NUR120 - FINAL - Class Prep

If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following? A. Fail to show changes in blood pressure. B. Produce a false-high measurement. C. Cause sciatic nerve damage. D. Produce a false-low measurement.

B. Produce a false-high measurement.

Which actions by the nurse could result in a BP measurement error? SELECT ALL THAT APPLY. a. Placing the diaphragm of the stethoscope over the brachial artery b. Using the same cuff for all clients c. Wrapping the bottom edge of the cuff over the antecubital space d. Releasing the valve quickly to prevent client discomfort e. Taking a measurement after the client rests quietly for 5 mins.

B. Using the same cuff for all clients C. Wrapping the bottom edge of the cuff over the antecubital space D. Releasing the valve quickly to prevent client discomfort

CHAPTER 31: SENSORY PERCEPTION The nurse is caring for an older adult who is hearing impaired and cannot wear his glasses because they are broken. What interventions would be appropriate? SELECT ALL THAT APPLY. A. Talk in a quiet tone of voice. B. Validate understanding of verbal communication. C. Speak slowly, articulating clearly. D. Ask whether he has a "good ear." E. Explain things before performing them.

B. Validate understanding of verbal communication. C. Speak slowly, articulating clearly. D. Ask whether he has a "good ear." E. Explain things before performing them.

CHAPTER 37 and 38: OXYGENATION and PERFUSION An oxygen delivery system is prescribed for a male patient with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed? A. Face tent B. Venturi mask C. Aerosol mask D. Tracheostomy collar

B. Venturi mask

CHAPTER 29: BOWEL ELIMINATION What is the primary function of the gastrointestinal system? A. mechanically process food into digestible pieces B. absorb nutrients and break down waste C. connect the mouth to the anus D. convert complex carbohydrates into simple sugars for energy

B. absorb nutrients and break down waste

CHAPTER 28: NUTRITION Vitamin E is needed for which of the following functions? SELECT ALL THAT APPLY. A. collagen synthesis B. antioxidant C. fight toxins D. protection of cells from damage E. immune system support

B. antioxidant C. fight toxins D. protection of cells from damage

A postoperative patient is breathing rapidly. You should immediately: a. ask the patient if he feels uncomfortable. b. assess the oxygen saturation. c. call the physician. d. count the respirations.

B. assess the oxygen saturation.

CHAPTER 31: SENSORY PERCEPTION The nurse is working with older adult patients in an extended care facility. To enhance the patients' gustatory sense, the nurse should: A. mix foods together B. assist with oral hygiene C. make sure foods are extremely spicy D. provide foods of similar texture and consistency

B. assist with oral hygiene

CHAPTER 31: SENSORY PERCEPTION A patient is admitted to the hospital for a scheduled cataract surgery. While assessing the patient, the nurse notes that the patient has a progressive hearing disorder and is visually impaired. Which possible effects could occur with this type of sensory deprivation? SELECT ALL THAT APPLY. A. stroke B. boredom C. disorientation D. malnourishment E. poor task performance

B. boredom C. disorientation E. poor task performance

CHAPTER 28: NUTRITION The nurse instructs a patient with a vitamin A deficiency on food sources that could prevent symptoms. Which of the following food combinations would be appropriate? A. corn and potatoes B. carrots and spinach C. iron-fortified bread or cereals D. raisins and papaya

B. carrots and spinach

CHAPTER 29: BOWEL ELIMINATION Which of the following describes normal bowel sounds? A. clicks, squeaks, and whistles B. clicks, gurgles and rumbles C. pulsing, growling, and whooshing D. rubbing, crackling, and swishing

B. clicks, gurgles and rumbles Growling is also considered normal, and sometimes there can be a prolonged bubbling sound.

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS The nurse sits at the unit computer to begin her shift documentation for her patient. She notes the previous user of the computer, the physical therapist, did not log off appropriately. The nurse should: A. call the physical therapist and have her come back and log off. B. complete the log off for the physical therapist before beginning her documentation. C. proceed with her documentation because it will be in a different screen. D. report the physical therapist to the unit manager.

B. complete the log off for the physical therapist before beginning her documentation.

CHAPTER 37 and 38: OXYGENATION and PERFUSION Bubbly, popping, cracking. Coarse and fine. Low to high pitch, discontinue sounds. Can't clear with coughing. Heard when a patient inhales and exhales as air passes through fluid or re-expands collapsed small airway. A. ronchi B. crackles C. wheezing D. pleural rub

B. crackles

CHAPTER 29: BOWEL ELIMINATION How does a hypertonic enema benefit the patient? A. large volume of fluid flushes out feces and bacteria B. draws fluid from the interstitial space, causing distention C. helps expel flatus and relieve bloating D. provides hydration to ease defecation

B. draws fluid from the interstitial space, causing distention The colon fills with fluid and the resultant distention promotes defecation. NOT for dehydrated patients or infants.

CHAPTER 29: BOWEL ELIMINATION A nurse discourages a patient from straining excessively when attempting to have a bowel movement. What physiological response primarily may be prevented by avoiding straining on defecation? A. incontinence B. dysrhythmias C. fecal impaction D. rectal hemorrhoids

B. dysrhythmias Straining or bearing down (Valsalva maneuver) requires the patient to hold their breath, which can precede dysrhythmias.

CHAPTER 37 and 38: OXYGENATION and PERFUSION Which of the following would be appropriate for the treatment of COPD? SELECT ALL THAT APPLY. A. albuterol and levalbuterol B. formoterol and salmeterol C. tiotroprium D. inotroprium

B. formoterol and salmeterol C. tiotroprium Albuterol and levalbuterol are short-acting beta2 adrenergic agonists; long-acting is needed.

CHAPTER 31: SENSORY PERCEPTION Which receptors are found in the cochlea and facilitate hearing? A. mechanoreceptors B. hair cells C. thermoreceptors D. proprioceptors E. photoreceptors F. chemoreceptors

B. hair cells

CHAPTER 28: NUTRITION What are the functions of lipids in the body? SELECT ALL THAT APPLY. A. healthy teeth and gums B. provide protection around organs C. energy storage D. hormone regulation E. muscle contraction F. build and repair body tissues

B. provide protection around organs C. energy storage D. hormone regulation

What are the vital signs?

BP Temp HR RR O2 Sat Pain

CH. 36: SKIN INTEGRITY and WOUND HEALING Which of the following patients is at greatest risk for developing a pressure injury? A. A 45-year-old with new onset of pre-diabetes. B. A 75-year-old who is on a high-protein diet. C. A 45-year-old patient on prolonged bedrest. D. A 58-year-old who has incontinence post coughing.

C. A 45-year-old patient on prolonged bedrest.

CHAPTER 37 and 38: OXYGENATION and PERFUSION Of the following reasons, why is it important for the asthmatic patient to use a spacer with his meter-dosed inhaler (MDI)? A. A spacer increases the amount of drug into the nares. B. A spacer increases the amount of drug into the oropharynx. C. A spacer increases the amount of drug into the lungs. D. A spacer slows down the amount of drug into the mouth.

C. A spacer increases the amount of drug into the lungs.

CHAPTER 32: PAIN An older adult with mild musculoskeletal pain is being seen by the primary care provider. The nurse anticipates that treatment of this patient's level of discomfort will include: A. Fentanyl B. Diazepam C. Acetaminophen D. Morphine

C. Acetaminophen

A nurse in the emergency room is caring for a client who has a knee injury. The client will be Discharged and will be using a pair of axillary crutches for the first time. which of the following instructions should the nurse include when discharging this patient? a. Leeane on the crutches to support body weight when standing b. Fully extend arms when holding onto the hand grips c. Hold the crutches on the unaffected side when preparing to sit in a chair d. Hold the crutches 9 to 12 inches in front of and to the side of each foot

C. Hold the crutches on the unaffected side when preparing to sit in a chair

CHAPTER 39: FLUIDS and ELECTROLYTES Which of the following statements by the student nurse requires further teaching regarding potassium? A. Potassium can be found in potatoes B. Potassium is considered a micronutrient C. It's better to consume potassium from oral supplements D. potassium is largely found in the intracellular fluid compartment

C. It's better to consume potassium from oral supplements

CHAPTER 25: ADMINISTERING MEDICATIONS The nurse needs to instill eyedrops for a patient. Which if the following is the ideal location to instill eyedrops? A. Cornea B. Outer canthus C. Lower conjunctival sac D. Opening of the lacrimal duct

C. Lower conjunctival sac

Individualized map to obtain specific patient goals and outcomes a. Assessment b. Implementation c. Planning d. Evaluation

C. Planning

The nurse knows that the family of the patient receiving home healthcare needs further education about that service when the family requests the RN to A. Teach the patient how to administer his own insulin. B. Change the patient's PICC line dressing. C. Take the patient shopping to buy high-protein foods. D. Call the social worker to obtain information about Medicare.

C. Take the patient shopping to buy high-protein foods.

What is negligence?

Careless neglect, often resulting in injury.. "Creating a risk of harm to others by failing to do something a reasonable person would ordinarily do, or do something that a reasonable person would ordinarily not do."

What is implementation?

Carrying out the nursing interventions in a systematic way.

CH. 21: PHYSICAL ASSESSMENT Which organs are in the right lower quadrant?

Cecum Appendix Right ureter Reproductive organs Large intestine

Decision making

Choosing the best action to take; usually action best for the desired patient outcome

Nursing process is _______________.

Client-centered, goal-directed, and involves thinking and doing.

Critical thinking

Combination of reasoned thinking, openness to alternatives, ability to reflect, and a desire to seek truth

Indirect contact

Contact with contaminated inanimate objects

Diagnosis

Identify clients health strengths and needs/problems -in nursing, reflects clients responses to actual or potential health problems

Problem-solving

Identifying a problem and finding reasonable solutions to it

What is nonmaleficence?

Do no harm; preventing harm

What is the drug class of Furosemide, what are the therapeutic effects, side effects, and contraindications?

Drug class: Loop diuretic *Most powerful diuretic* Therapeutic effects: decreases BP, HF caused by edema. Used when there needs to be an emergent need for mobilization of fluid, or when client is not responding to other diuretics. Increases excretion of water, sodium, chloride, and magnesium. Side effects: -ototoxicity -hypoKalemia -hypoNatremia -hypochloremia -hypomagnesemia -hypocalcemia -hpotension -dehydration -hyperglycemia Contraindications: -pregnant women (can cause low milk production) -Anuria (no urine output) Use cautiously in: -liver/ renal disease -Diabetes mellitus -patients taking dioxin

What is the drug class for hydrochlorothiazide, what are the therapeutic effects, side effects, and contraindications?

Drug class: Thiazide *Most commonly used diuretic* Therapeutic effects: • choice for HTN • decreases edema from mild/ moderate HF, liver and kidney disease. Side effects: • hypoKalemia • hypoNatremia • HYPERglycemia Contraindications: • Pregnant women • Anuria • Client with renal impairment Precautions: • Renal or liver disorders • diabetes mellitus

CH. 21: PHYSICAL ASSESSMENT Which organs are in the right upper quadrant?

Duodenum Stomach Pancreas Adrenal gland Kidney Liver Gall bladder transverse colon

Mrs. Clancy is a nursing home patient at risk for falls. The head nurse asked one of the unlicensed assistive Personnel to assist Mrs. Clancy to the dining hall and help prepare her for dinner. Which of the following Nursing processes does this represent? a. Assessment b. Diagnosis c. Planning outcomes d. Planning interventions e. Implementation f. Evaluation

E. Evaluation

CHAPTER 31: SENSORY PERCEPTION Where is the reticular activating system (RAS) found? A. thalamus B. cerebellum C. cerebrum D. sulcus E. brain stem

E. brain stem

CHAPTER 31: SENSORY PERCEPTION What is characterized by a clouded area over the lens of the eye causing photosensitivity and blurry, distorted vision? A. glaucoma B. macular degeneration C. presbyopia D. retinopathy E. cataracts

E. cataracts

CHAPTER 31: SENSORY PERCEPTION Which receptors are found in the retina and respond to light? A. mechanoreceptors B. hair cells C. thermoreceptors D. proprioceptors E. photoreceptors F. chemoreceptors

E. photoreceptors

What is hypertension?

Elevated blood pressure

What are nurse practice acts?

In the United States of America (USA), each state enacts its own laws that regulate nursing practice.

What is autonomy?

Every person has the right to decide their own course of action and make their own medical decisions.

Portal of exit?

Exit route for pathogen to leave its host

CHAPTER 31: SENSORY PERCEPTION Which receptors are responsible for taste and are found in the taste buds? A. mechanoreceptors B. hair cells C. thermoreceptors D. proprioceptors E. photoreceptors F. chemoreceptors

F. chemoreceptors

TRUE or FALSE: A nurse researcher who intends to interview clients about the factors that influence their compliance with insulin therapy and summarize the data as themes is doing quantitative research.

FALSE

CH. 27: HEALTH PROMOTION TRUE or FALSE: According to the U.S. Preventative Task Force, screening for alcohol should start at the age of 21.

FALSE. Many people drink before they are 21.

What is justice?

Fairness, equal treatment to all

What is fidelity?

Faithfulness, loyalty, keeping promises.

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS TRUE or FALSE: Accurate documentation for a patient given Diovan, 10 mg, once daily is: "Diovan, 10 mg, Q.D."

False

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS TRUE or FALSE: An example of a helpful and accurate nursing note is: "the patient appears to be resting more comfortably today than yesterday."

False

CHAPTER 29: BOWEL ELIMINATION TRUE OR FALSE: A nurse understands that hyperactive bowel sounds may indicate peritonitis or paralytic ileus.

False

CHAPTER 29: BOWEL ELIMINATION TRUE OR FALSE: The Valsalva maneuver may be contraindicated in people with cardiovascular problems because it increases blood flow to the atria and ventricles, temporarily increasing cardiac output.

False

CHAPTER 28: NUTRITION TRUE or FALSE: A 24-year-old woman has a higher basal metabolic rate than a pregnant 24-year-old woman.

False. Base metabolic rate increases by about 20% during pregnancy.

CHAPTER 39: FLUIDS and ELECTROLYTES TRUE or FALSE: Body fluids have only one major function or role.

False. Body fluids are responsible for: • supporting cellular metabolism • flushing toxins • molecular transport • delivering oxygen and nutrients to the cells • heat dissipation

CHAPTER 39: FLUIDS and ELECTROLYTES TRUE or FALSE: Fluid deficit is the only type of fluid imbalance.

False. Hypervolemia = excessive fluid volume Hypovolemia = deficient fluid volume

CHAPTER 39: FLUIDS and ELECTROLYTES TRUE or FALSE: Institute of Medicine [IoM] recommends that adults drink 1200ml of water per day.

False. IOM recommends 3500ml for men daily, and 2700 for women. Elderly people should consume 1500ml daily.

CHAPTER 39: FLUIDS and ELECTROLYTES TRUE or FALSE: You do not need to implement any interventions for a patient who is on restricted fluids.

False. Interventions include: • signage alerting care team to restrictions • patient and family education • measuring intake and output

CHAPTER 28: NUTRITION TRUE or FALSE: Most adults living in the US lack intake of sodium.

False. Most Americans consume more than 2300mg of sodium per day.

CHAPTER 28: NUTRITION TRUE or FALSE: You can eat a regular meal 2 hours before most surgical procedures.

False. Patients should have only clear liquids 2 hours before surgical procedures, and can consume light solid foods up to 6 hours before surgery.

CHAPTER 39: FLUIDS and ELECTROLYTES TRUE or FALSE: Weight is not an appropriate indicator of fluid loss.

False. Percentage of weight loss determines the severity of the fluid loss.

CHAPTER 28: NUTRITION TRUE or FALSE: You need large amounts of micronutrients such as Vitamin K and Vitamin D in your daily intake.

False. You need large amounts of macronutrients, but small amounts of micronutrients.

CHAPTER 28: NUTRITION TRUE or FALSE: Minerals such as calcium, potassium, and sodium are considered macronutrients.

False. Calcium, potassium and sodium are micronutrients.

CHAPTER 28: NUTRITION TRUE or FALSE: Table sugar is an example of a complex carbohydrate.

False. Table sugar is a simple carbohydrate; complex carbs include beans, peas, oatmeal, sweet potatoes and whole wheat bread.

CHAPTER 39: FLUIDS and ELECTROLYTES TRUE or FALSE: All adults enjoy drinking water.

False. Water tastes like apathy and disappointment.

Direct contact examples

Fecal, oral

CHAPTER 29: BOWEL ELIMINATION Which enema would be used for a patient with intestinal parasites? A. Nutritive enema B. Oil-retention enema C. Carminative enema D. Anthelmintic enema

D. Anthelmintic enema. Anthelmintic enemas destroy intestinal parasites.

CHAPTER 31: SENSORY PERCEPTION Which of the following reflexes would be considered abnormal in an adult? A. Anal. B. Biceps. C. Plantar. D. Babinski.

D. Babinski.

CHAPTER 25: ADMINISTERING MEDICATIONS The nurse is having difficulty deciphering the medication prescription written by the provider. What is the best strategy to clarify the information? A. Ask the patient what medication the provider prescribed. B. Call the pharmacist and ask him or her to read the prescription. C. Ask the nurse who knows the provider's handwriting to read the prescription. D. Call the provider and ask him or her to clarify the prescription.

D. Call the provider and ask him or her to clarify the prescription.

Prior to identifying accurate nursing diagnosis, which action MUST be taken by the nurse? a. Reading the patients history b. Setting realistic, measurable goals c. Comparing evidence- based practices d. Clustering related patient data

D. Clustering related patient data

A new nursing graduate has an interest in a position that will provide health promotion, illness prevention, early detection, and treatment within her rural community. Which type of nursing is this? a. International Nursing b. Public health nursing c. Community health nursing d. Community-oriented Nursing

D. Community-oriented Nursing

How does the nurse obtain a full set of data when performing an assessment of a client? A. Take a set of vital signs. B. Review diagnostic studies. C. Performing a client interview. D. Complete a nursing history & physical examination.

D. Complete a nursing history & physical examination.

Which statement illustrates the most measurable outcome indicator? A. Shows remorse. B. Understands instructions. C. Verbalizes a dressing change. D. Demonstrates self-injection of insulin.

D. Demonstrates self-injection of insulin.

It is Important for the nurse to understand the structure of the client's family so that he or she can... A. Address the various family members correctly. B. Tailor visiting hours to the family's needs. C. Avoid embarrassing moments during client interventions. D. Develop a holistic plan that includes the whole family.

D. Develop a holistic plan that includes the whole family.

CH. 20: COMMUNICATING & THERAPEUTIC RELATIONSHIPS Use of the statements "Tell me more about ..." or "I see" encourages patients to continue talking and expressing themselves. This is called A. Summarizing B. Open-ended questions C. Focusing D. Encouraging elaboration

D. Encouraging elaboration

CHAPTER 29: BOWEL ELIMINATION Which of the following gastrointestinal (GI) direct visualization studies is most likely to be used to detect upper GI bleeding? A. Colonoscopy B. Sigmoidoscopy C. Abdominal X-ray D. Esophagogastroduodenoscopy

D. Esophagogastroduodenoscopy An EGD examines the lining of the esophagus, stomach, and duodenum of the small intestine.

A nurse is revising a client's care plan. During which step of the nursing process does such revision take place? A. Assessment B. Planning C. Implementation D. Evaluation

D. Evaluation

Critique care plan and revise as needed, especially if patient situation has changed a. Diagnosis b. Implementation c. Assessment d. Evaluation

D. Evaluation

In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem? A. Assessment B. Diagnosis C. Planning outcomes D. Evaluation

D. Evaluation

Following hip surgery, a trochanter roll is used to prevent what type of movement? a. Supination b. Pronation c. Internal rotation d. External rotation

D. External rotation

CH. 27: HEALTH PROMOTION An example of a secondary health prevention activity would be: A. Chemotherapy IV infusion B. Hepatitis B vaccine series C. Gallbladder surgery D. Flexible sigmoidoscopy at age 50

D. Flexible sigmoidoscopy at age 50

CH. 36: SKIN INTEGRITY and WOUND HEALING The nurse understands intrinsic factors that contribute to formations of pressure injuries include all the following except. A. Age B. Nutrition C. Underlying health condition D. Friction

D. Friction

CHAPTER 9: DEVELOPMENT - INFANCY to MIDDLE ADULT The nurse is interviewing a 46-year-old woman who admits to using drugs and alcohol to "erase problems." According to Erikson, she may have not resolved which stage of development? A. Intimacy versus isolation B. Identify versus role confusion C. Integrity versus despair D. Generativity versus stagnation

D. Generativity versus stagnation

CH. 36: SKIN INTEGRITY and WOUND HEALING A patient who is on bedrest has a stage one pressure ulcer on the sacrum and is recovering from a pelvic injury sustained in a motor vehicle accident. What is the priority nursing diagnosis for this patient? A. Ineffective coping related to pelvic injury B. Whisper infection related to open wound site C. Risk for impaired tissue integrity in pain related to a motor vehicle accident D. Impaired skin integrity related to pressure, secondary to immobility

D. Impaired skin integrity related to pressure, secondary to immobility

A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? A. Acute pain related to surgery. B. Deficient fluid volume related to blood and fluid loss from surgery. C. Impaired physical mobility related to surgery. D. Risk for aspiration related to anesthesia.

D. Risk for aspiration related to anesthesia.

Which statement regarding heart sounds is correct? A. S1 and S2 sound equally loud over the entire cardiac area. B. S1 and S2 sound fainter at the apex. C. S1 and S2 sound fainter at the base. D. S1 is loudest at the apex, and S2 is loudest at the base.

D. S1 is loudest at the apex, and S2 is loudest at the base.

Which of the following teaching points for older adults would directly and immediately decrease fall risk? a. Exercise as per practitioner. b. Maintain proper weight. c. Proper body mechanics. d. Safety-proof home.

D. Safety-proof home.

CHAPTER 10: DEVELOPMENT - OLDER ADULTHOOD An older adult asks the nurse why she has hypertension. The nurse explains that this is often experienced because of which of the following? A. Myocardial damage B. Reduction in physical activity C. Ingestion of large amounts of processed foods D. Stiffening of the blood vessels, impairing blood flow.

D. Stiffening of the blood vessels, impairing blood flow.

A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says that he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to: A. Encourage the client to ask questions about personal sexuality. B. Provide time for privacy. C. Provide support for the spouse or significant other. D. Suggest referral to a sex counselor or other appropriate professional.

D. Suggest referral to a sex counselor or other appropriate professional.

Which assessment finding would indicate that a client has hemiparesis (weakness of one side of the body)? a. Bilateral lack of movement in the client's lower extremities b. Complaint of pain when the client attempts to ambulate c. Loss of sensation in both of the client's legs d. Weakness of the client's right arm and leg

D. Weakness of the client's right arm and leg

CHAPTER 39: FLUIDS and ELECTROLYTES Which organ is responsible for regulating fluids and electrolyte balance? A. adrenal gland B. thyroid C. pituitary gland D. kidneys E. liver

D. kidneys

CHAPTER 25: ADMINISTERING MEDICATIONS What patient identifiers can you use?

- Name - DOB

CHAPTER 25: ADMINISTERING MEDICATIONS What are appropriate resources to use to look up a drug?

- Nurse's Drug Handbook - Pharmacology Text - Physician's Desk Reference - Pharmacopoeia and formularies (online too!) - Clinical pharmacist - Medication package inserts

CHAPTER 25: ADMINISTERING MEDICATIONS Name the different routes of medication administration.

- Oral (sublingual, liquid, pill, buccal) - IV - Transdermal - Topical - Rectal - SubQ - Sub-dermal - IM

CHAPTER 25: ADMINISTERING MEDICATIONS What are some strategies used to prevent medication errors?

- alerts - cross-checks - patient ID

CHAPTER 25: ADMINISTERING MEDICATIONS What should the nurse do if a medication error is made?

- assess patient - tell charge nurse - contact provider - report error - not in pt record (variance or incidence report)

BASIC LAB VALUES: RENAL FUNCTION creatinine [Cr] (waste product of normal muscle breakdown filtered thru kidneys and excreted in urine)

0.6-1.2 mg/dL

CHAPTER 31: SENSORY PERCEPTION A patient who has vision and hearing problems has a history of striking out at caregivers. Which nursing intervention would be most appropriate? A. consulting the health care provider regarding the use of restraints B. performing tasks quickly to reduce risks to caregivers C. explaining to the patient that this is unacceptable behavior D. obtaining the patient's consent before starting care

D. obtaining the patient's consent before starting care

BASIC LAB VALUES: LIVER FUNCTION TEST albumin (responsible for plasma oncotic pressure)

3.5-5 g/dL

BASIC LAB VALUES: SERUM ELECTROLYTES potassium [K+ → major ICF electrolyte]

3.5-5 mEq/L [Regulated by renal function]

CHAPTER 31: SENSORY PERCEPTION Which receptors are located in the muscles and joints and are responsible for information about body position and movement? A. mechanoreceptors B. hair cells C. thermoreceptors D. proprioceptors E. photoreceptors F. chemoreceptors

D. proprioceptors

CHAPTER 33: ACTIVITY & EXERCISE To determine the degree of joint limitation for a patient with a long history of arthritis complaining of sensitivity and warmth in the knees, the nurse should assess: A. posture. B. activity tolerance. C. body mechanics. D. range of joint motion (ROM).

