Nursing Fundamentals Exam 3
graphesthesia
"read" number traced on skin, disability occurs with lesions of the sensory cortex
*Place the steps for an ostomy pouch change in the correct order.* 1. close the end of the pouch 2. measure the soma 3. cut the hole in the wafer 4. press the pouch in place over the stoma 5. Remove the old pouch 6. trace the correct measurement onto the back of the wafer 7. assess the stoma and the skin around it 8. cleanse and dry the peristomal skin
*Answer: 5, 8, 7, 2, 6, 3, 4, 1*
*Place the steps to administering a prepackaged enema the correct order.* 1. insert enema tip gently in the rectum 2. help pt to bathroom when he or she feels urge to defecate 3. position patient on side 4. perform hand hygiene and apply clean gloves 5. squeeze contents of container into rectum 6. explain procedure to the pt
*Answer: 6, 4, 3, 1, 5, 2 *
*A pt has not had a bowel movement for 4 days. Now she has nausea and severe cramping throughout her abdomen. On the basis of these findings, what do you suspect is wrong with the pt?* A. An intestinal obstruction B. Irritation of the intestinal mucosa C. Gastroenteritis D. A fecal impaction
*Answer: A* Rationale: Absence of bowel movement, nausea, cramping, and possibly vomiting are characteristic of an intestinal obstruction.
*During the administration of a warm tap-water enema, a pt complains of cramping abd pain that he rates 6 out of 10. What is your priority nursing intervention?* A. Stop the instillation B. Ask the pt to take deep breaths to decrease the pain C. Add soapsuds to the enema D. Tell the pt to bear down as he would when having a bowel movement
*Answer: A* Rationale: When a patient complains of pain during an enema, you need to stop the instillation and conduct an assessment before discontinuing or resuming the procedure.
*Which skills do you teach a pt with a new colostomy before discharge form the hospital? (Select all that apply)* A. How to change the pouch B. How to empty the pouch C. How to open and close the pouch D. How to irrigate the colostomy E. How to determine if the ostomy is healing appropriately
*Answer: A, B, C, E* Rationale: The patient must be able to do these tasks to successfully manage his or her colostomy when going home.
*Which of the following symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (select all that apply)* A. Change in bowel habits B. Blood in the stool C. A larger-than-normal bowel movement D. Fecal impaction E. Muscle aches F. Incomplete emptying of the colon G. Food particles in the stool H. Unexplained abd or back pain
*Answer: A, B, F, H* Rationale: According to the American Cancer Society current guidelines, anyone with these symptoms should seek medical evaluation because they may have colon cancer. Other conditions may also cause these symptoms; but, if colon cancer is present, early diagnosis is important.
*Which instructions do you include when educating a person with chronic constipation? (Select all that apply)* A. Increase fiber and fluids in the diet B. Use a low-volume enema daily C. Avoid gluten in the diet D. Take laxatives twice a day E. Exercise for 30 minutes every day F. Schedule time to use the toilet at the same time every day G. Take probiotics 5x a week
*Answer: A, E, F* Rationale: These are steps a patient needs to take to resolve chronic problems with constipation before considering regular laxative or enema use.
*Which of the following cause C. difficile infection? (Select all that apply)* A. Chronic laxative use B. Contact with C. difficile bacteria C. Overuse of antibiotics D. Frequent episodes of diarrhea caused by food intolerance E. Inflammation of the bowel
*Answer: B & C* Rationale: These are the two main causes of C. difficile infection.
*An elderly patient comes to the hospital with a complaint of severe weakness and diarrhea for several days. Of the following problems, which is the most important to assess initially?* A. malnutrition B. dehydration C. skin breakdown D. incontinence
*Answer: B* Rationale: Dehydration caused by fluid loss from the intestinal tract is an immediate and possibly dangerous consequence of diarrhea.
*Which of the following nursing actions do you take after placing a bedpan under an immobilized pt?* A. Lift the pt's hips off the bed and slide the bedpan under the pt B. After positioning the pt on the bedpan, elevate the head of the bed to a 45-defree angle C. Adjust the head of the bed so it is lower than the feet and use gently but firm pressure to push the bedpan under the pt D. Have the pt stand beside the bed and then have him or her sit on the bedpan on the edge of the bed
*Answer: B* Rationale: Elevating the head of the bed allows the patient the most normal and comfortable position for defecation on a bedpan.
*Which nursing intervention is most important when caring for a patient with an ileostomy?* A. cleansing the stoma with hot water B. inserting a deodorant tablet in the stoma bag C. selecting or cutting a pouch with an appropriate-size stoma opening D. wearing sterile gloves while caring for the stoma
*Answer: C* Rationale: A properly fitting pouch that does not leave skin exposed prevents peristomal skin breakdown.
*A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which of the following is the priority question to ask the patient or caregiver?* A. have you eaten more high-fiber foods lately? B. are your bowel movements soft and formed? C. have you experienced frequent, small liquid stools recently? D. have you taken antibiotics recently?
*Answer: C* Rationale: Frequent or continuous oozing of liquid stools occurs when liquid fecal matter above the impacted stool seeps around the fecal impaction.
*What do you need to teach family caregivers when a patient has fecal incontinence as a result of cognitive impairment?* A. cleanse the skin with antibacterial soap and apply talcum powder to the buttocks B. use diapers and heave padding on the bed C. initiate bowel or habit training program to promote continence D. help the pt to toilet once every hour
*Answer: C* Rationale: Patients who are cognitively impaired often forget how to respond to the urge to defecate and benefit from a structured program of bowel retraining.
*A nurse is teaching a pt to obtain a specimen for fecal occult blood testing using fecal immunochemical (FIT) testing at home. How does the nurse instruct the pt to collect the specimen?* A. get three fecal smears from an early-morning bowel movement B. obtain one fecal smear from an early-morning bowel movement C. collect one fecal smear from 3 separate bowel movements D. get three fecal smears when you see blood in your bowel movement
*Answer: C* Rationale: Samples from three separate bowel movements decrease the risk of a false-negative or a false-positive result.
*Your pt states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem do you suspect the pt has?* A. a food allergy B. irritable bowel syndrome C. increased peristalsis D. lactose intolerance
*Answer: D* Rationale: These symptoms are consistent with lactose intolerance, and they occur with ingestion of dairy products.
Which of the following nursing actions do you take after placing a bedpan under an immobilized patient?
- After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle.
A patient has no had a bowel movement in 4 days. Now she has nausea and severe cramping throughout her abdomen. On the basis of these findings, what do you suspect is wrong with the patient?
- An intestinal obstruction
Which of the following symptoms are warning signs of possible colorectal cancer according to American Cancer Society guidelines? (Select all that apply.)
- Change is bowel habits - Blood in the stool - Incomplete emptying of the colon - Unexplained abdominal or back pain
Which of the following cause Clostridium difficile infection? (Select all that apply)
- Contact with C. difficile bacteria - Overuse of antibiotics
An elderly patient comes to the hospital with a complaint of severe weakness and diarrhea for several days. Of the following problems, which is the most important to assess initially?
- Dehydration
A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which of the following is the priority question to ask the patient or caregiver?
- Have you experienced frequent, small liquid stools recently?
Which skills do you teach a patient with a new colostomy before discharge from the hospital? (Select all that apply)
- How to change the pouch - How to empty the pouch - How to open and close the pouch - How to determine if the stony is healing appropriately
What do you need to teach family caregivers when a patient has fecal incontinence as a result of cognitive impairment?
- Initiate bowel or habit training program to promote continence
Your patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem do you suspect the patient has?
- Lactose intolerance
Which nursing intervention is most important when caring for a patient with an ileostomy?
- Selecting or cutting a pouch with an appropriate-size stoma opening.
Base Excess
-2 to +2 mm Eq/L
Examples of evaluation
-Physician orders a follow-up CXR for eval pneumonia. -Inspection of wound to see if it has healed.
Examples of Independent nursing interventions
-eval edematous extremity, -offering counseling on coping -instruction on medication side effects
During INITIAL interview, you
-introduce yourself, explain your role -establish a therapeutic relationship -explain how you conduct interview -gain insight to pt's concerns -determine pt goals and expectations -obtain cues about what requires in-depth investigation
Sources of Data
-patient -family & significant others -Health Care Team -Medical Records -Other Records/Literature (Be aware of HIPAA)
Examples of Nursing-Sensitive Outcomes
-reduction in pain severity -incidence of pressure ulcers -incidence of falls
How many nurses would be required to place a patient in the semi-prone position?
1
The registered nurse is instructing a nursing student about the interventions that must be performed when there is any evidence of complication due to infusion therapy. Which instruction would the nurse follow for a patient with circulatory overload? 1 "Reduce the intravenous (IV) flow." 2 "Elevate the extremity." 3 "Disconnect the IV tubing." 4 "Discontinue the IV infusion."
1 "Reduce the intravenous (IV) flow."
Which saline solution draws water from cells into the extracellular fluid (ECF) by osmosis? 1 5% sodium chloride 2 0.9% sodium chloride 3 0.45% sodium chloride 4 0.225% sodium chloride
1 5% sodium chloride
Which complication of intravenous (IV) therapy indicates the need for pressure at the site? 1 Bleeding 2 Phlebitis 3 Infection 4 Fluid overload
1 Bleeding
Which type of dextrose solution is considered isotonic? 1 Dextrose 5% in water 2 Dextrose 10% in water 3 Dextrose 5% in 0.9% sodium chloride 4 Dextrose 5% in 0.45% sodium chloride
1 Dextrose 5% in water
Which clinical criteria of phlebitis should receive a grade of 3? 1 Formation of streak 2 Pain at access site with only erythema 3 Palpable venous cord greater than 2.54 cm 4 Erythema at access site with or without pain
1 Formation of streak
Which immediate intervention would be beneficial in a patient who developed redness and pain at the infusion site? 1 Stopping the infusion 2 Elevating the extremity 3 Applying warmth to the site 4 Notifying the health care provider
1 Stopping the infusion
A patient asks a nurse about therapeutic touch (TT). Which of the following does the nurse include when providing patient education about TT? Therapeutic touch: 1 Intentionally mobilizes energy to balance, harmonize, and repattern the recipient's biofield 2 Intentionally heals specific diseases or corrects certain symptoms 3 Is overwhelmingly effective in many conditions 4 Is completely safe and does not warrant any special precautions
1 Intentionally mobilizes energy to balance, harmonize, and repattern the recipient's biofield
The nurse manager of a community clinic arranges for staff in-services about various complementary therapies available in the community. What is the purpose of this training? (Select all that apply.) 1 Nurses have a long history of providing some of these therapies and need to be knowledgeable about their positive outcomes. 2 Nurses are often asked for recommendations and strategies that promote well-being and quality of life. 3 Nurses play an essential role in patient education to provide information about the safe use of these healing strategies. 4 Nurses appreciate the cultural aspects of care and recognize that many of these complementary strategies are part of a patient's life. 5 Nurses play an essential role in the safe use of complementary therapies. 6 Nurses learn how to provide all of the complementary modalities during their basic education.
1 Nurses have a long history of providing some of these therapies and need to be knowledgeable about their positive outcomes. 2 Nurses are often asked for recommendations and strategies that promote well-being and quality of life. 3 Nurses play an essential role in patient education to provide information about the safe use of these healing strategies. 4 Nurses appreciate the cultural aspects of care and recognize that many of these complementary strategies are part of a patient's life. 5 Nurses play an essential role in the safe use of complementary therapies.
NANDA-I identifies 3 TYPES of diagnoses:
1. Actual Diagnoses 2. Risk Diagnoses 3. Health Promotion Diagnoses
The two steps of assessment
1. Collection and verification of data from a primary source (the patient) and secondary sources (e.g., family, friends, health professionals, medical record) 2. Analysis of all data as a basis for the second step of the nursing process, developing nursing diagnoses and identifying collaborative problems (Potter 120)
Place the steps to administering a prepackaged enema the correct order.
1. Explain procedure to the patient. 2. Perform hand hygiene and apply clean gloves. 3. Position patient on side. 4. Insert enema tip gently in the rectum. 5. Squeeze contents of container into rectum. 6. Help patient to bathroom when he or she feels urge to defecate.
Implementation Process
1. Reassess the patient 2. Review and revise Care Plan 3.Organize Resources and Delivering Care (equipment, personnel, environment) 4. Anticipating & Preventing Complications 5 Implementation Skills
Place the steps for an stony pouch changes in the correct order.
1. Remove the old pouch. 2. Cleanse and dry the peristomal skin. 3. Assess the stoma and the skin around it. 4. Measure the stoma. 5. Trace the correct measurement onto the back of the wafer. 6. Cut the hole in the wafer. 7. Press the pouch in place over the stoma. 8. Close the end of the pouch.
Which nursing intervention would increase the risk for joint dislocation in a patient with hemiplegia who is immobile for an extended period? 1. Supporting the patient by holding the arm 2. Supporting the patient with assistive devices 3. Lowering the patient to the floor if he or she faints 4. Instructing the patient to use a cane while walking
1. Supporting the patient by holding the arm Supporting the patient by holding the arm may increase the risk of joint dislocation if the patient falls. Assistive devices, such as gait belts, reduce the risk of falling by maintaining the center of gravity in the midline. Lowering the patient to the floor if he or she faints helps reduce the risk for falls. Instructing the patient to use a cane while walking also helps reduce the risk of falls, but it would not be beneficial for patients with hemiplegia.
4. Which nursing action helps prevent trauma in a male patient with an indwelling urinary catheter? 1. applying a catheter securement device 2. washing the catheter with soap and water 3. keeping the foreskin retracted while the catheter is in 4. securing the drainage bag to patients walker
1. applying a catheter securement device
6 factors in choosing an Intervention
1. characteristics of the nursing dx 2 expected outcome and goals 3 evidence-based research 4 feasibility of the intervention 5 acceptability to the pt 6 your own competency
8. The urine flow has stopped in a patient;s indwelling urinary catheter, and the nurse assesses tenderness and distention over the lower abdomen. What is your initial nursing action? 1. check the drainage tubing for kinks 2. encourage patient to drink fluids 3. remove the catheter 4. notify the health care provider
1. check the drainage tubing for kinks
2. A patients health care provider orders a postpaid residual urine volume by either bladder scan or straight catheterization. The patient states an inability to void. What is your initial nursing intervention? 1. implement measures to stimulate voiding 2. catheterize the patient and record the amount of urine obtained 3. measure bladder volume with the bladder scan and record the volume 4. notify the health care provider that the patient cannot void
1. implement measures to stimulate voiding
9. What does a nurse teach a female patient recovering from a urinary tract infection about prevention? (Select all that apply) 1. keep the bowels regular 2. limit water intake to 1 - 2 glasses a day 3. wear cotton underwear 4. cleanse the perineum from front to back
1. keep the bowels regular 3. wear cotton underwear 4. cleanse the perineum from front to back
Purpose of goal setting
1. provide a clar direction for the selection and use of nursing interventions 2. Provide focus for evaluating the effectiveness of the interventions
Magnesium (Mg2+)
1.5-2.5 mEq/L
Sodium (Na+)
136-145 mEq/L
The health care provider's order is 1000 mL 0.9% NaCl IV over 6 hours. Which rate should the nurse program into the infusion pump? 1 125 mL/hr 2 167 mL/hr 3 200 mL/hr 4 1000 mL/h
2 167 mL/hr
A nurse is assessing the clinical markers of vascular volume. Which patient may require intravenous (IV) therapy due to extracellular fluid volume deficit? 1 A patient with a full pulse rate 2 A patient with dark yellow urine 3 A patient with increased blood pressure 4 A patient with crackles in the lobe of the lung
2 A patient with dark yellow urine
Which statement is true regarding vascular access devices (VADs)? 1 The word "central" applies to the insertion site. 2 Central catheters are used for fluid restoration. 3 Peripheral catheters are used for long-term antibiotic administration. 4 Peripheral catheters are more effective for administration of large volumes of fluids.
2 Central catheters are used for fluid restoration.
Which action can be performed to prevent the risk of dislodging the catheter during intravenous (IV) therapy? 1 Inserting a volume-control device into the IV container 2 Curling the loop of short or long IV tubing alongside the arm 3 Instructing the patient to avoid raising the arm with the catheter 4 Attaching the distal end of the IV tubing to a needleless connector
2 Curling the loop of short or long IV tubing alongside the arm
Which grade on the phlebitis scale is given to a patient with pain at the infusion site and erythema? 1 Grade 1 2 Grade 2 3 Grade 3 4 Grade 4
2 Grade 2
Which role do patients have in complementary and alternative medicine therapy? 1 Submissive to the practitioner 2 Actively involved in the treatment 3 An educator for other health care professionals 4 A total believer in what is being taught
2 Actively involved in the treatment
A patient is being transferred from bed to stretcher. Which precautions should the nurse take to ensure patient safety during transfer? Select all that apply. 1 Release the brakes of the bed to allow movement. 2 Raise the bed to the level of the stretcher. 3 Cross the patient's arms on chest while transferring. 4 Involve multiple caregivers for safe transfer. 5 Unlock the stretcher's wheels once it is in place alongside the bed.
2 Raise the bed to the level of the stretcher. 3 Cross the patient's arms on chest while transferring. 4 Involve multiple caregivers for safe transfer. The bed should be raised to the level of the stretcher to allow the patient to slide from the bed to the stretcher. Keep the patient's arms crossed when transferring to prevent any injury to the arm. Three caregivers are needed to transfer a patient safely and are positioned specifically to minimize caregivers stretching. The bed brakes should be locked to prevent it from moving. Once the stretcher is placed alongside the bed, the wheels should be locked to prevent further movement.
In addition to an adequate patient assessment, when the nurse uses one of the nursing-accessible complementary therapies, he or she must ensure that which of the following has occurred? 1 The family has provided permission. 2 The patient has provided permission and consent. 3 The health care provider has given approval or provided orders for the therapy. 4 He or she has documented that the patient has a complete understanding of complementary and alternative medicine.
2 The patient has provided permission and consent.
A nurse provides care for a diverse group of patients, including many immigrants. To better understand various types of health care, the nurse learns the traditional Chinese medicine system: 1 Uses acupuncture as its primary intervention modality 2 Uses many modalities that are based on the individual and include herbal therapies, moxibustion, and acupuncture 3 Uses primarily herbal remedies (that are known to have high levels of lead products) and exercise 4 Is the equivalent of medical acupuncture
2 Uses many modalities that are based on the individual and include herbal therapies, moxibustion, and acupuncture
List the correct order in which to apply an ostomy pouch: 1. Remove the used pouch and skin barrier 2. Perform hand hygiene, and apply clean gloves. 3. Asses the stoma for color, swelling, and healing. 4. Gently cleanse the preistomal skin with warm tap water. 5. Apply nonallergenic tape around the pectin skin barrier. 6. Cut an opening on the pouch 1/16 inch larger than the stoma. 7. Press the adhesive bakcing of the pouch smoothly against the skin.
2, 1, 3, 4, 6, 5, 7 Perform hand hygiene, and apply clean gloves. Remove the used pouch and skin barrier. Asses the stoma for color, swelling, and healing. Gently cleanse the preistomal skin with warm tap water. Cut an opening on the pouch 1/16 inch larger than the stoma. Apply nonallergenic tape around the pectin skin barrier. Press the adhesive bakcing of the pouch smoothly against the skin.
3. Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? 1. daily cleansing the urinary meatus with antiseptic solution 2. hanging the urinary drainage bag below the level with the bladder 3. changing the urinary drainage bag daily 4. irrigating the urinary catheter with sterile water
2. hanging the urinary drainage bag below the level with the bladder
6. An elderly woman with dementia is incontinent of urine. She ambulates with a cane, has poor short-term memory, and never alerts staff that she has an urge to void. The staff do not usually see her using the toilet. What is the best nursing intervention for this patient? 1. offer her a bedpan every 2 hours 2. start a scheduled toileting program 3. recommend an indwelling catheter 4. start a bladder-retraining program
2. start a scheduled toileting program
Phosphate
2.7-4.5 mg/dL
Total CO2 (CO2 total content)
22-30 mEq/L
Osmolality
280-300 mOsm/kgH20
Which location selected for venipuncture would increase the risk of lymphedema? 1 A fragile dorsal vein in an older patient 2 A site distal to a previous venipuncture site 3 An extremity affected previously by paralysis 4 An area with a tender, infected wound
3 An extremity affected previously by paralysis
While caring for a patient who is on intravenous (IV) therapy, the nurse finds that the skin around the catheter site is taut, blanched, cool to the touch, and edematous. Which complication is evident? 1 Phlebitis 2 Bleeding 3 Infiltration 4 Local infection
3 Infiltration
Several nurses on a busy unit are using relaxation strategies while at work. What is the desired workplace outcome from this intervention? (Select all that apply.) 1 Improved health among the staff 2 Increased patient safety 3 Improved staff satisfaction 4 Increased staff retention 5 Fewer overtime assignments
3 Improved staff satisfaction 4 Increased staff retention
The nurse understands that providing holistic care includes treating which of the following? 1 Disease, spirit, and family interactions 2 Desires and emotions of the patient 3 Mind-body-spirit of the patient and their families 4 Muscles, nerves, and spine disorders
3 Mind-body-spirit of the patient and their families
The nurse is planning care for a group of patients who have requested the use of complementary health modalities. Which patient is not a good candidate for imagery? 1 Pregnant patient 2 Hypertensive patient 3 Patient with posttraumatic stress disorder (PTSD) 4 A pediatric patient
3 Patient with posttraumatic stress disorder (PTSD)
Which complementary therapies are most easily learned and applied by the nurse? (Select all that apply.) 1 Massage therapy 2 Traditional Chinese medicine 3 Progressive relaxation 4 Breathwork and imagery 5 Therapeutic touch
3 Progressive relaxation 4 Breathwork and imagery
Which statement best describes the evidence associated with complementary therapies as a whole? 1 Many clinical trials in complementary therapies support their effectiveness in a wide range of clinical problems. 2 It is difficult to find funding for studies about complementary therapies. Therefore we should not expect to find evidence supporting its use. 3 The science supporting the effectiveness of complementary therapies is early in its development. Systematic reviews of the evidence often indicate beginning support for therapies, but there is a lack of strong evidence supporting their widespread use. 4 Most of the research examining complementary and alternative therapies has found little evidence, suggesting that although people like them, they are not effective.
3 The science supporting the effectiveness of complementary therapies is early in its development. Systematic reviews of the evidence often indicate beginning support for therapies, but there is a lack of strong evidence supporting their widespread use.
5. What is the recommended catheter and balloon size for an indwelling catheter for an adult patient with urinary retention? 1. 10 Fr, 3 mL 2. 14 Fr, 20 mL 3. 16 Fr, 10 mL 4. 20 Fr, 10 mL
3. 16 Fr, 10 mL
10. A healthy 50-year-old male has a history of prostate disease. Which nursing assessment question best indicates that he is no emptying his bladder completely and has overflow incontinence 1. do you leak urine when you cough or sneeze? 2. do you need help getting to the toilet? 3. do you dribble urine constantly? 4. does it burn when you pass your urine?
