers between the patient's body and the restraint."
A) "I should never use restraints on a patient."
A nursing instructor educates a student nurse about health promotion strategies. The instructor recognizes that additional instruction is needed when the student nurse states: A) "I will encourage patients to consume fewer fresh fruits." B) "I will encourage patients to exercise three times a week." C) "I will instruct patients about stress modification strategies." D) "I will encourage patients to consume more fresh vegetables."
A) "I will encourage patients to consume fewer fresh fruits."
A nursing instructor is educating a student nurse about methods to prevent orthostatic hypotension. The nursing instructor recognizes that further teaching is needed when the student states: A) "I will encourage the patient to remain flat in bed." B) "I will change the patient's position in bed frequently." C) "I will encourage dorsal and plantar flexion of the feet." D) "I will perform passive range of motion exercises if the patient can't move."
A) "I will encourage the patient to remain flat in bed."
A febrile patient's mother asks the nurse why her daughter's breathing rate is increased. The nurse replies: A) "It is normal for the fever to increase her metabolic rate. Because the heart and lungs work together, you see her breathing speed up along with her heart rate." B) "It is quite normal for this to happen, so you can expect her respiratory rate to increase by 8 to 10 respirations per minute for each 1°F elevation in temperature." C) "Breathing speeds up when the temperature is elevated to blow off some of the body heat." D) "It is rare that respirations are affected by fever. We should be very concerned about this."
A) "It is normal for the fever to increase her metabolic rate. Because the heart and lungs work together, you see her breathing speed up along with her heart rate."
A patient asks the nurse, "Why has my primary care physician ordered an antidepressant for me? I'm not depressed. I'm just in pain." The nurse could appropriately explain: A) "It was ordered because it is known to potentiate the pain medication that you are taking." B) "Anyone who is suffering from pain will eventually begin to suffer from depression, so your physician wants to prevent that." C) "Everyone experiences depression at one time or another." D) "I guess your primary care physician must have misunderstood you. I'll talk to the physician later."
A) "It was ordered because it is known to potentiate the pain medication that you are taking."
An instructor recognizes that a student requires further teaching about surgical asepsis when the student says: A) "Maintaining a clean patient environment is an important aspect of surgical asepsis." B) "Surgical asepsis requires the use of sterile supplies and equipment." C) "Surgical asepsis prevents contamination during invasive procedures." D) "I should follow a sterile technique when handling needles, syringes, and lancets."
A) "Maintaining a clean patient environment is an important aspect of surgical asepsis."
An instructor is teaching students the importance of understanding the changes brought about by aging that are not indicative of disease. The instructor points out that additional instruction is required when a student says: A) "Men and women will no longer have a need for sexual intimacy." B) "Blood flow and oxygen use in the brain will decrease." C) "There will be a decrease in bone density." D) "Bladder capacity will decrease because of loss of muscle tone."
A) "Men and women will no longer have a need for sexual intimacy."
A nursing instructor supervises a student nurse who is administering an intramuscular analgesic medication to a school age child. The nursing instructor intervenes when the student nurse tells the child: A) "My injections don't hurt." B) "This will only hurt for a little while." C) "This will feel like a prick and will hurt a little." D) "This medication will help take your pain away."
A) "My injections don't hurt."
A male patient, who was admitted for evaluation of the cardiovascular system, has strong and equal peripheral pulses. The nurse correctly documents: A) "Peripheral pulses 2+ and equal bilaterally." B) "Pedal and radial pulses 1+ and equal." C) "All pulses 3+ and equal bilaterally." D) "Peripheral pulses present and equal."
A) "Peripheral pulses 2+ and equal bilaterally."
An instructor explains that the microorganism Rickettsia rickettsii causes Rocky Mountain spotted fever. A student demonstrates understanding of the subject by stating: A) "Rocky Mountain spotted fever is spread by ticks." B) "Rocky Mountain spotted fever is caused by eating undercooked ground meat." C) "Rocky Mountain spotted fever is caused by spores that live in dead tissue." D) "Rocky Mountain spotted fever can lie dormant in nerve endings for years."
A) "Rocky Mountain spotted fever is spread by ticks."
An instructor explains to students the Handle With Care campaign that was instituted by the American Nurses Association (ANA). A student demonstrates understanding by saying: A) "The purpose of the Handle With Care campaign is to build an industry wide program in health care to prevent musculoskeletal injuries." B) "The Handle With Care campaign provides guidelines for disciplinary action for those who lift and move patients incorrectly." C) "The Handle With Care bill was passed by the House of Representatives and requires safe patient handling programs in all health care facilities." D) "The Handle With Care campaign instituted a 'no lifting' program that prevents nursing staff from lifting patients under any circumstance."
A) "The purpose of the Handle With Care campaign is to build an industry wide program in health care to prevent musculoskeletal injuries."
The nurse is supervising a certified nursing assistant (CNA). The nurse intervenes when the CNA asks a patient: A) "Would you like some more pain medication?" B) "Would you like some fresh sheets?" C) "When would you like your bath?" D) "Is it okay if I take your vital signs?"
A) "Would you like some more pain medication?"
An elderly Caucasian female patient tells a male nurse that she does not want him to be her nurse. An appropriate initial response by the nurse would be to say: A) "You are not comfortable with a male nurse?" B) "You need to calm down." C) "Discriminating against me may affect the care you receive." D) "I'll stay with you until you feel more comfortable with me."
A) "You are not comfortable with a male nurse?"
A nurse is caring for a patient who has end stage renal disease and will require dialysis three times per week. The patient states, "I'm upset that I didn't visit all the places I'd like to see. Now that I'm on dialysis, I won't be able to." The most therapeutic response by the nurse is: A) "You are upset that it's too late to visit places that you would like to see?" B) "There are many people who feel exactly the same as you do." C) "Don't worry. You can still visit all of the places that you would like to see." D) "I think you should visit the places you would like to see before it's too late."
A) "You are upset that it's too late to visit places that you would like to see?"
A nurse is supervising a certified nursing assistant (CNA) who is caring for a patient who is alert and oriented and independent concerning activities of daily living. The nurse appropriately intervenes when hearing the CNA say to the patient: A) "You should drink ice water rather than room temperature water." B) "Would you like to leave your socks on?" C) "Do you prefer your drinks with or without a straw?" D) "Would you prefer a cup of hot coffee, a glass of iced tea or fruit juice, or maybe a carbonated drink?"
A) "You should drink ice water rather than room temperature water."
A nurse has just completed the insertion of a nasogastric (NG) tube. The nurse should verify placement by aspirating for gastric contents and checking the pH of the aspirate. The nurse recognizes that the pH of gastric contents should be between A) 1 and 4. B) 2 and 5. C) 3 and 6. D) 4 and 7.
A) 1 and 4.
The individual admitted to the hospital who is at the greatest risk for acquiring a hospital acquired infection is A) A 2 month old infant with a head injury from being dropped. B) A 10 year old with a hairline fracture from sliding into third base. C) A 6 year old who fell off the monkey bars and has three broken ribs. D) A 17 year old with an elevated blood alcohol level.
A) A 2-month-old infant with a head injury from being dropped.
A nurse performing an assessment would correctly note that an absent pulse in one or more of the extremities indicates A) A blockage. B) Shock. C) Decreased plasma volume. D) Problems with the heart's electrical conduction system.
A) A blockage.
A nurse understands that special precautions must be taken when a whirlpool bath is administered to which of the following patients? Select all that apply. A) A patient who has been sedated to undergo a procedure B) A 70 year old patient C) A patient with a wound that requires débridement D) A patient with physical therapy scheduled E) An 8 year old patient
A) A patient who has been sedated to undergo a procedure B) A 70 year old patient E) An 8 year old patient
When conducting an in service about weight reduction, a nurse recognizes that participants will have accomplished true learning when they are able to demonstrate that they can do which of the following? Select all that apply. A) Adhere to a healthier diet. B) Memorize isolated facts. C) Exercise three times per week. D) Consume fewer processed foods. E) Recite a list of heart healthy foods.
A) Adhere to a healthier diet. C) Exercise three times per week. D) Consume fewer processed foods. E) Recite a list of heart healthy foods.
A patient who was admitted with severe back pain is watching TV and smiling. The patient received pain medication 4 hours ago and rates his pain at an 8. Knowing that the patient's pain medication may be given every 4 to 6 hours, the nurse will A) Administer the pain medication now. B) Tell the patient that if diversion does not work, then the nurse will administer pain medication in 2 hours. C) Explain the gate control theory and suggest a massage. D) Call the physician and request an order for a transcutaneous electrical nerve stimulator (TENS) unit.
A) Administer the pain medication now.
A nursing diagnosis for a patient suffering a terminal illness is "spiritual distress." Based on the diagnosis, which of the following is an appropriate nursing intervention? Select all that apply. A) Allowing the patient to express concerns about dying B) Soliciting an appropriate member of the clergy with the patient's consent C) Suggesting that family members limit their visits during the patient's distress D) Providing comfort by sitting quietly at the patient's bedside E) Encouraging the patient to leave the TV on and to keep room blinds open
A) Allowing the patient to express concerns about dying B) Soliciting an appropriate member of the clergy with the patient's consent D) Providing comfort by sitting quietly at the patient's bedside
When teaching children, a nurse should do which of the following? Select all that apply. A) Always tell the truth. B) Use teaching pamphlets created for adults. C) Emphasize the importance of hand washing. D) Refrain from telling a child that something will hurt. E) Use a doll or teddy bear as the patient when explaining a procedure.
A) Always tell the truth. C) Emphasize the importance of hand washing. E) Use a doll or teddy bear as the patient when explaining a procedure.
A patient with dysphagia is given a meal of scrambled eggs, cottage cheese, and tea. A nurse identifies that this patient is on a A) Mechanical soft diet. B) A full liquid diet. C) Protein restricted diet. D) Pureed diet.
A) Mechanical soft diet.
A nurse is assigned to care for four patients. The nurse determines that the patient who is most at risk for injury from trying to get out of bed is A) An 84 year old patient who has a fecal impaction. B) An 8 year old child who underwent a tonsillectomy. C) A 16 year old adolescent who had an appendectomy. D) A 62 year old patient who had a myocardial infection.
A) An 84 year old patient who has a fecal impaction.
A nurse recognizes that the most preventable cause of death during hospitalization is A) An embolism. B) Hospital acquired pneumonia. C) Skin breakdown because of not turning patients. D) A urinary tract infection leading to urosepsis.
A) An embolism.
Culture plays a strong role in determining whether a patient will be willing to communicate if he or she is in pain or how severe the pain may be. Therefore, a nurse understands that extra time may need to be taken to determine the pain level of A) An older South African woman B) A young Irishman C) A young Saudi woman D) An older Latina woman
A) An older South African woman
A nurse is caring for a severely underweight patient who has an admitting diagnosis of anorexia nervosa. When assessing this patient, the nurse anticipates which of the following? Select all that apply. A) Anemia B) Oily hair C) Brittle nails D) Severe diarrhea E) Muscle weakness
A) Anemia C) Brittle nails E) Muscle weakness
A nurse expects that a patient diagnosed with a deep vein thrombosis (DVT) in her right lower leg will most likely have an order for which method of heat application? A) Aquathermia pad B) Sitz bath C) Hot water bottle D) Warming blanket
A) Aquathermia pad
A nurse is caring for a patient who requires preoperative teaching. When performing patient teaching, the nurse should do which of the following? Select all that apply. A) Ask the patient for feedback. B) Ensure that the patient is comfortable. C) Provide teaching in a lecture format. D) Refrain from asking the patient questions. E) Establish a comfortable room temperature.
A) Ask the patient for feedback. B) Ensure that the patient is comfortable. E) Establish a comfortable room temperature.
While reviewing medications taken by a patient scheduled to have a bone marrow aspirate, a nurse would be most concerned if the patient reported taking which of the following? A) Aspirin (acetylsalicylic acid) B) Tylenol (acetaminophen) C) Gas X (simethicone) D) Prilosec (omeprazole)
A) Aspirin (acetylsalicylic acid)
A nurse is educating young parents regarding the proper medication to use for fever reduction in children. It is important that the nurse makes sure that the parents understand that A) Aspirin should never be given to children with a virus. B) Parents should never give their children ibuprofen. C) Acetaminophen should never be used to treat a child's fever. D) Advil should never be used to treat a fever in patients younger than 15 years.
A) Aspirin should never be given to children with a virus.
A nurse is caring for a patient who has a nasogastric (NG) tube to suction. When caring for this patient, the nurse should do which of the following? Select all that apply. A) Assess the tube once per shift for patency. B) Irrigate the clogged tube according to facility policy. C) Position the tube so that it puts pressure on the naris. D) Provide infrequent mouth care and lip moisturizer. E) Assess color, amount, and consistency of gastric drainage.
A) Assess the tube once per shift for patency. B) Irrigate the clogged tube according to facility policy. E) Assess color, amount, and consistency of gastric drainage.
A nurse correctly recognizes that most individuals prefer to recover from illness or injury A) At home. B) In the hospital. C) At a care center. D) In the emergency department.
A) At home.
When teaching the elderly, a nurse should do which of the following? Select all that apply. A) Be very patient. B) Use plenty of repetition. C) Allow limited time for teaching. D) Ignore cues that the patient does not understand. E) Have a caregiver or family member present.
A) Be very patient. B) Use plenty of repetition. E) Have a caregiver or family member present.
While assessing a patient in pain, a nurse knows that which of the following signs and symptoms support chronic as opposed to acute pain? Select all that apply. A) Blood pressure (BP) 116/84, pulse rate (P) 76, respiration rate (R) 18 B) Sudden sharp, stabbing pain C) Dull, aching pain over past 7 months D) Dilated pupils E) Withdrawn with loss of appetite
A) Blood pressure (BP) 116/84, pulse rate (P) 76, respiration rate (R) 18 C) Dull, aching pain over past 7 months E) Withdrawn with loss of appetite
A nurse would recognize that further instruction was needed if a nursing student expressed the assumption that a patient A) Cannot be in pain if she is sleeping. B) Is the pain expert. C) May be able to get more rest with pain medication. D) May experience sleeplessness because of the hospital environment.
A) Cannot be in pain if she is sleeping.
A nurse understands that perhaps the most important care that can be provided for the terminally ill patient is A) Caring and touching. B) Encouraging reminiscing. C) Giving pain medication. D) Encouraging visits from a member of the clergy.
A) Caring and touching.
A student nurse correctly performs a bed bath by A) Changing the water after bathing the feet. B) Washing extremities from proximal to distal. C) Washing with the same water throughout the bath. D) Washing from the dirtiest areas to the cleanest area.
A) Changing the water after bathing the feet.
A terminally ill patient's respiratory pattern has changed and is now cyclic in nature, with increasing and then decreasing depths that are spaced by brief periods of apnea. The nurse charts that the patient is having A) Cheyne Stokes respirations. B) Biot respirations. C) Apnea. D) Eupnea.
A) Cheyne Stokes respirations.
A nursing instructor is teaching students about bathing patients. Which of the following are benefits of bathing? Select all that apply. A) Cleanses the skin B) Increases sensation C) Allows for skin assessment D) Promotes circulation E) Improves self esteem
A) Cleanses the skin B) Increases sensation C) Allows for skin assessment D) Promotes circulation E) Improves self esteem
When using a refillable ice bag, a nurse correctly A) Fills the bag one half to two thirds with ice and some water. B) Fills the bag completely with water and then freezes it. C) Fills the bag completely with ice. D) Fills the bag one quarter to one third with ice and then partially melts the ice in the microwave.
A) Fills the bag one half to two thirds with ice and some water.
A nurse is conducting an admission assessment on a patient with a new diagnosis of AIDS. The nurse demonstrates a caring demeanor by A) Closing the door to the patient's room. B) Asking the patient questions at the nurse's station. C) Delivering nursing care as rapidly as possible to allow the patient more time alone. D) Refraining from telling the patient why he or she needs to ask personal questions.
A) Closing the door to the patient's room.
An adolescent volunteers to read to hospitalized children without being paid. The nurse recognizes that the adolescent is in which stage of Lawrence Kohlberg's moral development theory? A) Conventional morality B) Preoperational morality C) Preconventional morality D) Postconventional morality
A) Conventional morality
A nurse is caring for a patient who is newly diagnosed with Graves disease. The nurse selects the nursing diagnosis "Readiness for enhanced knowledge." Next, the nurse should A) Create a written teaching plan. B) Perform an admission assessment. C) Evaluate the patient's response to the interventions. D) Present the information in the teaching plan to the patient.
A) Create a written teaching plan.
A nurse provides care to the whole patient, incorporating within that care the cultural context of the patient's beliefs and values. The nurse is providing care that is A) Culturally competent. B) Culturally insensitive. C) Culturally incompetent. D) Culturally assimilated.
A) Culturally competent.
In preparation for contributing to a patient's plan of care, a nurse will assess a patient's rituals, values, customs, and beliefs. The nurse is assessing the patient's A) Culture. B) Race. C) Ethnicity. D) Heritage.
A) Culture.
A nursing instructor educates a class of nursing students about a common type of focus charting known as DAR. The nursing instructor teaches that the acronym DAR stands for A) Data, Action, Response. B) Data, Assessment, Revision. C) Diagnosis, Action, Response. D) Data, Assessment, Response.
A) Data, Action, Response.
A patient complains of feeling short of breath. His oxygen saturation level is 86%. When auscultating his lung sounds, a nurse notes wheezes and crackles throughout. The patient has a productive cough of thick green mucus. The nurse should chart these actions under the section of DAR charting that is called A) Data. B) Action. C) Response. D) Assessment.
A) Data.
The nursing process is a A) Decision making framework used by nurses to determine the needs of patients. B) Decision making framework used by social workers when discharging patients. C) Decision making framework used by nursing assistants when caring for patients. D) Decision making framework used by physicians to determine the needs of patients.
A) Decision making framework used by nurses to determine the needs of patients.
After increasing fluid intake and administering stool softeners for a patient complaining of constipation, a nurse calls the physician to obtain an order to administer an enema. This is an example of a(n) A) Dependent intervention. B) Indirect intervention. C) Independent intervention. D) Collaborative intervention.
A) Dependent intervention.
A nurse recognizes that the process in which food is broken down in the gastrointestinal (GI) tract, releasing nutrients for the body to use, is called A) Digestion. B) Peristalsis. C) Indigestion. D) Absorption.
A) Digestion.
A critically ill patient may have difficulty in getting the restorative sleep necessary for healing. A nurse will A) Dim the lights and close the door. B) Encourage the patient to get some exercise. C) Refrain from waking the patient for nursing care. D) Silence alarms on equipment to enhance rest.
A) Dim the lights and close the door.
A nurse is caring for a patient with an increased risk for aspiration due to severe gastroesophageal reflux disease (GERD). The nurse identifies that the correct type of nasointestinal (NI) tube for this patient would be a A) Dobbhoff tube. B) French tube. C) Salem sump tube. D) Levin tube.
A) Dobbhoff tube.
A nurse correctly recognizes that discharge planning should be initiated A) During the admission process. B) Before the patient is admitted to the hospital. C) Immediately before discharging the patient. D) The day after the patient's hospital admission.
A) During the admission process.
A problem solving approach to delivering health care that uses the best evidence from nursing research studies and patient care data, and considers the patient's preferences and values is known as A) Evidence based practice (EBP). B) The interacting systems framework. C) Quality and Safety Education for Nurses (QSEN). D) The adaptation model.
A) Evidence based practice (EBP).
A nurse is caring for a patient who has an admitting diagnosis of bulimia nervosa. When assessing this patient, the nurse anticipates which of the following? Select all that apply. A) Evidence of dental decay B) Complaints of indigestion C) Complaints of constipation D) Complaints of a sore throat E) Symptoms of gastric reflux
A) Evidence of dental decay B) Complaints of indigestion D) Complaints of a sore throat E) Symptoms of gastric reflux
A patient is admitted to a hospital unit with a diagnosis of anorexia nervosa. When caring for this patient, a nurse recognizes that anorexia nervosa is characterized by which of the following? Select all that apply. A) Evidence of emaciation B) An excessive leanness or wasting of the body C) An accurate self perception about body weight D) Obsessive thoughts about body shape and weight E) Attempts to reduce one's body weight below normal
A) Evidence of emaciation B) An excessive leanness or wasting of the body D) Obsessive thoughts about body shape and weight E) Attempts to reduce one's body weight below normal
When helping teens understand how to prevent accidents and injuries, a nurse should caution them about which of the following? Select all that apply. A) Experimentation B) Water safety C) Internet social networking D) Stranger danger E) Firearms
A) Experimentation C) Internet social networking E) Firearms
A nurse is caring for a visually impaired patient who requires discharge instructions. When speaking with the patient, the nurse should do which of the following? Select all that apply. A) Face the patient directly. B) Ensure that the patient's glasses are on. C) Sit in front of a light that causes a glare. D) Provide the patient with larger print handouts. E) Offer the patient handouts with small print.
A) Face the patient directly. B) Ensure that the patient's glasses are on. D) Provide the patient with larger print handouts.
A female Muslim patient is hospitalized and is scheduled for surgery later in the day. In preparing the patient for surgery, a nurse will A) Get the patient's husband to also sign the consent form. B) Make arrangements for family members to bring kosher food from home because a normal diet is allowed. C) Perform "laying on of the hands," or allow a trained individual to do so. D) Allow a shaman to perform a healing ritual in an attempt to thwart surgical intervention.
A) Get the patient's husband to also sign the consent form.
A nurse recognizes that the term for the physical changes that occur in the size of human beings is A) Growth. B) Spirituality. C) Regression. D) Development.
A) Growth.
A dietitian teaches a class of student nurses that various laws ensure that nutrition facts food labels are found on all processed food products. A student correctly identifies that each food label must include which of the following? Select all that apply. A) Health claims B) Bacterial content C) Macronutrient content D) Daily Reference Value E) Vitamin and mineral content
A) Health claims C) Macronutrient content D) Daily Reference Value E) Vitamin and mineral content
A dietician teaches that minerals are inorganic compounds used by all body tissues for numerous functions except A) Helping the body absorb fat soluble vitamins. B) Forming the structure of the hard parts of the body. C) Muscle contraction. D) Assisting in water metabolism.
A) Helping the body absorb fat soluble vitamins.
A nurse suspects that a female patient may have difficulty increasing the protein in her diet. The patient is most likely A) Hindu. B) Jewish. C) Asian. D) Mexican.
A) Hindu.
A nurse explains to a patient's family that his respirations are faster and deeper than normal because A) His blood oxygen level indicates hypoxemia. B) He is using his intercostal muscles to breathe. C) He has developed an inflammation of the phrenic nerve. D) He is expelling too much carbon dioxide.
A) His blood oxygen level indicates hypoxemia.
A nurse recognizes that the relationship among all living things is A) Holism. B) Acupressure. C) Acupuncture. D) Allopathic medicine.
A) Holism.
The nurse correctly uses percussion when assessing the patient for A) Hyperinflated lungs. B) An enlarged heart. C) A heart arrhythmia. D) Rebound tenderness.
A) Hyperinflated lungs.
A physician has ordered, "Clear liquids, advance as tolerated." A nurse identifies that which of the following factors indicate that the patient is not yet ready to advance his or her diet? Select all that apply. A) Hypoactive bowel sounds B) Nausea C) Complaints of indigestion D) Hunger E) Excessive thirst
A) Hypoactive bowel sounds B) Nausea C) Complaints of indigestion
When caring for a patient with diabetes, a nurse checks the morning laboratory values. The nurse notes that the patient's blood glucose level is 60 mg/dL. The nurse recognizes this reading is consistent with A) Hypoglycemia. B) Hyperglycemia. C) A normal value. D) Diabetic ketoacidosis.
A) Hypoglycemia.
While taking a shower, a patient becomes light headed and dizzy. A nurse recognizes that these symptoms are most likely the result of A) Hypotension. B) Hypertension. C) Vasoconstriction. D) Narrowing of blood vessels.
A) Hypotension.
A nurse is performing an initial admission assessment on a patient. The patient states that he takes an herb named chamomile. The nurse recognizes that chamomile is used to treat A) Insomnia. B) Migraine headaches. C) Hypercholesterolemia. D) Irritable bowel syndrome.
A) Insomnia.
A nursing instructor evaluates a student nurse's application of theory regarding continuous tube feedings. The nursing instructor recognizes that further teaching is warranted when the student nurse A) Instructs the patient to maintain a supine position. B) Ensures that the head of the patient's bed is continually raised 30 degrees or more. C) Interrupts the feeding every 4 hours to check placement. D) Interrupts the feeding every 4 hours to check residual volume.
A) Instructs the patient to maintain a supine position.
A nurse encourages a patient to be proactive in promoting and maintaining health by doing which of the following? Select all that apply. A) Introducing the patient to the benefits of a regular exercise program B) Discussing the importance of keeping blood sugar levels within normal range C) Referring to a clinic for blood pressure screening D) Suggesting that medical care is accessed in acute emergencies and that alternative forms of treatment are used when it is not E) Explaining effects of overwhelming stress on health
A) Introducing the patient to the benefits of a regular exercise program B) Discussing the importance of keeping blood sugar levels within normal range C) Referring to a clinic for blood pressure screening E) Explaining effects of overwhelming stress on health
A nursing instructor is educating a class of nursing students about effective communication. The nursing instructor teaches that which of the following is true about effective communication? Select all that apply. A) It is essential in proper documentation practices. B) It is the foundation of nurse patient relationships. C) It helps establish proper transfer of health care information. D) It is something that nurses often feel prepared to do in clinical situations. E. It is a key element when reporting information to other health care members.
A) It is essential in proper documentation practices. B) It is the foundation of nurse patient relationships. C) It helps establish proper transfer of health care information. E. It is a key element when reporting information to other health care members.