D. range of joint motion (ROM).

CH. 36: SKIN INTEGRITY and WOUND HEALING wound

A disruption in the normal integrity of the skin

What is planning?

A series of steps by which the nurse and the patient set priorities and goals.

CHAPTER 34: SEXUAL HEALTH In completing an admission history, the nurse learns that a female patient has a female sexual partner. This data speaks to the patient's: A. gender role. B. sexual bias. C. gender identity. D. sexual orientation.

D. sexual orientation.

CHAPTER 31: SENSORY PERCEPTION When performing the Romberg test, the nurse instructs the patient to: A. tandem walk. B. hop on one foot. C. do a deep knee bend. D. stand with feet together, eyes open then closed.

D. stand with feet together, eyes open then closed.

CHAPTER 29: BOWEL ELIMINATION What is docusate (Colace)? A. bulk-forming laxative B. stimulant laxative C. osmotic laxative D. stool softener

D. stool softener

CHAPTER 31: SENSORY PERCEPTION The nurse is working with a patient with a moderate hearing impairment. To promote communication with this patient, the nurse should: A. use a louder tone of voice than normal B. select a public area to have a conversation C. approach a patient quietly from behind before speaking D. use visual aids such as the hands when speaking

D. use visual aids such as the hands when speaking

CHAPTER 34: SEXUAL HEALTH After obtaining information on the signs & symptoms of an adolescent female's potential vaginal infection, what is the nurse's best response? A. "Let's discuss your current sexual activity." B. "Do you know how you got this infection?" C. "Have you told your mother about your concerns?" D. "Can you tell me what kind of infection you think you have?"

A. "Let's discuss your current sexual activity."

CHAPTER 37 and 38: OXYGENATION and PERFUSION The nurse assesses a patient with chronic obstructive pulmonary disease (COPD). Which finding does the nurse anticipate when inspecting the chest? A. A barrel chest. B. A concave sternum. C. A convex sternum. D. A severe lateral curvature of the spine.

A. A barrel chest.

CHAPTER 31: SENSORY PERCEPTION Which patient would be at the highest risk for developing sensory deprivation? A. A patient with quadriplegia on bed rest B. A patient who wears corrective contact lenses C. A patient who speaks English as a second language D. A patient who has no visitors

A. A patient with quadriplegia on bedrest

CHAPTER 10: DEVELOPMENT - OLDER ADULTHOOD Which represent common developmental tasks of older adults? SELECT ALL THAT APPLY. A. Adjusting to retirement B. Adjusting to the death of a spouse C. Adjusting to an increase in income D. Inability to live by themselves E. Adapting to flexible social roles

A. Adjusting to retirement B. Adjusting to the death of a spouse D. Inability to live by themselves E. Adapting to flexible social roles

Which factors are affecting the nursing shortage? SELECT ALL THAT APPLY. a. Aging faculty b. Increasing elderly population c. Job satisfaction due to adequate number of nurses d. Aging nursing workforce e. Greater autonomy for nurses

A. Aging faculty B. Increasing elderly population D. Aging nursing workforce

CHAPTER 37 and 38: OXYGENATION and PERFUSION Which respiratory organ is the site of gas exchange? A. Alveoli B. Bronchus C. Heart D. Venous system

A. Alveoli

CHAPTER 31: SENSORY PERCEPTION Which of the following interventions can help improve communication with the visually impaired? SELECT ALL THAT APPLY. A. Call the patient by name B. Introduce yourself when entering the room C. Don't say, "look" or "see" D. Describe the room layout E. Explain unfamiliar noises F. Speak before you touch the patient G. Speak loudly when entering the room H. Let the patient know when you are leaving the room

A. Call the patient by name B. Introduce yourself when entering the room D. Describe the room layout E. Explain unfamiliar noises F. Speak before you touch the patient H. Let the patient know when you are leaving the room Visual deficits can range from minor impairment (use of glasses) to total blindness. The nurse should communicate in a normal tone of voice to make the patient aware of the environment and presence while in the room.

CHAPTER 29: BOWEL ELIMINATION Which of the following gastrointestinal (GI) direct visualization studies is most recommended for colon cancer screening? A. Colonoscopy B. Sigmoidoscopy C. Abdominal MRI scan D. Kidney, ureter, & bladder (KUB) X-ray

A. Colonoscopy

The nurse is giving a bed bath to an elderly patient. What are factors to consider when assessing this patient's skin? SELECT ALL THAT APPLY. a. Color. b. Emotions. c. Sensation. d. Skin lesions. e. Vital signs (VS).

A. Color. C. Sensation. D. Skin lesions.

Which action should the nurse take 30 mins. after administering oral pain medication to a client? a. Evaluate the effectiveness of the administered pain medication b. Teach progressive relaxation strategies to relieve muscle tension c. Assess the client's coping skills to reduce expressed anxiety d. Encourage the client to read or watch TV to provide pain distraction

A. Evaluate the effectiveness of the administered pain medication

Which action should the nurse take 30 minutes after administering oral pain medication to a patient? a. Evaluate the effectiveness of the administered pain medication b. Teach progressive relaxation strategies to relieve muscle tension c. Assess the patient coping skills to reduce expressed anxiety d. Encourage the patient to read or watch TV to provide pain distraction

A. Evaluate the effectiveness of the administered pain medication

CHAPTER 32: PAIN Which of the following nursing interventions for a patient in pain is based on the gate control theory? A. Giving the patient a back massage B. Changing the patient's position in bed C. Giving the patient a pain medication D. Limiting the number of visitors

A. Giving the patient a back massage

Which of the following is the most effective way to break the Chain of Infection? a. Hand hygiene. b. Placing patients in isolation. c. Providing private rooms for patients. d. Wearing gloves.

A. Hand hygiene

The nurse is caring for a client who experienced major trauma and has lost approx. 2 units of blood. Which initial compensatory mechanisms would the nurse expect the client to exhibit. SELECT ALL THAT APPLY. a. Increased BP b. Increased urinary output c. Increased pulse rate d. Decreased temp. e. Decreased respirations

A. Increased blood pressure C. Increased pulse rate

A nurse goes to another unit to see a friend who has been admitted. The nurse goes to look at a friend's medical record. This is an example of: a. Invasion of privacy b. Breach of confidentiality c. Liability d. Malpractice

A. Invasion of privacy

Which nursing intervention would be effective when dealing with the family members of a critically ill client? A. Involve the family members in care conferences about the client's care. B. Complete all of the client's care so the family is not inconvenienced. C. Select the eldest child to involve in care conferences. D. Invite the family member with better coping skills to the care conference.

A. Involve the family members in care conferences about the client's care.

CH. 26: TEACHING and LEARNING When teaching an older adult patient, the nurse incorporates which teaching strategy into the plan? A. keep teaching sessions short B. include as many concepts as possible C. teach later in the evening D. focus on teaching the family members

A. Keep teaching sessions short. (Shorter teaching sessions may be best for comprehension and retention.)

CHAPTER 33: ACTIVITY & EXERCISE When the nurse assesses a pregnant patient, what is the expected spinal deformity? A. Lordosis. B. Kyphosis. C. Scoliosis. D. No Change.

A. Lordosis.

CHAPTER 31: SENSORY PERCEPTION Which of the following interventions can help decrease sensory overload? SELECT ALL THAT APPLY. A. Remove noxious odors promptly B. Minimize lighting C. Place the patient near the nurses' station D. Lower voice and alarm sounds E. Encourage frequent visitors F. Minimize nighttime interruptions G. Only use the television when the patient is interested H. Minimize pain medications

A. Remove noxious odors promptly B. Minimize lighting D. Lower voice and alarm sounds F. Minimize nighttime interruptions G. Only use the television when the patient is interested

CHAPTER 31: SENSORY PERCEPTION Which factors can impact a person's sensory alteration? SELECT ALL THAT APPLY. A. Sensory deprivation B. Sensory overload C. Sensory deficit D. Sensory withdrawal E. Sensory denial

A. Sensory deprivation B. Sensory overload C. Sensory deficit

The nurse would monitor the body temperature most closely/frequently in the care of the patient: a. With a head injury. b. With an infection. c. Who has experienced a heat stroke. d. Who is an infant.

A. With a head injury.

CHAPTER 31: SENSORY PERCEPTION Which of the following are types of receptors? SELECT ALL THAT APPLY. A. mechanoreceptors B. hair cells C. dendrites D. synapses E. thermoreceptors F. proprioceptors G. positive receptors H. photoreceptors I. chemoreceptors

A. mechanoreceptors B. hair cells E. thermoreceptors F. proprioceptors H. photoreceptors I. chemoreceptors

CHAPTER 28: NUTRITION Vitamin E is best obtained from which of the following foods? SELECT ALL THAT APPLY. A. nuts and seeds B. avocado C. wheat germ D. spinach E. mango and kiwi F. oily fish (salmon, tuna, trout)

A. nuts and seeds B. avocado C. wheat germ D. spinach E. mango and kiwi F. oily fish (salmon, tuna, trout)

CHAPTER 28: NUTRITION Vitamin D is best obtained from which of the following foods? SELECT ALL THAT APPLY. A. oily fish (salmon, tuna, trout) B. red meat (beef, lamb, venison) C. mushrooms D. cheese, yogurt, and milk E. prunes F. egg yolk

A. oily fish (salmon, tuna, trout) B. red meat (beef, lamb, venison) C. mushrooms F. egg yolk

CHAPTER 31: SENSORY PERCEPTION Which are the components that compose the sensory experience? SELECT ALL THAT APPLY. A. stimulus B. response C. reception D. perception E. reticulation F. arousal

A. stimulus C. reception D. perception F. arousal

CHAPTER 29: BOWEL ELIMINATION Select the most appropriate goal for a patient experiencing diarrhea related to antibiotic use: A. the patient will increase fluid intake. B. the patient will return to their previous elimination pattern. C. the patient will increase intake of grains, rice, and cereals. D. the patient will discontinue antibiotic use and contact the health care provider.

A. the patient will increase fluid intake. Diarrhea can lead to dehydration. Drink accordingly.

CHAPTER 31: SENSORY PERCEPTION How can cataracts present? SELECT ALL THAT APPLY. A. unilaterally B. intermittently C. bilaterally D. ipsilaterally E. contralaterally

A. unilaterally C. bilaterally

Assessment

Data gathering stage; from multiple reliable sources. Data found will help draw conclusions about client's health status

Intellectual curiosity

Desire for knowledge; ask questions to learn

Evaluation

Determine whether the final outcomes have been successful enough & judge whether your actions have treated or prevented the health problems. After, modify care plan as needed

What is assessment?

Gathering all data (objective and subjective) on the patient

Apnea

Absence of breathing

Implementation

Action phase; carry out or delegate the actions that you planned already

What is battery?

Actual physical harm caused to another person

Contextual Awareness

An awareness of what's happening in the total situation, including values, cultural issues, interpersonal relationships, and environmental influences. • Deciding what to observe and consider

What is evaluation?

Assessing the patient's response to the nursing interventions

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS ADPIE

Assessment Diagnosis Plan Implement Evaluate

Five Steps of Nursing Process

Assessment Diagnosis (PROBLEM STATEMENT) Planning Outcomes and Interventions Implementation Evaluation

CH. 36: SKIN INTEGRITY and WOUND HEALING scar

Avascular collagen tissue that does not sweat, grow hair, or tan in sunlight

Intellectual Humility

Aware they do not know everything and not afraid to ask for help

Normal oral temp. is 98.6 F. What is the temp for axillary, rectal, and tympanic?

Axillary: one lower than oral Rectal: one higher than oral Tympanic: same as oral

HAI

Hospital-Acquired Infection

CHAPTER 32: PAIN Mr. Zenobia's chronic cancer pain has recently increased and he asks the home health nurse what can be done. In relation to his long-acting morphine, which is an appropriate response by the nurse? A." If you take more morphine, it will not change your pain relief." B. "I'll call the primary care provider and ask for an increased dose." C. "The amount you are taking now is all I can give you." D. "I'm worried if we increase your dose that you will stop breathing."

B. "I'll call the primary care provider and ask for an increased dose."

CH. 20: COMMUNICATING & THERAPEUTIC RELATIONSHIPS A patient says to the nurse, "I feel so sick and weak, I don't think I'll ever be able to go home." Which response by the nurse is therapeutic? A. "Let's get you up and walking more; that will help." B. "It sounds like you are frustrated. What do you mean by 'sick and weak'?" C. "What can I do to help you feel better?" D. "I'm sure you are frustrated; you must miss being home."

B. "It sounds like you are frustrated. What do you mean by 'sick and weak'?"

Using Abraham Maslow's hierarchy of human needs, a nurse assigns highest priority to which client need? A. Security B. Elimination C. Safety D. Belonging

B. Elimination (because it's physiological, which beats out safety. But if we're being honest? If a bear is attacking me, I'm going to piss my pants so we're gonna have both, ok?)

A nurse is caring for a hospitalized patient who is performing active range of motion exercises. which of the following body movements should indicate to the nurse and the patient has full range of motion of the shoulder? a. I don't think the arm so that it lies next to the patient side b. Flexing the shoulder by raising the arm from a side position to a 180° angle c. Abducting the arm to a 90° angle from the side of the body d. Circumducting the shoulder in a 180° half circle

B. Flexing the shoulder by raising the arm from a side position to a 180° angle

CHAPTER 29: BOWEL ELIMINATION Which food is recommended for an older adult who is constipated? A. Eggs B. Fruit C. Cheese D. Cabbage

B. Fruit Fruits and vegetables have a laxative effect on the system.

CHAPTER 29: BOWEL ELIMINATION Which food is recommended for a patient who is constipated? A. Eggs. B. Fruit. C. Cheese. D. Cabbage. E. Taco Bell late-night menu

B. Fruit. (But obviously E too. Be safe out there.)

CHAPTER 39: FLUIDS and ELECTROLYTES A nurse assesses a patient for the clinical manifestations of electrolyte imbalances. Which of the following indicates that the patient may have a potassium deficiency? SELECT ALL THAT APPLY. A. Increased blood pressure B. Irregular pulse rhythm C. Muscle tension D. Chest pain E. Dry hair

B. Irregular pulse rhythm Hypokalemia can cause a weak, irregular pulse and ventricular dysrhythmias.

CHAPTER 31: SENSORY PERCEPTION Which of the following will mitigate the effects of sensory overload? SELECT ALL THAT APPLY. A. Playing music to mask external sounds B. Keeping lights low C. Surrounding the patient with familiar friends and family D. Removing scented soaps, lotions, candles from the room E. Projecting soft colored lights on the ceiling and walls F. Limiting intrusions by visitors and staff

B. Keeping lights low D. Removing scented soaps, lotions, candles from the room F. Limiting intrusions by visitors and staff

CH. 26: TEACHING and LEARNING Which of the following are accurate principles for patient teaching? SELECT ALL THAT APPLY. A. Teaching multiple concepts at once B. Keeping sessions short C. Continuing if the patient becomes fatigued D. Providing positive feedback to the patient E. Starting with familiar material and progressing to new info F. Reviewing key points at the end of the session

B. Keeping sessions short D. Providing positive feedback to the patient E. Starting with familiar material and progressing to new info F. Reviewing key points at the end of the session

CH. 21: PHYSICAL ASSESSMENT What musculoskeletal change is seen in pregnant women during the last trimester? A. Kyphosis B. Lordosis C. Scoliosis D. No Change

B. Lordosis

CHAPTER 32: PAIN Which of the following are opioid analgesic medications that may be used for pain management? SELECT ALL THAT APPLY. A. Acetaminophen B. Morphine C. Hydromorphone D. Ibuprofen E. Oxycodone

B. Morphine C. Hydromorphone E. Oxycodone

CHAPTER 37 and 38: OXYGENATION and PERFUSION A patient in respiratory distress enters the emergency department. The patient denies a history of COPD. The nurse anticipates an order for oxygen delivered by which method to achieve the highest possible concentration of oxygen? A. Simple face mask at 15 L/min B. Non-rebreather face mask at 15 L/min C. Venturi mask at 15 L/min D. Oxygen tent at 15 L/min

B. Non-rebreather face mask at 15 L/min Highest concentration of O2 via a mask; prevents rebreathing exhaled air.

CHAPTER 9: DEVELOPMENT - INFANCY to MIDDLE ADULT An infant has an Apgar score of 9 at 5 minutes after birth. The nurse assessing the infant knows that this indicates which situation? A. A medical emergency requiring resuscitation B. Normal function, but continued monitoring C. Robust, excellent health D. Observed in intensive care

B. Normal function, but continued monitoring

CH. 20: COMMUNICATING & THERAPEUTIC RELATIONSHIPS When using the SBAR model to communicate with a physician, what information does the nurse offer first? A. Statement of the problem and its probable cause B. Nurse's name, patient's name, and reason for the communication C. History of information related to and leading up to the situation D. A solution to the problem or what is needed from the physician

B. Nurse's name, patient's name, and reason for the communication

Gingivitis

Inflammation of the gums

Most effective barrier to infection?

Intact skin

What are primary services?

Keeping client well by preventing illness/ promoting illness preventions

Practical knowledge

Knowing what to do and how to do it, consists of processes and procedures and is an aspect of nursing expertise

CHAPTER 25: ADMINISTERING MEDICATIONS What is the difference between generic and brand names?

Literally nothing. Generic: name never changes but is closer to chemical name. Brand name: multiple manufacturers may make brand and sell it under multiple names.

CHAPTER 25: ADMINISTERING MEDICATIONS Can RNs delegate medication administration?

Nah. Some can be delegated to an LPN though. Check hospital policy.

What is slander?

Oral defamation of character (slander = spoken)

What is the incubation period?

Organisms growing and multiplying.

Direct contact?

Person to person or physical contact between source and susceptible host

Reservoir?

Place where the pathogen grows and may or may not multiply

What is the drug class for spironolactone?

Potassium-sparing diuretics

What is full stage of illness?

Presence of specific signs and symptoms of disease.

CHAPTER 25: ADMINISTERING MEDICATIONS What is the difference between primary effect vs secondary effect of a medication?

Primary: intended, expected effect Secondary: side effect, adverse effect, etc.

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS PIE charting =

Problem Intervention Evaluation

CH. 21: PHYSICAL ASSESSMENT Which cranial nerve(s) can be assessed by inspecting the patient's eyes?

Pupil constriction and eye movement abnormalities can indicate damage or malfunction of: Cranial Nerve III: oculomotor (motor) Cranial Nerve IV: trochlear (motor) Cranial Nerve VI: abducens (motor)

Independent thinking

Questioning assumptions and interpreting data and events according to one's own beliefs, ideas, and thinking, rather than pre-established rules or categories defined by others

What is convalescent period?

Recovery from infection.

Critical thinking skills

Refer to cognitive processes used in complex thinking operations like problem-solving and decision making

What are secondary services?

Screening/ early detection and treatment of diseases

Model

Set of interrelated concepts that represent a particular way of thinking about something - much in the same way that the shape of a lens affects what you see

What is the State Board of Nursing?

The agency responsible for regulating nursing practice (e.g., Massachusetts Board of Registration in Nursing or MBORN).

What is pulse pressure?

The difference between the diastolic and systolic pressures

Mode of transmission

The manner in which an infectious agent moves from one source to another

CH. 36: SKIN INTEGRITY and WOUND HEALING dehiscence

The partial or total disruption of wound layers at the suture line

What is the prodromal stage?

The person is most infectious, experiencing nonspecific (vague) signs of disease.

CH. 36: SKIN INTEGRITY and WOUND HEALING evisceration

The protrusion of viscera through the incisional area

CH. 36: SKIN INTEGRITY and WOUND HEALING What are the characteristics of a stage 2 pressure injury?

The skin breaks open, wears away, or forms an ulcer extending into deeper layers of the skin. Usually looks like a scrape (abrasion), blister, or a shallow crater in the skin.

CH. 36: SKIN INTEGRITY and WOUND HEALING What are the characteristics of a stage 4 pressure injury?

The wound is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur. (Patient may not experience pain due to severity.)

If you are unable to obtain BP on either arm, where else could you use use to find BP?

Thigh

Four main concepts that describe full-spectrum nursing

Thinking, doing, caring, & patient situation

CHAPTER 25: ADMINISTERING MEDICATIONS How many checks are there during Med Administration?

Three: 1. Verify before you pull it 2. Verify once retrieved 3. Verify at bedside/administration CONFIRM WITH MAR.

How does vector transmission occur?

Through a bite

Dental Caries

Tooth decay (cavities)

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS TRUE or FALSE: Critical pathways or care maps, used in the case management model, specify the plan of care that is linked to expected outcomes projected along a timeline.

True

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS TRUE or FALSE: In most agencies, the only circumstance in which orders may be issued verbally is in a medical emergency.

True

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS TRUE or FALSE: The patient record is the only permanent legal document that details the nurse's interactions with the patient.

True

CHAPTER 29: BOWEL ELIMINATION TRUE OR FALSE: An ileostomy allows liquid fecal content from the ileum of the small intestine to be eliminated through a stoma.

True

CHAPTER 29: BOWEL ELIMINATION TRUE OR FALSE: Chronic diarrhea typically lasts for more than 3 to 4 weeks.

True

CHAPTER 29: BOWEL ELIMINATION TRUE OR FALSE: The most common symptom of pinworm infection is perianal itching because adult pinworms migrate to the anal area during the night to deposit eggs.

True

CHAPTER 28: NUTRITION TRUE or FALSE: Carbohydrates are the body's main source of energy.

True.

CHAPTER 31: SENSORY PERCEPTION TRUE or FALSE: For any patient with an altered level of consciousness, the Glasgow Coma Scale score will help the nurse in planning care.

True.

CHAPTER 39: FLUIDS and ELECTROLYTES TRUE or FALSE: Decreases in hematocrit and Blood Urea Nitrogen (BUN) can be signs of fluid overload.

True. Fluid overload dilutes BUN and creatinine concentration.

CHAPTER 39: FLUIDS and ELECTROLYTES TRUE or FALSE: Thirst is a primary regulator of fluid intake.

True. Thirst is a conscious impulse leading to a voluntary response.

CHAPTER 39: FLUIDS and ELECTROLYTES TRUE or FALSE: Kidneys function largely in controlling and regulating water and electrolyte balance.

True. Kidneys have ADH (anti-diuretic hormone), aldosterone, angiotensin, renin, and they filter and excrete fluids.

CHAPTER 39: FLUIDS and ELECTROLYTES TRUE or FALSE: Sodium helps with fluid volume regulation and is the major cation in ECF compartment.

True. Sodium tells the body whether it needs to retain more or less fluid to promote homeostasis.

What is veracity?

Truthfulness, honesty

Airborne transmission

When infectious particles dispersed in the air enter the host by inhalation

Droplet infection

When the droplets from an infected hosted person are projected a short distance to the host's nasal mucosa, mouth or conjunctiva

What is accountability?

Willingness to take credit and blame for ones actions.

CH. 36: SKIN INTEGRITY and WOUND HEALING sanguineous wound drainage

Wound drainage that consists of large numbers of red blood cells and looks like blood

CH. 36: SKIN INTEGRITY and WOUND HEALING serous wound drainage

Wound drainage that is composed of the clear, serous portion of the blood and drainage from serous membranes

CH. 36: SKIN INTEGRITY and WOUND HEALING pustule

a blister with pus, e.g.; acne or carbuncle

CH. 36: SKIN INTEGRITY and WOUND HEALING bulla

a blister, usually from a burn

CH. 36: SKIN INTEGRITY and WOUND HEALING vesicle

a bubble with fluid, e.g.; a herpes blister

What is Assault?

a threat of bodily harm or violence caused by a demonstration of force by the perpetrator

CH. 21: PHYSICAL ASSESSMENT What are adventitious breath sounds?

abnormal breath sounds such as wheezing, stridor, rhonchi, and crackles.

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS SOAP(IER)

an acronym for Subjective data Objective data Assessment Plan Interventions Evaluation Revision May be used to address a single problem or to document summative notes on a patient.

CH. 21: PHYSICAL ASSESSMENT What should one observe when using percussion?

assessing location, shape, size, and density of tissues

CH. 21: PHYSICAL ASSESSMENT What should one observe when palpating a patient?

assessing mobility, moisture, pulsation, shape, size, skin turgor, temperature, texture, tenderness, and vibrations

CHAPTER 28: NUTRITION What are seven categories of macronutrients?

carbs fats fiber minerals proteins vitamins water

CH. 21: PHYSICAL ASSESSMENT In which four areas are the lymph nodes located?

cervical - neck axillary - armpits mediastinal - chest inguinal - groin

What is febrile?

client w/ fever

What is afebrile?

client w/o fever

CHAPTER 29: BOWEL ELIMINATION A __________ visualizes the rectum, colon, and bowel using a lighted scope.

colonoscopy

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS A nurse who fails to log off a computer after documenting patient care has breached patient __________.

confidentiality

Dyspnea

difficult, labored breathing - usually with a rapid, shallow pattern - that may be painful.

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS Computer-based records, or ____________ health records (EHRs), allow data to be distributed among many caregivers in a standardized format

electronic

CH. 36: SKIN INTEGRITY and WOUND HEALING plaque

elevated, solid, superficial, usually bigger than 1cm, e.g.; psoriasis

CHAPTER 29: BOWEL ELIMINATION An esophagogastroduodenoscopy (EGD) examines the __________, stomach, and upper duodenum through an optic scope.

esophagus

Caring

involves personal concern for people, events, projects, and things • specific for each encounter • not an abstraction • involves thinking and acting in ways that preserve human dignity and humanity

Ethical knowledge

knowledge of obligation, or right and wrong. consist of information about moral principles and processes for making moral decisions.

