NUR 183 TEST 1 2 3

Ch 38 An 82-year-old woman was brought to the emergency department by her granddaughter. She is a widow and lives alone, although her granddaughter checks on her daily. She has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6°F (37.6°C) orally; P = 110 beats/min, weak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/L BUN 29 mg/dL The nurse recognizes that the patient is displaying symptoms associated with which of the following? a) Hypovolemia b) Hypervolemia c) Hypernatremia d) Hyponatremia

ANS: A Hypovolemia may occur as a result of insufficient intake of fluid; bleeding; excessive loss through urine, skin, or the gastrointestinal tract; insensible losses; or loss of fluid into a third space. The first symptom of hypovolemia is thirst. Other symptoms are a rapid, weak pulse, a low blood pressure (although initially the blood pressure may rise), dry skin and mucous membranes, decreased skin turgor, and decreased urine output. Temperature increases because the body is less able to cool itself through perspiration. The person with fluid volume deficit usually has elevated BUN (blood urea nitrogen) and hematocrit levels. Hypervolemia involves excessive retention of sodium and water in the extracellular fluid, and the vital sign changes are opposite those of a patient with hypovolemia. Hypernatremia and hyponatremia are not applicable because the patient's sodium level is within normal range

Ch 38 The nurse records a patient's hourly urine output from an indwelling catheter as follows: 0700: 36 mL 0800: 45 mL 0900: 85 mL 1000: 62 mL 1100: 50 mL 1200: 48 mL 1300: 94 mL 1400: 78 mL 1500: 60 mL The nurse can conclude that the patient's urine output should be described as which of the following? a) Low b) Within normal limits c) High d) Inconclusive

ANS: B Urine accounts for the greatest amount of fluid loss. Normal urine output for an average-sized adult is approximately 1,500 mL in 24 hr. Urine output varies according to intake and activity but should remain at least 30 to 50 mL per hour. The patient's urine output is within the normal range. This patient has an indwelling catheter, which will result in continual flow of urine

Ch 41 The nurse reviews the patient's laboratory results. What component of informatics is the nurse viewing? a) Data b) Information c) Knowledge d) Wisdom

ANS: B The material reviewed on the laboratory report is information because they correspond to the patient's physiological condition. Data (raw numbers) alone have no meaning without associating the values with the patient's health status. The laboratory results become knowledge when the nurse interprets the laboratory readings to understand the patient's condition. The nurse uses wisdom when applying the laboratory values to findings to determine an appropriate plan of care for the patient

Ch 39 The staff RN is assigned to an operation with an operating room LPN. The physician employs another RN who will be first assistant for the operation. What role will the staff RN play? a) Scrub nurse b) Anesthesiologist c) Circulating nurse d) Technician

ANS: C The staff RN will act in the role of circulating nurse, which can be performed only by an RN. A physician acts as anesthesiologist, although an RN with advanced education (CRNA) could administer anesthesia. However, an RN could act as the CRNA; but the nurse in the question is not identified as a CRNA. Because only an RN can act as circulating nurse, the roles of scrub nurse or technician would be assigned to the LPN.

Ch 38 A patient has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6°F (37.6°C) orally; P = 110 beats/min, weak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/L BUN 29 mg/dL Which of the following is an appropriate nursing diagnosis for this patient? a) Impaired Gas Exchange related to ineffective breathing b) Excess Fluid Volume related to limited fluid output c) Deficient Fluid Volume related to abnormal fluid loss d) Electrolyte Imbalance related to decreased oral intake

ANS: C Vomiting has made this patient hypovolemic; therefore, she has deficient fluid volume. There is no information to indicate that she has respiratory problems or Impaired Gas Exchange. Her symptoms are not consistent with Excess Fluid Volume. Electrolyte Imbalance is not a nursing diagnosis.

Ch 7 The nurse reviews the patient chart and sees a physician prescription for a new medication. The nurse is able to clearly read the medication name but the dose is not legible. What is the best action by the nurse? a)Contact the physician for clarification. b)Ask another nurse to read the order. c)Ask the unit secretary to read the order. d)Contact the pharmacist to read the order.

ANS:A As a nurse, you are obligated ethically and legally to clarify or question orders that you believe to be unclear, incorrect, or inappropriate. In this case, the nurse should contact the physician to clarify the order, as it is not legible. It is inappropriate to ask the secretary or another nurse to read the order as they may read it incorrectly.

Ch 37 Three days ago, a patient had cardiac surgery to bypass three occlusions of his coronary arteries. Veins for the bypass were harvested from his right leg. He informs the nurse that his leg is warm and tender in his right calf. The nurse notes a 3-cm periwound erythema and swelling at the distal end of the incision. Staples are intact along the incision, and there is no drainage. Vital signs are stable. The nurse would suspect that the patient has what kind of complication? a) Deep vein thrombosis b) Dehiscence of the wound c) Internal bleeding d) Infection at the incisional site

ANS:A Deep vein thrombosis (DVT) is a clot in the veins that are deep under the muscles of the leg. DVT can occur after surgery, after lengthy bedrest, or after trauma. Symptoms include pain, warmth, redness, and swelling of the leg. Dorsiflexion of the foot (pulling toes forward) and Pratt's sign (squeezing calf to trigger pain) have not been found to be reliable in diagnosing DVT. Dehiscence is the rupture of a suture line, whereas evisceration is the protrusion of internal organs through the rupture. Internal bleeding is a wound-healing complication associated with hematoma formation, pain, hypotension, and tachycardia. Infection is a complication of wound healing that causes warmth, pain, inflammation of the affected area, and changes in vital signs (i.e., elevated pulse and temperature).

Ch 18 What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident is of a long-term care facility? a)14 days b)3 days c)2 days d)24 hours

ANS:A Federal regulations require that a resident be evaluated using the Minimum Data Set within 14 days of admission to a long-term care facility.

Ch 26 The nurse must administer ear drops to an infant. How should she proceed? a)Pull the pinna down and back before instilling the drops. b)Pull the pinna upward and outward before instilling the drops. c)Instill the drops directly; no special positioning is necessary. d)Position the patient supine with the head of the bed elevated 30°.

ANS:A For a child younger than 3 years old, the nurse should pull the pinna down and back. For older children and adults, the nurse should pull the pinna upward and outward. Doing each straightens the ear canal for proper channeling of the medication. The patient should be assisted into a side-lying position with appropriate ear facing up before instillation.

Ch 37 A patient diagnosed with hypertension is taking an angiotensin-converting enzyme (ACE) inhibitor. When planning care, which of the following outcomes would be appropriate for the patient? a) BP will be lower than 135/85 on all occasions. b) BP will be normal after 2 to 3 weeks on medication. c) Patient will not experience dizziness on rising. d) Urine output will increase to at least 50 mL/hr.

ANS:A Goals must be clearly stated so that it is easy to evaluate whether they have been met. "BP . . . lower than 135/85 . . ." is clearly stated and easily evaluated. In contrast, "BP will be normal . . ." does not clearly state the desired endpoint. Freedom from dizziness on rising is probably not achievable because ACE inhibitors are vasodilating agents, which may cause vessel dilation and hypotension, especially when the patient arises from a seated or lying position. Patients should be warned of this effect. The expected/desired effect of the ACE inhibitor is to lower the blood pressure; the urine output is minimally relevant in determining that outcome, if at all.

Ch 31 Which action should the nurse take first when the patient has a score of 4 on the sedation rating scale? a)Stimulate the patient. b)Prepare to administer naloxone (Narcan). c)Administer a dose of pain medication. d)Notify the physician immediately.

ANS:A If the patient's score on the sedation rating scale is equal to or greater than 4, the nurse should first stimulate the patient. He should next notify the physician. The nurse should consider administering naloxone, as prescribed, if the patient's respiratory rate is less than 8 breaths/min; if respirations are shallow with marginal or falling oxygen saturation; or if the patient is unresponsive to stimulation. Before the patient receives another dose of pain medication, the dose should most likely be reduced and other potential causes of sedation should be investigated.

Ch 39 A 2-year-old child is scheduled for a tonsillectomy. When determining the plan of care, the nurse should: a) Include the parents or caregivers in the plan of care b) Explain to the child that she will have a sore throat after surgery c) Tell the child that she can have her favorite foods for the first 24 hours after surgery d) Prepare the child for discharge from the hospital as soon as she is alert

ANS:A It is developmentally normal for toddlers to experience anxiety with separation from parents or caregivers. Be sure to include these people in the plan of care. Developmentally, a 2-year-old lives in the "here and now" and wouldn't grasp an intangible concept, such as pain in the future. The toddler would take liquids and soft foods within the first 24 hours when her throat is sore during swallowing. She should not eat foods that are rough and crunchy because they may scratch her throat and cause bleeding. After a tonsillectomy, the child will need to be monitored for bleeding and stable vital signs; therefore, she will not be discharged as soon as she is alert

Ch 41 The nurse is caring for a patient newly diagnosed with diabetes. The patient tells the nurse, "After searching the Internet, I found out that I don't need insulin. All I need to do to control blood sugar is drink a mixture of vinegar and apple juice." What teaching should the nurse provide? a) Show the patient how to choose reputable, trustworthy healthcare Web sites. b) Instruct on the importance of adhering to the prescriber's instructions. c) Inform the patient that the healthcare provider is always right and should be trusted. d) Return to the Web site to obtain more detailed information.

ANS:A Not all information available on the Internet is reliable. The nurse should teach the patient how to search authority sources, professional organization Web sites, nursing literature databases, and key government guidelines for trustworthy information. Although following the prescriber's instructions is important, if the patient believes the mixture of vinegar and apple juice will prevent needing daily injections of insulin, he will be unlikely to follow the prescriber's instructions. Saying the healthcare provider is always right is patronizing and does not promote the patient's active participation in his own healthcare. The information the patient obtained from the Web site is not reliable and is not suitable heath advice.

Ch 26 Which documentation entry related to prn medication administration is complete? a)6/5/14 0900 morphine 4 mg IV given in right antecubetal fossa for pain rated 8 on a 1-10 scale, J. Williams RN b)0600 famotidine 20 mg IV given in right hand, S. Abraham RN c)9/2/14 0900 levothyroxine 50 mcg PO given d)1/16/14 furosemide 40 mg PO given, J. Smith RN

ANS:A The longest option, signed by J. Williams, is complete because it contains the date and time the medication was administered, the name of the medication, the route of administration and injection site, and the name of the nurse administering the medication. Because the medication administered was a prn order, the nurse also included the reason the medication was administered. Other options are incomplete.

Ch 28 A mother tells the nurse at an annual well child checkup that her 6-year-old son occasionally "wets himself." Which response by the nurse is appropriate? a)Explain that occasional wetting is normal in children of this age. b)Tell the mother to restrict her child's activities to avoid wetting. c)Suggest "time-out" to reinforce the importance of staying dry. d)Inform the mother that medication is commonly used to control wetting.

ANS:A The nurse should explain that occasional wetting is normal in children during the early school years. The mother should handle the situation calmly and avoid punishing the child. Medications are occasionally prescribed for nocturnal enuresis when the child is older and not sleeping at home, but not for occasional daytime wetting.

Ch 31 The nurse is assessing an intubated patient who returned from coronary artery bypass surgery 3 hours ago. Which assessment finding might indicate that this patient is experiencing pain? a)Blood pressure 160/82 mm Hg b)Temperature 100.6°F c)Heart rate 80 beats/min d)Oxygen saturation 95%

ANS:A This patient has an elevation in blood pressure, which is a physiological finding associated with pain. The patient has a mild temperature elevation, which is a common response to surgery. Heart rate and oxygen saturation are within normal limits.

How should the nurse dispose of a contaminated needle after administering an injection? a)Place the needle in a specially marked, puncture-proof container. b)Recap the needle, and carefully place it in the trashcan. c)Recap the needle, and place it in a puncture-proof container. d)Place the needle in a biohazard bag with other contaminated supplies.

ANS:A To avoid needlestick injuries, the nurse should place the uncapped needle, pointing downward, directly into a specially marked, puncture-proof container. Recapping the needle should only be done when no other feasible alternative is available. When recapping is necessary, use an acceptable technique such as the one-handed scoop technique in which the nurse places the needle cap on a sterile surface and, using one hand, scoops up the cap with the needle. Placing the needle in an improper container (biohazard bag) that could be punctured by the contaminated needle places other staff members at risk.