3. do you dribble urine constantly?
Potassium (K+)
3.5-5.0 mEq/L
PaCO2
35-45 mm Hg
When meditation therapy is used, nurses need to monitor patients' medications carefully because meditation may augment the effects of certain drugs such as: 1 Prednisone and antibiotics. 2 Insulin and vitamins. 3 Cough syrups and aspirin. 4 Antihypertensive and thyroid-regulating medications.
4 Antihypertensive and thyroid-regulating medications.
When planning patient education, it is important to remember that patients with which of the following often find relief in complementary therapies? 1 Lupus and diabetes 2 Ulcers and hepatitis 3 Heart disease and pancreatitis 4 Chronic back pain and arthritis
4 Chronic back pain and arthritis
The nurse is caring for a patient experiencing a stress response. The nurse plans care with the knowledge that systems respond to stress in what manner? 1 Always fail and cause illness and disease 2 Cause structural damage to the body 3 React the same way for all individuals 4 Protect an individual from harm in the short term but cause negative responses over time
4 Protect an individual from harm in the short term but cause negative responses over time
The nurse is caring for a patient who uses several herbal preparations in addition to prescribed medications. What does the nurse need to understand about herbal preparations? 1 They are regulated by the Food and Drug Administration (FDA); therefore patients and providers should feel confident that they are completely safe. 2 They are natural products and therefore are safe as long as you use them cautiously and prudently for the conditions that are indicated. 3 They are covered by insurance, including Medicare, Medicaid, and private payers. 4 They should be treated as though they were "drugs" of sorts because many have active ingredients that can interact with other medications and change physiological responses.
4 They should be treated as though they were "drugs" of sorts because many have active ingredients that can interact with other medications and change physiological responses.
A patient who has been using relaxation wants a better response. The nurse recommends the addition of biofeedback. What is the expected outcome related to using this additional modality? 1 To eat less food 2 To control diabetes 3 To live longer with acquired immunodeficiency syndrome (AIDS) 4 To learn how to control some autonomic nervous system responses
4 To learn how to control some autonomic nervous system responses
Number the steps to irrigating a nasogastric tube in correct order: 1. Slowly aspirate the syringe. 2. Reconnect the NG tube to suction. 3. Clamp and disconnect the NG tube 4. Perform hand hygiene, and apply clean gloves. 5. Insert tip of syringe into NG tube, and slowly inject 30 mL saline.
4, 5, 2, 1, 3 Perform hand hygiene, and apply clean gloves. Insert tip of syringe into NG tube, and slowly inject 30 mL saline Reconnect the NG tube to suction. Slowly aspirate the syringe. Clamp and disconnect the NG tube
Ionized Calcium (Ca2+)
4.5-5.3 mg/dL
What is the correct order for changing an ostomy pouch? 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer. 4. Press the pouch into place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.
5, 8, 7, 2, 6, 3, 4, 1 5. Remove the old pouch. 8. Cleanse and dry the peristomal skin. 7. Assess the stoma and the skin around it. 2. Measure the stoma. 6. Trace the correct measurement onto the back of the wafer. 3. Cut the hole in the wafer. 4. Press the pouch into place over the stoma. 1. Close the end of the pouch.
Anion Gap
5-11 mEq/L
1. Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. insert and advance catheter 2. lubricate catheter 3. inflate catheter balloon 4. cleanse urethral meatus 5. drape patient with the sterile square and fenestrated drapes. 6. when urine appears advance another 2.5-5cm 7. prepare sterile field and supplies 8. gently pull catheter until resistance is felt 9. attach drainage tubing
5. drape patient with the sterile square and fenestrated drapes. 7. prepare sterile field and supplies 2. lubricate catheter 4. cleanse urethral meatus 1. insert and advance catheter 6. when urine appears advance another 2.5-5cm 3. inflate catheter balloon 8. gently pull catheter until resistance is felt 9. attach drainage tubing
pH (blood)
7.35-7.45
A cleansing enema is ordered for a 55 year-old client before intestinal surgery. The maximum amount of fluid used is: A. 150 to 200 mL B. 200 to 400 mL C. 400 to 750 mL D. 750 to 1000 mL
750 to 1000 mL
Total Calcium (Ca2+)
8.4-10.5 mg/dL
Pa02
80-100 mm Hg
O2 saturation
95%-100%
Chloride (Cl-)
98-106 mEq/L
14. A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing: a. Claudication. b. Sore muscles. c. Muscle cramps. d. Venous insufficiency.
A
26. A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that: a. Nonpitting, hard edema occurs with lymphatic obstruction. b. Alterations in arterial function will cause edema. c. Phlebitis of a superficial vein will cause bilateral edema. d. Long-standing arterial obstruction will cause pitting edema.
A
5. The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? a. Intraluminal valves ensure unidirectional flow toward the heart. b. Contracting skeletal muscles milk blood distally toward the veins. c. High-pressure system of the heart helps facilitate venous return. d. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.
A
A 45-year-old patient has breast cancer that has spread to the liver and spine. The patient has been taking oxycodone (OxyContin) and amitriptyline (Elavil) for pain control at home but now has constant severe pain and is hospitalized for pain control and development of a pain-management program. When doing the initial assessment, which question will be most appropriate to ask first? a. How would you describe your pain? b. How much medication do you take for the pain? c. How long have you had this pain? d. How many times a day do you medicate for pain?
A
A 7-year old pediatric patient tells you that he is in pain. The patient rates the pain as 4 on the Faces Pain Scale of 0-10. His mother, who is in the room, states that her son is having pain at a level of 8 on the 0-10 scale. Which is the most accurate assessment of the patient's pain? a. The patient is the best resource for assessing the pain and should receive the appropriate pain medication b. The patient is the best resource for assessing the pain, but should not receive any pain medication because his level is only 4 out of 10. c. The nurse is the best resource for assessing the pediatric patient's pain level and gives the dose of pain medication that matches the nurses' judgment. d. The mother is the best resource for assessing the pain in this case, and the patient should receive the maximum dose of pain medication ordered.
A
A bruit occurs with turbulent blood flow and indicates partial occlusion of the artery. The other responses are not correct. DIF: Cognitive Level: Understanding (Comprehension) REF: p. 521 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 25. How should the nurse document mild, slight pitting edema the ankles of a pregnant patient? a. 1+/0-4+ b. 3+/0-4+ c. 4+/0-4+ d. Brawny edema
A
A home health patient has a prescription for pentazocine (Talwin,) a mixed opioid agonist-antagonist. When teaching the patient and family about adverse effects, the nurse will plan to focus on how to monitor for a. agitation. b. respiratory depression. c. hypotension. d. physical dependence.
A
A hospice patient is in continuous pain, and the health care provider has left orders to administer morphine at a rate that controls the pain. When the nurse visits the patient, the patient is awake but moaning with severe pain and asks for an increase in the morphine dosage. The respiratory rate is 10 breaths per minute. The most appropriate action by the nurse is to a. titrate the morphine dose upward until the patient states there is adequate pain relief. b. administer a nonopioid analgesic, such as ibuprofen, to improve patient pain control. c. tell the patient that additional morphine can be administered when the respirations are 12. d. inform the patient that increasing the morphine will cause the respiratory drive to fail
A
A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions? a. Fluid volume overload b. Hemolytic reaction c. Anaphylactic shock d. Septicemia
A
A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output. The patient has voided 400 mL of urine. After reporting these values to the health care provider, which order does the nurse anticipate? a. Add a potassium supplement to replace loss from output. b. Decrease the rate of intravenous fluids to 100 mL/hr. c. Administer a diuretic to prevent fluid volume excess. d. Discontinue the nasogastric suctioning.
A
A nurse is caring for a patient with peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel? a. Recording intake and output b. Regulating intravenous flow rate c. Starting peripheral intravenous therapy d. Changing a peripheral intravenous dressing
A
A patient has dehydration. While planning care, the nurse considers that the majority of the patient's total water volume exists in with compartment? a. Intracellular b. Extracellular c. Intravascular d. Transcellular
A
A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient? a. Renal b. Endocrine c. Respiratory d. Gastrointestinal
A
A patient is receiving morphine sulfate intravenously (IV) for right flank pain associated with a kidney stone in the right ureter. The patient also complains of right inner thigh pain and asks the nurse whether something is wrong with the right leg. In responding to the question, the nurse understands that the patient a. is experiencing referred pain from the kidney stone. b. has neuropathic pain from nerve damage caused by inflammation. c. has acute pain that may be progressing into chronic pain. d. is experiencing pain perception that has been affected by the morphine received earlier.
A
A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (of a 0-10 scale) and requests "something for pain that will work quickly." The best way for the nurse to document this information is as a. breakthrough pain. b. neuropathic pain. c. somatic pain. d. referred pain
A
A patient with chronic abdominal pain has learned to control the pain with the use of imagery and hypnosis. A family member asks the nurse how these techniques work. The nurse's reply will be based on the information that these strategies. a. impact the cognitive and affective components of pain. b. prevent transmission of nociceptive stimuli to the cortex. c. increase the modulating effect of the efferent pathways. d. slow the release of transmitter chemicals in the dorsal horn.
A
Four patients arrive at the emergency department at the same time. Which patient will the nurse see first? a. An infant with temperature of 102.2° F and diarrhea for 3 days b. A teenager with a sprained ankle and excessive edema c. A middle-aged adult with abdominal pain who is moaning and holding her stomach d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60
A
One hour after administering the first dose of an intravenous opioid to your postoperative patient, about which of the following assessments should you be most concerned? a. Respiratory rate of 6 breaths per minute b. Oxygen saturation of 95% on room air c. Heart rate of 70 regular d. Blood pressure of 140/72
A
Severe cancer pain is most effectively treated with analgesics given: a. Around the clock, with extra doses available as needed b. Around the clock, in titrated doses c. As needed by the client d. Sparingly, to avoid side effects
A
The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare? a. 0.45% sodium chloride (1/2 NS) b. 0.9% sodium chloride (NS) c. Lactated Ringer's (LR) d. Dextrose 5% in Lactated Ringer's (D5LR)
A
The health care provider tells a patient to use ibuprofen (Motrin, Advil) to relieve pain after treating a laceration on the patient's forearm from a dog bite. The patient asks the nurse how ibuprofen will control the pain. The nurse will teach the patient that ibuprofen interferes with the pain process by decreasing the a. production of pain-sensitizing chemicals. b. spinal cord transmission of pain impulses. c. sensitivity of the brain to painful stimuli. d. modulating effect of descending nerves.
A
The hospice RN obtains the following information about a 72-year-old terminally ill patient with cancer of the colon. The patient takes oxycodone (OxyContin) 100 mg twice daily for level 6 abdomen pain on a 10-point scale. The pain has made it difficult to continue with favorite activities such as playing cards with friends twice a week. The patient's children are supportive of the patient's wish to stop chemotherapy but express sadness that the patient does not have long to live. Based on this information, which nursing diagnosis has priority in planning the patient's care? a. Impaired social interaction related to disabling pain b. Anxiety related to poor patient coping skills c. Disabled family coping related to patient-family conflict d. Risk for aspiration related to opioid use
A
The nurse administers an intravenous (IV) hypertonic solution to a patient. In which direction will the fluid shift? a. From intracellular to extracellular b. From extracellular to intracellular c. From intravascular to intracellular d. From intravascular to interstitial
A
The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient's medical record? a. Intake 255; output 375 b. Intake 285; output 375 c. Intake 505; output 125 d. Intake 535; output 125
A
The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis? a. pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L b. pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L c. pH 7.32, PaCO2 47 mm Hg, HCO3- 23 mEq/L d. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L
A
The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with D5W hanging with the blood b. A patient with type A blood receiving type O blood c. A patient with intravenous potassium chloride that is diluted d. A patient with a right mastectomy and an intravenous site in the left arm
A
The nurse is reviewing laboratory results. Which cation will the nurse observe is the most abundant in the blood? a. Sodium b. Chloride c. Potassium d. Magnesium
A
The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing? a. Osmosis b. Filtration c. Diffusion d. Active transport
A
The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order will the nurse perform the steps, starting with the first one? 1. Remove the sleeve of the gown from the arm without the IV. 2. Remove the sleeve of the gown from the arm with the IV. 3. Remove the IV solution container from its stand. 4. Pass the IV bag and tubing through the sleeve. a. 1, 2, 3, 4 b. 2, 3, 4, 1 c. 3, 4, 1, 2 d. 4, 1, 2, 3
A
our patient is being discharged home on an around-the-clock opioid for chronic rheumatoid arthritis pain. You would expect an order for which of the following classes of medications to accompany this order? a. Laxative b. Antibiotic c. Stool softener d. Proton pump inhibitor
A
2. A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? Select all that apply. a. Patient has a history of diabetes and cigarette smoking. b. Skin of the patient is pale and cool. c. His ankles have two small, weeping ulcers. d. Patient works long hours sitting at a computer desk. e. He states that the pain gets worse when walking. f. Patient states that the pain is worse at the end of the day.
A B E
1. A patient is recovering from several hours of orthopedic surgery. During an assessment of the patients lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply. a. Intense, sharp pain, with the deep muscle tender to the touch b. Aching, tired pain, with a feeling of fullness c. Pain that is worse at the end of the day d. Sudden onset e. Warm, red, and swollen calf f. Pain that is relieved with elevation of the leg
A D E
our patient is recovering from knee surgery and states that her pain level is 7 on a 0-10 pain scale. She received a dose of medication 15 minutes ago. Which interventions may be beneficial for this patient at this time? (Select all that apply.) a. Massage her back. b. Help her to reposition on her side. c. Tell her that she cannot have any more pain medication at this time as she may become addicted d. Take a few minutes and talk to her about the pictures of her family that she brought with her from home.
A and B
The health care provider plans to titrate a patient-controlled opioid infusion (PCA) to provide pain relief for a patient with acute surgical pain who has never received opioids in the past. Which of the following nursing actions regarding opioid administration are appropriate at this time? (Select all that apply.) a. Monitoring for therapeutic and adverse effects of opioid administration b. Teaching about the need to decrease opioid doses by the second postoperative day c. Assessing for signs that the patient is becoming addicted to the opioid d. Educating the patient about how analgesics improve postoperative activity level e. Emphasizing that the risk of opioid side effects increases over time
A and D
WHen irrigating a colostomy, the nurse is sure to use which of the follwoing equipment?: A. An enema set B. A cone-tipped irrigator C. A 50 mL irrigation syringe D. A 16-French Foley catheter with a 30 mL balloon
A cone-tipped irrigator
A patient has not had a bowel movement for 5 days. Now the patient has small amounts of liquid stool seepage and complains of "rectal pressure." Based on this scenario, which problem should the nurse suspect?
A fecal impaction
A nurse traned to care for ostomy clients is: A. A gastrointestinal therapist B. A nurse practitioner C. An ostomy practitioner D. A wound-ostomy-continence nurse
A wound-ostomy-continence nurse
29. Just before going home, a new mother asks the nurse about the *infant's umbilical cord*. Which of these statements is correct?
A) "It should fall off by 10 to 14 days."
34. The nurse is reviewing statistics for *lactose intolerance*. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group?
A) African-Americans
1. The nurse is percussing the *seventh right intercostal space at the midclavicular line* over the liver. Which sound should the nurse expect to hear?
A) Dullness
30. Which of these percussion findings would the nurse expect to find in a patient with a *large amount of ascites*?
A) Dullness across the abdomen
33. When palpating the abdomen of a 20-year-old patient, the nurse notices the *presence of tenderness in the left upper quadrant with deep palpation*. Which of these structures is most likely to be involved?
A) Spleen
36. During report, the student nurse hears that a patient has "*hepatomegaly*" and recognizes that this term refers to:
A) an enlarged liver.
19. A nurse notices that a patient has *ascites*, which indicates the presence of:
A) fluid.
24. During an assessment of a newborn infant, the nurse recalls that *pyloric stenosis* would be manifested by:
A) projectile vomiting.
A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? (Select all that apply.) a. Check for contraindications to the extremity. b. Start proximally and move distally on the arm. c. Choose a vein with minimal curvature. d. Choose the patient's dominant arm. e. Select a vein that is rigid. f. Avoid areas of flexion.
A, C, F
Which assessments will alert the nurse that a patient's IV has infiltrated? (Select all that apply.) a. Edema of the extremity near the insertion site b. Reddish streak proximal to the insertion site c. Skin discolored or pale in appearance d. Pain and warmth at the insertion site e. Palpable venous cord f. Skin cool to the touch
A, C, F
Areas of Direct Care
ADL --Activities of Daily Living IADL --Instrumental Activities of Daily Living Physical Care Techniques Lifesaving Measures Counseling Teaching Controling fro Adverse Reactions Preventive Measures
1. During the assessment of deep tendon reflexes, the nurse finds that a patient's responses are bilaterally normal. What number is used to indicate normal deep tendon reflexes when the documenting this finding? ____+
ANS: 2 Responses to assessment of deep tendon reflexes are graded on a 4-point scale. A rating of 2+ indicates normal or average response. A rating of 0 indicates no response, and a rating of 4+ indicates very brisk, hyperactive response with clonus, which is indicative of disease.
24. A patient is diagnosed with a bowel obstruction. The nurse chooses which type of tube for gastric decompression? a. Salem sump b. Dobhoff c. Sengstaken-Blakemore d. Small bore
ANS: A A bowel obstruction causes a backup into the gastric area; a nasogastric tube may be inserted to decompress secretions and gases from the gastrointestinal tract. The Salem sump has the width and functionality needed to both feed and suction, and it is ideal for a bowel obstruction. A Dobhoff tube is used for instillation of feedings. A Sengstaken-Blakemore tube is used to compress stomach contents to prevent hemorrhage. A small bore is intended for nutritional feedings only and does not have suction capacity.
52. The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma? a. 6 b. 12 c. 15 d. 24
ANS: A A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale (see Figure 23-59).
5. A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? a. Grape and walnut chicken salad sandwich on whole wheat bread b. Broccoli and cheese soup with potato bread c. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing d. Turkey and mashed potatoes with brown gravy
ANS: A A healthy diet for the bowel should include foods high in bulk-forming fiber. Whole grains, fresh fruit, and fresh vegetables are excellent sources. Foods without much fiber and with high levels of fat can slow down peristalsis, causing constipation.
33. In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all of the time, and when he is awake all he does is cry. The nurse hears that the infant's cries are very high pitched and shrill. What should be the nurse's appropriate response to these findings? a. Refer the infant for further testing. b. Talk with the mother about eating habits. c. Do nothing; these are expected findings for an infant this age. d. Tell the mother to bring the baby back in 1 week for a recheck.
ANS: A A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, and hyperirritability, as well as the parent's report of significant changes in behavior all warrant referral. The other options are not correct responses.
8. The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in _____ day(s). a. 4 b. 2 c. 1 d. 7
ANS: A A partial-thickness wound repair has three compartments: the inflammatory response, epithelial proliferation and migration, and re-establishment of the epidermal layers. Epithelial proliferation and migration start at all edges of the wound, allowing for quick resurfacing. Epithelial cells begin to migrate across the wound bed soon after the wound occurs. A wound left open to air resurfaces within 6 to 7 days, whereas a wound that is kept moist can resurface in 4 days. One or 2 days is too soon for this process to occur, moist or dry.
31. A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for further education? a. "If I get a positive result, I have gastrointestinal bleeding." b. "I should not eat red meat before my examination." c. "I should schedule to perform the examination when I am not menstruating." d. "I will need to perform this test three times if I have a positive result."
ANS: A A positive result does not mean GI bleeding; it could be a false positive from consuming red meat, some raw vegetables, or NSAIDs. Proper patient education is important for viable results. The patient needs to avoid certain foods to rule out a false positive. If the test is positive, the patient will need to repeat the test at least three times. Menses and hemorrhoids can also lead to false positives.
11. A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes? a. Reflexes will be normal. b. Reflexes cannot be elicited. c. All reflexes will be diminished but present. d. Some reflexes will be present, depending on the area of injury.
ANS: A A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.
28. A nurse is caring for an 8-year-old patient who is embarrassed about urinating in his bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence? a. "Drink your nightly glass of milk earlier in the evening." b. "Set your alarm clock to wake you every 2 hours, so you can get up to void." c. "Line your bedding with plastic sheets to protect your mattress." d. "Empty your bladder completely before going to bed."
ANS: A ANS: A Nightly incontinence and nocturia are often resolved by limiting fluid intake 2 hours before bedtime. Setting the alarm clock to wake does not correct the physiological problem, nor does lining the bedding with plastic sheets. Emptying the bladder may help with early nighttime urination, but will not affect urine produced throughout the night from late-night fluid intake.
20. A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, the next best step is to a. Inspect the wound for bleeding. b. Inspect the wound for foreign bodies. c. Determine the size of the wound. d. Determine the need for a tetanus antitoxin injection.
ANS: A After determining that a patient's condition is stable, inspect the wound for bleeding. An abrasion will have limited bleeding, a laceration can bleed more profusely, and a puncture wound bleeds in relation to the size and depth of the wound. Address any bleeding issues. Inspect the wound for foreign bodies; traumatic wounds are dirty and may need to be addressed. Determine the size of the wound. A large open wound may expose bone or tissue and be protected, or the wound may need suturing. When the wound is caused by a dirty penetrating object, determine the need for a tetanus vaccination.
36. The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial interventions should the nurse select to decrease this risk? a. Gentle cleaners and thorough drying of the skin b. Absorbent pads and garments c. Positioning with use of pillows d. Therapeutic beds and mattresses
ANS: A Assessment and skin hygiene are two initial defenses for preventing skin breakdown. Avoid soaps and hot water when cleansing the skin. Use gentle cleansers with nonionic surfactants. After bathing, make sure to dry the skin completely, and apply moisturizer to keep the epidermis well lubricated. Absorbent pads and garments are controversial and should be considered only when other alternatives have been exhausted. Positioning the patient reduces pressure and shearing force to the skin and is part of the plan of care but is not one of the initial components. Depending on the needs of the patient, a specialty bed may be needed, but again, this does not provide the initial defense for skin breakdown.
35. To assess the head control of a 4-month-old infant, the nurse lifts up the infant in a prone position while supporting his chest. The nurse looks for what normal response? The infant: a. Raises the head, and arches the back. b. Extends the arms, and drops down the head. c. Flexes the knees and elbows with the back straight. d. Holds the head at 45 degrees, and keeps the back straight.
ANS: A At 3 months of age, the infant raises the head and arches the back as if in a swan dive. This response is the Landau reflex, which persists until 1 years of age (see Figure 23-43). The other responses are incorrect.