CHAPTER 29: BOWEL ELIMINATION Cathartics and __________ are drugs that induce emptying of the intestinal tract.

laxatives

CH. 21: PHYSICAL ASSESSMENT Which organs are in the left lower quadrant?

left ureter reproductive organs sigmoid colon sm. and lg. intestine

CH. 36: SKIN INTEGRITY and WOUND HEALING wheal

local edematous bump with irregular borders, e.g.; a hive or a bug bite

CH. 36: SKIN INTEGRITY and WOUND HEALING In the _________________ phase, collagen is remodeled, forming a scar.

maturation

Comorbidities

more than one health problem occurring at the same time

CHAPTER 29: BOWEL ELIMINATION Blood that is hidden in a stool specimen or cannot be seen on gross examination is known as __________ blood, which can be detected with screening tests.

occult

CHAPTER 29: BOWEL ELIMINATION Direct manipulation of the bowel during abdominal surgery inhibits peristalsis, causing a condition termed __________ or postoperative ileus.

paralytic

CHAPTER 37 and 38: OXYGENATION and PERFUSION How would you characterize harsh grating or creaking sounds in the anterior lungs and lateral chest?

pleural rub

CHAPTER 37 and 38: OXYGENATION and PERFUSION How would you characterize snoring, low-pitched rumbling sounds inside the lungs?

ronchi

orthopnea

shortness of breath (dyspnea) which occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair.

CH. 21: PHYSICAL ASSESSMENT What should one look for when inspecting a patient?

size, color, shape, position, and bilateral symmetry

CH. 36: SKIN INTEGRITY and WOUND HEALING nodule

solid bump with distinct borders, going deep into the skin. a tumor, e.g.; a wart or lipoma

CH. 36: SKIN INTEGRITY and WOUND HEALING papule

solid elevation without fluid, but with clearly defined borders, e.g.; a mole

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS A _______-oriented patient record is one in which each health care group keeps data on its own separate form

source

CHAPTER 37 and 38: OXYGENATION and PERFUSION How would you characterize thick, high-pitched sounds in the lungs when the patient inhales?

stridor

CHAPTER 37 and 38: OXYGENATION and PERFUSION How would you characterize high-pitched squeaks or whistling sounds in the lungs?

wheezes

What are the contraindications of furosemide?

• Chronic kidney disease • Elderly patients • Pregnant women • Hypersensitivity • Anuria • Avoid if alcohol intolerant • Use cautiously in client who has liver disease, cardiovascular disease, diabetus mellitus, electrolyte, electrolyte depletion

Airborne transmission examples

• Coughing • Sneezing

What makes someone a susceptible host?

• age • illness • poor health • broken skin

CHAPTER 25: ADMINISTERING MEDICATIONS The patient is on acetaminophen 650mg ER orally BID; the patient wants it crushed in applesauce. What is the best response by the nurse?

- contact pharmacy for ER sprinkles

CHAPTER 25: ADMINISTERING MEDICATIONS How are medication orders obtained?

- from the provider - written (fax, paper) - verbal (emergency only) - telephone (repeat order to confirm) DOCUMENTATION IN MAR

CHAPTER 25: ADMINISTERING MEDICATIONS What is distribution and what factors affect it?

- membrane permeability - protein binding capacity - local blood flow

CHAPTER 25: ADMINISTERING MEDICATIONS What are some nursing considerations when instilling ear drops?

- patient lying on opposite side - ear is clear from wax buildup - pull back pinna (kids: down, adults: up) - remain lying for 5-10 minutes

CHAPTER 25: ADMINISTERING MEDICATIONS What are the components of the medication order (prescriptions)?

- strength/dosage - frequency - duration - route - medication name - patient's name - date

CHAPTER 25: ADMINISTERING MEDICATIONS What are the four processes of pharmacokinetics?

1. Absorption 2. Distribution 3. Metabolism 4. Excretion

CH. 21: PHYSICAL ASSESSMENT What is the correct order for assessing the abdomen?

1. Inspection 2. Auscultation 3. Palpation 4. Percussion

For all body systems except the abdomen, what is the preferred order for the nurse to perform the following examination techniques?

1. Inspection 2. Palpation 3. Percussion 4. Auscultation

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS What are 6 variables that influence self-concept?

1. developmental considerations 2. culture 3. internal and external resources 4. history of success and failure 5. crisis or life stressors 6. aging, illness, trauma

CH. 36: SKIN INTEGRITY and WOUND HEALING What are the four stages of skin healing?

1. hemostasis (clotting begins) 2. inflammation (WBCs move to wound) 3. proliferation (granulation tissue fills wound) 4. maturation (collagen remodeled; scar forms)

BASIC LAB VALUES: URINALYSIS specific gravity

1.005-1.030

BASIC LAB VALUES: SERUM ELECTROLYTES magnesium [Mg++]

1.3-2.1 mEq/L [Primarily eliminated in the kidneys]

BASIC LAB VALUES: RENAL FUNCTION blood urea nitrogen [BUN] (liver breaks down food proteins which then end up in the kidneys)

10-20 mg/dL [Used to assess or monitor hydration status, protein tolerance, and renal function]

BASIC LAB VALUES: CBC hemoglobin [Hgb] (O2-carrying capacity of the blood)

12-18 g/dL Males: 14-18 g/dL Females: 12-16 g/dL

BASIC LAB VALUES: SERUM ELECTROLYTES sodium [Na+ → major ECF electrolyte]

136-145 mEq/L [H2O regulation]

BASIC LAB VALUES: CBC platelets [PLTs] (thrombocytes)

150,000-400,000/mm3 [Critical <20,000 or >1,000,000]

CHAPTER 25: ADMINISTERING MEDICATIONS The provider orders 100mg of a hypnotic medication to help the patient sleep. The label on the medication bottle reads Seconal 50mg per tablet. How many tablets should the nurse give the patient?

2 tablets

BASIC LAB VALUES: SERUM ELECTROLYTES phosphorous [PO4-]

3-4.5 mEq/L [Inverse relationship with Ca++]

CHAPTER 29: BOWEL ELIMINATION A patient should be instructed to retain the oil from an oil-retention enema for at least ____________________ for best cleansing results.

30 minutes

CHAPTER 25: ADMINISTERING MEDICATIONS The provider orders a trough for a medication. When should the nurse expect the lab to be drawn?

30 minutes before dose administration. (Test to find out when the lowest concentration of the medication has a therapeutic effect = trough)

To reduce shearing force to an elderly patient or an immobilized patient, position them with the head of the bed at no less than what angle?

30º

BASIC LAB VALUES: CBC hematocrit [Hct] (% of blood composed of erythrocytes)

37-52% Males: 42-52% Females: 37-47%

BASIC LAB VALUES: CBC red blood cells [RBCs] (erythrocytes)

4.2-6.1 million/uL

BASIC LAB VALUES: CBC white blood cells [WBCs] (leukocytes)

5,000-10,000/mm3

BASIC LAB VALUES: BLOOD GLUCOSE LEVELS fasting glucose

70-105 mg/dL

BASIC LAB VALUES: SERUM ELECTROLYTES calcium total [Ca++ → most abundant electrolyte in body]

9-10.5 mg/dL

BASIC LAB VALUES: RENAL FUNCTION estimated glomerular filtration rate [eGFR]

90-130 mL/min/1.73 m2 Males: 90-139 mL/min/1.73 m2 Females: 80-125 mL/min/1.73 m2

BASIC LAB VALUES: SERUM ELECTROLYTES chloride [Cl-]

98-106 mEq/L [Follows Na+ & H2O]

BASIC LAB VALUES: CBC erythrocyte sedimentation rate [ESR or "sed rate"] (checks for inflammation i.e., infection or cancer)

<20 mm/hr

End result of planning phase

A holistic nursing care plan, individualized to reflect the client's problems and strengths

Susceptible host?

A personal who becomes ill after pathogens enter the body because they cannot fight off the pathogen

What is the chain of infection?

A sequence of circumstances where all events must occur to develop an infection

What is a Felony?

A serious crime that results in the perpetrator being imprisoned in a state or federal facility for more than a year

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS The nurse is preparing to interview a teenage patient who has low self-esteem. Which statements might the nurse expect from this patient? SELECT ALL THAT APPLY. A. "I do not like the way I look." B. "I feel stupid when I mess up." C. "I am confident when I speak at school." D. "I feel I can make independent decisions." E. "I feel more comfortable staying at home." F. "I really worry about what others think of me."

A. "I do not like the way I look." B. "I feel stupid when I mess up." E. "I feel more comfortable staying at home." F. "I really worry about what others think of me."

A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? a. "I will determine the most important client problems that we should address." b. "I will review the past medical history on the clients records to get more information." c. "I will carry out the new prescriptions from the provider." d. "I will ask the client if their nausea has resolved."

A. "I will determine the most important client problems that we should address." Rationale: Prioritize the client's problems during the planning step of the nursing process.

Which statement or command mean by the nurse is an example of the evaluation phase of the nursing process? a. "I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal." b. "Mr. Sullivan will be able to walk the length of the hallway before discharge." c. "Mr. Sullivan may be able to ambulate with the use of a walker and standby assistance." d. "Ambulate Mr. Sullivan in the hallway three times today, please."

A. "I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal."

Which of the following clients may give consent to participate in a clinical trial? A. An emancipated 16-year-old B. A 4-year-old child C. An incompetent adult D. An elder with dementia

A. An emancipated 16-year-old

The nurse is completing a postoperative assessment on a client in the post-anesthesia recovery unit. Which VS requires further assessment by the nurse for the possible hypovolemic (low blood volume) shock? a. An increase in HR b. An increased temp. reading c. A decrease in BP d. A decrease in RR

A. An increase in heart rate

CHAPTER 29: BOWEL ELIMINATION What are some medications that can cause constipation? SELECT ALL THAT APPLY. A. Antacids B. Contraceptives C. Antihistamines D. Diuretics E. Anticholinergics F. Iron supplements G. NSAIDs and opioids

A. Antacids B. Contraceptives C. Antihistamines D. Diuretics E. Anticholinergics F. Iron supplements G. NSAIDs and opioids

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS A 52-year-old patient comes to the outpatient clinic complaining of a throbbing headache over the past 3 days. The patient has tried several over-the-counter (OTC) medications with no relief. When checked, the blood pressure reads 220/110. When you ask whether the patient has ever been treated for high blood pressure, the patient replies, "Yes, but I quit taking it because it affected my sex life." What would be an appropriate response by the nurse? A. Apply a holistic approach to assessment and formulating strategies to address sexual concerns. B. Explain to the patient there are medications that can help with any sexual dysfunction he or she may be experiencing. C. Offer to refer the patient to a counselor who specializes in aging adults and sexual dysfunction. D. Assess the patient, obtain subjective data including current lab results, and create a nursing plan that will address the immediate need for intervention of hypertension.

A. Apply a holistic approach to assessment and formulating strategies to address sexual concerns.

CHAPTER 37 and 38: OXYGENATION and PERFUSION Which diagnostic test/exam would best measure a patient's level of hypoxemia? A. Arterial blood gas (ABG) sampling B. Chest x-ray (CXR) C. Pulse oximeter reading D. Peak expiratory flow rate

A. Arterial blood gas (ABG) sampling

CHAPTER 31: SENSORY PERCEPTION Which of the following interventions can help improve taste? SELECT ALL THAT APPLY. A. Assess for sores in the mouth. B. Allow patient to select favorite foods. C. Provide oral hygiene. D. Eat smaller meals more frequently. E. Encourage spices, salt substitutes, and seasonings. F. Monitor dietary intake. G. Add cookies and candy to the diet. H. Encourage sucking on a breath mint between meals.

A. Assess for sores in the mouth. B. Allow patient to select favorite foods. C. Provide oral hygiene. E. Encourage spices, salt substitutes, and seasonings. F. Monitor dietary intake. When a person's taste is impaired, nutritional deficits and weight loss can occur, so monitoring of dietary intake is important. Provide favorite foods that offer a variety of appealing flavors. Be sure to assess the mouth for sores and provide routine oral care.

A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to: A. Assess the client's airway. B. Provide pain relief. C. Encourage deep breathing and coughing. D. Splint the chest wall with a pillow.

A. Assess the client's airway.

The nurse is assessing the dorsalis pedis pulses on an 88-year-old patient. She notes the feet to be cool and assesses weak, thready pulses. What should the nurse do next? a. Assess the popliteal and femoral pulses. b. Assess a 1-minute apical pulse. c. Apply a warm pack and reassess in 20 minutes. d. Notify the provider STAT.

A. Assess the popliteal and femoral pulses.

A charge nurse is observing a newly licensed nurse caring for a client who reports pain. The nurse checked the clients MAR and noted the last dose of pain medication was six hours ago. The prescription reads every four hours PRN for pain. The nurse administered the medication and checked with the client 40 minutes later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? a. Assessment b. Planning c. Intervention d. Evaluation

A. Assessment

CHAPTER 37 and 38: OXYGENATION and PERFUSION Which condition would be associated with inspiratory wheezing in a patient's lower posterior thorax A. Asthma B. Pneumonia C. Pneumothorax D. Congestive Heart Failure (CHF)

A. Asthma

An adult client's vs are: BP 160/98, temp 99.0 F, HR 80, and RR 18. The VS that should be of most concern to the nurse is: a. BP b. Temp c. Pulse d. RR

A. BP

A nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein? A. Baked beans, hamburger, and milk B. Spaghetti with cream sauce, broccoli, and tea C. Bouillon, spinach, and soda D. Chicken cutlet, spinach, and soda

A. Baked beans, hamburger, and milk

A nurse is performing a physical assessment on a patient and instructs the patient to stand with his feet together and arms at his side. The purpose of positioning the patient in this manner is to test which of the following? a. Balance b. Muscle strength c. Reflexes d. Coordination

A. Balance

CHAPTER 9: DEVELOPMENT - INFANCY to MIDDLE ADULT What physiological changes occur during middle adulthood? SELECT ALL THAT APPLY. A. Blood vessels become less elastic. B. Skin increases in turgor. C. Muscle loses tone. D. Gastrointestinal motility increases. E. Loss of height occurs.

A. Blood vessels become less elastic. C. Muscle loses tone.

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS Which component of self-concept is for a person who feels beautiful and fit; thus, a positive view of oneself? A. Body image. B. Self-esteem. C. Personal identity. D. Role performance.

A. Body image.

The nurse is caring for a patient admitted with chronic obstructive pulmonary disease (COPD) and hypertension (HTN). Before administering Propanolol, the nurse assesses the patient carefully. What is the most likely complication of this medication? a. Bronchospasm b. Heart block c. Heart failure d. Tachycardia

A. Bronchospasm

CHAPTER 31: SENSORY PERCEPTION Which cranial nerve (CN) does the nurse test on a patient when biting down on a tongue blade? A. CN V B. CN VI C. CN VII D. CN VIII

A. CN V

CHAPTER 25: ADMINISTERING MEDICATIONS A priority for the nurse in the administration of oral medications and prevention of aspiration is: A. Checking for dysphagia B. Making sure the head of the bed is at 30º C. Allowing the patient to self-administer D. Using straws and extra water for administration.

A. Checking for dysphagia

CHAPTER 31: SENSORY PERCEPTION Which of the following interventions can help improve visual senses? SELECT ALL THAT APPLY. A. Clean glasses B. Hang artwork on walls C. Close curtains D. Encourage visitors E. Place patient in a private room F. Arrange family pictures in the room G. Offer colorful clothing

A. Clean glasses B. Hang artwork on walls F. Arrange family pictures in the room G. Offer colorful clothing Patientsneeding stimulation of their visual senses should be in brightly lit rooms with natural sunlight when possible. Colors, pictures, and surroundings should be brightly colored. Apply clean glasses daily, only removing them when the patient is in bed.

CHAPTER 29: BOWEL ELIMINATION What type of enema might typically be prescribed to a patient prior to a diagnostic procedure? A. Cleansing enema B. Carminative enema C. Return-flow enema D. Oil-retention enema E. Anthelmintic enema

A. Cleansing enema A cleansing enema removes feces and may be helpful in the treatment of constipation as well as the removal of fecal matter prior to screening/diagnostic examinations such as colonoscopies, etc.

A profession has specific characteristics. In regard to how nursing meets these characteristics, which criteria are consistent and standardized processes? SELECT ALL THAT APPLY. a. Code of ethics b. Licensing c. Body of knowledge d. Educational preparation e. Altruism

A. Code of ethics B. Licensing C. Body of knowledge E. Altruism

A profession has specific characteristics. In regard to how nursing meets these characteristics, which criteria are consistent and standardized processes? SELECT ALL THAT APPLY. a. Code of ethics b. Licensing c. Body of knowledge d. Educational preparation e. Altruism

A. Code of ethics B. Licensing C. Body of knowledge E. Altruism

CHAPTER 29: BOWEL ELIMINATION Which of the following gastrointestinal (GI) direct visualization studies is most recommended for colon cancer screening? A. Colonoscopy B. Sigmoidoscopy C. Abdominal X-ray D. Esophagogastroduodenoscopy

A. Colonoscopy

The nurse is giving a bed bath to an elderly patient. What are factors to consider when assessing this patient's skin? SELECT ALL THAT APPLY. A. Color. B. Emotions. C. Sensation. D. Skin lesions. E. Vital signs (VS).

A. Color C. Sensation D. Skin lesions

CHAPTER 34: SEXUAL HEALTH What option does the nurse discuss with a patient who wants a non-prescription contraceptive? A. Condoms. B. Hormonal implants. C. Intrauterine devices (IUDs). D. Oral contraceptive pills (OCPs).

A. Condoms.

CHAPTER 31: SENSORY PERCEPTION Which of the following interventions can help confused patients? SELECT ALL THAT APPLY. A. Decrease anxiety. B. Promote orientation. C. Increase stimulation. D. Maintain safety. E. Provide independence. F. Promote alone time. G. Provide continuity of care. H. Simplify communication.

A. Decrease anxiety. B. Promote orientation. D. Maintain safety. G. Provide continuity of care. H. Simplify communication.

CHAPTER 9: DEVELOPMENT - INFANCY to MIDDLE ADULT While working in a pediatrician's office, the nurse notices an 11-month-old has not met developmental milestones and appears to be distant and not engaged. After questioning the young mother, she states he "eats good" and she hasn't "paid much attention" to his play habits. The physician admits the infant with failure to thrive. What would be an appropriate nursing diagnosis for this patient? A. Delayed growth and development related to parental deficient knowledge, lack of stimulation, and nutrition deficit B. Patient (newborn) will achieve realistic developmental and growth milestones based on existing abilities, extent of disability, and functional age C. Nurse will encourage setting of short-term, realistic goals for achieving developmental potential D. Delayed development and improper nutrition

A. Delayed growth and development related to parental deficient knowledge, lack of stimulation, and nutrition deficit

CHAPTER 10: DEVELOPMENT - OLDER ADULTHOOD A 78-year-old female was admitted overnight for confusion, delirium, and depression. She lives alone and has recently exhibited signs of memory loss and increased confusion, especially in the evening. She currently is on several medications for health-related issues, medication to help her sleep, and anti-anxiety medications. What should the nurse assess this patient for? SELECT ALL THAT APPLY. A. Dementia B. Polypharmacy C. Depression D. Ageism E. Nutritional status

A. Dementia B. Polypharmacy C. Depression

Which statement illustrates the most measurable outcome indicator? a. Demonstrates dressing changes b. Shares innermost thoughts c. Understand instructions d. Shows personal remorse

A. Demonstrates dressing changes

CH. 11: HEALTH and ILLNESS The patient has received a prescription for a metered-dose inhaler from the care provider. Before the patient leaves the clinic, the nurse instructs the patient on how to use the inhaler. The nurse is tending to the patient's need in which stage of illness behavior? A. Dependence on others B. Sick role behavior C. Seeking professional care D. Recovery

A. Dependence on others

Analyze assessment data to focus on the client's priority needs a. Diagnose b. Planning c Implementation d. Evaluation

A. Diagnose

CHAPTER 32: PAIN Upon entering the room, the nurse discovers that the patient is experiencing acute pain. What is an expected assessment finding for this patient? SELECT ALL THAT APPLY. A. Diaphoresis B. Tachycardia C. Pallor D. Pupil dilation E. Increased blood pressure

A. Diaphoresis B. Tachycardia C. Pallor

When caring for a client with rubella, in addition to standard precautions, which precautions would be used? a. Droplet precautions b. Airborne precautions c. Contact precautions d. Universal precautions

A. Droplet precautions

CHAPTER 10: DEVELOPMENT - OLDER ADULTHOOD Following a physical assessment of an older adult, the nurse compares the results with what is expected for individuals in this age group. An expected finding is: A. Dry eyes B. Enlarged liver C. A decrease in blood pressure D. A better ability to hear high-pitched sounds

A. Dry eyes

CHAPTER 39: FLUIDS and ELECTROLYTES The nurse anticipates finding which of the following clinical manifestations for a patient who is severely dehydrated? A. Dry skin B. Oliguria C. Weight gain D. Bounding pulses E. Urine specific gravity >1.030

A. Dry skin B. Oliguria E. Urine specific gravity >1.030

CHAPTER 28: NUTRITION Identify which of the following signs and symptoms is/are associated with a nutritional deficit. SELECT ALL THAT APPLY. A. Dry, stiff hair B. Pink, moist oral membranes C. Constipation D. Decreased albumin level E. White, evenly colored teeth

A. Dry, stiff hair C. Constipation D. Decreased albumin level

CHAPTER 39: FLUIDS and ELECTROLYTES An assessment of which of the following is most important when a nurse is caring for an adult patient experiencing vomiting? A. Electrolyte values B. Bowel function C. Body weight D. Oral mucosa

A. Electrolyte values Vomiting causes lost electrolytes, including sodium which can lead to dysrhythmias and cardiac arrest.

CHAPTER 10: DEVELOPMENT - OLDER ADULTHOOD A nurse is caring for a 77-year-old patient in the hospital. What are some methods the nurse can apply to promote independence and functional ability? SELECT ALL THAT APPLY. A. Ensure the patient has access to a telephone at the bedside. B. Ask the patient if he or she would like to ambulate in the hall. C. Encourage the patient to remain in bed in order to regain strength. D. Offer the patient meal choices. E. Do not provide detailed explanations about medications, as this could confuse the patient.

A. Ensure the patient has access to a telephone at the bedside. B. Ask the patient if he or she would like to ambulate in the hall. D. Offer the patient meal choices.

Which action should a nurse take 30 minutes after administering oral pain medication to a patient? a. Evaluate the effectiveness of the administered pain medication b. Teach progressive relaxation strategies to relieve muscle tension c. Assess the patients coping skills to reduce expression anxiety. d. Encourage the patient to read or watch tv to provide pain distraction

A. Evaluate the effectiveness of the administered pain medication

The nurse is determining possible health problems for a 57-year-old. Which findings could indicate a concern? SELECT ALL THAT APPLY. A. Height 5 feet 6 inches, weight 210 pounds B. Small palpable lump in the neck C. Shortness of breath when running 3 miles D. Lack of health insurance E. Blood pressure 118/74 mm Hg

A. Height 5 feet 6 inches, weight 210 pounds B. Small palpable lump in the neck

CHAPTER 30: URINARY ELIMINATION What clinical manifestations might a nurse expect to see if a patient has impaired renal function? SELECT ALL THAT APPLY. A. High blood pressure B. Altered mental status C. Increased urine production D. Fluid retention E. Decreased heart rate

A. High blood pressure B. Altered mental status D. Fluid retention

What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to: A. Identify personal biases that may affect his thinking and actions. B. Identify the most effective interventions for a patient. C. Communicate more efficiently with colleagues, patients, and families. D. Learn and remember new procedures and techniques.

A. Identify personal biases that may affect his thinking and actions.

CH. 20: COMMUNICATING & THERAPEUTIC RELATIONSHIPS 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

A. Impaired Communication

Specific nursing interventions to meet patient goals and outcomes. a. Implementation b. Planning c. Evaluation d. Diagnosis

A. Implementation

CHAPTER 10: DEVELOPMENT - OLDER ADULTHOOD A 78-year-old female was admitted overnight for confusion, delirium, and depression. She lives alone and has recently exhibited signs of memory loss and increased confusion, especially in the evening. She currently is on several medications for health-related issues, medication to help her sleep, and anti-anxiety medications, and has been diagnosed with "polypharmacy-induced pseudodementia." What would be the appropriate nursing diagnosis in this aging patient? A. Ineffective therapeutic management r/t knowledge deficit of medication regimen B. Impaired self-administration of medications C. Impaired cognition r/t polypharmacy D. Memory loss as demonstrated by pseudodementia

A. Ineffective therapeutic management r/t knowledge deficit of medication regimen

CHAPTER 30: URINARY ELIMINATION Which interventions should the nurse instruct the patient to perform to decrease the incidence of urinary incontinence? SELECT ALL THAT APPLY. A. Limit caffeine intake to one cup of coffee a day. B. Limit the intake of fluids. C. Stop smoking. D. Lose weight. E. Increase the use of artificial sweeteners.