Ch 28 The nurse identifies the nursing diagnosis Urinary Incontinence (Total) in an older adult patient admitted after a stroke. Urinary Incontinence places the patient at risk for which complication? a)Skin breakdown b)Urinary tract infection c)Bowel incontinence d)Renal calculi

ANS:A Urine contains ammonia, which may cause excoriation with prolonged contact with the skin. Bowel incontinence, not urinary incontinence, increases the patient's risk for urinary tract infection. Immobility and high consumption of calcium-containing foods increase the risk for renal calculi.

Ch 41 Which informatics concept concerns the appropriate use of knowledge in managing or solving human problems? a)Wisdom b)Data c)Knowledge d)Information

ANS:A Wisdom is the appropriate use of knowledge in managing or solving human problems. Data are raw, unprocessed numbers, symbols, or words that have no meaning by themselves. Information consists of groupings of data processed into a meaningful, structured form. Knowledge is formed when data are grouped, creating meaningful information and relationships, which are then added to other structured information.

Ch 39 A patient had a hiatal hernia repair earlier today and is now in the postanesthesia care unit (PACU). The family asks the nurse why the patient is in the PACU rather than back in his room on the postsurgical unit. The nurse should inform the family that: a)Patients who have had surgical complications are observed in the PACU until they are stable enough to return to the floor b)Patients recover from the effects of anesthesia in the PACU and then return to the postsurgical unit for further care c)The PACU is a holding area for patients awaiting a surgical unit bed or awaiting adequate staff to provide care on the postsurgical unit d)The nurse will ask the surgeon to explain to them why the patient is not on the postsurgical unit as per usual procedure

ANS:B A client remains in the PACU until he has recovered from the effects of anesthesia. In the PACU, the client is assessed every 5 to 15 minutes so that the nurse may quickly identify surgical or anesthesia-related problems. Most surgical units routinely admit patients to the PACU for a period of observation. Admission to the PACU does not indicate surgical complications nor imply that a holding area is required. There is no reason the surgeon would need to explain this to the family, as the nurse could communicate the procedure. It is not usual procedure for a patient to be transferred directly from surgery to the postsurgical unit.

The nurse is administering a purified protein derivative (PPD) test to a homeless client. Which of the following statements concerning PPD testing is true? a)A positive reaction indicates that the client has active tuberculosis (TB). b)A positive reaction indicates that the client has been exposed to the disease. c)A negative reaction always excludes the diagnosis of TB. d)The PPD can be read within 12 hours after the injection.

ANS:B A positive reaction means the client has been exposed to TB; it isn't conclusive of the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn't exclude the presence of active disease.

Ch 41 In informatics, raw, unprocessed numbers, symbols, or words that have no meaning by themselves are called which of the following? a)Information b)Data c)Knowledge d)Wisdom

ANS:B Data are raw, unprocessed numbers, symbols, or words that have no meaning by themselves. Information consists of groupings of data processed into a meaningful, structured form. Knowledge is formed when data are grouped, creating meaningful information and relationships, which are then added to other structured information. Wisdom is the appropriate use of knowledge in managing or solving human problems.

Ch 26 The primary care provider prescribes nitroglycerin 1/150 g SL for a patient experiencing chest pain. How should the nurse administer the drug? a)Place the drug in the cheek and allow it to dissolve. b)Place the drug under the tongue and allow it to dissolve. c)Inject the drug superficially into the subcutaneous tissue. d)Give the pill and water to the patient for him to swallow the tablet.

ANS:B Drugs administered by the sublingual (SL) route should be placed under the patient's tongue and allowed to dissolve. Drugs administered by the buccal route are placed in the cheek and allowed to dissolve. A subcutaneous injection is administered into the subcutaneous tissue. Placing the drug into the patient's mouth, giving him water, and instructing him to swallow the tablet describe oral administration.

Ch 37 A patient with heart failure has BP 120/60, HR 64, R 18, T 97.6°F, coarse crackles bilaterally, and 3+ edema to the lower extremities. An appropriate nursing diagnosis for this patient is: a) Impaired gas exchange b) Excess Fluid Volume c) Ineffective Tissue Perfusion d) Deficient Knowledge

ANS:B Excess Fluid Volume is an appropriate nursing diagnosis for someone demonstrating increased isotonic fluid retention, as demonstrated by adventitious breath sounds (crackles bilaterally) and edema. There is no indication that this patient is experiencing impaired gas exchange or inefficient tissue perfusion based on the information provided. Although the patient may have knowledge deficit, this is not a priority at this time.

Ch 39 The patient tells the nurse, "I'm so nervous. I want to be knocked out for the surgery so that I don't know what is going on." When the nurse communicates with the surgeon and anesthetist, she tells them that the patient desires which type of anesthesia? a)Conscious sedation b)General anesthesia c)Local anesthesia d)Regional anesthesia

ANS:B General anesthesia produces rapid unconsciousness and loss of sensation. During conscious sedation, the client feels sleepy but is easily aroused by touch or speech. Regional anesthesia interrupts nerve impulses to and from the affected area, but the patient remains alert. Local anesthesia produces loss of pain sensation at the desired site and is typically used for minor procedures. The client remains alert during local anesthesia.

Ch 39 A patient is admitted from a local skilled nursing facility to the outpatient surgery center for surgical debridement of a stage IV sacral pressure ulcer. The perioperative nurse discovers that the patient does not have a signed consent form for the surgery on the chart or in the surgery center. The patient says that she has not talked to the surgeon and that she has many questions regarding her surgery. When informed of this, the surgeon tells the nurse to have the patient sign the informed consent form, and he will review it prior to the surgery. What should the nurse do? a) Follow the surgeon's orders, and ask the patient to sign the surgical consent form. b) Inform the surgeon that she will have the patient sign after he discusses the surgery with the patient. c) Ensure that the signed surgical consent is witnessed by two nurses, because the surgeon is not available. d) Cancel the surgery and transfer the patient back to the long-term care facility.

ANS:B Informed surgical consent requires that the surgeon communicates information about the surgery to the patient, that the patient understands the communication and agrees to the surgery, and that the patient has not been coerced to give consent. As a patient advocate, the nurse should verify with the patient that the surgeon has explained the procedure and answered all her questions. The surgeon is responsible for giving the patient the necessary information and determining the patient's competence to make an informed decision about the surgery. If the patient has further questions, the nurse should notify the surgeon and delay sending the patient to surgery until an informed consent is obtained

Ch 28 While performing a physical assessment, the student nurse tells her instructor that she cannot palpate her patient's bladder. Which statement by the instructor is best? a)"Try to palpate it again; it takes practice but you will locate it." b)"Palpate the patient's bladder only when it is distended by urine." c)"Document this abnormal finding on the patient's chart." d)"Immediately notify the nurse assigned to the care of your patient."

ANS:B The bladder is not palpable unless it is distended by urine. It is not difficult to palpate the bladder when distended. The nurse should document her finding, but it is not an abnormal finding. It is not necessary to notify the nurse assigned to the patient.

Ch 26 Which body organ is mostly responsible for medication excretion? a)Liver b)Kidney c)Lungs d)Exocrine glands

ANS:B The kidneys are the primary site of excretion. Adequate fluid intake facilitates renal excretion. If the patient has decreased renal function, the nurse should closely monitor for medication toxicity.

Ch 31 Which nursing diagnosis is most appropriate for the patient who returns from the postanesthesia care unit after undergoing right hemicolectomy surgery for colon cancer? a)Acute Pain secondary to surgery b)Acute Pain (abdominal) secondary to surgery for colon cancer c)Chronic Pain secondary to cancer diagnosis d)Chronic Pain (abdominal) secondary to abdominal surgery

ANS:B The nurse should identify a diagnosis by specifying the location of the pain and any precipitating or etiological factors. This patient is experiencing acute abdominal pain that is related to his surgery for colon cancer; therefore, nursing diagnosis that specifies the surgery is the most appropriate diagnosis for this patient. In addition, options listing chronic pain are incorrect because the pain is acute, not chronic.

Ch 41 A nurse is entering a pharmacy request for patient medication in the patient's electronic health record (EHR) while seated at a computer in the nursing station. A physician approaches her and asks her to access another patient's EHR so that he can look at the patient's laboratory report. Which of the following is the best action for the nurse to take? a)Access the lab report for the physician. b)Log off the computer before proceeding. c)Quickly finish the pharmacy requisition before the physician logs on. d)Allow the physician to access the laboratory report immediately.

ANS:B The nurse should log off the computer and then allow the physician to log on under his own password. Accessing information that is not relevant to the care that the nurse is providing is a HIPAA violation. Rushing to complete a pharmacy request for patient medication is a situation of risk for medication error. The nurse should never hurriedly order or administer medication because that is when errors are more likely to occur. The nurse should never allow anyone to use her password to access information. The nurse must log off before any other provider uses the terminal for accessing patient data.

Ch 39 The focus of nursing activities in the preoperative phase is to: a) Admit the patient to the surgical suite b) Prepare the patient mentally and physically for surgery c) Set up the sterile field in the operating room d) Perform the primary surgical scrub to the surgical site

ANS:B The nursing focus in the preoperative phase is to prepare the patient mentally and physically for surgery. The patient is in the intraoperative phase when admitted to the surgical suite. The sterile field and the surgical scrub would be performed in the surgery suite during the intraoperative phase.

Ch 28 The nurse instructs a woman about providing a clean-catch urine specimen. Which of the following statements indicates that the patient correctly understands the procedure? a)"I will be sure to urinate into the 'hat' you placed on the toilet seat." b)"I will wipe my genital area from front to back before I collect the specimen midstream." c)"I will need to lie still while you put in a urinary catheter to obtain the specimen." d)"I will collect my urine each time I urinate for the next 24 hours."

ANS:B To obtain a clean-catch urine specimen, the nurse should instruct the patient to cleanse the genital area from front to back and collect the specimen midstream. This follows the principle of going from "clean" to "dirty." The nurse should have the ambulatory patient void into a "hat" (container for collecting the urine of an ambulatory patient) when monitoring urinary output, but not when obtaining a clean-catch urine specimen. A urinary catheter is required for a sterile urine specimen, not a clean-catch specimen. A 24-hour urine collection may be necessary to evaluate some disorders but a clean-catch specimen is a one-time collection.

Ch 41 The nurse who is not assigned to care for the patient can access the patient's electronic health record in which circumstance? a)The patient is the nurse's son in the emergency department and has pending lab results. b)The nurse had previously provided care to the patient during past hospitalizations. c)The nurse is reporting lab results to the Code Blue team during resuscitation. d)The patient is the nurse's neighbor who asks the nurse to review the chart.

ANS:C Although not directly assigned to the patient's care, the nurse is participating on the team providing emergency resuscitative care when relaying information from the patient's health record. In order to gain access to the patient's health information, regardless of her employment at the hospital where the patient was receiving care, the nurse would need to sign the HIPPA releases, just as any parent would need to do. While the nurse may have provided healthcare to the patient in the past, the nurse does not have permission to access the patient's records on the current admission if not assigned to provide care. Although the patient gave verbal permission to access of the records, the permission is not in writing and would be unauthorized access.

Ch 36 The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis. Which of the following responses indicates to the nurse that the medication is effective? a)The amount of sputum the patient expectorates decreases with each dose administered. b)Cough is completely suppressed, and she is able to sleep through the night. c)Dry, unproductive cough is reduced, but her voluntary coughing is more productive. d)Involuntary coughing produces large amounts of thick yellow sputum.

ANS:C Antitussives are cough suppressants that reduce the frequency of an involuntary, dry, nonproductive cough. Antitussives are useful for adults when coughing is unproductive and frequent, leading to throat irritation or interrupted sleep. Expectorants help make coughing more productive. The goal of an antitussive/expectorant combination is to reduce the frequency of dry, unproductive coughing while making voluntary coughing more productive.

Ch 26 Which body organ is mostly responsible for the metabolism of medications? a)Kidney b)Skin c)Liver d)Large intestine

ANS:C Drug metabolism takes place mainly in the liver, but medications can also be detoxified in the kidneys, blood plasma, intestinal mucosa, and lungs. If liver function is impaired due to liver disease, medications will be eliminated more slowly, and toxic levels may accumulate.

Ch 31 The patient reports pain after surgery, ranking it 6 on a scale of 1 to 10. She tells the nurse, "I don't want to be all doped up. My family is coming to visit and I want to be alert enough to visit with them." Which of the following medications would likely be most effective for postoperative pain relief without excessive sedation? a)Fentanyl IV b)Morphine IV c)Ibuprofen PO d)Hydrocodone PO

ANS:C Ibuprofen is a nonsedating analgesic. This would be the best choice but the nurse should instruct the patient to call if the pain is not tolerable because a stronger analgesic may be needed. If the patient desires to be alert, an opioid analgesic would not be the best choice because it produces drowsiness. Hydrocodone and fentanyl are opioid agonists and, based on the patient's request to be alert, would not be the best choice.