4. A patient requests the nurse's assistance to the bedside commode and becomes frustrated when unable to void in front of the nurse. The nurse understands the patient's inability to void because a. Anxiety can make it difficult for abdominal and perineal muscles to relax enough to void. b. The patient does not recognize the physiological signals that indicate a need to void. c. The patient is lonely, and calling the nurse in under false pretenses is a way to get attention. d. The patient is not drinking enough fluids to produce adequate urine output.
ANS: A Attempting to void in the presence of another can cause anxiety and tension in the muscles that make voiding difficult. The nurse should give the patient privacy and adequate time if appropriate. No evidence suggests that an underlying physiological or psychological condition exists.
19. When viewing a urine specimen under a microscope, what would the nurse expect to see in a patient with a urinary tract infection? a. Bacteria b. Casts c. Crystals d. Protein
ANS: A Bacteria indicate a urinary tract infection. Crystals would be seen with renal stone formation. Casts indicate renal alterations. Protein is not visible under a microscope and indicates renal disease.
21. After a patient returns from a barium swallow, the nurse's priority is to a. Encourage the patient to increase fluids to flush out the barium. b. Monitor stools closely for bright red blood or mucus, which indicates trauma from the procedure. c. Inform the patient that his bowel movements are radioactive, and that he should be sure to flush the toilet three times. d. Thicken all patient drinks to prevent aspiration.
ANS: A Encourage the patient to increase fluid intake to flush and remove excess barium from the body. Barium swallow is a noninvasive procedure for which no trauma would produce blood or mucus or increase aspiration risk. Barium is not a radioactive substance, so multiple flushes are not needed.
23. A nurse is educating a patient on how to irrigate an ostomy bag. Which statement by the patient indicates the need for further instruction? a. "I can use a fleet enema to save money because it contains the same irrigation solution." b. "Sitting on the toilet lets the irrigation sleeve eliminate into the bowl." c. "I should never attempt to reach into my stoma to remove fecal material." d. "Using warm tap water will reduce cramping and discomfort during the procedure."
ANS: A Enema applicators should never be used in the stoma because they can cause damage. A special coned irrigation device is used for ostomies. Irrigating a stoma into the toilet is an effective management technique. Fingers and other objects should not be placed into the stoma because they may cause trauma to the intestinal wall. Warm tap water will reduce cramping during irrigation.
46. In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect? a. Hyperreflexia b. Fasciculations c. Loss of muscle tone and flaccidity d. Atrophy and wasting of the muscles
ANS: A Hyperreflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions. The other options reflect a lesion of lower motor neurons (see Table 23-7).
6. A patient informs the nurse that she was using laxatives three times daily to lose weight. After stopping use of the laxative, the patient had difficulty with constipation and wonders if she needs to take laxatives again. The nurse educates the patient that a. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. b. Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis. c. Natural laxatives such as mineral oil are safer than chemical laxatives for relieving constipation. d. Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced.
ANS: A Long-term laxative use can lead to constipation. Increasing fluid and fiber intake can help with this problem. Laxatives do not cause scarring. Natural laxatives like mineral oil come with their own set of risks, such as inability to absorb fat-soluble vitamins. Even if malnourished, the body will produce waste if substance is consumed.
2. When reviewing laboratory results, the nurse should immediately notify the health care provider about which finding? a. Glomerular filtration rate of 20 mL/min b. Urine output of 80 mL/hr c. pH of 6.4 d. Protein level of 2 mg/100 mL
ANS: A Normal glomerular filtration rate should be around 125 mL/min
15. A patient has developed a decubitus ulcer. What laboratory data would be important to gather? a. Serum albumin b. Creatine kinase c. Vitamin E d. Potassium
ANS: A Normal wound healing requires proper nutrition. Serum proteins are biochemical indicators of malnutrition, and serum albumin is probably the most frequently measured of these parameters. The best measurement of nutritional status is prealbumin because it reflects not only what the patient has ingested, but also what the body has absorbed, digested, and metabolized. Measurement of creatine kinase helps in the diagnosis of myocardial infarcts and has no known role in wound healing. Potassium is a major electrolyte that helps to regulate metabolic activities, cardiac muscle contraction, skeletal and smooth muscle contraction, and transmission and conduction of nerve impulses. Vitamin E is a fat-soluble vitamin that prevents the oxidation of unsaturated fatty acids. It is believed to reduce the risk of coronary artery disease and cancer. Vitamin E has no known role in wound healing.
37. To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate? Ask the child to: a. Hop on one foot. b. Stand on his head. c. Touch his finger to his nose. d. Make "funny" faces at the nurse.
ANS: A Normally, a child can hop on one foot and can balance on one foot for approximately 5 seconds by 4 years of age and can balance on one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skills. Asking the child to touch his or her finger to the nose checks fine motor coordination; and asking the child to make "funny" faces tests CN VII. Asking a child to stand on his or her head is not appropriate.
3. Which of the following is not a function of the large intestine? a. Absorbing nutrients b. Absorbing water c. Secreting bicarbonate d. Eliminating waste
ANS: A Nutrient absorption is done in the small intestine. The other options are all functions of the large intestine.
22. While a cleansing enema is administered to an 80-year-old patient, the patient expresses the urge to defecate. What is the next priority nursing action? a. Positioning the patient in the dorsal recumbent position with a bed pan b. Assisting the patient to the bedside commode c. Stopping the enema cleansing and rolling the patient into right-lying Sims' position d. Inserting a rectal plug to contain the enema solution
ANS: A Patients with poor sphincter control may not be able to hold in all of an enema solution. Positioning the patient on a bed pan in dorsal recumbent position will allow the nurse to continue to administer the enema. Having the patient get up to toilet is unsafe because the rectal tube can damage the mucosal lining. The purpose of the enema is to promote defecation; stopping it early may inhibit its effectiveness. Use of a rectal plug to contain the solution is inappropriate.
14. A patient asks about treatment for urge urinary incontinence. The nurse's best response is to advise the patient to a. Perform pelvic floor exercises. b. Drink cranberry juice. c. Avoid voiding frequently. d. Wear an adult diaper.
ANS: A Poor muscle tone leads to an inability to control urine flow. The nurse should recommend pelvic muscle strengthening exercises such as Kegel exercises; this solution best addresses the patient's problem. Drinking cranberry juice is a preventative measure for urinary tract infection. The nurse should not encourage the patient to reduce voiding; residual urine in the bladder increases the risk of infection. Wearing an adult diaper could be considered if attempts to correct the root of the problem fail.
2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is a. Pressure. b. Resistance. c. Stress. d. Weight.
ANS: A Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capillary exceeds 12 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin breakdown. Resistance (the ability to remain unaltered by the damaging effect of something), stress (worry or anxiety), and weight (individuals of all sizes, shapes, and ages acquire skin breakdown) are not major causes of pressure ulcers.
17. While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infant's ability to suck and grasp the mother's finger. What is the nurse assessing? a. Reflexes b. Intelligence c. CNs d. Cerebral cortex function
ANS: A Questions regarding reflexes include such questions as, "What have you noticed about the infant's behavior," "Are the infant's sucking and swallowing seem coordinated," and "Does the infant grasp your finger?" The other responses are incorrect.
38. Which observation by the nurse best indicates that bladder irrigation for urinary retention has been effective? a. Recording an output that is larger than the amount instilled b. Presence of blood clots or sediment in the drainage bag c. Reduction in discomfort from bladder distention d. Visualizing clear urinary catheter tubing
ANS: A Recording an output that is greater than what was irrigated into the bladder shows progress that the bladder is draining urine. The other observations do not objectively measure the increase in urine output.
38. During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate? a. These findings are normal, resulting from aging. b. These findings could be related to hyperthyroidism. c. These findings are the result of Parkinson disease. d. This patient should be evaluated for a cerebellar lesion.
ANS: A Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and a weakness of voluntary movement. The other responses are incorrect.
39. The nurse should place the patient in which position when preparing to administer an enema? a. Left Sims' position b. Fowler's c. Supine d. Semi-Fowler's
ANS: A Side-lying Sims' position allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon. This helps to improve retention of the enema. Administering an enema in a sitting position may allow the curved rectal tube to scrape the rectal wall.
29. The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurse's next response should be to: a. Ask the patient to lock her fingers and pull. b. Complete the examination, and then test these reflexes again. c. Refer the patient to a specialist for further testing. d. Document these reflexes as 0 on a scale of 0 to 4+.
ANS: A Sometimes the reflex response fails to appear. Documenting the reflexes as absent is inappropriate this soon in the examination. The nurse should try to further encourage relaxation, varying the person's position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. The person should be asked to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, the person should be asked to lock the fingers together and pull.
39. The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage a. I. b. II. c. III. d. IV.
ANS: A Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. This allows visual inspection and monitoring. A transparent dressing could be used to protect the patient from shear but cannot be used in the presence of excessive moisture. A composite film, hydrocolloid, or hydrogel can be utilized on a clean stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, gauze, and growth factors can be utilized with a clean stage III. Hydrogel, calcium alginate, gauze, and growth factors can be utilized with a clean stage IV. An unstageable wound cover with eschar should utilize a dressing of adherent film or gauze with an ordered solution of enzymes. In rare cases when eschar is dry and intact, no dressing is used, but this is an unstaged ulcer.
30. The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign? a. Ineffective tissue perfusion b. Risk for infection c. Imbalanced nutrition: less than body requirements d. Acute pain
ANS: A The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has resulted in tissue damage. The most appropriate nursing diagnosis with this information is Ineffective tissue perfusion. Risk for infection, Acute pain, and Imbalanced nutrition may be part of this patient's nursing diagnosis, but the data provided do not support this nursing diagnosis.
49. The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)? a. Cerebrum b. Cerebellum c. CNs d. Medulla oblongata
ANS: A The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other structures are not responsible for a person's level of consciousness.
2. The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe. a. Frontal b. Parietal c. Occipital d. Temporal
ANS: A The frontal lobe has areas responsible for personality, behavior, emotions, and intellectual function. The parietal lobe has areas responsible for sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is responsible for hearing, taste, and smell.
26. The nurse is completing an assessment of the skin's integrity, which includes a. Pressure points. b. All pulses. c. Breath sounds. d. Bowel sounds.
ANS: A The nurse continually assesses the skin for signs of ulcer development. Assessment of tissue pressure damage includes visual and tactile inspection of the skin. Observe pressure points such as bony prominences and areas next to treatments such as a binasal cannula and the nares. Assessment of pulses, breath sounds, and bowel sounds is part of a head-to-toe assessment and could influence the function of the body and ultimately skin integrity; however, this assessment is not a specific part of a skin assessment.
40. The nurse is assessing a patient 2 hours after a colonoscopy. Based on the procedure done, what focused assessment will the nurse include? a. Bowel sounds b. Presence of flatulence c. Bowel movements d. Nausea
ANS: A The nurse does want to hear the presence of bowel sounds; absent bowel sounds may indicate a complication from the surgery. Bowel movements and flatulence are not expected in the hours after surgery. The nurse does want to hear the presence of bowel movements. Nausea is not a problem following colonoscopy.
27. The nurse knows that the ideal time to change an ostomy pouch is a. Before eating a meal, when the patient is comfortable. b. When the patient feels that he needs to have a bowel movement. c. When ordered in the patient's chart. d. After the patient has ambulated the length of the hallway.
ANS: A The nurse wants to change the ostomy appliance when as little output as necessary ensures a smooth procedure. Patients with ostomies do not feel the urge to defecate because the sensory portion of the anus is not stimulated. Changing the ostomy pouch is a nursing judgment decision. After a patient ambulates, stool output is increased.
14. The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which of the following outcomes would the nurse evaluate as successful for the patient to establish normal defecation? a. The patient reports eliminating a soft, formed stool. b. The patient has quit taking opioid pain medication. c. The patient's lower left quadrant is tender to the touch. d. The nurse hears bowel sounds present in all four quadrants.
ANS: A The nurse's goal is for the patient to be on opioid medication and to have normal bowel elimination. Normal stools are soft and formed. Ceasing pain medication is not a desired outcome for the patient. Tenderness in the left lower quadrant indicates constipation and does not further address bowel elimination. Present bowel sounds indicate that the bowels are moving; however, they are not an indication of defecation.
2. The nurse would expect the least formed stool to be present in which portion of the digestive tract? a. Ascending b. Descending c. Transverse d. Sigmoid
ANS: A The path of digestion goes from the ascending, across the transverse, to the descending and finally passing into the sigmoid; therefore, the least formed stool would be in the ascending.
17. The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse? a. Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results. b. Notify the charge nurse about the change in status and the potential for infection. c. Notify the physician by utilizing Situation, Background, Assessment, and Recommendation (SBAR). d. Notify the wound care nurse about the change in status and the potential for infection.
ANS: A The patient is showing signs and symptoms associated with infection in the wound. It is serious and needs treatment but is not a life-threatening emergency, where care is needed immediately or the patient will suffer long-term consequences. The nurse should complete the assessment; gather all data such as current treatment modalities, medications, vital signs including temperature, and laboratory results such as the most recent complete blood count or white cell count. The nurse can then notify the physician and receive treatment orders for the patient. It is important to notify the charge nurse and consult the wound nurse on the patient's status and on any new orders.
21. What signs and symptoms would the nurse expect to observe in a patient with excessive white blood cells present in the urine? a. Fever and chills b. Difficulty holding in urine c. Increased blood pressure d. Abnormal blood sugar
ANS: A The presence of white blood cells in urine indicates a urinary tract infection. Difficulty with urinary elimination indicates blockage or renal damage. Increased blood pressure is associated with renal disease or damage and some medications. Abnormal blood sugars would be seen in someone with ketones in the urine, as this finding indicates diabetes.
43. During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with: a. Parkinsonism. b. Cerebral palsy. c. Cerebellar ataxia. d. Muscular dystrophy.
ANS: A The stooped posture, shuffling walk, short steps, flat facial expression, and pill-rolling finger movements are all found in parkinsonism. (See Table 23-8 for more information and for the descriptions of the other options.)
30. Which nursing action best reduces risk of excoriation to the mucosal lining of the nose from a nasogastric tube? a. Lubricating the nares with water-soluble lubricant b. Applying a small ice bag to the nose for 5 minutes every 4 hours c. Instilling Xylocaine into the nares once a shift d. Changing the tape holding the tube in place once a shift
ANS: A The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble lubricant decreases the likelihood of excoriation. Ice is not applied to the nose. Ice may be applied externally to the throat if the patient reports a sore throat. Xylocaine requires a physician order and is used to treat sore throat, not nasal mucosal excoriation. Changing the tape should be done daily, not every shift.
34. A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse would expect which other assessment finding? a. Hypoactive bowel sounds b. Jaundice in sclera c. Decreased skin turgor d. Soft tender abdomen
ANS: A Three or more days with no bowel movement indicates hypomotility of the GI tract. Assessment findings would include hypoactive bowel sounds, a firm distended abdomen, and pain or discomfort upon palpation.
10. Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. The nurse should follow up by asking a. "When was the last time you voided?" b. "Do you lose urine when you cough or sneeze?" c. "Have you noticed any change in your urination patterns?" d. "Do you have a fever or chills?"
ANS: A To obtain an accurate assessment, the nurse should first determine the source of the discomfort. Urinary retention causes the bladder to be firm and distended. Further assessment to determine the pathology of the condition can be performed later. Questions concerning fever and chills, changing urination patterns, and losing urine during coughing or sneezing focus on specific pathological conditions.
34. Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant? a. Denver II b. Stereognosis c. Deep tendon reflexes d. Rapid alternating movements
ANS: A To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones. Stereognosis tests a person's ability to recognize objects by feeling them and is not appropriate for an 11-month-old infant. Testing the deep tendon reflexes is not appropriate for checking motor coordination. Testing rapid alternating movements is appropriate for testing coordination in adults.
15. During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this finding as: a. Vertigo. b. Syncope. c. Dizziness. d. Seizure activity.
ANS: A True vertigo is rotational spinning caused by a neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem. Syncope is a sudden loss of strength or a temporary loss of consciousness. Dizziness is a lightheaded, swimming sensation. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances.
39. The nurse anticipates urinary diversion from the kidneys to a site other than the bladder for which patient? a. A 12-year-old female with severe abdominal trauma b. A 24-year-old male with severe genital warts around the urethra c. A 50-year-old male with recent prostatectomy d. A 75-year-old female with end-stage renal disease
ANS: A Urinary diversion would be needed in a patient with abdominal trauma who might have injury to the urinary system. Genital warts are not needed for urinary diversion. Patients with a prostatectomy may require intermittent catheterization after the procedure. End-stage renal disease would not be affected by rerouting the flow of urine.
26. A nurse anticipates urodynamic testing for a patient with which symptom? a. Involuntary urine leakage b. Severe flank pain c. Presence of blood in urine d. Dysuria
ANS: A Urodynamic testing evaluates the muscle function of the bladder and is used to look for the cause of urinary incontinence. Severe flank pain indicates renal calculi; CT scan or IVP would be a more efficient diagnostic test. Blood indicates trauma to the urethral or bladder mucosa. Pain on elimination may warrant cultures to check for infection.
37. To reduce patient discomfort during closed catheter irrigation, the nurse should a. Use room temperature irrigation solution. b. Administer the solution as quickly as possible. c. Allow the solution to sit in the bladder for at least 1 hour. d. Raise the bag of irrigation solution at least 12 inches above the bladder.
ANS: A Using cold solutions, instilling solutions too quickly, and prolonging filling of the bladder can cause discomfort and cramping. To reduce this, ensure that the solution is at room temperature, lower the solution bag so it instills slowly, and drain the bladder fully after an ordered amount of time.
47. A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual? a. Hyporeflexia b. Increased muscle tone c. Positive Babinski sign d. Presence of pathologic reflexes
ANS: A With a herniated intervertebral disk or lower motor neuron lesion, loss of tone, flaccidity, atrophy, fasciculations, and hyporeflexia or areflexia are demonstrated. No Babinski sign or pathologic reflexes would be observed (see Table 23-7). The other options reflect a lesion of upper motor neurons.
14. Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence? a. Complaint by patient that something has given way b. Protrusion of visceral organs through a wound opening c. Chronic drainage of fluid through the incision site d. Drainage that is odorous and purulent
ANS: A occurs is when a wound fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Patients often report feeling as though something has given way. Evisceration is seen when vital organs protrude through a wound opening. A fistula is an abnormal passage between two organs or between an organ and the outside of the body that can be characterized by chronic drainage of fluid. Infection is characterized by drainage that is odorous and purulent.
2. The nurse properly obtains a 24-hour urine specimen collection by (Select all that apply.) a. Asking the patient to void and to discard the first sample. b. Keeping the urine collection container on ice. c. Withholding all patient medications for the day. d. Asking the patient to notify the staff before and after every void.
ANS: A, B When obtaining a 24-hour urine specimen, it is important to keep the urine in cool condition. The patient should be asked to void and to discard the urine before the procedure begins. Medications do not need to be held unless indicated by the provider. If properly educated about the collection procedure, the patient can maintain autonomy and perform the procedure alone, taking care to maintain the integrity of the solution.
1. The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care understands the need for a multidisciplinary approach. The nurse evaluates the need for several consults. Which of the following should always be included in the consults? (Select all that apply.) a. Registered dietitian b. Enterostomal and wound care nurse c. Physical therapist d. Case management personnel e. Chaplain f. Pharmacist
ANS: A, B, C, D A registered dietitian is useful in working with the nurse to determine a meal plan that will support wound healing. An enterostomal or wound care nurse specializes in caring for the needs of the patient with wounds. Physical therapy is concerned about the mobility of the patient and can assist an immobile patient to progress toward mobility and decrease the risk for pressure ulcers. Pressure ulcers take a long time to heal and usually require continued therapy in the home. Case management personnel are useful in obtaining care for the patient outside the home. If the patient has a spiritual need, the chaplain can assist. If the patient has a need associated with medications, the pharmacist can assist. However, chaplains and pharmacists usually are not part of the wound care multidisciplinary team, unless a special need arises.
5. The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. The nurse's responsibilities and activities before applying the bandage and binder include which of the following? (Select all that apply.) a. Inspecting the skin for abrasions and edema b. Covering exposed wounds c. Assessing condition of current dressings d. Assessing the skin at underlying areas for circulatory impairment e. Marking the sites of all abrasions f. Cleansing the area with hydrogen peroxide
ANS: A, B, C, D Before applying a bandage or a binder, the nurse has several responsibilities. The nurse would need to inspect the skin for abrasions, edema, and discoloration or exposed wound edges. The nurse also is responsible for covering exposed wounds or open abrasions with a sterile dressing and assessing the condition of underlying dressings and changing if soiled, as well as assessing the skin of underlying areas that will be distal to the bandage. This checks for signs of circulatory impairment, so that a comparison can be made after bandages are applied. Marking the sites of all abrasions is not necessary. Although it is important for the skin to be clean, and even though it may need to be cleaned with a noncytotoxic cleanser, cleansing with hydrogen peroxide can interfere with wound healing.
3. The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.) a. "Can you easily change your position?" b. "Do you have sensitivity to heat or cold?" c. "How often do you need to use the toilet?" d. "Is movement painful?" e. "What medications do you take?" f. "Have you ever fallen?"
ANS: A, B, C, D Changing positions is important for decreasing the pressure associated with long periods of time in the same position. If the patient is able to feel heat or cold and is mobile, he can protect himself by withdrawing from the source. Knowing toileting habits and any potential for incontinence is important because urine and feces in contact with the skin for long periods can increase skin breakdown. Knowing whether the patient has problems with mobility such as pain will alert the nurse to any potential for decreased movement and increased risk for skin breakdown. Medications and falling are safety risk questions.
3. Which of the following are indications for irrigating a urinary catheter? (Select all that apply.) a. Sediment occluding within the tubing b. Blood clots in the bladder following surgery c. Rupture of the catheter balloon d. Bladder infection e. Presence of renal calculi
ANS: A, B, D Catheter irrigation is used to flush and remove blockage that may be impeding the catheter from properly draining the bladder. Irrigation is used to remove blood clots in the bladder following surgery. For patients with bladder infection, an antibiotic irrigation is often ordered. A ruptured catheter balloon will involve extensive follow-up and possible surgery to remove the particles. Renal calculi obstruct the ureters and therefore the flow of urine before it reaches the bladder
2. The nurse is caring for a patient with wound healing by tertiary intention. Which factors does the nurse recognize as influencing wound healing? (Select all that apply.) a. Nutrition b. Evisceration c. Tissue perfusion d. Infection e. Hemorrhage f. Age
ANS: A, C, D, F Normal wound healing requires proper nutrition. Oxygen and the ability to provide adequate amounts of oxygenated blood are critical for wound healing. Wound infection prolongs the inflammatory phase, delays collagen synthesis, prevents epithelialization, and decreases the production of proinflammatory cytokines, which leads to additional tissue destruction. As patients age, all aspects of wound healing are delayed. Hemorrhage and evisceration are complications of wound healing.