A. Limit caffeine intake to one cup of coffee a day. C. Stop smoking. D. Lose weight.

CHAPTER 9: DEVELOPMENT - INFANCY to MIDDLE ADULT Which of the following statements are accurate for middle adults? A. Many adults live with families. B. This is the period for "launching children and moving on". C. This age group has the worst financial status. D. Positive relationships can promote wellbeing. E. Heart disease is one of the leading causes of death.

A. Many adults live with families. B. This is the period for "launching children and moving on". D. Positive relationships can promote wellbeing.

CHAPTER 37 and 38: OXYGENATION and PERFUSION Which pieces of objective data should the nurse obtain to confirm the quality of oxygenation of a patient diagnosed with pneumonia? SELECT ALL THAT APPLY. A. Mental status B. Full set of vital signs C. Patent says, "I feel tired" D. Auscultation of lung sounds E. Patient complains of productive cough

A. Mental status B. Full set of vital signs D. Auscultation of lung sounds The other options are subjective data.

A nurse stands facing a client to demonstrate AROM exercises. which of the following should the nurse do when demonstrating hyperextension of the hip? a. Move the leg behind the body b. Move the leg forward and up c. Move the leg medically towards the other leg d. Turn the foot and leg away from the other leg

A. Move the leg behind the body

CHAPTER 39: FLUIDS and ELECTROLYTES A nurse is assessing a patient's fluid status. Which of the following assessments indicate that the patient has a deficient fluid volume? SELECT ALL THAT APPLY. A. Negative balance of intake and output B. Increased body temperature C. Decreased blood pressure D. Flat neck veins E. Weight loss

A. Negative balance of intake and output B. Increased body temperature C. Decreased blood pressure D. Flat neck veins E. Weight loss

CHAPTER 29: BOWEL ELIMINATION A nurse identifies that a patient's colostomy stoma is pale. What should the nurse do? A. Notify the practitioner B. Listen for bowel sounds C. Wash the area with warm water D. Gently massage around the stoma

A. Notify the practitioner A pale stoma has compromised circulation and the doctor needs to intervene right away to preserve the viability of the tissue.

CHAPTER 29: BOWEL ELIMINATION What should be reviewed during a health assessment to obtain information about a patient's bowel elimination patterns? SELECT ALL THAT APPLY. A. Nutrition (fiber, fluid, etc.) B. Activity level C. Occupation D. Medications and supplements E. Last BM F. Hygiene habits

A. Nutrition (fiber, fluid, etc.) B. Activity level D. Medications and supplements E. Last BM

CHAPTER 9: DEVELOPMENT - INFANCY to MIDDLE ADULT Which are common health problems of middle adulthood? SELECT ALL THAT APPLY. A. Obesity B. Hypertension C. Unintentional Injury D. Cancer E. Eating disorders

A. Obesity B. Hypertension D. Cancer

Johnston would like to better understand his hospital bill. He calls the hospital and the billing department suggest he meet with a representative and get an explanation. What is this an example of? a. Patient care partnership b. Good Samaritan law c. Standard of practice d. Nurse practice acts

A. Patient care partnership

CHAPTER 29: BOWEL ELIMINATION The nursing instructor is teaching information about constipation in the elderly. Which statement from the student indicates a need for further instruction on this topic? A. Patients receiving tube feedings often experience constipation. B. Poor fluid intake and inability to eat a high-fiber diet often cause constipation. C. Patients with impaired mobility may experience constipation. D. Medications commonly taken by elders often contribute to constipation.

A. Patients receiving tube feedings often experience constipation. Patients on tube feedings often experience diarrhea, not constipation.

CHAPTER 31: SENSORY PERCEPTION Which actions assist the nurse in orienting a confused patient to time, place, person, or situation? SELECT ALL THAT APPLY. A. Place a clock in the patient's room. B. Schedule activities at different times every day. C. Wear a readable name tag. D. Maintain a clean, uncluttered environment. E. Speak in a louder voice than usual.

A. Place a clock in the patient's room. C. Wear a readable name tag. D. Maintain a clean, uncluttered environment.

CHAPTER 31: SENSORY PERCEPTION Which of the following interventions can help improve smelling and tactile senses? SELECT ALL THAT APPLY. A. Place fresh fruits nearby B. Ask before touching a patient C. Hold a patient's hand when giving bad news D. Place fresh flowers nearby E. Use aromatherapy F. Dress them in tight clothing G. Give a firm back massage when they're upset

A. Place fresh fruits nearby C. Hold a patient's hand when giving bad news D. Place fresh flowers nearby E. Use aromatherapy G. Give a firm back massage when they're upset The stimulation of smell can be achieved by placing fresh fruits, flowers, and aromatherapy near the patient. The use of essential oils can be helpful. Pleasant smells may also improve appetite. Touch should be gentle and adjusted according to the patient's reaction. Restrictive clothing is irritating to people who are sensitive to touch.

CHAPTER 31: SENSORY PERCEPTION Which of the following interventions can help improve auditory senses? SELECT ALL THAT APPLY. A. Place in a quiet area B. Confirm ears are clean C. Speak in a normal tone of voice D. Move within 3 inches of the ears E. Increase the audio on the television F. Place the hearing aids daily G. Check hearing aid batteries regularly

A. Place in quiet area B. Confirm ears are clean E. Increase the audio on the television F. Place the hearing aids daily G. Check hearing aid batteries regularly To stimulate hearing, hearing devices should be used daily with fresh batteries and placed in clean ears. The patient should be in a quiet area for conversations and you should speak directly toward the patient's face so he or she can see your mouth move. Increase audio on television or stereo when in use. Talking directly into the ear can be considered an invasion of privacy in many cultures and so should be avoided.

CHAPTER 9: DEVELOPMENT - INFANCY to MIDDLE ADULT When discharging a mother and her infant, it is important to educate the parent on what topics? SELECT ALL THAT APPLY. A. Placing the baby on its back when sleeping B. Proper use of a car seat C. The dangers of shaking a baby or picking up a baby by arm/leg D. What to look for in the developmental stages of an infant E. The CDC's recommendations on immunizations

A. Placing the baby on its back when sleeping B. Proper use of a car seat C. The dangers of shaking a baby or picking up a baby by arm/leg

CHAPTER 10: DEVELOPMENT - OLDER ADULTHOOD Which of the following changes are associated with the normal aging process? SELECT ALL THAT APPLY. A. Presbycusis B. Reduced peristalsis C. Enhanced ability to smell D. Decreased bone density E. Slower immune response

A. Presbycusis B. Reduced peristalsis D. Decreased bone density E. Slower immune response

The nurse is explaining the health insurance portability and accountability act to a group of new employees. What should the nurse include when explaining its purpose? SELECT ALL THAT APPLY. a. Protects health insurance benefits b. Provide transferability of insurance to others c. Protects family members d. Protects those with pre-existing conditions e. Provides personal health information privacy

A. Protects health insurance benefits D. Protects those with pre-existing conditions E. Provides personal health information privacy

CHAPTER 31: SENSORY PERCEPTION Which of these communication strategies are most useful when interacting with a patient who has a hearing deficit? SELECT ALL THAT APPLY. A. Provide paper and pen for writing. B. Talk in an even tone of voice. C. Use gestures and facial expressions. D. Speak at a normal pace. E. Face the patient directly when speaking.

A. Provide paper and pen for writing. B. Talk in an even tone of voice. C. Use gestures and facial expressions. D. Speak at a normal pace. E. Face the patient directly when speaking.

This nurse works with the government to provide millions of immunizations at no charge to those within the community. Which type of nursing is this? a. Public health clinics b. Community-oriented Nursing c. Community health nursing d. School nursing

A. Public health clinics

The nurse is tracking the trend of increased measles outbreaks in state public universities and providing immunization boosters to the campus health clinics. Which type of nursing is this? a. Public health nursing b. Community health nursing c. Public health clinics d. Parrish Nursing

A. Public health nursing

While performing a complete bed bath for a patient, the nurse should a. Raise the room temperature b. Completely remove the linens c. Add soap to the water in the basin before beginning the bath d. Complete the bathing for one side of the body and a time

A. Raise the room temperature

CH. 20: COMMUNICATING & THERAPEUTIC RELATIONSHIPS A nurse observes an interaction between a patient and another healthcare team member. Which observations demonstrate active listening by the team member? SELECT ALL THAT APPLY. A. Recognizing nonverbal cues by the patient B. Eliminating intrusions and distractions in the room C. Using all the senses to interpret verbal messages D. Seeking clarification of unclear ideas E. Limiting the use of direct eye contact

A. Recognizing nonverbal cues by the patient B. Eliminating intrusions and distractions in the room C. Using all the senses to interpret verbal messages D. Seeking clarification of unclear ideas

CHAPTER 31: SENSORY PERCEPTION What would be the focus assessment by the ER nurse of a potential spinal cord injury patient who dived into shallow waters? A. Reflexes B. Mental Status C. Balance & Gait D. Sensory Perception

A. Reflexes

CHAPTER 9: DEVELOPMENT - INFANCY to MIDDLE ADULT Practicing positive health habits may prevent the development of chronic illness later in life. Which positive health habits will the nurse teach to a middle-aged adult patient? SELECT ALL THAT APPLY. A. Routine screening and diagnostic tests B. Unprotected sexual activity C. Regular exercise D. Excess alcohol consumption

A. Routine screening and diagnostic tests C. Regular exercise

CHAPTER 39: FLUIDS and ELECTROLYTES A nurse suspects that an older adult may have a fluid and electrolyte imbalance. Which assessment best reflects fluid and electrolyte balance in an older adult? A. Serum laboratory values B. Intake and output results C. Condition of the skin D. Presence of tenting

A. Serum laboratory values Labs provide objective data.

The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment? A. Sitting upright. B. Lying flat on the back with knees flexed. C. Lying flat on the back with arms and legs fully extended. D. Side-lying with the knees flexed.

A. Sitting upright.

CHAPTER 30: URINARY ELIMINATION A nurse is assessing a urostomy on a patient. She should be most concerned about which findings? SELECT ALL THAT APPLY. A. Sloughing of skin B. Moisture C. Skin breakdown D. Encrustation E. Red in color

A. Sloughing of skin C. Skin breakdown D. Encrustation E. Red in color

CHAPTER 31: SENSORY PERCEPTION Which of the following interventions can help improve communication with the hearing impaired? SELECT ALL THAT APPLY. A. Speak to the patient's stronger ear B. Don't speak when chewing gum or eating C. Use paper and pencil as needed D. Speak slowly and articulate clearly E. Repeat statements until understood F. Don't shout G. Use visual cues H. Validate understanding

A. Speak to the patient's stronger ear B. Don't speak when chewing gum or eating C. Use paper and pencil as needed D. Speak slowly and articulate clearly F. Don't shout G. Use visual cues H. Validate understanding Hearing impairment can limit communication and place a person in social isolation. The nurse should face the patient so she can possibly read lips. If hearing in one ear is better than in the other, then direct speech toward that side. Speak clearly and slowly in a steady voice, explaining actions clearly before performing them. Shouting can distort words, especially for those reading lips. Validate understanding by having the person explain what you said. Nodding the head is not sufficient to validate understanding.

Calvin is considering a transfer to the interventional radiology department. He's unfamiliar with the expectations in the nursing role within that department and looks for practice guidelines. What is this an example of? a. Standard of practice b. Scope of practice c. American nurses Association code of ethics d. Nurse practice acts

A. Standard of practice

CHAPTER 29: BOWEL ELIMINATION To prevent constipation in an inactive patient, which early interventions should the nurse implement? SELECT ALL THAT APPLY. A. Stool softener administration B. Enema administration C. Increasing the fiber in the diet D. Increasing physical activity E. Increasing fluid intake

A. Stool softener administration C. Increasing the fiber in the diet D. Increasing physical activity E. Increasing fluid intake Administering stool softeners, increasing the fiber and fluids in the diet, and increasing physical activity are all early interventions to prevent constipation. Although used to treat constipation, an enema would not be an early intervention for prevention.

CHAPTER 31: SENSORY PERCEPTION The nurse is caring for a patient with visual impairment. The nurse understands that which comorbidity is associated with visual deficits? SELECT ALL THAT APPLY. A. Stroke B. Dizziness C. Hypertension D. Convergence E. Diabetes

A. Stroke C. Hypertension E. Diabetes

CHAPTER 32: PAIN Knowing the major side effect of non-steroidal anti-inflammatory drug medications, the nurse instructs the patient to: A. Take the medication with food. B. Avoid taking it with other drugs. C. Take the medication in the morning. D. Apply sunscreen before going outdoors.

A. Take the medication with food.

The nurse understands that which statements regarding BP and the BP requirement are true? SELECT ALL THAT APPLY. a. The highest pressure is the systolic pressure; the lowest pressure is the diastolic pressure b. The client should be in a comfortable lying or sitting position when taking the blood pressure c. Maximum BP is created in the arteries when the right ventricle pushes blood into the aorta d. The difference between systolic pressure and diastolic pressure is known as pulse deficit e. The point on the gauge where the 1st faint but clear sound appears is known as diastolic pressure

A. The highest pressure is the systolic pressure; the lowest pressure is the diastolic pressure B. The client should be in a comfortable lying or sitting position when taking the blood pressure

CHAPTER 9: DEVELOPMENT - INFANCY to MIDDLE ADULT A nurse suspects that a young adult being evaluated is in an abusive relationship. What are some observations that may lead the nurse to that conclusion? SELECT ALL THAT APPLY. A. The patient avoids eye contact. B. The patient has bruises in various stages of healing. C. The patient mentions that she has just lost 10 lb. D. The patient does not speak; her partner answers questions for her. E. She is of a low socioeconomic class.

A. The patient avoids eye contact. B. The clipatient ent has bruises in various stages of healing. D. The patient does not speak; her partner answers questions for her.

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS A 32-year-old healthy runner has fallen and has an acute metatarsal fracture, which will mean the patient will be in plaster for approximately 6 to 8 weeks. The patient now feels unhealthy. What is more than likely the cause of this perception of his or her health status? A. The patient is young and physically active. B. The patient has a genetic predisposition for being healthy. C. The patient is now unable to engage in meaningful work. D. The patient has poor coping abilities.

A. The patient is young and physically active.

The nurse is recording assessment data. She writes, "The patient seems worried about his surgery. Other than that, he had a good night." Which errors did the nurse make? SELECT ALL THAT APPLY. A. Used a vague generality. B. Did not use the patient's exact words. C. Used a "waffle" word (e.g., appears). D. Recorded an inference rather than a cue. E. Did not record the patient's vital signs.

A. Used a vague generality. C. Used a "waffle" word (e.g., appears). D. Recorded an inference rather than a cue. E. Did not record the patient's vital signs.

CHAPTER 31: SENSORY PERCEPTION The nurse is reviewing the physiology of sensory perception. Which sensory perceptions are associated with internal stimuli? SELECT ALL THAT APPLY. A. Visceral B. Visual C. Stereognosis D. Gustatory E. Olfactory

A. Visceral (internal organs) C. Stereognosis (ability to identify 3D objects) D. Gustatory (taste)

CHAPTER 28: NUTRITION What nutrients are absorbed in the ileum? SELECT ALL THAT APPLY. A. Vitamin A B. Vitamin B12 C. Vitamin C D. Vitamin D E. Vitamin E F. Calcium G. Magnesium H. Vitamin K I. Iron J. Sodium

A. Vitamin A B. Vitamin B12 D. Vitamin D E. Vitamin E H. Vitamin K I. Iron J. Sodium

When providing home-going instructions for a recently discharged client, which statement by the client's son would indicate an understanding of methods to prevent complications from immobility? a. We'll make sure that Dad eats plenty of lean protein foods b. We will limit Dad's fluid intake to prevent bladder incontinence c. Dad should sit more and restrict the time he walks around the house d. His arm sling should be kept on at all times to prevent an elbow contracture

A. We'll make sure that Dad eats plenty of lean protein foods

The nurse is caring for a client that has a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following infection control practices should the nurse implement? SELECT ALL THAT APPLY. a. Wear a protective gown when entering the client's room b. Don a particulate respirator mask when administering medication to the client c. Ensure all staff serving the client's meal trays don gloves d. Instruct all visitors to wear a surgical mask when entering the client's room e. Use sterile gloves when performing dressing changes f. Use a face shield before irrigating the client's wounds

A. Wear a protective gown when entering the client's room C. Ensure all staff serving the client's meal trays don gloves F. Use a face shield before irrigating the client's wounds

CH. 26: TEACHING and LEARNING A patient with a history of diarrhea is seen in the clinic. Which nursing intervention is most essential to include in this patient's plan of care? A. Weighing the patient daily B. Encouraging a diet high in fiber C. Decreasing the patient's fluid intake D. Instructing the patient to increase protein in the diet

A. Weighing the patient daily

CH. 21: PHYSICAL ASSESSMENT The nurse assesses a patient with chronic obstructive pulmonary disease (COPD). Which finding does the nurse anticipate when inspecting the chest? A. A barrel chest B. A concave sternum C. A convex sternum D. A severe lateral curvature of the spine

A. a barrel chest

CHAPTER 29: BOWEL ELIMINATION Which of the following foods would have a laxative effect on the body? SELECT ALL THAT APPLY. A. a bran muffin B. bananas C. rice D. a salad E. chocolate

A. a bran muffin D. a salad E. chocolate

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS A patient you are assisting has fallen in the shower. You must complete an occurrence report. The purpose of an occurrence report is to: A. aid in the hospital's quality improvement program. B. ensure proper care for the patient. C. exchange information among health care members. D. provide information about patients from one unit to another unit.

A. aid in the hospital's quality improvement program.

CHAPTER 37 and 38: OXYGENATION and PERFUSION Which of the following would be appropriate for the treatment of acute bronchospasm? A. albuterol and levalbuterol B. formoterol and salmeterol C. tiotroprium D. inotroprium

A. albuterol and levalbuterol For acute bronchospasm, you want short-acting medication. Formoterol and salmeterol are long-acting. Tiotroprium is for COPD maintenance (long-acting).

CHAPTER 29: BOWEL ELIMINATION In order to promote peristalsis, a nurse should provide opportunities for the patient who is NPO after surgery to: A. ambulate B. stay in bed all day C. sleep on the left lateral side D. receive Morphine IVP as needed

A. ambulate

CHAPTER 31: SENSORY PERCEPTION The nurse cares for an injured athlete with a right leg cast. What is the term used to describe decreased muscle mass through disuse? A. atrophy B. spacticity C. muscle tone D. hypertrophy

A. atrophy

CHAPTER 31: SENSORY PERCEPTION What is kinesthesia? A. awareness of the position and movement of body parts B. awareness of the orientation of the head and body C. awareness of the proximity of the body to stimuli like heat D. awareness of environmental characteristics like smell, sound, etc.

A. awareness of the position and movement of body parts

CHAPTER 37 and 38: OXYGENATION and PERFUSION All of the following are vasodilators except A. beta-blockers B. nitrates C. angiotensin II receptor blockers D. ACE inhibitors E. calcium channel blockers

A. beta-blockers E. calcium channel blockers

CHAPTER 28: NUTRITION Vitamin C is best obtained from which of the following foods? SELECT ALL THAT APPLY. A. broccoli and cauliflower B. citrus, papaya, and strawberries C. nuts D. avocado E. kale F. potatoes G. carrots and spinach

A. broccoli and cauliflower B. citrus, papaya, and strawberries E. kale F. potatoes G. carrots and spinach

CHAPTER 29: BOWEL ELIMINATION What is psyllium? A. bulk-forming laxative B. stimulant laxative C. osmotic laxative D. stool softener

A. bulk-forming laxative

CHAPTER 28: NUTRITION Vitamin K is best obtained from which of the following foods? SELECT ALL THAT APPLY. A. cabbage B. prunes C. pork chops D. chicken E. mushrooms F. hard cheeses

A. cabbage B. prunes C. pork chops D. chicken F. hard cheeses

CHAPTER 28: NUTRITION Vitamin A is best obtained from which of the following foods? SELECT ALL THAT APPLY. A. cheese, yogurt, and milk B. chicken C. liver D. oily fish (salmon, tuna, trout) E. eggs F. bananas G. carrots and spinach

A. cheese, yogurt, and milk C. liver D. oily fish (salmon, tuna, trout) E. eggs G. carrots and spinach

CHAPTER 28: NUTRITION Vitamin C is needed for which of the following functions? SELECT ALL THAT APPLY. A. collagen synthesis B. bone remodeling C. wound healing D. long-distance visual acuity E. immune system support F. iron absorption

A. collagen synthesis C. wound healing E. immune system support F. iron absorption

CHAPTER 29: BOWEL ELIMINATION A newly admitted patient states that stools are dry and hard to pass. This type of bowel pattern is consistent with: A. constipation B. fecal impaction C. fecal incontinence D. abnormal defecation

A. constipation

CHAPTER 39: FLUIDS and ELECTROLYTES What are functions of fluid in the body? SELECT ALL THAT APPLY. A. decreasing thirst B. temperature regulation C. healthy hygiene D. carries nutrients and oxygen to cells and tissues E. promote fecal and urinary elimination F. lubricate and protect joints and tissues

A. decreasing thirst B. temperature regulation C. healthy hygiene D. carries nutrients and oxygen to cells and tissues E. promote fecal and urinary elimination F. lubricate and protect joints and tissues While sufficient hydration might ease thirst, that isn't its purpose because the purpose of thirst is to alert us that we need water. Water is important for healthy hygiene, but that is outside the body.

CHAPTER 29: BOWEL ELIMINATION A nurse is caring for a patient who is experiencing diarrhea. Which physiological response to diarrhea should the nurse be most concerned? A. dehydration B. malnutrition C. excoriated skin D. urinary incontinence

A. dehydration With diarrhea, the amount of time fluids spend in the intestine is decreased, which means there's less time for reabsorption - so you're losing it as fast as you're drinking it.

CHAPTER 31: SENSORY PERCEPTION An older adult patient in a nursing home has visual and hearing losses. The nurse is alert to which of the following signs representing the effects of sensory deprivation? A. depression B. diminished anxiety C. improved task completion D. decreased need for physical stimulation

A. depression

CH. 21: PHYSICAL ASSESSMENT The nurse is palpating the patient's lymph nodes 1" above the elbow. This site is best for assessing: A. epitrochlear nodes B. axillary lymph nodes C. cervical lymph nodes D. inguinal lymph nodes

A. epitrochlear nodes

CHAPTER 29: BOWEL ELIMINATION Which conditions could be helped with the administration of a return-flow enema? SELECT ALL THAT APPLY. A. flatus relief B. deficient mucosal fluid volume C. intestinal illness D. constipation E. diarrhea

A. flatus relief D. constipation

CHAPTER 37 and 38: OXYGENATION and PERFUSION A patient who requires supplemental oxygen at 1L/min uses an oxygen concentrator at home. Which of the following oxygen delivery systems would be most appropriate for patient use during short outings? A. gas cylinders B. liquid oxygen unit C. portable membrane oxygenator D. battery-powered oxygen concentrator

A. gas cylinders

CHAPTER 31: SENSORY PERCEPTION Which of the following are potential causes of generalized seizures? SELECT ALL THAT APPLY. A. genetics B. electronics C. fever D. excessive vomiting E. depression

A. genetics C. fever

CHAPTER 29: BOWEL ELIMINATION The nurse gives a patient a cleansing enema to: A. help promote peristalsis. B. help destroy intestinal parasites. C. help expel flatus from the rectum. D. provide medication absorbed through the rectal mucosa.

A. help promote peristalsis.

CHAPTER 31: SENSORY PERCEPTION Which of the following are potential causes of partial seizures? SELECT ALL THAT APPLY. A. illness, infection B. brain injury C. hypertension D. drug and alcohol abuse or withdrawal E. depression

A. illness, infection B. brain injury C. hypertension D. drug and alcohol abuse or withdrawal

CHAPTER 31: SENSORY PERCEPTION Which of the following can affect the sensory experience? SELECT ALL THAT APPLY. A. illness, pain, or injury B. deprivation or overload C. location D. aging E. neurological condition F. medication G. occupation

A. illness, pain, or injury B. deprivation or overload D. aging E. neurological condition F. medication G. occupation

CHAPTER 28: NUTRITION Vitamin A is needed for which of the following functions? SELECT ALL THAT APPLY. A. immune system support B. healthy muscle development C. skin and mucus membranes D. low-light vision and visual acuity E. renal sufficiency F. tissue growth

A. immune system support C. skin and mucus membranes D. low-light vision and visual acuity F. tissue growth

CHAPTER 34: SEXUAL HEALTH Upon hospital admission, when gathering a patient's sexual history, nurses should: A. include questions related to sexual function. B. use emotionally laden terms when discussing sexual concepts. C. focus only on physical factors that affect sexual functioning. D. discuss sexual concerns only if the patient raises questions or concerns.

A. include questions related to sexual function.

CHAPTER 29: BOWEL ELIMINATION What are nursing interventions for a patient who is constipated? SELECT ALL THAT APPLY. A. increase fluid intake B. encourage ambulation C. suggest eating rice, bananas, eggs and cheese D. laxatives and enemas as needed

A. increase fluid intake B. encourage ambulation D. laxatives and enemas as needed

An infection occurs as a result of a cyclical process. The 6 components of infection are: a. infectious agent, source of infection, portal of exit, mode of transmission, portal of entry, and susceptible host. b. infectious agent, reservoir, portal of exit, vehicle of movement, portal of entry, and susceptible host. c. infectious agent, reservoir, portal of exit, vehicle of transmission, portal entry, and unsusceptible host. d. invading agent, reservoir, portal of exit, vehicle transmission, portal of entry, and susceptible host.