A nursing instructor supervises a student nurse who is caring for a patient who is on fall precautions. The nursing instructor would intervene if he or she observed the student nurse A) Keeping the bed at the highest position at all times. B) Using furniture to block areas that are off limits to the patient. C) Placing the patient's bed at the lowest level when the patient is sleeping. D) Placing the overbed table across the wheelchair when the patient is seated.
A) Keeping the bed at the highest position at all times.
A student nurse is out shopping when he or she hears that a mass casualty event (MCE) has occurred in the area. It is his or her responsibility as a student and as a nurse to A) Know and follow his or her facility's disaster plan. B) Immediately return to his or her place of work. C) Go to the scene and begin treating the victims who are most likely to survive. D) Call the Department of Health and Human Services for instructions.
A) Know and follow his or her facility's disaster plan.
A nurse is performing an admission assessment on a patient who states that he adheres to a discipline in which the mind is focused on an object of thought or awareness, and usually involves turning attention to a single point of reference. The nurse recognizes that the patient participates in a form of complementary and alternative medicine (CAM) known as A) Meditation. B) Biofeedback. C) Aromatherapy. D) Phytonutrients.
A) Meditation.
A nurse recognizes that the ability to think at higher levels and develop a value system that differentiates right from wrong is called A) Moral development. B) Physical development. C) Cognitive development. D) Psychosocial development.
A) Moral development.
A nurse explains to family members that they can anticipate that death is very near for their loved one when they see which of the following? Select all that apply. A) Mottling of feet and legs B) Edema of lower extremity C) Slow and thready pulse D) Agitation and withdrawal E) Nonresponsiveness
A) Mottling of feet and legs B) Edema of lower extremity C) Slow and thready pulse E) Nonresponsiveness
A care plan is often used as a basis for documentation. The type of plan that contains areas for respiratory therapists, social services workers, physical therapists, and dietitians to document their plans and the patient's response is called a A) Multidisciplinary care plan. B) Standardized care plan. C) Computerized care plan. D) Student care plan.
A) Multidisciplinary care plan.
A patient is newly diagnosed with noninsulin dependent diabetes mellitus (NIDDM). The patient asks a nurse about potential complications related to his or her illness. The nurse states that it can lead to which of the following? Select all that apply. A) Neuropathy B) Retinopathy C) Heart disease D) Renal disease E) Poor circulation
A) Neuropathy B) Retinopathy C) Heart disease D) Renal disease E) Poor circulation
A patient suffering from back spasms has an order for continued heat therapy at home and indicates to a nurse that he will use his heating pad. The nurse correctly advises the patient to A) Never use any setting above medium. B) Use the highest setting for maximum comfort. C) Apply heat for 1 hour every 3 hours. D) Not use heat because cold therapy is more effective at stopping spasms.
A) Never use any setting above medium.
While educating a class of nursing students, an instructor teaches that growth occurs in which of the following patterns? Select all that apply. A) Orderly B) Predictable C) Disorganized D) Proximodistal E) Cephalocaudal
A) Orderly B) Predictable D) Proximodistal E) Cephalocaudal
When performing a physical assessment of a patient, a nurse uses the five techniques of obtaining objective data. The technique that provides data by using the hands is A) Palpation. B) Auscultation. C) Observation. D) Olfaction.
A) Palpation.
While performing a shift assessment, a nurse touches and feels a patient's pulses bilaterally. This is an example of an assessment technique called A) Palpation. B) Inspection. C) Percussion. D) Auscultation.
A) Palpation.
A patient who appears to be in pain does not ask the nurse for pain medication because he feels it would upset the nurse. The style of communication that the patient is demonstrating is A) Passive. B) Assertive. C) Aggressive. D) Demeaning.
A) Passive.
Adolescence includes a period of rapid growth referred to as puberty. During this period, girls develop breasts and boys develop facial hair. A nurse identifies these changes as a normal stage of A) Physical development. B) Psychosocial development. C) Cognitive development. D) Moral development.
A) Physical development.
A nurse is caring for a patient with a repaired fractured hip. The nurse recognizes that the most appropriate health care worker to collaborate with is a(n) A) Physical therapist. B) Respiratory therapist. C) Occupational therapist. D) Speech and language therapist.
A) Physical therapist.
While caring for a patient who is complaining of abdominal pain, the nurse determines that the top priority is to manage the patient's pain with medication. This step in the nursing process is called A) Planning. B) Diagnosis. C) Assessment. D) Implementation.
A) Planning.
The National Institutes of Health (NIH) issued a statement that there is clear evidence supporting the effectiveness of acupuncture for the treatment of which of the following? Select all that apply. A) Postoperative nausea B) Postoperative vomiting C) Chemo induced nausea and vomiting D) Nausea with pregnancy E) Postoperative dental pain
A) Postoperative nausea B) Postoperative vomiting C) Chemo induced nausea and vomiting D) Nausea with pregnancy E) Postoperative dental pain
When teaching, a nursing instructor stands 15 feet from the class of nursing students. The personal space distance zone that the nursing instructor is in is A) Public. B) Intimate. C) Casual personal. D) Social consultative.
A) Public.
A student nurse is making up a bed while the patient is out receiving therapy. A supervising nurse intervenes when the student A) Puts soiled linens on the floor. B) Sprays a damp mattress with a disinfectant spray. C) Removes the pillow from the pillowcase and places it in a chair. D) Tucks the draw sheet between the mattress and springs.
A) Puts soiled linens on the floor.
A patient suffering from dyspnea tells a nurse that she does not wish to take any additional drugs to help relieve her condition. The nurse suggests a nonpharmacological intervention such as A) Putting a fan near the bed to circulate the air B) Giving the patient small sips of warm water C) Providing additional movement and range of motion exercises D) Music therapy
A) Putting a fan near the bed to circulate the air
A nurse is caring for a patient who was admitted to the hospital for a cerebrovascular accident (CVA) resulting in difficulty understanding speech. The nurse recognizes that the patient is experiencing A) Receptive aphasia. B) Expressive aphasia. C) Receptive dysphagia. D) Expressive dysphagia.
A) Receptive aphasia.
During a discussion with a patient participating in a health screening, a nurse suggests which of the following positive ways to cope with stress? Select all that apply. A) Relaxing with family and friends B) Accepting all challenges C) Saying no when one has other obligations D) Eating a diet high in fat and carbohydrates E) Getting rid of excessive possessions
A) Relaxing with family and friends C) Saying no when one has other obligations E) Getting rid of excessive possessions
As a nurse enters the room of a patient who has had an amputation, the nurse notes that the patient is crying. The best response by the nurse is to A) Say, "I'm here if you'd like to talk," while standing close to the patient's bed. B) Say, "I'll leave you alone for a little while," while leaving the room. C) Ask, "Is there someone you'd like me to call?" while picking up the phone. D) Say, "Everyone feels this way at first, but it will get easier," while patting the patient's shoulder.
A) Say, "I'm here if you'd like to talk," while standing close to the patient's bed.
It would be considered inappropriate for a nurse to A) Set a meal tray down on a patient's over the bed table and then immediately leave the room. B) Remove any item from a patient's over the bed table before the delivery of meal trays. C) Assist a patient with dentures before mealtime. D) Inquire whether the patient needs to go to the bathroom before eating.
A) Set a meal tray down on a patient's over the bed table and then immediately leave the room.
To complete the process of active listening, a nurse should do which of the following? Select all that apply. A) Share perceptions. B) Avoid confrontation. C) Exhibit a superior attitude. D) Refrain from sharing feelings. E) Respond and provide feedback to the content heard in the message.
A) Share perceptions. E) Respond and provide feedback to the content heard in the message.
A nurse delegates activities of daily living (ADLs) to a certified nursing assistant (CNA). ADLs that can be delegated to a CNA include which of the following? Select all that apply. A) Shaving a patient B) Showering a patient C) Washing a patient's hair D) Assisting a patient with dressing E) Assisting a patient with denture care
A) Shaving a patient B) Showering a patient C) Washing a patient's hair D) Assisting a patient with dressing E) Assisting a patient with denture care
A nurse knows that when skin slides over another surface in the opposite direction, it can cause abrasions and open skin areas, which is known as A) Shearing. B) Peristalsis. C) Atelectasis. D) Deep vein thrombosis (DVT).
A) Shearing.
A patient is treated with a Japanese style massage that uses thumb pressure to work along energy meridians and is similar to acupressure. This type of massage is called A) Shiatsu. B) Swedish. C) Reflexology. D) Deep tissue.
A) Shiatsu.
A nurse is caring for a patient who requires discharge teaching. When performing patient teaching, the nurse should do which of the following? Select all that apply. A) Sit near the patient. B) Stand over the patient. C) Sit far from the patient. D) Allow time for the patient to absorb information. E) Present several pieces of information at once.
A) Sit near the patient. D) Allow time for the patient to absorb information.
When admitting a patient to a hospital unit, a nurse demonstrates a caring demeanor by A) Smiling and speaking kindly. B) Exhibiting tense body language and frowning. C) Informing the patient he or she is shorthanded. D) Avoiding eye contact and speaking in a clipped manner.
A) Smiling and speaking kindly.
A nurse is working at a clinic when an electrical fire begins. The nurse determines that there are no patients in the immediate area. The nurse should next A) Sound the fire alarm. B) Obtain a fire extinguisher. C) Confine the fire to one area. D) Close all of the doors in the immediate area.
A) Sound the fire alarm.
A dietitian teaches a student nurse about complete proteins. The student nurse demonstrates understanding when identifying an example of a complete protein as A) Soy. B) Seeds. C) Wheat. D) Brown rice.
A) Soy.
A new mother reports that her infant is experiencing acute diarrhea. The mother asks a nurse what type of herb she could use to treat the diarrhea. The nurse responds that an herb that helps improve acute diarrhea in infants is A) Soy. B) Valerian. C) Capsaicin. D) Saw palmetto.
A) Soy.
While educating a class of nursing students, a nursing instructor teaches which of the following about back massages? Select all that apply. A) Stimulate circulation B) Decrease circulation C) Can cause bradycardia D) Prevent pressure ulcers E) Can cause vagus nerve stimulation
A) Stimulate circulation B) Decrease circulation C) Can cause bradycardia D) Prevent pressure ulcers E) Can cause vagus nerve stimulation
A national standard for patient safety has been established by the organization that is responsible for evaluating and accrediting health care organizations and programs in the United States. This organization is known as A) The Joint Commission. B) The State Board of Nursing. C) The National League for Nursing. D) The American Nurses Association.
A) The Joint Commission.
A nurse is caring for a Mormon patient who had complications following the birth of her sixth child. Although the physician has told the patient that another pregnancy could result in her death, the patient tells the nurse that she refuses permanent sterilization. The nurse is aware that A) The Mormon faith does not permit sterilization. B) The patient is afraid of having more children. C) If the patient becomes pregnant again, she will most likely seek an abortion. D) The patient believes her complications were caused by her sins.
A) The Mormon faith does not permit sterilization.
A nurse explains to a patient with hypertension that diastolic pressure is a measurement of A) The amount of force blood places on the arterial walls while the ventricles relax. B) The amount of force blood places on the arterial walls while the ventricles contract. C) The amount of force blood places on the arterial walls while both the atria and the ventricles relax. D) The amount of force blood places on the arterial walls while both the atria and the ventricles contract.
A) The amount of force blood places on the arterial walls while the ventricles relax.
A 3 year old who has suffered a bee sting on the foot is screaming and cannot be consoled. The patient's response indicates that A) The child lacks previous remembered experience with pain and is frightened. B) The bee sting is extremely painful. C) There may be something wrong in addition to the bee sting, because bee stings do not usually hurt this much. D) The child has suffered bee stings or similar injuries before and is expressing the remembered pain, as well as responding to current discomfort.
A) The child lacks previous remembered experience with pain and is frightened.
A nurse may fail to provide spiritual care for a patient if A) The nurse does not understand the relationship between mind, body, and spirit. B) The nurse's religious background differs greatly from that of his or her patient. C) The nurse believes that a patient's illness is caused by his or her lack of religious practice. D) The nurse notifies a clergyman, with the patient's consent, to provide spiritual care.
A) The nurse does not understand the relationship between mind, body, and spirit.
An elderly male patient is displaying a fearful attitude toward the nurse. The patient has multiple unexplained bruises, and several old fractures appear on his x ray that were never treated. The nurse suspects that A) The patient may have been abused by a caregiver. B) The patient may be suffering from poor balance. C) The patient may have been injured on the job. D) The patient may have dementia.
A) The patient may have been abused by a caregiver.
A nurse is caring for a patient who requires teaching about a heart healthy diet. The patient states that she is a visual learner. The nurse recognizes that a visual learner learns by seeing, reading, and watching. When selecting handouts for the patient to read, the nurse ensures which of the following about the handouts? Select all that apply. A) They are in simple language. B) They include short sentences. C) They clearly define medical terms. D) They are written in complex language. E) They are at a fifth grade reading level.
A) They are in simple language. B) They include short sentences. C) They clearly define medical terms. E) They are at a fifth grade reading level.
While supervising a student who is manually transferring a patient from a bed to a chair, a nurse intervenes when the student transfers the patient while A) Twisting at the torso. B) Standing close to the patient. C) Using proper body mechanics. D) Maintaining a wide base of support.
A) Twisting at the torso.
A nurse is caring for a patient who develops dyspnea that does not improve with oxygen therapy and nebulizer treatment. The nurse immediately calls the patient's primary health care provider. This type of communication is called A) Upward. B) Bilateral. C) Horizontal. D) Downward.
A) Upward.
The pulse oximeter indicates a patient's blood oxygen level is 89%. A nurse knows that it is important to A) Verify the oximeter is placed on a site that has adequate capillary refill. B) Call the laboratory and order arterial blood gases to get a more accurate oxygen level. C) Encourage the patient to get out of bed and ambulate more. D) Let the patient rest quietly to reduce the need for oxygen.
A) Verify the oximeter is placed on a site that has adequate capillary refill.
A nurse, in addressing spirituality concerns of a patient, will first assess A) Whether the patient practices a religion. B) A patient's understanding of religion. C) The patient's definition of morality. D) Whether the patient has a lower frequency of health complaints.
A) Whether the patient practices a religion.
7. A patient who appears to be in pain does not ask the nurse for pain medication because he feels it would upset the nurse. The style of communication that the patient is demonstrating is A. Passive B. Assertive C. Aggressive D. Demeaning
A. Passive
12. The nurse is caring for a patient who has just been diagnosed with a brain tumor. The patient asks the nurse if he should choose to have surgery. The Nurse's most therapeutic response is: A. "Tell me what you know about surgery." B. "I would never decide against having surgery." C. "If I were you, I would definitely have the surgery." D. "Don't worry. You will be fine if you don't have surgery."
A. "Tell me what you know about surgery."
11. A nurse is caring for a patient who has end stage renal disease and will require dialysis three times per week. The patient states, "I'm upset that I didn't visit all the places I'd like to see. Now that I'm on dialysis I won't be able to." The most therapeutic response by the nurse is: A. "You are upset that it's too late to visit places that you would like to see?" B. "There are many people who feel exactly the same as you do." C. "Don't worry. You can still visit all of the places hat you would like to see." D. "I think you should visit the places you would like to see before it's too late."
A. "You are upset that it's too late to visit places that you would like to see?"
2. The nurse understands that when communicating with a patient face to face, communication is: Select all that apply A. An active process B. As simple as telling C. As simple as informing D. A passive, one sided event E. Completed when the receiver offers feedback F. Involves both parties sending and receiving messages simultaneously
A. An active process E. Completed when the receiver offers feedback F. Involves both parties sending and receiving messages simultaneously
Select All that Apply 1. A nursing instructor is educating a class of nursing students about effective communication. The nursing instructor teaches that effective communication: A. Is essential in proper documentation practices B. Is the foundation of nurse patient relationships C. Helps establish proper transfer of health care information. D. Is a vital component in building professional relationships. E. Is something that nurses often feel prepared to do in clinical situations. F. Is a key element when reporting information to other health care members.
A. Is essential in proper documentation practices B. Is the foundation of nurse-patient relationships C. Helps establish proper transfer of health care information. D. Is a vital component in building professional relationships. F. Is a key element when reporting information to other health care members.
5. When teaching a class of nursing students, the nursing instructor stands 15ft from he audience. The personal space distance zone that the nursing instructor is in is A. Public B. Intimate C. Casual personal D. Social consultative
A. Public
16. The nurse is caring for a patient who was admitted to the hospital for a cerebrovascular accident (CVA) resulting in difficulty understanding speech. The nurse recognizes that the patient is experiencing: A. Receptive aphasia B. Expressive aphasia C. Receptive dysphagia D. Expressive dysphagia
A. Receptive aphasia
6. To complete the process of active listening, the nurse should: A. Share perceptions B. Avoid confrontation C. Exhibit a superior attitude D. Refrain from sharing feelings E. Respond to the content heard in the message F. Provide feedback about understanding what was said
A. Share perceptions E. Respond to the content heard in the message F. Provide feedback about understanding what was said
8. The nurse is caring for a patient with wemicke's aphasia. When communicating with the patient, the nurse should: A. Speak slowly B. Speak rapidly C. Use long sentences D. Ask yes or no questions E. Avoid interrupting the patient F. Speak in a normal tone of voice
A. Speak slowly D. Ask yes or no questions F. Speak in a normal tone of voice
13. The nurse is caring for a patient who develops dyspnea that does not improve with oxygen therapy and nebulizer treatment. The nurse immediately calls the patient's primary health care provider. This type of communication is called A. Upward: Escalating to a person of authority B. Bilateral: someone on the same level C. Horizontal D. Downward: delegating to someone you're in charge of
A. Upward: Escalating to a person of authority
NCLEX STYLE PRACTICE:The nurse understands that if a restraint is needed, it should be: A. released once a day B. Tied to itself, so the patient cannot get out C. Be the least restrictive as possible D. Unpadded, so it does not become loose
A. released once a day—No, they should be released every 2 hours B. Tied to itself, so the patient cannot get out—No, they should be slipped knotted to the bed C. Be the least restrictive as possible—YES D. Unpadded, so it does not become loose—No, padding should be used
Prioritization and Maslow's Hiearchy
ABCs 1ST!! Phsyiological Safety & Security (In that order)
Prioritization of abnormal vital signs
ABCs then physiologic Airway Breathing Circulation/Cardiac
When dealing with maslow hierarchy of needs, what is done first?
ABCs!!
Types of pain
Acute Cutaneous Visceral Phantom Somatic Radiating Referred Neuropathic Chronic
An instructor explains that a type of intermittent tube feeding in which a physician ordered volume of formula is administered using a large irrigating syringe at set intervals throughout the day is called ____________________ feeding.
Bolus
A nurse is aware that a patient is at increased risk for falling due to orthostatic hypotension. This risk contravenes the use of which method of heat therapy? A) Warming blanket B) Aquathermia pad C) A sitz bath D) Warm soaks
C) A sitz bath
NCLEX STYLE PRACTICE:A nurse is caring for an older adult who is cognitively impaired and has a history of pulling out tubes and falling. List the following safety devices in the order of least restrictive to most restrictive that may be employed to ensure the safety of this patient. • 1. Cloth vest • 2. Two wrist straps • 3. Four side rails up • 4. Bed exiting alarm device • 5. Four point restraint tied to the bed frame
ANSWER: 4, 3, 1, 2, 5. Rationales: • 4. A bed exiting alarm device will signal caregivers when the patient attempts to exit the bed. These devices do not curtail the patient's movement but will alert staff members that the patient needs supervision. This is a safety device that does not require an order from a primary health-care provider. • 3. Although four side rails will curtail the patient to the bed, the patient is still able to turn and sit up with ease. • 1. A cloth vest permits turning from side to side and sitting up but physically restricts the patient to the bed by the use of straps tied to the bed frame. • 2. Two wrist restraints curtail the movement of the upper extremities and prevent turning from side to side; also, they curtail the patient to the bed because the straps are tied to the bed frame. • 5. This is the most restrictive physical restraint because the extremities are for all practical purposes immobilized; all four extremities are tied to the bed frame.
What is perfusion?
Adequate arterial blood flow to the peripheral tissue.
Basic physiological needs (needs that are essential for the maintenance of life)
Air, Food (Nutrition), water, temp regulation, elimination, rest (sleep effects), sex, physical activity (mobility assessment), blood flow (perfusion) is necessary to meet other basic needs
Example pf stereotype
All Asians are naturally intelligent. All Africans are naturally athletes or runners.
Ex. of Arcgetype
All Irish population will have reddish tone hair color. All Mexican will have brown eyes. All Europeans will have light color skin.
Respect
Allow the client to make choices. Be flexible when meeting the needs of each client.
peppermint oil
Anti-Spasmodic; Used for IBS,the common cold, headaches, muscle aches & itching
Dominant culture in the U.S.
Anglo-Saxon Christian of European descent
Last Rites
Anointing of the Sick (Catholic)
Cutaneous pain
Arises from burning your skin like on a hot iron or from touching a hot pan on the stove.
Different types of bathing
Assist Bath Partial Bath Bed Bath Towel Bath Bag bath Basin & Water bath Shower
A student nurse encounters an unresponsive patient in a waiting room. The patient is not breathing and has no pulse or respirations. The first thing they should do is A) Begin rescue breathing. B) Alert the emergency team. C) Begin cardiopulmonary resuscitation (CPR). D) Perform the Heimlich maneuver.
B) Alert the emergency team.
A nurse recognizes that a therapy used instead of conventional treatment is A) Physical therapy. B) Alternative therapy. C) Conventional therapy. D) Complementary therapy.
B) Alternative therapy.
An intervention on the part of a nursing instructor would be required if A) A student dons a gown and gloves before entering the room of a patient on contact precautions. B) A student ties the lower strings of a mask up on the head. C) A student performs hand washing immediately after removing his or her gloves. D) A student performs hand washing before touching the tubes connected to a patient.
B) A student ties the lower strings of a mask up on the head.
An instructor explains that patients are different. Their beliefs are different. Their responses to illness and wellness are different depending on their cultural backgrounds—even patients from the same cultural group may have differences in their health care beliefs and practices. The knowledge of various cultural beliefs and values is known as cultural ____________________.
Awareness
While bathing a patient, a nurse finds that the patient's previous IV site is tender and the vein feels hard upon palpation, indicating inflammation. The nurse should apply A) A cold pack using a glove filled with ice. B) A warm compress using a washcloth dipped in hot water. C) Heat by submerging the arm in a basin of very warm water. D) A refreezable chemical cold pack.
B) A warm compress using a washcloth dipped in hot water.
When a patient complains of pain, a nurse assesses the pain level and administers pain medication. Using DAR charting, the nurse should chart these actions under A) Data. B) Action. C) Response. D) Assessment.
B) Action.
While working with elderly patients, a nurse must use all of his or her senses to interpret verbal and nonverbal messages using a technique known as A) Aggressive style. B) Active listening. C) Intimate communication. D) Upward communication.
B) Active listening.
A nurse is caring for a patient with a fever of 10C.2°F whose wife asks, "Why does his body get so hot like that?" The nurse's best response is: A) "Actually, a fever is often what makes people seek medical help." B) "A fever is the body's way of creating an environment that is harmful to germs." C) "It is frustrating that his fever is still high when I gave him Tylenol 10 minutes ago." D) "I think the fever is still up because the antibiotics haven't had time to work yet."
B) "A fever is the body's way of creating an environment that is harmful to germs."
The mother of a child with a viral infection is demanding that you give the child an antibiotic to treat the infection. The best response to a request of this type would be to say: A) "Please remain patient. I will ask the doctor to write you a prescription." B) "Antibiotics would not be effective against a viral infection." C) "I cannot suggest antibiotics unless the child's fever exceeds 102°F." D) "A virus is caused by a microorganism and must be treated with anthelmintics."
B) "Antibiotics would not be effective against a viral infection."
A nursing instructor is discussing the importance of a nurse's responsibility to serve as a patient's advocate. The instructor recognizes that additional explanation is warranted when a student nurse says: A) "As a patient's advocate, I must assert myself in the patient's best interest." B) "As a patient's advocate, I must subjectively examine the patient's values." C) "As a patient's advocate, I must provide my patients with care and comfort." D) "As a patient's advocate, I must develop empathy for my patients and their families."
B) "As a patient's advocate, I must subjectively examine the patient's values."
After a Seventh Day Adventist clergyman performed anointing of oil, a nurse bathed the patient. Upon entering the room, the family immediately became upset. When questioned by the nurse, the family states: A) "Bathing is painful and we don't wish anyone to cause him further discomfort." B) "He should not have been bathed for several hours following anointment with oils." C) "The Church forbids anyone but family to bathe loved ones." D) "His bath should be done by a nurse of the same sex."
B) "He should not have been bathed for several hours following anointment with oils."
An instructor explains precautions that nurses can take when dealing with the possibility of exposure to blood and bodily fluids. The instructor identifies that additional guidance is needed when a student says: A) "I always place my used needles into a puncture proof, labeled container." B) "I always recap my used needles before disposing of them." C) "I always wash my hands before and after patient contact." D) "I always wear gloves if there is a chance for exposure to bodily fluids."
B) "I always recap my used needles before disposing of them."
A very ill patient is admitted to the hospital with severe symptoms of nausea, vomiting, and diarrhea that have lasted almost 24 hours. Once discovering that the patient may have ingested contaminated food, a nurse was able to identify this as a(n) A) Exacerbation. B) Acute illness. C) Remission. D) Chronic illness.
B) Acute illness.
When educating a student nurse about hospital identification bands, a nurse appropriately recognizes that additional teaching is warranted when the student nurse states: A) "The hospital identification band displays the patient's name and birth date and the hospital identification number." B) "I have taken care of this patient before, so I will not need to check the patient's identification band before administering medication." C) "I should instruct the patient to state his or her name and verify that it matches the name on the hospital identification band." D) "I should ask the patient to state his or her date of birth and verify that it matches the date of birth listed on the hospital identification band." Table for Individual Question Feedback
B) "I have taken care of this patient before, so I will not need to check the patient's identification band before administering medication."