23. The nurse is caring for a patient who has a stage IV pressure ulcer awaiting plastic surgery consultation. Which of the following specialty beds would be most appropriate? a. Standard mattress b. Nonpowered redistribution air mattress c. Low-air-loss therapy unit d. Lateral rotation
ANS: B A low-air-loss therapy unit is utilized for stage IV pressure ulcers and when prevention or treatment of skin breakdown is needed. If the patient has a stage III or stage IV ulcer or a postoperative myocutaneous flap, the low-air-loss therapy unit would be an appropriate selection. A static air mattress or nonpowered redistribution is utilized for the patient at high risk for skin breakdown. A standard mattress is utilized for an individual who does not have actual or potential altered or impair skin integrity. Lateral rotation is used for treatment and prevention of pulmonary complications associated with mobility.
9. When caring for a patient with urinary retention, the nurse would anticipate an order for a. Limited fluid intake. b. A urinary catheter. c. Diuretic medication. d. A renal angiogram.
ANS: B A urinary catheter would relieve urinary retention. Reducing fluids would reduce the amount of urine produced but would not alleviate the urine retention. Diuretic medication would increase urine production and may worsen the discomfort caused by urine retention. A renal angiogram is an inappropriate diagnostic test for urinary retention.
11. The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by a. Tertiary intention. b. Secondary intention. c. Partial-thickness repair. d. Primary intention.
ANS: B A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. A clean surgical incision is an example of a wound with little loss of tissue that heals by primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial- thickness repair are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved.
32. The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. The nurse consults a a. Respiratory therapist. b. Registered dietitian. c. Chaplain. d. Case manager.
ANS: B Assessment and a plan for the patient to optimize the diet are essential. Adequate calories, protein, vitamins, and minerals promote wound healing. The nurse is the coordinator of care, and collaborating with the dietitian would result in planning the best meals for the patient. The respiratory therapist can be consulted when a patient has issues with the respiratory system. Case management can be consulted when the patient has a discharge need. A chaplain can be consulted when the patient has a spiritual need.
29. Many individuals have difficulty voiding in a bedpan or urinal while lying in bed because they a. Are embarrassed that they will urinate on the bedding. b. Would feel more comfortable assuming a normal voiding position. c. Feel they are losing their independence by asking the nursing staff to help. d. Are worried about acquiring a urinary tract infection.
ANS: B Assuming a normal voiding position helps patients relax and be able to void; lying in bed is not the typical position in which people void. Men usually are most comfortable when standing; women are more comfortable when sitting and squatting. Embarrassment at using the bedpan and worrying about a urinary tract infection are not related to the lying-in-bed position. Fear of loss of independence is not related to use of the bedpan or urinal.
26. The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this? a. The patient has hyperesthesia as a result of the aging process. b. This response is most likely the result of the summation effect. c. The nurse was probably not poking hard enough with the pin in the other areas. d. The patient most likely has analgesia in some areas of arm and hyperalgesia in others.
ANS: B At least 2 seconds should be allowed to elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus. The other responses are incorrect.
22. The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. What would be the nurse's next best step? a. Remove the drain; a drain is no longer needed. b. Call the physician; a blockage is present in the tubing. c. Call the charge nurse to look at the drain. d. As long as the evacuator is compressed, do nothing.
ANS: B Because a drainage system needs to be patent, look for drainage flow through the tubing, as well as around the tubing. A sudden decrease in drainage through the tubing may indicate a blocked drain, and you will need to notify the physician. The health care provider determines the need for drain removal and removes drains. Notifying the charge nurse, although important for communication, is not the next step in providing care for this patient. The evacuator may be compressed when a blockage is present.
21. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which of these actions should the nurse take first? a. Don sterile gloves. b. Provide analgesic medications as ordered. c. Avoid accidentally removing the drain. d. Gather supplies.
ANS: B Because removal of dressings is painful, if often helps to give an analgesic at least 30 minutes before exposing a wound and changing the dressing. The next sequence of events includes gathering supplies for the dressing change, donning gloves, and avoiding the accidental removal of the drain during the procedure.
15. The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately? a. Liquid consistency of stool b. Presence of blood in the stool c. Noxious odor from the stool d. Continuous output from the stoma
ANS: B Blood in the stool may indicate a problem with the surgical procedure, and the physician should be notified. All other options are expected findings for an ileostomy.
9. A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate? a. "This is probably a false negative; we should rerun the test." b. "Do you take iron supplements?" c. "You should schedule a colonoscopy as soon as possible." d. "Sometimes severe stress can alter stool color."
ANS: B Certain medications and supplements, such as iron, can alter the color of stool. The fecal occult test takes three separate samples over a period of time and is a fairly reliable test. A colonoscopy is health prevention screening that should be done every 5 to 10 years; it is not the nurse's initial priority. Stress alters GI motility and stool consistency, not color.
35. The home health nurse is caring for a patient with impaired skin integrity in the home. The nurse is reviewing dressing changes with the caregiver. Which intervention assists in managing the expenses associated with long-term wound care? a. Sterile technique b. Clean dressings and no touch technique c. Double bagging of contaminated dressings d. Ability of the caregiver
ANS: B Clean dressings as opposed to sterile dressings are recommended for home use. This recommendation is in keeping with principles regarding nosocomial infection, and it takes into account the expense of sterile dressings and the dexterity required for application. The caregiver can use the same no touch technique for dressing changes that is used for changing surface dressings without touching the wound or the surface that might come in contact with the wound. Double bagging is required for the disposal of contaminated dressings. The dressings go in a bag, which is fastened and then placed in the household trash. The ability of the caregiver certainly is a component of the success of home treatment, but it does not influence the cost of supplies.
7. The ability that humans have to perform very skilled movements such as writing is controlled by the: a. Basal ganglia. b. Corticospinal tract. c. Spinothalamic tract. d. Extrapyramidal tract.
ANS: B Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, and purposeful movements, such as writing. The corticospinal tract, also known as the pyramidal tract, is a newer, "higher" motor system that humans have that permits very skilled and purposeful movements. The other responses are not related to skilled movements.
54. The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as: a. Negative Babinski sign, which is normal for adults. b. Positive Babinski sign, which is abnormal for adults. c. Clonus, which is a hyperactive response. d. Achilles reflex, which is an expected response.
ANS: B Dorsiflexion of the big toe and fanning of all toes is a positive Babinski sign, also called up-going toes. This response occurs with upper motor neuron disease of the corticospinal (or pyramidal) tract and is an abnormal finding for adults.
6. The nurse knows that urinary tract infection (UTI) is the most common health care-associated infection because a. Catheterization procedures are performed more frequently than indicated. b. Escherichia coli pathogens are transmitted during surgical or catheterization procedures. c. Perineal care is often neglected by nursing staff. d. Bedpans and urinals are not stored properly and transmit infection.
ANS: B E. coli is the leading pathogen causing UTIs; this pathogen enters during procedures. Sterile technique is imperative to prevent the spread of infection. Frequent catheterizations can place a patient at high risk for UTI; however, infection is caused by bacteria, not by the procedure itself. Perineal care is important, and buildup of bacteria can lead to infection, but this is not the greatest cause. Bedpans and urinals may become bacteria ridden and should be cleaned frequently. Bedpans and urinals are not inserted into the urinary tract, so they are unlikely to be the primary cause of UTI.
50. During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes: a. Is a normal occurrence. b. May indicate disease of the cerebellum or brainstem. c. Is a sign that the patient is nervous about the examination. d. Indicates a visual problem, and a referral to an ophthalmologist is indicated.
ANS: B End-point nystagmus at an extreme lateral gaze normally occurs; however, the nurse should carefully assess any other nystagmuses. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.
40. The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What should the nurse do to decrease the patient's anxiety? a. Tell the patient to close his eyes. b. Explain the procedure. c. Turn on the television. d. Ask the family to leave the room.
ANS: B Explaining the procedure educates the patient regarding the dressing change and involves him in his care, thereby allowing the patient some control in decreasing anxiety. Telling the patient to close his eyes and turning on the television are distractions that do not usually decrease a patient's anxiety. If the family is a support system, asking support systems to leave the room can actually increase a patient's anxiety.
34. When caring for a hospitalized patient with a urinary catheter, which nursing action best prevents the patient from acquiring an infection? a. Inserting the catheter using strict clean technique b. Performing hand hygiene before and after providing perineal care c. Fully inflating the catheter's balloon according to the manufacturer's recommendation d. Disconnecting and replacing the catheter drainage bag once per shift
ANS: B Hand hygiene helps prevent infection in patients with a urinary catheter. A catheter should be inserted in the hospital setting using sterile technique. Inflating the balloon fully prevents dislodgement and trauma, not infection. Disconnecting the drainage bag from the catheter creates a break in the system and an open portal of entry and increases risk of infection.
41. During an assessment of a 22-year-old woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What do these findings suggest? a. Injury to the right eye b. Increased intracranial pressure c. Test inaccurately performed d. Normal response after a head injury
ANS: B In a person with a brain injury, a sudden, unilateral, dilated, and nonreactive pupil is ominous. CN III runs parallel to the brainstem. When increasing intracranial pressure pushes down the brainstem (uncal herniation), it puts pressure on CN III, causing pupil dilation. The other responses are incorrect.
51. The nurse knows that testing kinesthesia is a test of a person's: a. Fine touch. b. Position sense. c. Motor coordination. d. Perception of vibration.
ANS: B Kinesthesia, or position sense, is the person's ability to perceive passive movements of the extremities. The other options are incorrect.
7. A patient with a hip fracture is having difficulty defecating into a bed pan while lying in bed. Which action by the nurse would assist the patient in having a successful bowel movement? a. Administering laxatives to the patient b. Raising the head of the bed c. Preparing to administer a barium enema d. Withholding narcotic pain medication
ANS: B Lying in bed is an unnatural position; raising the head of the bed assists the patient into a more normal position that allows proper contraction of muscles for elimination. Laxatives would not give the patient control over bowel movements. A barium enema is a diagnostic test, not an intervention to promote defecation. Pain relief measures should be given; however, preventative action should be taken to prevent constipation.
28. The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility, which intervention is most important for the nurse to complete? a. Encourage the patient to sit up in the chair. b. Provide analgesic medication as ordered. c. Explain the risks of immobility to the patient. d. Turn the patient every 3 hours while in bed.
ANS: B Maintaining adequate pain control and patient comfort increases the patient's willingness and ability to increase mobility, which in turn reduces pressure ulcer risks. It is good to encourage a patient to move about but even better if the patient actually sits up in the chair. Explaining the risk of immobility is important for the patient because it may impact the patient's willingness but not his or her ability. Turning the patient is important for decreasing pressure ulcers but needs to be done every 2 hours, and again does not influence the patient's ability to increase mobility.
1. The nurse knows that most nutrients are absorbed in which portion of the digestive tract? a. Stomach b. Duodenum c. Ileum d. Cecum
ANS: B Most nutrients are absorbed in the duodenum with the exception of certain vitamins, iron, and salt (which are absorbed in the ileum). Food is broken down in the stomach. The cecum is the beginning of the large intestine.
20. A nurse is preparing a patient for a magnetic resonance imaging scan. Which nursing action is most important? a. Ensuring that the patient does not eat or drink 2 hours before the examination b. Removing all of the patient's metallic jewelry c. Administering a colon cleansing product 12 hours before the examination d. Obtaining an order for a pain medication before the test is performed
ANS: B No jewelry or metal products should be in the same room as an MRI machine because of the high-power magnet used in the machine. The patient needs to be NPO 4 to 6 hours before the examination. Colon cleansing products are not necessary for MRIs. Pain medication is not needed before the examination is performed.
13. Which nursing diagnosis related to alternations in urinary function in an older adult should be a nurse's first priority? a. Self-care deficit related to decreased mobility b. Risk of infection c. Anxiety related to urinary frequency d. Impaired self-esteem related to lack of independence
ANS: B Older adults often experience poor muscle tone, which leads to an inability of the bladder to fully empty. Residual urine greatly increases the risk of infection. Following Maslow's hierarchy of needs, physical health risks should be addressed before emotional/cognitive risks such as anxiety and self-esteem. Decreased mobility can lead to self-care deficit; the nurse's priority concern for this diagnosis would be infection, because the elderly person must rely on others for basic hygiene.
1. The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include a. A diet low in calories and fat. b. Alteration in level of consciousness. c. Shortness of breath. d. Muscular pain.
ANS: B Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and a diet low in calories and fat are not included among the predisposing factors.
4. The nurse is caring for a patient who is confined to the bed. The nurse asks the patient if he needs to have a bowel movement 30 minutes after eating a meal because a. The digested food needs to make room for recently ingested food. b. Mastication triggers the digestive system to begin peristalsis. c. The smell of bowel elimination in the room would deter the patient from eating. d. More ancillary staff members are available after meal times.
ANS: B Peristalsis occurs only a few times a day; the strongest peristaltic waves are triggered by mastication of the meal. The intestine can hold a great deal of food. A patient's voiding schedule should not be based on the staff's convenience.
29. An older adult's perineal skin appears to be dry and thin with mild excoriation. When providing hygiene after a bowel movement, the nurse should a. Thoroughly scrub the skin with a wash cloth and hypoallergenic soap. b. Apply a skin protective lotion after perineal care. c. Tape an occlusive moisture barrier pad to the patient's skin. d. Massage the skin with deep kneading pressure.
ANS: B Proper skin care and perineal cleaning require that the nurse gently clean the skin and apply a moistening barrier cream. Tape and occlusive dressings can damage skin. Excessive pressure and force are inappropriate and may cause skin breakdown.
26. A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most appropriate? a. Changing the skin barrier portion of the ostomy pouch daily b. Selecting a pouch that is able to hold excess output to reduce the frequency of pouch emptying c. Thoroughly scrubbing the skin around the stoma to remove excess stool and adhesive d. Measuring the correct size for the barrier device while leaving a 1/8-inch space around the stoma
ANS: B Selecting a pouch that holds a large volume of output will decrease the frequency of emptying the pouch and may ease patient anxiety about pouch overflow. The barrier device should be changed every few days unless it is leaking or is no longer effective. Peristomal skin should be gently cleansed; vigorous rubbing can cause further irritation or skin breakdown. Approximately 1/16 of an inch is present between the barrier device and the stoma. Excess space allows fecal matter to have prolonged exposure to skin, resulting in skin breakdown.
18. In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what response should the nurse make? a. "Does your family know you are drinking every day?" b. "Does the tremor change when you drink alcohol?" c. "We'll do some tests to see what is causing the tremor." d. "You really shouldn't drink so much alcohol; it may be causing your tremor."
ANS: B Senile tremor is relieved by alcohol, although not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.
28. The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding? a. Extinction b. Astereognosis c. Graphesthesia d. Tactile discrimination
ANS: B Stereognosis is the person's ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions. Tactile discrimination tests fine touch. Extinction tests the person's ability to feel sensations on both sides of the body at the same point.
8. Which patient is most at risk for increased peristalsis? a. A 5-year-old child who ignores the urge to defecate owing to embarrassment b. A 21-year-old patient with three final examinations on the same day c. A 40-year-old woman with major depressive disorder d. An 80-year-old man in an assisted-living environment
ANS: B Stress can stimulate digestion and increase peristalsis. Ignoring the urge to defecate, depression, and age-related changes of the elderly are causes of constipation.
10. Which physiological change can cause a paralytic ileus? a. Chronic cathartic abuse b. Surgery for Crohn's disease and anesthesia c. Suppression of hydrochloric acid from medication d. Fecal impaction
ANS: B Surgical manipulation of the bowel can cause a paralytic ileus. The other options are incorrect.
13. Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs that prevents ambulation? a. Elevate the head of the bed 45 degrees 60 minutes after breakfast. b. Use a mobility device to place the patient on a bedside commode. c. Give the patient a pillow to brace against the abdomen while bearing down. d. Administer a soap suds enema every 2 hours.
ANS: B The best way to promote normal defecation is to assist the patient into a posture that is as normal as possible while defecating. Using a mobility device promotes nurse and patient safety. Elevating the head of the bed would be appropriate if the patient were to void with a bed pan. However, the patient's condition does not require use of a bed pan. Giving the patient a pillow may reduce discomfort, but this is not the best way to promote defecation. A soaps suds enema is indicated for a patient who needs assistance to stimulate peristalsis. It promotes non-natural defecation.
20. During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs? a. Motor component of CN IV b. Motor component of CN VII c. Motor and sensory components of CN XI d. Motor component of CN X and sensory component of CN VII
ANS: B The findings listed reflect a dysfunction of the motor component of the facial nerve (CN VII).
3. Which statement concerning the areas of the brain is true? a. The cerebellum is the center for speech and emotions. b. The hypothalamus controls body temperature and regulates sleep. c. The basal ganglia are responsible for controlling voluntary movements. d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.
ANS: B The hypothalamus is a vital area with many important functions: body temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not in the thalamus.
12. A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. The nurse knows that the reason for this is: a. A demyelinating process must be occurring with her infant. b. Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. c. The cerebral cortex is not fully developed; therefore, control over motor function gradually occurs. d. The spinal cord is controlling the movement because the cerebellum is not yet fully developed.
ANS: B The infant's sensory and motor development proceeds along with the gradual acquisition of myelin, which is needed to conduct most impulses. Very little cortical control exists, and the neurons are not yet myelinated. The other responses are not correct.
11. Which of the following is the primary function of the kidney? a. Metabolizing and excreting medications b. Maintaining fluid and electrolyte balance c. Storing and excreting urine d. Filtering blood cells and proteins
ANS: B The main purpose of the kidney is to maintain fluid and electrolyte balance by filtering waste products and regulating pressures. The kidneys filter the byproducts of medication metabolism. The bladder stores and excretes urine. The kidneys help to maintain red blood cell volume by producing erythropoietin.
1. The two parts of the nervous system are the: a. Motor and sensory. b. Central and peripheral. c. Peripheral and autonomic. d. Hypothalamus and cerebral.
ANS: B The nervous system can be divided into two parts—central and peripheral. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves (CNs), the 31 pairs of spinal nerves, and all of their branches.
42. The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. What is the best explanation for the nurse to use when teaching the patient the reason for the binder? a. The binder creates pressure over the abdomen. b. The binder supports the abdomen. c. The binder reduces edema at the surgical site. d. The binder secures the dressing in place.
ANS: B The patient has a large abdominal incision. This incision will need support, and an abdominal binder will support this wound, especially during movement, as well as during deep breathing and coughing. A binder can be used to create pressure over a body part, for example, over an artery after it has been punctured. A binder can be used to prevent edema, for example, in an extremity but is not used to reduce edema at a surgical site. A binder can be used to secure dressings such as elastic webbing applied around a leg after vein stripping.
3. Which nursing observation would indicate that the patient was at risk for pressure ulcer formation? a. The patient ate two thirds of breakfast. b. The patient has fecal incontinence. c. The patient has a raised red rash on the right shin. d. The patient's capillary refill is less than 2 seconds.
ANS: B The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the skin is moistened and softened, causing maceration. Eating a balanced diet is important for nutrition, but eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg again is a concern and can affect the integrity of the skin, but it is located on the shin, which is not a high-risk area for skin breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary response is within normal limits.
5. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage a. I. b. II. c. III. d. IV.
ANS: B This would be a stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.
27. A patient is having difficulty voiding in a bedpan but states that she feels her bladder is full. To stimulation micturition, which nursing intervention should the nurse try first? a. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient's progress b. Utilizing the power of suggestion by turning on the faucet and letting the water run c. Obtaining an order for a Foley catheter d. Administering diuretic medication
ANS: B To stimulate micturition, the nurse should attempt noninvasive procedures first. Running warm water or stroking the inner aspect of the upper thigh promotes sensory perception that leads to urination. A patient should not be left alone on a bedpan for 30 minutes because this could cause skin breakdown. Catheterization places the patient at increased risk of infection and should not be the first intervention attempted. Diuretics are useful if the patient is not producing urine, but they do not stimulate micturition.
22. During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? a. Firm, rigid resistance to movement b. Mild, even resistance to movement c. Hypotonic muscles as a result of total relaxation d. Slight pain with some directions of movement
ANS: B Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretching. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.
1. If obstructed, which component of the urination system would cause peristaltic waves? a. Kidney b. Ureters c. Bladder d. Urethra
ANS: B Ureters drain urine from the kidneys into the bladder; if they become obstructed, peristaltic waves attempt to push the obstruction into the bladder. The kidney, bladder, and urethra do not produce peristaltic waves. Obstruction of both bladder and urethra typically does not occur.
33. The nurse would question an order to insert a urinary catheter on which patient? a. A 26-year-old patient with a recent spinal cord injury at T2 b. A 30-year-old patient requiring drug screening for employment c. A 40-year-old patient undergoing bladder repair surgery d. An 86-year-old patient requiring monitoring of urinary output for renal failure
ANS: B Urinary catheterization places the patient at increased risk for infection and should be performed only when necessary. Urine can be obtained via clean-catch technique for a drug screening or urinalysis. Spinal cord injury, surgery, and renal failure with critical intake and output monitoring are all appropriate reasons for catheterization.
12. While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, the nurse would expect to find a. An indwelling Foley catheter. b. Reddened irritated skin on the buttocks. c. Tiny blood clots in the patient's urine. d. Foul-smelling discharge indicative of a UTI.
ANS: B Urinary incontinence is uncontrolled urinary elimination; if the urine has prolonged contact with the skin, skin breakdown can occur. An indwelling Foley catheter is a solution for urine retention. Blood clots and foul-smelling discharge are often signs of infection.
17. The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. What is the next priority nursing action? a. Preparing the patient for a second tap water enema b. Donning gloves for digital removal of the stool c. Positioning the patient on the left side d. Inserting a rectal tube
ANS: B When enemas are not successful, digital removal of the stool may be necessary occasionally to break up pieces of the stool or to stimulate the anus to defecate. Tap water enemas should not be repeated because of risk of fluid imbalance. Positioning the patient on the left side does not promote defecation. A rectal tube is indicated for a patient with liquid stool incontinence but would not be applicable or effective for this patient.
5. The nurse understands that peritoneal dialysis and hemodialysis use which processes to clean the patient's blood? (Select all that apply.) a. Gravity b. Osmosis c. Diffusion d. Filtration
ANS: B, C Osmosis and diffusion are the two processes used to clean the patient's blood in both types of dialysis. In peritoneal dialysis, osmosis and dialysis occur across the semi-permeable peritoneal membrane. In hemodialysis, osmosis and dialysis occur through the filter membrane on the artificial kidney. In peritoneal dialysis, the dialysate flows by gravity out of the abdomen. Gravity has no effect on cleansing of the blood. Filtration is the process that occurs in the glomerulus as blood flows through the kidney.
4. Which of the following symptoms are most closely associated with uremic syndrome? (Select all that apply.) a. Fever b. Nausea and vomiting c. Headache d. Altered mental status e. Dysuria
ANS: B, C, D Uremic syndrome is associated with end-stage renal disease. Signs and symptoms include headache, altered mental status, coma, seizures, nausea, vomiting, and pericarditis.