A. infectious agent, source of infection, portal of exit, mode of transmission, portal of entry, and susceptible host.

CH. 36: SKIN INTEGRITY and WOUND HEALING A nurse is caring for a patient who is at risk for developing a pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the patient's skin? SELECT ALL THAT APPLY. A. keep the head of the bed elevated 30º B. massage the patient's bony prominences frequently C. apply lotion liberally to the skin after bathing D. reposition the patient at least every 3 hr while in bed

A. keep the head of the bed elevated 30º C. apply lotion liberally to the skin after bathing

CHAPTER 31: SENSORY PERCEPTION Which of the following occupations poses the least risk of sensory alteration? A. librarian B. welder C. computer programmerd D. construction worker

A. librarian

CHAPTER 29: BOWEL ELIMINATION Which of the following foods would have a constipating effect on the body? SELECT ALL THAT APPLY. A. mac and cheese B. an omelet C. chocolate D. a salad E. steak

A. mac and cheese B. an omelet E. steak

CHAPTER 31: SENSORY PERCEPTION Which receptors detect mechanical stimuli and provide sensations of touch, pressure, and vibration? A. mechanoreceptors B. hair cells C. thermoreceptors D. proprioceptors E. photoreceptors F. chemoreceptors

A. mechanoreceptors

CHAPTER 31: SENSORY PERCEPTION Which of the following are normal and expected aspects of aging? SELECT ALL THAT APPLY. A. presbyopia B. strabismus C. presbycusis D. hyperacusis E. misophonia

A. presbyopia C. presbycusis

CHAPTER 28: NUTRITION Vitamin K is needed for which of the following functions? SELECT ALL THAT APPLY. A. protein synthesis for blood clotting B. fight toxins C. calcium and phosphorous absorption D. bone development E. immune system support

A. protein synthesis for blood clotting D. bone development

CHAPTER 29: BOWEL ELIMINATION How does a stool softener help relieve constipation? A. pulls water from the intestine to tenderize hard, dry stool B. triggers the intestines to push out stool C. contains fiber to soak up water for a larger stool D. attracts water to the bowel to soften stool and increase BM frequency

A. pulls water from the intestine to tenderize hard, dry stool

CHAPTER 25: ADMINISTERING MEDICATIONS The nurse assesses a patient for urinary signs & symptoms. Which term best describes pus in the urine? A. pyuria B. polyuria C. glycosuria D. proteinuria

A. pyuria

CHAPTER 29: BOWEL ELIMINATION What would be the purpose for administering a carminative enema? SELECT ALL THAT APPLY. A. relieve flatus B. cleanse the bowel C. destroy pathogens or parasites D. stimulate peristalsis E. deliver medication to the bowel

A. relieve flatus D. stimulate peristalsis A carminative enema is usually given to relieve flatus and stimulate peristalsis to make it easier to defecate.

CHAPTER 37 and 38: OXYGENATION and PERFUSION Coarse, snoring. Loud, low-pitched, continuous sounds. Can clear with coughing. Heard when a patient inhales and exhales as air passes through fluid or mucus (secretions) A. ronchi B. crackles C. wheezing D. pleural rub

A. ronchi

CHAPTER 31: SENSORY PERCEPTION Which of the following are ways to communicate with a patient who has hearing and visual deficits? SELECT ALL THAT APPLY. A. speak clearly and slowly B. move closer to the patient so they can see you C. speak loudly and firmly D. provide written documents in large print E. provide a notepad and marker F. speak in a higher pitch G. remove obstacles and hazards

A. speak clearly and slowly B. move closer to the patient so they can see you D. provide written documents in large print E. provide a notepad and marker G. remove obstacles and hazards

CH. 20: COMMUNICATING & THERAPEUTIC RELATIONSHIPS 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, assuming 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. "Lie still, please; I need to elevate the head of the bed and insert this tube."

B. "I'm going to insert a tube through your nose into your stomach to prevent you from vomiting."

A nurse is caring for an adult patient who is NPO. The patient is refusing oral care. Which of the following is an appropriate response by the nurse? a. "Since you are not eating, we can wait and do it before bedtime." b. "Oral care is still important even though you are not eating." c. "I'll give you a sip of water to swish around in your mouth, and then you can spit it out." d."We will wait until your family gets here to help."

B. "Oral care is still important even though you are not eating."

CH. 20: COMMUNICATING & THERAPEUTIC RELATIONSHIPS 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."

B. "Tell me more about your experience with your high blood pressure medication."

CH. 20: COMMUNICATING & THERAPEUTIC RELATIONSHIPS A patient comes to the emergency department with severe shortness of breath and difficulty breathing. He is restless and anxious. Which response made by the nurse offers reassurance and builds trust? SELECT ALL THAT APPLY. A. "I'll give you some medication to help with your breathing." B. "Would you like your family to stay here with you as I step out?" C. "Please try not to think about the breathing." D. "This must be a frightening situation for you." E. "Tell me more about what you are doing when your breathing is most difficult."

B. "Would you like your family to stay here with you as I step out?" D. "This must be a frightening situation for you." E. "Tell me more about what you are doing when your breathing is most difficult."

CHAPTER 39: FLUIDS and ELECTROLYTES According to the Institute of Medicine [IOM], how much water should an 82-year-old male drink daily? A. 1000-1500 mL B. 1500-2000 mL C. 2700-3000 mL D. 3000-3500 mL

B. 1500-2000 mL

CHAPTER 39: FLUIDS and ELECTROLYTES A nurse is caring for a critically ill patient with a urinary retention catheter. Which hourly urine output should first alert the nurse that the primary healthcare provider should be notified? A. 20 mL B. 30 mL C. 60 mL D. 120 mL

B. 30 mL If a person's urine output is less than 30mL, it indicates that there is insufficient circulating volume, inadequate renal perfusion, or kidney disease. The provider should be notified.

CHAPTER 28: NUTRITION A name-brand ice cream contains the following nutrition information for each serving: 30g carbohydrates, 19g fat, 5g protein. The total number of calories in a serving would be: A. 366 B. 311 C. 435 D. 176

B. 311 Carbs: 4 cal/gram = 120 cal Fat: 9 cal/gram = 171 cal Protein: 4 cal/gram = 20 cal Total: 311 cal

CH. 21: PHYSICAL ASSESSMENT When auscultating the abdomen, how long should the nurse listen before concluding the bowel sounds are absent? A. 1 minute B. 5 minutes C. 10 minutes D. 15 minutes

B. 5 minutes

The nurse completed an admission history & physical examination on a client admitted for chest pain (CP), rule out (R/O) myocardial infarction (MI) [or "heart attack"]. Which of the following are objective data? SELECT ALL THAT APPLY. A. "I have chest pain." B. 57-year-old client. C. Blood pressure (BP) 158/90. D. Heart rate (HR) 110. E. "I am afraid something serious is wrong."

B. 57-year-old client. C. Blood pressure (BP) 158/90. D. Heart rate (HR) 110.

CHAPTER 10: DEVELOPMENT - OLDER ADULTHOOD Which of the following are facts about aging? SELECT ALL THAT APPLY. A. All older adults have Alzheimer's disease B. A majority of older adults are unemployed or retired. C. Independence is often related to financial status. D. The population is becoming more racially diverse.

B. A majority of older adults are unemployed or retired. C. Independence is often related to financial status. D. The population is becoming more racially diverse.

Which of the following clients are not able to give consent? SELECT ALL THAT APPLY. a. Legal guardian b. A mentally incompetent adult c. A married 16 yr old d. An intoxicated adult e. The health care proxy

B. A mentally incompetent adult D. An intoxicated adult

CHAPTER 31: SENSORY PERCEPTION The nurse moves a patient's arm away from the midline of the body. What is the term used to describe this type of movement? A. Adduction B. Abduction C. Extension D. Circumduction

B. Abduction

CH. 20: COMMUNICATING & THERAPEUTIC RELATIONSHIPS A young adult with a severe episode of asthma bronchoconstriction comes to the emergency department with signs of respiratory distress. When the nurse performs the admission assessment, she notes that the patient is not able to say where she is or the time. Which nursing diagnosis is probably most suitable for this patient? A. Chronic Confusion B. Acute Confusion C. Impaired Verbal Communication D. Readiness for Enhanced Communication

B. Acute Confusion

Which intervention is an example of primary prevention? A. Administering digoxin (lanoxicaps) to a patient with heart failure. B. Administering measles, mumps, and rubella immunization to an infant. C. Obtaining a Papanicolaou smear to screen for cervical cancer. D. Using occupational therapy to help a patient cope with arthritis.

B. Administering measles, mumps, and rubella immunization to an infant.

Which are roles of the community health nurse. SELECT ALL THAT APPLY. a. Facilitator b. Advocate c. Teacher d. Counselor e. Case manager

B. Advocate C. Teacher D. Counselor E. Case manager

Accepted money from a client as a "thank you" gift. Her employer found out and fired her. When is this an example of? a. Standard of practice b. American Nurses Association Code of ethics c. Nurse practice act d. Scope of practice

B. American Nurses Association Code of ethics

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS Which statement best defines "dementia"? A. One's overall view of oneself. B. An irreversible decline in mental abilities. C. A vague, uneasy feeling of discomfort or dread. D. A mood disorder with a persistent feeling of sadness.

B. An irreversible decline in mental abilities.

CHAPTER 29: BOWEL ELIMINATION A patient is scheduled for an upper GI series. Which information is most important to obtain from him before the procedure? A. Allergy to lorazepam. B. Any difficulty swallowing. C. Last bowel movement (BM). D. Time the enema was administered.

B. Any difficulty swallowing. The patient will need to drink barium for this x-ray; therefore, swallowing ability should be assessed prior to the start of the procedure.

CHAPTER 25: ADMINISTERING MEDICATIONS Which of the following actions performed by the new staff nurse and observed by the nurse manager requires additional instruction? A. Giving docusate sodium 100mg PO 20 minutes before the scheduled time B. Applying a topical medicated cream without gloves C. Alternating the sides of the cheeks for buccal medications D. Documenting on the MAR that the patient refused the medication

B. Applying a topical medicated cream without gloves

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS The nurse is caring for a patient with severe anxiety. When assessing the patient, what should the nurse do when asking questions? A. Ask open-ended questions. B. Ask simple and direct questions. C. Avoid asking questions until the anxiety subsides. D. Postpone questions until the patient can offer information.

B. Ask simple and direct questions. Rapport must be established between the nurse and patient, and questions should be straightforward.

A postoperative patient is breathing rapidly. You should immediately: a. Ask the patient if he feels uncomfortable. b. Assess the oxygen saturation. c. Call the physician. d. Count the respirations.

B. Assess the oxygen saturation.

A nurse admits a patient to the cardiac care unit following the place of a cardiac stent. Which step of the nursing process does the nurse do first? a. Planning b. Assessment c. Evaluation d. Implementation

B. Assessment

A nurse has performed a physical examination of the client and reviewed the laboratory and diagnostic test results on the client's chart. The nurse is performing which specific nursing function. a. Diagnosis b. Assessment c. Education d. Avocacy

B. Assessment

Mr. Patel was recently started on a new hypertension medication. During a home visit, the nurse asked what Mr. Patel has eaten in the last 24 hours. What is the step of the nursing process this represents: a. Diagnosis b. Assessment c. Planning d. Implementation e. Evaluation

B. Assessment

A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.D. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming: A. Fresh, green vegetables B. Bananas and oranges C. Lean red meat D. Creamed corn

B. Bananas and oranges

CHAPTER 28: NUTRITION While doing a nutritional assessment of a low-income family, the community health nurse determines the family's diet is inadequate in protein content. The nurse suggests which of the following lower-cost foods to increase protein content? A. Rice B. Beans C. Potatoes D. Fruit

B. Beans

The nurse is caring for a patient admitted with a history of hypertension (HTN). The patient's medication history includes Hydrochlorothiazide for the past 10 years. Which parameter would indicate the optimal intended effect of this medication? a. Absence of ankle edema. b. Blood pressure 116/70. c. Output of 600 mL per 8 hours. d. Weight loss of 2 lbs.

B. Blood pressure 116/70.

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS The nurse is working with a patient who is ready to improve his or her self-concept. What do the four interrelated components of self-concept include? SELECT ALL THAT APPLY. A. Gender B. Body image C. Role performance D. Locus of control E. Personality F. Self-esteem

B. Body image C. Role performance E. Personality F. Self-esteem

Which specific aspect of a profession does the development of theories provide? a. Altruism b. Body of knowledge c. Autonomy d. Accountability

B. Body of knowledge

Which specific aspect of a profession does the development of theories provide? a. Atruism b. Body of knowledge c. Autonomy d. Accountability

B. Body of knowledge

CHAPTER 28: NUTRITION The patient has dysphagia. What are appropriate interventions to decrease the risk of aspiration? SELECT ALL THAT APPLY. A. Keep HOB at 30º while eating B. Check for a gag reflex before giving food or oral medicine C. Use a straw to help with fluids D. Cut food into small pieces E. Keep suction setup readily available

B. Check for a gag reflex before giving food or oral medicine D. Cut food into small pieces E. Keep suction setup readily available

CHAPTER 31: SENSORY PERCEPTION A nurse is providing teaching for a patient diagnosed with an olfactory deficit. Which interventions specifically related to an olfactory deficit will the nurse include in the teaching? SELECT ALL THAT APPLY. A. Set up a schedule for changing the batteries in carbon monoxide detectors. B. Check the expiration dates on food. C. Recommend the patient purchase smoke detectors with flashing lights. D. Darken the rooms with shades. E. Review home cleaning supplies with the patient.

B. Check the expiration dates on food. E. Review home cleaning supplies with the patient.

CHAPTER 34: SEXUAL HEALTH What is the most common sexually transmitted infection (STI) among adolescents and young adults? A. Syphilis. B. Chlamydia. C. Gonorrhea. D. Genital herpes.

B. Chlamydia.

What actions by the nurse are critical to ensure client safety? SELECT ALL THAT APPLY. a. Place the call light on the client's nightstand b. Clean up fluid spills on the floor immediately c. Instruct the client to wear socks when ambulating d. Keep linens and intravenous tubing off the floor e. Return the bed to low position prior to exiting the room

B. Clean up fluid spills on the floor immediately D. Keep linens and intravenous tubing off the floor E. Return the bed to low position prior to exiting the room

The nurses working at a low-income prenatal clinic provide free services, including dietary counseling, exercise, and parenting classes. Which type of nursing is this? a. Public health nursing b. Community health nursing c. Community-oriented Nursing d. School Nursing

B. Community health nursing

A patient, with a right-sided weakness, is being ambulated at least twice a day in a healthcare facility. Since the patient is elderly, what other factors besides decreased joint mobility might affect ambulation? a. Decreased ability to learn how to use a walker. b. Decreased muscle strength & tone. c. Increased cardiac workload & pulse rate. d. Increased sensory perception.

B. Decreased muscle strength & tone.

CHAPTER 31: SENSORY PERCEPTION The nurse is reviewing the chart of an older adult patient. Which sensory changes does the nurse anticipate have occurred? SELECT ALL THAT APPLY. A. Increased tactile sensation B. Decreased sense of taste C. Decreased sense of hearing D. Impaired sense of smell E. Increased sense of taste

B. Decreased sense of taste C. Decreased sense of hearing D. Impaired sense of smell

CHAPTER 39: FLUIDS and ELECTROLYTES A patient has continuous bladder irrigation. Which should the nurse do with the irrigant on the I&O sheet when calculating the fluid balance for this patient? A. Add it to the oral intake column. B. Deduct it from the total urine output. C. Subtract it from the intravenous flow sheet as output. D. Document the intake hourly in the urine output column

B. Deduct it from the total urine output. Because the patient is not ingesting the fluid, it should not be counted as output.

What type of logical reasoning is the nurse using when he/she starts with the big picture and anticipates specific findings? A. Inductive B. Deductive C. Careful reasoning D. Critical reasoning

B. Deductive

The global health nurse will often see which of these conditions? SELECT ALL THAT APPLY. a. Metabolic syndrome b. Dehydration c. Malnutrition d. Insect-related illness e. Parasite infections

B. Dehydration C. Malnutrition D. Insect-related illness E. Parasite infections

CHAPTER 37 and 38: OXYGENATION and PERFUSION A patient is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? A. Assess the patient's oxygen saturation and, if normal, turn off the oxygen B. Determine if the patient can switch to a nasal cannula during the meal. C. Have the patient lift the mask off the face when taking bites of food. D. Turn the oxygen off while the patient eats the meal and then restart it.

B. Determine if the client can switch to a nasal cannula during the meal. A nasal cannula will deliver oxygen via prongs placed in the patient's nose, leaving the mouth unobstructed and allowing talking and eating.

CH. 20: COMMUNICATING & THERAPEUTIC RELATIONSHIPS The nurse is teaching the patient about his upcoming procedure and the patient is very stressed. What is most important for the nurse to do? A. Use humor first to decrease the patient's stress level. B. Determine if the teaching should take place at a different time. C. Introduce himself as the RN to give credibility to his message. D. Speak to the patient when family members are there so they can teach the patient.

B. Determine if the teaching should take place at a different time.

In which step of the nursing process does the nurse analyze data and identify client problems? A. Assessment B. Diagnosis C. Planning outcomes D. Evaluation

B. Diagnosis

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS What behavioral findings does the nurse expect in a patient with poor self-concept? SELECT ALL THAT APPLY. A. Makes eye contact. B. Difficulty making decisions. C. Refuses to participate in care. D. Spends time with friends & family. E. Inability to discuss a change in body function.

B. Difficulty making decisions. C. Refuses to participate in care. E. Inability to discuss a change in body function.

CHAPTER 9: DEVELOPMENT - INFANCY to MIDDLE ADULT The nurse is obtaining a health history from a 22-year-old female patient following a minor car accident. The patient checks her phone frequently and sends text messages throughout the interview. Based on the behavior observed, which health concern should the nurse be alert to? A. Sexually transmitted infections B. Distracted driving C. Substance abuse D. Eating disorder

B. Distracted driving

One aspect of implementation related to drug therapy is: A. Developing a content outline. B. Documenting drugs given. C. Establishing outcome criteria. D. Setting realistic client goals.

B. Documenting drugs given.

CHAPTER 10: DEVELOPMENT - OLDER ADULTHOOD Which is a normal developmental change of aging? A. Confusion and dementia B. Dry skin C. Joint pain D. Tooth loss

B. Dry skin

CHAPTER 31: SENSORY PERCEPTION What is an occurrence of an interruption of electrical activity on both sides of the brain resulting in muscle tension or twitching? A. Cerebrovascular Accident (CVA) B. Generalized Seizure (Tonic-Clonic) C. Transient Ischemic Attack (TIA) D. Electrical Brain Stimulation (EBS)

B. Generalized Seizure (Tonic-Clonic)

CHAPTER 25: ADMINISTERING MEDICATIONS The nurse reviews each medication with the patient and the patient agrees to take them all. As the nurse hands the medications to the patient, the patient states, "You know, now that I think about it, I'm not sure if these meds are necessary." What is the best response by the nurse? A. Sure, you have the right to refuse B. I see you're uncertain; tell me what you're thinking C. That's unfortunate. I just reviewed all of them with you D. I would take them if I were you. You don't want to end up with a clot.

B. I see you're uncertain; tell me what you're thinking

Which of the following are classified as skilled nursing services? SELECT ALL THAT APPLY. a. Meal prep b. IV therapy c. Ostomy care d. bathing e. assistance with feedings f. respiratory care

B. IV therapy C. Ostomy care F. Respiratory care

A male client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal? A. Inadequate vitamin D intake. B. Inadequate protein intake. C. Inadequate massaging of the affected area. D. Low calcium level.

B. Inadequate protein intake.

A patient has pitting pedal edema, crackles, and elevated blood pressure. The nurse concludes that the patient has fluid volume excess. Which type of reasoning did the nurse use? A. Theoretical B. Inductive C. Deductive D. Conceptual

B. Inductive

The nurse in charge is assessing a patient's abdomen. Which examination technique should the nurse use first? A. Auscultation B. Inspection C. Percussion D. Palpation

B. Inspection

CHAPTER 39: FLUIDS and ELECTROLYTES A nurse evaluates a patient's fluid balance by monitoring the patient's intake and output. Which must the nurse understand about the ratio of the patient's fluid intake to output? A. Intake should be much higher than the fluid output. B. Intake should be slightly more than the output C. Intake should be lower than the urine output. D. Intake should be equal to the urine output.

B. Intake should be slightly more than the output We need slightly more because we also excrete it through exhalations, feces and sweating, etc.

CH. 20: COMMUNICATING & THERAPEUTIC RELATIONSHIPS Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment? A. Small group B. Interpersonal C. Group D. Intrapersonal

B. Interpersonal

A nurse is observing an assistive personnel who is using a mechanical lift with a hammock sling to transfer a patient from the bed to a chair. The nurse should intervene if the AP a. Places the sling under the patient from shoulders to knees b. Leaves the bed in the lowest position throughout the procedure. c. Locks the hydraulic valve before attaching the sling to the lift d. Raises the head of the bed to a sitting position just before transfer

B. Leaves the bed in the lowest position throughout the procedure.

Bones function in what important roles within the body? SELECT ALL THAT APPLY. a. Regulate potassium levels b. Maintain calcium balance c. Protect critical organs d. Produce blood cells e. Control motor activity

B. Maintain calcium balance C. Protect critical organs D. Produce blood cells

CHAPTER 32: PAIN A non-pharmacologic approach that the nurse may implement for patients experiencing pain that focuses on creating a calm state with controlled breathing and relaxation is: A. Acupressure. B. Meditation. C. Biofeedback. D. Hypnosis.

B. Meditation.

CHAPTER 31: SENSORY PERCEPTION The nurse is caring for a confused patient who is becoming more agitated. Which actions could should the nurse take? SELECT ALL THAT APPLY. A. Leave the television on to block out other noises. B. Minimize unnecessary light in the patient's room. C. Plan care to provide uninterrupted periods of sleep. D. Speak calmly in a moderate tone. E. Awaken the patient frequently to see whether the confusion is continuing.

B. Minimize unnecessary light in the patient's room. C. Plan care to provide uninterrupted periods of sleep. D. Speak calmly in a moderate tone.

The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process? A. Assessment B. Nursing diagnosis C. Planning D. Evaluation

B. Nursing diagnosis

CHAPTER 32: PAIN The nurse is assessing the confused patient. In trying to determine the patient's level of pain, the nurse should A. Be aware that confused patients do not feel as much pain due to their confusion. B. Observe the patient carefully for changes in behavior or vital signs. C. Ask the patient's family how much pain the patient normally has. D. Use only pain scales that feature numbers or "faces" the patient can point to.

B. Observe the patient carefully for changes in behavior or vital signs.

CH. 36: SKIN INTEGRITY and WOUND HEALING What does wound irrigation require? A. A bulb syringe and 0.9% normal saline B. Personal protective equipment including goggles C. Use of an antiseptic solution such as Betadine D. Twice daily dressing changes

B. Personal protective equipment including goggles

CHAPTER 31: SENSORY PERCEPTION Sallie Jo, an older adult, is being admitted with confusion. What actions should the nurse take in preparing for her stay? A. Place her in a semiprivate hospital room. B. Place her bed in the lowest position. C. Assign a team of caregivers. D. Restrict visitation.

B. Place her bed in the lowest position.

Rosalee, a nurse, considers the most recent evidence-based policy on care of the client with pneumonia while identifying the patient's needs. Which of the steps of the nursing process does this represent? a. Planning outcomes b. Planning interventions c. Implementation d. Evaluation e. Diagnosis f. Assessment

B. Planning interventions

CHAPTER 39: FLUIDS and ELECTROLYTES Hydrochlorothiazide, a diuretic, is prescribed for a patient who is retaining fluid. The nurse should encourage the patient to ingest nutrients that contain which electrolyte? A. Magnesium B. Potassium C. Calcium D. Sodium

B. Potassium Most diuretics affect the body's retention of potassium, so it's important to keep just enough in the body either through potassium-rich foods or through supplements. Too little potassium and you'll experience muscle cramping. Too much is cardiotoxic. (hyperkalemia)

A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client? A. Promote fluid balance B. Prevent infection C. Promote rest D. Prevent injury

B. Prevent infection

CHAPTER 31: SENSORY PERCEPTION The patient who has had a stroke states to the nurse, "You know I can't even tell where my left leg is." This reflects a lack of response to stimuli by the A. Mechanoreceptors B. Proprioceptors C. Thermoreceptors D. Chemoreceptors

B. Proprioceptors Proprioceptors allow us to determine the location of our bodies in relation to space.

CHAPTER 30: URINARY ELIMINATION Which condition in older men can result in impaired flow of urine from the bladder into the urethra? A. Renal calculi B. Prostatic hypertrophy C. Cardiovascular disorders D. Stroke

B. Prostatic hypertrophy

CHAPTER 30: URINARY ELIMINATION What anatomical feature makes women more prone to urinary tract infections than men? A. Increased width of the pelvic bones B. Proximity of the urethra to the vagina and anus C. Larger bladder D. Decreased length of the ureters

B. Proximity of the urethra to the vagina and anus

The program chairperson sends a survey to collect data on how many nursing instructors still work in the clinical setting. What type of research method is being used? A. Qualitative B. Quantitative C. Meta-analysis D. Longitudinal

B. Quantitative

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS The nurse documents the following: "Patient able to administer own insulin per subcutaneous injection using correct technique." In Focus Charting, this statement would be followed by which letter? A. D B. R C. P D. E

B. R - for response. In Focus Charting, the acronym used is "DAR": data, action, response. This statement describes how the patient responded to the nursing intervention of teaching, so it is "R" for "Response."