A nurse is providing instructions for a patient who is to begin wearing a Holter monitor. Which of the following statements indicates further teaching is necessary? A) "I should press this button if I feel any chest pain or pressure." B) "I need to write down what I eat each day." C) "I should make notes about the activities I'm doing while I wear the monitor." D) "I'll wear this for 2 days so the doctor can be sure to capture anything that may be going on."
B) "I need to write down what I eat each day."
A nursing instructor explains that a good nurse must make certain that the professional nurse patient relationship boundaries are never crossed. The instructor realizes that additional clarification is needed when a student nurse says: A) "I must be careful to never get emotionally involved with my patients." B) "I should avoid serving as the patient's advocate." C) "I should never become physically involved with a patient." D) "It is unethical to accept gifts or tips from a patient."
B) "I should avoid serving as the patient's advocate."
An instructor is teaching students about addressing a patient's environmental concerns. The instructor identifies that additional instruction is needed when a student says: A) "I should keep the patient's door closed or nearly closed to help block out hallway noise and activity." B) "I should only wear lightly scented perfumes, colognes, or body lotions while caring for patients." C) "I should remove food trays promptly if the patient does not wish to eat." D) "I should not remove personal items from within reach of the patient without their permission."
B) "I should only wear lightly scented perfumes, colognes, or body lotions while caring for patients."
The wife of a patient who is nearing the end of his life tells a nurse that she is worried because her husband is not getting enough fluids. The nurse responds by saying: A) "He will drink when he gets thirsty. Don't worry about him." B) "It is natural to become dehydrated before death. It will actually make him more comfortable." C) "I will let his physician know about it. He may want to start an IV to keep him hydrated." D) "Your husband has signed a living will indicating he doesn't want to be given food and water."
B) "It is natural to become dehydrated before death. It will actually make him more comfortable."
A nurse overhears a student nurse talking about making patients' hospital beds. The nurse feels the need to intervene when the student says: A) "I must make certain the bed rails are raised on the opposite side of the bed from where I am working." B) "Making the bed in a hospital is just like making my bed at home." C) "A poorly made bed can contribute to the development of pressure ulcers." D) "Draw sheets are used to help lift and turn heavier patients."
B) "Making the bed in a hospital is just like making my bed at home."
An instructor is discussing circumstances that could make the removal of jewelry in piercings necessary. The instructor intervenes when a student says: A) "It is necessary to remove jewelry from a piercing if it interferes with intubation." B) "Stainless steel and titanium jewelry must be removed before magnetic resonance imaging (MRI)." C) "A Prince Albert piercing will need to be removed before catheterization." D) "New piercings must be kept clean and monitored for infections."
B) "Stainless steel and titanium jewelry must be removed before magnetic resonance imaging (MRI)."
A primary care physician has told a patient that she has a pulse deficit. She asks her nurse to explain what that means. The nurse replies: A) "It is when your radial pulse is faster than your apical pulse, and they should always be equal." B) "The irregularity of your heart beat is compromising your blood flow, resulting in your radial pulse being slower than your heart rate." C) "A pulse deficit exists when the heart sounds become distant and, in some cases, such as yours, muffled." D) "Pulse deficit simply means that your heart muscle has been damaged and can no longer pump as effectively."
B) "The irregularity of your heart beat is compromising your blood flow, resulting in your radial pulse being slower than your heart rate."
An elderly patient with a compression fracture of the spine says, "I've had plenty of pain in my lifetime, but never anything like this. I feel like I'm being stabbed." A nurse could correctly respond: A) "The type of pain you're feeling is radiating pain. Because the pain originates in a nerve, it spreads to other areas of the body." B) "The type of pain you're feeling is neuropathic pain. Instead of pain in the surrounding tissue that the nerve is relaying to the brain, it is pain caused by pressure on the nerve itself." C) "The type of pain you're feeling is deep somatic pain. This is often caused by fractures and is more intense than other kinds of pain." D) "Your pain must feel more intense than pain you've felt previously because your pain 'gate' is open. It's possible that massage or a distraction like reading will help the pain."
B) "The type of pain you're feeling is neuropathic pain. Instead of pain in the surrounding tissue that the nerve is relaying to the brain, it is pain caused by pressure on the nerve itself."
A nurse is supervising a student nurse on a pediatric nursing unit. The nurse appropriately intervenes when the student nurse tells a child: A) "Do you want to hold my stethoscope?" B) "This shot will not hurt." C) "Let's pretend to give the teddy bear a shot." D) "Would you like to take the teddy bear's temperature?"
B) "This shot will not hurt."
A nurse is admitting a patient to a hospital unit. When admitting the patient, the nurse should A) Maintain prolonged eye contact. B) Address the patient by his or her last name. C) Speak rapidly when interacting with the patient. D) Use terms of endearment when conversing with the patient.
B) Address the patient by his or her last name.
A bedridden patient in hospice care is suffering from nausea, vomiting, confusion, constipation, lethargy, decreased deep tendon reflexes, polyuria, and extreme thirst. A nurse identifies these symptoms as A) Dyspnea. B) Hypercalcemia. C) Cyanosis. D) Cheyne Stokes respirations.
B) Hypercalcemia.
A student nurse is discussing ways to assist with meals and improve a patient's eating experience in the hospital. A nurse intervenes when the student says: A) "I should wipe off the over the bed table with disinfectant if a urinal or any other contaminated item has been on it." B) "To avoid contamination, I should never open any container—milk cartons, juice containers, or cellophane packaging for plastic utensils—on the tray." C) "I should make rounds to my patients' rooms during mealtimes and ask if they have any needs." D) "I should ensure that each meal tray is assessed for the correct diet and appropriate temperature of food."
B) "To avoid contamination, I should never open any container—milk cartons, juice containers, or cellophane packaging for plastic utensils—on the tray."
A nurse is satisfied that the mother of a 2 year old with a history of febrile seizures understands how to effectively decrease body temperature when the mother states: A) "I will put my child in a lukewarm bath, making sure the temperature of the water is somewhere between 105°F and 110°F." B) "When his temperature reaches 10B.5°F, I will carefully place ice bags in the armpits and groin." C) "If his fever spikes, I will bring him to the emergency department because he will most likely need to be lavaged with cold water." D) "If I put ice bags around his body, his temperature will not get high enough to cause seizures."
B) "When his temperature reaches 10B.5°F, I will carefully place ice bags in the armpits and groin."
A nurse is caring for a patient on bedrest who repeatedly attempts to get out of bed without assistance. The most therapeutic response by the nurse is: A) "Why do you keep trying to get out of bed?" B) "Would you like me to give you a back rub?" C) "I need for you to behave and stop trying to get out of bed." D) "If you don't stop trying to get up, I will have to restrain you."
B) "Would you like me to give you a back rub?"
While supervising a student nurse who is providing patient care, a nursing instructor intervenes when hearing a student nurse tell a patient: A) "I will be happy to help you with your bath if you are ready." B) "You don't want me to help with your bath now, do you?" C) "Would you like me to give you a back rub when I help you with your bath?" D) "Would you like help with your bath now, or would you prefer that I come back in an hour?"
B) "You don't want me to help with your bath now, do you?"
A student nurse is caring for a patient at a rehabilitation facility. The student nurse educates the patient about the rehabilitation facility. A nurse intervenes when the student states: A) "You will receive intense therapy services while you're here." B) "You must participate in at least 6 hours of therapy each day." C) "You will be seen by a physician who specializes in rehabilitation." D) "If you get sick while you're here, we can transfer you to the hospital."
B) "You must participate in at least 6 hours of therapy each day."
A nursing instructor is explaining the initial steps of most nursing interventions. The instructor recognizes that additional explanation is required when a student nurse states: A) "You should always check the chart to be certain of a physician's or other health care provider's order." B) "You should always carry out the physician's order as quickly as possible without question." C) "You should always explain the procedure to the patient using words the patient understands." D) "You should always think critically about the order to make sure the patient's condition has not changed in such a way that the order might no longer be appropriate."
B) "You should always carry out the physician's order as quickly as possible without question."
A nurse teaches a patient ways to prevent chronic illness and disease by modifying risk factors. The nurse states: A) "It is important that you receive the flu vaccination every year." B) "Your diet should be moderate in calories and include a variety of foods." C) "Running at least 4 to 5 miles per day will ensure that you do not develop cancers or heart diseases." D) "Smoking cigarettes that are low in tar and nicotine will greatly decrease your risk for developing respiratory problems."
B) "Your diet should be moderate in calories and include a variety of foods."
A patient has orders for a heating pad to be placed on the lower back. A nurse teaches the patient that to prevent rebound phenomenon, the heating pad is to be removed after A) The swelling has decreased. B) 25 to 30 minutes. C) The discomfort has resolved. D) 2 to 3 hours.
B) 25 to 30 minutes.
The mother of a 1 year old child asks a nurse how much her child should weigh. The nurse asks the mother what the child weighed at birth. The mother responds that the child weighed 7 pounds and 8 ounces at birth. The nurse tells the mother that the child's weight at 1 year of age should be A) 2A.5 pounds. B) 2B.5 pounds. C) 2C.5 pounds. D) 2D.5 pounds.
B) 2B.5 pounds.
When taking a patient's temperature, a nurse understands that regardless of what route is used, the normal core temperature range is A) 96.2°F to 99.4°F. B) 97°F to 99.6°F. C) 97°F to 100.2°F. D) 98.6°F to 99.2°F.
B) 97°F to 99.6°F.
In Eastern medicine, illness and disease are viewed as which of the following? Select all that apply. A) Balance of energy in the body B) A defect of energy in the body C) Functional changes in the body D) An energy imbalance in the body E) Disharmony of energy in the body
B) A defect of energy in the body C) Functional changes in the body D) An energy imbalance in the body E) Disharmony of energy in the body
When taking an inventory of items that a patient has brought to the hospital, a nurse should document the patient's diamond and ruby wedding ring as A) A ring with rubies and diamonds. B) A gold colored ring with red stones and clear stones. C) A 24 karat gold wedding ring. D) A 1 karat diamond wedding ring.
B) A gold colored ring with red stones and clear stones.
When teaching a student nurse about performing an assessment on a neonate, a nurse strokes the sole of the infant's foot, which causes fanning of the toes while the great toe pulls upward. The nurse teaches the student nurse that this assessment finding is A) Indicative of cerebral edema. B) A normal assessment finding. C) Indicative of a genetic anomaly. D) An abnormal assessment finding.
B) A normal assessment finding.
A patient with malabsorption syndrome is able to meet some nutritional needs orally but requires partial parenteral nutrition for a limited period because of illness. A nurse identifies that the patient will require A) A central venous catheter. B) A peripherally inserted central catheter. C) A jejunostomy tube. D) A percutaneous endoscopic gastrostomy tube.
B) A peripherally inserted central catheter.
One aspect of professional behavior includes the participation in professional organizations. Which of the following organizations is not available to the student nurse? A) National Federation of Licensed Practical Nurses (NFLPN) B) American Nurses Association (ANA) C) The National Student Nurse Association (NSNA) D) Health Occupations Students of America (HOSA)
B) American Nurses Association (ANA)
A nurse is caring for a resident in a long term setting. The nurse best demonstrates a caring approach when A) Performing all activities of daily living for the resident. B) Asking the resident's spouse to bring a family picture for the resident's room. C) Answering the resident's questions quickly without allowing time for clarification. D) Encouraging the resident's spouse to decide which activities the resident should do.
B) Asking the resident's spouse to bring a family picture for the resident's room.
A patient throws his urinal at the nurse and tells the nurse that he thinks she is terrible at her job. The nurse informs the patient that his behavior is inappropriate. The style of communication that the nurse is demonstrating is A) Passive. B) Assertive. C) Aggressive. D) Demeaning.
B) Assertive.
While lying in bed, a patient has a blood pressure of 142/86 mm Hg and a heart rate of 76 beats/min. When a nurse helps the patient to sit up and dangle at the side of the bed, the patient becomes dizzy. The nurse rechecks the patient's vital signs and finds that the patient's blood pressure is now 112/54 mm Hg, and the patient's heart rate is now 98 beats/min. The next action to take would be to A) Recheck the patient's vital signs. B) Assist the patient to a Fowler position. C) Assist the patient to a standing position. D) Assist the patient to a lithotomy position.
B) Assist the patient to a Fowler position.
A home health care nurse delegates to a home health care aide the responsibility of A) Administering the patient's intravenous (IV) medications. B) Assisting the patient in the shower. C) Communicating the patient's condition with the physician. D) Assessing the patient for any changes from baseline.
B) Assisting the patient in the shower.
A nurse thoughtfully plans care that will be provided to the patients assigned to him or her. To provide culturally competent nursing care, the nurse will A) Deliver appropriate care that is not discriminating to any race, sex, or ethnic group. B) Become familiar with any facet of the patient's culture that may have an impact on his or her care. C) Show respect for each individual for whom he or she provides care. D) Openly discuss his or her thoughts and beliefs about the patient's culture.
B) Become familiar with any facet of the patient's culture that may have an impact on his or her care.
A nurse is caring for a patient who is lethargic, unable to tolerate standing for long periods, and short of breath with exertion. The nurse determines that the most appropriate type of bath for this patient is a A) Shower. B) Bed bath. C) Tub bath. D) Therapeutic bath.
B) Bed bath.
The ability of a nurse to care for several patients, help families understand what is happening to a patient, and notice changes in a patient's condition are all examples of an important characteristic of nurses known as A) Being helpful. B) Being responsible. C) Being organized. D) Being compassionate.
B) Being responsible.
Which of the following is not identified as a boundary when establishing the safety zone? A) Above waist level B) Below the nipple line C) In front of the body D) Below eye level
B) Below the nipple line
A patient who has tried several forms of complementary and alternative medicine (CAM) is looking for a way to become more aware of the changes in her heart rate, blood pressure, and muscle contractions. The nurse suggests A) Music therapy. B) Biofeedback. C) Meditation. D) Aromatherapy.
B) Biofeedback.
While caring for a patient who just underwent a paracentesis, a nurse would be most concerned by which of the following findings? A) Patient reports itching at the puncture site. B) Blood pressure is 92/60 mm Hg. C) Oxygen saturation is 94%. D) Blood sugar is 102.
B) Blood pressure is 92/60 mm Hg.
While looking over the chart of an elderly patient, a nurse noted several findings that are to be expected as a result of long standing hypertension. One of those findings would be A) A chest radiograph indicating the possibility of pneumonia. B) Blood work suggestive of kidney failure. C) A brain scan ruling out a diagnosis of Alzheimer disease. D) Blood work ruling out a myocardial infarction, or heart attack.
B) Blood work suggestive of kidney failure.
When educating a new graduate nurse about how to minimize physical hazards, a charge nurse teaches that one of the best ways to prevent physical injuries when lifting and moving anything is to use good posture and A) Strong muscles. B) Body mechanics. C) Twisting movements. D) A narrow base of support.
B) Body mechanics.
A nurse is assessing a sedated patient whose respiratory rate has fallen below 12 respirations per minute. The nurse identifies this condition as A) Eupnea. B) Bradypnea. C) Tachypnea. D) Apnea.
B) Bradypnea.
Standard precautions are required when A) An infection is spread by indirect contact with an organism. B) Caring for any patient, regardless of whether an infection has been identified. C) A pathogen can spread via moist droplets. D) An infection that is transmitted on air currents is present.
B) Caring for any patient, regardless of whether an infection has been identified.
When caring for a patient with bilateral wrist restraints, a nurse can delegate which of the following to a certified nursing assistant (CNA)? A) Education of restraint alternatives B) Checks and releases of the restraints C) Assessment of bilateral radial pulses D) Teaching of when restraints can be removed
B) Checks and releases of the restraints
A nursing instructor is explaining safety issues for preschoolers and school age children. The instructor realizes that a student requires additional instruction when the student begins focusing on A) Playground safety. B) Choking prevention. C) Stranger danger. D) Water safety.
B) Choking prevention.
A nursing instructor educates a student nurse about the correct application of a vest restraint. The student nurse demonstrates understanding when applying the vest restraint so that the crossover is A) In the back. B) In the front. C) On the left side. D) On the right side.
B) In the front.
When communicating with a patient, a nurse recognizes that patient centered communication is defined as which of the following? Select all that apply. A) Communication focused primarily on the nurse B) Communication that empowers patients to participate in their care C) Communication that discourages patients from participating in their care D) Communication that discourages patients from participating in decisions E) Communication essential to establishing a positive nurse patient relationship
B) Communication that empowers patients to participate in their care E) Communication essential to establishing a positive nurse patient relationship
An instructor is teaching students about anger and hostility in communication. The instructor explains that the by product of anger projected outward toward others is A) Guilt. B) Conflict. C) Sarcasm. D) Resentment.
B) Conflict.
A nurse recognizes that to effectively meet the goal of shared meaning in communication, verbal and nonverbal language should be A) Absent. B) Congruent. C) Equally direct. D) Incongruent.
B) Congruent.
An instructor explains that a nurse must provide care to the patient and show respect for and incorporate the patient's specific cultural beliefs and values into his or her care. This idea is known as A) Morality. B) Cultural sensitivity. C) Diversity. D) Cultural awareness.
B) Cultural sensitivity.
The most appropriate teachable moment to discuss with the patient that his or her weight gain is being caused by fluid and not food intake would be during A) Meals. B) Daily weights. C) Medication administration. D) Bathing and personal care.
B) Daily weights.
A patient tells a nurse that she recently lost her job and that ever since, she has been going home and verbally abusing her spouse and child. The patient has lost all of her friends and feels confused. This patient is presenting the defense mechanism of A) Repression. B) Displacement. C) Conversion. D) Restitution.
B) Displacement.
A patient who has been sexually abused continues to describe the situation as if it happened to a friend instead. This patient is presenting the defense mechanism of A) Repression. B) Dissociation. C) Rationalization. D) Regression.
B) Dissociation.
The staff is caring for a patient with a wound contaminated with methicillin resistant staphylococcus aureus (MRSA). The proper contact precautions would be to A) Instruct all visitors to be fitted for a special mask that should be worn when entering the patient's room. B) Don a clean gown and gloves each time the patient's room is entered and care is provided. C) Place the patient in a room with another patient who requires droplet precautions. D) Notify the supervisor that the patient should be transferred to a negative pressure room.
B) Don a clean gown and gloves each time the patient's room is entered and care is provided.
After completing the initial head to toe shift assessment, the nurse determines that no changes are needed in the patient's plan of care. This decision is a result of the nurse's A) Ensuring that each patient receives a comprehensive health assessment. B) Evaluating the effectiveness of nursing interventions. C) Reviewing the organizational plan for the shift. D) Learning that the patient may be discharged from the hospital during this shift.
B) Evaluating the effectiveness of nursing interventions.
If a nurse needs to rouse a patient to perform a neurological assessment, the nurse may correctly A) Skip the neurological assessment if the patient appears to be comatose, since she can't hear the nurse or follow instructions. B) Exert mild pain on the patient (e.g., pressing on a nailbed). C) Turn up the volume on the radio or television. D) Gently slap the patient.
B) Exert mild pain on the patient (e.g., pressing on a nailbed).
A patient is in the acute phase of an intestinal disorder and has been scheduled for surgery. A nurse identifies that this patient's diet should be A) Calorie restricted. B) Fiber restricted. C) Sodium restricted. D) Protein restricted.
B) Fiber restricted.
When creating handouts for patients, a nurse should keep the handouts at the reading level of a A) Fourth grader. B) Fifth grader. C) Sixth grader. D) Seventh grader.
B) Fifth grader.
A nurse is caring for an elderly patient who is unable to eat more than a few bites at a time. The nurse should modify the patient's diet to A) A high calorie, high protein diet. B) Five to six small, frequent feedings. C) A sodium restricted diet. D) An antigen avoidance diet.
B) Five to six small, frequent feedings.
A patient has complained several times of minor gastrointestinal pain, flatulence, and diarrhea after meals. A nurse identifies that this is most likely caused by A) Anaphylaxis. B) Food intolerance. C) A food allergy. D) Food poisoning.
B) Food intolerance.
A doctor has ordered NPO status for a vomiting patient. A nurse violates the order by A) Providing the patient with intravenous (IV) fluids. B) Giving the patient ice chips. C) Removing the patient's water carafe and drinking glass from the bedside. D) Putting a sign that reads NPO over the patient's bed.
B) Giving the patient ice chips.
A telemetry monitor technician notifies a nurse that the patient in room 223 has a poor tracing. Which of the following actions should the nurse take first? A) Move the code cart closer to the patient's room. B) Go to the patient's room and check the patient's status. C) Instruct the technician to call a code. D) Report to the nursing station to view the tracing.
B) Go to the patient's room and check the patient's status.
A nurse trying to establish trust and rapport with a newly admitted patient would want to avoid A) Touching the patient. B) Greeting the patient using his first name. C) Using a relaxed posture. D) Putting the patient in a private room.
B) Greeting the patient using his first name.
A nurse explains to a family that research supports that the last sense to leave a dying patient is A) Sight. B) Hearing. C) Taste. D) Vision.
B) Hearing.
The husband of a dying woman expresses that he believes remorse for the dead leads to more suffering of the soul and will increase the soul's difficulty in leaving the earthly plane. He prefers to think only happy thoughts to facilitate her journey. A nurse identifies that the couple must be A) Jewish. B) Hindu. C) Hispanic American. D) Amish.
B) Hindu.
A nurse is caring for multiple patients on a medical unit. The nurse can best practice the art of nursing with an emphasis on caring by A) Providing identical care to each patient. B) Individualizing care provided to each patient. C) Viewing the patients in terms of a cellular disorder. D) Viewing the patients as seriously ill and needing a cure.
B) Individualizing care provided to each patient.
While performing a shift assessment, a nurse visually examines a patient's body for rashes and breaks in the skin, and looks for normal appearance of eyes, ears, nose, mouth, limbs, and genitals. This is an example of an assessment technique called A) Palpation. B) Inspection. C) Percussion. D) Auscultation.
B) Inspection.
While supervising a certified nursing assistant (CNA), a nurse intervenes when observing the CNA A) Answering a call light promptly. B) Instructing a patient whose primary language is not English to call for assistance. C) Rapidly responding when alarms sound on equipment. D) Instructing a patient how to press the call button.
B) Instructing a patient whose primary language is not English to call for assistance.
While bathing a patient, a nurse recognizes that the personal space distance zone that he or she is in when physically touching the patient is A) Public. B) Intimate. C) Casual personal. D) Social consultative.
B) Intimate.
A patient complains that regardless of the methods of alternative pain control that have been used, her pain remains a 7 on a scale of 10. The nurse suggests that her pain may be ____ pain. A) Radiating B) Intractable C) Referred D) Chronic
B) Intractable
A nurse is caring for a patient with kidney disease whose respirations have increased in rate and depth, with long, strong, blowing or grunting exhalations. The nurse identifies this condition as A) Biot respirations. B) Kussmaul's respirations. C) Cheyne Stokes respirations. D) Korotkoff sounds.
B) Kussmaul's respirations.
At the staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell) to determine whether a patient is exhibiting signs of illness or injury. These signs of illness or injury are A) Subjective. B) Measurable. C) Reported by the patient. D) Hidden.
B) Measurable.
A nurse enters a room to assist a patient who has used the bedside commode. The nurse washes the patient's hands, puts on clean gloves, assists the patient in cleaning the genital area, and then assists the patient into bed. The nurse then empties, rinses, and replaces the pan of the bedside commode. The nurse removes the gloves and washes his or her hands. The student nurse identifies this process as an example of A) Surgical asepsis. B) Medical asepsis. C) Sterile technique. D) Primary defenses.
B) Medical asepsis.
The federal government's health insurance program for people older than 65 years or those with certain disabilities or conditions is known as A) Medicaid. B) Medicare. C) Social security. D) Private insurance.
B) Medicare.
A nurse is performing an initial admission assessment on a patient. The patient states that she takes an herb named feverfew. The nurse recognizes that feverfew is used to treat A) Insomnia. B) Migraine headaches. C) Hypercholesterolemia. D) Irritable bowel syndrome.
B) Migraine headaches.
A patient appears anxious. The patient speaks quickly and paces the hospital halls. Using the SOAPIER method, a nurse should chart this finding under the initial A) S. B) O. C) A. D) P.
B) O.
A young adult is bragging to a nurse that she never gets sick and has not needed to see a doctor for years. The nurse explains to the patient that even when she feels healthy, she should have physical examinations and screenings A) Every 6 months. B) Once a year. C) Every other year. D) Every 5 years.
B) Once a year.
The nurse of a Jewish patient who has just died knows that some Jewish families believe that A) No one, with the exception of close family members, is permitted to touch the body. B) Only a member of Chevra Kadisha should touch or prepare the body for burial. C) The eyes must not be closed, nor may anyone remain with the body after preparation for burial. D) The patient's feet must be positioned away from the exit.
B) Only a member of Chevra Kadisha should touch or prepare the body for burial.
While a nurse assists a patient from a lying position to a sitting position, the patient suddenly becomes dizzy, pale, clammy, and nauseated. The nurse recognizes these symptoms are most likely related to A) Thromboembolism. B) Orthostatic hypotension. C) Orthostatic hypertension. D) Symptomatic bradycardia.
B) Orthostatic hypotension.
A nurse discusses with a patient ways to improve health and prevent disease. The nurse suggests that the patient A) Use emergency and urgent care facilities for routine care. B) Participate in stress management techniques. C) Worry less about food groups and more about calories. D) Eliminate certain food groups from the diet.
B) Participate in stress management techniques.
A nurse recognizes that the physical size and functioning of a person is called A) Moral development. B) Physical development. C) Cognitive development. D) Psychosocial development.
B) Physical development.
A nurse is caring for a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). The patient has limited knowledge about COPD and states that he is primarily a kinesthetic learner. The nurse determines that the patient will learn best by A) Watching a video about management of COPD. B) Placing medications used to treat COPD in a pill organizer. C) Listening to an audiotape about the pathophysiology of COPD. D) Reading a pamphlet about pharmacological treatments for COPD.
