PN Course 1 Test 3

what should a patient with home O2 be instructed to avoid when O2 is in use? a. eating b. smoking c. driving d. working

B. smoking is never allowed when O2 is in use because it could spark a fire.

reactive hyperemia occurs when: a. pressure on the skin causes the skin to turn white. b. pressure on the skin causes the skin to turn red c. blood rushes to a place where there is an increase in circulation d. blood rushes to a place where there is a decrease in circulation

D. reactive hyperemia occurs when blood rushes to a site where there was limited circulation. interference with circulation causes the skin to blanch. if pressure is relieved the skin will become red due to vasodilation.

the phase V korotkoff sound is a. silence b. muffling. c. swishing d. auscultatory gap

Silence is considered to be the Phase V Korotkoff sound and makes diastolic pressure in adults. Muffling is Phase IV and indicates diastolic pressure in children and some adults. Swishing, or Phase II, increases as the cuff is deflated. Auscultatory gap is silence as the cuff deflates for 30 to 40 mmHg

what are the degrees for a. low fowlers b. semi fowlers c. high fowlers

a. 15-30 with feet at 10-15 degrees to prevent sliding b. 30-60 degrees and feet 10-15 degrees to prevent sliding c. 60-90 degrees and feet 10-15 degrees to prevent sliding

the most common type of bath is a: a. cleansing bath b. whirlpool c. sitz bath d. bag bath

a. cleansing bath (BEDBATH) chapter 19

which of the following chemical weapons prevent the nervous system from working properly? a. nerve agents b. blood agents c. pulmonary agents. d. incapacitating agents

a. nerve agents pg334

what is an example of an element that can release radiation? a. chlorine b. plutonium c. botulism d. sarin

b. plutonium pg 333

when transferring a patient with left sided weakness from the bed to the chair, where is it best to place the chair in relation to the patient? a. left side b. right side c. in front d. behind

b. right side chapter 18

frequent and excessive sweating of a pt is also known as a. reactive hyperemia b. cognition c. braden syndrome d. diaphoresis

d. diaphoresis chapter 19

when breaking a fall, it is best to primarily support the patients: a. shoulders b. lower back c. knees. d. head

d. head chapter 18

the correct technique to measure a pt's BP is a. sit in a chair and cross legs at the knees b. sit in a chair and rest for 2-3 minutes prior to take BP c. if supine, no rest time is required prior to taking BP d. brachial artery should be at the level of the right atrium.

D. The correct technique to measure BP is to position the patient in a chair or in supine position. The brachial artery should be at the level of the right atrium. Crossing legs at knees causes an elevated BP. The patient should rest for at least 5 minutes before BP is taken

the release of pathogenic or hazardous substances with the aim to harm humans is known as: a. bioterrorism b. vesicant c. oplague d. chemical restraint

a. bioterrorism pg 333

skin that is often wet is at risk for: a. maceration b. diaphoresis c. blanching d. induration

a. maceration chapter 19

how often must the nurse remove a patient's protective device and change the patient's position? a q30min b. q2h c. q4h d. q8h

b. q2h pg 336

where are pillows placed in side lying position?

between the legs (one leg straight one leg bent) one under head and shoulders one rolled up under the back one under the arm across the body.

which type of respiration describes fast, deep breathing a. bradypnea b. biots c. kussmauls d. cheyne-stokes

c. kussmaul ch 21

the best way to maintain the center of gravity while making a bed is to a. keep the bed at arms length. b. use barrier precautions and clean linens c. lift the pt first. d. raise the bed to an appropriate height

d. raise the bed to an appropriate height chapter 18

What does RACE stand for?

in a fire it is the steps of what to do in the event of a fire. Rescue Alarm Confine Extinguish

which statement describes the dorsal recumbent position? a. pts are on their back with knees flexed and soles of the feet are flat on the bed. b. pts are on their back with knees extended and feet plantar-flexed. c. pts are on their abdomen with their knees extended. d. pts are on their abdomen with knees flexed and feet dorsiflexed