Ch 29 The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse should explain that ingestion of which substance may cause a false-negative fecal occult blood test? a)Vitamin D b)Iron c)Vitamin C d)Thiamine

ANS:C Ingestion of vitamin C can produce a false-negative fecal occult blood test; ingestion of vitamin D, iron, and thiamine does not. Iron can lead to a false-positive result.

Ch 41 You are a preceptor for a new nursing employee at the local hospital. She needs to access a patient's electronic health record (EHR) to retrieve laboratory results; however, the newly hired nurse has not yet received a computer password. What action should you take? a)Give her your password to use until she obtains her own password. b)Log on and remain with her while she views the record. c)Notify your supervisor that the new employee needs a password. d)Inform her that she will not receive a password until her orientation is complete.

ANS:C Never share your password with another person or log on to a computer to allow another access to information. Instead, notify your supervisor that the new employee needs a password. In most hospitals, nurses are given a password during their orientation.

Ch 28 The nurse is caring for a patient who underwent a bowel resection 2 hours ago. His urine output for the past 2 hours totals 50 mL. Which action should the nurse take? a)Do nothing; this is normal postoperative urine output. b)Increase the infusion rate of the patient's IV fluids. c)Notify the provider about the patient's oliguria. d)Administer the patient's routine diuretic dose early.

ANS:C The amount of 50 mL in 2 hours is not normal output. The kidneys typically produce 60 mL of urine per hour. Therefore, the nurse should notify the provider when the patient shows diminished urine output (oliguria). Patients who undergo abdominal surgery commonly require increased infusions of IV fluid during the immediate postoperative period. The nurse cannot provide increased IV fluids without a provider's order. The nurse should not administer any medications before the scheduled time without a prescription. The provider may hold the patient's scheduled dose of diuretic if he determines that the patient is experiencing deficient fluid volume.

Ch 38 The nurse assesses that her patient's intravenous solution has infiltrated into the tissues. What action should she take first? a) Aspirate, then inject 0.5 mL normal saline. b) Restart the IV line in a different vein. c) Stop the infusion immediately. d) Notify the primary care provider.

ANS:C The nurse should first stop the infusion to avoid further tissue trauma. Because the IV has infiltrated, you must assume that the nurse has already checked the patency of the line by aspirating. There is no point in injecting saline because doing so puts even more fluid in the tissues. Injecting fluid to try to clear a clot from the catheter is not recommended because of the possibility of causing an embolism. Once the infusion is stopped, the nurse must assess whether the patient needs additional IV therapy. If so, a new IV line must be restarted above the site of infiltration or in the opposite arm. The nurse may need to inform the primary care provider if she is unable to find a new IV site or if she believes the patient no longer needs an IV.

Ch 26 A patient has difficulty taking liquid medications from a cup. How should the nurse administer the medications? a)Request that the physician change the order to the IV route. b)Administer the medication by the IM route. c)Use a needleless syringe to place the medication in the side of the mouth. d)Add the dose to a small amount of food or beverage to facilitate swallowing.

ANS:C When a patient has difficulty taking liquid medications from a cup, the nurse should use a syringe without a needle to place the medication in the side of the patient's mouth. After placing the syringe between the gum and cheek, the nurse should push the plunger to administer the medication slowly. It is not necessary to ask the prescriber to change the order to the IV route; it is preferable to use the least invasive route. The nurse cannot administer a drug by another route without a prescription to do so. Dosing might not necessarily be the same in the oral versus the IM route; thus, a prescription is needed to change the route. Some drugs are not compatible with various food or liquid substances and should be taken on an empty stomach. Consult a pharmacist, prescriber, or drug formulary.

Ch 38 Which of the following is the principal site for regulation of fluid and electrolyte balance? a) Cardiac system b) Vascular system c) Pulmonary system d) Renal system

ANS:D A balance of fluid and electrolytes is essential to maintain homeostasis. Excesses or deficits can lead to severe disorders. The kidneys are the principal regulator of fluid and electrolyte balance and are the primary source of fluid output. Specific hormones (e.g., ADH, aldosterone) cause the kidneys to regulate the body's fluid and electrolyte balance. The heart and vascular system are involved in fluid balance but not in electrolyte balance and not as dramatically in fluid balance as are the kidneys—that is, they do not actually regulate electrolytes. The pulmonary system plays a major role in regulation of acid-base balance

Ch 2 How does a nursing diagnosis differ from a medical diagnosis? A nursing diagnosis is: a)Terminology for the client's disease or injury b)A part of the client's medical diagnosis c)The client's presenting signs and symptoms d)A client's response to a health problem

ANS:D A nursing diagnosis is the client's response to actual or potential health problems.

Ch 19 During advanced cardiac life support (ACLS) training, a nurse performs defibrillation using a mannequin. Which teaching strategy is being employed? a)One-to-one instruction b)Computer-assisted instruction c)Role modeling d)Simulation

ANS:D ACLS training uses simulation by creating a scenario using resuscitation mannequins and teaching healthcare workers to respond appropriately to life-threatening cardiopulmonary events. The nurse is demonstrating the skill of defibrillation. ACLS certification requires learners to perform the skill for the examiner. With one-to-one instruction, one instructor orally presents information to one student. With ACLS training, the healthcare team is involved and not just individual nurses. In role modeling, the teacher teaches by example, demonstrating the behaviors (not skills) that need to be acquired by learners.

Ch 39 A patient is to have a sequential compression device (SCD) applied on the postoperative unit. The patient is wearing knee-high elastic (antiembolism) stockings. When applying the SCD, what should the nurse do? a) Remove the antiembolism stockings and not replace them. b) Replace the knee-high stockings with thigh-high stockings. c) Notify the surgeon that the patient is wearing antiembolism stockings. d) Apply the SCD over the knee-high antiembolism stockings.

ANS:D If elastic stockings have been ordered with the sequential compression device, leave them in place; if the patient is not yet wearing them, obtain them and put them on the patient. Knee-high stockings do not need to be replaced with thigh-high stockings. Some research has shown knee-high stockings to be equally effective. There is no need to notify the surgeon, as patients commonly return from surgery wearing antiembolism stockings, as prescribed.

Ch 39 A patient has chronic confusion secondary to dementia. As a result, he is unable to sign an informed consent for surgery. In this situation: a) An informed consent is not needed b) Two nurses may sign the informed consent for the patient c) The surgeon must sign the informed consent d) A family member will be asked to sign the informed consent

ANS:D In most states, a family member, conservator, or legal guardian may give consent for a procedure if a patient is not capable of giving an informed consent or if the patient is a minor.

Ch 41 The nurse is looking for the most current evidence related to safe medication administration. What source provides the most reliable information? a)Peer-reviewed scholarly journals b)Popular periodicals c)Social media Internet sites d)Online drug formulary

ANS:D Online drug formularies published by authoritative sources are reliable and current, for example, the U.S. FDA Medication Guides or the Physicians' Desk Reference (PDR). Peer-reviewed journal articles are read by experts in the field and critiqued before they are published to check for reliability. They are a good source of reliable information, although they would be a secondary source. Popular periodicals are secondary sources of information; they are not scholarly, technical, peer-reviewed, or verified by an authoritative source. Social media sites are largely merely a sharing of opinions and lack reliability.

Ch 26 Which action should the nurse take immediately after administering a medication through a nasogastric tube? a)Verify correct nasogastric tube placement in the stomach. b)Auscultate the abdomen for presence of bowel sounds. c)Immediately administer the next prescribed medication. d)Flush the tube with water using a needleless syringe.

ANS:D The nurse should flush the nasogastric tube with water using a needleless syringe after administering each medication. Some medications are less effective when given in combination with others. The nurse should verify nasogastric tube placement and auscultate the abdomen for bowel sounds before administering the medication.

Ch 31 After receiving ibuprofen (Motrin) 800 mg orally for right hip pain, the patient states that his pain is 8 out of 10 on the numerical pain scale. Which action should the nurse take? a)Use nonpharmacological therapy while waiting 3 more hours before next dose. b)Administer an additional 800 mg oral dose of ibuprofen right away. c)Do nothing because the patient's facial expression indicates he is comfortable. d)Notify the prescriber that the current pain management plan is ineffective.

ANS:D The nurse should notify the prescriber that the current pain management plan is ineffective. The nurse should not delay treatment for 3 hours when the next dose of medication is due. The nurse cannot administer an extra dose of ibuprofen without a prescriber's order to do so. Ibuprofen 800 mg is a maximum dose for most individuals. The nurse should not assume that the patient is not in pain simply because he appears comfortable; pain is what the patient states it is.

Ch 28 Which intervention should the nurse take first to promote micturation in a patient who is having difficulty voiding? a)Insert an indwelling urinary catheter. b)Notify the provider immediately. c)Insert an intermittent, straight catheter. d)Pour warm water over the patient's perineum.

ANS:D The nurse should perform independent nursing measures such as pouring warm water over the patient's perineum before notifying the provider. If nursing measures fail, the nurse should notify the provider. The provider may order an indwelling urinary catheter or a straight catheter to relieve the patient's urinary retention.

Ch 38 A patient's vital signs prior to a blood transfusion were: T = 97.6°F (36.4°C); P = 72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg. Twenty minutes after the transfusion was begun, the patient began complaining of feeling "itchy and hot." The nurse discovered a rash on the patient's trunk. Vital signs were T = 100.8°F (38.2°C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the priority intervention? a) Administer an antihistamine (antiallergenic) medication. b) Flush the blood tubing with D5W immediately. c) Prepare for emergency resuscitation. d) Stop the blood transfusion immediately.

ANS:D The nurse should suspect a transfusion reaction. When a transfusion reaction is suspected, the infusion should be stopped immediately. The blood bag and tubing must be sent to the laboratory for analysis. A new IV line of normal saline should be hung. Diphenhydramine (an antihistamine) may be ordered once the physician has been notified of the patient's condition. There is no information indicating that the patient is in danger of cardiovascular collapse or requires resuscitation.

Ch 39 The preoperative phase encompasses which period of time? a) Entry to the operating suite until admission to postanesthesia care b) Entry into the operating suite until discharge from the hospital c) The decision to have surgery until admission to postanesthesia care d) The decision to have surgery until entry to the operating suite

ANS:D The preoperative phase begins with the decision to have surgery and ends when the patient enters the operating room. The intraoperative phase begins when the patient enters the operating suite and ends when the patient is admitted to the postanesthesia care unit.

Ch 36 You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patient's respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern? a)Biot's breathing b)Kussmaul's respirations c)Sleep apnea d)Cheyne-Stokes respirations

ANS:D This respiratory pattern is known as Cheyne-Stokes respirations. It is often associated with damage to the medullary respiratory center or high intracranial pressure due to brain injury.

Ch 39 The postoperative patient returned to the surgical nursing unit at 1:30 p.m. The evening shift nurse receives the report and begins working at 3:30 p.m. How often will the evening shift nurse take this patient's vital signs? a)Immediately, then every 30 minutes for the next 2 hours b)Immediately, then every hour for the next 4 hours c)Every hour beginning 30 minutes from now until end of shift d)Immediately, then every 30 minutes 2 more times, then hourly

ANS:D Vital signs would have been taken every 15 minutes for the first hour (1:30 to 2:30), then every 30 minutes for the next 2 hours (2:30 to 4:30). It is now 3:30, so the nurse will take vital signs immediately, again at 4:00, and again at 4:30, at which time the nurse can begin to take hourly vital signs if the patient's vital signs are within acceptable and stable range. Vital signs would have been taken every 15 minutes for the first hour (1:30 to 2:30), then every 30 minutes for the next 2 hours (2:30 to 4:30); therefore, "immediately and every 30 minutes for the next 2 hours" is incorrect (on that schedule, the nurse would be taking VS at 3:30, 4:00, 4:30, 5:00, and 5:30). It is too soon to begin hourly vital signs. At this time, the patient should be assessed more often than every hour.

Ch 26 The physician prescribes warfarin 5 mg orally at 1800 for a patient. After administering the medication, the nurse realizes that she administered a 10 mg tablet instead of the prescribed 5 mg PO. Which of the following actions by the nurse is appropriate? a)No action is necessary because an extra 5 mg of warfarin is not harmful. b)Call the prescriber and ask her to change the order to 10 mg. c)Document on the chart that the drug was given and indicate the drug was given in error. d)Complete an incident report according to the facility's policy.