B) Placing medications used to treat COPD in a pill organizer.
A female patient who was admitted for severe low back pain has asked a nurse if she can have more pain medication. The nurse tells coworkers that patients admitted with back pain are drug seeking. The nurse is likely demonstrating A) Misunderstanding. B) Prejudice. C) Discrimination. D) Empathy.
B) Prejudice.
A nursing instructor explains that a complete nursing diagnosis may be a one part, two part, or three part statement. Three part statements are often called PES statements, which stands for A) Prognoses, examination, and solution. B) Problem, etiology, and signs and symptoms. C) Pathogen, etymology, and symptoms. D) Problems, evaluations, and solutions.
B) Problem, etiology, and signs and symptoms.
While working at a hospital, a fire begins in the break room. A nurse immediately removes patients from the room adjacent to the break room, sounds the fire alarm, and confines the fire by closing doors. Next, the nurse obtains the fire extinguisher. When using a fire extinguisher, the nurse should first A) Squeeze the handles together. B) Pull the pin found between the handles. C) Aim the nozzle at the base of the flames. D) Sweep the nozzle back and forth at the base of the flames.
B) Pull the pin found between the handles.
A patient has a sore, injured hip. If rising out of a chair causes the patient's back and upper leg to hurt as well, then a nurse would document the pain as A) Referred pain. B) Radiating pain. C) Acute pain. D) Intractable pain.
B) Radiating pain.
When delegating bedtime care to a nursing student, a nurse intervenes when observing the student A) Dimming the patient's lights. B) Removing the patient's urinal. C) Removing the patient's dentures. D) Removing the patient's hearing aids.
B) Removing the patient's urinal.
A nurse is caring for a patient with increasing difficulty breathing. The nurse recognizes that the most appropriate health care worker to collaborate with is a(n) A) Physical therapist. B) Respiratory therapist. C) Occupational therapist. D) Speech and language therapist.
B) Respiratory therapist.
A nursing supervisor asks a nurse for a double lumen nasogastric (NG) tube. The nurse should bring the supervisor a A) Levin tube. B) Salem sump tube. C) French tube. D) Dobbhoff tube.
B) Salem sump tube.
When a nurse sees an infant picking up items and immediately putting them in his or her mouth, the nurse identifies that the infant is encouraging cognitive development through A) Egocentric experiences. B) Sensorimotor experiences. C) Formal operational thinking. D) Concrete operational thought.
B) Sensorimotor experiences.
A nurse observes a student nurse caring for a hearing impaired patient. The nurse will intervene if the student nurse A) Speaks clearly without shouting. B) Speaks directly to the patient's interpreter. C) Positions himself or herself in front of the patient when speaking. D) Turns down the radio volume when speaking to the patient.
B) Speaks directly to the patient's interpreter.
While auscultating a patient's lungs, a nurse hears an audible, high pitched crowing sound. The nurse identifies this sound as A) Rhonchi. B) Stridor. C) Wheezes. D) Rales.
B) Stridor.
A patient complains of pain and joint stiffness. A nurse recommends that the patient seek a calming massage that features long, flowing strokes, kneading, vibration, and compression. This type of massage is called A) Shiatsu. B) Swedish. C) Reflexology. D) Deep tissue.
B) Swedish.
A nurse assessing a patient's oral health must assess which of the following as an immediate safety hazard? A) The color of the mucous membranes B) The ability to swallow C) The presence of ulcerations or lesions in the mouth D) The presence of bleeding in the mouth
B) The ability to swallow
The Affordable Care Act was designed to address all of the following issues in the existing health care system with the exception of A) The cost containment of health care. B) The expansion of Medicaid programs to cover everyone. C) The treatment of patients with pre existing conditions. D) The removal of lifetime benefit caps.
B) The expansion of Medicaid programs to cover everyone.
A nurse explains to a patient that health is measured on a continuum scale and that A) It proves that health is constant and rarely fluctuates. B) The higher the measurement is, the better one's health is. C) It measures only the physical aspects of health. D) It would be more accurate if mental and emotional aspects could be measured.
B) The higher the measurement is, the better one's health is.
Upon entering a patient's room, a nurse decides to check the patient's vital signs rather than delegate the task. Which of the following reasons would best justify the nurse's decision not to delegate the task? A) The patient has just ambulated to the bathroom. B) The nurse has a nagging concern that something is not right. C) The patient is being discharged from the hospital. D) The patient has a long history of hypertension.
B) The nurse has a nagging concern that something is not right.
A nurse is performing a shift assessment on a patient. While collecting objective and subjective data, the nurse identifies as objective data that A) The patient reports feelings of depression. B) The patient demonstrates facial grimacing. C) The patient complains of feeling nauseated. D) The patient complains of visual disturbances.
B) The patient demonstrates facial grimacing.
A physician has ordered a sitz bath for a patient. The nurse understands that it is important to check the patient's chart A) To see whether the patient has had a tub or whirlpool bath before and prefers that treatment. B) To see whether the patient has had a sitz bath before and what the response was. C) To see whether the patient has an active infection that would contraindicate the sitz bath. D) To see whether the patient is mobile, in which case a tub or whirlpool bath is preferable to a sitz bath.
B) To see whether the patient has had a sitz bath before and what the response was.
A nurse needs to transfer a female patient who is only partially capable of bearing her own weight into a wheelchair for transport to an x ray. The nurse determines that the correct device for transferring this patient is a A) Slide sheet. B) Transfer belt. C) Slide board. D) Lift.
B) Transfer belt.
When caring for a hospitalized adolescent, a nurse should do which of the following? Select all that apply. A) Talk down to the adolescent. B) Treat the adolescent with respect. C) Encourage peers to visit. D) Insist that a parent be present during examinations and procedures. E) Assume that the adolescent has no knowledge of his or her illness.
B) Treat the adolescent with respect. C) Encourage peers to visit.
While supervising a student, a nurse intervenes when the student performs a bed bath and A) Covers the patient with a bath blanket. B) Uncovers the entire body when washing. C) Washes extremities from distal to proximal. D) Folds the washcloth into a mitt around the hand.
B) Uncovers the entire body when washing.
A nurse is caring for a patient who can speak and understand some English but is not fluent. The nurse should A) Ask one of the patient's children to help with interpretation. B) Use a professional or certified interpreter from the hospital's list of available interpreters. C) Ask one of the patient's adult family members to help with interpretation. D) Find a nonfamily member in the waiting room who speaks the same language as the patient.
B) Use a professional or certified interpreter from the hospital's list of available interpreters.
A nurse educates a patient with newly diagnosed diabetes about his illness. The patient asks where he can find information on the Internet. The nurse's best recommendation is A) A blog. B) WebMD. C) Wikipedia. D) A commercial site.
B) WebMD.
An instructor teaches that it is important for nurses to emphasize changing unhealthy practices like smoking, eating unhealthy foods, and using alcohol. The instructor identifies that these are all examples of A) Teachable moments. B) Wellness strategies. C) Nursing diagnosis. D) Reinforcement.
B) Wellness strategies.
A nursing instructor explains to students that the confidentiality of a patient's chart, the results of diagnostic procedures and consultations, and any notes they might write regarding the patient's health status is guaranteed by A) The Joint Commission. B) the Health Insurance Portability and Accountability Act (HIPAA). C) the ethics committee. D) the Nurse Practice Act (NPA).
B) the Health Insurance Portability and Accountability Act (HIPAA).
8. A patient throws his urinal at the nurse and tells the nurse that he thinks she is a terrible nurse. The nurse informs the patient that his behavior is inappropriate. The style of communication that the nurse is demonstrating is A. Passive B. Assertive C. Aggressive D. Demeaning
B. Assertive
1. The nurse recognizes that in order to effectively meet the goal of shared meaning in communication, verbal and nonverbal language should be A. absent B. Congruent C. Equally direct D. Noncongruent
B. Congruent
7. When communicating with a patient, the nurse recognizes that patient centered communication is defined as communication that: A. Is focused primarily on the nurse B. Empowers patients to participate in their care C. Encourages patients to participate in their care D. Discourages patients to participate in their care E. Discouraging patients from participating in decisions F. Is essential to establishing a positive nurse patient relationship
B. Empowers patients to participate in their care C. Encourages patients to participate in their care F. Is essential to establishing a positive nurse patient relationship
2.While bathing a patient, the nurse recognizes that the personal space distance zone that he or she is in when physically touching the patient is A. Public B. Intimate C. Casual personal D. Social consultative
B. Intimate
15. The nurse observes a student nurse caring for a hearing impaired patient. The nurse would intervene if the student nurse: A. Speaks clearly without shouting. B. Speaks directly to the patients interpreter. C. Positions himself or herself in front of the patient when speaking. D. Turns down the radio volume when speaking to a patient.
B. Speaks directly to the patients interpreter.
3. When performing an admission assessment, the nurse assesses the patient's verbal communication. The nurse recognizes that verbal communication includes: A. The patient's tense posture B. The patient's written words C. The patient's facial grimacing D. The patient's verbal complaints E. The patient's vocalization of pain F. The patient's disheveled appearance
B. The patient's written words D. The patient's verbal complaints E. The patient's vocalization of pain
5. The nurse demonstrates active listening when: A. Ignoring nonverbal cues B. Tuning out intrusions and distractions C. Using all of the senses to interpret verbal messages D. Paying attention to what the speaker is saying E. Using all of the senses to interpret nonverbal messages F. Paying attention to what the speaker is not saying
B. Tuning out intrusions and distractions C. Using all of the senses to interpret verbal messages D. Paying attention to what the speaker is saying E. Using all of the senses to interpret nonverbal messages F. Paying attention to what the speaker is not saying
An instructor explains that in 1895, D. D. Palmer was the first person in the United States to practice an art and science that dates back to writings from China and Greece as long as 4700 years ago. This type of practice is called A) Acupuncture. B) Massage therapy. C) Chiropractic. D) Yoga.
C) Chiropractic.
A wife is extremely upset about her husband's respirations. A nurse explains that this type of breathing is a symptom of end stage disease. The breathing is called Cheyne Stokes and is characterized by A) Slow, shallow respirations. B) Slow, deep respirations. C) A cycle of shallow and deep respirations. D) Cyanosis of the hands and feet.
C) A cycle of shallow and deep respirations.
A homeless man is admitted to the hospital with severe emaciation, a swollen abdomen, lethargy, and skin infections. The patient is diagnosed with a disease known as kwashiorkor, a condition caused by A) A vitamin B deficiency. B) Eating too many simple carbohydrates. C) A failure to eat adequate protein. D) A failure to eat an adequate amount of polyunsaturated fats.
C) A failure to eat adequate protein.
A student nurse was discussing the subject of incident reports. All of the statements made by the student were accurate until she said: A) "Incident reports are to be completed in the event of an unusual occurrence or an accident." B) "An incident report should be completed according to agency policy, including notification of the supervisor and designated personnel." C) "A copy of the incident report should be filed as part of the involved patient's chart." D) "An incident report should include what happened, who was involved, witnesses to the event, and treatment provided."
C) "A copy of the incident report should be filed as part of the involved patient's chart."
A nurse is instructing a student nurse about the best methods to use when teaching a visual learner. The nurse determines that additional instruction is needed when the student nurse states: A) "A visual learner learns best by seeing." B) "A visual learner learns best by reading." C) "A visual learner learns best by touching." D) "A visual learner learns best by watching."
C) "A visual learner learns best by touching."
An instructor explains that the old MyPyramid food management system has been replaced with a simpler visual symbol called MyPlate. The instructor realizes that additional instruction is required when a student says: A) "Half of a plate of food should be fruits and vegetables, with veggies making up the greater portion of the two groups." B) "Grains and protein should make up half of the plate, with the grains portion being the larger of the two groups." C) "Adults should consume four to six servings a day from the vegetable group." D) "Depending on the age of the individual, the entire daily intake of dairy should be restricted to a total of 2 to 3 cups of low fat or nonfat milk."
C) "Adults should consume four to six servings a day from the vegetable group." B) A decrease in high density lipoprotein (HDL).
While reviewing the nursing diagnoses in a student nurse's written care plan, a nursing instructor recognizes that additional teaching is warranted when the student nurse includes a nursing diagnosis of A) "Pain related to abdominal incision." B) "Altered sensory perception related to surgery." C) "Chronic fatigue syndrome related to poor diet." D) "Altered nutrition related to nausea and vomiting."
C) "Chronic fatigue syndrome related to poor diet."
An instructor is discussing various factors that can affect a patient's blood pressure. The instructor identifies that additional teaching is needed when a student says: A) "Herbs, over the counter medications, and illicit drugs can all affect a patient's blood pressure." B) "Blood pressure is higher in some overweight and obese individuals." C) "Dehydration tends to raise a patient's blood pressure." D) "The average systolic pressure in newborns is around 40 mm Hg."
C) "Dehydration tends to raise a patient's blood pressure."
A nurse could appropriately respond to a patient's complaint that he awakens frequently during the night by saying: A) "Perhaps you should try going to bed earlier." B) "You could try watching TV. That helps me fall asleep." C) "Drinking alcohol can cause you to wake up during the night." D) "Exercising at night before you go to bed can enhance sleep."
C) "Drinking alcohol can cause you to wake up during the night."
A nurse supervising a certified nursing assistant (CNA) would correctly intervene upon hearing the CNA say: A) "Hi again, Mr. Jones. Are you feeling better today? Oh, really? Tell me what's wrong and I'll see what I can do." B) "Hello, Mr. Jones, my name is Andrea. The doctor says we need to move you to another unit today, so please let me know where you're keeping your personal belongings so we can send those along as well." C) "Hello, Mr. Jones. Please roll up your sleeve." D) "Hi, Mr. Jones. Ah, I see the Girl Scouts have come through today because you've got some cookies there, haven't you? Well, make sure to leave those alone till your kids come by to visit, okay? [Laughs] We don't want the doctor getting mad about you going off your diet."
C) "Hello, Mr. Jones. Please roll up your sleeve."
A patient's spouse asks a nurse about hospice. The nurse educates that hospice is A) A service that provides care to the terminally ill patient only. B) Warranted when the patient still seeks a cure for his or her terminal illness. C) A program that focuses on palliative treatment and emotional support. D) Appropriate when the patient is expected to live for fewer than 9 months.
C) A program that focuses on palliative treatment and emotional support.
A nurse instructs a patient, "You can decrease your risks for developing many diseases and illnesses by developing healthy habits and participating in health screenings." The patient validates understanding when he or she states: A) "As long as I begin to limit the amount of bad carbohydrates in my diet and begin exercising by the age of 50, I probably will not develop type 2 diabetes." B) "Performing monthly breast self examinations if I have a family history of breast cancer will decrease my chances of developing it." C) "I can take responsibility for reducing risks by eating a well balanced diet and seeing my primary care physician for routine health screenings." D) "Since I am at risk for developing high cholesterol, it will be important for me to ask my primary care physician for medications to prevent it."
C) "I can take responsibility for reducing risks by eating a well balanced diet and seeing my primary care physician for routine health screenings."
An instructor is teaching students about providing oral care on an unconscious patient. The teacher realizes that additional instruction is required when a student says: A) "I should assess the mouth for lesions and dried mouth secretions known as sordes." B) "I must position the patient to minimize any chance of aspiration of fluids." C) "I should use lemon glycerin swabs to clean the lips and inside of the mouth." D) "I should apply a water soluble lip balm to keep the lips moist."
C) "I should use lemon glycerin swabs to clean the lips and inside of the mouth."
A nurse is assisting in the discharge of a patient who had a right hip replacement. Additional teaching is necessary if the patient states: A) "I will need an extender to pick things up from the floor." B) "I should keep a wide stance when I walk with my walker." C) "I will have to bend way over to tie my shoes." D) "I have to keep this special pillow between my legs when I'm sleeping."
C) "I will have to bend way over to tie my shoes."
When educating a student nurse about how to correctly logroll a patient, a nursing instructor recognizes that additional teaching is necessary when the student nurse states: A) "I will count to three before the move occurs." B) "I will ask two people to help me logroll a patient." C) "I will stand at the patient's feet and control the turn." D) "I will ensure that staff members turn the patient as one unit."
C) "I will stand at the patient's feet and control the turn."
A patient has refused to take the medications brought in by a nurse. The nurse will chart, A) "Instructed patient that the medications will be taken now or later." B) "Explained to patient that unless medications are taken, the physician will likely issue a discharge." C) "Medications refused; physician notified." D) "Physician notified that patient is uncooperative."
C) "Medications refused; physician notified."
A patient requests that a nurse copy his chart for his daughter. The nurse replies: A) "I'll get a copy made right away. How many copies do you need?" B) "Only your lawyer can request a copy, so you need to contact her." C) "The chart belongs to the hospital, but if you give written permission, a copy can be made for you." D) "The Health Insurance Portability and Accountability Act, or HIPAA, prevents the hospital from copying your chart, but you could speak to your physician about it."
C) "The chart belongs to the hospital, but if you give written permission, a copy can be made for you."
A nurse is educating a student nurse about the purpose of written documentation. The nurse recognizes that additional teaching is warranted when the student nurse states: A) "The purpose of written documentation is to communicate pertinent data to the health care team." B) "The purpose of written documentation is to serve as a record of accountability for accreditation." C) "The purpose of written documentation is to serve as a legal record for the health care provider only." D) "The purpose of written documentation is to serve as a record of accountability for quality assurance."
C) "The purpose of written documentation is to serve as a legal record for the health care provider only."
A nursing instructor recognizes that teaching has been effective if a student who is providing care for a patient with right sided weakness reports: A) "The top of the cane is level with the iliac crest." B) "The patient is holding the cane in the right hand." C) "The top of the cane is even with the patient's hip joint." D) "The base of the cane is even with the tip of the patient's shoe."
C) "The top of the cane is even with the patient's hip joint."
A young couple that is about to start a family is discussing motor vehicle safety with a nurse. The nurse intervenes when one of them says: A) "Motor vehicle accidents are a cause of injury and death among toddlers." B) "Vigilance must be used when driving in areas where toddlers may be playing." C) "The use of a car seat becomes optional once the child grows out of the infant stage." D) "I always look for small children when I am backing up or pulling into a driveway."
C) "The use of a car seat becomes optional once the child grows out of the infant stage."
When monitoring the fluid intake of an average adult patient over a 24 hour period, a nurse should expect the patient to consume between A) 500 and 1200 mL of fluid B) 1200 and 1500 mL of fluid C) 1500 and 2500 mL of fluid D) 2500 and 3500 mL of fluid
C) 1500 and 2500 mL of fluid
A surgical hand scrub should be performed for a minimum of A) 30 seconds. B) 2 minutes. C) 3 minutes. D) 10 minutes.
C) 3 minutes.
Which of the following patients could successfully use a cane? A) A 59 year old with a left below the knee amputation B) A 47 year old with orders for non weight bearing on the left C) A 69 year old recovering from a stroke with mild right sided weakness D) A 70 year old who cannot bear full weight on both legs
C) A 69 year old recovering from a stroke with mild right sided weakness
A nurse suspects that the ice bag on a patient's left foot is too cold because the patient is complaining of A) Feeling chilled. B) Increased swelling. C) A burning sensation. D) Feeling confused.
C) A burning sensation.
According to Piaget, young school age children, up to age 7 years, are making a transition to concrete operational thought. A nurse identifies that an example of this would be A) A child, upon hearing a parent arrange for a babysitter, becoming upset because it means his or her parents are going to leave for the evening. B) A child becoming more secure about the limits of his or her acceptable behavior. C) A child no longer believing that an adult dressed in a mouse suit is a giant mouse. D) A child becoming interested in politics, environmental issues, and social justice.
C) A child no longer believing that an adult dressed in a mouse suit is a giant mouse.
A nurse educator explains to student nurses that according to Selye, the general adaptation syndrome (GAS) is A) An explanation of how the body's response to stress prevents death. B) Validated by how many people are struggling with terminal illnesses, such as cancer. C) A theory explaining the body's attempt to adjust to stress. D) What prevents the threat to health when there is long term stress.
C) A theory explaining the body's attempt to adjust to stress.
When applying cold therapy, a nurse correctly understands that A) Ice or another source of cold should be placed directly on the patient's skin. B) Cold therapy works best when alternated with heat therapy. C) A thin cloth barrier should be placed between the source of cold and the patient's skin. D) The treatment should be applied for about 45 minutes.
C) A thin cloth barrier should be placed between the source of cold and the patient's skin.
A nurse recognizes that the ancient practice of inserting fine needles into carefully selected points located along meridians, or energy pathways, in the body is called A) Holism. B) Acupressure. C) Acupuncture. D) Allopathic medicine.
C) Acupuncture.
A nurse appropriately recognizes that a patient will develop his or her initial impression of the nurse during the A) Teaching process. B) Discharge process. C) Admission process. D) Implementation process.
C) Admission process.
Following a discussion with a patient about treatment options given by the primary care physician, a nurse assures the patient that the physician will support whatever decision is made. This nurse is acting as the patient's A) Ethics board B) Value system C) Advocate D) Conscience
C) Advocate
A charge nurse is receiving four patients from surgery. The charge nurse recognizes that the most appropriate patient to place in the room closest to the nurses' station is A) A 9 year old child who is tearful. B) A 62 year old patient who is anxious. C) An 87 year old patient who is confused. D) A 16 year old adolescent who is depressed.
C) An 87 year old patient who is confused.
A patient complains of pain at 9 on a scale of 10 and requests pain medication. Understanding that it is important to quickly treat severe pain, a nurse will expect to administer A) An NSAID. B) A nonopiate analgesic. C) An opiate/opioid analgesic. D) An adjuvant analgesic.
C) An opiate/opioid analgesic.
A nurse understands that when a terminal patient states, "No, I don't need anything. What would you get me anyway?" he or she is most likely in the stage of grief called A) Denial. B) Acceptance. C) Anger. D) Bargaining.
C) Anger.
A nurse uses the DESC (Describe, Explain, State, Consequences) communication method to promote the A) Passive style. B) Aggressive style. C) Assertive style. D) Avoidant style.
C) Assertive style.
A nursing instructor teaches a class of student nurses that the most effective communication style for nurses to practice is A) Passive. B) Avoidant. C) Assertive. D) Aggressive.
C) Assertive.
A nurse is preparing to administer a sponge bath to reduce fever in a patient. Which of the following is the most appropriate action to take? A) Lower the temperature of the room to aid in reducing the patient's body temperature. B) Place ice in a bowl of water so that it is cold enough to have the desired effect. C) Assess the patient's temperature to have a baseline. D) Plan to provide care to other patients after applying moist cloths to this patient's axilla and groin.
C) Assess the patient's temperature to have a baseline.
Before applying a warm pack to reduce a patient's discomfort from back spasms, a nurse will A) Warm the towel in the microwave. B) Check peripheral pulses for a baseline. C) Assess the skin for edema and color. D) Prepare the warm pack using sterile technique.
C) Assess the skin for edema and color.
While caring for a newly admitted patient, a registered nurse (RN) gathers information by interviewing the patient to obtain a health history and reviewing the results of laboratory and diagnostic tests. This step in the nursing process is called A) Planning. B) Evaluation. C) Assessment. D) Implementation.
C) Assessment.
A nurse is caring for a Jewish patient with strong cultural beliefs. The nurse must intervene when food services brings him A) Steak. B) Fish fillet. C) Bacon and eggs. D) Chicken breast.
C) Bacon and eggs.
The patient's blood pressure at 8:00 a.m. was 124/80 mm Hg, and now at 12:00 p.m., it is 152/94 mm Hg. The charge nurse appropriately instructs the newly hired nurse that A) The patient's blood pressure should be rechecked in 15 minutes. B) Any abnormal findings should be rechecked within 8 hours. C) Because the blood pressure has become elevated, it should be rechecked in 1 to 2 hours. D) There is no reason to recheck the blood pressure because this pattern of elevation is typical for this patient.
C) Because the blood pressure has become elevated, it should be rechecked in 1 to 2 hours.
A patient with a terminal illness does not have a do not resuscitate (DNR) order, and upon entering the room, a nurse finds that the patient is not breathing. The first action that the nurse will take is to A) Ask another nurse to write the order for a DNR. B) Call the physician to get an order for a DNR. C) Begin cardiopulmonary resuscitation (CPR) because an order for a DNR is not written. D) Notify the selected funeral home that the patient has expired.
C) Begin cardiopulmonary resuscitation (CPR) because an order for a DNR is not written.
A nurse intervenes when a nursing student says that an enteral tube should be used for A) Postoperative decompression of the stomach. B) Nutritional support. C) Breathing assistance. D) Medication administration.
C) Breathing assistance.
While obtaining a patient health history, a nurse recognizes that the personal space distance zone that he or she is in when standing within 3 feet of the patient is A) Public. B) Intimate. C) Casual personal. D) Social consultative.
C) Casual personal.
While supervising a home health care aide, a nurse intervenes when observing the home health care aide A) Giving the patient a back massage. B) Preparing the patient's favorite meal. C) Changing the dressing on a patient's wound. D) Transporting the patient to a medical appointment.
C) Changing the dressing on a patient's wound.
A male patient in dire need of medical assistance has refused treatment, stating it is against his religion. A nurse correctly identifies and documents the patient's refusals of treatment because he is a A) Latter Day Saint. B) Seventh Day Adventist. C) Christian Scientist. D) Buddhist.
C) Christian Scientist.
A nurse recognizes that how an individual learns is called A) Moral development. B) Physical development. C) Cognitive development. D) Psychosocial development.
C) Cognitive development.
In certain situations when a patient is in the terminal stages of a disease and not expected to live much longer, a physician may be authorized to write a do not resuscitate (DNR) order in the patient's chart that limits life. extending measures to A) Tube feeding. B) Use of a ventilator. C) Comfort and dignity. D) Cardiopulmonary resuscitation.
C) Comfort and dignity.