4. The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment? (Select all that apply.) a. Mobility b. Hyperemia c. Induration d. Blanching e. Temperature of skin f. Nutritional status
ANS: B, C, D, E Assessment of the skin includes both visual and tactile inspection. Assess for hyperemia and abnormal reactive hyperemia (when the skin turns red after an obstruction of blood flow returns and vasodilatation causes the tissue to turn red). Assess for indurated (hardened) areas on the skin and palpate reddened areas for blanching. Changes in temperature can indicate changes in blood flow to that area of the skin. Mobility and nutritional status are certainly part of the overall assessment for pressure ulcer risk but are not part of the actual skin assessment
1. A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying "I'm just getting old!" After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer disease? Select all that apply. a. Occasionally forgetting names or appointments b. Difficulty performing familiar tasks, such as placing a telephone call c. Misplacing items, such as putting dish soap in the refrigerator d. Sometimes having trouble finding the right word e. Rapid mood swings, from calm to tears, for no apparent reason f. Getting lost in one's own neighborhood
ANS: B, C, E, F Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in one's own neighborhood can be warning signs of Alzheimer disease. Occasionally forgetting names or appointments, and sometimes having trouble finding the right word are part of normal aging. (For other examples of Alzheimer disease, see Table 23-2.)
6. The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity. Which of the following outcomes when met indicate progression toward goals? (Select all that apply.) a. Ask whether patient's expectations are being met. b. Prevent injury to the skin and tissues. c. Obtain the patient's perception of interventions. d. Reduce injury to the skin. e. Reduce injury to the underlying tissues. f. Restore skin integrity.
ANS: B, D, E, F Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin, reduce injury to underlying tissues, and restore skin integrity. Asking the patient's perceptions and whether expectations are being met allows one to obtain information regarding the experience, but these are not actual measurable outcomes.
1. Which nursing actions are acceptable when collecting a urine specimen? (Select all that apply.) a. Growing urine cultures for up to 12 hours b. Labeling all specimens with date, time, and initials c. Wearing gown, gloves, and mask for all specimen handling d. Allowing the patient adequate time and privacy to void e. Squeezing urine from diapers into a urine specimen cup f. Transporting specimens to the laboratory in a timely fashion g. Placing a plastic bag over the child's urethra to catch urine
ANS: B, D, F, G All specimens should be labeled appropriately and processed in a timely fashion. Allow patients time and privacy to void. Children may have difficulty voiding; attaching a plastic bag gives the child more time and freedom to void. Urine cultures can take up to 48 hours to develop. Gown, gloves, and mask are not necessary for specimen handling unless otherwise indicated. Urine should not be squeezed from diapers.
30. The nurse would anticipate inserting a Coudé catheter for which patient? a. An 8-year-old male undergoing anesthesia for a tonsillectomy b. A 24-year-old female who is going into labor c. A 56-year-old male admitted for bladder irrigation d. An 86-year-old female admitted for a urinary tract infection.
ANS: C A Coudé catheter has a curved tip that is used for patients with enlarged prostates. This would be indicated for a middle-aged male who needs bladder irrigation. Coudé catheters are not indicated for children or women.
28. The nurse administers a cathartic to a patient. The nurse determines that the cathartic has had a therapeutic effect when the patient a. Has a decreased level of anxiety. b. Experiences pain relief. c. Has a bowel movement. d. Passes flatulence.
ANS: C A cathartic is a laxative that stimulates a bowel movement. It would be effective if the patient experiences a bowel movement. The other options are not outcomes of administration of a cathartic
10. A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation? a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed. b. The dermatome served by this nerve will no longer experience any sensation. c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. d. A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component.
ANS: C A dermatome is a circumscribed skin area that is primarily supplied from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic insurance; that is, if one nerve is severed, then most of the sensations can be transmitted by the spinal nerve above and the spinal nerve below the severed nerve.
35. A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding would the nurse expect? a. Increased energy levels b. Distended abdomen c. Decreased serum bicarbonate d. Increased blood pressure
ANS: C ANS: C Chronic diarrhea can result in metabolic acidosis, which is diagnostic of low serum bicarbonate. Patients with chronic diarrhea are dehydrated with decreased blood pressure. Diarrhea also causes loss of electrolytes, nutrients, and fluid, which decreases energy levels. A distended abdomen would indicate constipation.
19. The nurse is preparing to perform a fecal occult blood test. The nurse plans to properly perform the examination by a. Applying liberal amounts of stool to the guaiac paper. b. Testing the quality control section before collecting the specimen section. c. Reporting any abnormal findings to the provider. d. Applying sterile disposable gloves.
ANS: C Abnormal findings such as a positive test should be reported to the provider. A fecal occult blood test is a clean procedure; sterile gloves are not needed. A thin specimen smear is all that is required. The quality control section should be developed after it is determined whether the sample is positive or negative.
29. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns which of the following nursing diagnoses? a. Readiness for enhanced nutrition b. Impaired physical mobility c. Impaired skin integrity d. Chronic pain
ANS: C After the assessment is completed and the information that the patient has a stage IV pressure ulcer is gathered, a diagnosis of Impaired skin integrity is selected. Readiness for enhanced nutrition would be selected for an individual with an adequate diet that could be improved. Impaired physical mobility and Chronic pain, as well as the nutrition nursing diagnosis, could well be the nursing diagnoses selected for this patient, but current data in the question strongly support Impaired skin integrity.
16. When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information? a. "Does your muscle tone seem tense or limp?" b. "After the seizure, do you spend a lot of time sleeping?" c. "Do you have any warning sign before your seizure starts?" d. "Do you experience any color change or incontinence during the seizure?"
ANS: C Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor. The other questions do not solicit information about an aura.
33. The nurse is caring for a patient with a stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. What is the best goal for this patient? a. The patient's family will demonstrate specific care of the wound site. b. The patient will state what to look for with regard to an infection. c. The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound. d. The patient's family members will wash their hands when visiting the patient.
ANS: C Because the patient has an open wound and the skin is no longer intact to protect the tissue, the patient is at increased risk for infection. The nurse will be assessing the patient for signs and symptoms of infection, including an increase in temperature, an increase in white count, and odorous and purulent drainage from the wound. The patient is unconscious and is unable to communicate the signs and symptoms of infection; also, this is an intervention, not a goal for this diagnosis. It is important for the patient's family to be able to demonstrate how to care for the wound and wash their hands, but these statements are interventions, not goals or outcomes for this nursing diagnosis.
16. The nurse would anticipate which diagnostic examination for a patient with black tarry stools? a. Ultrasound b. Barium enema c. Upper endoscopy d. Flexible sigmoidoscopy
ANS: C Black tarry stools are an indication of ulceration or bleeding in the upper portion of the GI tract; upper endoscopy would allow visualization of the bleeding. No other option would allow upper GI visualization.
25. The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the nurse question? a. Use a low-air-loss therapy unit. b. Consult a dietitian. c. Irrigate with hydrogen peroxide. d. Utilize hydrogel dressing.
ANS: C Clean pressure ulcers with noncytotoxic cleansers such as normal saline, which will not kill fibroblasts and healing tissue. Cytotoxic cleansers such as Dakin's solution, acetic acid, povidone-iodine, and hydrogen peroxide can hinder the healing process and should not be utilized on clean granulating wounds. Consulting a dietitian for the nutritional needs of the patient, utilizing a low-air-loss therapy unit to decrease pressure, and applying hydrogel dressings to provide a moist environment for healing are all orders that would be appropriate.
41. The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included? a. Allowing the solution to flow from the most contaminated to the least contaminated b. Scrubbing vigorously when applying solutions to the skin c. Cleansing in a direction from the least contaminated area d. Utilizing clean gauge and clean gloves to cleanse a site
ANS: C Cleanse surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or irrigations. Cleanse in a direction from the least contaminated area. Use gentle friction when applying solutions to the skin, and allow irrigation to flow from the least to the most contaminated area.
15. The nurse suspects that a urinary tract infection has progressed to cystitis when the patient complains of which symptom? a. Dysuria b. Flank pain c. Frequency d. Fever and chills
ANS: C Cystitis is inflammation of the bladder; associated symptoms include hematuria and urgency/frequency. Dysuria is a common symptom of a lower urinary tract infection. Flank pain, fever, and chills are all signs of pyelonephritis.
53. A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse's finger, then his own nose, then the nurse's finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following? a. Cerebral injury b. Cerebrovascular accident c. Acute alcohol intoxication d. Peripheral neuropathy
ANS: C During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorder or acute alcohol intoxication should be suspected. The person's movements should be smooth and accurate. The other options are not correct.
25. A patient had an ileostomy surgically placed 2 days ago. Which diet would the nurse recommend to the patient to ease the transition of the new ostomy? a. Eggs over easy, whole wheat toast, and orange juice with pulp b. Chicken fried rice with stir fried vegetables and iced tea c. Turkey meatloaf with white rice and apple juice d. Fish sticks with macaroni and cheese and soda
ANS: C During the first week or so after ostomy placement, the patient should consume easy-to-digest low-fiber foods such as poultry, rice and noodles, and strained fruit juices. Fried foods can irritate digestion and can cause blockage. Foods high in fiber will be useful later in the recovery process but can cause blockage if the GI tract is not accustomed to digesting with an ileostomy.
24. The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes a. Monitoring of the wound. b. Irrigation of the wound. c. Débridement of the wound. d. Management of drainage.
ANS: C Débridement is the removal of nonviable necrotic tissue. Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base for healing. A wound will not move through the phases of healing if the wound is infected. Irrigating the wound with noncytotoxic cleaners will not damage or kill fibroblasts and healing tissue and will help to keep the wound clean once débrided. When treating a pressure ulcer, it is important to monitor and reassess the wound at least every 8 hours. Management of drainage will help keep the wound clean.
9. The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? a. Eschar b. Slough c. Granulation d. Purulent drainage
ANS: C Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft yellow or white tissue is characteristic of slough—a substance that needs to be removed for the wound to heal. Black or brown necrotic tissue is called eschar, which also needs to be removed for a wound to heal. Purulent drainage is indicative of an infection and will need to be resolved for the wound to heal.
34. The nurse is caring for a postpartum patient. The patient has an episiotomy after experiencing birth. The physician has ordered heat to treat this condition, and the nurse is providing this treatment. This patient is at risk for a. Infection. b. Impaired skin integrity. c. Trauma. d. Imbalanced nutrition.
ANS: C Heat causes vasodilatation and is used to improve blood flow to an injured body part. The application of heat incorrectly when the treatment is too hot, or is applied too long or to the wrong place, can result in a burn for the patient and risk for additional trauma. The skin already has impaired integrity owing to the surgical procedure, and because of this has been at risk for infection since the surgical procedure was performed. This patient is of childbearing age and has had a child. Additional needs for nutrition are present during pregnancy and breastfeeding, but this is an established nursing diagnosis. Data are insufficient to support the nursing diagnosis of Imbalanced nutrition.
43. The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the procedure, which intervention should the nurse implement? a. Monitor vital signs every 15 minutes. b. Apply brace to right knee. c. Elevate right knee and apply ice. d. Check pulses in right foot.
ANS: C Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the body part. Elevation assists in preventing edema, which in turn can cause pain. Monitoring vital signs every 15 minutes is routine postoperative care and includes a pain assessment but in itself is not an intervention that decreases pain. Applying a brace provides support and decreases the opportunity for additional trauma, which in turn assists in the healing process. Checking the pulses is important to monitor the circulation of the extremity but in itself is not a pain management intervention.
32. A nurse notifies the provider immediately if a patient with an indwelling catheter a. Complains of discomfort upon insertion of the catheter. b. Places the drainage bag higher than the waist while ambulating. c. Has not collected any urine in the drainage bag for 2 hours. d. Is incontinent of stool and contaminates the external portion of the catheter.
ANS: C If the patient has not produced urine in 2 hours, the physician needs to be notified immediately because this could indicate renal failure. Discomfort upon catheter insertion is unpleasant but unavoidable. The nurse is responsible for maintaining the integrity of the catheter by ensuring that the drainage bag is below the patient's bladder. Stool left on the catheter can cause infection and should be removed as soon as it is noticed. The nurse should ensure that frequent perineal care is being provided.
20. The nurse would expect the urine of a patient with uncontrolled diabetes mellitus to be a. Cloudy. b. Discolored. c. Sweet smelling. d. Painful.
ANS: C Incomplete fat metabolism and buildup of ketones give urine a sweet or fruity odor. Cloudy urine may indicate infection or renal failure. Discolored urine may result from various medications. Painful urination indicates an alteration in urinary elimination.
18. The nurse should question which order? a. A normal saline enema to be repeated every 4 hours until stool is produced b. A hypertonic solution enema with a patient with fluid volume excess c. A Kayexalate enema for a patient with hypokalemia d. An oil retention enema for a patient using mineral oil laxatives
ANS: C Kayexalate binds to and helps excrete potassium, so it would be contraindicated in patients who are hypokalemic (have low potassium). Normal saline enemas can be repeated without risk of fluid or electrolyte imbalance. Hypertonic solutions are intended for patients who cannot handle large fluid volume and are contraindicated for dehydrated patients. Because mineral oil laxatives and an oil retention enema have the same intended effect of lubricating the colon and rectum, an oil retention enema is not needed.
27. The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect? a. Hyperalgesia b. Hyperesthesia c. Peripheral neuropathy d. Lesion of sensory cortex
ANS: C Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome. The other responses are incorrect.
16. Which of the following would be the most important piece of assessment data to gather with regard to wound healing? a. Muscular strength assessment b. Sleep assessment c. Pulse oximetry assessment d. Sensation assessment
ANS: C Oxygen fuels the cellular functions essential to the healing process; the ability to perfuse tissues with adequate amounts of oxygenated blood is critical in wound healing. Blood flow through the pulmonary capillaries provides red blood cells for oxygen attachment. Oxygen diffuses from the alveoli into the pulmonary blood; most of the oxygen attaches to hemoglobin molecules within the red blood cells. Red blood cells carry oxygenated hemoglobin molecules through the left side of the heart and out to the peripheral capillaries, where the oxygen detaches, depending on the needs of the tissues. Pulse oximetry measures the oxygen saturation of blood. Assessment of muscular strength and sensation, although useful for fitness and mobility testing, does not provide any data with regard to wound healing. Sleep, although important for rest and for integration of learning and restoration of cognitive function, does not provide any data with regard to wound healing.
24. Which statement by the patient about an upcoming computed tomography (CT) scan indicates a need for further teaching? a. "I'm allergic to shrimp, so I should monitor myself for an allergic reaction." b. "I will complete my bowel prep program the night before the scan." c. "I will be anesthetized so that I lie perfectly still during the procedure." d. "I will ask the technician to play music to ease my anxiety."
ANS: C Patients are not put under anesthesia for a CT scan; instead the nurse should educate patients about the need to lie perfectly still and about possible methods of overcoming feelings of claustrophobia. The other options are correct. Patients need to be assessed for an allergy to shellfish if receiving contrast for the CT. Bowel cleansing is often performed before CT. Listening to music will help the patient relax and remain still during the examination.
31. The nurse knows that which indwelling catheter procedure places the patient at greatest risk for acquiring a urinary tract infection? a. Emptying the drainage bag every 8 hours or when half full b. Kinking the catheter tubing to obtain a urine specimen c. Placing the drainage bag on the side rail of the patient's bed d. Failing to secure the catheter tubing to the patient's thigh
ANS: C Placing the drainage bag on the side rail of the bed could allow the bag to be raised above the level of the bladder and urine to flow back into the bladder. The urine in the drainage bag is a medium for bacteria; allowing it to reenter the bladder can cause infection. The drainage bag should be emptied and output recorded every 8 hours or when needed. Urine specimens are obtained by temporarily kinking the tubing; a prolonged kink could lead to bladder distention. Failure to secure the catheter to the patient's thigh places the patient at risk for tissue injury from catheter dislodgment.
7. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of a. Primary intention. b. Partial-thickness wound repair. c. Full-thickness wound repair. d. Tertiary intention.
ANS: C Pressure ulcers are full-thickness wounds that extend into the dermis and heal by scar formation because the deeper structures do not regenerate, hence the need for full-thickness repair. The full-thickness repair has three phases: inflammatory, proliferative, and remodeling. A wound heals by primary intention when wounds such as surgical wounds have little tissue loss; the skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges approximated. Wound closure is delayed until risk of infection is resolved.
18. The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a meal plan that includes increased a. Fat. b. Carbohydrates. c. Protein. d. Vitamin E.
ANS: C Protein needs are especially increased in supporting the activity of wound healing. The physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals of zinc and copper. A balanced diet of fat and carbohydrates, along with protein, vitamins, and minerals, is needed in any diet. Wound healing does not require increased amounts of fats or carbohydrates. Vitamin E has no known role in wound healing.
8. A patient has fallen several times in the past week when attempting to get to the bathroom. The patient informs the nurse that he gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem? a. Clear the path to the bathroom of all obstacles before bed. b. Leave the bathroom light on to illuminate a pathway. c. Limit fluid and caffeine intake before bed. d. Practice Kegel exercises to strengthen bladder muscles.
ANS: C Reducing fluids, especially caffeine and alcohol, before bedtime can reduce nocturia. Clearing a path to the restroom or illuminating the path, or shortening the distance to the restroom, may reduce falls but will not correct the urination problem. Kegel exercises are useful if a patient is experiencing incontinence.
48. A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as: a. Ataxia. b. Astereognosis. c. Presence of dysdiadochokinesia. d. Loss of kinesthesia.
ANS: C Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease. The condition is termed dysdiadochokinesia. Ataxia is an uncoordinated or unsteady gait. Astereognosis is the inability to identify an object by feeling it. Kinesthesia is the person's ability to perceive passive movement of the extremities or the loss of position sense.
13. During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate: a. CN dysfunction. b. Lesion in the cerebral cortex. c. Normal changes attributable to aging. d. Demyelination of nerves attributable to a lesion.
ANS: C Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.
36. A nurse is providing education to a patient being treated for a urinary tract infection. Which of the following statements by the patient indicates an understanding? a. "Since I'm taking medication, I do not need to worry about proper hygiene." b. "I should drink 15 to 20 glasses of fluid a day to help flush the bacteria out." c. "My medication may discolor my urine; this should resolve once the medication is stopped." d. "I should not have sexual intercourse until the infection has resolved."
ANS: C Some anti-infective medications turn urine colors; this is normal and will dissipate as the medication leaves the system. Even if the patient is on medication, hygiene is important to prevent spread or reinfection. Fluid intake should be increased to help flush out bacteria; however, 15 to 20 glasses is too much. Sexual intercourse is allowed with a urinary tract infection, as long as good hygiene and safe practices are used.
40. The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? a. CNs, motor function, and sensory function b. Deep tendon reflexes, vital signs, and coordinated movements c. Level of consciousness, motor function, pupillary response, and vital signs d. Mental status, deep tendon reflexes, sensory function, and pupillary response
ANS: C Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be closely monitored for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.
5. The nurse knows that indwelling catheters are placed before a cesarean because a. The patient may void uncontrollably during the procedure. b. A full bladder can cause the mother's heart rate to drop. c. Spinal anesthetics can temporarily disable urethral sphincters. d. The patient will not interrupt the procedure by asking to go to the bathroom.
ANS: C Spinal anesthetics may cause urinary retention due to the inability to sense or carry out the need to void. The patient is more likely to retain urine, rather than experience uncontrollable voiding. With spinal anesthesia, the patient will not be able to ambulate during the procedure. A full bladder has no impact on the pulse rate of the mother.
16. Which assessment question should the nurse ask if stress incontinence is suspected? a. "Does your bladder feel distended?" b. "Do you empty your bladder completely when you void?" c. "Do you experience urine leakage when you cough or sneeze?" d. "Do your symptoms increase with consumption of alcohol or caffeine?"
ANS: C Stress incontinence can be related to intra-abdominal pressure causing urine leakage, as would happen during coughing or sneezing. Asking the patient about the fullness of his bladder would rule out retention and overflow. An inability to void completely can refer to urge incontinence. Physiological causes and medications can effect elimination, but this is not related to stress incontinence.
36. While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position, followed by the infant bringing in the arms and legs to the body. What does the nurse know about this response? a. This response could indicate brachial nerve palsy. b. This reaction is an expected startle response at this age. c. This reflex should have disappeared between 1 and 4 months of age. d. This response is normal as long as the movements are bilaterally symmetric.
ANS: C The Moro reflex is present at birth and usually disappears at 1 to 4 months. Absence of the Moro reflex in the newborn or its persistence after 5 months of age indicates severe central nervous system injury. The other responses are incorrect.
8. A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse? a. Thalamus b. Brainstem c. Cerebellum d. Extrapyramidal tract
ANS: C The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. The thalamus is the primary relay station where sensory pathways of the spinal cord, cerebellum, and brainstem form synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking.
31. When the nurse is testing the triceps reflex, what is the expected response? a. Flexion of the hand b. Pronation of the hand c. Extension of the forearm d. Flexion of the forearm
ANS: C The normal response of the triceps reflex is extension of the forearm. The normal response of the biceps reflex causes flexion of the forearm. The other responses are incorrect.
31. The nurse is caring for a patient with a stage III pressure ulcer. The nurse has assigned a nursing diagnosis of Risk for infection. Which intervention would be most important for this patient? a. Teach the family how to manage the odor associated with the wound. b. Discuss with the family how to prepare for care of the patient in the home. c. Encourage thorough handwashing of all individuals caring for the patient. d. Encourage increased quantities of carbohydrates and fats.
ANS: C The number one way to decrease the risk of infection by breaking the chain of infection is to wash hands. Encouraging fluid and food intake helps with overall wellness and wound healing, especially protein, but an increase in carbohydrates and fats does not relate to the risk of infection. If the patient will be discharged before the wound is healed, the family will certainly need education on how to care for the patient. Teaching the family how to manage the odor associated with a wound is certainly important, but these interventions do not directly relate to the risk of infection and breaking the chain of the infectious process.
3. A patient is experiencing oliguria. Which action should the nurse perform first? a. Increase the patient's intravenous fluid rate. b. Encourage the patient to drink caffeinated beverages. c. Assess for bladder distention. d. Request an order for diuretics.
ANS: C The nurse first should gather all assessment data to determine the potential cause of oliguria. It could be that the patient does not have adequate intake, or it could be that the bladder sphincter is not functioning and the patient is retaining water. Increasing fluids is effective if the patient does not have adequate intake, or if dehydration occurs. Caffeine can work as a diuretic but is not helpful if an underlying pathology is present. An order for diuretics can be obtained if the patient was retaining water, but this should not be the first action.