ANS:D When a medication error is made, the nurse should first check the patient to assess for negative effects. If she is unfamiliar with the side effects of the medication, she should consult a drug reference, the licensed pharmacist at the institution, or the prescriber. Next, she should verify that she made an error and identify the type. Notify the nurse in charge and the physician. Follow any orders the physician prescribes. Document the drug, the dose, site, route, date, and time in the patient's healthcare record but do not document that the drug was given in error. Complete an incident report according to the facility's policy; submit the signed report to the nurse manager. Finally, critically review the error, and identify ways to improve your practice.

Ch 18 A patient refuses a dose of medication. How should the nurse document the event? a)Patient is uncooperative and refuses the prescribed dose of digoxin. b)Patient refuses the 0900 dose of digoxin. c)Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin. d)0900 dose of digoxin not given.

ANS:B "Patient refuses the 0900 dose of digoxin" objectively describes the event in which the patient refuses to take his 0900 dose of digoxin. "0900 dose of digoxin not given," provides no explanation why the medication was not given. The other two options offer judgmental information, which should be avoided when charting.

Ch 44 A patient who is being discharged asks the nurse, "Can I take you out for dinner to show my appreciation for all that you have done for me? I really like you." The nurse's best response is which of the following? a)"Yes, that would be nice. It is really great to be appreciated." b)"No, and please do not ask again. You should have been told that already." c)"Thank you; however, I have to refuse, even though the thought is appreciated." d)"We will have to wait 3 days after you have been discharged to have a relationship."

ANS: C Accepting gifts from patients is a breach of professional boundaries: social contact. Nurses cannot accept gifts from patients in the form of dinners, money, social contact, and the like. The nurse should not enter into a relationship based on the patient's attempt to compensate her for performing her role responsibilities. Waiting 3 days would not change that. Telling the patient not to ask again, and that she should already know that, borders on rudeness. Although it reflects the understanding about gifts and professional boundaries, it is not an empathetic response and would not help build a trusting relationship.

Ch 4 What is wrong with the following diagnostic statement? "Impaired Physical Mobility related to laziness and not having appropriate shoes." The statement is: a)Judgmental b)Too complex c)Legally questionable d)Without supportive data

ANS:A "Lazy" implies criticism of the client and therefore is judgmental. There need to be several (certainly more than two) etiological factors for the statement to be complex. There is no blame implied or harm resulting, so the statement is not legally questionable. There is no minimum "amount" of supportive data for a diagnosis and the stated etiology related to the nursing diagnosis. No supportive data are given in the stem of the question, so you could not choose "lack of data" as the best answer because all the options lack data as far as you can tell from the information given in the question. In addition, it is not necessary to include supportive data in the diagnostic statement (although some do prefer to use AMB and include defining characteristics).

Ch 20 The nurse assesses the following changes in a client's vital signs. Which client situation should be reported to the primary care provider? a)Decreased blood pressure (BP) after standing up b)Decreased temperature after a period of diaphoresis c)Increased heart rate after walking down the hall d)Increased respiratory rate when the heart rate increases

ANS:A A decrease in the client's blood pressure when standing indicates orthostatic hypotension, and the cause should be investigated. The changes in vital signs indicated in the other options are normal changes for the situations.

Ch19 Which intervention by the nurse would be best to motivate a patient newly diagnosed with hypertension to learn about the prescribed treatment plan? a)Explain that when left untreated, hypertension may lead to stroke. b)Ask the patient to let you know when he is ready to learn. c)Encourage the patient to learn about various treatment options. d)Reassure the patient that adhering to the treatment produces a good outcome.

ANS:A A patient newly diagnosed with hypertension may not be motivated to learn because he most likely has not experienced physical symptoms or other outward complications. Therefore, the nurse should motivate the patient by pointing out serious risks to the quality of life if the blood pressure control is not achieved. Although readiness to learn is an important consideration, treatment might be delayed too long if the patient does not appropriately perceive the immediacy of the health risk. Simply encouraging a patient to learn about blood pressure and treatment options might not be suitable motivation to engage in active learning and to comply with prescribed treatment. Reassuring the patient and promising a good outcome by complying with medical treatment is not appropriate. Adhering to medical therapy reduces the risk for stroke and other complications; however, this can't be guaranteed.

Ch 45 Before the end of the shift, the nurse records the occurrences for each patient in the electronic medical record. Which statement below indicates that the nurse understands the main principle of accurate charting? a)"Charting communicates to members of the healthcare team the patient's care and responses during my shift." b)"Charting is important so that I may share with the healthcare team my opinions of what happened with the patient." c)"Charting allows the other nurses to understand the patient care provided during my shift." d)"Charting is important to comply with practice guidelines and institutional policies."

ANS:A Accurate charting is needed to clearly communicate the patient's care and responses to other members of the healthcare team, not just the other nurses. This statement reflects the nurse's understanding of this principle. The nurse's opinions are not to be placed in a chart because they are not factual. While charting is important to comply with standards of practice and institutional policy, it is not the main principle of accurate charting.

Ch 2 It is important for nurses to be critical thinkers because: a)All clients are unique and have individual needs and differences b)All nursing actions are based on theoretical knowledge c)Nurses choose their actions primarily by following professional guidelines d)Nurses provide care based on individual client preferences

ANS:A All clients are unique and have individual differences. Nursing actions are not solely based on theoretical knowledge. Actions are based on theoretical knowledge, practical knowledge, and self-knowledge. Following guidelines does not usually require critical thinking, and guidelines often do not offer adequate help in managing complex situations. Client preferences are certainly included in the plan of care but they do not cover the broad spectrum of being a critical thinker—it does not require critical thinking merely to do what the client prefers.

Ch 5 What do initial, ongoing, and discharge planning have in common? a)They are based on assessment and diagnosis. b)They focus on the patient's perception of his needs. c)They require input from a multidisciplinary team. d)They have specific time lines in which to be completed.

ANS:A All planning is based on nursing assessment data and identified nursing diagnoses. The patient should have input, and multidisciplinary input may be used; however, the planning is based on the nursing assessment. The different types of planning are intertwined and may or may not be done at distinct, separate times. Discharge planning often requires a multidisciplinary team, but initial and ongoing planning may not. Initial planning is usually begun after the first patient contact, but there is no specified time for completion. Ongoing planning is more or less continuous and is done as the need arises. Discharge planning must be done before discharge.

Ch 4 Which of the following is an example of a problem that nurses can treat independently? a)Hemorrhage b)Nausea c)Fracture d)Infection

ANS:B A nursing diagnosis (or nursing problem) is a human response to a disease, injury, or other stressor that nurses can identify, prevent, or treat independently. Nausea is the only problem that meets that criterion; all others are medical or collaborative problems.

Ch 3 Which of the following is an example of an ongoing assessment? a)Taking the patient's temperature 1 hour after giving acetaminophen (Tylenol) b)Examining the patient's mouth at the time she complains of a sore throat c)Requesting the patient to rate intensity on a pain scale at the first perception of pain d)Asking the patient in detail how he will return to his normal exercise activities

ANS:A An ongoing assessment occurs when a previously identified problem is being reassessed—for example, taking an hourly temperature when a patient has a fever. Examining the mouth is a focused assessment to explore the patient's complaint of sore throat. Asking for a pain rating is a focused assessment at the first complaint of pain. A detailed interview about exercise is a special needs assessment; there is no way to know whether it is initial or ongoing.

Ch 45 The nurse on night shift is caring for a patient who is confused and gets out of bed frequently. The nurse pushes him into a chair and states, "Do not get out of this chair or I will tie you up and leave you alone for hours." The nurse's action is an example of: a)Assault and battery b)Libel c)False imprisonment d)Safe nursing practice

ANS:A Assault is putting the patient in fear of harm and battery is touching him without his permission or in a way that is forceful. Pushing the patient into the chair is considered battery; threatening to restrain him and leave him alone for hours is assault. False imprisonment is the restraint of a person without proper legal authorization. The patient was not restrained. This is not an example of safe nursing practice, which would require the nurse to initiate the hospital's fall precaution protocol. Restraints are applies as a last resort. Libel is a verbal or written type of character defamation.

Ch 19 Prior to discharge, a patient with diabetes needs to learn how to check a finger-stick blood sugar reading before taking insulin. Which action will best help the patient remember proper technique? a)Encouraging the patient to check the blood sugar each time the nurse gives insulin b)Providing feedback after the patient takes his blood sugar reading for the first time c)Verbally instructing the patient about how to obtain a finger-stick blood sugar reading d)Offering a brochure that describes the technique for checking a blood sugar reading

ANS:A Having the patient perform a finger stick with the nurse each time insulin is administered is the best way to practice the correct technique and gain confidence prior to discharge. Repetition increases the likelihood that the patient will retain information and incorporate it into the daily management of his diabetes care. Although feedback is important, the patient might need it on more than one occasion. Verbal instructions for performing a new skill are most useful when the patient has an opportunity to perform the technique. A brochure is informative and useful for later reference; however, information about performing a new skill is best offered when the patient can see it demonstrated and has the opportunity to practice it with the feedback from the nurse.

Ch 21 A patient who speaks little English is admitted to the hospital after experiencing severe abdominal pain. Which nursing diagnosis is preferred for this patient? a)Impaired Communication b)Readiness for Enhanced Communication c)Impaired Verbal Communication d)Sensory Alteration

ANS:A Impaired Communication is the preferred nursing diagnosis when the patient is unfamiliar with the dominant language. Impaired Verbal Communication is an appropriate diagnosis for the patient with expressive or receptive aphasia. Readiness for Enhanced Communication is appropriate when the patient expresses willingness to enhance communication. Sensory Alteration is appropriate when there is a change in the characteristics of the patient's incoming stimuli.

Ch 7 Which type of client-centered evaluation is performed at specific, scheduled times? a)Intermittent b)Ongoing c)Terminal d)Process

ANS:A Intermittent evaluation is performed at specific times; it enables the nurse to judge the progress toward goal achievement and to modify the plan of care as needed. Ongoing evaluation is performed while implementing, immediately after an intervention, or with each client contact; these are not necessarily scheduled events. Terminal evaluation is performed at the time of discharge. It describes the client's health status and progress toward goals at that time. Process evaluation focuses on the manner in which care is given. It may be performed at specific times, but it is not considered a client-centered evaluation.

Ch 24 Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis? a)Risk for Falls b)Risk for Ineffective Airway Clearance (choking) c)Risk for Poisoning d)Risk for Suffocation (drowning)

ANS:A Loss of muscle strength and joint mobility place older adults at risk for falls. Choking, drowning, and ingesting poisons are primary safety concerns for infants and toddlers.

Ch 23 The patient in the intensive care unit has developed a urinary tract infection related to the indwelling urinary catheter. Which of the following best describes this type of infection? a) Nosocomial b) Healthcare associated c) Multidrug-resistant organisms (MDRO) d) Unavoidable occurrence

ANS:A Nosocomial infections refer specifically to hospital-acquired infections. Healthcare-associated infections (HAIs) refer to infections associated with healthcare given in any setting (hospitals, long-term care facilities); however, nosocomial is more specific. A multi-drug-resistant organism (MDRO) is a bacterium that is resistant to many antibiotics. Examples of MDROs include methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Indwelling urinary catheters are needed in many circumstances, and might be unavoidable in that sense. However, the infection itself is not unavoidable because it can be prevented in most instances with meticulous nursing care. Therefore "unavoidable occurrence" is an incorrect option.

Ch 18 The nursing instructor is teaching the student about occurrence reports. Which statement by the student indicates an understanding of the purpose of occurrence reports? a)"Occurrence reports track problems and identify areas for quality improvement." b)"Occurrence reports are required by the Food and Drug Administration (FDA) to report drug errors." c)"The Joint Commission requires occurrence reports for all client falls." d)"Occurrence reports provide legal information should the patient seek legal action after an unusual occurrence."

ANS:A Occurrence reports are used to track problems and identify areas for quality improvement. Occurrence reports are not used to provide legal information should a patient seek legal action. As an internal communication and documentation tool, occurrence reports are not required to be reported to the FDA or The Joint Commission.

Ch 21 The nursing student is assigned to care for a patient who has just been diagnosed with advanced stage cancer. The patient is very upset and crying. The nursing student states to her instructor, "I don't know what to do. My patient just can't stop crying." What is the best response from the instructor? a)"Sometimes just sitting with patient and remaining silent can be the best care." b)"You will need to wait patiently until your patient stops crying to complete your care." c)"You will not be effective while he is crying. Tell the patient you will come back later." d)"Try to distract the patient from crying by trying to change the conversation."