While working at a hospital, a fire begins in the break room. A nurse immediately removes patients from the room adjacent to the break room and sounds the fire alarm. Next, the nurse should A) Call the fire department. B) Obtain a fire extinguisher. C) Confine the fire to one area. D) Open all of the doors in the immediate area.
C) Confine the fire to one area.
A patient comes to urgent care with a swollen, painful ankle. While the patient is waiting to be seen by the physician, a nurse could appropriately A) Apply a cold pack to the ankle to reduce pain and edema. B) Apply a hot pack to the ankle to improve mobility and promote healing. C) Confirm that there are standing orders to apply ice to recent, localized joint injuries. D) Confirm that there are standing orders to apply heat to recent, localized injuries involving edema.
C) Confirm that there are standing orders to apply ice to recent, localized joint injuries.
A patient admitted for depression tells a nurse that he feels so hopeless that he doesn't care if he lives or dies. The patient tells the nurse that he no longer attends church with his family. The nurse identifies that possibly the patient A) Does not value faith the way he previously had. B) Wishes to be left alone to reflect on his lost faith. C) Could be experiencing spiritual distress. D) Wants the nurse to discuss his feelings with his family
C) Could be experiencing spiritual distress.
When conducting an admission assessment and taking an inventory of items that a patient has brought to the hospital, a nurse appropriately instructs the patient to send home with a family member her A) Dentures. B) Eyeglasses. C) Credit cards. D) Hearing aids.
C) Credit cards.
While caring for a patient who has just been diagnosed with a terminal illness, a nurse expects to see the patient exhibit the traditional first stage of grief, which is called A) Bargaining. B) Anger. C) Denial. D) Depression.
C) Denial.
While assessing a patient's pulse, a nurse identifies that the pulse obliterates. This means the pulse A) Is full and has a bounding quality. B) Is weak, faint, and not perfusing. C) Disappears upon palpation. D) Indicates contractions are perfusing.
C) Disappears upon palpation.
When performing a physical assessment on a neonate, a nurse notes a triangular shaped soft area that is not yet fused together toward the back of the top of the head. The nurse should A) Notify the health care provider. B) Assess the neonate's vital signs. C) Document this as a normal assessment finding. D) Document this as an abnormal assessment finding.
C) Document this as a normal assessment finding.
A nurse educates a patient about increasing his or her intake of complete proteins. The patient demonstrates understanding when identifying an example of a complete protein as A) Nuts. B) Corn. C) Eggs. D) Beans.
C) Eggs.
When caring for an elderly patient who is experiencing anxiety related to a new diagnosis of cancer, a nurse appropriately seeks to alleviate the anxiety by A) Telling the patient that her cancer is curable. B) Discouraging the patient from asking questions. C) Encouraging the patient's spouse to stay with the patient. D) Explaining cancer to the patient using medical terminology.
C) Encouraging the patient's spouse to stay with the patient.
A nurse is caring for a patient with asthma who is having difficulty breathing. The nurse notifies the respiratory therapist, who administers treatment. After the treatment, the nurse reflects on the results to determine whether the goal of relief has been accomplished. When the nurse determines whether the goal has been met, he or she is performing a step in the nursing process called A) Planning. B) Diagnosis. C) Evaluation. D) Implementation.
C) Evaluation.
A middle aged female patient taking digoxin for a heart condition is complaining about the effectiveness of her medication. Upon explaining to the nurse that she takes no other medications but regularly takes herbal supplements, the nurse suspects the problem may be the herb A) Ginger. B) Saw palmetto. C) Ginseng. D) Peppermint oil.
C) Ginseng.
An elderly female patient is interested in practicing yoga to help lower her blood pressure and stress levels while improving her flexibility. She expresses concern that it may be too fast paced and intense for her. The nurse recommends A) Ashtanga yoga. B) Power yoga. C) Hatha yoga. D) Iyengar yoga.
C) Hatha yoga.
A male patient has been admitted with congestive heart failure. Although the patient is sitting in a semi Fowler position, the nurse cannot auscultate distinct heart tones. The nurse will correctly first A) Document that the heart tones are muffled. B) Count the apical rate as best as possible and then document it. C) Have the patient lean forward and toward his left side. D) Report the findings to the charge nurse.
C) Have the patient lean forward and toward his left side.
When caring for a confused patient who has a history of falls, a nurse demonstrates caring when A) Removing the patient's night light. B) Keeping the patient's bed in the highest position at all times. C) Having the patient sit in a rocking chair near the nurses' station. D) Offering infrequent opportunities for the patient to go to the bathroom.
C) Having the patient sit in a rocking chair near the nurses' station.
A female Hindu patient with a broken right hand has not touched her vegetarian food for several meals. The nurse intervenes once realizing the problem is A) Hindus do not like vegetarian food. B) Hindus can only eat after sundown. C) Hindus avoid eating with their left hand. D) Hindus can only eat if they are facing east.
C) Hindus avoid eating with their left hand.
A nurse delegates the task of assisting patients with ambulation to a student nurse. The nurse intervenes when observing the student A) Instructing the patient to move from supine to standing positions in stages. B) Assisting the patient to a dangling position with his or her feet firmly on the floor. C) Holding the transfer belt loosely near the patient's body while ambulating. D) Raising the head of the bed and assisting the patient with sitting on the side of the bed.
C) Holding the transfer belt loosely near the patient's body while ambulating.
When performing an initial admission assessment on a patient with diabetes, a nurse checks the patient's blood glucose level. The nurse notes that the patient's blood glucose level is 280 mg/dL. The nurse recognizes this reading is consistent with A) Hypoglycemia. B) Diabetic coma. C) Hyperglycemia. D) A normal value.
C) Hyperglycemia.
A nurse is aware that the best method to ensure documentation accuracy is to consistently chart A) At the completion of each shift. B) Within 4 hours of providing care. C) Immediately after care is provided. D) Immediately before providing care.
C) Immediately after care is provided.
A fire breaks out in a hospital. A nurse makes sure that the fire extinguisher is designated for type C fires before using it because the fire started A) In a trashcan full of paper. B) On a stove in the kitchen. C) In a piece of electrical equipment. D) From a combustible liquid.
C) In a piece of electrical equipment.
A nurse assesses a patient's urine and notices that it is dark yellow, concentrated, and lower in volume than normal. The nurse decides to put the patient on intake and output measurement because the patient has a risk for imbalanced fluid volume. This is an example of a(n) A) Dependent intervention. B) Indirect intervention. C) Independent intervention. D) Collaborative intervention.
C) Independent intervention.
A physician writes an order to discontinue a nasogastric (NG) tube. When discontinuing the NG tube, the nurse should A) Slowly withdraw the tube from the patient's nose. B) Show the removed tube to the patient and his or her spouse. C) Instill 10 to 20 mL of air into the NG tube's main lumen. D) Instruct the patient to breathe deeply while removing the tube.
C) Instill 10 to 20 mL of air into the NG tube's main lumen.
A nurse plans care that includes a patient's health care beliefs because A) The patient otherwise could accuse the nurse of stereotyping. B) Not doing so could result in a patient's discrimination claim. C) It could determine whether a patient rejects treatment. D) It results in more expedient and cost effective care.
C) It could determine whether a patient rejects treatment.
A nurse is providing oral care to an unconscious patient. The nurse attempts to minimize any chance of aspiration of fluids by placing the patient in a A) Prone position. B) Supine position. C) Lateral position. D) Lithotomy position.
C) Lateral position.
A patient has a written document containing medical decisions should the patient be unable to make them as the illness progresses. The nurse understands that the patient has a A) Durable power of attorney (DPR). B) Do not resuscitate (DNR) order. C) Living will. D) Terminal illness.
C) Living will.
A nurse is caring for a patient who is receiving formula through intermittent tube feedings. When caring for this patient, the nurse should A) Keep the patient in a supine position. B) Warm the formula in the microwave oven. C) Maintain the formula at room temperature. D) Administer the formula directly from the refrigerator.
C) Maintain the formula at room temperature.
A nurse is educating a nursing student about nursing history. The nurse explains that throughout ancient history, nursing care was provided by family members and A) Nurses. B) Physicians. C) Male Priests. D) Female Priests.
C) Male Priests.
When questioned by a patient about the difference between palliative care and the services provided by hospice, a nurse explains that palliative treatment A) Is aggressive, but administered to cure the disease. B) Is geared toward the patient, family, and their wishes. C) May be aggressive and is directed at eliminating discomfort. D) Indicates the patient has fewer than 6 months to live.
C) May be aggressive and is directed at eliminating discomfort.
A nurse is monitoring a patient's intake and output. The patient drinks part of a can of cola. The nurse should A) Ask the patient to finish the can of cola. B) Estimate how much of the can was consumed by the patient. C) Measure the remainder to determine the amount ingested. D) Not record such a small amount of fluid.
C) Measure the remainder to determine the amount ingested.
A patient's daughter approaches a nurse to explain that upon his death, female nurses should not touch him. The family also asks that the body remain completely covered with his feet turned toward Mecca. The nurse identifies that the family is A) Buddhist. B) Jewish. C) Muslim. D) Orthodox.
C) Muslim.
After providing a.m. care for his patient, a nurse forgot to put the bed in the lowest position and left one of the bed rails down. The patient got out of bed and fell. The nurse could be reported to the board of nursing for A) Assault. B) Battery. C) Negligence. D) Libel.
C) Negligence.
A nurse is preparing to discharge a patient from telemetry to allow the patient to take a shower. Which of the following actions should the nurse take? A) Instruct the patient to keep the telemetry patches in place. B) Inform the patient not to apply lotion or powder on her chest after the shower. C) Notify the monitor technician that telemetry will be turned off. D) Ask the patient if she has a history of falls in the bathroom.
C) Notify the monitor technician that telemetry will be turned off.
A nurse receives an order from the physician for an intravenous (IV) antibiotic to be administered to a patient who has experienced development of pneumonia. The nurse remembers that the patient has an allergy to another medication in the same family of antibiotics. The nurse should A) Retest the patient for allergies. B) Call the laboratory for clarification. C) Notify the physician of the potential for the patient to have a reaction to the ordered antibiotic. D) Follow the physician's orders and administer the IV.
C) Notify the physician of the potential for the patient to have a reaction to the ordered antibiotic.
A nurse intervenes when he or she observes a student nurse who is caring for a toddler A) Encourage the toddler to feed herself. B) Guide the toddler gently if she makes a mistake. C) Offer the toddler unlimited choices on what time to go to bed. D) Ask the toddler if she would like to wear the red shirt or the blue shirt.
C) Offer the toddler unlimited choices on what time to go to bed.
While performing an assessment, a physician taps on the patient's abdomen to detect abnormalities. This is an example of an assessment technique called A) Palpation. B) Inspection. C) Percussion. D) Auscultation.
C) Percussion.
To help reduce hospital acquired infections (HAIs), the nurse's first priority is to A) Provide small bedside bags to dispose of used tissues. B) Administer antibiotics as ordered. C) Perform strict hand washing before and after care of each patient. D) Instruct each staff member to wear a mask while providing care.
C) Perform strict hand washing before and after care of each patient.
A nurse educator teaches a student nurse that prevention of venous thrombosis includes A) Limiting movement of the extremities. B) Applying bilateral ankle restraints. C) Performing passive range of motion exercises. D) Discouraging the patient from wearing sequential compression devices.
C) Performing passive range of motion exercises.
A student nurse is caring for a patient who has been diagnosed with a cerebral vascular accident that resulted in right sided weakness. In developing a plan of care that focuses on optimizing mobility, collaborative interventions should involve which of the following health care team members? A) Chaplain B) Social worker C) Physical therapist D) Dietitian
C) Physical therapist
A nurse explains to a patient that it is important to slowly change positions to diminish or eliminate the symptoms of A) Essential hypertension. B) Pulse pressure. C) Postural hypotension. D) Pre hypertension.
C) Postural hypotension.
A nurse is caring for a child who wants his parents to buy him a cat when he gets better. The parents refuse because they are both allergic to cat hair. The child states, "That's not fair. I want a cat." The nurse recognizes that the child is in which stage of Lawrence Kohlberg's moral development theory? A) Conventional morality B) Preoperational morality C) Preconventional morality D) Postconventional morality
C) Preconventional morality
A patient at the clinic is complaining to a nurse that she has no specific symptoms, but that her body aches, she is fatigued, and she just does not feel good. This patient's phase of illness is the A) Dependency phase. B) Seeking help phase. C) Prodromal phase. D) Symptomatic phase.
C) Prodromal phase.
An elderly female patient is becoming progressively more confused. She begins talking to long gone loved ones about places and events that do not make any sense to her family. A nurse should A) Verify the patient's level of consciousness. B) Attempt to reorient the patient. C) Protect the patient from injury by bed rails or equipment. D) Hydrate the patient.
C) Protect the patient from injury by bed rails or equipment.
A nurse is working in a critical care unit where the focus is on primary care nursing. The nurse demonstrates understanding of primary care nursing when A) Asking an unlicensed assistant to give a bed bath. B) Asking another nurse to call the physician for orders. C) Providing all aspects of nursing care for assigned patients. D) Instructing the nursing assistant to take the patient's vital signs.
C) Providing all aspects of nursing care for assigned patients.
Children in preschool often learn from pretending, role playing, and exploring the identities of adults in various positions, such as nurses, doctors, teachers, police, firefighters, and others who serve as role models. A nurse identifies this type of behavior is an example of A) Cognitive development. B) Moral development. C) Psychosocial development. D) Physical development.
C) Psychosocial development.
A patient who is recovering from a myocardial infarction (MI) asks a nurse about following a heart healthy diet. The patient states that she is primarily a visual learner. The nurse determines that the patient will learn best by A) Chopping up fruits and vegetables to eat. B) Listening to an audiotape about a heart healthy diet. C) Reading a chapter in a book about a heart healthy diet. D) Attending a lecture in which the speaker talks about a heart healthy diet.
C) Reading a chapter in a book about a heart healthy diet.
When questioned about the automobile accident that brought him into the hospital, the patient began to cry loudly. The patient then proceeded to curl up in a ball on the bed and suck his thumb. This patient is presenting the defense mechanism of A) Sublimation. B) Displacement. C) Regression. D) Avoidance.
C) Regression.
A mentally competent patient with a terminal illness refuses to take his medications, stating, "I don't want to live like this." The nurse will A) Ask the physician to change the patient's medications so they can be given intravenously. B) Speak to the patient's family about his refusal of medications so they can discuss it with him. C) Report the patient's decision to the physician and continue to provide appropriate compassionate care. D) Explain to the patient the unwise nature of his decision and the effect that it will have on his family.
C) Report the patient's decision to the physician and continue to provide appropriate compassionate care.
A patient being seen in the clinic tells a nurse, "The pain is in my right side." The patient's phase of illness is A) Prodromal. B) Symptomatic. C) Seeking help. D) Dependency.
C) Seeking help.
A Native American patient tells a nurse that she does not desire medical treatment for her terminal illness. Respecting the patient's decision, the nurse explains to staff nurses that A) The Native American culture dictates that terminal illnesses are to be treated only by folk healers. B) Terminal illness is believed to be a condition created by an imbalance in yin and yang. C) Some Native Americans feel that rituals performed by a shaman are the best treatment for illness. D) Illness is a result of sinful behavior, so medical treatment will not be effective.
C) Some Native Americans feel that rituals performed by a shaman are the best treatment for illness.
A nurse has just witnessed a terminally ill patient telling the physician that he does not wish to have his life prolonged as stated in his living will. The nurse expects that the physician will A) Explain to the patient why he should be more hopeful. B) Write a do not resuscitate (DNR) order. C) Speak to the patient's family before writing a DNR order. D) Ignore the patient's request.
C) Speak to the patient's family before writing a DNR order.
A nursing instructor is educating a class of student nurses about charting direct statements made by a patient. The best example of this would be A) States, "He vomited everything he ate and drank yesterday." B) States, "He is in excruciating pain. The pain is unrelieved by analgesics." C) States, "The pain is getting worse. I don't know if I can stand it or not." D) States, "His pain is getting worse and he doesn't know if he can stand it or not."
C) States, "The pain is getting worse. I don't know if I can stand it or not."
A nursing instructor educates a class of nursing students about SOAPIER charting. The nursing instructor teaches that the acronym SOAPIER stands for A) Symptoms, Objective, Assessment data, Plan, Intervention, Evaluation, Revision. B) Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Results. C) Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision. D) Subjective data, Objective data, Assessment data, Problems, Intervention, Evaluation, Revision.
C) Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision.
A nurse encounters a bed made up with the top linens fanfolded to the side of the bed. The nurse identifies this as a(n) A) Closed bed. B) Open bed. C) Surgical bed. D) Occupied bed.
C) Surgical bed.
A nurse explains to a patient that blood pressure measures A) The amount of blood volume within the blood vessels. B) The amount of resistance within the veins during heart contractions. C) The amount of force being placed on arteries by blood. D) The amount of pressure exerted by the veins and arteries on the heart.
C) The amount of force being placed on arteries by blood.
A nurse feels that his patient needs to be placed in a protective restraint device to protect him from injury. To place a patient in restraints, A) The patient must give his or her consent for restraints to be used. B) A family member must give his or her consent to use restraints. C) The nurse must have documentation that other methods have been used and failed to protect the patient. D) The patient must be alert and oriented.
C) The nurse must have documentation that other methods have been used and failed to protect the patient.
A nurse is caring for a patient with an order for non weight bearing to the left leg. Which of the following would indicate that the patient is using the correct crutch gait? A) The patient moves one foot and the opposite crutch forward at the same time. B) The patient moves the first crutch forward and then the opposite foot forward. C) The patient moves both crutches and the nonaffected foot forward at the same time. D) The patient moves both crutches forward at the same time and then swings both feet forward.
C) The patient moves both crutches and the nonaffected foot forward at the same time.
While performing a thorough physical assessment on a patient, the licensed practical nurse (LPN) begins collecting primary data. An example of primary data is that A) The patient's spouse reports the patient has difficulty sleeping. B) The patient's caregiver complains of feeling overwhelmed. C) The patient reports a history of chronic obstructive pulmonary disease. D) The patient's daughter appears anxious about the patient's hospitalization.
C) The patient reports a history of chronic obstructive pulmonary disease.
A nurse applies a cooling blanket to a patient with a temperature of 10E.4°F. The nurse would recognize which of the following as an indication of therapeutic effectiveness? A) The patient begins to shiver. B) The blood pressure and pulse increase. C) The temperature slowly falls to 100°F. D) The level of consciousness decreases.
C) The temperature slowly falls to 100°F.
A nurse witnesses a young patient watching his older sibling and then imitating everything the older sibling does. The nurse identifies this as an example of the cognitive development of A) Infants. B) School age children. C) Toddlers. D) Adolescents.
C) Toddlers.
A patient with an ocular prosthesis (artificial eye) requires a nurse's help removing it for cleaning. The nurse assists the patient by A) Removing the prosthesis like a thick contact lens. B) Unscrewing the prosthesis from the eye socket. C) Using a small suction cup on a hollow handle to help remove the prosthesis. D) Pressing on either side of the prosthesis until it pops out.
C) Using a small suction cup on a hollow handle to help remove the prosthesis.
While observing a student nurse performing a bed bath, a nursing instructor recognizes that additional instruction is needed when the student A) Covers the patient with a bath blanket. B) Changes the water after bathing the feet. C) Washes extremities from proximal to distal. D) Washes from the cleanest areas to the dirtiest area.
C) Washes extremities from proximal to distal.
While helping a patient clean his natural blind globe prosthesis, a nurse makes a mistake by A) Assessing the socket for large amounts of thick yellow or green mucus. B) Irrigating the eye socket with eye irrigating solution. C) Wiping off the cornea area with a clean, dry cloth. D) Cleansing the prosthesis with sterile water or saline.
C) Wiping off the cornea area with a clean, dry cloth.
10. A nursing instructor teaches a class of student nurses that the most effective communication style for nurses to practice is: A. Passive B. Avoidant C. Assertive D. Aggressive
C. Assertive
3. While obtaining a patient health history, the nurse recognizes that the personal space distance zone that he/she is in when standing within 3 feet of the patient is A. Public B. Intimate C. Casual personal D. Social consultative
C. Casual personal
Define empathy in 1-3 words
Caring Self in patients place Compassion Understanding Listening
Visceral pain
Caused from deep internal disorders such as menstrual cramps, labor pains, or gastrointestinal infections.
Cultures that refuse medications?
Christian Scientists
Partial Bath
Cleanse only the areas that may cause odor or discomfort
Therapeutic communication
Client-centered communication directed to achieve the patients' goal. (Avoid asking "why")
Stereotype
Considering everyone are the same under their racial or ethnic group. i. Assuming everyone from that culture practices health or treats illnesses the same way.
Elderly are primarily at high risk for?
falls
An Asian American patient explains to a nurse that yin and yang can be compared with the sympathetic and parasympathetic nervous systems and the way they maintain balance in the body. This type of belief is an example of A) A magico religious belief. B) Folk healing. C) A biomedical based belief. D) A holistically based belief.
D) A holistically based belief.
Proper hand washing technique requires that a nurse wash for at least A) 1 minute. B) 30 seconds. C) 45 seconds. D) 20 seconds.
D) 20 seconds.
When performing a patient assessment, a nurse correctly recognizes that subjective data include A) A patient's vital signs. B) A patient's unsteady gait. C) A patient's foul smelling wound. D) A patient's complaint of discomfort.
D) A patient's complaint of discomfort.
A mother, concerned that her toddler is not getting enough rest, asks a nurse what the average amount of sleep is for a 4 year old. The nurse replies: A) "A 4 year old should sleep 16 hours a day, including naps." B) "A 4 year old should sleep no more than 10 hours a day." C) "A 4 year old should sleep an average of 13 to 14 hours a day." D) "A 4 year old should sleep approximately 12 hours a day."
D) "A 4 year old should sleep approximately 12 hours a day."
A nursing instructor is teaching a student nurse about the best methods to use when teaching an auditory learner. The student nurse demonstrates understanding when stating: A) "An auditory learner learns best by doing." B) "An auditory learner learns best by seeing." C) "An auditory learner learns best by reading." D) "An auditory learner learns best by listening."
D) "An auditory learner learns best by listening."
A student nurse was overheard talking about maintaining a safe and clean environment. A nurse realizes that the student has a strong understanding when the student says: A) "It is not necessary to disinfect equipment unless it comes in direct contact with the patient." B) "It is housekeeping's job to empty the bedside commode." C) "Disinfection will eliminate all viruses and spore forming bacteria." D) "Even though that blood has dried, some viruses may still be present."
D) "Even though that blood has dried, some viruses may still be present."
A nurse discovers a patient lying on the floor. When completing an incident report, the nurse should write: A) "Patient fell out of bed onto the floor." B) "Heard patient fall from the bed to the floor." C) "Patient accidentally fell out of bed onto the floor." D) "Found patient lying facedown on the floor beside the bed."
D) "Found patient lying facedown on the floor beside the bed."
While listening to a patient's apical pulse, a nurse identifies that it is difficult to hear both heart sounds. This would be charted as: A) "Heart tones are distinct." B) "Heart tones are strong." C) "Heart tones are absent." D) "Heart tones are muffled."
D) "Heart tones are muffled."
The family of a terminally ill patient asks the nurse what they should expect when she dies. The nurse tells the family: A) "Her heart will stop, and she will stop breathing a few minutes later." B) "Respirations and heart rate first become very irregular and then stop altogether." C) "Everybody is different, so it is difficult to say." D) "Her breathing will stop, and her heart will cease beating within a few minutes."
D) "Her breathing will stop, and her heart will cease beating within a few minutes."
A patient in spiritual distress asks a nurse what he thinks about religion. Which of the following replies would be appropriate and therapeutic? A) "Religion is not for everyone. Whether you go to church or not does not affect your health, so don't worry so much about it." B) "We all worry from time to time about whether our beliefs are based on truth or not, so it's normal to worry some." C) "An individual's feelings about religion are personal. I cannot divulge personal information about myself." D) "I find comfort in my religious beliefs. Is there a member of the clergy with whom you would like to visit?"
D) "I find comfort in my religious beliefs. Is there a member of the clergy with whom you would like to visit?"
A nurse teaches a patient about eating combinations of incomplete proteins to provide the body with all nine amino acids that are needed for complete protein synthesis. The patient demonstrates understanding by stating: A) "I will combine eggs and milk." B) "I will combine bacon and eggs." C) "I will combine fish and soy products." D) "I will combine red beans and brown rice."
D) "I will combine red beans and brown rice."
A nurse teaches a patient about the importance of consuming more complex carbohydrates. The patient demonstrates understanding by stating: A) "I will consume more fruit." B) "I will consume more milk." C) "I will consume more syrup." D) "I will consume more pasta."
D) "I will consume more pasta."
A nurse teaches a student nurse about what type of occurrence requires completion of an incident report. The nurse recognizes that additional instruction is warranted when the student nurse states: A) "If my patient falls out of a chair, I will complete an incident report." B) "If I give the wrong medication to my patient, I will complete an incident report." C) "If a visitor is injured while seeing my patient, I will complete an incident report." D) "If my patient refuses to cooperate with physical therapy, I will complete an incident report."
D) "If my patient refuses to cooperate with physical therapy, I will complete an incident report."
A nurse wakes the patient for a focused assessment. The patient, trying to rest, tells the nurse, "I wish you would quit waking me up. Do you really need to keep bothering me?" The nurse appropriately responds: A) "Most patients would love to get the attention that you are getting." B) "I understand your frustration, but this has been ordered by your physician." C) "It is necessary that I do a head to toe assessment from which I can determine whether there are any changes in your condition." D) "It is important to assess your blood pressure and pulse since we just started your new blood pressure medicine."
D) "It is important to assess your blood pressure and pulse since we just started your new blood pressure medicine."
A nurse is educating a student nurse about the responsibilities of a student nurse. The nurse recognizes that additional teaching is needed when the student nurse states: A) "I will check laboratory results for my patients often." B) "I am responsible for noting abnormal assessment findings." C) "I will frequently check the patient's chart for diagnostic test results." D) "It is not within my scope of practice to notify someone of abnormal findings."