A patient is admitted for dehydration & SOB caused by pneumonia (PNA). He has a history of heart disease and cardiac dysrhythmias. The nursing assistant tells you his admitting vital signs. Which measurement(s) should you reassess? SELECT ALL THAT APPLY. a. Right arm BP: 120/80. b. Radial pulse rate: 72 and irregular. c. Temporal temperature: 37.4°C (99.3°F). d. Respiratory rate: 28. e. Oxygen saturation: 90%.

B. Radial pulse rate: 72 and irregular. D. Respiratory rate: 28. E. Oxygen saturation: 90%.

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important? A. A history of increased aspirin use. B. Recent pelvic surgery. C. An active daily walking program. D. A history of diabetes.

B. Recent pelvic surgery.

You are making a home visit to a family of 5 children. The youngest, aged 5, has a temp of 101.1 F, is lethargic, and has a poor appetite. This assessment leads you to the diagnosis of influenza. Based on your knowledge that influenza is an airborne communicable disease, all of the following patient teachings regarding infection are appropriate for the mother and family except: a. Keep children home from daycare and school while symptoms are present b. Remind family that they only need to wash their hands if they are visibly dirty c. Do not share tissues, dishes, or personal care items to reduce the risk of transmission d. Encourage the family to receive their annual influenza vaccine

B. Remind family that they only need to wash their hands if they are visibly dirty

CHAPTER 25: ADMINISTERING MEDICATIONS A student nurse calls the nurse at 1600 and reports that at 1500 her instructor gave the medication for patient A to patient B and the medication for patient B to patient A. The student then hung up. The instructor did not report a medication error and is no longer on the unit. What is the nurse's next best action? A. Email the instructor an incident report and request that she return the completed report within 24 hours B. Review the medication record for each patient prior to performing an assessment C. Contact each patient's provider to report the medication error and request guidance

B. Review the medication record for each patient prior to performing an assessment

The nurse provides perineal care to a middle-aged female patient who just got off the bedpan. Before leaving the patient's room, what should the nurse do to ensure bedside safety? SELECT ALL THAT APPLY. a. Functioning call light out of patient's reach. b. Room is free of clutter. c. The bed is in its highest position. d. The bed controls are not functioning. e. The casters or wheels are locked.

B. Room is free of clutter. E. The casters or wheels are locked.

A new grad is exploring the role of the community health nurse. What services might be provided by this person? SELECT ALL THAT APPLY. a. Trending of community illness b. Running a health clinic for uninsured children c. Monitoring polio outbreaks in a geographic location d. Conducting diabetic education at the senior community center e. Performing tuberculosis testing for high-risk homeless individuals

B. Running a health clinic for uninsured children D. Conducting diabetic education at the senior community center E. Performing tuberculosis testing for high-risk homeless individuals

CH. 27: HEALTH PROMOTION Blood pressure screening is an example of which type of healthcare? A. Primary prevention B. Secondary prevention C. Tertiary prevention

B. Secondary prevention

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS A patient diagnosed with an aggressive cancer is estimated to have 6 months to live. Two months later, the patient's wife calls the nurse's office because she is upset that her husband has taken up motorcycle racing and has already been injured twice. Which of the following is profoundly affected by the diagnosis of a terminal disease? A. Spirituality. B. Self-concept. C. Personal affect. D. Physical attributes.

B. Self-concept.

What are common expectations of the community-based nurse? SELECT ALL THAT APPLY. a. Previous hospital experience b. Sensitive to differences in people c. Live in the community they serve d. Nonjudgmental e. High level of professionalism

B. Sensitive to differences in people D. Nonjudgmental E. High level of professionalism

CHAPTER 31: SENSORY PERCEPTION The nurse is caring for a patient who has been in the intensive care unit for a week. The nurse notes that the patient is experiencing restlessness, anxiety, and intermittent confusion. What could be contributing to the behavior changes? A. Sensory deprivation B. Sensory overload C. Sensory deficit D. Sensory withdrawal

B. Sensory overload

CHAPTER 39: FLUIDS and ELECTROLYTES A nurse identifies that an older adult patient may have a problem with excess fluid volume. Which characteristics of the patient's skin support this conclusion? A. Dry and scaly B. Taut and shiny C. Red and irritated D. Thin and inelastic

B. Taut and shiny As edema increases, the fluid collects in the interstitial compartment which causes swelling, stretching the skin taut.

The nurse is caring for a client with a temp of 103 F, respirations of 30 per min., pulse rate of 50 beats per minute, and BP of 100/60. The client is cold and clammy. What does the nurse conclude about these findings? a. The temp is causing a lowered pulse rate; it will improve if the temp. decreases. b. The low pulse rate is causing a decreased cardiac output, which has caused a low BP c. The pulse rate and BP are compensatory mechanisms to decrease the increased metabolic rate from the temp. d. The cool, clammy skin will help to increase the BP and pulse as the body tries to warm the skin

B. The low pulse rate is causing a decreased cardiac output, which has caused a low BP

The new graduate RN needs to have a preceptor assigned to him as he begins working in the pediatric clinic. The BEST person for this assignment would be A. The charge RN who is a natural leader and knows all of the policies. B. The staff RN who has 3 years of experience and enjoys orienting new employees. C. The LPN with 15 years of experience who knows all of the doctors' preferences. D. The staff RN with 10 years of experience who refuses to work with students.

B. The staff RN who has 3 years of experience and enjoys orienting new employees.

CH. 21: PHYSICAL ASSESSMENT When percussing the abdomen, what sound would the nurse expect to hear over the intestines? A. Dullness B. Tympany C. Resonance D. Hyperresonance

B. Tympany

CHAPTER 39: FLUIDS and ELECTROLYTES When a patient is under extreme stress, there is an increased production of antidiuretic hormone (ADH) and aldosterone. The nurse plans to monitor the patient routinely because an increase in these hormones will cause a decrease in which of the following? A. Blood pressure B. Urinary output C. Body temperature D. Sweat gland secretions

B. Urinary output Hypervolemia causes hypertension, pulmonary edema and headache.

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS The nurse is caring for an older adult with metastatic colon cancer. Which of the following would indicate that the patient is achieving (positive) adaptive patterns of behavior? SELECT ALL THAT APPLY. A. Declines visitors. B. Use of available resources. C. Depends on others for care. D. Declines responsibility for his care. E. Refuses to participate in his own care planning.

B. Use of available resources. C. Depends on others for care.

CH. 26: TEACHING and LEARNING The patient needs to be taught how to find and check his own radial pulse. The nurse will complete this teaching A. Only if the patient asks her to do so, to avoid causing stress. B. When the patient recognizes the need to learn the skill. C. Before pain medication is administered when the patient is alert. D. Right before the patient is discharged so he can remember the skill.

B. When the patient recognizes the need to learn the skill.

CH. 26: TEACHING and LEARNING The nurse assesses the patient's readiness to learn wound care. What is the most important factor for the nurse to determine first? A. Intelligence level of the patient B. Willingness to learn the technique C. Financial resources available to the patient D. Support from the patient's family

B. Willingness to learn the technique

CHAPTER 31: SENSORY PERCEPTION Which patient is most likely to experience sensory deprivation? A. a 79-year-old visually impaired resident of a nursing home who enjoys taking part in different hobbies and activities B. a 14-year-old girl isolated in the hospital because of severe immune system suppression C. a 66-year-old hearing-impaired adult who lives in an assisted-living facility D. A 9-year-old boy who is deaf and uses sign language to communicate with his friends, family, and teachers

B. a 14-year-old girl isolated in the hospital because of severe immune system suppression

CHAPTER 31: SENSORY PERCEPTION What can happen if the body experiences sensory starvation (or deprivation)? A. decreased blood pressure B. hallucinations C. heart palpitations D. peripheral neuropathy

B. hallucinations

CHAPTER 29: BOWEL ELIMINATION The nurse determines that the teaching about a guaiac test of stool is understood when the patient states, "This test can detect the presence of: A. ova and parasites B. hidden blood C. bacteria D. bile

B. hidden blood Occult blood is hidden and may not be visible to the eyes, so the hemoccult test (guiac) reacts to its presence.

The Health Information Portability and Privacy Act (HIPAA) influences nursing research primarily in the area of: A. the cost of the study B. how the data will be protected. C. what type of research method can be used. D. where the study may be published.

B. how the data will be protected.

CHAPTER 31: SENSORY PERCEPTION What nursing interventions are needed for patients who are unconscious? SELECT ALL THAT APPLY. A. ambulation B. hygiene C. eating D. fluid intake E. monitoring vitals F. speech therapy

B. hygiene C. eating D. fluid intake E. monitoring vitals

CHAPTER 39: FLUIDS and ELECTROLYTES A state of abnormally low extracellular fluid in the body is A. hypervolemia B. hypovolemia C. hyponatremia D. hypernatremia E. hypoglycemia

B. hypovolemia

CHAPTER 29: BOWEL ELIMINATION How does an oil-retention enema assist with elimination? SELECT ALL THAT APPLY. A. softens the rectal tissue B. lubricates the rectum and colon C. softens the stool D. increases peristalsis

B. lubricates the rectum and colon C. softens the stool The feces absorbs the oil and becomes softer and easier to pass. To enhance the action of the oil, the patient retains the enema for several hours, if possible.

CH. 21: PHYSICAL ASSESSMENT The nurse would be able to gather the most complete data about a patient's pedal edema using the assessment skill of: A. inspection B. palpation C. percussion D. auscultation

B. palpation

CHAPTER 29: BOWEL ELIMINATION A school nurse is planning a health class about bodily functions. What information should be included regarding the purpose of mucus in the GI tract? A. activates digestive enzymes B. protects the gastric mucosa C. enhances gastric acidity D. emulsifies fats

B. protects the gastric mucosa Mucus is a lubricant that protects the tissues from friction and erosion.

CHAPTER 31: SENSORY PERCEPTION The nurse has completed the admission assessment for a patient admitted to the hospital's subacute care unit. Of the following nursing diagnoses identified by the nurse, which takes the highest priority? A. risk of isolation from social activity B. risk for injury C. impaired ability to manage adjustment D. ineffective verbal communication

B. risk for injury Safety first!

CHAPTER 29: BOWEL ELIMINATION What is bisacodyl (Dulcolax)? A. bulk-forming laxative B. stimulant laxative C. osmotic laxative D. stool softener

B. stimulant laxative

CHAPTER 29: BOWEL ELIMINATION How does a stimulant help relieve constipation? A. pulls water from the intestine to tenderize hard, dry stool B. triggers the intestines to push out stool C. contains fiber to soak up water for a larger stool D. attracts water to the bowel to soften stool and increase BM frequency

B. triggers the intestines to push out stool

CH. 36: SKIN INTEGRITY and WOUND HEALING What is an unstageable pressure injury?

Base of ulcer covered by slough and or eschar in wound bed.

Intellectual Courage

Being willing to consider and examine fairly your own beliefs and the views of others. They will rethink and even change their views

What is the drug class for metoprolol?

Beta Blockers

What is blood pressure?

Blood pressure (BP): the force of the blood against arterial walls rises as the ventricle contracts (systole), and it falls as the heart relaxes (diastole) creating a pressure wave through the arterial system.

CHAPTER 29: BOWEL ELIMINATION Which statement by a patient with an ileostomy alerts the nurse to the need for further education? A.. "I don't expect to have much of a problem with fecal odor." B. "I will have to take special precautions to protect my skin around the stoma." C. "I'm going to irrigate my stoma so I have a bowel movement every morning." D. "I should avoid gas-forming foods like beans to limit funny noises from the stoma."

C. "I'm going to irrigate my stoma so I have a bowel movement every morning." An ileostomy produces liquid fecal drainage, not formed stool that would require irrigation.

CH. 20: COMMUNICATING & THERAPEUTIC RELATIONSHIPS Which statement by the nurse indicates that the nurse-patient relationship is entering the termination phase? A. "I'll be admitting you to our nursing unit as soon as I obtain your health history." B. "You seem upset today. Would you like to talk about whatever is bothering you?" C. "I'm leaving for the day. Is there anything I can do for you before I leave?" D. "Hello. My name is Leslie, and I'm going to be your nurse today."

C. "I'm leaving for the day. Is there anything I can do for you before I leave?"

You are caring for a 22-year-old female client admitted with complaints of headache. She was accompanied by her roommate, her best friend since age 5, who confidentially confides that the patient is a victim of dating violence. What is the nurse's initial best response? A. "I can only take a history from the client." B. "Thank you. I will pass the information to the provider." C. "Tell me more and how this relates to her headaches." D. "What is his name and how have you tried to help her get out of the relationship?"

C. "Tell me more and how this relates to her headaches."

CH. 26: TEACHING and LEARNING Which of the following statements by the patient indicates that he may not be ready to learn at this time? A. "So I'll call and make an appointment with the physical therapist for the follow-up on the exercises." B. "I want to know more about the side effects of the meds." C. "There's no sense of talking right now, I'm not feeling well." D. "Let me know if I am doing this dressing the right way."

C. "There's no sense of talking right now, I'm not feeling well."

CHAPTER 10: DEVELOPMENT - OLDER ADULTHOOD Older adults (those over 65) make up approximately what percentage of the total population in the United States? A. 1% B. 5% C. 15% D. 50%

C. 15%

CHAPTER 39: FLUIDS and ELECTROLYTES According to the Institute of Medicine [IOM], how much water should a 41-year-old woman drink daily? A. 1000-1500 mL B. 1500-2000 mL C. 2700-3000 mL D. 3000-3500 mL

C. 2700-3000 mL

CHAPTER 9: DEVELOPMENT - INFANCY to MIDDLE ADULT Which describes a normal head circumference for a newborn infant? A. 13 to 14 cm B. 17 to 18 cm C. 33 to 35 cm D. 43 to 45 cm

C. 33 to 35 cm

Which assessment findings would require the nurse to further assess the client? A. A young adult male with a pulse rate of 136 after running 2 miles B. A 40 yr old female with a BP of 110/70 when 1st awakened C. A 72 yr old female with a respiratory rate of 10 breaths per min. D. A 50 yr old male with a pulse rate of 88 beats per min.

C. A 72 yr old female with a respiratory rate of 10 breaths per min.

Which assessment findings would require the nurse to further assess the client? a. A young adult male with a pulse rate of 136 after running 2 miles b. A 40 yr old female with a BP of 110/70 when 1st awakened c. A 72 yr old female with a respiratory rate of 10 breaths per min. d. A 50 yr old male with a pulse rate of 88 beats per min.

C. A 72 yr old female with a respiratory rate of 10 breaths per min.

A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? a. A nurse on a medical-surgical unit demonstrates signs of chemical impairment. b. A nurse overheard another nurse telling an older adult that if he doesn't stay in bed, she will have to apply restraints. c. A family has conflicting feelings about the initiation of external tube feedings for their father who is terminally ill. d. A client who is terminally ill hesitates to name their partner on their durable power of attorney form.

C. A family has conflicting feelings about the initiation of external tube feedings for their father who is terminally ill.

A nurse makes a medication error, immediately assesses the client, and reports the error to the nurse manager and the primary care provider. Which characteristic of a professional is the nurse demonstrating? a. Autonomy b. Collaboration c. Accountability d. Altruism

C. Accountability

CHAPTER 25: ADMINISTERING MEDICATIONS Which medication is the nurse giving if it is scheduled at 0900, 1400, and 2000? A. Morphine sulfate 10mg q4h PRN B. Inderal 10mg PO bid C. Acetaminophen 500mg PO tid D. Keflex 500mg PO q8h for 7 days

C. Acetaminophen 500mg PO tid

A nurse is about to transfer to a chair a client who has a weak left leg. Which of the following actions by the nurse demonstrates correct transfer technique? a. Positioning the chair slightly behind the nurse so that the seat faces the clients bed. b. Placing the clients left leg infront of her right leg just prior to the transfer. c. Aligning the nurses knees with the clients knees just before the transfer. d. Grasping the client under the axils to assist her to her feet.

C. Aligning the nurses knees with the clients knees just before the transfer.

The nurse, Susie, has an allergy to latex. Her employer and replaced all latex Products used on the unit with non—latex substitutions so Susie will not get sick. What is this an example of? a. EMTALA b. PSDA c. ADA d. HIPPA

C. Americans with Disabilities Act

CHAPTER 28: NUTRITION The patient has had throat surgery and is able to have clear liquid oral intake. The nurse should offer the patient: A. Fresh-squeezed orange juice B. Chicken noodle soup C. Apple juice D. Oatmeal

C. Apple juice

The nurse notes that the client has an irregular pulse. What is the 1st action the nurse should take? a. Asses the pulse at the carotid artery b. Asses the pulse with a Doppler ultrasound c. Assess the pulse for a full minute d. Asses the pulse at two different sites

C. Assess the pulse for a full minute.

CH. 27: HEALTH PROMOTION As the nurse, you are going to teach a patient about strategies to prevent hypertension. In order to provide effective care, you know that the action that you should implement first is: A. Set mutual goals for knowledge of hypertension. B. Teach what the patient wants to know about hypertension. C. Assess what the patient already knows about hypertension. D. Evaluate the outcomes of patient education for hypertension.

C. Assess what the patient already knows about hypertension.

The statement "ongoing collection of data" best describes which phase of the nursing process? a. Planning b. Evaluation c. Assessment d. Implementation

C. Assessment

The nurse admits a chest pain patient to the cardiac care unit. Which step of the nursing process does the nurse do first? A. Planning. B. Evaluation. C. Assessment. D. Implementation.

C. Assessment.

CHAPTER 9: DEVELOPMENT - INFANCY to MIDDLE ADULT To encourage primary health promotion for young and middle adults, the nurse will: A. Tell individuals to abstain from all alcohol consumption B. Demonstrate blood pressure measurements C. Assist in determining effective daily exercise plans for stress reduction D. Describe the usual types of medications used for common disorders.

C. Assist in determining effective daily exercise plans for stress reduction

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS An adolescent is talking to a nurse about the loss of his or her parent. Which adolescent behavior indicates a need for intervention? A. Attends grief and loss counseling every 2 weeks B. Makes a scrapbook with photos of the family C. Begins to cut his or her arms or legs D.Stays in his or her room frequently talking on the phone with friends

C. Begins to cut his or her arms or legs

CHAPTER 31: SENSORY PERCEPTION Mr. Arbor complains to the nurse that he is feeling anxious. He states, "I'm just so tired of all these tests they are doing, and it's so noisy here at night." Mr. Arbor's pulse is 110 beats/min and his blood pressure is 140/70 mm Hg. Nursing actions should include which of the following? A. Turn on the television to provide distraction. B. Ask the patient if he would like to discuss his anxiety further. C. Close the blinds, dim the lights and ask the patient what other measures would help him rest. D. Call the physician and obtain an order for an anti-anxiety medication for prn use.

C. Close the blinds, dim the lights and ask the patient what other measures would help him rest. These actions help to reduce the patient's sensory overload.

CH. 36: SKIN INTEGRITY and WOUND HEALING Which of the following statements about wound healing would indicate further teaching for the student nurse? A. Wound healing can be a long process up to 3 months or more. B. Inflammation phase of wound healing is characterized by edema and erythema. C. Clot formation during wound healing is an unexpected finding. D. Maturation phase is the last stage of wound healing.

C. Clot formation during wound healing is an unexpected finding.

Healthcare workers are discussing a diverse group of clients respectfully and are being responsive to the health beliefs and practices of these clients. What important aspect of nursing professional practice are they exhibiting? a. Autonomy b. Accountability c. Cultural competence d. Leadership

C. Cultural competence

Healthcare workers are discussing a diverse group of patients respectfully and are being responsive to the health beliefs and practices of these patients. What important aspect of Nursing professional practice are they exhibiting? a. Autonomy b. Accountability c. Cultural competence d. Leadership

C. Cultural competence

CH. 36: SKIN INTEGRITY and WOUND HEALING Of the following factors, which would put a patient at greatest risk for impaired skin integrity? A. Medication B. Moisture C. Decreased sensation D. Dehydration

C. Decreased sensation

CHAPTER 39: FLUIDS and ELECTROLYTES A nurse is caring for two patients; one has oliguria and the other has polyuria. Which is the priority problem that is a concern for the nurse regarding both of these patients? A. Diarrhea B. Cachexia (wasting away) C. Deficient fluid volume D. Impaired skin integrity

C. Deficient fluid volume Oliguria typically happens when there is insufficient fluid volume (so there's nothing to pee out) and polyuria is peeing too much so it means the fluid volume would be out of balance.

The new charge RN on a hospital unit is leading a committee that must choose new paint colors for the nurses' station. She elicits the opinions of all group members and then organizes a vote. The charge nurse's leadership style can be said to be A. Laissez-faire B. Autocratic C. Democratic D. Scientific

C. Democratic

CHAPTER 32: PAIN It is most important for the nurse to understand the various ways in which pain is classified so that he or she can A. Document the patient's pain using accurate terms. B. Be clear in communication with the physician. C. Develop an effective pain management plan. D. Educate the patient thoroughly.

C. Develop an effective pain management plan.

CHAPTER 30: URINARY ELIMINATION A nurse is placing an indwelling catheter in an obese female patient and realizes that the catheter is in the vagina rather than the urinary meatus. Which action should the nurse take? A. Remove the catheter from the vagina and again try to place the catheter. B. Adjust the patient's position or lighting and attempt again with the same catheter. C. Discard the catheter, adjust the patient's position and lighting, and try again with a new catheter. D. Discard the catheter and ask another nurse to try to place the catheter.

C. Discard the catheter, adjust the patient's position and lighting, and try again with a new catheter.

CHAPTER 25: ADMINISTERING MEDICATIONS The patient has been on a low-protein diet. This will most likely affect which pharmacokinetic process? A. Absorption B. Excretion C. Distribution D. Metabolism

C. Distribution Low-protein diet can lead to an insufficient level of plasma proteins, which limits the availability of the drug in the body.

What term best describes the nature of the nursing process? a. Static b. Linear c. Dynamic d. Predictable

C. Dynamic

A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing? A. Ongoing assessment B. Comprehensive physical assessment C. Focused physical assessment D. Psychosocial assessment

C. Focused physical assessment

Henry, a nurse, is driving home from work when there is a major motor vehicle accident in front of him. He runs to the side of the driver, finding him bleeding from the nose and mouth. Henry calls 911 and begins treating the driver after receiving consent. What is this an example of? a. Nurse practice acts b. Standard of practice c. Good Samaritan law d. American nurses Association code of ethics

C. Good Samaritan law

The nurse performs care on an unconscious person at the grocery store. What law protects the nurse in this situation? a. Medical treatment and Active Labor Act b. American Nurses Association Code of ethics c. Good Samaritan laws d. Nurse practice act

C. Good Samaritan laws

CHAPTER 30: URINARY ELIMINATION Which ion controls acid-base balance? A. Sodium B. Oxygen C. Hydrogen D. Potassium

C. Hydrogen

CHAPTER 39: FLUIDS and ELECTROLYTES A nurse is caring for a patient who has dependent edema. Which pressure has caused the excess fluid in the interstitial compartment? A. Oncotic pressure B. Diffusion pressure C. Hydrostatic pressure D. Intraventricular pressure

C. Hydrostatic pressure

CHAPTER 39: FLUIDS and ELECTROLYTES A patient is admitted to the hospital for a fever of unknown origin. The nursing assessment reveals profuse diaphoresis; dry, sticky mucous membranes; weakness; disorientation; and a decreasing level of consciousness. Which electrolyte imbalance do these data support? A. Hyperkalemia B. Hypercalcemia C. Hypernatremia D. Hypermagnesemia

C. Hypernatremia Excess sodium causes excess fluid loss, which leads to the signs and symptoms described.

CHAPTER 39: FLUIDS and ELECTROLYTES A patient exhibits an increasing blood pressure and 2-pound weight gain over 2 days. Which additional clinical manifestation can be clustered with these data? A. Decrease in heart rate B. Increase in skin turgor C. Increase in pulse volume D. Decrease in pulse pressure

C. Increase in pulse volume With excess fluid volume, the amount of circulating blood volume increases, which results in bounding peripheral pulses.

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS The student nurse (SN) has completed a research paper detailing the pros and cons of a medical ethical issue. Which element of informatics does this paper reflect? A. Data. B. Information. C. Knowledge. D. Wisdom.

C. Knowledge.

Nurses may be held liable for actions that are considered unintentional torts. Which of the following actions is an example of this type of tort? a. Restraining a client who refuses care and wants to leave the hospital. b. Taking photos of a client surgical wound to post to a website. c. Leaving the side rails down, leading to the client falling and becoming injured. d. Discussing the clients sexually transmitted disease while riding the elevator with visitors.

C. Leaving the side rails down, leading to the client falling and becoming injured.

The doctor has ordered progressive ambulation for a patient who has been on bed rest. When the nurse prepares to assist the patient out of bed for the first time, the patient becomes dizzy as the head of the bed is raised to high Fowler's. The nurse should: a. Direct the patient to focus on control of dizziness. b. Inform the physician that the patient is not ready to ambulate. c. Lower the head of the bed and wait until dizziness subsides. d. Move the patient very slowly out of bed.