ANS:A One of the most effective and useful tools in enhancing therapeutic communication is the use of silence. Using silence demonstrates acceptance and allows the patient to compose his thoughts and perhaps provide other information. It is especially effective when the patient is emotionally upset. Waiting for the patient to stop crying to complete care is a missed opportunity for the nurse to support the patient's emotional needs and show caring during a difficult time. Additionally, the patient would be denied the opportunity to express his feelings, fears, and other emotions. Distracting patients or changing the topic of the conversation is actually a barrier to communication. This may make the patient feel that his feelings are not accepted or warranted, or that the nurse is uninterested.

Ch 7 Which task can be delegated to nursing assistive personnel (NAP)? a)Turn and reposition the patient every 2 hours. b)Assess the patient's skin condition. c)Change pressure ulcer dressings every shift. d)Apply hydrocolloid dressing to the pressure ulcer.

ANS:A The nurse can delegate turning the client every 2 hours to the nursing assistive personnel. Assessing the client's skin condition, changing pressure ulcer dressings, and applying a hydrocolloid dressing to a pressure ulcer are all interventions that require nursing knowledge and judgment.

Ch 21 The wife of an elderly patient begins crying after she is informed that he is has a terminal illness. Which intervention by the nurse is best? a)Sit quietly with the patient's wife while she composes her thoughts. b)Inform his wife that a chaplain is available if she would like to speak to him. c)Remind his wife that her husband has lived a long and good life. d)Tell his wife there are always options and suggest she not give up hope.

ANS:A The nurse can intervene best by sitting quietly with the patient's wife, allowing her to compose her thoughts. Silence communicates acceptance. After processing the bad news, the wife can provide the nurse with further information, such as whether she would like to consult with a chaplain. Telling the wife there are always options offers false reassurance and would probably discourage her from further communication.

Ch 26 When the nurse enters a patient's room to administer a medication, he calls out from the bathroom, telling her to leave his medication on the bedside table. He reassures her that he will take the medication as soon as he is finished. How should the nurse proceed? a)Inform the patient that she will return when he is finished in the bathroom. b)Wait outside the bathroom door until the patient is ready for the dose. c)Withhold the dose until the next administration time later in the day. d)Document that the dose was omitted in the medication administration record.

ANS:A The nurse should inform the patient that she will return with the medication when he is finished in the bathroom. The nurse likely would not have time to stand outside the door and wait for the patient to finish in the bathroom. If the medication is left at the bedside for the patient, the nurse cannot be sure that the patient actually took the medication. Withholding the dose until the next administration time may compromise the patient's condition and is not appropriate nursing action. The drug should not be omitted; therefore, the nurse should not document a missed dose in the medication administration record.

Ch 18 The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order? a)Repeat the order to the prescriber even if she believes she understood the order correctly. b)Immediately notify the pharmacy of the order and verify it with a pharmacist. c)Ask the unit secretary to listen to the prescriber on the phone to verify the order. d)Transcribe the order on notepaper and verify the dosage in a drug handbook.

ANS:A The nurse should repeat the order to the prescriber even if she believes she understood it entirely. If possible, she should have a second nurse (not the unit secretary) listen to the order to verify accuracy. Only the prescribing provider, not the pharmacist, can verify the order. The nurse should transcribe the order directly on the patient's chart. Transcribing it on a piece of paper and then copying it again introduces one more chance of error.

Ch 25 For which patient is it most important to provide frequent perineal care? The patient: a)With active lower gastrointestinal bleeding b)Who has had an episode of diabetic ketoacidosis c)Who has a circumcised penis d)With a history of acute asthma

ANS:A The patient admitted with active lower GI bleeding will require frequent perineal care because of the irritating effect of enzymes in the stools. The uncircumcised patient, not the circumcised patient, may require frequent perineal care. Those with diabetic ketoacidosis or who have had acute asthma do not require frequent perineal care.

Ch 45 A registered nurse administers the wrong medication to a patient. She does not notify anyone of the error and documents that the correct medication was administered. The nurse was reported to the state board of nursing. Which of the following actions can the state board of nursing take against the nurse in this situation? a)Disciplinary action against the nurse's license to practice b)Criminal misdemeanor charges against the nurse c)Medical malpractice lawsuit against the nurse d)Employment release from the institution

ANS:A The state board of nursing is empowered to initiate disciplinary action against the nurse's license for professional misconduct. The board does not bring criminal charges or sentence the nurse to jail; that is the parameter of the state prosecutor and judge. A patient or the person harmed can bring medical malpractice lawsuits against the nurse.

Ch 20 The nurse is caring for a critically ill patient with a severe midbrain injury involving the hypothalamus. Which vital sign is most critical for the nurse to monitor closely for this patient? a)Temperature b)Pulse c)Respiration d)Blood pressure

ANS:A Thermoregulation is the process of maintaining a stable body temperature. To keep the body temperature constant, the body must balance heat production and heat loss. This balance is controlled by the hypothalamus, located between the cerebral hemisphere of the brain. Similar to a thermostat, the hypothalamus recognizes even small changes in body temperature that are sent to it by sensory receptors in the skin.

Ch 20 Which one of the following clients would probably have a higher than normal respiratory rate? A client who has: a)Had surgery and is receiving a narcotic analgesic b)Had surgery and lost a unit of blood intraoperatively c)Lived at a high altitude and then moved to sea level d)Been exposed to the cold and is now hypothermic.

ANS:B A reduction in hemoglobin from blood loss would increase the respiratory rate. Narcotics and hypothermia slow the respiratory rate. Going from lower altitudes to higher altitudes inhibits oxygen binding, so going to a lower altitude would decrease the respiratory rate or have no effect. Hypothermia decreases the metabolic rate, so the respiratory rate would like decrease.

Ch 45 A 4-year-old child is brought to the emergency department by his mother. He has a large bruise on his left chest and multiple contusions on his face. His mother tells you her boyfriend intentionally pushed the child down the stairs in anger. The child appears to be in a great deal of pain. Which of the following four correct items should the nurse do first? a)Notify the nursing supervisor of the suspected physical abuse. b)Complete a physical assessment of the child. c)Obtain an order for pain medication. d)Notify Child Protective Services of the suspected abuse.

ANS:B Although the nurse must report to designated authorities (Child Protective Services) suspected physical abuse, the primary responsibility of the nurse in this situation is to evaluate the patient's physical condition and extent of his injuries for appropriate medical treatment to be provided. Pain medication should not be administered prior to a thorough physical assessment. The nurse should always notify the nursing supervisor if any outside agencies may need to be contacted.

Ch 22 The nurse asks the patient to spread his fingers and then bring them together again. Which of the following is the nurse testing when asking him to bring his fingers together? a)Abduction b)Adduction c)Flexion d)Extension

ANS:B Asking the patient to spread his fingers tests abduction; asking him to bring them together assesses adduction. Asking the patient to make a fist tests flexion, whereas asking him to extend the hand tests extension.

Ch 21 The nurse must insert a nasogastric (NG) tube into a patient with a bowel obstruction. Before inserting the tube, the nurse must explain the procedure to the patient. Which explanation by the nurse is best? Assume that all provide correct information. a)"I'm going to insert an NG tube and connect it to low Gomco to keep your stomach empty." b)"I'm going to insert a tube through your nose into your stomach to prevent you from vomiting." c)"I'm going to insert an NG tube through your nares to suction your secretions and prevent emesis." d)"Hold still, please; I need to elevate the head of the bed and insert this tube."

ANS:B Because patients are typically confused by medical terminology, the nurse should use language that the patient can understand. "NG tube," "Gomco," "suction secretions," "nares," and "emesis" are all medical jargon that the patient might not understand. Moreover, the nurse should explain all procedures before performing them to help minimize the patient's anxiety. "Hold still, please . . ." offers no explanation of the reason that the NG tube is being inserted.

Ch 18 The nursing assistive personnel (NAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and provides care. Identify the correct documentation of the fall. a)Patient found on floor after falling out of bed and verbalizes (L) hip pain. b)Patient found on floor by NAP Smith and verbalizing (L) hip pain. c)Patient fell out of bed but is currently in bed. d)Patient reminded not to climb OOB after falling.

ANS:B Charting must be accurate and succinct. Only chart what you observe. Do not chart what others have observed as your own observation. Avoid judging patients; instead, chart objectively.

Ch 44 The Code of Ethics for Nurses: a)Is legally binding b)Is not legally binding c)Is legally binding in some circumstances d)Cannot be used in legal

ANS:B Codes of ethics are open to public scrutiny. The ethical aspects of nursing work, just like the technical aspects, are subject to review by professional groups and licensure boards, which may use sanctions to punish code violations. The Code of Ethics for Nurses establishes standards of practice for nurses. Although nursing codes are not legally binding, they are often used in legal cases involving nurses (e.g., malpractice) to identify deviations from professional standards of practice.

Ch 7 The nurse works with the respiratory therapist to administer a patient's breathing treatments. He reports the patient's breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. This is an example of: a)Delegation b)Collaboration c)Coordination of care d)Supervision of care

ANS:B Collaboration means working with other caregivers to plan, make decisions, and perform interventions. Delegation is the transfer to another person of the authority to perform a task in a selected situation. Coordination of care involves scheduling treatments and activities with other departments, putting together all the patient data to obtain "the big picture." Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity or task.

Ch 18 The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone prescription for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order? a)09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain. Kay Andrews, RN b)09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain T.O.: Dr. D. Kelly/Kay Andrews, RN c)09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain V.O.: Dr. D. Kelly/Kay Andrews, RN d)09/02/16 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN

ANS:B Correct documentation of a telephone order is as follows: "09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain T.O.: Dr. D. Kelly/Kay Andrews, RN" (date, time, medication, route, frequency of dose, circumstances under which it is to be given, prescriber's name and title, nurses name and title.) The other options demonstrate incomplete documentation of a telephone order.

Ch 2 What do critical thinking and the Nursing Process have in common? a)They are both linear processes used to guide one's thinking. b)They are both thinking methods used to solve a problem. c)They both use specific steps to solve a problem. d)They both use similar steps to solve a problem.

ANS:B Critical thinking and the Nursing Process are ways of thinking that can be used in problem-solving (although critical thinking can be used for other than problem-solving applications). Neither method of thinking is linear. The Nursing Process has specific steps; critical thinking does not.

Ch 3 Which of the following examples includes both objective and subjective data? a)The client's blood pressure reading is 132/68 mm Hg and heart rate is 88 beats/min. b)The client's cholesterol is elevated, and he states he likes fried food. c)The client states she has trouble sleeping and that she drinks coffee in the evening. d)The client states he gets frequent headaches and that he takes aspirin for the pain.

ANS:B Elevated cholesterol is objective and "states he likes fried food" is subjective. Objective data can be observed by someone other than the patient (e.g., from physical assessments or laboratory and diagnostic tests). Subjective data are information given by the client. Blood pressure and heart rate measurements are both objective. "States . . . trouble sleeping and . . . drinks coffee . . ." are both subjective. States ". . . frequent headaches and . . . takes aspirin . . ." are both subjective.

Ch 20 A client's vital signs 4 hours ago were temperature (oral) 101.4°F (38.6°C), heart rate 110 beats/min, respiratory rate 26 breaths/min, and blood pressure 124/78 mm Hg. The temperature is now 99.4°F (37.4°C). Based only on the expected relationship between temperature and respiratory rate, the nurse might best anticipate the client's respiratory rate to be: a)16 b)18 c)20 d)22

ANS:B For every degree Fahrenheit (0.6°C) the temperature falls, the respiratory rate may decrease up to four breaths per minute. The client's temperature has fallen 2 degrees; multiplied by 4, this is 8. It was 26 breaths/minute. 26 minus 8 = 18 breaths/min. Keep in mind that this is an estimate and would vary depending on the patient's baseline health, current condition, age, and other factors.

Ch 19 A patient with a diabetic foot ulcer will need to perform dressing changes after discharge. When should the nurse schedule the teaching session(s)? a)Within 10 minutes after his next dose of oral pain medication b)After the patient wakes up from a restful nap c)Before the surgeon debrides the wound d)Before the patient undergoes flow studies of his affected leg

ANS:B For learning to be most effective, teaching must occur when the patient is most receptive. A patient's capacity to take in new information is reduced when he is anxious, in this example about testing or treatment, or is tired, or experiencing pain. Therefore, the best time to teach this patient is when he is rested, such as after a restful nap. Ten minutes is not enough time for oral medication to take effect and relieve pain.