D) "It is not within my scope of practice to notify someone of abnormal findings."
An 8 year old patient has a new cast for a hairline fracture of the radius. The child asks a nurse, "How long do I have to wear this?" The nurse's best response would be: A) "It depends how fast your bones grow back together." B) "The doctor will be able to tell you all about it before you leave." C) "Don't worry. Before you know it, you'll be playing soccer again." D) "Most broken bones take at least 4 weeks to heal all the way."
D) "Most broken bones take at least 4 weeks to heal all the way."
Following a nurse's explanation of why a warm pack should be applied to an infected hang nail, a patient demonstrates understanding by stating: A) "Heat to the area causes the blood vessels to constrict, concentrating the white blood cells needed to fight infection." B) "If I apply moist heat to the area, it will decrease the metabolism of the germs that are trying to multiply." C) "Applying heat will decrease the blood flow and as a result will increase my body's ability to fight infection." D) "My body's ability to fight off infection will be enhanced by allowing more white blood cells to get to the wound."
D) "My body's ability to fight off infection will be enhanced by allowing more white blood cells to get to the wound."
A student nurse is caring for a patient who is on a clear liquid diet. The best example of nursing documentation related to this patient is: A) "Average intake of clear liquid diet noted." B) "Patient tolerates the clear liquid diet well." C) "Patient swallowing clear liquids normally." D) "No complaints of nausea while on clear liquid diet."
D) "No complaints of nausea while on clear liquid diet."
A nursing instructor is teaching a class about safety precautions that must be taken in the presence of gasses. The teacher realizes that additional clarification is needed when a student says: A) "Static electricity can cause a spark that can ignite a fire or cause an explosion." B) "Sheets and gowns saturated in oxygen will burn very rapidly." C) "No smoking or open flame are allowed in the presence of oxygen." D) "Oxygen is explosive."
D) "Oxygen is explosive."
A nurse is caring for a patient who is newly diagnosed with diabetes mellitus type B. The patient cares for a spouse at home who also has diabetes mellitus type B. When formulating a nursing diagnosis for this patient, the nurse selects A) "Deficient knowledge." B) "Diabetes knowledge deficit." C) "Risk for deficient knowledge." D) "Readiness for enhanced knowledge."
D) "Readiness for enhanced knowledge."
An instructor is teaching students about caring for a patient diagnosed with Clostridium difficile. The instructor identifies that further teaching is required when a student says: A) "I should wear gloves while treating this type of patient." B) "I should wash my hands with alcohol based hand gel after treating the patient." C) "Clostridium difficile is an example of a multiple drug resistant organism."
D) "Visitors should put on gowns, gloves, and perhaps masks before entering the room." B) "I should wash my hands with alcohol based hand gel after treating the patient."
A nurse realizes that a terminally ill patient is ready to talk about dying when he or she states: A) "I'm feeling a little stronger each day." B) "Do you think you could just sit with me for a while?" C) "I've decided to begin taking chemotherapy again." D) "What do you think death feels like?"
D) "What do you think death feels like?"
A student nurse is instructing a patient restricted to partial weight bearing on the safe use of crutches. A nurse intervenes when she hears the student say: A) "If the knee is flexed and the foot is held behind the crutches, it can affect your balance, causing you to fall backward." B) "Since you are able to bear partial weight on the affected limb, you should use a two point gait." C) "Bearing weight on the axilla can cause compression of nerves and can lead to nerve damage affecting the arm and hand." D) "When walking upstairs on crutches, you should place the affected leg on the step, then move up the crutches and the unaffected leg."
D) "When walking upstairs on crutches, you should place the affected leg on the step, then move up the crutches and the unaffected leg."
A nurse will verify that a 33 year old patient's heat application is set at ____ to prevent the threat of tissue injury. A) 85°F B) 90°F C) 100°F D) 105°F
D) 105°F
After taking a patient's vital signs, a nurse removes the blankets used to cover the patient because the patient's temperature was A) 100°F axillary. B) 97.8°F rectal. C) 99.1°F tympanic. D) 10B.6°F oral.
D) 10B.6°F oral.
An emergency department nurse admits an adult patient for a drug overdose. The physician writes an order for the nurse to instill charcoal through a nasogastric (NG) tube. When selecting the NG tube, the nurse should choose a size A) 4 French. B) 8 French. C) 12 French. D) 16 French.
D) 16 French.
What can occur if you have the wrong cuff size?
false reading
A student nurse would properly contact and advise the supervisory staff nurse if A) A patient demands to be moved to a different room but will not say why. B) A physically larger patient for whom the student nurse is providing ambulation therapy has trouble getting back into bed and the student is unable to get him into bed herself. C) A patient seems to be trying to communicate something urgent but cannot do so because of a language barrier. D) A patient's condition seems worse than at the staff nurse's last assessment.
D) A patient's condition seems worse than at the staff nurse's last assessment.
When conducting an admission assessment, the nurse correctly recognizes that objective data include A) A patient's family history. B) A patient's complaint of pain. C) A patient's description of anxiety. D) A patient's fruity smelling breath.
D) A patient's fruity smelling breath.
A nurse recognizes that the process in which nutrients are taken into the gastrointestinal (GI) tract is called A) Digestion. B) Peristalsis. C) Indigestion. D) Absorption.
D) Absorption.
When a nurse educates a patient about his medications, the patient tells the nurse that he should go back to nursing school because he does not know very much about medications. The style of communication that the patient is demonstrating is A) Passive. B) Avoidant. C) Assertive. D) Aggressive.
D) Aggressive.
A nurse demonstrates an understanding of how to evaluate what he or she has taught a patient when A) Having the patient restate what has been taught. B) Asking the patient to give a return demonstration of a new task. C) Asking questions to determine understanding. D) All of the above.
D) All of the above.
A patient taking the blood thinner warfarin tells a nurse that he regularly takes herbal supplements along with his vitamins. The nurse cautions the patient about the possible negative interactions of warfarin with A) Saint John's wort. B) Feverfew. C) Echinacea. D) All of the above.
D) All of the above.
A terminally ill patient asks a nurse to promise him that all of his symptoms and discomfort will be effectively managed until his death. The nurse promises the patient with confidence that A) Pain can be relieved. B) Nausea can be managed. C) Respiratory distress can be eliminated. D) All of the above.
D) All of the above.
After several weeks alone, a patient on transmission based precautions is feeling secluded. The nurse can help alleviate these feelings by A) Offering to bring the patient a newspaper or magazine. B) Spending some time talking with the patient while in the room. C) Remembering that patients are people first, and that their diagnoses are secondary. D) All of the above.
D) All of the above.
An instructor explains that patients may need a nurse's assistance to help cope with the stress of hospitalization. The nurse validates understanding by A) Using appropriate humor therapy. B) Providing a back massage and other comfort measures to help the patient relax. C) Explaining what the patient should expect before performing a procedure or treatment. D) All of the above.
D) All of the above.
For nurses to be able to give care to patients, they must quickly establish a trusting relationship with them. Nurses can establish a trusting relationship with their patients by A) Conveying that they are confident and competent when providing care. B) Communicating that they are approachable and ready to listen. C) Communicating empathy to their patients. D) All of the above.
D) All of the above.
When working in a health clinic, a nurse recognizes that a communicable disease that should be reported to the health department is A) Hepatitis. B) Rubella. C) Tuberculosis. D) All of the above.
D) All of the above.
While providing oral care for patients, a nurse should assess the mouth for A) Decaying, broken, or missing teeth. B) Ulcerations of the mucosa. C) Leukoplakia. D) All of the above.
D) All of the above.
A patient begins to fall during ambulation. The nurse should A) Hold the patient upright. B) Keep his or her back bent while lowering the patient. C) Keep his or her knees straight while lowering the patient. D) Allow the patient to slide down his or her leg to the floor.
D) Allow the patient to slide down his or her leg to the floor.
While supervising a certified nursing student who is positioning a patient in bed, a nurse intervenes when observing the student A) Locking the wheels on the bed. B) Elevating the bed to a comfortable working height. C) Changing a patient's position at least every 2 hours. D) Allowing a patient's arm to dangle over the side of the bed.
D) Allowing a patient's arm to dangle over the side of the bed.
A nursing student is asked to identify the difference between a nasogastric (NG) tube and a nasointestinal (NI) tube. The student correctly identifies that A) Only an NI tube is inserted through the nose. B) An NG tube is inserted through the stomach and into the duodenum. C) An NI tube is shorter than an NG tube. D) An NI tube is smaller in bore size and more flexible than an NG tube.
D) An NI tube is smaller in bore size and more flexible than an NG tube.
A nurse performing an assessment would correctly identify that a patient has a greater chance of contracting health care facility acquired pneumonia if he has A) Difficulty swallowing. B) An existing respiratory disease. C) Poor oral hygiene. D) Any of the above.
D) Any of the above.
An elderly patient with hip pain tells a nurse that continuous heat has been the most effective means of relieving pain. After confirming that the patient has an order for heat therapy, the nurse correctly selects which method for the patient? A) Hot water bottle B) Warming blanket C) Heating pad D) Aquathermia K pad
D) Aquathermia K pad
The nurse charts that the patient is eupneic. This finding indicates that respirations A) Require the use of costal, sternal, and subclavicular muscles. B) Are very shallow and at a rate between 8 and 12 per minute. C) Are between 20 and 24 per minute and that the patient is using his thoracic muscles. D) Are considered to be normal in depth and rate with use of the abdominal muscles.
D) Are considered to be normal in depth and rate with use of the abdominal muscles.
A pregnant nurse is assigned to a patient undergoing internal radiation therapy for thyroid cancer. As a precaution, the nurse should A) Wear a film badge. B) Limit her amount of time around the patient. C) Wear a lead apron when near the patient. D) Request an alternative assignment.
D) Request an alternative assignment.
A nurse is caring for a patient who requires preoperative teaching and who does not speak the same language as the nurse. The nurse best demonstrates a caring demeanor by A) Speaking more slowly to the patient. B) Facing the patient when speaking to him or her. C) Providing the patient with written communication. D) Arranging for an interpreter or translator to be present.
D) Arranging for an interpreter or translator to be present.
While a nurse is trying to complete the morning care for a female patient, she tells the nurse that she does not want anyone else in the room while her spiritual advisor is visiting. The nurse will A) Assure the patient that once her bath is done, she may see her spiritual advisor. B) Suggest that she ask her spiritual advisor to visit later because there are several more patients who need to be cared for as well. C) Tell the patient that he or she will leave the room if the spiritual advisor visits. D) Ask the patient when the spiritual advisor plans to visit and schedule her care around it.
D) Ask the patient when the spiritual advisor plans to visit and schedule her care around it.
During the admission procedure, a patient informs a nurse that he is a Sikh and must keep his head covered at all times. He normally wears a turban. The other patient in the double room he has been assigned to is recovering from detoxification and has had episodes where he's used racial slurs. In processing the patient's admission, which of the following should the nurse do? A) Make a note on the patient's record that a curtain should be kept drawn between the two patients at all times so the verbally abusive patient cannot see the new patient and make offensive remarks based on his appearance. B) Assume that the patient will be fine because Sikh men pride themselves on their strength. C) Inform the patient of the situation and ask if he is comfortable being in the same room with the abusive patient. D) Ask to have the patient assigned to a different room, without an abusive roommate.
D) Ask to have the patient assigned to a different room, without an abusive roommate
A nursing instructor is teaching students the importance of individualized nursing interventions. The instructor recognizes that a student nurse understands when he or she A) Encourages a patient to increase fluid intake. B) Assesses a patient for signs and symptoms of dehydration. C) Records a patient's fluid intake and output. D) Asks a patient which type of fluid he or she would like to drink.
D) Asks a patient which type of fluid he or she would like to drink.
While performing a focused assessment, a nurse listens to a patient's heart and lung sounds. This is an example of an assessment technique called A) Palpation. B) Inspection. C) Percussion. D) Auscultation.
D) Auscultation.
A patient dying of colon cancer tells a nurse that he is sure that he can beat the cancer if he changes his eating habits. The nurse understands that the patient is likely in the stage defined by Kübler Ross as A) Acceptance. B) Anger. C) Denial. D) Bargaining.
D) Bargaining.
Immediately after a patient's death, a nurse performs postmortem care. Correct care would include A) Insisting that the family bathe the patient so they can begin the grieving process. B) Documenting the time when the patient stopped breathing and the heart ceased. C) Notifying the physician so that the patient will be legally pronounced dead. D) Bathing the body and removing all tubes, unless an autopsy might be ordered.
D) Bathing the body and removing all tubes, unless an autopsy might be ordered.
A nurse is caring for a patient from Germany. The nurse must keep in mind to respect the comfort levels of people from different cultures regarding A) Touch. B) Body position. C) Personal space. D) Both 1. and 3.
D) Both 1. and 3.
A nurse is caring for a patient who is having trouble communicating because of involuntary muscle movements. The nurse suspects the condition may be caused by a problem or malfunction in the patient's A) Left frontal lobe. B) Occipital lobe. C) Left parietal lobe. D) Cerebral cortex.
D) Cerebral cortex.
A physician has ordered an aquathermia pad to treat a patient's deep vein thrombosis (DVT) in the lower legs. Before applying heat therapy, a nurse should assess the patient for A) Apical pulse. B) Respiration. C) Anorexia. D) Cognitive level of function and orientation.
D) Cognitive level of function and orientation.
A nurse recognizes that a therapy used along with conventional treatment is A) Physical therapy. B) Alternative therapy. C) Conventional therapy. D) Complementary therapy.
D) Complementary therapy.
A patient lies in a special type of bed frame that allows the entire bed to turn from side to side. The mattress is low air loss and the bed can be programmed to turn by degrees at set intervals. The nurse explains to the patient that this is a type of specialty bed called a A) Specialized mattress. B) Mattress overlay. C) Combination bed. D) Continuous lateral rotation bed.
D) Continuous lateral rotation bed.
A patient seeks a vigorous, strenuous massage with focused pressure applied to tightened muscle areas and trigger points. This type of massage is called A) Shiatsu. B) Swedish. C) Reflexology. D) Deep tissue.
D) Deep tissue.
A nurse recognizes that the increase in complexity of skills performed by a person is called A) Growth. B) Regression. C) Ambivalence. D) Development.
D) Development.
A nurse delegates early morning care to a certified nursing assistant (CNA). The nurse intervenes when observing the CNA A) Shaving a patient with an electric razor. B) Assisting a patient on bedrest with the bedpan. C) Brushing a patient's hair. D) Dimming the lights.
D) Dimming the lights.
While documenting in a patient's chart, a nurse recognizes that A) Documentation serves as a temporary part of the medical record. B) Documentation is one of the least important tasks performed in nursing. C) Documentation is the act of charting only abnormal information related to a patient. D) Documentation is evidence of what transpired during an event requiring medical care.
D) Documentation is evidence of what transpired during an event requiring medical care.
A nurse takes a tympanic temperature in a 2 year old patient by pulling the pinna A) Upward and back. B) Upward and forward. C) Downward and forward. D) Downward and back.
D) Downward and back.
A nurse is caring for a patient who requires assistance with feeding. The nurse delegates this task to the certified nursing assistant (CNA). This type of communication is called A) Upward. B) Bilateral. C) Horizontal. D) Downward.
D) Downward.
A nurse is caring for a female patient who has been hospitalized for a right sided cerebrovascular accident (CVA). The patient is impulsive and confused. She has weakness on the left side of her body and requires assistance when ambulating. The nurse's highest priority when caring for this patient is A) Range of motion exercises. B) Performing a calorie count. C) Ordering a social service consult. D) Ensuring that the bed alarm is turned on.
D) Ensuring that the bed alarm is turned on.
A nurse provides care that is unique to a patient's race. The nurse is taking into account the patient's A) Acculturation. B) Ethnocentrism. C) Diversity. D) Ethnicity.
D) Ethnicity.
A nurse admits a patient and selects the priority nursing diagnosis of acute pain. The nurse plans to administer pain medication as needed. When the patient complains of pain, the nurse medicates the patient. Next, the nurse should A) Assess the patient's laboratory values. B) Create a new nursing diagnosis. C) Administer an additional dose of medication. D) Evaluate the effects of the medication.
D) Evaluate the effects of the medication.
It is important for a nurse to understand that the American family of a dying Hindu patient may A) Expect the nurse to prepare the body for burial. B) Use amulets to ward off evil spirits lingering after death. C) Get comfort from visiting with a psychiatrist or psychologist. D) Exhibit grieving by thinking only happy thoughts about their loved one.
D) Exhibit grieving by thinking only happy thoughts about their loved one.
A nurse instructor explains that health care professionals should assess their patients' abilities to comprehend and understand basic health care information, and use that information to make good decisions about their health. This type of assessment is known as A) High level wellness assessment. B) The wellness illness continuum. C) Fitzpatrick's rhythm model. D) Health literacy.
D) Health literacy.
A nurse, preparing to auscultate breath sounds, correctly positions the patient in the most favorable position, which is A) Supine position. B) Low Fowler position. C) Semi Fowler position. D) High Fowler position.
D) High Fowler position.
A member of the hospital maintenance staff is mopping when patients begin to complain about watery eyes and irritated throats. Once the worker's mop bucket is identified as the source of the irritation, a nurse should A) Evacuate the affected area immediately. B) Notify the Centers for Disease Control and Prevention (CDC). C) Treat the patients with medication for chemical exposure. D) Identify the chemicals and consult the material safety data sheets (MSDSs).
D) Identify the chemicals and consult the material safety data sheets (MSDSs).
A nurse is caring for a patient who has a broken leg. When the patient complains of pain, the nurse administers additional pain medication. When the nurse medicates the patient, he or she is performing a step in the nursing process that is called A) Planning. B) Evaluation. C) Assessment. D) Implementation.
D) Implementation.
A nurse is caring for a patient who is newly diagnosed with chronic obstructive pulmonary disease (COPD). The patient cares for a spouse at home who also has COPD. When formulating a nursing diagnosis for this patient, the nurse selects "Readiness for enhanced knowledge." When the nurse sits down with the patient and presents the information included in his or her teaching plan, the nurse is performing the step in the nursing process called A) Planning. B) Evaluation. C) Assessment. D) Implementation.
D) Implementation.
A nurse closely monitors a patient with a head injury. Upon assessment of vital signs, the nurse notes changes indicative of increased intracranial pressure caused by brain swelling. Which changes depict increased intracranial pressure? A) Decreased temperature and decreased blood pressure B) Increased blood pressure, increased temperature, increased respirations, and increased pulse rate C) Decreased blood pressure, increased pulse rate, and increased respiratory rate D) Increased blood pressure, decreased respiratory rate, and decreased pulse rate
D) Increased blood pressure, decreased respiratory rate, and decreased pulse rate
A physician writes an order for a nurse to insert a nasogastric (NG) tube for gastric decompression. When inserting the NG tube, the nurse should A) Force the tube toward the nasopharynx. B) Instruct the patient to avoid swallowing while inserting the tube. C) Push the tip of the tube upward against the top side of the nasal passage. D) Instruct the patient to hyperextend his or her head slightly and then gently insert the tube into the intended naris.
D) Instruct the patient to hyperextend his or her head slightly and then gently insert the tube into the intended naris.
A nurse is caring for a patient who has a history of falls. The nurse would intervene if he or she observed the certified nursing assistant (CNA) A) Placing the patient in a wheelchair near the nurses' station. B) Standing next to the patient while he or she bathes in the bathroom. C) Placing the patient in a room that is visible from the nurses' station. D) Instructing the patient to put his or her call light on when finished using the commode.
D) Instructing the patient to put his or her call light on when finished using the commode.
When asked why pain is considered the sixth vital sign, a nurse explains to a patient that pain A) Indicates the prescribed pain medication is not sufficient. B) Is thought to be at the root of all changes in vital signs. C) Increases the blood pressure to dangerous levels. D) Is a baseline that allows measurement of slight changes.
D) Is a baseline that allows measurement of slight changes.
A nurse educator explains to student nurses Fitzpatrick's rhythm model theory. According to this theory, a patient's health A) Is only a state of mind over matter and is controlled by the patient. B) Is always changing and fluctuates throughout four wellness quadrants. C) Defines how well the individual promotes his or her physical well being. D) Is the result of the interaction between an individual and the environment.
D) Is the result of the interaction between an individual and the environment.
When interacting with patients, a nurse demonstrates a willingness to communicate by A) Standing over seated patients. B) Slumping while talking to patients. C) Folding arms while talking to patients. D) Leaning slightly forward toward patients.
D) Leaning slightly forward toward patients.
A patient who underwent a carotid endarterectomy asks a nurse about care for his neck incision. The patient informs the nurse that he is an auditory learner. The nurse determines that the patient will learn best by A) Watching while the nurse performs incision care. B) Reading a pamphlet about how to perform incision care. C) Opening the dressing and applying ointment to the incision. D) Listening to the nurse's verbal instructions about care of the incision.
D) Listening to the nurse's verbal instructions about care of the incision.
While supervising a student nurse who is caring for a patient on bedrest, a nurse intervenes when observing the student A) Using mild soaps for cleansing the skin. B) Repositioning in bed at 2 hour intervals. C) Offering the patient high protein snacks. D) Massaging directly on reddened bony prominences.
D) Massaging directly on reddened bony prominences.
An infant is brought into a medical center and diagnosed with measles, a communicable disease. The correct course of action in this situation would be to A) Refer the patient to a rehabilitation facility. B) Notify the local police department. C) Prepare the patient for hospice care. D) Notify the health department.
D) Notify the health department.
A charge nurse supervises an unlicensed assistive personnel (UAP) providing care to a patient at risk for falls who repeatedly attempts to get out of bed without assistance. The charge nurse intervenes when observing the UAP A) Placing the patient's mattress on the floor. B) Having the patient fold washcloths and towels. C) Having the patient sit in a rocking chair near the nurses' station. D) Offering infrequent opportunities for the patient to go to the bathroom.
D) Offering infrequent opportunities for the patient to go to the bathroom.
A student nurse is caring for a patient who is covered by Medicaid. When speaking with the case manager about Medicaid, the case manager tells the student nurse that Medicaid A) Offers the same benefits in every state. B) Is funded by the city health department. C) Is a county government matching funding program. D) Offers assistance for poor and medically indigent individuals.
D) Offers assistance for poor and medically indigent individuals.
The nurse correctly recognizes that separation anxiety is particularly common in children and A) Adolescents. B) Young adults. C) Middle aged individuals. D) Older adults.
D) Older adults.
A nurse is assisting with a thoracentesis. In preparation, the nurse should position the patient in the A) Semi Fowler position. B) Supine position. C) Side lying position. D) Orthopneic position.
D) Orthopneic position.
At a health fair, a nurse explains to a participant, who is complaining of nagging pain, that it is important to report the pain to the primary care physician rather than ignoring it because A) The physician may have to order a potent analgesic. B) Being stoic is not a trait that many nurses and physicians respect. C) Pain will interfere with the gate, according to gate control theory. D) Pain could be an indication that tissue damage has occurred.
D) Pain could be an indication that tissue damage has occurred.
A nurse assesses a patient's skin after an ice bag has been applied. Which of the following findings would indicate that the ice bag is too cold? A) Pink, cool skin B) Warm, red skin C) Cool, scaly skin D) Pale, mottled skin
D) Pale, mottled skin
A patient who requires long term feeding has a surgical endoscopic placement of a feeding tube in the stomach. A nurse correctly identifies this as a A) Jejunostomy tube (J tube). B) Nasogastric (NG) tube. C) Nasointestinal (NI) tube. D) Percutaneous endoscopic gastrostomy (PEG) tube.
D) Percutaneous endoscopic gastrostomy (PEG) tube.
A certified nursing assistant (CNA) is assisting a patient with bathing. A charge nurse intervenes when the CNA A) Helps the patient with bathing as needed. B) Stays nearby while the patient bathes. C) Observes how the patient tolerates the activity of bathing. D) Places a pan of water with soap in front of the patient and disappears.
D) Places a pan of water with soap in front of the patient and disappears.
A male patient with severe chronic obstructive pulmonary disease (COPD) was brought to the hospital by emergency personnel. He lives alone, has no relatives or friends living nearby, and lives on a fixed income, which prevents him from purchasing all of the medications that he needs. Based on Dunn's wellness grid, a nurse determines that the patient's quadrant is A) High level wellness in a favorable environment. B) Emergent high level wellness in an unfavorable environment. C) Protected poor health in a favorable environment. D) Poor health in an unfavorable environment.
D) Poor health in an unfavorable environment.
A nurse is caring for a patient who has been attending a local university to earn a law degree. The patient states, "I want to earn my degree so that I can fight for justice and human rights for people throughout the world." The nurse recognizes that the patient is in which stage of Lawrence Kohlberg's moral development theory? A) Conventional morality B) Preoperational morality C) Preconventional morality D) Postconventional morality
D) Postconventional morality
A nurse is unable to palpate a patient's dorsalis pedis pulse. The nurse will next attempt to palpate the A) Brachial pulse. B) Carotid pulse. C) Femoral pulse. D) Posterior tibialis.
D) Posterior tibialis.
A nurse recognizes that the type of development that occurs throughout one's life in distinct stages, each stage requiring that specific tasks must be mastered, is called A) Moral development. B) Physical development. C) Cognitive development. D) Psychosocial development.
D) Psychosocial development.
Nurses who are comfortable in their religious beliefs are more likely to understand the importance of good spiritual health in patients because they know A) Religious beliefs determine patients' concepts of good health practices. B) Patients who practice religion do not suffer spiritual distress. C) Patients with strong belief systems do not suffer long term illnesses. D) Religious beliefs give individuals hope and motivate them toward a better outcome.
D) Religious beliefs give individuals hope and motivate them toward a better outcome.