C. Lower the head of the bed and wait until dizziness subsides.

The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to: SELECT ALL THAT APPLY. A. A body systems model B. A head-to-toe framework C. Maslow's hierarchy of needs D. Gordon's functional health patterns E. Adaptation Model of Nursing

C. Maslow's hierarchy of needs D. Gordon's functional health patterns

CHAPTER 31: SENSORY PERCEPTION The nurse is caring for a patient who says, "Food just doesn't taste good anymore." What priority action should the nurse take? A. Determine who fixes the patient's meals. B. Ask what dietary restriction he follows. C. Monitor dietary intake. D. Determine what medications are taken.

C. Monitor dietary intake.

CHAPTER 9: DEVELOPMENT - INFANCY to MIDDLE ADULT A nurse is preparing an education program for a group of young adults. On the basis of the leading cause of mortality and morbidity for this age group, the nurse will focus on which of the following? A. Birth Control B. Occupational Hazards C. Motor Vehicle Safety D. Prevention of Sports Injuries

C. Motor Vehicle Safety

CHAPTER 37 and 38: OXYGENATION and PERFUSION A patient with COPD has carbon dioxide retention and is ordered oxygen therapy. The nurse anticipates the use of which oxygen delivery system? A. Face tent B. Face mask C. Nasal cannula D. Non-rebreather mask. E. Partial rebreather mask

C. Nasal cannula

Annie is planning to move to another state. She looks at the board of nursing website to explore the state's regulations for registered nurses. What is this an example of? a. Standard of practice b. Scope of practice c. Nurse practice acts d. Patient care partnership

C. Nurse practice acts

CHAPTER 31: SENSORY PERCEPTION Which interventions are helpful when caring for a patient with impaired vision? SELECT ALL THAT APPLY. A. Suggest the patient use soft, diffuse lighting. B. Advise the patient to avoid wearing sunglasses when outdoors. C. Offer large-print books and reading material. D. Clean the patient's eyeglasses daily. E. Place call light and necessary items within reach.

C. Offer large-print books and reading material. D. Clean the patient's eyeglasses daily. E. Place call light and necessary items within reach.

CHAPTER 39: FLUIDS and ELECTROLYTES Which should a nurse do to encourage a confused patient to drink more fluid? A. Serve fluid at a tepid temperature. B. Explain the reason for the desired intake. C. Offer the patient something to drink every hour. D. Leave a pitcher of water at the patient's bedside.

C. Offer the patient something to drink every hour. Frequent, smaller amounts of water are more easily tolerated and the patient likely needs the reminder.

CHAPTER 31: SENSORY PERCEPTION The nurse assesses a patient's sense of smell. What is the term used to describe this type of sense? A. Tactile B. Auditory C. Olfactory D. Gustatory

C. Olfactory

CHAPTER 10: DEVELOPMENT - OLDER ADULTHOOD Which is the fastest-growing segment of the older adult population? A. 65- to 75-year-olds B. 75- to 80-year-olds C. Over 85 D. None of these

C. Over 85

CHAPTER 39: FLUIDS and ELECTROLYTES For a patient with a nursing diagnosis of fluid volume excess the nurse is alert to which of the following signs and symptoms? A. Dry mucous membranes B. Weak, thready pulse C. Pale, cool skin D. Oliguria

C. Pale, cool skin

A client is asking about developing a living will. What act protects this right? a. Americans with disabilities act b. Emergency medical treatment and active labor act c. Patient self-determination act d. Health insurance portability and accountability act

C. Patient self-determination act

CHAPTER 30: URINARY ELIMINATION How would the nurse assess for costovertebral angle tenderness? A. Inspect the urinary meatus. B. Auscultate over the abdominal aorta. C. Percuss between the 12th rib and spine. D. Palpate in the pubic area over the bladder.

C. Percuss between the 12th rib and spine.

CH. 26: TEACHING and LEARNING To best determine the patient's competency in changing an ostomy appliance, what should the nurse ask the patient to do? A. Verbalize the procedure B. Identify the supplies needed C. Perform the procedure D. List the steps in the procedure

C. Perform the procedure

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS Which component of self-concept represents an outgoing male whose favorite hobbies are camping and hiking? A. Body image. B. Self-esteem. C. Personal identity. D. Role performance.

C. Personal identity.

The nurse inspects a client's back and notices small hemorrhagic spots. The nurse documents that the client has: A. Extravasation B. Osteomalacia C. Petechiae D. Uremia

C. Petechiae

To prevent injury to a client during logrolling, which action by the nurse is most important? a. Place an ankle-foot orthotic on the client prior to movement b. Remove the client's drawsheet to avoid lower extremity entanglement c. Position a pillow between the client's legs to maintain body alignment d. Raise all four side rails prior to initiating logrolling independently

C. Position a pillow between the client's legs to maintain body alignment

The nurse is performing an assessment on a client. What should be included in this process? a. Ability to pay for a hospital stay b. Who brought patient to the hospital c. Religious and spiritual needs d. Level of education

C. Religious and spiritual needs

CH. 21: PHYSICAL ASSESSMENT When percussing the chest, what sound would the nurse expect to hear over the lungs? A. Dullness B. Tympany C. Resonance D. Hyperresonance

C. Resonance

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS The elder patient's daughter is vice president of a large company. She is experiencing great conflict in trying to care for her mother while managing her work-related responsibilities. In planning to help the daughter, the nurse focuses on which component of the daughter's self-concept? A. Body image. B. Personal identity. C. Role performance. D. Self-esteem.

C. Role performance.

When learning a patient's apical pulse, you listen until you hear the S1 and S2 heart sounds clearly and regularly. S2 is produced when the: A. Atria contract vigorously B. Ventricular walls vibrate C. Semi lunar valves close

C. Semi lunar valves close

CHAPTER 28: NUTRITION While assisting the patient with meal selection, the nurse realizes that patients who practice Judaism share an avoidance of: A. Alcohol B. Chicken C. Shellfish D. Caffeine

C. Shellfish

CHAPTER 37 and 38: OXYGENATION and PERFUSION The nurse is administering oxygen (O2) therapy to a patient. Which of the following oxygen delivery systems would be most appropriate for a mouth breather who requires a minimum of 5L/minute of O2 to prevent carbon dioxide (CO2) retention? A. CPAP machine B. Venturi mask C. Simple face mask D. Partial rebreather mask

C. Simple face mask This reduces the risk of retaining CO2.

CH. 20: COMMUNICATING & THERAPEUTIC RELATIONSHIPS Which nonverbal behavior best enhances communication? A. Keeping a neutral facial expression B. Maintaining a distance of 6 to 8 inches C. Sitting down to speak with the patient D. Asking open-ended questions

C. Sitting down to speak with the patient

CHAPTER 30: URINARY ELIMINATION A female patient tells the nurse: "Every time I sneeze, I wet my pants." What genitourinary (GU) condition does she have? A. Urge incontinence. B. Mixed incontinence. C. Stress incontinence. D. Uncontrolled voiding.

C. Stress incontinence.

The nurse is caring for a client who was burned in a house fire. The right arm is heavily bandaged and there is an intravenous line that was placed in the left forearm after 3 attempts. Which action does the nurse take related to obtaining VS? a. A BP is not needed because the client is awake, alert, and talking to the nurse. b. A smaller cuff should be used to cover less of the upper arm c. The BP should be taken on the popliteal artery d. The systolic pressure should be palpated from the radial artery

C. The BP should be taken on the popliteal artery

CHAPTER 10: DEVELOPMENT - OLDER ADULTHOOD When planning nursing care for an older adult, which consideration should have the highest priority? A. All older adults should have similar plans of care. B. The care plan should take loss of cognitive function into consideration. C. The care plan should be individualized, not based on age. D. A 65-year-old will have needs similar to an 85-year-old.

C. The care plan should be individualized, not based on age.

Which organization is directly responsible for regulating the practice of nursing in each state? a.The American Nurse's Association (ANA). b.The American Medical Association (AMA). c.The state board of nursing. d.The state legislature.

C. The state board of nursing.

CHAPTER 37 and 38: OXYGENATION and PERFUSION According to the 2015 AHA CPR Guidelines, which cardiac rhythm can be defibrillated? SELECT ALL THAT APPLY. A. Atrial fibrillation (Afib) B. Complete heart block (CHB) C. Ventricular fibrillation (Vfib) D. Ventricular Tachycardia (V-tach) E. Pulseless Electrical Activity (PEA)

C. Ventricular fibrillation (Vfib) D. Ventricular Tachycardia (V-tach)

CHAPTER 32: PAIN The patient tells the nurse about a deep crampy tender sensation in the epigastric area. The nurse should describe the origin of pain as which of the following? A. Cutaneous B. Radiating C. Visceral D. Phantom pain

C. Visceral

CHAPTER 39: FLUIDS and ELECTROLYTES An accumulation of fluid in the peritoneal cavity, causing abdominal swelling is A. astrocytes B. peripheral edema C. ascites D. pulmonary edema E. auscultation

C. ascites

CHAPTER 37 and 38: OXYGENATION and PERFUSION The nurse knows that the proper technique for assessing a patient's carotid arteries is to: A. palpate on the carotid arteries bilaterally at the same time with your hands B. palpate on the side of the neck using the diaphragm of the stethoscope C. auscultate with the bell of the stethoscope on the side of the neck, listen for bruits, and palpate for thrills D. auscultate with the diaphragm of the stethoscope on the side of the neck, listen for bruits, and palpate for thrills

C. auscultate with the bell of the stethoscope on the side of the neck, listen for bruits, and palpate for thrills

CHAPTER 37 and 38: OXYGENATION and PERFUSION What are expected findings in patients with COPD? SELECT ALL THAT APPLY. A. small, inflexible lungs B. increased breath capacity C. barrel-shaped chest D. shortness of breath E. productive cough with sputum F. over-inflated lungs

C. barrel-shaped chest D. shortness of breath E. productive cough with sputum F. over-inflated lungs

CHAPTER 28: NUTRITION Vitamin D is needed for which of the following functions? SELECT ALL THAT APPLY. A. protein synthesis B. wound healing C. calcium and phosphorous absorption D. strong bones and teeth E. protection of cells from damage

C. calcium and phosphorous absorption D. strong bones and teeth

CHAPTER 39: FLUIDS and ELECTROLYTES The patient has heart failure and is on a restricted sodium diet. Which of the following foods in the patient's diet is the nurse most concerned about? A. celery B. baked fish C. canned soup D. dried fruit

C. canned soup

CHAPTER 29: BOWEL ELIMINATION What desirable outcome does a soapsuds enema cause? A. gas relief B. abdominal tenderness C. colon irritability D. mucosal secretion

C. colon irritability Soapsuds are added to saline or tap water to increase colon irritability. Only pure Castile soap is safe to use in a soapsuds enema; other soaps cause serious bowel inflammation.

CHAPTER 29: BOWEL ELIMINATION How does a bulk-forming laxative help relieve constipation? A. pulls water from the intestine to tenderize hard, dry stool B. stimulates the intestines to push out stool C. contains fiber to soak up water for a larger stool D. attracts water to the bowel to soften stool and increase BM frequency

C. contains fiber to soak up water for a larger stool

CHAPTER 31: SENSORY PERCEPTION With advancing age, which of the following physiological changes in sensory function occurs? A. decreased sensitivity to glare B. increased number of taste buds C. decreased sensitivity to pain D. difficulty discriminating vowel sounds

C. decreased sensitivity to pain

CHAPTER 29: BOWEL ELIMINATION A nurse is caring for a group of patients. Which patient factor should the nurse determine provides the greatest risk for bowel incontinence? A. being 90 years old B. taking a sedative for sleep C. disoriented to time, place, and person D. receiving multiple antibiotic medications

C. disoriented to time, place, and person If they're disoriented, they may not have the awareness to recognize cues that they need to go.

CHAPTER 31: SENSORY PERCEPTION At which developmental stage do senses peak? A. infancy B. adolescence C. early adulthood D. middle adulthood E. late adulthood (old age)

C. early adulthood

CHAPTER 29: BOWEL ELIMINATION Low-pitched, infrequent, and quiet bowel sound indicating decreased peristalsis A. hyperactive bowel sounds B. deficient bowel sounds C. hypoactive bowel sounds D. normal bowel sounds

C. hypoactive bowel sounds

CHAPTER 29: BOWEL ELIMINATION Which is the correct sequence of abdominal assessment? A. auscultation, inspection, palpation, percussion B. RUQ → RLQ → LLQ → LUQ C. inspection, auscultation, palpation, percussion D. inspection, percussion, auscultation, palpation

C. inspection, auscultation, palpation, percussion

CHAPTER 31: SENSORY PERCEPTION Why does isolation cause sensory deprivation? A. it can lead to depression, which dulls the senses B. the mechanical senses become atrophied from lack of use C. it leads to understimulation of the nervous system D. the synaptic connections deteriorate without stimulus

C. it leads to understimulation of the nervous system

CHAPTER 29: BOWEL ELIMINATION What is polyethylene-glycol (Miralax)? A. bulk-forming laxative B. stimulant laxative C. osmotic laxative D. stool softener

C. osmotic laxative

CHAPTER 34: SEXUAL HEALTH The nurse knows that preconception care is: A. healthy pregnancy. B. menopausal management. C. pre-pregnancy preparation. D. sexually transmitted infection (STI) prevention.

C. pre-pregnancy preparation.

CHAPTER 29: BOWEL ELIMINATION The nurse is about to perform an enema on a constipated patient. A medicated enema: A. helps destroy intestinal parasites B. helps expel flatus from the rectum C. provides medication absorbed through the rectal mucosa D. lubricates the stool and intestinal mucosa, easing defecation

C. provides medication absorbed through the rectal mucosa

CHAPTER 31: SENSORY PERCEPTION A home safety measure specific for a patient with diminished olfaction is the use of: A. extra lighting in the hallways B. amplified telephone receivers C. smoke detectors on all levels D. mild water heater temperatures

C. smoke detectors on all levels

CHAPTER 37 and 38: OXYGENATION and PERFUSION What is the function of an anticholinergic medicine? A. promote oxygenation to the cells B. increase neurotransmitter activity C. stop involuntary muscle movements D. decrease hypertension

C. stop involuntary muscle movements Because anticholinergics stop involuntary muscle movements, they are effective for the treatment of bronchospasm, and relaxes and enlarges the airway for those with COPD.

CHAPTER 31: SENSORY PERCEPTION Which receptors are located in the skin and are responsible for information about changes in temperature? A. mechanoreceptors B. hair cells C. thermoreceptors D. proprioceptors E. photoreceptors F. chemoreceptors

C. thermoreceptors

CHAPTER 28: NUTRITION A patient tells the nurse that he needs to increase his intake of potassium because he has been taking large doses of diuretics. To minimize complications from hypokalemia, the nurse should instruct the patient to include which of the following foods as a part of his diet? A. cheese and crackers B. peanut butter and jelly sandwich C. tomatoes and spinach D. apples and grapes

C. tomatoes and spinach

During normal client care that does not soil hands, effective hand hygiene between clients require: a. at least a 20-sec soap and water scrub b. at least a 23 min, scrub with antimicrobial soap c. use of an alcohol-based antiseptic hand rub d. a mask must be worn while scrubbing is occurring

C. use of an alcohol-based antiseptic hand rub

A client has been diagnosed with cancer, but the primary care provider is hesitant to share the information with her. The nurse encourages the provider to tell the client so that she can make decisions about her care. The nurse is using th ethical principal of: a. Justice b. Fidelity c. Veracity d. Nonmaleficense

C. veracity

CHAPTER 37 and 38: OXYGENATION and PERFUSION Musical, whistling, squeaking. High-pitched, continuous sounds. Heard when a patient inhales and exhales as air passes through narrowed or obstructed airways, usually louder on expiration. A. ronchi B. crackles C. wheezing D. pleural rub

C. wheezing

CHAPTER 25: ADMINISTERING MEDICATIONS What do you do if you cannot read a provider's order?

Call for clarification and confirmation.

CH. 11: HEALTH and ILLNESS A nurse is using a caring approach with a patient to influence healthy lifestyle changes. The best statement by the nurse is: A. "I would like you to perform this exercise once a day." B. "Your physician has left orders for you to follow." C. "The laboratory tests reveal the need to reduce your daily percentage of fat grams." D. "Adapting your diet and activity will lower your blood glucose levels."

D. "Adapting your diet and activity will lower your blood glucose levels."

CHAPTER 32: PAIN The patient is receiving medication through a patient-controlled analgesia (PCA) system. Which of the following statements demonstrates the patient understands this method of pain medication administration? A. "This is the best option for pain control." B. "I can choose the dosage of the drug received." C. "I won't get as constipated while I'm using this." D. "I can push the delivery button as often as desired."

D. "I can push the delivery button as often as desired."

CHAPTER 9: DEVELOPMENT - INFANCY to MIDDLE ADULT Which comment made by a woman in her early 50s would indicate the need for further assessment for a potential health issue? A. "I have episodes when I feel really hot even when others are comfortable." B. "It's getting harder to lift the heavy bags of groceries into the car." C. "My skin is so dry I need to use lotion every day after I bathe." D. "Sometimes my heart feels like it skips beats."

D. "Sometimes my heart feels like it skips beats."

CHAPTER 9: DEVELOPMENT - INFANCY to MIDDLE ADULT The nurse learns that his 43-year-old neighbor has not had a physical exam in 20 years. He states, "I don't see a reason to go to the doctor since I haven't been sick." How should the nurse respond? A. "That's a good point. If you are not sick, there is no point in seeing a doctor. It will just cost you money." B. "Don't you have insurance? Some people don't go because of insurance." C. "You could be sick and not even know it. You should go to find out." D. "You are at risk for heart disease and cancer as you get older. It's best to catch those things early."

D. "You are at risk for heart disease and cancer as you get older. It's best to catch those things early."

CHAPTER 39: FLUIDS and ELECTROLYTES According to the Institute of Medicine [IOM], how much water should a 36-year-old male drink daily? A. 1000-1500 mL B. 1500-2000 mL C. 2700-3000 mL D. 3000-3500 mL

D. 3000-3500 mL

Of the following clients, which client is at a higher risk of infection? a. 27 yr old female who is an athlete b. 60 yr old male with arthritis c. 12 yr old female with a broken leg d. 36 yr old female with HIV

D. 36 yr old female with HIV

CH. 26: TEACHING and LEARNING The patient is given a pamphlet to read about how to manage his newly inserted central venous access device at home. It will be most important for the nurse to assess the patient's A. Health beliefs B. Literacy level C. Fine motor abilities D. Ability to see

D. Ability to see

CHAPTER 29: BOWEL ELIMINATION What should be included in teaching for a patient who will be discharged with a prescription for a laxative? A. Know the difference between cathartics and laxatives. B. Continue use of laxatives to encourage bowel evacuation. C. Call the healthcare provider (HCP) if nausea, vomiting, or abdominal pain occurs. D. Add regular exercise, sufficient fluids, and regular defecation habits to his or her routine.

D. Add regular exercise, sufficient fluids, and regular defecation habits to his or her routine.

A nurse admits a 5-year-old female to the postanesthesia unit following a tonsillectomy. The child is crying. What should be the nurse's first action? a. Tell the child that if she stops crying, her parents can be with her. b. Check to see what pain medication is ordered for the child. c. Notify the surgeon of the child's postoperative condition. d. Assess the child to determine why she is crying.

D. Assess the child to determine why she is crying.

CHAPTER 30: URINARY ELIMINATION What is the term for the amount of blood that is filtered in a minute? A. Creatinine B. Ammonia C. Blood urea nitrogen D. Glomerular filtration rate

D. Glomerular filtration rate

CH. 20: COMMUNICATING & THERAPEUTIC RELATIONSHIPS Which intervention by the nurse first helps to establish a trusting nurse-patient relationship? A. Avoiding topics that may provoke emotional responses from the patient B. Listening to the patient while performing care activities C. Performing care interventions quietly and respectfully D. Greeting the patient by name whenever entering the patient's room

D. Greeting the patient by name whenever entering the patient's room

What nursing intervention would be the 1st priority to prevent constipation in an immobile client? a. Administration of a soap suds enema b. Decreased dietary fiber consumption c. Narcotic analgesic pain relief use d. Increased daily oral fluid intake

D. Increased daily oral fluid intake

CHAPTER 33: ACTIVITY & EXERCISE When the nurse assesses an immobile patient, what is one effect of immobility on the cardiovascular system? A. Impaired gas exchange. B. Increased risk for contractures. C. Increased bone mineralization. D. Increased risk for venous thrombosis.

D. Increased risk for venous thrombosis.

CHAPTER 30: URINARY ELIMINATION The nurse is caring for a patient with acute kidney injury and reviews the medical record for new orders. Which order given by the healthcare provider should the nurse question? A. Cystoscopy B. Cystometry C. Renal biopsy D. Intravenous pyelogram

D. Intravenous pyelogram An intravenous pyelogram is contraindicated in a patient with acute kidney injury, as the intravenous dye is nephrotoxic and can worsen the kidney injury.

CHAPTER 39: FLUIDS and ELECTROLYTES A nurse is assessing several patients for fluid and electrolyte imbalances. Which of the following is common to both excess fluid volume and deficient fluid volume? SELECT ALL THAT APPLY. A. Increased pulse amplitude B. Decreased blood pressure C. Difficulty breathing D. Mental confusion E. Muscle weakness

D. Mental confusion E. Muscle weakness

While taking an adult patient's pulse, a nurse assesses a new finding of the rate to be 150 beats per minute up from 80s-90s over the past 2 days. What should the nurse do first? a. Assess the popliteal and femoral pulses. b. Assess a 1-minute apical pulse. c. Apply a warm pack and reassess in 20 minutes. d. Notify the provider STAT.

D. Notify the provider STAT.

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS Which of the listed basic needs identified by Maslow must be addressed first when providing nursing care? A. Self-esteem. B. Self-actualization. C. Love and belonging. D. Nutrition and elimination.

D. Nutrition and elimination.

The population served by this nurse is the congregation of the church. Which type of nursing is this? a. School nursing b. Public health clinics c. Community health nursing d. Parish Nursing

D. Parish Nursing

Josephine wants to make her own decisions about her end-of-life care. She talks to her significant other about creating a LivingWell and durable power of attorney. What is this an example of? a. HIPPA b. EMTALA c. ADA d. PSDA

D. Patient Self-Determination Act

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS A patient states, "I am so angry that my father gave me depression. It's all his fault that I am in the hospital right now." The nurse knows which theory is related to this statement? A. Psychodynamic theory B. Cognitive theory C. Social/environmental theory D. Physiological theory

D. Physiological theory

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS Which interventions should the nurse include in the plan of care for a patient with dementia? SELECT ALL THAT APPLY. A. Assessment for suicidal ideations B. Assessment for causative factors C. Administration of pharmacological restraints D. Promotion of independence with daily activities E. Provision of activities that provide socialization

D. Promotion of independence with daily activities E. Provision of activities that provide socialization

Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance? A. Administer sleeping medication before bedtime. B. Ask the client each morning to describe the quantity of sleep during the previous night. C. Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation. D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.

D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.

Which client care activity can be delegated by the RN to unlicensed assistive personnel? a. Completing an admission skin assessment b. Administering an ordered stool softener c. Teaching deep vein thrombosis prophylaxis d. Range of motion exercises

D. Range of motion exercises

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS In assessing patients who may be experiencing a depressive disorder, what should the nurse determine as a priority? A. Family and community supports. B. Onset and severity of symptoms. C. Previous history of depression. D. Risk of self-harm.

D. Risk of self-harm.

CH. 11: HEALTH and ILLNESS A nurse is performing health promotion activities for patients at a local health care clinic. Which nursing actions show the focus of secondary preventative care? SELECT ALL THAT APPLY. A. Scheduling a series of immunizations for a child B. Teaching parents about child safety in the home C. Performing ROM exercises D. Screening for hypertension E. Scheduling a mammogram for a patient F. Referring a patient to outpatient mental health counseling for chronic depression

D. Screening for hypertension E. Scheduling a mammogram for a patient

What phrase BEST describes the essence of critical thinking? a. Understanding without conscious reasoning b. Providing care based on nursing experience c. Consulting with a primary care provider d. Seeking solutions to problems

D. Seeking solutions to problems

CHAPTER 13: PSYCHOSOCIAL HEALTH & ILLNESS When the nurse assesses the patient, which stage of anxiety is completely focused on oneself? A. Panic. B. Mild. C. Moderate. D. Severe.

D. Severe.

Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client? A. Semi-Fowler's B. Supine C. High-Fowler's D. Side-lying

D. Side-lying

What info should the nurse include when teaching a client abt deep vein thrombosis (DVT) prevention? a. Avoid movement of the extremities to prevent potential DVT formation b. Encourage use of sequential compression devices (SCDs) during ambulation c. Utilize an ankle foot orthotic (AFO) or pressure relief orthotic (PRAFO) to stretch ligaments d. Sit with legs uncrossed to promote circulation and venous blood flow to the heart.

D. Sit with legs uncrossed to promote circulation and venous blood flow to the heart.

CHAPTER 30: URINARY ELIMINATION The nurse cares for a patient who has a urinary tract infection (UTI). Which of the following antibiotics is considered first-line treatment? A. Cephalexin. B. Ciprofloxacin. C. Sulfadoxine/Pyrimethamine. D. Sulfamethoxazole/Trimethoprim.