Ch 4 Based only on Maslow's Hierarchy of Needs, which nursing diagnosis should have the highest priority? a)Self-Care Deficit b)Risk for Aspiration c)Impaired Physical Mobility d)Functional Urinary Incontinence

ANS:B Highest priority is given to problems that are life threatening or that could be destructive to the client. Safety is most basic in Maslow's hierarchy. Even though Risk for Aspiration is not an actual problem, it poses the most immediate life-threatening risk to the client; nursing interventions must be performed to prevent it from becoming an actual problem.

Ch 20 The nurse administers two blood pressure (BP) medications to a patient and asks the certified nurse assistant (CNA) to obtain a BP reading in 30 minutes. The CNA states, "I just took his BP." What is the most appropriate response by the nurse? a)"Take it again so we can be sure nothing else is wrong with him." b)"I need to check the patient's response to the BP medications." c)"If his BP drops too much, I'll need to discontinue one of the medications" d)"If you just took his BP, then recheck it in 2 hours instead."

ANS:B Many factors affect blood pressure including age, gender, family history, lifestyle, stress, and medications. In this item, the nurse has just administered BP medications to the patient. Many BP medications alter BP. The effect may be intended, as with antihypertensive medications, or unintended, such as a drop in BP when patients take pain medications. The nurse must evaluate the effectiveness of the BP medications and also unintended effects, such as too great a fall in BP. A nurse may contact the prescriber regarding BP medications, but she cannot discontinue them without an order. Two hours is too long to wait to evaluate medication effects, as the drugs will likely peak before that.

Ch 20 After obtaining a full set of vital signs, the nurse assesses the client's fifth vital sign as a 7 on a scale of 1 to 10 (or 7/10). Which action by the nurse is most appropriate? a)Document the pulse pressure as normal and continue the client's assessment. b)Review the client's records to determine the last time he received pain medication. c)Assess the client's pulse on the opposite side for comparison. d)Wait 2 minutes and retake the client's blood pressure.

ANS:B Pain is considered to be the "fifth vital sign." A pain rating of 7 out of 10 means the patient is experiencing a significant amount of pain. This can lead to an increase in blood pressure and pulse rate. The nurse's initial focus is on addressing the patient's pain.

Ch 24 Which is the most commonly reported incident in hospitals? a)Equipment malfunction b)Patient falls c)Laboratory specimen errors d)Treatment delays

ANS:B Patient falls are by far the most common incident reported in hospitals and long-term care facilities. Although equipment (e.g., infusion pump) malfunctions, missed or incorrectly identified laboratory specimen collection, and treatment delays sometimes occur, they do not occur as frequently as do patient falls.

Ch 1 Which of the following is considered a primary care service? a)Providing wound care b)Administering childhood immunizations c)Providing drug rehabilitation d)Providing outpatient hernia repair

ANS:B Primary care services focus on health promotion and disease prevention; administering childhood immunizations is one such service. Providing wound care and drug rehabilitation are examples of tertiary care services. Outpatient hernia repair surgery is an example of a secondary care service.

Ch 21 A patient newly diagnosed with breast cancer tells the nurse, "I'm worried I won't survive to see my children grow up." Which response by the nurse best conveys concern and active listening? a)"There have been many advances in breast cancer treatment; hope for the best." b)"Breast cancer is a serious disease; I can understand why you're worried." c)"You're strong and have youth on your side to fight the breast cancer." d)"I'd be worried too; I've seen a lot of patients die of breast cancer."

ANS:B Restating the patient's concern by saying, "Breast cancer is a serious disease; I can understand why you're worried" conveys concern and active listening. Stating that there have been many advances in breast cancer treatment minimizes the patient's concern. Stating that the patient is young and should have no trouble surviving breast cancer minimizes the patient's concern and offers false reassurance. Stating that the nurse has seen a lot of patients die of breast cancer could frighten the patient and cause emotional harm.

Ch 20 The nurse hears rhonchi when auscultating a client's lungs. Which nursing intervention would be appropriate for the nurse to implement before reassessing lung sounds? a)Have the client take several deep breaths. b)Request the client take a deep breath and cough. c)Take the client's blood pressure and apical pulse readings. d)Count the client's respiratory rate for 1 minute.

ANS:B Rhonchi are caused by secretions in the large airways and may clear with coughing. This is how you differentiate between rhonchi and other adventitious sounds. Deep breathing will not help to clear rhonchi. Taking the blood pressure and apical pulse readings and counting the respiratory rate are not effective for clearing rhonchi, and would not be sufficient for the nurse to identify whether the sounds were, indeed, rhonchi.

Ch 21 The nurse is preparing a patient for a computed tomography (CT) scan of the abdomen. Which statement by the nurse is best? Assume all are true. a)"You will need to remain NPO for the 8 hours prior to your CT scan." b)"You cannot have anything to eat or drink for 8 hours before your test." c)"You will need to be NPO and drink this contrast medium before your test." d)"You may need to void before you go down to the department for your CT scan."

ANS:B Telling the patient that he cannot have anything to eat or drink for a specific time before his test is the best statement. It uses terms that the patient can understand. The other options use medical jargon that many patients may not understand.

Ch 18 Which prescription below is not consistent with the standards established by The Joint Commission? a)Administer Lasix 20 mg PO daily at 1000. b)Administer Lasix 10.0 mg PO daily at 1000. c)Administer digoxin 10 mg PO daily at 1000. d)Administer digoxin 0.3 mg IV daily at 1000.

ANS:B The Joint Commission recommends that certain words are written out instead of using symbols and abbreviations to minimize the risk of medication errors. The trailing zero should not be used in medication prescriptions; thus, 10.0 mg is incorrect. It should be correctly written as 10 mg. The word daily should be used in place of qd or q.d., as is done in all the options. The Joint Commission does not support the lack of a leading zero; thus, 0.3 mg is correctly written.

Ch 20 Which assessment data best support a report of severe pain in an adult client whose baseline vital signs are within an average normal range? a)Oral temperature 100°F (37.8°C) b)Respiratory rate 26 breaths/min and shallow c)Apical heart rate 56 beats/min d)Blood pressure 124/82 mm Hg

ANS:B The data "Respiratory rate 26 breaths/min and shallow" best support a report of severe pain in such a client. Acute pain causes an increase in respiratory rate, but a decrease in depth. Elevated temperature does not indicate pain. The apical pulse is lower than normal, but because the pulse increases with pain, a rate of 56 beats/min does not indicate pain. A blood pressure of 124/82 mm Hg is within normal limits for most people. Blood pressure usually elevates temporarily with acute pain; it may decrease over time with unremitting chronic pain.

Ch 22 Which portion of the ear is responsible for maintaining equilibrium? a)External ear b)Inner ear c)Middle ear d)Ossicles

ANS:B The inner ear is responsible for hearing and equilibrium. The middle ear, which contains the ossicles (auditory structures), conducts sound waves to the inner ear. The external ear collects and conveys sound waves to the middle ear.

Ch 19 How can the nurse best provide teaching for a patient whose primary spoken language is not the same as hers? a)Provide written materials in the patient's primary language. b)Make arrangements to teach using an interpreter. c)Provide a demonstration and request a return demonstration. d)Use visual teaching aids to convey information.

ANS:B The nurse can best provide teaching for the patient whose primary spoken language is not the same as her own by requesting the aid of an interpreter. An interpreter can help the nurse to communicate clearly and accurately when assessing learning needs; dispersing the information; providing feedback to learners; and determining whether teaching is effective. An interpreter also allows the patient to ask questions when necessary and for the healthcare provider to respond with meaningful information. Written materials in the patient's primary language can help reinforce teaching. Demonstrating and requesting a return demonstration may be difficult if the patient does not understand the spoken language of the nurse. Visual aids may also be helpful for some learners, but they should not be the primary method for teaching, nor do they offer an opportunity for the exchange of information through questions, demonstration, or discussion.

Ch 21 A patient being admitted in hypertensive crisis informs the nurse that he stopped taking his blood pressure medication 3 weeks ago. Which response by the nurse is best? a)"You're lucky you didn't have a stroke; you really need to take your medication." b)"Tell me more about your experience with your high blood pressure medication." c)"Why did you stop taking your high blood pressure medication?" d)"It's very important to take your blood pressure medication."

ANS:B The nurse can gather more information about the patient's reasons for stopping his blood pressure medication by asking him to tell her more about his experience with the medication. Telling the patient he is lucky he did not have a stroke suggests criticism. Asking the patient why he stopped taking his high blood pressure medication may cause the patient to become defensive and halt further communication. Telling the patient that it is very important to take his blood pressure medication is patronizing and also suggests criticism; at the very least, it fails to elicit more communication from the patient.

Ch 44 A nurse is providing care to a patient who is a Jehovah's Witness. Against the patient's wishes, the physician ordered the nurse to give the patient two units of packed red blood cells. The nurse knows that the blood will save the patient's life, but also that it is against the patient's wishes; she is unsure what is the right thing for her to do. The nurse is experiencing a(n): a) Reflection encounter b) Ethical dilemma c) Moral outrage d) Moral distress

ANS:B The nurse is experiencing an ethical dilemma based on the conflict between the ethical principles of beneficence and autonomy. The nurse has not yet made a decision. This is not a situation of moral distress, in which the nurse would have made an acceptable moral decision, but was unable to implement it because of external constraints. The nurse does not perceive that others are acting immorally; thus, this is not moral outrage.

Ch 22 A mother brings her 6-month-old infant to the clinic for a well-baby checkup. How should the nurse proceed when weighing the patient? a)Have the mother remain outside the room. b)Ask the mother to remove the infant's clothing and diaper. c)Weigh the infant with the diaper only. d)Place the infant supine on the scale with his knees extended.

ANS:B The nurse should ask the mother to remove the infant's clothing and diaper before weighing and measuring the infant. An older child can be examined in his underwear; infants should be undressed. Infants are typically more comfortable with the parent close by so the mother should remain in the room. The infant should be supine with knees extended on the examination table when being measured, not when being weighed.

23 A patient is admitted to the hospital with tuberculosis. Which precautions must the nurse institute when caring for this patient? a)Droplet transmission b)Airborne transmission c)Direct contact d)Indirect contact

ANS:B The organisms responsible for measles and tuberculosis, as well as many fungal infections, are spread through airborne transmission. Neisseria meningitidis, the organism that causes meningitis, is spread through droplet transmission. Pathogens that cause diarrhea, such as Clostridium difficile, are spread by direct contact. The common cold can be spread by indirect contact or droplet transmission.

Ch 20 A 1-day postoperative client has a temperature of 36.8°C. What is the nurse's next best action? a)Contact the primary care provider for guidance. b)Document the temperature and continue with his care. c)Administer the prescribed antipyretic medication. d)Instruct the client to drink more fluids.

ANS:B The temperature of 36.8°C is equivalent to 98.2°F. This is a normal temperature for a postoperative patient. To convert Fahrenheit to centigrade, subtract 32 from the temperature, and multiply by 5/9. Because this is a normal temperature, no change in action is needed. The nurse should compare this reading with the previous temperature reading and document the temperature in the medical records.

Ch 45 Upon initial assessment of a 75-year-old patient, you identify bruises and scratches on the patient's arms, legs, and trunk in various stages of healing. You notify your supervisor when you suspect the patient may be a victim of physical abuse. You are complying with which of the following state laws? a)Good Samaritan Law b)Mandatory Reporting Law c)Nurse Practice Act d)Nursing Standards of Practice

ANS:B Under state mandatory reporting laws, nurses must report to designated authorities (e.g., Adult Protective Services) suspected physical, sexual, emotional, or verbal abuse or neglect by healthcare workers or family members. In general, nurses who fail to report suspected abuse or neglect may be held criminally or civilly liable.

Ch 21 The nurse manager of the medical intensive care unit formed a group to help her staff cope with stress more effectively. Which of the comments by group members will lead the manager to evaluate the group as successful? a)"This was a good idea to form a group; I've been wanting to get to know some of the people from the other shifts." b)"It really helps me to share feelings about how hard it is to see pain and suffering every day." c)"I now have a group to help me when I need to work through situations at home causing personal stress." d)"It's nice to have a chance to get away from the unit and talk on a regular basis."

ANS:B Work-related social support groups assist members of a profession to cope with the stress associated with their work. The focus of the group is to share feelings about the stress of the work environment. Although this may also be an opportunity to meet other staff members, get away from the unit, or share personal and family problems, these are not the primary focus of the group.