A nurse is working on a nursing unit when an electrical fire starts. The nurse should first A) Sound the fire alarm. B) Obtain a fire extinguisher. C) Confine the fire to one area. D) Remove patients from immediate danger.
D) Remove patients from immediate danger.
When positioning a patient to listen to breath sounds, the nurse is correctly aware that which of the following lobes can only be heard by anterior or lateral auscultation? Select all that apply. A) Left upper lobe B) Left lower lobe C) Right upper lobe D) Right middle lobe E) Right lower lobe
D) Right middle lobe
A patient has been placed on a feeding tube. To prevent aspiration, a nurse should place the patient's bed in the A) Flat position. B) Fowler position. C) Trendelenburg position. D) Semi Fowler position.
D) Semi Fowler position.
A 52 year old Chinese American patient is admitted to hospice care because of terminal cancer. The nurse understands that this patient may hold that pain A) Is better expressed by moaning than by complaining in words. B) Should be verbalized instead of communicated by grimacing. C) Does not need to be endured, so pain medication should be asked for when needed. D) Should be suffered in silence, without verbal complaints or other expressions of discomfort.
D) Should be suffered in silence, without verbal complaints or other expressions of discomfort.
When interacting with a physician, a nurse recognizes that the personal space distance zone that he or she is in when standing within 5 feet of the physician is A) Public. B) Intimate. C) Casual personal. D) Social consultative.
D) Social consultative.
During auscultation, the nurse hears fine rales in the patient's lower lobes bilaterally. Fine rales are described as A) Noisy, snoring sounds during respirations. B) Musical or whistling sounds with respirations. C) A sonorous wheeze upon inspiration. D) Sounding like hair being rubbed between the thumb and index fingers.
D) Sounding like hair being rubbed between the thumb and index fingers.
A nurse doing an assessment would correctly summon a physician immediately if he detected the breath sounds known as A) Rales. B) Rhonchi. C) Wheezes. D) Stridor.
D) Stridor.
A patient calls the clinic complaining of a sore throat and congestion. He is not sure whether he should come to the clinic, wait to see if the symptoms resolve, or treat himself with over the counter products. This patient's phase of illness is the A) Dependency phase. B) Seeking help phase. C) Prodromal phase. D) Symptomatic phase.
D) Symptomatic phase.
While caring for a patient who is on a continuous passive motion machine (CPM) after a total knee replacement, a nurse notices that the patient is grimacing. Pain medication is not due for 2 hours, but the CPM machine is supposed to continue for another 20 minutes. The best action by the nurse is to A) Call the physician for additional pain medication. B) Encourage the patient to bear it for 20 minutes longer. C) Instruct the patient to tense and then relax his or her leg muscles. D) Teach the patient relaxation techniques.
D) Teach the patient relaxation techniques.
A terminally ill patient is refusing to take adequate pain medication. The patient expresses worry that the use of pain medication may result in addiction. A nurse should A) Express admiration for the patient's strength. B) Explain to the patient that morphine does not cause addiction. C) Place the medication in an intravenous (IV) drip. D) Teach the patient that addiction is not a concern during the terminal stages of illness.
D) Teach the patient that addiction is not a concern during the terminal stages of illness.
While supervising a home health care aide, a nurse intervenes when observing the home health care aide A) Braiding a patient's hair. B) Driving a patient to a medical appointment. C) Giving a patient a bed bath. D) Teaching a patient about nutrition.
D) Teaching a patient about nutrition.
A patient who is admitted for observation following an episode of chest pain relieved by rest and two nitroglycerin tablets tells a nurse that his job as CEO of a large firm is becoming too much to handle. According to Selye, the nurse suspects that the patient most likely is experiencing A) An interaction between the individual and the environment. B) Protected poor health in a favorable environment. C) The seeking help phase of illness. D) The exhaustion phase of stress.
D) The exhaustion phase of stress.
The nurse takes additional time getting to know a patient admitted for surgery because A) The patient may not fully cooperate with the nurse otherwise. B) It is important that the nurse be prepared to answer any questions that the family may have about the patient. C) The nurse believes that a patient responds better if she and the patient are on a first name basis. D) The nurse believes that establishing rapport with a patient leads to a trusting nurse patient relationship.
D) The nurse believes that establishing rapport with a patient leads to a trusting nurse patient relationship.
When assessing a patient's pain, a nurse will note all of the following except A) The exact location of the pain. B) What causes the pain to become better or worse. C) The patient's desires for pain relief. D) The nurse's opinion of whether the patient is over reporting or underreporting the severity of the pain.
D) The nurse's opinion of whether the patient is over reporting or underreporting the severity of the pain.
A nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies as subjective data that A) The patient is short of breath. B) The patient has wound drainage. C) The patient has low blood pressure. D) The patient reports feelings of fatigue.
D) The patient reports feelings of fatigue.
While performing an admission history on a confused patient, a licensed practical nurse (LPN) assists the registered nurse (RN) by collecting secondary information about the patient. An example of secondary information would be that A) The patient reports a history of chest pain. B) The patient complains of chronic constipation. C) The patient verbalizes anxiety about hospitalization. D) The patient's spouse reports experiencing marital issues.
D) The patient's spouse reports experiencing marital issues.
A nurse explains to a patient that an instructional directive means A) A family member has been appointed as having power of attorney. B) A patient's wishes must be followed in the event of a major illness. C) There is a do not resuscitate (DNR) order for emergency personnel. D) There are written guidelines specifying care desired and under what circumstances
D) There are written guidelines specifying care desired and under what circumstances
New crutches are the correct size if A) The top of the crutch is 4 inches above the elbow. B) The patient's arms are at 90 degrees when holding the handles. C) The crutch tips are resting against the outer aspect of the patient's shoes. D) Three fingers fit between the axilla and the axillary pad of each crutch.
D) Three fingers fit between the axilla and the axillary pad of each crutch.
A nurse is caring for a male patient who is able to do very little or nothing for himself. The nurse identifies that this type of patient requires A) Self care. B) Assisted care. C) Supervised care. D) Total care.
D) Total care.
An older patient requires assistance with the removal of her new custom fit hearing aids. The first thing her nurse should do is A) Turn the earmold slightly toward the patient's nose and lift out. B) Check the battery by turning the hearing aid to full volume. C) Clean the screen or filter. D) Turn off the hearing aid.
D) Turn off the hearing aid.
Aware that continuing education is a must in providing a high standard of patient care, a nurse will enhance her practice by A) Taking a cooking class. B) Becoming computer literate. C) Studying the history of nursing. D) Using research to improve practice.
D) Using research to improve practice.
As a result of major surgery, a patient feels deep pain. The nurse correctly documents this pain as A) Cutaneous pain. B) Neuropathic pain. C) Deep somatic pain. D) Visceral pain.
D) Visceral pain.
A nurse explains micronutrients to a patient. The patient identifies that micronutrients include A) Amino acids. B) Water. C) Proteins. D) Vitamins.
D) Vitamins.
A nurse understands that a patient with a history of congestive heart failure has a low cardiac output resulting from A) An expected increase in stroke volume. B) A long history of pain and fatigue. C) The low blood volume that accompanies congestive heart failure. D) Weakened and damaged heart muscle.
D) Weakened and damaged heart muscle.
A patient with diabetes with irritable bowel syndrome (IBS) asks the nurse for a recommendation of a supplemental complementary and alternative (CAM) therapy that may help with her conditions. The nurse suggests A) Chiropractic. B) Acupuncture. C) Massage therapy. D) Yoga.
D) Yoga.
9. When the nurse educates a patient about his medications, the patient tells the nurse that she should go back to nursing school because she doesn't know very much about medications. The style of communication that the patient is demonstrating is A. Passive B. Avoidant C. Assertive D. Aggressive
D. Aggressive
14. The nurse is caring for a patient who requires assistance with feeding. The nurse delegates this task to the certified nursing assistant (CNA). This type of communication is called: A. Upward B. Bilateral C. Horizontal D. Downward
D. Downward
6. When interacting with patients, the nurse demonstrates a willingness to communicate when A. Standing over seated patients B. Slumping while talking to patients C. Folding arms while talking to patients D. Leaning slightly forward toward patients
D. Leaning slightly forward toward patients
4. When interacting with a physician, the nurse recognizes that the personal spacedistance zone that he/she is in when standing within 5 feet of the physician is A. Public B. Intimate C. Casual personal D. Social consultative
D. Social consultative
Ginko Biloba
Depression and memory (dementia)
Contact burns
Direct contact with a hot surface, such, as metals, vinyl, etc.
Priority hygiene practices
Dry skin folds Moisturized skin promote venous retour
Hypoxia S/S
Dyspnea Elevated blood pressure Increase respirations Increased pulse Pallor/pale skin Cyanosis/blue-tinged lips or oral cavity Anxiety Restlessness Confusion Drowsiness
A nurse must have the ability to intellectually, not emotionally, identify with or experience the feelings, thoughts, or attitudes of others. This is known as ____________________.
Empathy
Five qualities of therapeutic relationship
Empathy Respect Genuineness Concreteness Confrontation
NCLEX STYLE PRACTICE: A patient who is cognitively impaired is admitted to the hospital for pneumonia. The patient has a history of wandering at night. What should the nurse do to ensure the safety of this patient? *Encourage a family member to remain with the patient every night. *Obtain a sedative to be administered to the patient at bedtime. *Apply a vest restraint when the patient plans to go to sleep. *Activate the bed alarm on the patient's bed.
Encourage a family member to remain with the patient every night. - NO unrealistic to have family EVERY single night Obtain a sedative to be administered to the patient at bedtime. NO- it's a chemical restraint Apply a vest restraint when the patient plans to go to sleep. - NO, too restrictive; less restrictive method must be tried first Activate the bed alarm on the patient's bed. YES- Will alert the nurse
Oral hygiene principles
Encourage pt assist HOB (Head of bed) elevated Unconscious-suction NPO-Oral care q2hrs
How often do you assess the patient when they're in restraints?
Every 30 minutes
FLACC pain scale
F:face L:legs A:activity C:cry C:consolability
Nursing Interventions to achieve esteem
Facilitating visits from loved ones
What is the most reported incident in healthcare settings?
Falls
Social organization of the culture
Family composition or units (single-parent, extended family), and wider organizations (community, religion) that the individual or family identifies. • Close Social Organization Examples • Most common: Middle Eastern and Latinos the man is the dominant family member and the woman is the housemaker • Many African American household the female is the leader and decision maker (Matriarchal) Social Organization related to birth, death, illness, grieving & mourning • Patient who does not believe in the healthcare institutions will delay treatment and will use home remedies instead. Kinship and Social Ties • VIP care for famous celebrities compared to a poor individual or homeless.
Self determination
Feeling free to decide how to do your work
Food borne pathogenic causes
Food poisoning; eggs, fish, uncooked meats, poultry, raw fruits & vegetables, milk, etc
Bed Bath
For patients who must remain in bed but who are able to bathe themselves. - You will assist by placing the bath supplies on the bedside stand or overbed table.
Waste is excreted by the body & how?
GI tract (as feces) urinary system (as urine)
A nurse explains to a student that a patient's stomach contents will be removed by inserting a double lumen nasogastric (NG) tube through the nose into the stomach, then connecting the drainage lumen to a suction source. The student correctly identifies this procedure as ____________________.
Gastric Decompression
Non verbal cues for pain
Grimacing, guarding, and holding or touching the affected area
Kava
Herbal Antianxiety Agent and Depression
Health belief system
Individual perception of health
Culturally Competent Care
Initiative to provide care to everyone with the goal to eliminate any disparities in care. • Understanding the different cultural aspects that affect the care of the dominant cultural groups
Valerian (Herbal Product)
Insomnia
Urge incontinence
Involuntary loss of large amounts of urine accompanied by a strong urge to urinate.
Stress incontinence
Involuntary loss of urine associated with sneezing or laughing.
Cultures that refuse blood?
Jehovah witness
Chronic pain
Last 6 months or longer and interferes with activities of daily living.
Why incident reports?
Lessen future risks Medication errors Needle sticks Falls
Fall safety
Lighting Visualize patient Orient to enviornment 2 bed rails
Functional incontinence
Loss of urinary control related to immobility or external obstacles, or problems in thinking or communicating that prevent the client from reaching the bathroom.
Overflow incontinence
Loss of urine along with a distended bladder.
Unconscious incontinence
Loss of urine when the person does not realize the bladder is full and has no urge to urinate
Parenteral Nursing Care
Measure intake and output accurately Monitor weight dail Monitor calorie counts encourage additional fluid intake orally
Ethnicity
Member share a common social & cultural heritage (race, physical characteristics)
Esteem
Met when a person feels a sense of accomplishment and are recognized by others for that achievement.
SelfActualization
Met when the person reaches maximum potential and acts in an unselfish manner.
Priority safety for different age groups
Middle age drugs Adolescent suicide Elderly falls Infant Suffocation
Vector borne pathogenic causes
Mosquitoes = West Nile, Malaria; flies, fleas, ticks, cockroaches, rodents, bird droppings, mice, etc.
Shower
Most ambulatory patients prefer a shower. It is a time- saver and refreshing as well as cleansing.
Know delegation to other staff, like Nurse Assistants
No assessments, double check if they find a critical finding
Is silence a communication barrier?
No, Remaining attentive and waiting for the client to compose the next statement in the conversation enhances therapeutic communication.
What is the Joint Commission?
Non-profit organization that established the National Patient Safety Goals to ensure safety and quality care is provided to all patients. ii. Medication reconciliation, communication, National Patient Safety goals iii. Required for Medicare and Medicaid reimbursement
Resp Rate, Rhythm, and depth
Normal, deep, or shallow
Assist Bath
Nurse helps the patient with areas that may be difficult to reach
Who is at higher risk for fires at home?
Older adults & children < 5 y/o
Referred pain
Occurs in an area distant from the site of origin. Example: pain from a heart attack might be felt in the left arm or jaw.
Different methods temperature can be taken
Orally, Axillary Rectally Temporal Artery Tympanic
Deep Somatic pain
Originates from the ligaments, tendons, nerves, blood vessels and bones. Examples would be fractures or sprains.
Fire safety
Oxygen RACE PASS Smoke detectors Code Red
How to do pain assessment
PQRST - Pain rating scales 0-10 - reassess pain after interventions given to reduce pain (eg. Analgesia) have had time to work - Assessment of pain history
Things to know about pain assessment
PQRST If treatment works It's subjective
The distance or personal space that people place between themselves and others is called
PROXEMICS
Phantom pain
Pain that is perceived from an area that has been surgically or traumatically removed. Example: pain from an amputated limb.
who is the most reliable source of pain?
Patient
What does peripheral and central perfusion relate to?
Peripheral=peripheral tissue Central=major organs
NCLEX STYLE PRACTICE:Which is an important step when transferring a patient using a mechanical lift? • Position the chair as close as possible to the bed. • Remove the sling after the patient is moved to the chair. • Position the sling at the middle of the patient's back to the ankles. • Attach the longer belts to the lower grommets on each side of the sling.
Position the chair as close as possible to the bed. • It is not necessary to position the chair as close as possible to the patient's bed. Mechanical lifts are designed to move a patient completely across a room safely. Remove the sling after the patient is moved to the chair. • The sling remains under the patient after the transfer. It would be difficult or even impossible to remove and then reposition the sling if the patient were obese or immobile Position the sling at the middle of the patient's back to the ankles. • The sling should start at the shoulders and end at the knees. This completely supports the patient for the transfer. If it is too high, the patient could slide out from the bottom of the sling. If it is too low, the patient could slide out from the top of the sling. Attach the longer belts to the lower grommets on each side of the sling. • When the longer belts/chains are attached to the bottom of the sling and the shorter belts/chains are attached to the top of the sling, the patient will be raised to a sitting position when the lift raises the sling and the patient up and off the bed
Communicatio with patients with aphasia
Practice patience Speak clearly Closed ended questions
What are the phases of therapeutic relationships?
Pre-interaction Orientation Working phase Termination phase
Nursing Interventions to achieve safety and security
Prevent falls & Communicating concerns
Nursing Interventions to achieve self actualization
Provide art supplies
Culture Characteristics
Provide identity and sense of belonging • Consist of common beliefs & practices • Material (clothing, art) and non-material (language, beliefs) • Dynamic & adaptive • Complex • Diverse • Influences thinking and activities
Concreteness
Provide your answers in specific understandable terms.
Pulse
Pulse allows the nurse to assess the how adequate the heart is pumping the blood to the body
Meaning of RACE acronym
R : Rescue: • Remove clients from the general area A: Alert/Alarm: • Sound alarm C :Confine: • Contain fire (close doors and windows, make sure fire doors close) E : Extinguish fire
Nursing Interventions to achieve love & belonging
Referring a patient to a support group
Magico
Religious belief - "alternative or indigenous" (supernatural forces of healing, rituals)
Falls are the most?
Reported incidents
Confrontation
Request the client express his or her thoughts clearly so you can understand the meaning of the communication.
Techniques to promote/help therapeutic nurse patient relationships
Respect Individualized care Assertiveness
Genuineness
Respond honestly. If the answer is not known to you, do not guess. Tell the client you need assistance prior to answering the question.
Check backs
Restate what a person said to verify understanding by all team members.
Neuropathic pain
Results from an injury of one or more nerves where messages regarding pain are transmitted without a pain stimulus occurring.
Pain assessment before and after treatment
Scale of 0-10(0 being no pain 10 being the worst pain you have ever felt)
Maslow Hierarchy of needs
Self-Actulaization, Esteem, Safety & Security, Love & Belonging, & physiological
Physiological needs
are essential for maintenance of life
Never Events - Senital Events
Serious injuries or death to a patient that should have never happened in a hospital. (Ex. Air embolism, wrong transfusion, falls, and trauma or injuries) a. These mistakes may have been prevented with proper surveillance by the health care professionals involved in the event.
Ineffective communication is a major cause of medical errors. Hand off or ____________________ reporting has been identified as an area in patient care that is vulnerable to ineffective communication.
Shift to shift
Acute pain
Short duration, rapid onset, and associated with some kind of injury.
Call outs
Shout out important information (such as vital signs) for all team members to hear at one time
What does the acronym stand for (SBAR)?
Situation, Background, Assessment, Recommendation-Readback
Culture
Socially transmitted behaviors, arts, beliefs, values, customs, lifeways and other characteristics that guide decision making
Archetype
Something recurrent that makes beliefs that everyone has under the same racial or ethical group
Radiating pain
Starts at an origin but extends to other locations. Example: pain from a sore throat might extend to ears and head.
CUS words
State "I'm concerned; I'm uncomfortable; I don't feel like this is safe"
Two-challenge rule
State a concern twice as needed; if ignored, follow the chain of command to get the concern addressed.
Goldenseal
Stimulates immune system and bile secretion
Examples of Sentinel Events
Suicide Death during/after labor Wrong place surgery Surgical error Infant abduction in hospital Medication errors
Oral
Taking all nutritional intake by mouth
Enteral
Taking all nutritional intake through an MG tube, G-Tube, Peg Tube Jejunostomy tube
Parenteral
Taking nutrition through a centrally inserted IV line such as a PICC or central venous access device
what is the American Nurses Association (ANA) goal?
Their goal is to foster high-standards of the nursing practices, promoting a safe and ethical work environment, bolstering nursing health and wellness, and advocate for healthcare issues that affect the nurses and public.
Care that crosses cultural boundaries or combines the elements of more than one culture is known as ____________________ nursing.
Transcultural
Jehovah witness refuse
Transplants & blood transfusions Do NOT self donate blood
Incident reports (primary purpose)
Tries to prevent the problem from happening in the future. a. Used to analyze the event b. Identify areas of improvement c. formulate strategies to prevent future occurrences 2. Incident Report steps a. Define problem b. Collect data c. Identify possible causal factors d. Identify root causes e. Recommend and implement solutions
What is communication?
Two-way process of sending & receiving messages
Towel Bath
Type of bed bath in which you place a large towel and a bath blanket in a plastic bag, saturate them with a warmed, commercially prepared mixture, and use them to bathe the patient. - No need to towel-dry the patient due to solution drying quickly
Basin and Water Bath
Type of bed bath, you use a disposable basin with water; washcloths; lotion; and a pH-balanced, no-rinse soap or a chlorhexidine and water solution.
Safe patient transfer techniques
Use mechanical lift Nonslip shoes/socks Don't twist back Don't pull on neck
Warming food or formula
Using a microwave causes the food or formula to become hotter than intended. -Leads to infant and young children injuries
Perineal Care Principles
Wipe front to back Clean rag and water Away urethral meatus
Who do the Agency for Healthcare Research and Quality (AHRQ) work with?
With the HHS as a partner for evidence.
wheezing is generally caused by
a combination of bronchoconstriction, mucus plugging and edema of the bronchioles
Hypoxia is
a low oxygen level in the blood, which leads to symptoms that may affect the client's basic care and comfort needs.
What is assimilation?
a new member will learn and eventually take essential values, beliefs, and behaviors of the dominant culture gradually.
What does Maslow believe about the hierarchy of needs?
a person could not meet the needs of love and belonging and self-esteem without meeting basic physiological needs .
Using rails to restrict the patient's independence is considered
a restraint and can cause more harm. DO NOT use this method of restraint.
Healthcare Falls
a. Complete a comprehensive fall risk assessment. b. Keep the bed in the lowest position. c. Lock wheels on the bed and wheelchair if transferring the client. d. Place call light within reach. e. Keep floors dry and free of clutter. 3. Equipment related accidents a. Related to malfunction or improper use. b. Get familiar with the equipment before using it on the patient. c. Contact Biomed if the equipment is faulty and DO NOT use it
How to reduce the risk of UTI
a. 8-10 oz glasses of water a day b. Urinate when you feel like it c. Wipe from front to back d. Wear cotton underwear e. Urinate after sex f. avoid bubble baths g. report any symptoms promptly X. What can proper footwear prevent? a. Falls b. Foot problems like bunions or ingrown toenails
Pollution
a. Contact local agencies to inquire about proper disposal of paint, tires, etc. b. Use local public transportation to reduce air pollution.
What to know about peripheral vascular disease and Diabetes? (nail care)
a. Do not cut nails or put lotion on
Priority assessments (think ABC's, who would you see first)
a. A: Airway b. B: Breathing c. C: Cardiac
Recognize empathy by
a. Adapt to different styles, tone, vocabulary and behavior b. Place yourself in the patients situation c. Understand the needs (be sensitive)
Barriers of communication
a. Asking too many questions b. Offering advice c. Changing the subject d. Expressing approval or disapproval e. Providing false reassurance f. Stereotyping g. Using patronizing language
Communication with visual, hearing, speech and cognitive patients
a. Be positive and patient b. Provide forms of nonverbal communication c. Use gestures d. Use short sentences when communicating e. Be concrete and specific f. Call client by name g. Minimize environmental noise h. Face the client when speaking
What are the interventions of choking?
a. Inspect toys for small, removable parts. b. Do not attach pacifiers, rattles, or other infant toys to ribbons or strings. c. Do not use sweatshirts or jackets with neck tie strings. d. Position mobiles well above the crib, out of the infant's reach. e. Keep window blind cords out of the child's reach. f. Store plastic bags away from young children in a secure place. g. Ensure that the crib is designed to meet federal regulations: Crib slats must be less than 23⁄8 inches (6 cm) apart, and the mattress must fit snugly. h. When feeding children meat, cheese, or other firm foods, cut the food into very tiny pieces. Do not give a young child hard candy, chewing gum, nuts, popcorn, grapes, or marshmallows. Supervise children's balloon play, and dispose of burst balloons promptly.
Steps for fire safety in healthcare
a. Know where emergency equipment is located b. Know the types of extinguishers appropriate for different types of fires c. Know how to use a fire extinguisher d. Know the location of fire alarms and the procedure for calling in a fire alarm e. Know what to do to ensure the safety of clients in the immediate area of the fire f. Know the code name for "fire" in your facility's public address system
Motor Vehicle accidents
a. Leading cause of accidental death b. Not wearing seat belt
How do we prevent falls in healthcare facilities?
a. Lock the bed b. Safety locks on wheelchairs c. Apply nonskid slippers d. Keep water, urinal, bedpan, and tissues within easy reach of the patient. e. Place the call light within reach. Have the patient demonstrate the ability to call for the nurse. f. Provide a night light. g. Keep floors dry and free of clutter. h. For patients at risk for falls, place a warning sticker on the chart or door. i. Place patient in a room next to the nurse's station j. Stay with patient in bathroom k. Keep bed at lowest level l. Place overbed table across wheelchair m. Offer regular opportunities to toilet n. Provide back rubs and distractions
What are our assessment priorities if falls are unwitnessed? (ex. Patient hits head)
a. Neuro assessment
Best interventions with a client who has dementia
a. Orient client b. Observe closely c. Avoid cultivation of false ideas d. Discourage suspiciousness e. Use simple explanations f. Positive feedback when thinking and behavior is appropriate
Healthcare Biological hazards
a. Review the hospital policy and procedure regarding proper management of spills.
Storms
a. Seek shelter inside a building when there is a storm. b. Avoid riding/driving open vehicles such as bicycles or motorcycles. c. Do not seek shelter under a tree.
Healthcare Violence
a. Treat underlying medical conditions, i.e. anxiety. b. Use a calm approach. c. Do no wear anything that dangles around your neck. d. Do not go into a room alone with an angry patient. e. If there is an active shooter event, the best action is to leave the building.
Skin integrity (how to prevent pressure ulcers)
a. Turn every 2 hours b. keep area dry
Skin integrity (How to prevent shearing and friction)
a. Use a lift- don't use drawsheet
Would you promote self determination/autonomy?
a. Yes- independence
Know interventions if you have a patient falling and you are with them
a. accompany client during ambulation utilizing a transfer safety belt if he/she is weak or dizzy b. encourage client to request assistance whenever needed c. provide ambulatory aids (e.g. walker, cane) if client is weak or unsteady on feet d. Do not rush client e. instruct and assist client to rise and change positions slowly f. perform actions to increase strength and activity tolerance g.