D. Sulfamethoxazole/Trimethoprim.

Patient advocacy is best demonstrated by the nurse: a. Learning how to do a new procedure b. Returning with the client at the agreed-upon time. c. Preparing the client's room for comfort and privacy. d. Supporting the client's right to refuse treatment.

D. Supporting the client's right to refuse treatment.

CH. 11: HEALTH and ILLNESS A nurse is caring for a patient who has COPD, a chronic illness of the lungs. The patient is in remission. Which statement best describes a period of remission in a patient with a chronic illness? A. The symptoms of the illness reappear B. The disease is no longer present C. New symptoms occur at this time. D. Symptoms are not experienced

D. Symptoms are not experienced

Jason just vomited blood but is hesitant to go to the emergency department because he does not have insurance. He tells this to the admitting nurse, who assured him he won't be turned away from medical care. What is this an example of? a. HIPPA b. PSDA c. ADA d. EMTALA

D. The Emergency Medical Treatment and Labor Act

A nurse observes an assistive personnel make a clients bed while the client is out of the room. Which of the following actions by the assistive personnel is appropriate for this task? a. The assistive personnel records the task when it is completed. b. The assistive personnel wears sterile gloves while making the bed. c. The assistive personnel makes a miltered corner with the blanket and spread. d. The assistive personnel reuses the patients blanket and spread.

D. The assistive personnel reuses the patients blanket and spread.

CH. 11: HEALTH and ILLNESS What is the goal of using a patient history assessment tool to gather data about nutrition, exercise, leisure activities, spirituality, and home environment? A. To gather data required by insurers and regulatory agencies B. To assist the physician in developing a medical diagnosis C. To gather data about the causes of the patient's illness D. To increase the patient's awareness of lifestyle choices and his or her role in wellness

D. To increase the patient's awareness of lifestyle choices and his or her role in wellness

CHAPTER 37 and 38: OXYGENATION and PERFUSION Which nursing intervention is used to reduce the risk of clot formation in the legs? A. Limit hydration by limiting oral intake. B. Apply cold compression intermittently while in bed. C. Keep the patient's hips and knees flexed while the patient is in bed. D. Turn the patient frequently or encourage frequent position changes.

D. Turn the patient frequently or encourage frequent position changes.

CHAPTER 30: URINARY ELIMINATION A female patient complains of painful urination and foul-smelling urine. What does the nurse suspect? A. Bowel impaction. B. Urinary retention. C. Urge incontinence. D. Urinary tract infection (UTI).

D. Urinary tract infection (UTI).

CH. 26: TEACHING and LEARNING In the affective domain of learning, the patient exhibits the ability to do which of the following? A. Perform self-catheterization B. Provide info on dialysis C. Return demonstrate BP measurement D. Verbalize feelings about how to manage arthritis pain

D. Verbalize feelings about how to manage arthritis pain

CHAPTER 29: BOWEL ELIMINATION How does an osmotic laxative help relieve constipation? A. pulls water from the intestine to tenderize hard, dry stool B. stimulates the intestines to push out stool C. contains fiber to soak up water for a larger stool D. attracts water to the bowel to soften stool and increase BM frequency

D. attracts water to the bowel to soften stool and increase BM frequency

CHAPTER 29: BOWEL ELIMINATION A patient complains of constipation. What should the nurse encourage the patient to eat? A. applesauce B. bananas C. cheese D. beans

D. beans Beans contain both insoluble and soluble fibers.

CHAPTER 29: BOWEL ELIMINATION A patient is admitted with lower GI tract bleeding. Which characteristic of the stool supports this diagnosis? A. tarry stool B. orange stool C. green mucoid stool D. bright red-tinged stool

D. bright red-tinged stool This is the primary indicator of a lower-GI bleed. The blood doesn't turn black because it's too close to the anus to have been digested.

CHAPTER 31: SENSORY PERCEPTION Areas of blindness due to retinal damage resulting from uncontrolled diabetes is A. hypertensive retinopathy B. diabetic retinal degeneration C. retinal malignancy D. diabetic retinopathy

D. diabetic retinopathy

CHAPTER 29: BOWEL ELIMINATION Which portion of the gastrointestinal (GI) tract are most nutrients are absorbed? A. cecum B. rectum C. stomach D. duodenum

D. duodenum The duodenum is part of the small intestine.

CHAPTER 31: SENSORY PERCEPTION A patient has been on contact isolation for 4 days because of a gastrointestinal infection. Which nursing measures to reduce sensory deprivation would the nurse implement? SELECT ALL THAT APPLY. A. arranging for him to have a roommate B. turning off the lights and closing the room drapes C. arranging for peacefulness and frequent rest periods D. helping him to a chair or bringing flowers into the room E. sitting down, speaking, touching, and listening to his feelings and perceptions

D. helping him to a chair or bringing flowers into the room E. sitting down, speaking, touching, and listening to his feelings and perceptions

CHAPTER 28: NUTRITION An elderly patient is admitted with a diagnosis of osteoporosis and bone scan results that reveal a reduction in bone mass. The nurse encourages the patient to eat foods that are A. high in iron B. low in vitamin E C. low in sodium D. high in calcium

D. high in calcium

CHAPTER 39: FLUIDS and ELECTROLYTES A nurse is assessing a patient's fluid status, noting that the patient has low blood pressure, decreased urinary output, poor skin turgor, and dry skin and mucous membranes. Lab results indicate a urine specific gravity of 1.04 and both BUN and hematocrit are elevated. What might these findings indicate? A. hypervolemia B. hypernatremia C. hyponatremia D. hypovolemia E. hypoglycemia

D. hypovolemia BUN and hematocrit are more concentrated in the blood, so they would be elevated. The urine specific gravity is higher than 1, and normal values are 1.005 to 1.030.

CHAPTER 29: BOWEL ELIMINATION A provider orders a return-flow enema (Harris flush drip) for an adult patient with flatulence. When preparing to administer this enema the nurse compares the steps of a return-flow enema with cleansing enemas. What should the nurse do that is unique to a return-flow enema? A. lubricate the last 2 inches of the rectal tube B. insert the rectal tube about 4 inches into the anus C. raise the solution container about 12 inches above the anus D. lower the solution container after instilling about 150 mL of solution

D. lower the solution container after instilling about 150 mL of solution Lowering the container creates a suction effect, which draws out the gas from the intestines. It is only done with a return-flow enema.

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS The nurse has just admitted a patient with a medical diagnosis of congestive heart failure (CHF). When completing the admission paperwork, the nurse needs to record: A. abbreviations familiar to the nurse. B. an interpretation of patient behavior. C. lengthy entry using lay terminology. D. objective data that are observed.

D. objective data that are observed.

CHAPTER 31: SENSORY PERCEPTION The patient was working in the kitchen and was splashed in the face with a caustic cleaning agent. His eyes were affected and he was brought to the hospital for treatment. After cleansing and evaluation, his eyes were bandaged. When assisting this patient to eat, the nurse should: A. feed the patient the entire meal B. allow the patient to experiment with foods C. encourage the family to feed the patient D. orient that patient to the location of foods on the plate

D. orient that patient to the location of foods on the plate Promote ADL independence whenever possible.

CHAPTER 31: SENSORY PERCEPTION What is a seizure that affects one side of the brain? A. differential seizure B. bilateral seizure C. incomplete seizure D. partial seizure

D. partial seizure

CHAPTER 37 and 38: OXYGENATION and PERFUSION Coarse and grating. Sounds like walking on freshly-fallen snow. Raspy and heard during respiration. A. ronchi B. crackles C. wheezing D. pleural rub

D. pleural rub

CH. 21: PHYSICAL ASSESSMENT An emaciated patient complains of thirst and headache. Upon physical examination, the nurse finds that the skin does not return to normal shape; thus, consistent with: A. pallor B. edema C. erythema D. poor skin turgor

D. poor skin turgor

CHAPTER 31: SENSORY PERCEPTION Photoreceptors and proprioceptors are examples of A. preceptors B. stimulants C. synapses D. receptors E. acceptors

D. receptors Sensory receptors are specialized cells that respond to environmental stimuli such as light, touch, etc.

CHAPTER 29: BOWEL ELIMINATION The nurse is caring for a patient admitted for a severe flare-up of inflammatory bowel disease. The physician has ordered an enema containing betamethasone. The nurse knows that the commonly used type of enema to give medication is which of these? A. carminative enema B. cleansing enema C. return-flow enema D. retention enema

D. retention enema A retention enema is typically the best form of enema to deliver medication directly to the mucosal surface of the bowel. Once given, the solution is retained by the patient for an hour or more.

CHAPTER 30: URINARY ELIMINATION A healthcare provider (HCP) may suspect that a patient is experiencing urinary retention when the person has: A. pain in the suprapubic region. B. large amounts of voided cloudy urine. C. spasms and difficulty during urination. D. small amounts of urine voided 2-3 times per hour.

D. small amounts of urine voided 2-3 times per hour.

What is beneficence?

Doing good or causing good to be done; being kind

Intellectual Perseverance

Don't jump to conclusions or settle for the quick, obvious answer. Important questions are usually complex and are given serious thought.

What is the drug class for metoprolol, what are the therapeutic uses, side effects and contraindications?

Drug class: Beta Blocker (Beta 1) Therapeutic uses: • decreases BP and HR. Side effects: -ED -hypoglycemia (client cannot tell bc HR is decreased from beta 1) • fatigue • weakness • bradycardia • pulmonary edema • HF Contraindications: • bradycardia • uncompensated HF • pulmonary edema • cardiogenic shock • heart block Use cautiously in: -renal/ hepatic impairment -people with asthma -Diabetes (may mask signs of hypoglycemia) *start medication at low dosage

Upon discharge, the nurse realizes that all care plan goals were met. The documentation is updated to reflect this. Which part of the nursing process does this represent? a. Assessment b. Diagnosis c. Planning outcomes d. Planning interventions e. Evaluation f. Implementation

E. Evaluation

Mary is a 17 year old, diagnosed with a brain tumor, who has recently begun chemotherapy. The nurse asked her how being hospitalized is impacting her senior year of high school. What nursing process does this step represent? a. Diagnosis b. Planning outcomes c. Planning interventions d. Implementation e. Evaluation f. Assessment

F. Assessment

Adrian, a nurse, reflects on her client's information, including physical assessment and related family concerns. She considers all information to reach conclusions. Which step of the nursing process does this represent? a. Assessment b. Planning outcomes c. Planning interventions d. Implementation e. Evaluation f. Diagnosis

F. Diagnosis

The nurse, Linda, identifies some concerns about her patient's financial situation and ability to pay the hospital bill. She approaches the healthcare provider to request that a social worker meet with the client prior to discharge. Which step of the nursing process does this represent? a. Assessment b. Diagnosis c. Planning interventions d. Implementation e. Evaluation f. Planning outcomes

F. Planning outcomes

CHAPTER 28: NUTRITION TRUE or FALSE: You should limit all fats and lipids in your diet as they have no beneficial role in the function of the body.

False. Fats and lipids provide protection for internal organs, are used for cell membranes, and are a backup energy source.

CH. 21: PHYSICAL ASSESSMENT What should one observe when auscultating?

Four characteristics of sound: pitch, loudness, quality and duration.

Civil Law

Governs unjust acts against individuals rather than federal or state crimes.

Different unique factors to consider on patients may be:

Individual differences, multiple and varying concerns, clients culture, clients roles, age, personal bias, personality, previous experience with healthcare problems

Stomatitis

Inflammation of the oral mucosa.

Glossitis

Inflammation of the tongue

Theoretical knowledge

Knowing why • consists of info, facts, principles, and evidence-based theories in nursing and related disciplines • to describe patients, understand health status, explain the reasoning, and predict patient responses to treatments

Reasoning

Logical thinking that links thoughts, ideas, and facts together in a meaningful way; used in scientific inquiry and problem-solving

What are tertiary services?

Long term treatment for chronic illness

What is the drug class for furosemide?

Loop diuretic

CH. 36: SKIN INTEGRITY and WOUND HEALING hemorrhage

May occur from a slipped suture, a dislodged clot from stress at the suture line, infection, or the erosion of a blood vessel by a foreign body (such as a drain)

CH. 36: SKIN INTEGRITY and WOUND HEALING epithelialization

Natural act of healing of dermal and epidermal tissue in which a protective membrane forms over a wound

CH. 36: SKIN INTEGRITY and WOUND HEALING eschar

Necrotic tissue; a dry, dark scab or falling away of dead skin, typically caused by a burn.

What is Malpractice?

Negligence committed by people who hold licenses to practice their profession

CH. 36: SKIN INTEGRITY and WOUND HEALING granulation tissue

New tissue, pink-red in color, composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal

Eupnea

Normal respiration with a normal rate and depth for the patient's age

BASIC LAB VALUES: COAGULATION PANEL international normalized ratio [+INR] Normal: 0.8-1.1 Therapeutic [Warfarin]: 2-3 [Critical >5]

Normal: 0.8-1.1 Therapeutic [Warfarin]: 2-3 [Critical >5]

BASIC LAB VALUES: BLOOD GLUCOSE LEVELS A1c or Hgb A1c [Glycosylated hemoglobin]

Normal: 4-5.6% Pre-Diabetes Mellitus: 5.7-6.4% DM: 6.5% or above [Poorly controlled DM: >8%]

The process by which the assessment data are sorted and analyzed so that specific actual and potential health problems are identified.

Nursing diagnosis

Mrs. Waters fell in her room at the care center and fortunately was not injured. Documented in her chart was "no further falls will occur while in the care center". Which part of the nursing process does this represent a. Assessment. diagnosis b. Implementation c. Evaluation d. Planning outcomes e. Planning interventions.

Planning outcomes

What is Standards of Practice?

Provide a guide to the knowledge, skills, and attitudes (KSAs) that nurses must incorporate into their practice to provide safe, quality care.

Evidence-based practice

Research-based method for judging and choosing nursing interventions

What is confidentiality?

Respecting the privacy of both parties and keeping details secret

CHAPTER 25: ADMINISTERING MEDICATIONS Name the 7 rights of medication administration

Right medication Right dosage Right patient Right route Right time Right documentation Right reason

CH. 21: PHYSICAL ASSESSMENT Which organs are in the left upper quadrant?

Stomach Pancreas Adrenal gland Kidney Liver Spleen small intestine transverse colon

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS SOAP note =

Subjective Objective Assessment Plan

What is primary data?

Subjective and objective information obtained directly from the client in what the client says or what you observe

What is orthostatic hypotension?

Sudden drop of 20 mmHg in SBP and or 10 mmHg in diastolic blood pressure (DBP) when the client moves from a lying to sitting to standing position

Fair-mindedness

Try to make impartial judgments; treat all viewpoints fairly, realizing that biases can influence their thinking

Intellectual Empathy

Try to understand feelings and perceptions of others and try to see the situation as the other person sees it

Cheilosis

Ulceration of the lips (reddened fissures at the angles of the mouth).

Critical thinking helps you know...

What is important about the patient's situation, when more info is needed, and when you need help to make the best decision

CH. 36: SKIN INTEGRITY and WOUND HEALING purulent wound drainage

Wound drainage that is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria

CH. 36: SKIN INTEGRITY and WOUND HEALING What are the characteristics of a stage 3 pressure injury?

Wound extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but no muscle, tendon, or bone. (There may be little or no pain due to extensive tissue damage.)

CH. 36: SKIN INTEGRITY and WOUND HEALING red wounds

Wounds in the proliferative stage of healing that are the color of granulation tissue

CH. 36: SKIN INTEGRITY and WOUND HEALING yellow wounds

Wounds that are characterized by oozing from the tissue covering the wound, often accompanied by purulent drainage

CH. 36: SKIN INTEGRITY and WOUND HEALING black wounds

Wounds that are covered with thick eschar, which is usually black but may be brown gray or tan

What is libel?

Written (text) forms of defamation of character. Online counts too.

What is a tort?

Wrongful act committed against another person that does not involve a contract

CHAPTER 25: ADMINISTERING MEDICATIONS The nurse reviews a new order submitted by the provider. Does the order need clarification? Patient: Debbie Lawson DOB: 03/14/1975 MR# 123333 Oxycodone 5 PO PRN

Yes. - units - time (e.g.; PRN every 4 hours) - provider name - reason/indication

CHAPTER 25: ADMINISTERING MEDICATIONS Is an assessment required for medication administration?

Yes. Assess for vitals, history, orientation, pain, etc.

What is fever (pyrexia)?

an increase in normal body temp; when heat loss mechanisms of the body are unable to keep pace with excess heat production.

Primary Intervention

an intervention that occurs before the onset of the disease

CH. 21: PHYSICAL ASSESSMENT What are the four techniques used when performing a physical assessment?

auscultation inspection palpation percussion

CHAPTER 37 and 38: OXYGENATION and PERFUSION How would you characterize wet, slight bubbling, clicking, or rattling sounds in the lungs?

crackles

CH. 36: SKIN INTEGRITY and WOUND HEALING macule

discolored spot, e.g.; a freckle

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS Quality Process Review recognizes that _____________ is the primary source of evidence used to continuously measure performance outcomes against predetermined standards.

documentation

Xerostomia

dry mouth (caused by altered salivation, dehydration, mouth breathing, and/or medications).

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS Charting by ____________ is a shorthand documentation method in which only deviations from well-defined standards of practice are documented in narrative notes

exception

Any portal of _____ can also because a portal of _____.

exit; entry

CHAPTER 29: BOWEL ELIMINATION Carminative enemas help expel __________ from the rectum.

flatus (gas)

CH. 36: SKIN INTEGRITY and WOUND HEALING Which part of the healing process is characterized by lumpy, pink tissue containing new connective tissue and capillaries forming around the edges of a wound?

granulation

CH. 36: SKIN INTEGRITY and WOUND HEALING In _______________, involved blood vessels constrict and blood clotting begins.

hemostasis

CH. 36: SKIN INTEGRITY and WOUND HEALING In the _____________________ phase of wound healing, white blood cells move to the wound.

inflammation

CH. 18 and 45e: DOCUMENTING & REPORTING; INFORMATICS Nursing _________ is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge

informatics

BASIC LAB VALUES: URINALYSIS +ketones (i.e., DKA, fasting, fever, high-PRO diet, impaired protein metabolism, or starvation)

negative

BASIC LAB VALUES: URINALYSIS +nitrite (indicative of nitrogen-forming bacteria)

negative

BASIC LAB VALUES: URINALYSIS leukocyte esterase (a type of enzyme produced by WBCs)

negative

CHAPTER 29: BOWEL ELIMINATION Contractions of the circular and longitudinal muscles of the intestine, known as __________, occur every 3 to 12 minutes, moving waste products along the length of the intestine continuously.

peristalsis

CH. 11: HEALTH and ILLNESS A nurse is immunizing children against measles. This is an example of what level of preventive care?

primary

CH. 36: SKIN INTEGRITY and WOUND HEALING In the _________________ phase, granulation tissue is formed to fill the wound.

proliferation

Clinical reasoning

reflective, concurrent, and creative thinking about patients and patient care

CH. 11: HEALTH and ILLNESS A nurse refers an HIV-positive patient to a local support group. This is an example of what level of preventive care?

tertiary

CHAPTER 25: ADMINISTERING MEDICATIONS What is metabolism?

the sum of all chemical reactions in the body - the chemical reactions based on components of medications as they are metabolized by the body

Full-spectrum nursing is a unique blend of ______ and ______that translates caring into action.

thinking and doing

What are the side effects of metoprolol?

• AV block • Bradycardia • Dizziness • Decreased cardiac output • Bronchospasm

What are the seizure precautions?

• Bed in lowest position • Pillow under head • Oxygen & suction apparatus • Loosen clothing • Client in side-lying position (immediately post-seizure) • Side rails up & padded • Privacy provided as soon as possible

Portal of exit examples

• Blood • Skin • Mucous membranes • Respiratory tract • Genitourinary tract • Gastrointestinal tract

What are the side effects of Furosemide?

• Blood dyscrasias • Dehydration • Hypokalemia (low K+) • Hyponatremia (low Na+) • Ototoxicity (hearing loss) • Hypochloremia

Portal of entry examples

• Break in skin • Mucous membrane • Mouth, nose • Genitourinary tract

What causes hypotension?

• Causes = disruption in cardiovascular dynamics. • Decreased blood volume (hemorrhage). • Decreased cardiac output (heart attack or heart failure). • Decreased peripheral vascular resistance (shock).

What are the therapeutic uses of spironolactone?

• Combined with other diuretics for potassium-sparing effects to treat hypertension and edema • For heart failure • Blocks actions of aldosterone in hyperaldosteronism which causes opposite effect of aldosterone in distal nephrons • Effects can take up to 12-48 hrs

What are the contraindications metoprolol?

• DO NOT use in patients w/ bradycardia, heart block, or shock. • Pregnant or nursing women. • Patients with kidney or liver problems, asthma, diabetes, or hyperthyroidism (overactive thyroid). • Patients with hypotension, uncompensated heart failure, pulmonary edema

What are the expected pharmacological action of metoprolol?

• Decrease HR • Decrease cardiac output • Decreased myocardial contractility (ability of the heart to contract)

What are the uses of metoprolol?

• Decreased BP • Decreased HR • Angina, heart failure, myocardial infarction, tachydysrhythmia • Decreased rate of cardiovascular mortality

Two types of contact for HAIs:

• Direct Contact • Indirect Contact

Roles of the Home Health Nurse

• Direct care provider • Client/family educator • Client advocate • Care coordinator

Vector transmission examples

• Fleas • Ticks • Mosquitoes

What diseases are considered contact?

• Hepatitis A • Antibiotic-resistant bacteria • Scabies • Impetigo • Lice • MDRO (multi-drug resistant organism) • MRSA (methicillin-resistant Staphylococcus aureus) • VRE (vancomycin-resistant enterococcus)

Chain of infection

• Infectious Agent (pathogen) • Reservoir • Portal of Exit • Mode of Transmission • Portal of Entry • Susceptible Host

Five components of caring:

• Knowing • Being with • Doing for • Enabling • Maintaining belief

What diseases are considered droplet?

• Meningitis • Influenza • Mumps • Pertussis • Rubella • Common cold • Measles • Diphtheria • Rubella

Indirect contact examples

• Needles • Utensils • Hospital equipment

Examples of reservoirs

• Patient • Staff member • Animal • Food

What is hypotension?

• Systolic BP of less than 100 mmHg • 20-30 mmHg below the client's normal blood pressure • Diastolic BP of less than 60 mmHg

What diseases are considered airborne?

• TB • Measles • Chickenpox • Herpes zoster (shingles) • Smallpox

CH. 36: SKIN INTEGRITY and WOUND HEALING What are the characteristics of a stage 1 pressure injury?

• The skin may be painful, but it has no breaks or tears. • Skin temperature is often warmer. • Sore can feel either firmer or softer than the area around it. • The skin appears reddened and does not blanch (lose color briefly when you press your finger on it and then remove your finger). NOTE: In a dark-skinned person, the area may appear to be a different color than the surrounding skin, but it may not look red.

Mode of transmission examples

• Touch • Airborne droplets • Medical instruments • Mosquitoes • Vermin

What are the therapeutic uses for furosemide?

• When there needs to be an emergent need for rapid mobilization of fluid. • Pulmonary edema caused by heart failure • Conditions are not responsive to other diuretics • Decreased BP

What are the expected pharmacological action of furosemide?

• Work in the loop of Henle • Block reabsorption of sodium and prevent reabsorption of water • Increases renal excretion of water, sodium, chloride, and magnesium • Causes extensive diuresis even with renal impairment

CHAPTER 29: BOWEL ELIMINATION During the health history, how would a nurse assess a patient's bowel elimination patterns?

• assess mouth and rectum • patient's description of usual stool characteristics • history of surgery or medications • changes in appetite • diet history and description of daily fluid intake • amount of exercise • history of pain or discomfort • mobility

CH. 27: HEALTH PROMOTION Name some health promotion focus and screenings for older adults.

• bone density • shingles and pneumonia vaccines • decline (cognitive, visual, etc.) • blood pressure and cholesterol • fall risk and safety

CH. 27: HEALTH PROMOTION Name some health promotion focus and screenings for middle-aged adults.

• colonoscopy • mammogram • stress management • skin assessments • prostate exam

What are the side effects of spironolactone?

• hyperkalemia (high K+) • irregular menses in women • male impotence

CH. 26: TEACHING and LEARNING Your patient is an adolescent girl recently diagnosed with diabetes mellitus, type 1. You develop a teaching plan for insulin therapy and dietary management. While you are teaching, she is texting and not paying attention. What would happen if she failed to learn to manage her insulin and diet correctly?

• ketoacidosis • weight loss • high blood sugar

CH. 26: TEACHING and LEARNING Your patient is an adolescent girl recently diagnosed with diabetes mellitus, type 1. You develop a teaching plan for insulin therapy and dietary management. While you are teaching, she is texting and not paying attention. What would be another way to teach her if she resists your approach?

• offer links for YouTube videos • refer to peer support groups

CH. 27: HEALTH PROMOTION Name some health promotion focus and screenings for young adults.

• sexual safety • drug and alcohol use • vaccinations • PAP smear • breast exam

Planning: outcomes and interventions

• work with the client to decide goals for client care (wanted outcomes) • develop list of possible interventions based on knowledge and then choose the best choice to achieve the client goal