32. A nurse is caring for an older adult patient with fecal incontinence due to cathartic use. The nurse is most concerned about which complication that has the greatest risk for severe injury? a. Rectal skin breakdown b. Contamination of existing wounds c. Falls from attempts to reach the bathroom d. Cross-contamination into the upper GI tract
ANS: C The nurse is most concerned about the worst injury the patient could receive, which involves falling while attempting to get to the bathroom. To reduce injury, the nurse should clear the path and reinforce use of the call light. The question is asking for the greatest risk of injury, not the most frequent occurrence or the event most likely to occur.
18. To obtain a clean-voided urine specimen for a female patient, the nurse should teach the patient to a. Cleanse the urethral meatus from the area of most contamination to least. b. Initiate the first part of the urine stream directly into the collection cup. c. Hold the labia apart while voiding into the specimen cup. d. Drink fluids 5 minutes before collecting the urine specimen.
ANS: C The patient should hold the labia apart to reduce bacterial levels in the specimen. The urethral meatus should be cleansed from the area of least contamination to greatest contamination (or front-to-back). The initial steam flushes out microorganisms in the urethra and prevents bacterial transmission in the specimen. Drink fluids 30 to 60 minutes before giving a specimen.
19. The nurse is completing an assessment on an individual who has a stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following? a. "I think I will be ready to go home early next week." b. "I am so weak and tired, I want to feel better." c. "I am ready for my bath and linen change as soon as possible." d. "I am hoping there will be something good for dinner tonight."
ANS: C The patient's psychological response to any wound is part of the nurse's assessment. Body image changes can influence self-concept. Factors that affect the patient's perception of the wound include the presence of scars, drains, odor from drainage, and temporary or permanent prosthetic devices. The wound is odorous, and a drain is in place. The patient who is asking for a bath and change in linens gives you a clue that he or she may be concerned about the smell in the room. The patient stating that he or she wants to feel better, talking about going home, and caring about what is for dinner could be interpreted as positive statements that indicate progress along the health journey.
6. A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements? a. A problem exists with the sensory cortex and its ability to discriminate the location. b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain. c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. d. A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.
ANS: C The sensory cortex is arranged in a specific pattern, forming a corresponding map of the body. Pain in the right hand is perceived at a specific spot on the map. Some organs, such as the heart, liver, and spleen, are absent from the brain map. Pain originating in these organs is referred because no felt image exists in which to have pain. Pain is felt by proxy, that is, by another body part that does h
4. The area of the nervous system that is responsible for mediating reflexes is the: a. Medulla. b. Cerebellum. c. Spinal cord. d. Cerebral cortex.
ANS: C The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves; it is responsible for mediating reflexes.
5. While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact? a. Corticospinal tract, medulla, and basal ganglia b. Pyramidal tract, hypothalamus, and sensory cortex c. Lateral spinothalamic tract, thalamus, and sensory cortex d. Anterior spinothalamic tract, basal ganglia, and sensory cortex
ANS: C The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch. Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas the sensations of crude touch form the anterior spinothalamic tract. At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation. The other options are not correct.
24. The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect? a. Vestibular disease b. Lesion of CN IX c. Dysfunction of the cerebellum d. Inability to understand directions
ANS: C When a person tries to perform rapid, alternating movements, responses that are slow, clumsy, and sloppy are indicative of cerebellar disease. The other responses are incorrect.
4. The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer? a. Stage I pressure ulcer b. Healing stage II pressure ulcer c. Healing stage III pressure ulcer d. Stage III pressure ulcer
ANS: C When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled with the words "healing stage." Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a stage III, it cannot return to a previous stage such as stage I or II. This ulcer is healing, so it is no longer labeled a stage III.
37. The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair? a. At least 3 hours b. Not longer than 30 minutes c. Less than 2 hours d. As long as the patient remains comfortable
ANS: C When patients are able to sit up in a chair, make sure to limit the amount of time to 2 hours or less. The chair sitting time should be individualized. In the sitting position, pressure on the ischial tuberosities is greater than in a supine position. Utilize foam, gel, or an air cushion to distribute weight. Longer than 2 hours can increase the chance of ischemia.
38. The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. What is the best method for repositioning the patient? a. Obtain assistance and use the drawsheet to place the patient into the new position. b. Place the patient in a 30-degree supine position. c. Utilize a transfer sliding board and assistance to slide the patient into the new position. d. Elevate the head of the bed 45 degrees.
ANS: C When repositioning the patient, obtain assistance and utilize a transfer sliding board under the patient's body to prevent dragging the patient on bed sheets and placing the patient at high risk for shearing and friction injuries. The patient should be placed in a 30-degree lateral position, not supine position. The head of the bed should be elevated less than 30 degrees to prevent pressure ulcer development from shearing forces.
32. The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding? a. Positive Babinski sign b. Plantar reflex abnormal c. Plantar reflex present d. Plantar reflex 2+ on a scale from "0 to 4+"
ANS: C With the same instrument, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, similar to an upside-down J. The normal response is plantar flexion of the toes and sometimes of the entire foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale.
27. The nurse is completing a skin risk assessment utilizing the Braden scale. The patient has some sensory impairment and skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. What would be the patient's Braden scale total score? a. 15 b. 17 c. 20 d. 23
ANS: C With use of the Braden scale, the patient receives 3 for slight sensory impairment, 4 for skin being rarely moist, 3 for walks occasionally, 3 for slightly limited mobility, 4 for intake of meals, and 4 for no problem with friction and shear. The total score is 20.
39. While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n): a. Great sense of humor. b. Uncooperative behavior. c. Inability to understand questions. d. Decreased level of consciousness.
ANS: D A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.
10. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by a. Tertiary intention. b. Secondary intention. c. Partial-thickness repair. d. Primary intention.
ANS: D A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved. A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater.
11. Fecal impactions occur in which portion of the colon? a. Ascending b. Descending c. Transverse d. Rectum
ANS: D A fecal impaction is a collection of hardened feces wedged in the rectum that cannot be expelled. It results from unrelieved constipation. Feces at this point in the colon contain the least amount of moisture. Feces found in the ascending, transverse, and descending colon still consist mostly of liquid and do not form a hardened mass.
13. The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the patient was experiencing a complication of wound healing? a. The incision site has started to itch. b. The incision site is approximated. c. The patient has pain at the incision site. d. The incision has a mass, bluish in color.
ANS: D A hematoma is a localized collection of blood underneath the tissues. It appears as swelling, change in color, sensation, or warmth or a mass that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because it can put pressure on the vein or artery and obstruct blood flow. Itching of an incision site can be associated with clipping of hair, dressings, or possibly the healing process. Incisions should be approximated with edges together. After surgery, when nerves in the skin and tissues have been traumatized by the surgical procedure, it is expected that the patient would experience pain.
9. Which of these statements about the peripheral nervous system is correct? a. The CNs enter the brain through the spinal cord. b. Efferent fibers carry sensory input to the central nervous system through the spinal cord. c. The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers. d. The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers.
ANS: D A nerve is a bundle of fibers outside of the central nervous system. The peripheral nerves carry input to the central nervous system by their sensory afferent fibers and deliver output from the central nervous system by their efferent fibers. The other responses are not related to the peripheral nervous system.
36. The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately? a. Stoma is protruding from the abdomen. b. Stoma is moist. c. Stool is discharging from the stoma. d. Stoma is purple.
ANS: D A purple stoma may indicate strangulation or poor circulation to the stoma and may require surgical intervention. A stoma should be reddish-pink and moist in appearance. It can be flush with the skin, or it can protrude. Stool is an expected outcome of stoma placement.
12. Which nursing observation would indicate that a wound healed by secondary intention? a. Minimal scar tissue b. Minimal loss of tissue function c. Permanent dark redness at site d. Scarring can be severe.
ANS: D A wound healing by secondary intention takes longer than one healing by primary intention. The wound is left open until it becomes filled with scar tissue. If the scarring is severe, permanent loss of function often occurs. Wounds that heal by primary intention heal quickly with minimal scarring. Scar tissue contains few pigmented cells and has a lighter color than normal skin.
12. The nurse provides knows that a bowel elimination schedule would be most beneficial in the plan of care for which patient? a. A 40-year-old patient with an ileostomy b. A 25-year-old patient with Crohn's disease c. A 30-year-old patient with C. difficile d. A 70-year-old patient with stool incontinence
ANS: D ANS: D A bowel elimination program is helpful for a patient with incontinence. It helps the person who still has neuromuscular control defecate normally. An ileostomy, Crohn's disease, and C. difficile all relate to uncontrollable bowel movements, for which no method can be used to set up a schedule of elimination.
23. When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as: a. Ataxia. b. Lack of coordination. c. Negative Homans sign. d. Positive Romberg sign.
ANS: D Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling. A positive Romberg sign is a loss of balance that is increased by the closing of the eyes. Ataxia is an uncoordinated or unsteady gait. Homans sign is used to test the legs for deep-vein thrombosis.
7. An 86-year-old patient tells the nurse that she is experiencing uncontrollable leakage of urine. Which nursing diagnosis should the nurse include in the patient's plan of care? a. Urinary retention b. Hesitancy c. Urgency d. Urinary incontinence
ANS: D Age-related changes such as loss of pelvic muscle tone can cause involuntary loss of urine known as Urinary incontinence. Urinary retention is the inability to empty the bladder. Hesitancy occurs as difficulty initiating urination. Urgency is the feeling of the need to void immediately.
14. A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting, she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be: a. "Have you been extremely tired lately?" b. "You probably just need to drink more liquids." c. "I'll refer you for a complete neurologic examination." d. "You need to get up slowly when you've been lying down or sitting."
ANS: D Aging is accompanied by a progressive decrease in cerebral blood flow. In some people, this decrease causes dizziness and a loss of balance with a position change. These individuals need to be taught to get up slowly. The other responses are incorrect.
25. The nurse anticipates preparing a patient who is allergic to shellfish for an arteriogram by a. Obtaining baseline vital signs after the start of the procedure. b. Monitoring the extremity for neurocirculatory function. c. Keeping the patient on bed rest for the prescribed time. d. Administering an antihistamine medication to the patient.
ANS: D Before the procedure is begun, the nurse should assess the patient for food and other allergies and should administer an antihistamine, because a contrast iodine-based dye is used for the procedure. Baseline vitals should be obtained before the start of the procedure and frequently thereafter. The procedure site is monitored and the patient kept on bed rest after the procedure is complete
42. A 32-year-old woman tells the nurse that she has noticed "very sudden, jerky movements" mainly in her hands and arms. She says, "They seem to come and go, primarily when I am trying to do something. I haven't noticed them when I'm sleeping." This description suggests: a. Tics. b. Athetosis. c. Myoclonus. d. Chorea.
ANS: D Chorea is characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face. Chorea occurs at irregular intervals, and the movements are all accentuated by voluntary actions. (See Table 23-5 for the descriptions of athetosis, myoclonus, and tics.)
35. An 86-year-old patient asks the nurse what lifestyle changes will reduce the chance of a urinary tract infection. Which response is accurate? a. Urinary tract infections are unavoidable in the elderly because of a weakened immune system. b. Decreasing fluid intake will decrease the amount of urine with bacteria produced. c. Making sure to cleanse the perineal area from back to front after voiding will reduce the chance of infection. d. Increasing consumption of acidic foods such as cranberry juice will reduce the chance of infection.
ANS: D Cranberry juice and other acidic foods decrease adherence of bacteria to the bladder wall. Urinary tract infections are avoidable in the elderly population with proper knowledge and hygiene. Perineal skin should be cleansed from front to back to avoid spreading fecal matter to the urethra. Increasing fluids will help to flush bacteria, thus preventing them from residing in the bladder for prolonged periods of time.
38. A guaiac test has been ordered. The nurse knows that this is a test for a. Bright red blood. b. Dark black blood. c. Blood that contains mucus. d. Blood that cannot be seen.
ANS: D Fecal occult blood tests are used to test for blood that may be present in stool that cannot be seen by the naked eye. This is usually indicative of a GI bleed. All other options are incorrect.
22. The nurse would anticipate an order for which diagnostic test for a patient who has severe flank pain and calcium phosphate crystals revealed on urinalysis? a. Renal ultrasound b. Bladder scan c. KUB x-ray d. Intravenous pyelogram
ANS: D Flank pain and calcium phosphate crystals are associated with renal calculi. An intravenous pyelogram allows the provider to observe pathological problems such as obstruction of the ureter. A renal ultrasound is performed to identify gross structures. A bladder scan measures the amount of urine in the bladder. A KUB x-ray shows size, shape, symmetry, and location of the kidneys.
30. In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side? a. Lack of reflexes b. Normal reflexes c. Diminished reflexes d. Hyperactive reflexes
ANS: D Hyperreflexia is the exaggerated reflex observed when the monosynaptic reflex arc is released from the influence of higher cortical levels. This response occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect.
23. A nurse is caring for a patient who just underwent intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse's first priority in caring for this patient? a. Turn the patient on the right side to alleviate pressure on the left kidney. b. Encourage the patient to increase fluid intake to flush the obstruction. c. Administer narcotic medications to alleviate pain. d. Monitor the patient for fever, rash, and difficulty breathing.
ANS: D Intravenous pyelography is performed by administering iodine-based dye to view functionality of the urinary system. Many individuals are allergic to shellfish; therefore, the first nursing priority is to assess the patient for an allergic reaction that could be life threatening. The nurse should then encourage the patient to drink fluids to flush dye resulting from the procedure. Narcotics can be administered but are not the first priority. Turning the patient on the side will not affect patient safety.
33. The nurse is caring for a patient with Clostridium difficile. Which of the following nursing actions will have the greatest impact in preventing the spread of bacteria? a. Monthly in-services about contact precautions b. Placing all contaminated items in biohazard bags c. Mandatory cultures on all patients d. Proper hand hygiene techniques
ANS: D Proper hand hygiene is the best way to prevent the spread of bacteria. Monthly in-services place emphasis on education, not on action. Biohazard bags are appropriate but cannot be used on every item that C. difficile comes in contact with, such as a human. Mandatory cultures are expensive and unnecessary and would not prevent the spread of bacteria.
37. A patient has constipation and hypernatremia. The nurse prepares to administer which type of enema? a. Oil retention b. Carminative c. Saline d. Tap water
ANS: D Tap water enema would draw fluid into the system and would help flush out excess sodium. Oil retention would not address sodium problems. Carminative enemas are used to provide relief from distention caused by gas. A saline enema would worsen hypernatremia.
44. The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission. The nurse has implemented interventions for this nursing diagnosis. Upon reassessment, which Braden score would be the best sign that the risk for skin breakdown is decreasing? a. 12 b. 13 c. 20 d. 23
ANS: D The Braden scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development. The cutoff score for onset of pressure ulcer risk with the Braden scale in the general adult population is 18. The best sign is a perfect score of 23.
21. The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient: a. Demonstrates the ability to hear normal conversation. b. Sticks out the tongue midline without tremors or deviation. c. Follows an object with his or her eyes without nystagmus or strabismus. d. Moves the head and shoulders against resistance with equal strength.
ANS: D The following normal findings are expected when testing the spinal accessory nerve (CN XI): The patient's sternomastoid and trapezius muscles are equal in size; the person can forcibly rotate the head both ways against resistance applied to the side of the chin with equal strength; and the patient can shrug the shoulders against resistance with equal strength on both sides. Checking the patient's ability to hear normal conversation checks the function of CN VIII. Having the patient stick out the tongue checks the function of CN XII. Testing the eyes for nystagmus or strabismus is performed to check CNs III, IV, and VI.
17. When establishing a diagnosis of altered urinary elimination, the nurse should first a. Establish normal voiding patterns for the patient. b. Encourage the patient to flush kidneys by drinking excessive fluids. c. Monitor patients' voiding attempts by assisting them with every attempt. d. Discuss causes and solutions to problems related to micturition.
ANS: D The nurse should assess first to determine cause, then should discuss and create goals with the patient, so nurse and patient can work in tandem to normalize voiding. The nurse should incorporate the patient's input into creating a plan of care for the patient. Drinking excessive fluid will not help and may worsen alterations in urinary elimination. The nurse does not need to monitor every void attempt by the patient; instead the nurse should provide patient education. The nurse asks the patient about normal voiding patterns, but establishing voiding patterns is a later intervention.
25. During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." When assessing his sensory system, which action by the nurse is most appropriate? a. The nurse would not test the sensory system as part of the examination because the results would not be valid. b. The nurse would perform the tests, knowing that mental status does not affect sensory ability. c. The nurse would proceed with an explanation of each test, making certain that the wife understands. d. Before testing, the nurse would assess the patient's mental status and ability to follow directions.
ANS: D The nurse should ensure the validity of the sensory system testing by making certain that the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.
19. A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? a. Glasgow Coma Scale b. Neurologic recheck examination c. Screening neurologic examination d. Complete neurologic examination
ANS: D The nurse should perform a complete neurologic examination on an individual who has neurologic concerns (e.g., headache, weakness, loss of coordination) or who is showing signs of neurologic dysfunction. The Glasgow Coma Scale is used to define a person's level of consciousness. The neurologic recheck examination is appropriate for those who are demonstrating neurologic deficits. The screening neurologic examination is performed on seemingly well individuals who have no significant subjective findings from the health history.
44. During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patient's response: a. Indicates a lesion of the cerebral cortex. b. Indicates a completely nonfunctional brainstem. c. Is normal and will go away in 24 to 48 hours. d. Is a very ominous sign and may indicate brainstem injury.
ANS: D These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.
6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging an ulcer on this patient? a. Cotton-tipped applicator b. Disposable measuring tape c. Sterile gloves d. Halogen light
ANS: D When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the first step in assessment—inspection—and the whole assessment process. Natural light or a halogen light is recommended. Fluorescent light sources can produce blue tones on darkly pigmented skin and can interfere with an accurate assessment. Other items that could possibly be used during the assessment include gloves for infection control, a disposable measuring device to measure the size of the wound, and a cotton-tipped applicator to measure the depth of the wound, but these items not the first item used.
45. A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing? a. Scissors gait b. Cerebellar ataxia c. Parkinsonian gait d. Spastic hemiparesis
ANS: D With spastic hemiparesis, the arm is immobile against the body. Flexion of the shoulder, elbow, wrist, and fingers occurs, and adduction of the shoulder, which does not swing freely, is observed. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident. (See Table 23-6 for more information and for the descriptions of the other abnormal gaits.)
Collaborative problem
Actual or potential physiological complication that nurses monitor to detect an onset of changes in a patient's status.
Bicarbonate (HCO3-)
Arterial: 22-26 mEq/L Venous: 24-30 mEq/l
In assessing a 55 year-old client who is in the clinic for a routine physical, the nurse instructs the client about the need to proved a stool specimen for guaiac fecal occult blood testing: A. If the client notices rectal bleeding B. If there is a family history of intestinal polyps C. As part of a routine screening for colon cancer D. If a palpable mass is detected on digital exam
As part of a routine screening for colon cancer
The nurse is obtaining a client's medication history. Which of the follwing mediactions my cause gastrointestinal bleeding? (Select all that apply.) A. Aspirin B. Cathartics C. Antidiarrheal opiate agents D. Nonsteroidal anti-inflammatory drugs (NSAIDS)
Aspirin Nonsteroidal anti-inflammatory drugs (NSAIDS)
List 5 steps of Nursing Process
Assessment Nursing Diagnosis Planning Implementation Evaluation
1. Which statement is true regarding the arterial system? a. Arteries are large-diameter vessels. b. The arterial system is a high-pressure system. c. The walls of arteries are thinner than those of the veins. d. Arteries can greatly expand to accommodate a large blood volume increase.
B
11. A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient? a. Hard and fixed cervical nodes b. Enlarged and tender inguinal nodes c. Bilateral enlargement of the popliteal nodes d. Pelletlike nodes in the supraclavicular region
B
12. The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect? a. Excessive swelling of the lymph nodes b. Presence of palpable lymph nodes c. No palpable nodes because of the immature immune system of a child d. Fewer numbers and a smaller size of lymph nodes compared with those of an adult
B
15. A patient complains of leg pain that wakes him at night. He states that he has been having problems with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed a sore on the inner aspect of the right ankle. On the basis of this health history information, the nurse interprets that the patient is most likely experiencing: a. Pain related to lymphatic abnormalities. b. Problems related to arterial insufficiency. c. Problems related to venous insufficiency. d. Pain related to musculoskeletal abnormalities.
B
16. During an assessment, the nurse uses the profile sign to detect: a. Pitting edema. b. Early clubbing. c. Symmetry of the fingers. d. Insufficient capillary refill.
B
18. When assessing a patient, the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next? a. Document the finding. b. Auscultate the site for a bruit. c. Check for calf pain. d. Check capillary refill in the toes.
B
23. The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate? a. The patient is asked to assume a prone position. b. The patient is asked to bend his or her knees to the side in a froglike position. c. The nurse firmly presses against the bone with the patient in a semi-Fowler position. d. The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese person is extremely difficult.
B
28. During an assessment, the nurse has elevated a patients legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him sit up and dangle his legs over the side of the table, the nurse should expect that a normal finding at this point would be: a. Significant elevational pallor. b. Venous filling within 15 seconds. c. No change in the coloration of the skin. d. Color returning to the feet within 20 seconds of assuming a sitting position.
B
29. During a visit to the clinic, a woman in her seventh month of pregnancy complains that her legs feel heavy in the calf and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings? a. Deep-vein thrombophlebitis b. Varicose veins c. Lymphedema d. Raynaud phenomenon
B
30. During an assessment, the nurse notices that a patients left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem? a. Venous stasis b. Lymphedema c. Arteriosclerosis d. Deep-vein thrombosis
B
35. During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing: a. Lymphedema. b. Raynaud disease. c. Deep-vein thrombosis. d. Chronic arterial insufficiency.
B
8. The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease? a. Woman in her second month of pregnancy b. Person who has been on bed rest for 4 days c. Person with a 30-year, 1 pack per day smoking habit d. Older adult taking anticoagulant medication
B
9. The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement? a. Lymph flow is propelled by the contraction of the heart. b. The flow of lymph is slow, compared with that of the blood. c. One of the functions of the lymph is to absorb lipids from the biliary tract. d. Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue spaces into the bloodstream.