Word of Wisdom (Mormon Culture)
advises healthful living and pro- hibits the use of tea, coffee, alcohol, and tobacco
Opened questions
a. specify a topic to be explored, but phrase it broadly to encourage the patient to elaborate
Closed ending questions
a. those that can be answered with a "yes," "no," or other short, factual answer.
A nurse recognizes that ____________________ medicine is the name used to describe traditional medicine, conventional medicine, or Western medicine.
allopathic
A nurse explains to young parents that adolescence is a time of conflict, and that wise parents expect older adolescents to pull away, to be somewhat critical of them, and to feel ____________________ toward them, or have opposing feelings about them.
ambivalent
What is acculturation?
an individual assumes the characteristics of a culture they just immigrated too
Stridor is generally caused by
an obstruction or narrowing of the upper airway resulting from infections, blockages, foreign bodies, or tracheal anomalies.
Sentinel Event
an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof within hospital
A terminally ill patient's respirations have become cyclic in nature, beginning with periods of shallow, slow breaths before becoming progressively deeper. A nurse expects that the respirations will become progressively shallower again, ending the cycle with 15 to 50 second periods of ____________________.
apnea
When asked by the family of an 86 year old terminally ill patient about treatment options, a nurse states, "Treatment options are more difficult with the elderly, as the choices are dependent on the patient's dependence on others, the terminal illness itself, and ____________________."
comorbidity
Tachycardia pulse rate
beats higher than 100/min
(Mormon) Nurses may remove garments
before surgery, but it must at all times be considered intensely private and be treated with respect
Orientation phase
begins when you meet the client and introduce yourself and role in the relationship ● Build rapport and trust
Personal space is
boundary lines that determine how close another person can come
Catholic End-of-Life indviduals may be
brought to hospitalized patients by a priest, deacon, or designated lay Eucharis- tic minister
Chamomile
calming and soothing properties.
NCLEX STYLE PRACTICE QUESTION:A health team member is using a type C fire extinguisher to put out a fire in a health
care facility. What kind of fire is the health team member attempting to extinguish because a type C fire extinguisher is the only extinguisher that should be used in this situation? • 1. Burning material in a garbage can • 2. Smoke from a rag in a maintenance closet • 3. Smoldering sparks from a patient's mattress • 4. Flames emanating from a toaster in a pantry- 1. Material in a garbage can usually is paper or textiles; these items are extinguished with a type A or type ABC fire extinguisher. 2. A maintenance closet commonly contains flammable liquids; flammable materials are extinguished with a type B or type ABC fire extinguisher. 3. A mattress consists of cloth covered in plastic; these materials are extinguished with a type A or type ABC fire extinguisher. • 4. A toaster is an electrical appliance; fire involving live electrical wires or equipment is extinguished with a type C or type ABC fire extinguisher.
Pulse points
carotid radial femoral popliteal posterior tibial dorsalis pedis arteries
Sleep patterns
circadian rhythm is a biorhythm based on the day- night pattern in a 24-hour cycle pattern that occurs everyday that the body is used to
types of patients who may have fluid restrictions
clients who have a problem with fluid volume excess such as chronic renal failure, heart failure, and SIADH
Echinacea
common cold; Reduce inflammation, control blood sugar, lowers BP
Termination phase
conclusion of the relationship ● Ex: end of shift; client is discharged
Enteral Nursing Care
confirm tube pplacement proper patient postion proper labeling monitor patient status
What are stereotypes?
considers everyone are the same (ex. Cultural practices, health treatments, illnesses) under their racial or ethnic group
Intake
consumed throughout the date. • Measured in mLs • Everything that is liquid • Solid food intake will be determined as percentage % • Example: Patient ate 55% of dinner
Chemical Agents
contact with acids, alkali and other organic compounds
Interventions for elevated/decreased vitals
continue to monitor patient recheck vitals
Most common cause of fires
cooking fires, smoking, heating equipment, and home oxygen administration equipment (75% of home fires involves oxygen, smoking materials are the ignition source)
Crepitus is a
crinkly, crackling or grating sound or feeling in the subcutaneous tissue. It can be an indication that free air has entered the tissue. Review signs and symptoms of hypoxia
Depth of respiration
deep, moderate, shallow
Bicultural
describes who identifies with two cultures and integrates some of the values and lifestyles of each into his life ○ Will use one more than the other during certain situations ○ May feel divided or may enjoy the best of both worlds Rest - the body being in a decreased state of activity. Sleep - a state of rest accompanied by an alteration of consciousness and inactivity.
Verbal cues for pain
describing quality -sharp, dull, aching, mild, constant
Nursing care for a client with incontinence
diet high in fiber eating fruits, vegetables, and whole grains drinking 8 to12 glasses of water each day unless medically contraindicated. Remind them to promptly toilet or void when the urge occurs
Barriers of communication will
discourage the client from sharing information openly with the nurse.
Inspiration
drawing air into the lungs (diaphragm contracts > lungs expand); Breathing in
When do falls frequently occur?
during night time, weekends and holidays
rhythm of respiration
even, regular
An instructor explains that rheumatoid arthritis is an example of a chronic illness. A nurse explains to a patient with rheumatoid arthritis that an increase or flare up in the severity of his or her symptoms is known as ____________________.
exacerbation
Sunburn
excess unprotected exposure to sun. Causes 1st & 2nd degree burns
expiration
expulsion of air from the lungs (diaphragm relaxes > lungs recoil); breathing out
Ginseng
fatigue, depression, antioxidant and anti-inflammatory effects
Feverfew
fevers, migraine headaches, rheumatoid arthritis, stomach aches, toothaches, insect bites, infertility, and problems with menstruation and labor during childbirth.
Safety and security
freedom from physical harm and feelings of fear and anxiety.
Hypotension related to dehydration
from inadequate fluid intake, from diarrhea, elevated temp fits well with this unit.
Pre interaction phase
gathering info about client before meeting client
Who is at risk for falls?
h. Everyone but older adults are more at risk
Stridor
harsh, high pitched, crowing like sound
Wheezing
high or low pitched whistling sound
Mormons wear garments at all times except for
hygiene, elimination, or being intimate in marriage
Pharmacological Interventions
i. Analgesics are the mainstay for relieving pain. ii.NSAIDs iii.Opioids 1.PCA 2.IM 3.Transdermal 4.Epidural
Suffocation
i. Avoid toys with small removable parts. ii. Do not attach pacifiers to ribbons or strings. iii. Keep window blind cords out of a child's reach. iv. Do not give a young child hard candy, gum, nuts, popcorn, grapes, or marshmallows. v. Dispose of burst balloons immediately. h. Toxins from work environment i. Remove contaminated clothing. ii. Shower before going home.
What is OSHA's primary purpose?
i. Defines types of personal protective equipment and situations in which you are required to wear it E. Community Safety
Falls
i. Do one thing at a time. ii. Change positions slowly to avoid dizziness. iii. Be sure pathways are well lit. iv. Have your eyes checked at least once a year. v. Wear shoes with non-skid soles. vi. Avoid clutter.
Biological effect in care
i. Genetic and physical aspects that determine situations ii. Ex. African American Females have a higher risk for breast cancer, Pacific Islanders and Native Hawaiians have a higher rate of uncontrolled diabetes and hypertension
Carbon Monoxide
i. Have a functioning CO2 monitor in the home. ii. Ensure all gas and wood burning devices are vented to the outside. iii. Be sure vehicles do not allow exhaust fumes to enter the passenger area. iv. Never use a kerosene heater, gas stove, or gas oven to heat the home. v. Never burn charcoal inside the home.
Fires
i. Have a smoke alarm system. ii. Have an escape plan. iii. Never leave candles burning unattended. iv. Do not smoke in bed, especially in a home where oxygen is in use. v. Never use an open flame when oxygen is in use.
Poisoning
i. Have the poison control 800 number posted so it is easily accessible. ii. Keep all chemicals and medications in a locked cabinet. iii. Dispose of unused medication by mixing it with cat litter or take it to a community disposal center.
What types of situations are appropriate for use of SBAR?
i. Interdisciplinary communication ii. Critical situations iii. Rapid response needed iv. Nurse- physician communication v. Team communication and collaboration
Non pharmacological interventions
i. Mind-body practices (yoga,chiropractic manipulation) ii. Cognitive approaches (meditation, distraction) iii. Natural products (herbs, oils) iv. Exercise v. Relaxation techniques vi. Cutaneous Stimulation vii. Warm and colf therapies
Interventions to treat hypoxia
i. Monitor for manifestations of respiratory depression, such as decreased respiratory rate and decreased level of consciousness. Notify the provider if findings are present.
Restraints should
i. Never interfere with treatment ii. Restrict movement as little as is necessary iii. Fit properly and be as discreet as possible iv. Be easy to remove or change v. Be avoided as much as possible vi. Not be used without doctor's order use least restrictive first Have pt close to nurses station
Firearms
i. Store guns and ammunition separately. ii. Store guns in a locked box. iii. Teach children to never touch a gun.
Burns
i. Turn pot handles toward the back of the stove. ii. Never warm infant formula or food for a young child in a microwave. iii. Always check the temperature of bath water for young children prior to placing them in the tub. iv. Wear sunscreen and protective clothing when out in the sun.
Environmental effect in care
i. person's beliefs that they could change the outcomes of an illness without seeking help.
Complementary and alternative therapy (CAM)
inclusion of different approaches to achieve health
Saw Palmetto
increase testosterone levels, improve prostate health, reduce inflammation, prevent hair loss, and enhance urinary tract function
Autonomy
independence
Elderly are at high risk for
injury;primarily from falls
An instructor explains that nurses and other health care practitioners must learn about complementary and alternative medicine (CAM) and how its practices influence and assist traditional medicine. The term used to describe the use of Western medicine and CAM in a coordinated way is called ____________________ health care.
integrative
Why sleep is necessary for the body's normal function?
is an important regulator of energy metabolism may improve learning and adaptation affects almost every tissue in our bodies reduce stress and anxiety Nourishes health Growth hormone is released during sleep Important for mental health
Pulse Ox
measures the oxygen level in the blood
Holistic belief
need for harmony and balance of the body with nature (yoga, meditation, etc.)
Love and belonging
needs are met when the person seeks personal relationships with others.
Folk medicine effects in meeting basic care & comfort needs
o Beliefs and practices an individual performs when ill than conventional medicine (eating soup, resting, folk healer, teas, circumcision) o Passed down by generations to generations
Rate of pulse
number of times the heart beats per minute; varies person to person
Nursing actions/interventions for communication
o Be positive and patient o Call client by their preferred nameo Minimize environmental noise o Provide forms of nonverbal communication o Use gestures o Be concrete and specific o Keep eye contact (hearing impaired patients will read your lips)
Social effect in meeting basic care & comfort needs
o Close social organization (Man is dominant and female is housemaker) o Social organization related to birth, death, illness, grieving & mourning (Delaying treatment with home remedies)o Kinship and social ties (VIP care compared to homeless)
Communication for cognitive impaired patients
o Do not use in-room intercom to speak to pt o Reduce environmental distractions o Approach patient directly o Don't rush the client
Influences for pulses?
o Exercise o Age o Gender o Anxiety o Pain
Preventing falls at home
o Exercise regularly o Take your time o Lighten loads/brighten paths
Fires at home (Healthcare environment hazards)
o Home fires are the major cause of death and injuries o Older adults & children < 5 y/o have the highest risk o Most common cause of fires: cooking fires, smoking, heating equipment, and home oxygen administration equipment (75% of home fires involves oxygen, smoking materials are the ignition source)
Communication with hearing impaired patients
o Inquire about possible hearing aid devices o Talk slowly, and enunciate o Avoid slang words or complex jargon
Communication with speech impaired patients
o Nonverbal communication is key (hand gestures, picture board) o Family assistance o Provide comfortable environment that allows pt to practice speaking o Possible refer to speech pathologist
Bladder training
o Program to help with elimination
Documentation for pulse?
o Rhythm - even tempo o Strength (0-4+, absent, weak or thready, normal, strong, bounding) o Regular rhythm: 30 seconds x 2- or 15-seconds x 4o Irregular rhythm (regular/irregular); full minute; apical. o •Amplitude is what is measured o •Rate, rhythm (regular or irregular), and quality (strong, weak or bounding)
Health effects in meeting basic care & comfort needs
o Scientific (hospitals, clinics, medications)o Magico-Religious: alternative or indigenous (supernatural forces of healing, rituals) o Holistic: need for harmony and balance of the body with nature (yoga, meditation)
Fires in healthcare settings (Healthcare environment hazards)
o Smoking is prohibited in healthcare facilities (think about home fires 75% are related to oxygen). Oxygen is highly used in every healthcare facility. o Our role is to ensure the patients and family follow these policies. o If a fire occurs call a "Code Red" or "Code yellow" depending on the institution process. Stay safe and evacuate if needed. Use RACE or PASS
Nutrients are used for
optimal cellular metabolism and health promotion
Oral Nursing Care
patient position sterile enviornment restrict liquid intake frequent small meals warm food
The morse scale is used to assess?
patient's likelihood of falling
Water-borne pathogenic causes
poor sanitation; Giardia lamblia, Cryptosporidium, Escherichia coli
RACE is an acronym used to
prioritize order of procedures for a fire
What do the Agency for Healthcare Research and Quality (AHRQ) do?
produces evidence to make healthcare safer, higher-quality, accessible, equitable and affordable.
An interpreter is specially trained to
provide the meaning behind the words Serve as a cultural broker by conveying the client's responses to questions and by providing general information about the client's culture.
Grunting can be associated with
pulmonary edema, pneumonia or atelectasis, a partially expanded lung.
An instructor explains that chronic illness is characterized by periods of either minimal symptoms or a complete absence of symptoms. A nurse explains to a chronically ill patient that his or her absence of symptoms is known as ____________________.
remission
stridor, wheezing, crackles, pleural rubs or crepitus, as these are associated with
respiratory distress.
A hospice nurse notices that the family of a terminally ill patient has not left the patient's room for several days. The nurse knows that providing ____________________ for a period even as brief as 3 to 4 hours can provide some temporary relief for the family members.
respite
Definition of pulse?
rhythmic expansion of an artery produced when a bolus of oxygenated blood is forced into it by contraction of the heart.
Sex/Reproduction is
seen as a basic physiological need
Crackles
sharp sounds heard on inspiration
Grunting is a
short, deep, guttural sound heard during expiration.
Melatonin
sleep
Moist crackles
sound wet on auscultation and are related to the accumulation of alveolar fluid.
Pleural rubs
sounds of inflamed pleural surfaces rubbing over each other, they are loud, low pitched and localized
A nurse tells the charge nurse that her patient will not accept his lunch tray. When questioned, the nurse states, "Well, I think it's because most Asians are Buddhists and are vegetarians." This is an example of ____________________.
stereotyping
Increased risk of needlestick due to
stress, +12hr shifts, low skill level, lack of protective devices
Race
strictly related to biology ○ Skin color, blood type, bone structure
Quality of pulse
strong, weak or bounding
Hyperthermia
temperature above the normal range that may be related to exercise or exposure to an abnormally hot environment -Temp is greather than 104 degrees
Hypothermia:
temperature below the normal range that may be related to exposure to a cold environment -Temp lower than 95
Intimate Distance is
the area immediately surround- ing people that they define as their "private space."
Dry crackles
the sound one might hear when rubbing several hairs together close to the ear are associated with small airway collapse and lung disease.
Ethnocentrism
the tendency to think that your own group (cultural, professional, ethnic, or social) is superior to others and to view behaviors and beliefs that differ greatly from your own as somehow wrong, strange, or unenlightened ○ This exists in all groups, not just the dominant group*
Capsaicin (Herb)
treat minor aches and pains of the muscles/joints
Promote and prevent skin injuries
turn patient every 2 hours, keep clean and dry
systolic blood pressure
ventricles contract, 90-120, maximum pressure on the arteries
Diastolic Blood Pressure (DBP)
ventricles relax, 60-80, minimum pressure on the arteries
One of the most critical nursing interventions the nurse has is the ability to monitor and interpret the client's?
vital signs.
A Roman Catholic who is seriously ill might
wish to receive the sacrament of anointing the sick. (last rites)
Storms (Community Safety)
· Deaths caused by lighting strikes is the lead cause of fatalities due to weather conditions. · The second leading cause is flooding · Education about outdoor activities during a storm is important to reduce the incidents.
Motor vehicle accidents (Community Safety)
· Failure to use seat belts and proper child car seats are the main factor of deadly accidents · Use of cellphones while driving increases the risk of accidents · Motor vehicle accidents are the leading cause of accidental deaths in the U.S.
Pathogenic causes (Community Safety)
· Food-borne: Food poisoning; eggs, fish, uncooked meats, poultry, raw fruits & vegetables, milk, etc .· Water-borne: poor sanitation; Giardia lamblia, Cryptosporidium, Escherichia coli · Vector borne illnesses: Mosquitoes = West Nile, Malaria; flies, fleas, ticks, cockroaches, rodents, bird droppings, mice, etc.
Biological Hazards (Healthcare environment hazards)
· Hand hygiene is the #1 mechanism of defense against contaminants. · As nurses our role is to maintain our patient safe and reduce the risk of cross-contamination. · Complete hand-hygiene when entering, exiting and change of gloves to help keep the patients safe.
Restraints (Healthcare environment hazards)
· Method use to restrict movement or access. · Use in the hospitals when the situation or all other approaches have been tried without success. · Avoid their use as much as possible by promoting commitment to reduce restraints and seclusion, educate caregivers about options, maintain 1 to 1 view of patients who are restrained or secluded, have adequate staff and involve all the staff members in the decision making. · Sometimes restraints are needed to maintain safety because it outweighs other methods. · Using rails to restrict the patient's independence is considered a restraint and can cause more harm. DO NOT use this method of restraint.· Perform constant assessment · Do not use without a Doctor's order
Hypoxia Interventions
· Oxygen therapy (O2 delivery methods, amount of O2 delivered per device, safety education) · Incentive spirometry · Turn, Cough and Deep Breath · Pursed lip breathing · Collecting a sputum specimen as examples
Assessment of pain history
· P: Provocation and Palliati o no What causes it? o What makes it better? o What makes it worse? · Q: Quality and Quantity o How does it feel, look, or sound? o How much of it is there? · R: Region and Radiationo Where is it? o Does it spread? · S: Severity and Scale o Does it interfere with activities? o How does it rate on a severity scale of 1-10? · T: Timing and Type of Onseto When did it begin? o How often does it occur? o Is it sudden or gradual?
Violence (Healthcare environment hazards)
· Raising in the professional healthcare system· Higher risk in the ED · Recognizing the signs are important, They include: · Anxiety, angry, acute illness that they don't understand can trigger aggression, it can escalate to physical aggression. · Gang violence is common in the ED or acute setting· Stay alert!
Equipment related accidents (Healthcare environment hazards)
· Related to malfunction or improper use · Get familiar with the equipment before using it on the patient · Contact Biomed if the equipment is faulty and DO NOT use it
Hypotension Nursing interventions
· Vital signs Initially increase HR and BP · Discuss other signs and symptoms associated with fluid loss · Identify high-risk populations · I & O, daily weights as examples
NCLEX STYLE: A nurse is caring for a 60yo pt in rehab recovering from right sided CVA. The pt has orders for OOB ambulation with assistance as tolerated. Which intervention is most important? 1. Assessing balance 2. Using a bed alarm 3. Encouraging the use of a walker 4. Teaching to rise slowly from a lying to a sitting position
• 1. Assessment is the first step of the nursing process. The nurse must first assess the patient for the presence of problems with strength and balance before moving a pa- tient out of bed. People with problems with balance may not be able to maintain the sitting position while sitting on the side of the bed. 2. A bed alarm is unnecessary. There is no information in the stem that indicates that the patient is confused or unwilling to call for assistance when getting out of bed. 3. This is implementing an intervention before the patient's needs are assessed. 4. Although this should be done, it is not as critical as another option. Even though a patient may become dizzy when moving from a lying to sitting position, the patient is in bed and has little risk of falling out of bed. The upper rails should be raised to provide for the patient's safety. • TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word most in the stem sets a priority. Identify the option that is unique. Option 1 is the only option that is an assess
NCLEX STYLE PRACTICE:A patient who is legally blind says to the nurse, "I once was able to see a little bit, but now I can't see anything." What should the nurse encourage the patient to do while hospitalized? • Wear dark tinted eyeglasses. • Keep a light on in the room at all times. • Close the window blinds during the day. • Call for assistance when getting out of bed
• 1. Dark-tinted eyeglasses will not benefit a patient who "can't see anything." • 2. Keeping a light on in the room may help a patient with partial vision, but it will be insignificant for a patient who "can't see anything." • 3. Closing window blinds will be beneficial for a patient with partial vision who is affected by glare; this intervention will not benefit a patient who "can't see anything." • 4. A patient who is in a strange environment and who has a visual impairment is at an increased risk for falls. The patient should seek assistance with transfers and ambulating until the patient feels comfortable engaging in these activities and the nurse determines that the patient is safe to perform this activity unassisted. • TEST-TAKING TIP: Identify the option with a specific determiner. Option 2 contains the specific determiner all. Identify the unique option. Option 4 is unique because it is the only option that involves another person and it is the only option that does not engage in adjusting the light in the room. Identify options that are equally plausible. Option 1 and 3 are equally plausible. Both reduce light that meets the eye. Option 1 is no better than option 3. Eliminate both from further consideration.
Enhancing therapeutic Communication
• Active Listening • Establishing trust • Being assertive • Validating messages • Exploring issues • Using silence • Process recordings
Healthcare Worker risks
• Back Injury • Needle stick Injury • Radiation Injury
Communicating with clients from other cultures
• Be aware of your own biases • Learn about other culture in the geographical location • Convey empathy and respect • Be aware of cultural preferences related to eye contact, space, and touch • Address the client appropriately • Appropriate use of interpreters
Identify nursing interventions beyond relieving discomfort/pain, which promote rest and sleep
• Create a restful environment (clean, dry linens, dark, quiet room) • Promote relaxation techniques (back rub, guided imagery) • Avoid caffeine, smoking, and alcohol at bedtime • Eat a small carbohydrate snack before bed. • And others
medication that affects hydration status
• Diuretics • laxatives • enemas • over-the-counter medications • herbal remedies.
Interventions promoting normal bowel elimination patterns
• Encouraging pt to have diet high in fiber • Create meal plan • Keep track of stools everyday and how it appears • Make sure they use the toilet when they need to
High Risk factors for falls
• Poor vision • Cognitive impaired • Weakness • Dizziness • Drowsiness
Diarrhea Nursing interventions
• Protect the perineal and buttock area with zinc oxide or other barrier cream to prevent skin irritation and excoriation, especially for patients who are incontinent. • Wash and dry skin where stool and urine have made contact, especially for patients who are incontinent. • Encourage fluid intake and ensure that the patient consumes foods high in potassium such as oranges and potatoes. • Document food and fluid intake and urinary/stool output. • • Check the patient's weight each day for weight loss. • • Collaborate with the primary health care provider for prescribing an antifungal cream if needed. - provide fluid-balanced -administered medications as needed, - keep accurate track of I&O. -If severe diarrhea, keep patient NPO but provide IV fluids
PASS
• Pull the pin; • Aim the nozzle; • Squeeze the handle • Sweep at the base of the fire.
How do changes in mastication and swallowing influence nutritional intake?
• When the client is unable to chew, the food is ground or placed in a blender to eliminate the step of chewing, therefore the appearance of the food on the plate is not attractive. If the client has a swallowing issue, thickener is added to liquids to thicken them to a heavier consistency (such as thickening water to the consistency of pudding) to make it safe for swallowing without choking. The thickener also changes the flavor of the fluid.
Constipation Nursing interventions
• health teaching and collaboration with the interprofessional health care team. • teaching about measures to prevent worsening of constipation • stool softeners, • bulk-forming agents • mild laxatives as needed to restore normal elimination patterns. • enemas to stimulate peristalsis and empty the rectum. -Encourage a high-fiber diet - use medications as needed -increase activity -increase fluid intake.
Health disparities among race and ethnicity
○ Health status ○ Quality of care ○ Access to care
What would be the proper follow up for cultures that refuse blood?
● Never force ● Educate the patient on why you would give blood ● Document why the reason the patient refused ● Try to find alternatives
Know different types of culture, how to take care of refusals
● Never force it ● Educate the pt as to why we need it.
most common causes of accidental death for all age groups (Infants, Children, adolescents, adults, older adults)
● Poisoning and exposure to noxious substances ● Motor vehicles ● Firearms ● Falls ● Drowning ● Fires, flames, and smoke
Order of bed bath
● Use prepackaged bathing products. ● Check the temperature of the packaged bath wipes after microwaving. ● Avoid chilling or tiring the patient. ● Bathe the patient following the principles of "head to toe" and "clean to dirty." ● For extremities, cleanse from distal to proximal. ● Use a new wipe for cleansing the perineum and whenever the wipe becomes soiled. ● Perform hand hygiene when moving from a contaminated body part to cleanse a clean body part.
NCLEX STYLE PRACTICE:Connor's elderly patient becomes disoriented as the day wears on and starts to wander in the hall and go into other patient's rooms. Connor persuades him to get back to bed four separate times. The nurse understands that to avoid using patient restraints, they should: • Select All That Apply • ❑ Orient patient to the environment • ❑ Get a sitter • ❑ Do not encourage family to stay • ❑ Use consistent scheduling of patient activities • ❑ Place the patient away from the nurses' station, so they are not disturbed • ❑ Ask for medication from the primary care provider
❑ Orient patient to the environment- Yes • ❑ Get a sitter-Yes • ❑ Do not encourage family to stay—No, it is safer if they stay • ❑ Use consistent scheduling of patient activities—YES • ❑ Place the patient away from the nurses' station, so they are not disturbed—No, place the patient by the nurses' station • ❑ Ask for medication from the primary care provider—No, often increasing medications makes patients more confused