A. pt lies on their back with knees flexed and feet flat on the bed.

one of the most common accidents among patients is: a. falls b. hip fracture c. subdural hematoma d. hand trauma

A. the most common accident among patients are falls, burns, cuts, bruises

a nurse finds that a patient's vital sings have significantly changed. the nurse should: a. chart only objective pt data b. continue to evaluate the pt w/o notifying the HCP c. notify the HCP d. measure VS every shift

C. Notification of the health care provider and his or her response should be documented with any significant change in vital signs. Objective and subjective patient data should be charted. Notification of the health care provider is necessary. Vital signs must be measured repeatedly until they return to acceptable limits.

which of the following patients is burned more easily that a person in good health? a. pt c. pneumonia b. pt c. hypothyroidism c. pt c. diabetes. d. pt c. morbid obesity

C. patient with diabetes have impaired sensation and are burned easily.

which acronym is used to decribe the process that should occur in response to a fire? A. PACE B. AREA C. RACE D. RACK

RACE- rescue, activate/alarm, contain, extinguish/evacuate

a dominant factor influencing hygiene practice is: a. mood b. culture c. peers d. meds

b. culture chapter 19

a patient on bed rest may assist in being lifted from the bed by: a. turning on one side first b. flexing both knees c. keeping elbows extended d. extending both ankles.

b. flexing the knees. chapter 18

the pulse rate/heart rate is measured by a. using a BP cuff b. placeing 2-3 fingers over a superficial artery that has bone behind it c. counting the pts respirations d. listening to the pts breath sounds

b. placing 2-3 fingers over a superficial artery that has bone behind it. chapter 21

cardiac contractions produce the: a. O2 sat b. pulse c. temp d. hypertension

b. pulse

the nurse is assisting with the insertion of an NG tube into a client. the nurse should place the client in what position for insertion? a. right side lying b. low fowlers c. high fowlers d. supine with head flat

c before the insertion of an NG tube the nurse places the client in a sitting/high fowlers position to reduce the risk of aspiration if the client should vomit. place a pillow behind the pts head and shoulders to promote swallowing during the procedure.

a tendon connects: a. muscle to bursa b. muscle to cartilage c. cartilage to bone d. muscle to bone

d. muscle to bone chapter 18

a principle of body movement for nurses when transferring a patient is a. bend at the waist. b. use smooth coordinated movements c. keep feet together d. fully extend the elbows

B. use smooth coordinated movements instead of jerking or sudden pulling motions will decrease the risk of injury. bend at the knees not the waist and keep feet shoulder width apart. do not extend the elbows to prevent stress and strain on back muscles.

which change occurs with aging? a. bone mass increase b. muscle cells replaced by connective tissue c. joint motion decreases. d. elasticity of muscle fibers is increased.

C, joint motion may decrease, and decreased flexibility are age related changes. joint motion, mobility, activity, and exercise will decrease. bone mass is lost because of resorption of minerals. muscle cells are lost and replaced by fat. elasticity of muscle fibers is decreased or lost.

BP is affected by a. increase in blood volume b. body temp. c. gender d. loss of appetite

a. increase in blood volume chapter 21

passive range of motion (ROM) is appropriate for which movable joints? a, knees. b. ribs. c. pelvis d. clavicle

a. knees chapter 18

an infant's temperature is taken a. when the infant is crying b. immediately following a feeding c. rectally d. before bathing

c. rectally chapter 21

the acronym for a fire emergency is a. MATCH b. GO c. FLAME d. RACE

d. race pg 332

A couple who is caring for their aging parents are concerned about factors that put them at risk for falls. Which factors are most likely to contribute to an increase in falls in the elderly? Select all that apply. a. inadequate lighting b. throw rugs c. multiple meds d. doorway threasholds e. cords covered by carpets f. staircases with handrails

A, B, C, D, E Falls most often occur while transferring from beds, chairs, and toilets; getting into or out of bathtubs; tripping over items such as cords covered by rugs or carpets, carpet edges, or doorway thresholds; slipping on wet surfaces; and descending stairs. Multiple medications also contribute to fall risk.

what is your role as a nurse during a fire? select all that apply a. help to evacuate pts b. shut off medical gasses c. use a fire extinguisher d. single carry pts out e. direct ambulatory pts.