B
A 2-year-old child is brought into the emergency department after ingesting a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis
B
A 24-year old patient is admitted to the trauma unit with a diagnosis of a fractured femur after a motor vehicle accident. He states that he has pain in the injured leg. What should be the first action taken by the nurse? a. Administer the lowest dose of pain medication b. Assess the characteristics of the pain c. Call the orthopedic surgeon d. Complete the admission assessment
B
A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 50 mL/hr. At what time should the infusion be completed? a. 2300 Monday b. 2345 Monday c. 0015 Tuesday d. 0045 Tuesday
B
A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately? a. Blood pressure 110/60 b. Temperature 101.3° F c. Poor skin turgor and pallor d. Heart rate of 100 beats/min
B
A nurse is administering a diuretic to a patient and teaching the patient about foods to increase. Which food choices by the patient will best indicate successful teaching? a. Milk and cheese b. Potatoes and fresh fruit c. Canned soups and vegetables d. Whole grains and dark green leafy vegetables
B
A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit? a. Moist mucous membranes b. Postural hypotension c. Supple skin turgor d. Pitting edema
B
A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding will the nurse expect? a. Dry mucous membranes b. Abdominal distention c. Distended neck veins d. Flushed skin
B
A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe? a. Respiratory alkalosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory acidosis
B
A patient with chronic cancer pain experiences breakthrough pain (level 9 of 10) and anxiety while receiving sustained-release morphine sulfate (MS Contin) 160 mg every 12 hours. All these medications are ordered for the patient. Which one will be most appropriate for the nurse to administer first? a. Ibuprofen (Motrin) 400-800 mg orally b. Immediate-release morphine 30 mg orally c. Amitriptyline (Elavil) 10 mg orally. d. Lorazepam (Ativan) 1 mg orally
B
A patient with extensive second-degree burns on the legs and trunk is using patient-controlled analgesia (PCA) with IV morphine to be delivered at 1 mg every 10 minutes to control the pain. Several times during the night, the patient awakens in severe pain, and it takes more than an hour to regain pain relief. The most appropriate action by the nurse is to a. request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. b. consult with the patient's health care provider about adding a continuous morphine infusion to the PCA regimen at night. c. teach the patient to push the button every 10 minutes for an hour before going to sleep even if the pain is minimal. d. administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping.
B
In which patient will the nurse expect to see a positive Chvostek sign? a. A 7-year-old child admitted for severe burns b. A 24-year-old adult admitted for chronic alcohol abuse c. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism d. A 75-year-old patient admitted for a broken hip related to osteoporosis
B
The nurse observes that the patient's calcium is elevated. When checking the phosphate level, what does the nurse expect to see? a. Increased b. Decreased c. Equal to calcium d. No change in phosphate
B
The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? a. Sodium of 145 mEq/L b. Calcium of 15.5 mg/dL c. Potassium of 3.5 mEq/L d. Chloride of 100 mEq/L
B
Which action should the nurse take when preparing patient-controlled analgesia for a postoperative patient? a. Caution the patient to limit the number of times he presses the dosing button. b. Ask another nurse to double-check the setup before patient use. c. Instruct the patient to administer a dose only when experiencing pain. d. Provide clear, simple instructions for dosing if the patient is cognitively impaired.
B
Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis? a. pH 7.60, PaCO2 40 mm Hg, HCO3- 30 mEq/L b. pH 7.53, PaCO2 30 mm Hg, HCO3- 24 mEq/L c. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L d. pH 7.25, PaCO2 48 mm Hg, HCO3- 23 mEq/L
B
Which of the following instructions for use of a patient-controlled analgesia (PCA) pump is most important when educating the patient and family before implementation? a. Notify the nurse when you need to push the button on the pump. b. Only the patient should push the button for more medication. c. A spouse can push the button when the patient is asleep. d. Wait for the pain to become at least a 7 on the pain scale before pushing the button.
B
31. A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to *explain what a hernia is*. Which response by the nurse is appropriate?
B) "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles."
11. The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the *reason auscultation precedes percussion and palpation of the abdomen*?
B) "It prevents distortion of bowel sounds that might occur after percussion and palpation."
27. During an abdominal assessment, the nurse is *unable to hear bowel sounds* in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least:
B) 5 minutes.
14. During an abdominal assessment, the nurse would consider which of these findings as *normal*?
B) A tympanic percussion note in the umbilical region
1. The nurse suspects that a patient has *appendicitis*. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? *Select all that apply*.
B) Test for Blumberg's sign. D) Perform iliopsoas muscle test.
28. A patient is suspected of having *inflammation of the gallbladder, or cholecystitis*. The nurse should conduct which of these techniques to assess for this condition?
B) Test for Murphy's sign
23. The nurse is assessing the *abdomen of an aging adult*. Which of these statements regarding the aging adult and abdominal assessment is true?
B) The abdominal musculature is thinner.
12. The nurse is listening to *bowel sounds*. Which of these statements is true of bowel sounds?
B) They are usually high-pitched, gurgling, irregular sounds.
17. An older patient has been diagnosed with *pernicious anemia*. The nurse knows that this condition could be related to:
B) decreased gastric acid secretion.
20. The nurse knows that during an abdominal assessment, *deep palpation* is used to determine:
B) enlarged organs.
39. The nurse is preparing to examine a patient who has been complaining of *right lower quadrant pain*. Which technique is correct during the assessment? The nurse should:
B) examine the tender area last.
10. A patient has *hypoactive bowel sounds*. The nurse knows that a potential cause of hypoactive bowel sounds is:
B) peritonitis.
15. The nurse is assessing the *abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time*. The nurse knows that esophageal reflux during pregnancy can cause:
B) pyrosis.
A nurse is discontinuing a patient's peripheral IV access. Which actions should the nurse take? (Select all that apply.) a. Wear sterile gloves and a mask. b. Stop the infusion before removing the IV catheter. c. Use scissors to remove the IV site dressing and tape. d. Apply firm pressure with sterile gauze during removal. e. Keep the catheter parallel to the skin while removing it. f. Apply pressure to the site for 2 to 3 minutes after removal.
B, E, F
The nurse teaches clients with a new colostomy that they can eat whatever roods they like but that which of the follwing foods typically produce gas and should be consumed cautiously? (Select all that apply? ) A. Pasta B. Beans C. Garlic D. Onions E. Cauliflower
Beans Onions Cauliflower
Step 4 of Nursing Process: IMPLEMENTATION
Begins after care plan. Performance of interventions necessary for achieving goals and outcomes
13. During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process? a. Hormonal changes causing vasodilation and a resulting drop in blood pressure b. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency c. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure d. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities
C
17. The nurse is performing an assessment on an adult. The adults vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next? a. Ask the patient about a history of frostbite. b. Suspect that the patient has venous insufficiency. c. Consider this a delayed capillary refill time, and investigate further. d. Consider this a normal capillary refill time that requires no further assessment.
C
19. When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patients skin is warm and capillary refill time is normal. Next, the nurse should: a. Check for the presence of claudication. b. Refer the individual for further evaluation. c. Consider this finding as normal, and proceed with the peripheral vascular evaluation. d. Ask the patient if he or she has experienced any unusual cramping or tingling in the arm.
C
20. The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _______ pulse. a. Normal b. Absent c. Bounding d. Weak, thready
C
21. The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? a. To measure the rate of lymphatic drainage b. To evaluate the adequacy of capillary patency before venous blood draws c. To evaluate the adequacy of collateral circulation before cannulating the radial artery d. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded
C
32. The nurse is performing a well-child checkup on a 5-year-old boy. He has no current condition that would lead the nurse to suspect an illness. His health history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this patient? a. Enlarged, warm, and tender nodes b. Lymphadenopathy of the cervical nodes c. Palpable firm, small, shotty, mobile, and nontender lymph nodes d. Firm, rubbery, and large nodes, somewhat fixed to the underlying tissue
C
33. When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard? a. Low humming sound b. Regular lub, dub pattern c. Swishing, whooshing sound d. Steady, even, flowing sound
C
34. The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct? a. Is easily palpable; pounds under the fingertips. b. Has greater than normal force, then suddenly collapses. c. Is hard to palpate, may fade in and out, and is easily obliterated by pressure. d. Rhythm is regular, but force varies with alternating beats of large and small amplitude.
C
36. During a routine office visit, a patient takes off his shoes and shows the nurse this awful sore that wont heal. On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of: a. Varicosities. b. Venous stasis ulcer. c. Arterial ischemic ulcer. d. Deep-vein thrombophlebitis.
C
4. A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _______ the left leg. a. Venous obstruction of b. Claudication due to venous abnormalities in c. Ischemia caused by a partial blockage of an artery supplying d. Ischemia caused by the complete blockage of an artery supplying
C
A 73-year-old patient who sustained a right hip fracture in a fall requests pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing? a. Phantom b. Visceral c. Deep somatic d. Referred
C
A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let the blood infuse? a. 30 minutes b. 2 hours c. 4 hours d. 6 hours
C
A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan? a. Stimulate the patient's appetite to eat. b. Deliver antibiotics to fight off infection. c. Replace fluid, electrolytes, and nutrients. d. Provide medication to raise blood pressure.
C
A nurse is preparing to start a blood transfusion. Which type of tubing will the nurse obtain? a. Two-way valves to allow the patient's blood to mix and warm the blood transfusing b. An injection port to mix additional electrolytes into the blood c. A filter to ensure that clots do not enter the patient d. An air vent to let bubbles into the blood
C
A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute flow rate (drops/min)? a. 12 drops/min b. 24 drops/min c. 125 drops/min d. 150 drops/min
C
A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare? a. 0.225% sodium chloride (1/4 NS) b. 0.45% sodium chloride (1/2 NS) c. 0.9% sodium chloride (NS) d. 3% sodium chloride (3% NaCl)
C
A patient with a history of stroke 4 years ago resulting in aphasia (inability to verbally express thoughts) returns to the surgical unit after a cholecystectomy. The surgeon ordered an intravenous pain medication every 4 hours as needed (PRN) for postoperative pain. The best nursing intervention related to pain control after surgery would be to: a. Administer the pain medication when the patient becomes restless b. Wait until the patient verbalizes that hse is experiencing pain to administer the pain medication. c. Assess the patient's level of pain using a Faces Pain Scale and administer pain medication as ordered d. Administer the pain medication every 4 hours as the client can't express pain.
C
All the following medications are included in the admission orders for an 86-year-old patient with moderate degenerative arthritis in both hips. Which medication will the nurse use as an initial therapy? a. Aspirin (Bayer) 650 mg orally b. Oxycodone (Roxicodone) 5 mg orally c. Acetaminophen (Tylenol) 650 mg orally d. Naproxen (Aleve) 200 mg orally
C
Following surgery, a client has great difficulty getting out of bed, walking, and coughing and deep breathing. Although patient-controlled analgesia (PCA) is in place, it is rarely used, even when suggested by the nurse. This concerns the nurse. Which statement is the best way to address this concern with the client? a. "I noticed you use very little pain medication. You must be very brave and strong. But without pain medication, you will get weaker, not stronger." b. "I noticed you don't use much pain medication. If you don't push that button, I will. You need that medicine. Don't worry about getting addicted. It won't happen." c. "I noticed you haven't used your pain medication as often as you could, even though it is painful for you to get out of bed and to walk. Many people are reluctant to take pain medication. Tell me what makes you reluctant." d. "I can understand why you are reluctant to use pain medication. Many people feel the same way. Yet without pain relief, you can get atelectasis, pneumonia, and blood clots, and maybe even develop an ileus."
C
Patient-controlled analgesia (PCA) effectiveness is evaluated by: a. The number of minutes on the lockout interval b. How large a loading dose is required to relieve pain c. The client's indicating that pain is a 1 on a scale of 1 to 10 d. When the client is sleeping
C
The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients? a. Assess the patients for edema in extremities. b. Ask the patients to record their intake and output. c. Weigh the patients every morning before breakfast. d. Measure the patients' blood pressures every 4 hours.
C
The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action will the nurse take first? a. Offer calcium-rich foods. b. Administer diuretic. c. Raise head of bed. d. Increase fluids.
C
The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement? a. Urine output increases to 150 mL/hr. b. Systolic and diastolic blood pressure decreases. c. Serum sodium concentration returns to normal. d. Large amounts of emesis and diarrhea decrease.
C
The nurse observes edema in a patient who has venous congestion from right heart failure. Which type of pressure facilitated the formation of the patient's edema? a. Osmotic b. Oncotic c. Hydrostatic d. Concentration
C
When caring for a patient who is receiving epidural morphine, which information obtained by the nurse indicates that the patient may be experiencing a side effect of the medication? a. The patient complains of a "pounding" headache. b. The patient becomes restless and agitated. c. The patient has not voided for over 10 hours. d. The patient has cramping abdominal pain.
C
While the nurse is taking a patient history, the nurse discovers the patient has a type of diabetes that results from a head injury and does not require insulin. Which dietary change should the nurse share with the patient? a. Reduce the quantity of carbohydrates ingested to lower blood sugar. b. Include a serving of dairy in each meal to elevate calcium levels. c. Drink plenty of fluids throughout the day to stay hydrated. d. Avoid food high in acid to avoid metabolic acidosis.
C
While waiting to perform x-rays on an injured right hand according to non-pharmacological pain management practice, pain can be modulated or reduced if the nurse: a. Performs frequent pain assessment b. Administers a placebo c. Applies ice to the right elbow d. Turns off the light and shuts the door
C
26. The nurse is reviewing the *assessment of an aortic aneurysm*. Which of these statements is true regarding an aortic aneurysm?
C) A pulsating mass is usually present.
22. During an abdominal assessment, the nurse elicits *tenderness on light palpation in the right lower quadrant*. The nurse interprets that this finding could indicate a disorder of which of these structures?
C) Appendix
40. During a health history, the patient tells the nurse, "*I have pain all the time in my stomach. It's worse two hours after I eat, but it gets better if I eat again*!" The nurse suspects that the patient has which condition, based on these symptoms?
C) Duodenal ulcer
37. During an assessment the nurse notices that a patient's *umbilicus is enlarged and everted. It is midline, and there is no change in skin color*. The nurse recognizes that the patient may have which condition?
C) Umbilical hernia
3. A patient is having *difficulty in swallowing* medications and food. The nurse would document that this patient has:
C) dysphagia.
21. The nurse notices that a patient has had a *black, tarry stool* and recalls that a possible cause would be:
C) gastrointestinal bleeding.
18. A patient is complaining of a *sharp pain along the costovertebral angles*. The nurse knows that this symptom is most often indicative of:
C) kidney inflammation.
9. While examining a patient, the nurse observes *abdominal pulsations between the xiphoid and umbilicus*. The nurse would suspect that these are:
C) normal abdominal aortic pulsations.
16. The nurse is performing *percussion during an abdominal assessment*. Percussion notes heard during the abdominal assessment may include:
C) tympany, hyperresonance, and dullness.
upper motor neurons
CNS; diseases: CVA, cerebral palsy, MS
When a patient has fecal incontinence, which point is important for the nurse to instruct to all caregivers?
Cleanse the skin with a no-rinse cleanser and apply a barrier ointment.
The nurse is instructing the client about the use of opioids for pain relief. Included in the teaching is the fact that opioids may cause: A. Headaches. B. Constipation C. Hypertension D. Muscle weakness
Constipation
The nurse is positioning a hemiplegic patient in the supine position. The nurse places a folded towel under the hip of the patient. What is the reason behind this intervention?
Control hip position
Nursing process
Critical thinking process that professional nurses use to apply the best available evidence to care giving and the promotion of human functions and responses to health and illness.
10. When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? a. Assess the patients abdomen, and notice any tenderness. b. Carefully assess the cervical lymph nodes, and check for any enlargement. c. Ask additional health history questions regarding any recent ear infections or sore throats. d. Examine the patients lower arm and hand, and check for the presence of infection or lesions.
D
22. A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? a. Unilateral cool foot b. Thin, shiny, atrophic skin c. Pallor of the toes and cyanosis of the nail beds d. Brownish discoloration to the skin of the lower leg
D
24. When auscultating over a patients femoral arteries, the nurse notices the presence of a bruit on the left side. The nurse knows that bruits: a. Are often associated with venous disease. b. Occur in the presence of lymphadenopathy. c. In the femoral arteries are caused by hypermetabolic states. d. Occur with turbulent blood flow, indicating partial occlusion.
D
27. When assessing a patients pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus: a. Alternans. b. Bisferiens. c. Bigeminus. d. Paradoxus.
D
3. The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? a. Behind the knee b. Over the lateral malleolus c. In the groove behind the medial malleolus d. Lateral to the extensor tendon of the great toe
D
31. The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true? a. Normal ABI indices are from 0.5 to 1.0. b. Normal ankle pressure is slightly lower than the brachial pressure. c. The ABI is a reliable measurement of peripheral vascular disease in individuals with diabetes. d. An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication.
D
6. Which vein(s) is(are) responsible for most of the venous return in the arm? a. Deep b. Ulnar c. Subclavian d. Superficial
D
A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate? a. "Are you following any weight loss program?" b. "How many calories a day do you consume?" c. "Do you have dry mouth or feel thirsty?" d. "How many times a day do you urinate?"
D
A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)? a. Preps skin with povidone-iodine solution. b. Suggests the femoral vein for insertion site. c. Applies double gloving without hand hygiene. d. Uses chlorhexidine skin antisepsis prior to insertion.
D
A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient's peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action? a. Record a phlebitis grade of 4. b. Assign an infiltration grade. c. Apply moist compress. d. Discontinue the IV.
D
A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one? 1. Clean site. 2. Select vein. 3. Apply tourniquet. 4. Release tourniquet. 5. Reapply tourniquet. 6. Advance and secure. 7. Insert vascular access device. a. 1, 3, 2, 7, 5, 4, 6 b. 1, 3, 2, 5, 7, 6, 4 c. 3, 2, 1, 5, 7, 6, 4 d. 3, 2, 4, 1, 5, 7, 6
D
A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, which is the nurse's next action? a. Discontinue the IV catheter. b. Return the blood to the blood bank. c. Run normal saline through the existing tubing. d. Start normal saline at TKO rate using new tubing.
D
Both clients and nurses have misconceptions about pain. Which statement reflects a misconception? a. People can adapt to severe pain. b. Minor injuries can cause intense pain. c. The client is the authority about pain. d. Regular administration of analgesics leads to addiction.
D
The nurse administers codeine sulfate 30 mg orally to a patient who underwent craniotomy 3 days ago for a brain tumor. How soon after administration should the nurse reassess the patient's pain? a. Immediately b. In 10 minutes c. In 15 minutes d. In 60 minutes
D
The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? a. Gastrointestinal b. Neurological c. Respiratory d. Cardiac
D
To obtain the most complete assessment data about a patient's chronic pain pattern, the nurse asks the patient a. "Can you describe where your pain is the worst?" b. "What is the intensity of your pain on a scale of 0 to 10?" c. "Would you describe your pain as aching, throbbing, or sharp?" d. "Can you describe your daily activities in relation to your pain?"
D
When asked about pain, a client complains of having severe discomfort from arthritis. Vital signs are unchanged, and the client is calmly watching television. Which of the following nursing diagnoses is most appropriate? a. Acute pain b. Altered sensory perception c. Impaired mobility d. Chronic pain
D
Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? a. Weak quadriceps muscles b. Decreased deep tendon reflexes c. Light-headedness when standing up d. Tingling of extremities with possible tetany
D
Your patient developed respirator depression after her first dose of intravenous (IV) morphine. After giving 0.2mg of nalozone (Narcan) IV push, the patient's respiratory rate and depth are within normal limits. Which action do you take now? a. Leave the patient alone to sleep now. b. Discontinue all pain medications ordered c. Administer another dose of naloxone in 1 hours d. Assess the patient's vital signs every 15 minutes for 2 hours
D
7. A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, What happens to my circulation when this vein is removed? The nurse should reply: a. Venous insufficiency is a common problem after this type of surgery. b. Oh, you have lots of veinsyou wont even notice that it has been removed. c. You will probably experience decreased circulation after the vein is removed. d. This vein can be removed without harming your circulation because the deeper veins in your leg are in good condition.
D good condition
6. A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have *injured his spleen*. Which of these statements is true regarding assessment of the spleen in this situation?
D) An enlarged spleen should not be palpated because it can rupture easily.
35. The nurse is assessing a patient for possible *peptic ulcer disease* and knows that which condition often causes this problem?
D) Frequent use of nonsteroidal antiinflammatory drugs
4. The nurse suspects that a patient has a *distended bladder*. How should the nurse assess for this condition?
D) Percuss and palpate the midline area above the suprapubic bone.
25. To detect *diastasis recti*, the nurse should have the patient perform which of these maneuvers?
D) Raise the head while remaining supine.
2. Which structure is located in the left lower quadrant of the abdomen?
D) Sigmoid colon
38. During an abdominal assessment, the nurse tests for a *fluid wave. A positive fluid wave *test occurs with:
D) ascites.
8. The nurse is describing a *scaphoid abdomen. To the horizontal plane*, a scaphoid contour of the abdomen depicts a _____ profile.
D) concave
32. A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse *percusses the abdomen and notices an area of dullness above the right costal margin of about 10 cm*. The nurse should:
D) consider this a normal finding and proceed with the examination.
5. The nurse is aware that one change that may occur in the *gastrointestinal system of an aging adult* is:
D) decreased gastric acid secretion.
13. The physician comments that a patient has *abdominal borborygmi*. The nurse knows that this term refers to:
D) hyperactive bowel sounds.
7. A patient's abdomen is *bulging and stretched in appearance*. The nurse should describe this finding as:
D) protuberant.
An athletic young woman has just broken her leg while training for a marathon. The use of meditation has many physiological properties that will help the young woman to... A. Raise blood pressure B. Increase mood swings C. Increase oxygen consumption D. Lower muscle tension
D. Lower muscle tension
Areas of Indirect Care
Delegating, supervising and evaluating he work of other staff members.
Which of the following nursing interventions can improve the effectiveness of relaxation? (Select all that apply.)
Describe any sensations that patients will experience as they begin to relax When using guided imagery, explain the technique in detail
2 Care Plan Revisions
Discontinuing Care Plan--goals have been met Modifying Care Plan--goals have not been met
Soon after the client's abdominal surgery the nurse includes in the plan of care which of the follwing interventions, which is essential for promoting peristalsis? A. Consumption of a high-fiber diet B. Early ambulation C. Restriction of fluid intake D. Administration of large doses of opioids
Early ambulation
The nurse instructs the client to avoid which of the following foods, which could give a false reading on the fecal occult blood test? (Select all the apply.) A. Fish B. Lasagna C. Cranberry juice D. Raw vegetables
Fish Raw vegetables
Errors in DIAGNOSTIC STATEMENTS
Follow guidelines to reduce errors. Be APPROPRIATE, CONCISE, and PRECISE. USE STANDARDIZED LANGUAGE. 1. Identify pt's response -NOT MEDICAL DX! 2.Identify a nursing dx statement-NOT A SYMPTOM 3.Identify a treatable etiology- NOT A CLINICAL SIGN OR CHRONIC PROBLEM. 4. Identify the problem caused by a tx--NOT THE TREATMENT OR STUDY. 5. Identify the problem caused by the equipment, NOT THE EQUIPMENT ITSELF. 6. Identify pt problems--NOT YOUR PROBLEMS. 7. identify pt problem--NOT NURSING INTERVENTION 8.Identify problem--NOT GOAL 9.Make professional, NOT PREJUDICIAL, judgments. 10. Avoid statements that imply blame, neglegence or malpractice. 11. Avoid circular satements 12. ONE problem in a diagnostic statement.