Ch 18 A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system? a)It involves a cooperative effort among various disciplines. b)The system requires diligence in maintaining a current problem list. c)Data may be fragmented and scattered throughout the chart. d)It allows the nurse to provide information in an unorganized manner.

ANS:C A major disadvantage of a source-oriented medical record is that data may be fragmented and scattered throughout the chart. The problem-oriented medical record requires a cooperative effort among disciplines and diligence in maintaining a current problem list. Narrative charting allows the nurse to provide information in a disorganized manner.

Ch 44 Which of the following concepts refers to conflicts that arise between two or more ethical principles in patient care scenarios? a)Nursing ethics b)Bioethics c)Ethical dilemma d)Moral distress

ANS:C An ethical dilemma occurs when a choice must be made between two or more equally undesirable actions, and there is no clearly right or wrong option. Moral distress occurs when someone is unable to carry out his or her moral decision. Nursing ethics refers to ethical questions that arise out of nursing practice. Bioethics is a broader field that refers to the application of ethics to healthcare.

Ch 2 Which of the following is the most important reason for nurses to be critical thinkers? a)Nurses need to follow policies and procedures. b)Nurses work with other healthcare team members. c)Nurses care for clients who have multiple health problems. d)Nurses have to be flexible and work variable schedules.

ANS:C Critical thinking is essential for client care, particularly when the care is complex, involving numerous health issues. Following policies and procedures does not necessarily require critical thinking; working with others or being flexible and working different schedules do not necessarily require critical thinking.

Ch 20 A client's vital signs at the beginning of the shift are as follows: oral temperature 99.3°F (37°C), heart rate 82 beats/min, respiratory rate 14 breaths/min, and blood pressure 118/76 mm Hg. Four hours later, the client's oral temperature is 102.3°F (39.1°C). Based on the temperature change, the nurse should anticipate the client's heart rate would be how many beats/min? a)62 b)82 c)102 d)122

ANS:C Heart rate increases about 10 beats/min for each degree Fahrenheit of temperature to meet increased metabolic needs and compensate for peripheral dilation.

Ch 18 What is one advantage of problem-intervention-evaluation (PIE) charting? a)Focuses on a complete list of client problems b)Assesses the client in a comprehensive manner c)Documents the planning portion of the client's care d)Establishes an ongoing plan of care for the client

ANS:D The PIE charting format organizes information by the client's problems and requires a daily assessment record and progress notes, thus eliminating the need for a nursing care plan. It documents, in a comprehensive manner, the client information. It does not assess the client.

Ch 5 The nurse is planning care for a patient. She is using a standardized care plan for Impaired Walking related to left-side weakness. Which of the following activities will the nurse perform when individualizing the plan for the patient? a)Validating conflicting data with the patient b)Transcribing medical orders c)Stating the frequency for ambulation d)Performing a comprehensive assessment

ANS:C Individualizing the care plan means identifying specific problems, outcomes, and interventions and the frequency of those interventions to meet the patient's needs. Validating data ensures your assessment is accurate. Transcribing orders is a part of developing and implementing the care plan but not of individualizing the plan. Performing an assessment is the beginning step in developing a care plan. Assessment helps you to know the ways in which a standardized plan needs to be individualized.

Ch 23 What is the most frequent cause of the spread of infection among institutionalized patients? a)Airborne microbes from other patients b)Contact with contaminated equipment c)Hands of healthcare workers d)Exposure from family members

ANS:C Patients are exposed to microbes by contact (direct contact, airborne, or otherwise) with other patients, family members, and contaminated healthcare equipment. Some of these are pathogenic (cause illness) and some are nonpathogenic (do not cause illness). But most microbes causing infection among patients are spread by direct contact on the hands of healthcare workers.

A patient with terminal cancer requires increasing doses of an opioid pain medication to obtain relief from pain. This patient is exhibiting signs of drug: a)Abuse b)Misuse c)Tolerance d)Dependence

ANS:C Patients in the terminal stages of cancer commonly exhibit drug tolerance, a decreasing response to repeated doses of a medication. Therefore, pain management must be carefully planned to promote patient comfort. Drug abuse is the inappropriate intake of a substance continually or periodically. Drug misuse is the nonspecific, indiscriminate, or improper use of drugs, including alcohol, over-the-counter preparations, and prescription drugs. Drug dependence occurs when a person relies on or needs a drug. Dependence leads to lifestyle changes that focus on obtaining and administering the drug.

Ch 2 Which of the following is an example of practical knowledge? Assume all are true. a)The tricuspid valve is located between the right atrium and ventricle of the heart. b)The pancreas does not produce enough insulin in type 1 diabetes. c)When assessing the abdomen, you should auscultate before palpating. d)Research shows pain medication given intravenously acts faster than medication given by other routes.

ANS:C Practical knowledge is knowing what to do and how to do it, such as how to make an assessment. The others are examples of theoretical knowledge, anatomy (tricuspid valve), facts (type 1 diabetes), and research (intravenous pain medication).

Ch 2 Which of the following is an example of self-knowledge? The nurse thinks, "I know that I: a)Should take the client's apical pulse for 1 full minute before giving digoxin" b)Should follow the client's wishes even though it is not what I would want" c)Have religious beliefs that may make it difficult to take care of some clients" d)Need to honor the client's request not to discuss his health concern with the family"

ANS:C Self-knowledge is being aware of your religious and cultural beliefs and values. Taking the pulse is an example of practical knowledge. Following client wishes and honoring client requests are examples of ethical knowledge.

Ch 19 Which technique is best for teaching a nursing assistant how to perform finger-stick glucose testing? a)Provide a manufacturer's pamphlet with detailed instruction. b)Explain the best technique for performing glucose testing. c)Demonstrate the procedure; then ask for a return demonstration. d)Suggest that the assistant watch a DVD showing the procedure.

ANS:C The best way to teach a psychomotor skill is to demonstrate the procedure and then ask for a return demonstration. Supplementary written information or DVD can also be supplied to the patient to reinforce learning. However, they are not the best method for teaching a psychomotor skill; enacting the procedure is more effective.

Ch 23 A patient develops localized heat and erythema over an area on the lower leg. These findings are indicative of which secondary defense against infection? a)Phagocytosis b)Complement cascade c)Inflammation d)Immunity

ANS:C The classic signs of inflammation, a secondary defense against infection, are erythema (redness) and localized heat. The secondary defenses of phagocytosis (process by which white blood cells engulf and destroy pathogens) and the complement cascade (process by which blood proteins trigger the release of chemicals that attack the cell membranes of pathogens) do not produce visible findings. Immunity is a tertiary defense that protects the body from future infection.

Ch 20 The nurse palpates a radial pulse on her 80-year-old patient and notes that it feels irregular. What is the most appropriate method to count this patient's pulse? a)Count for 15 seconds, multiply by 4. b)Count for 30 seconds, multiply by 2. c)Count for 1 full minute. d)Count for 10 seconds multiply by 6.

ANS:C The intervals between heartbeats establish a pulse pattern known as the rhythm. Normally, the heat beats at regular intervals, much like a metronome. When the intervals between beats are enough to be noticeable, the rhythm is abnormal. When assessing an irregular pulse, it is important to determine whether the beat is regularly irregular or irregularly irregular. To make this distinction, the nurse must count the rate for 1 full minute.

Ch 22 A female patient has excessive facial hair. The nurse should document this finding as: a)Alopecia b)Albinism c)Hirsutism d)Lanugo

ANS:C The nurse should document this finding as hirsutism, excess facial or trunk hair. Hair loss should be documented as alopecia. Albinism is a condition caused by lack of pigment in which the patient has white hair and very pale skin. Lanugo is the fine, downy growth of hair that covers the body of a newborn.

Ch 25 The nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient? a)Avoid bathing the patient. b)Use cool water for bathing. c)Provide care in short intervals. d)Rub briskly when towel drying.

ANS:C The nurse should provide care in short intervals to avoid overstimulating the patient, thereby causing a rise in his intracranial pressure. It is not necessary to avoid bathing the patient. Using cool water to bathe the patient may cause shivering, which may elevate intracranial pressure and increase metabolic demands. Rubbing briskly when drying might also overstimulate, leading to an elevation in intracranial pressure.

Ch 19 Assume all of the following written instructions about digoxin provide correct information for patient care. Which one is best worded for patient understanding? a)Obtain your radial pulse every morning before taking your digoxin dose. b)Return to your healthcare provider for monthly laboratory studies of your digoxin levels. c)Call your provider if you notice that objects look yellow or green. d)Always take the same brand of medication because certain brands may not be interchangeable.

ANS:C The nurse should provide written instructions that contain short sentences and easy-to-read words. If instructions are written at too high a reading level, the patient may not understand and make a harmful error in dosing. Calling the provider when objects look yellow or green is the clearest statement for patient teaching because the instruction is short, concrete, and written with easy-to-understand words. Patient instructions must not contain words that require a higher level of reading or medical jargon. The instruction pertaining to being consistent with brand use is too wordy, especially for patients who are ill or for whom English is not a primary language.

Ch 24 While eating in the hospital cafeteria, the nurse sees a visitor display the "universal sign of choking." Her first action is to: a)Page a "Code Blue" emergency. b)Immediately perform five abdominal thrusts. c)Assess for ineffective breathing by asking, "Are you choking?" d)Deliver four sharp back blows between the scapulae.

ANS:C The nurse's first response is to assess that the person is actually choking and then rapidly proceed to intervene performing abdominal thrusts. Back blows are not indicated in adults with obstructed airways and might actually create a complete obstruction by dislodging a foreign body that was only partially blocking the airway.

Ch 26 While receiving an intravenous dose of an antibiotic, levofloxacin, a patient develops severe shortness of breath, wheezing, and severe hypotension. Which action should the nurse take first? a)Administer epinephrine IM. b)Give bolus dose of intravenous fluids. c)Stop the infusion of medication. d)Prepare for endotracheal intubation.

ANS:C The patient is experiencing an anaphylactic reaction (severe shortness of breath, wheezing, and severe hypotension), a life-threatening allergic reaction. Therefore, the nurse should immediately discontinue the medication. The first priority is to eliminate the cause of the problem. Next, the nurse should notify the physician, give IV fluids, and administer epinephrine, steroids, and diphenhydramine. Respiratory support ranging from oxygen administration to endotracheal intubation and mechanical ventilation may also be necessary.

Ch 18 At 1000 on 11/14/16, the nurse takes a telephone prescription for "metoprolol 5 mg intravenously now." What is the latest date and time the nurse will expect the prescriber to countersign the order? a)11/14/16 at 1200 b)11/14/16 at 2200 c)11/15/16 at 1000 d)11/16/16 at 1000

ANS:C The prescriber must countersign all verbal and telephone orders within 24 hours.

Ch 4 The nurse receives the following report on four patients on the medical-surgical unit. Which patient will the nurse attend to first? a)Gait unsteady, uses walker, needs 2-person assist with ambulation b)Abdominal wound is draining foul-smelling fluid, incision margins are red, heart rate 100 beats/min c)Blood pressure 90/50 mm Hg, heart rate 40 beats/min, rates chest pain at 8 on a 0 to 10 pain scale d)Verbalizes history of migraine headaches, eyes closed during assessment interview

ANS:C Unstable vital signs with chest pain is of the highest priority because these symptoms may be life threatening. These instabilities must be addressed at once. Although an unsteady gait places a patient at risk for falls, this answer indicates that the patient uses a walker and 2-person assist. The draining wound is infected; however, this can be addressed with medications. Infections do not usually progress rapidly (i.e., as compared with chest pain). The wound symptoms are not immediately life threatening. A patient with a history of migraine headaches is not a priority at this time, although the patient's pain should be relieved as quickly as possible after dealing with the highest priority problem(s).

Ch 20 A client who has been hospitalized for an infection states, "The nursing assistant told me my vital signs are all within normal limits; that means I'm cured." The nurse's best response would be which of the following? a)"Your vital signs confirm that your infection is resolved; how do you feel?" b)"I'll let your healthcare provider know so you can be discharged." c)"Your vital signs are stable, but there are other things to assess." d)"We still need to keep monitoring your temperature for a while."

ANS:C Vital signs are one indicator of a client's physiological status, but they are not an absolute indicator of well-being from every aspect. It may be inaccurate to state that the vital signs indicate the infection is resolved; vital signs could stabilize even if the infection remains active. The healthcare provider's decision regarding the client's readiness for discharge is not based exclusively on the vital signs but rather is based on a compilation of other sources of information, primarily the client's clinical status, but also cultures, complete blood counts, and various other laboratory and possibly radiological evidence. Although the nurse will need to continue monitoring the temperature, other clinical signs must also be monitored; therefore, the statement "We still need to keep monitoring your temperature . . ." is incomplete and less useful than the statement that begins "Your vital signs are stable, but . . ."