A, B, C, E. Direct all ambulatory patients to walk by themselves to a safe area. If you have to carry a patient, do so correctly (e.g., two-man carry). After a fire is reported and patients are out of danger, nurses and other personnel take measures to contain or extinguish it such as closing doors and windows, placing wet towels along the base of doors, turning off sources of oxygen and electrical equipment, and using a fire extinguisher.

at noon the ED nurse hears that an explosion has occurred in a local manufacturing plant, which action does the nurse take first? a. prep for an influx of pts b. contact the American Red Cross c. determine how to resume normal operations. d. evacuate pts per the disaster plan.

A. The emergency department nurse needs to prepare for the potential influx of patients first. Staff need to be aware of the disaster plan. Patients may need to be evaluated but not initially. The American Red Cross is not contacted initially. Determination of how to resume normal operations is part of the disaster plan and is determined before an actual event.

a nurse is performing mouth care on an unconscious pt. the nurse should: a. provide full oral care q8h b. provide full oral care q24h c. provide moist swabbing of oral cavity q4h provide moist swabbing of oral cavity q8h

A. full mouth care should be done q8h. mouth swabbing is q2h PRN

a nursing intervention for a pt with a protective device is: a. secure the ties of a protective device to an immovable part of the bedframe b. use a complete bow knot to secure the device to the bedframe or chair c. remove the device every shift d. check the area distal to the device qh.

A. whne using a protective device tie the ties to an immovable part of the bed frame. use half bow knot to secure the device to a chair or bed frame. remove the device q2h. and check distal to the device q15-30 mins

The nurse enters a client's room and finds that the wastebasket is on fire. the nurse quickly assists the client out of the room. Which is the next nursing action? A. Call for help B. Extinguish the fire C. Activate the fire alarm D. Confine the fire by closing the room door.

Ans. C. Activate the fire alarm. Rationale: the order of priority in the event of a fire is to rescue the clients who are in immediate danger. the next step is to activate the alarm, then confine the fire by closing the doors, and then finally extinguis the fire

The nurse is caring for a client with a health care associated infection caused by methicillin-resistant staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions should the nurse use to perform this procedure? Select all that apply. A. Put on a mask. B. Don gown and gloves C. Wear shoe protectors D. Wear a pair of protective goggles E. Have the pt wear a mask and goggles

Ans: A, B, D Rationale: Contact precautions are in place, which include wearing gloves and a gown while providing care to the client. The mask and goggles are indicated because of the potential of splash contact during the wound irrigation procedure. goggles are worn to protect the mucous membranes of the eye during during interventions. Shoe protection is not necessary and are used in ORs and surgical depts. If the pt is on airborne or droplet precautions a mask is only worn when the patient leaves the room, goggles are not worn by the client

The ED nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. the victims will be brought to the ED. Which should be the initial nursing action? A. prep triage rooms B. Activate the agency's emergency response plan C. obtain additional nursing staff to assist with and treating injuries. D. Obtain additional nursing staff to assist with treating the casualties

Ans: B. Activate the agency's emergency response plan. Rationale: during a wide spread disaster, many people are brought to the ED for tx. health care institutions are required to have an emergency response plan in place and perform practice drills. the initial nursing action is to activate this response. the plan entails the other options.

the nurse should institute which interventions for a client diagnosed with clostridium difficil? Select all that apply. A. wear a mask within 3ft of the pt. B. Place a mask on the client when client leaves the room. C. Wear gloves and gown while in the room caring for the pt. D. use soap and water, not alcohol based hand rub for hand hygiene. E. keep the door to the room shut except when entering and exiting the room.