To prevent the client from performing Vlsalva maneuver, the nurse might request a stool softener for a client with which of the following conditions? (Select all that apply.) A. Glaucoma B. Hypotension C. Cardiovasular disease D. Risk for increased intracranial pressure
Glaucoma Cardiovasular disease Risk for increased intracranial pressure
When caring for a patient with a new colostomy on the first postoperative day, which of the following tasks would be appropriate to teach the patient?
How to open and close the pouch
Evaluation Process
Identifying Critria and Standards Collecting Data Interpreting and Summarizing Findings Documenting Findings Care Plan Revision
What is the desired outcome when the head of the bed is elevated to 60 degrees in supported Fowler's position?
Improves ventilation
Comprehensive Health history
Includes information about his or her physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations about the health care system.
Which points would the nurse include when doing patient teaching for a patient with chronic complaints of constipation? (Select all that apply.)
Increasing fiber and fluids, exercising 30 minutes each day, and creating a toileting schedule are all the initial lifestyle changes to take to resolve chronic problems with constipation before considering regular laxative or enema usage
Diarrhea may be a result of which of the following conditions in the intestinal tract?
Infection, inflammation, food intolerance
Cue
Information you obtain through use of senses. Anything a pt says and any behaviors you observe are important cues.
Methods of Data Collection
Interview & Health Hx Physical Exam Observation of Behavior Diagnostic & Lab Data
A client with a Salem sump tube begins to drain stomach contents from the blue "pigtail". Which nursing actions would be approprate for the nurse to impelemt at this time? ( Select all that apply.) A. Clamp the blue pigtail B. Attach suction to the blue pigtail. C. Irrigate the large lumen with saline D. Position the blu pigtail at the level of the client's ear.
Irrigate the large lumen with saline
During the nursing assessment the client revels that he has diarrhea and cramping every time he eats ice cream. He attributes this to the cold termperature of the food. However, the nurse begins to suspect the these symptoms might be associated with. A. Food allergy B. Irritable bowel C. Lactose intolerance D. Increased peristalsis
Lactose intorlerance
Expected Outcomes
MEASURABLE criteria to eval goal achievement.
While positioning a patient in the supported supine position, the nurse places a pillow under the upper shoulders. What is the rationale behind this intervention?
Maintain correct alignment
Nursing-Sensitive Outcome
Measurable pt or family STATE, BEHAVIOR, or PERCEPTION that are largely influenced by and sensitive to nursing interventions.
Functional health patterns
Method for organizing assessment data based on the level of patient function in specific areas, for example, mobility.
Vague or circular statements
NO: Acute pain related to alteration in comfort YES: Acute pain related to incisional trauma.
problem caused by tx vs tx itself
NO: Anxiety related to Cardiac Catheterization YES: Anxiety relate to lack of knowledge about....
response to equip vs equipment itself
NO: Anxiety related to Cardiac Monitor YES: Deficient Knowledge regarding need for.....
blame, negligence or malpractice statements
NO: Chronic Pain related to insufficient pain medication. YES: Chronic Pain related to iimproper use of medications.
treatable etiology vs clinical sign or chronic dz
NO: Fatigue related to low RBC Yes: Fatigue related to chronic dz process
problem vs nursing intervention
NO: Offer bedpan frequently bc of altered elemination patterns YES: Diarrhea related to food intolerance.
ONE statement
NO: Pain and Anxiety related to difficulty ambulating YES: 1. Impaired Physical mobility related to pain in rt knee. 2. Anxiety related to fear of fall.
pt problem vs YOUR proble
NO: Potential IV Complications related to poor vascular access (YOU couldn't get a good IV) YES: Risk for infection related to presence of invasive lines.
problem vs goal
NO: Pt needs high protein diet related to potential alteration in nutrition YES: Imbalanced Nutrition: Less than body requirements related to inadequate protein intake
professional vs prejudice
NO: Risk for Impaired Skin Integrity related to poor hygiene habits YES: Risk for Impaired Skin Integrity related to lack of knowledge about perineal care.
statement vs symptom
NO: SOB Yes: Ineffective Breathing Pattern related to increased airway secretions.
response vs med dx
No: Fatigue Related to Cancer Yes: Fatigue Related to chronic dz process.
NANDA-I
North American Nursing Diagnosis Association, organized in 1973, which formally identifies, develops, and classifies nursing diagnoses for DOCUMENTATION, AUDITING, & COMMUNICATION purposes
NIC
Nursing Intervention Classification
NOC
Nursing Outcomes Classification
Objective data
Observations or measurements of a patient's health status.
The nurse is teaching the patient to obtain a specimen for fecal occult blood testing (FOBT) at home. Which is the correct way for the patient to collect the specimen?
Obtain specimens from three different stools.
lower motor neurons
PNS; diseases: spinal cord lesions, poliomyelitis, amyotrophic lateral sclerosis
What approach is essential in all steps of nursing process?
Patient-centered
7 guidelines for writing Goals & Outcomes
Patient-centered Singular Observable Measurable Time limited Mutual Factors Realistic
Subjective data
Patients verbal descriptions
Dependent Nursing Interventions
Physician-initiated require an order
Which positioning aid increases the cervical flexion?
Pillows
To test for stereognosis, you would...
Place a coin in the persons hand and ask them to identify it
Which intervention should the nurse perform while positioning a patient in the supported Fowler's position to decrease flexion of vertebrae?
Place a small pillow at the lower back
Which nursing action prevents tension on the spinal column and adduction of the hips while logrolling the patient?
Placing small pillows between patient's knees
The nurse is assisting a patient in the supported supine position. Which nursing action should the nurse implement to reduce the rotation of the hip?
Placing trochanter rolls parallel to the lateral surface of the thighs
The nurse is caring for four different patients with immobility with different conditions. Which patient should the nurse place in the side-lying position?
Pressure ulcers
While positioning a hemiplegic patient in the supported Fowler's position, the nurse positions the head of the patient against a small pillow with the chin slightly forward. What is the rationale behind this nursing action?
Prevent flexion contractures
While logrolling a patient, the nurse crosses the patient's arms on the chest. What is the reason for the nurse's action?
Prevent injury to arms
After assessing a patient with immobility, the nurse observes that the patient has acute respiratory distress syndrome. Which positioning of the patient would be appropriate to improve oxygenation?
Prone position
The nurse is caring for a patient with acute respiratory distress syndrome. While positioning the patient, the nurse observes hyperextension of the lumbar spine. Which patient positioning would likely have caused this condition?
Prone position
Basic Components of NURSING HEALTH HX
Reason for Seeking Care Present Illness Prior Health Hx Family Health Hx Environmental Hx Psychosocial/Cultural Hx Review of systems (head-to-toe)
A nurse is instructing the patient regarding collection of stool specimens for fecal occult blood testing. Which of the following should the nurse instruct the patient to avoid a few days before and during the testing period to reduce the risk of false-positive results?
Red meat, poultry, seafood, and some raw vegetables can cause false positive fecal occult blood testing results.
The nurse is positioning a patient in supported Fowler's position. Which action should the nurse perform to prevent flexion contractures of the cervical spine?
Rest the head of the patient against the mattress
Which positioning aid is contraindicated in a patient with spastic paralysis?
Rolled wash clothes Rolled washcloths are contraindicated in a patient with spastic paralysis, as they do not keep the thumb well abducted.
A client who recently experience a bout of diarrhea is requesting something to drink. There is an order to force clear liqueids to prevent fluid and electrolyte imbalance. The nurse decides to give the client: A. Ice cream B. A cold fruit pop C. A cup of hot coffee D. Room-temperature bouillon
Room-temperature bouillon
Diarrhea that occurs with a fecal impaction is the result of: A. A clear liquid diet B. Irritation of the intestinal mucosa C. Inability of the client to form a stool D. Seepage of stool around the impaction
Seepage of stool around the impaction
Step 3 of Nursing Process: PLANNING
Setting Priorities Identifying Patient-Centered Goals and Outcomes Prescribing Nursing Interventions
The nurse is positioning a postoperative patient to place the major portion of the body weight on the hip and shoulder. In which position does the nurse place the patient?
Side-lying
Clinical Practice Guideline
Standards for specific clinical situations: Protocols
Goals are based on -----& ------
Standards of CAre Clinical guidelines established for minimal safe practice.
During the enema the client begins to complain of pain. THe nurse notes blood in the return fluid and rectal bleeding. The nurs's next action is to: A. Stop the instillation. B. Slow down the rate of instillation C. Stop the instillation and meausre vital signs D. Tell the client to breathe
Stop the instillation and meausre vital signs
While caring for a postoperative patient, the nurse spreads trochanter rolls on the bed before positioning the patient. In which position is the nurse preparing to place the patient?
Supine position
Which nursing intervention would increase the risk for joint dislocation in a patient with hemiplegia who is immobile for an extended period?
Supporting the patient by holding the arm
Example goal of IV care
The IV site will remain free of phlebitis (established on the basis of sound nursing practice standards)
The nurse begins to suspect a fecal impaction in a client who has not had a stool in 10 days when which of the following occurs: A. The client feels nauseated B. The client oozes liquid stool C. The client has a rounded abdomen D. The client has continous bowel sounds.
The client feels nauseated The client oozes liquid stool The client has continous bowel sounds
NURSING DIAGNOSIS (2nd step in Nurse Process)
The second step of the nursing process, during which the patient's actual and potential unhealthy responses to an illness or condition are identified.Diagnostic Conclusions to determine a patient's problems and level of care required. A nurses can legally and independently treat. NOT A MEDICAL DX.
Most nutrients and electrolytes are absorbed in: A. The colon B. The stomach C. The esophagus D. The small intestine
The small intestine
You are caring for a patient who receives an opioid analgesic and a corticosteroid for breast cancer that has spread to the bones. The patient's husband inquires about the purpose of the corticosteroid. What is your best answer?
The steroid is an adjuvant to reduce inflammation.
Which positioning aid increases cervical flexion?
Thick pillow
While helping a patient move up in bed, the nurse turns the patient from side to side to place the drawsheet under the patient. What is the reason for this nursing action?
To reduce the friction during the movement
While caring for a patient with immobility, the nurse positions the patient in the supported supine position. The nurse places pillows under the pronated forearms keeping the upper arms parallel to the patient's body. What is the reason for this nursing action?
To reduce the internal rotation of shoulders
Which positioning aid decreases the shearing action from sliding across up and down in bed?
Trapeze bar
Which site is at risk for skin breakdown when the patient is in the side-lying position?
Trochanter
Which positioning aid prevents external rotation of the hips when the patient is in the supine position?
Trochanter roll
The nurse places the patient in prone position. Which nursing action reduces the flexion or hyperextension of the cervical vertebrae?
Turning the patient's head to one side and supporting it with a small pillow
Nursing Intervention
Tx based on clinical judgment & knowledge that a nurse performs to enhance patient outcomes.
Setting Goals
What is the best approach to address and resolf the problem? What do you plan to achieve?
Inference
Your judgement or interpretation of these cues.
What are some ways to think critically through data collection?
`Look for CUES. `Make INFERENCES
An assessment DATABASE includes:
`comprehensive health hx `physical exam `lab and diagnostic findings
Nursing Process is a _________ ___ ________ that can _____________ nurses against ____________ ________ related to nursing care
`standard of practice `protect `legal problems
Concept Mapping
a visual representation that shows the connection between the nursing dx and the problem
7. The healthcare provider order is 500 mL of 0.9% NaCL IV over 4 hours. Which rate does a nurse program into the infusion pump? a. 125 mL/hr b. 167 mL/hr c. 200 mL/hr d. 1000 mL/hr
a. 125 mL/hr
1. An IV fluid is infusing more slowly than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select All) a. Infiltration at vascular access device site b. Patient lying on tubing c. Roller clamp wide open d. Tubing kinked in bedrails e. Circulatory overload
a. Infiltration at vascular access device site b. Patient lying on tubing d. Tubing kinked in bedrails
6. What assessment does a nurse make before hanging a IV fluid that contains potassium? a. Urine output b. Arterial blood gases c. Fullness of neck veins d. LOC- level of consciousness
a. Urine output
hematuria
abnormal presence of blood in the urine
parasthesia
abnormal sensation
urinary reflux
abnormal, backward flow of urine
anesthesia
absent touch sensation
Strong Clinical reasoning and decision making help you:
accurately identify APPROPRIATE nursing interventions for a specific nursing diagnosis and achieve appropriate outcomes
micturition
act of passing or expelling urine voluntarily through the urethra
Example of direct nursing interventions
admin meds IV counseling during grief
2 types of peripheral nervous system fibers
afferent/sensory= to the PNS efferent/motor= from the CNS
Function of Cranial nerve VII Facial
anterior tongue taste, facial muscles, and closes eyes
Priorities help _____ and _____ nursing interventions when a pt has multiple problems.
anticipate, sequence
Cognitive Skills
application of critical thinking
stoma
artificially created opening between a body cavity and the body's surface
37. The nurse is reviewing an assessment of a patients peripheral pulses and notices that the documentation states that the radial pulses are 2+. The nurse recognizes that this reading indicates what type of pulse? a. Bounding b. Normal c. Weak d. Absent
b
2. Which patients does a nurse plan to teach regarding water restriction? a. 23-yr old with extracellular fluid vol. (ECV) deficit b. 34-YR old with hyponatremia c. 47-yr old with hypercalcemia d. 69-yr old with metabolic acidosis
b. 34-YR old with hyponatremia
nystagmus
back and forth oscillation of the eyes
A patient-centered goal is a:
broad statement that describes a desired change in a pts condition or behavior. "Pt will achieve improved energy level within 2 weeks"
2. The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery. a. Ulnar b. Radial c. Brachial d. Deep palmar
c
8. An older patient is receiving IV 0.9% NaCl. A nurse detects new onset of crackles in the lung bases. What is the priority action? a. Notify a health care provider b. Record in medical record c. Decrease the IV flow rate d. Discontinue the IV site
c. Decrease the IV flow rate
4. When delegating the I&O measurement to NAP, a nurse instructs them to record what information for ice chips? a. The total volume b. 2/3 Volume c. ½ Volume d. ¼ Volume
c. ½ Volume
test for CN IV
cardinal positions of gaze
test for CN VI
cardinal positions of gaze
test for CN III
cardinal positions of gaze PERRLA
The order of priorities _______________ with pt condition
change
Purpose of NOC
classifies, identifies, labels and validates nursing-sensitive outcomes.
test for CN V
clench teeth, superficial touch, corneal reflex
Defining Chracteristics of NANDA-I diagnoses
clicical criteria or assessment findings that support an actual nursing dx.
Selection of nursing interventions is part of _____ ____ ____.
clinical decision making
3 Implementation SKILLS
cognitive skills, interpersonal skills, Psychomotor skills
Goals and Outcomes are sometimes _____________________
combined (into one statement) "The patient will experience and improved energy level as evidenced by a self-report of fatigue of 3 or less on a scale of 0 to 10 within 2 weeks"
postvoid residual
complete inability of the bladder to empty
Cerebellar function is assessed by which of the following tests?
coordination-hop on one foot, tandem walking, tip-toe, heel walking
5. Which assessment does a nurse interpret as a transfusion reaction? a. Crackles in dependent lobes of lungs b. High fever, severe hypotension c. Anxiety, itching, confusion d. Chills, tachycardia, and flushing
d. Chills, tachycardia, and flushing
3. A nurse assesses pain and redness at a vascular access device (VAD). Which action is taken first? a. Apply warm moist compress b. Monitory the patient's BP c. Aspirate the infusion fluid form the VAD d. Stop the infusion and discontinue the IV infusion
d. Stop the infusion and discontinue the IV infusion
Assessment is ________ ___________. You build a ______________ of pt's PERCEIVED needs, health problems, and _________ to these problems
data collection database RESPONSES
5th (final) step of Nursing Process: EVALUATION
decide whether interventions have improved the pt's condition or well-being.
anosmia
decrease or loss of smell
hypoesthesia
decreased touch sensation
strabismus
deviated gaze
urometer
device for measuring frequent and small amounts of urine from an indwelling urinary catheter system
dysarthria
difficulty forming words
The medical record indicates that a person has an injury to broca's area. When meeting this person you expect...
difficulty speaking
dysphasia
difficulty with language comprehension or expression
Nursing Interventions can be ____ or ____
direct indirect
ureterostomy
diversion of urine away from a diseased or defective bladder through an artificial opening of the skin
3 levels of the NIC model
domain, classes and interventions
A positive Babinski sign is...
dorsiflexion of the big toe and fanning of all toes
Function of cranial nerve IV trochlear
down and inward eye movement
Care Plans
enhance the continuity of care by listing specific nursing actions necessary to achieve the goals of care.
NOC links _________ ______ ________ to every_____ _____ ________.
evidence-based outcomes NANDA-I nursing diagnosis
The Glasgow Coma Scale is divided into three areas. They include...
eye opening, motor response to verbal stimuli, verbal response
9. Place the following steps for discontinuing an IV access in the correct order: a. Perform hand hygiene and apply gloves b. Explain procedure to patient c. Remove IV site dressing and tape d. Use 2 ID's for patient e. Stop infusion and clamp tubing f. Carefully check healthcare order g. Clean site, withdraw catheter, apply pressure.
f. Carefully check healthcare order d. Use 2 ID's for patient b. Explain procedure to patient a. Perform hand hygiene and apply gloves e. Stop infusion and clamp tubing c. Remove IV site dressing and tape g. Clean site, withdraw catheter, apply pressure.
test for CN VII
facial movements some against resistance, identify tastes on anterior tongue
summation
frequent consecutive stimuli are perceived as one strong stimulus
Assessment questions move from ____ to ____.
general specific
test for CN VIII
hearing acuity
Function of Cranial nerve VIII Acoustic
hearing and equilibrium
Priorities
identify as high, medium, low
stereognosis
identify familiar object placed in hand; disability (astereognosis) occurs with sensory cortex lesions
test for CN I
identify odors
dysmetria
inability to control the distance, power and speed of muscular action
urinary incontinence
inability to control urination
hyperesthesia
increased touch sensation
direct and indirect interventions can be ____ or ____.
independent dependent
pyelonephritis
infection in the upper urinary tract
Role of Patient in Goal Setting
involved. Goal setting is mutual. Involves pt and family
Implementation through DIRECT CARE
involves patient interaction
The cremasteric response
is positive when the ipsilateral testicle elevates upon stroking the inner aspect of the thigh.
To establish a pt database you apply _______ & __________
knowledge (of science) and experience (recognition and anticipation) to help guide you to ask the right questions.
function of cranial nerve VI abducens
lateral eye movement
paralysis
loss of motor fx d/t a lesion/ loss of sensory innervation
Bell's palsy
lower motor neuron lesion ; causes paralysis of entire/partial face
Your patient is recovering from knee surgery and states that her pain level is 5 on a 0- to-10 pain scale. She received a dose of medication 15 minutes ago. Which interventions may be beneficial for this patient at this time? (Select all that apply.)
massage her back reposition her on her side take a few minutes and talk to her about the pictures of her family that she brought with her
Function of Cranial nerve V trigeminal
mastication and sensation of face, scalp and cornea
proper sequence for euro exam
mental status, cranial nerves, motor systems, sensory system, reflexes
Student Care Plans
more elaborate than hospital care plan
Function of Cranial nerve XII Hypoglossal
movement of the tongue
Function of Cranial nerve XI Spinal
movement of trapezius and sternomastoid muscles
Independent nursing interventions
nurse-initiated do not require an order
Types of Interventions
nurse-initiated physician-initiated collaborative interventions
Function of Cranial nerve III oculomotor
ocular movements, pupil constriction, lens shape, opening eyes
urosepsis
organisms in the bloodstream
Following the 5 steps of Nursing Practice helps you become _______ & ________
organized systematic
3 phases of Assessment
orientation phase--intro, establish trust, lay groundwork for understanding needs working phase-gathering info using various communication techniques (listening, paraphrasing, restating, summarizing, etc.) termination phase-Give cues as to the end of interview is upcoming. Summarize. Ask if accurate. Any Questions? End with Thank you and when you will return.
dysuria
painful urination resulting from bacterial infection of the bladder and obstructive conditions of the urethra
hemianopsia
partial/incomplete blindness
paresis
partial/incomplete paralysis
test for CN X
phonate "ah", gag reflex, voice quality and swallowing
Function of Cranial nerve IX Glossopharyngeal
phonation, swallowing, gag reflex, posterior tongue taste, and equilibrium
parietal lobe
post-central gyrus
frontal lobe
pre-central gyrus
Standing Order
preprinted document containing orders for conducting routine therapies, monitoring guidelines and/or diagnostic procedures for specific patients.
proteinuria
presence in the urine of abnormally large quantities of protein
temporal lobe
primary auditory reception center
occipital lobe
primary visual reception center
Student Care plans teach
problem-solving techniques nursing process skills of written communication organization
test for CN XII
protrude tongue and wiggle from side to side.
Psychomotor skills
putting together cognitive skill with motor skills (Example: know anatomy and physiology of taking pulse PLUS knowing how)
urinal
receptacle for collecting urine
urine hat
receptacle for collecting urine that fits toilet
graduated measuring container
receptacle for volume measurement
During a neurologic examination, the tendon reflex failed to appear. Before striking the tendon again, the examiner might use the technique of...
reinforcement
The absense of a defining characteristic suggests that you ______________ a diagnosis under consideration
reject
Dependent Nursing Interventions involve specific
responsibilities & technical knowledge
urinary retention
retention of urine in the bladder, condition frequently caused by a temporary loss of muscle function
Senile tremors may resemble Parkinsonism, except that senile tremors do not include...
rigidity and weakness of voluntary movement
Examples of indirect nursing interventions
safety & infection control documentation collaborations
Consulting other Health Care Professionals (part of Plannning)
seek the expertise of a specialist (instructor or clinical nurse specialist)
Goals can have two time limits
short term, long term
People who have Parkinson disease usually have which of the following characteristic styles of speech?
slow, monotonous
Function of Cranial nerve I olfactory
smell
Why are goals time limited?
so that the team has a common time frame for resolution.
To elicit a Babinski reflex...
stroke the lateral aspect of the sole of the foot from heel to the ball
Two primary types of data
subjective objective
urinary diversion
surgical diversion of the drainage of urine
Function of Cranial nerve X Vagus
talking, swallowing, and sensory of pharynx
The control of body temperature is located in...
the hypothalamus
voiding
the process of urinating
cerebral cortex responsible for
thought, memory, reasoning, sensation, and voluntary movement
Interpersonal Skills
trusting relationships, express caring, communicate clearly
test for CN XI
turn head and shrug shoulders against resistance
corneal reflex test is only done when....
unilateral sensioneural hearing loss is present
_______________ causes paralysis of lower 1/2 of face leaving the forehead intact.
upper motor neuron lesions
suprapubic catheter
urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis
Client has a blocked bowl. How would you describe the pain
visceral
Function of Cranial nerve II optic
vision
test for CN II
visual acuity, confrontation
residual urine
volume of urine remaining in the bladder after a normal voiding