Ch 45 A pregnant 15-year-old girl presents to the emergency department (ED) of the local private hospital. She has been transported by her mother and appears to be in active labor. The girl is crying uncontrollably and says she is scared and experiencing painful contractions. Her mother states, "We don't have any money or insurance, but this hospital is closer than the public hospital, and she needs help now." What is the first step that the ED staff should take? a)Arrange for an ambulance to transport her to the nearest public hospital. b)Explain to the girl and her mother that the hospital only accepts patients who can pay the hospital bill. c)Examine her to determine whether her condition is stable or whether she requires immediate medical attention. d)Inform her mother that she will need to transport her daughter to the nearest public hospital.

ANS:C When a client comes to the ED requesting examination or treatment for an emergency medical condition (including labor), the hospital must provide stabilizing treatment; the client cannot be transferred until she is stable.

Ch 20 In evaluating a client's blood pressure for hypertension, it would be most important to: a)Use the same type of manometer each time b)Auscultate all five Korotkoff sounds c)Measure the blood pressure in both arms d)Monitor the blood pressure for a pattern

ANS:D Blood pressure fluctuates a great deal during the day and is influenced by age, sex, activity, and many other factors. Any determination of hypertension must be done after two or more BP readings taken on separate occasions. The type of manometer does not greatly influence the reliability of BP readings. Although more accurate, the manual manometer is being replaced by nonmercury-containing devices, such as the aneroid or electronic blood pressure monitors. Only the first and last Korotkoff sounds are necessary to determine a BP reading. The first time BP is assessed for a patient, the nurse should compare the reading in the left and right arm; however, this is not specific to evaluating for hypertension.

Ch 1 Which organization can require nurses to take continuing education courses as a condition of licensure renewal? a)American Nurses Association b)National League for Nursing c)Sigma Theta Tau d)State Board of Nursing

ANS:D Continuing education is a professional strategy designed to ensure that nurses remain current in their clinical knowledge. Many states require nurses to engage in a certain number of continuing-education requirements to renew their license. The knowledge gained in the nursing curriculum is sufficient for nursing school graduates to obtain their initial license. Requirements for renewal of a nurse's license can be found in the state's nurse practice act (state board of nursing).

Ch 20 During a clinic interview, a client states he has been experiencing dizziness upon standing. Which nursing action is appropriate for the nurse to implement? a)Ask the client when in the day dizziness occurs. b)Help the client to assume a recumbent position. c)Measure both heart rate and blood pressure with the client standing. d)Measure vital signs with the client supine, sitting, and standing.

ANS:D Dizziness upon standing is a symptom of orthostatic hypotension. The nurse should obtain orthostatic vital signs (measure pulse and blood pressure with the patient supine, sitting, and standing) to assess for orthostatic hypotension. The time of day is irrelevant to the diagnosis. If the nurse observes the patient become dizzy upon standing, the first action would be to help the client lie down, and then obtain orthostatic vital signs; but this is not necessary when the symptom is not present. The nurse needs to measure both the heart rate and the blood pressure but not only in the standing position.

Ch 3 Why is it important to obtain information about nutritional and herbal supplements as well as about complementary and alternative therapies? a)To determine what type of therapies are acceptable to the client b)To identify whether the client has a nutrition deficiency c)To help you to understand cultural and spiritual beliefs d)To identify potential interaction with prescribed medication and therapies

ANS:D Herbs and nutritional supplements can interact with prescription medications, and complementary and alternative treatments can interfere with conventional therapies. Physical assessment and laboratory tests are needed to assess a nutritional deficiency. To identify cultural and spiritual beliefs and well as what therapies are acceptable to the client, you need more than just information about nutritional and herbal supplements.

Ch 23 The patient is just beginning to feel symptoms after being exposed to an upper respiratory infection. Which antibody would be most likely to be found in a test of immunoglobulin levels? a)IgA b)IgE c)IgG d)IgM

ANS:D IgM antibodies are the first to be made in response to infection. IgE is the antibody primarily responsible for this allergic response. IgA antibodies protect the body in fighting viral and bacterial infections, and appear later. IgG antibodies also appear later— perhaps up to 10 days later.

Ch 26 A patient with end-stage cancer is prescribed morphine sulfate to reduce pain. For which effect is this medication prescribed? a)Supportive b)Restorative c)Substitutive d)Palliative

ANS:D Morphine is prescribed for its palliative effects—to relieve pain, a symptom of cancer. Supportive effects support the integrity of body functions until other medications or treatments become effective. Restorative effects return the body to or maintain the body at optimal levels of health. Substitutive effects replace either body fluids or a chemical required by the body for improved functioning.

Ch 18 A student nurse makes the following comments to her preceptor: "I love getting information from the chart. Everything related to the patient's problem is together and addressed by various members of the healthcare team." The student nurse has been introduced to which type of charting system? a)Narrative b)Focus c)Source oriented d)Problem oriented

ANS:D Narrative charting is a free text description of the patient status and nursing care, not usually organized according to patient problems. Focus charting highlights the patient's concerns, problems, and strengths in a three-column format. Source-oriented record systems require members of each discipline to record their findings in a separately labeled section of the chart. A problem-oriented record system is organized around the patient's problems and each member of the healthcare team document in the area designated for that problem. This method makes it easier to view the patient's progress and integrate the interdisciplinary perspective.

Ch 1 Which of the following is the most important reason to develop a definition of nursing? a)Recruit more informed people into the nursing profession b)Evaluate the degree of role satisfaction c)Dispel the stereotypical images of nurses and nursing d)Differentiate nursing activities from those of other health professionals

ANS:D Nursing organization leaders think it is important to develop a definition of nursing to bring value and understanding to the profession, differentiate nursing activities from those of other health professionals, and help student nurses understand what is expected of them. A definition of nursing likely would not increase the number of informed people recruited into nursing. A definition of nursing would do little to improve the nurse's role satisfaction. Although a definition of nursing might contribute to fighting stereotypes of nursing, other, more powerful influences (e.g., media portrayals), exist to counteract it.

Ch 24 The nurse will teach the community-based client that the most common cause of injury related to a house fire is/are: a)Explosion b)Falls from second-story windows c)Thermal damage to skin and body surfaces d)Smoke inhalation injury

ANS:D Smoke inhalation injury is associated with significant morbidity and mortality. Manifestations might not show up until 24 hours postexposure.

Ch 26 A nurse is being investigated for stealing narcotics from several patients. Which federal agency can become involved in the investigation of this incident? a)State Board of Nursing b)U.S. Food and Drug Administration c)U.S. Drug Compliance Department d)U.S. Drug Enforcement Agency

ANS:D The U.S. Drug Enforcement Agency (DEA) can investigate diversion and theft of controlled substances. The State Board of Nursing is not a federal agency and is only empowered to discipline a nurse's license. The U.S. Food and Drug Administration regulates the testing, sale, and manufacture of drugs.

Ch 18 A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client's condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first? a)Study the discharge plan. b)Check the graphic data for vital signs. c)Examine the history and physical examination. d)Look for an advance directive.

ANS:D The advance directive, which should be located in a special section of the patient's medical record, should be examined first because the patient's symptoms indicate that he may need to be resuscitated. The advance directive contains information about the patient's wishes for intensity of care and actions that should be taken in the event of a life-threatening event. The discharge plan contains data from utilization review, case managers, or discharge planners on anticipated needs after discharge. Graphic data record assessment should be done frequently, such as vital signs. The history and physical examination provide a detailed summary of the patient's current problem, past medical and social history, medications taken by the patient, review of systems, and physical examination data.

Ch 45 Which statement describes the primary purpose of an incident report? a)This report is used by nurse managers to discipline the nurse for her errors. b)It is imperative that this report be kept in the patient's medical record in case of a lawsuit. c)A copy should be provided to the patient to promote open communication. d)This report is used by risk management to prevent the incident from reoccurring.

ANS:D The main function of an incident report is to prevent the incident from happening again. The report allows the nurse manager and risk management to evaluate the context in which the incident occurred and to identify appropriate strategies to prevent a reoccurrence. Although incident reports have been used to discipline nurses, this is not the current trend and is not their purpose. These reports are not a part of the patient record and therefore are not part of accurate patient charting. A copy should not be shared with the patient.

Ch 21 During admission to the unit, a patient states, "I'm not worried about the results of my tests. I'm sure I'll be all right." As he observes the patient, the nurse notes that the patient is shaky, tearful, and does not make eye contact. Unfortunately, the nurse is called away to an emergency before he has time to complete this discussion. Which of the following goals is most appropriate for the nurse to establish when returning to the patient? The patient will: a)Explain the reason for his incongruent statements b)Engage in diversional activities to cope with stress c)Express his concerns to his primary care provider d)Discuss his concerns and fears with the nurse

ANS:D The nurse has observed a mismatch between verbal and nonverbal communication. Unfortunately, an emergency has required the nurse to leave the patient. To resolve this mismatch, the nurse will set a goal to have the patient discuss his concerns and fears at their next interaction. It is inappropriate to ask the patient to explain why his verbal message did not match the nonverbal message because this will inhibit further conversation. It may be appropriate to have the patient discuss his concerns with his primary care provider; however, we do not have enough information to suggest this course of action. For example, if the patient is upset about some other matter, this action would not be appropriate. Similarly, it is not appropriate to suggest diversional activities until the reason for the mismatch between his words and behavior is identified.

Ch 21 After a physician discusses cancer treatment options with a patient, the patient asks the nurse which treatment he should choose. Which response by the nurse is best? a)"If I were you, I'd go with chemotherapy." b)"What do you think about radiation therapy?" c)"Why don't you see what your wife thinks?" d)"I'll give you some information about each option."

ANS:D The nurse should avoid giving a personal opinion; instead, offer the patient more information so he can make an informed decision. Responses such as, "If I were you, I'd go with chemotherapy," "Why don't you see what your wife thinks?" do not respect the patient's right to make his own decisions. "What do you think about radiation therapy," is leading the patient without exploring the other options.

Ch 26 A patient is given furosemide 40 mg orally at 0900. The duration of action for this drug is approximately 6 hours after oral administration. At which time in military hours should the nurse no longer expect to see the effects of this drug? a)0930 b)1000 c)1100 d)1500

ANS:D The nurse should no longer see the effects of furosemide at around 1500 hours (3:00 p.m.). The effects of oral furosemide should be seen 30 to 60 minutes after administration, which is 0900 (9:30 a.m. in this case). Peak effect (diuresis) should occur in 1 to 2 hours, which is 1000 hours (10:00 a.m.) to 1100 (11:00 a.m.) in the scenario.

Ch 26 Before administering a medication, the nurse must verify the six rights of medication administration, which include: a)Right patient, right room, right drug, right route, right dose, and right time b)Right drug, right dose, right route, right time, right physician, and right documentation c)Right patient, right drug, right route, right time, right documentation, and right equipment d)Right patient, right drug, right dose, right route, right time, and right documentation

ANS:D The six rights of medication administration are the right patient, right drug, right dose, right route, right time, and right documentation.

Ch 3 Which of the following is an example of data that should be validated? a)The client's weight measures 185 lb at the clinic. b)The client's liver function test results are elevated. c)The client's blood pressure reading is 160/94 mm Hg; he states that is typical for him. d)The client states she eats a low-sodium diet; she reports eating processed food.

ANS:D Validation should be done when the client's statements are inconsistent (processed foods are generally high in sodium). Validation is not necessary for laboratory data when you suspect an error has been made in the results. Personal information that patients might be embarrassed about, such as weight, is best validated with a scale.

Ch 44 A mentally competent patient has an extremely low blood count and will likely die without a blood transfusion. The patient knows the risk, but continues to refuse the blood. Which action by the nurse is the most appropriate? a)Assume the patient is confused and give the blood anyway. b)Request a psychological evaluation to ensure that the patient understands the risk. c)Ask family members to intervene and make the patient consent to receiving blood. d)Follow the patient's wishes and do not administer a blood transfusion.

ANS:D You should follow the patient's wishes and do not administer a blood transfusion. There is no evidence of confusion; the patient is competent, is aware of the risk, and has given a valid refusal. The nurse should not assume that a patient is confused simply because of the choice a patient makes. A psychological evaluation is not needed simply because the patient refuses treatment that might result in his death. Family members cannot override a patient's decision. The nurse should respect the patient's decision.