Ans: C, D Rationale: contact precautions are necessary for colonization/infection w. a multi-drug resistant organism, this includes C. diff. measures used to prevent C. Diff are wearing gloves and gowns while in the room, not just during care, b/c the spores are on many surfaces. washing with soap and water for hand hygiene is most effective against spores. the use of the mask on a patient is unnecessary because it is not transmitted via respiratory route. and the door does not need to be shut.

A mother calls a neighborhood nurse and tells the nurse that her 3 y.o child has just ingested liquid furniture polish. which action should the nurse instruct the mother to take first? A. Induce vomiting B. Call an ambulance. C. Call the poison control center. D. Bring the child to the ED

Ans: C. Call the poison control center Rationale: if a suspected poisoning occurs, the poison control center should be contacted immediately. The nurse can assist the mother with contacting the poison control center. Vomiting should not be induced without instructions from the poison control center. Inducing vomiting is not done if the client is unconscious or the substance ingested is a strong corrosive or petroleum product. Bringing the child to the ED or calling an ambulance would delay Tx. the poison control center may advice the mother to bring the child to the ED; if this is the case , the mother should call an ambulance.

A LPN attends a session about bioterrorism agents including anthrax. which statement by an attendee demonstrates the need for further teaching about anthrax? A. it is treated with antibiotics. B. the most lethal form of anthrax is contracted by inhalation of spores. C. anthrax can be transmitted by consumption of meat from an infected animal. D. anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis.

Ans: D: anthrax bacteria produces a neurotoxin leading to paralysis. rationale: anthrax is caused by bacillus anthracis, and can be contracted via GI tract, abrasions in the skin or inhalation. antibiotic are administered. botulism is caused by a neurotoxin that causes paralysis.

older adults have an increased risk for developing impaired skin integrity resulting from: a. increased subQ fat. b. decreased skin elasticity c. increased sebaceous gland activity. d. ineffective mucous membrane protection

B. older adults have decreased subcutaneous fat, sebaceous gland activity, and elasticity in their skin. these changes increase the risk for developing impaired skin integrity. older adults have decreased subQ fat, and decreased sebaceous gland activity, mucous membrane function is not directly affected by age.

the nurse obtains a prescription to restrain a client using a belt/ safety restraint and instructs the UAP to apply the restraint. Which observation, if made by the nurse indicates unsafe application of the restraint? A. A safety knot is made in the restraint starp B. the restraint straps are safely secured to the side rails C. the restrain strap does not tighten when force is applied against it. D. the restraint is secure and the client is able to turn from back to side

B. the restraint strap is secured to the bedframe not the rails to avoid accidental injury when the side rail is released. half-bow/safety knot should be used b/c it does not tighten with force but allows for quick easy removal if there's an emergency.

body temp is regulated by: a. the pituitary acting to control body temp b. air movement causing heat to be transferred from the skin to the air molecules by convection c. blood flow from the skin carrying heat to the internal organs d. endocrine glands contributing to evaporative loss by secreting sweat

B. Air movement causes heat to be transferred from the skin to air molecules by convection to regulate body temperature. Heat loss increases when the skin is moistened and evaporation occurs. The hypothalamus controls body temperature by a feedback mechanism. Blood flow from internal organs carries heat to the skin. Sweat glands contribute to evaporative loss by secreting sweat

which is the proper technique when performing a transfer with a lift sheet? a. remove the pillow from under the patient's head b. roll the lift sheet close to the patients body. c. the nurse/nursing assistants face the end with feet together d. preferably two people stand on opposite sides of the bed.

B. roll the lift sheet close to the patients body, and on the count of three lift the pt to one side of the bed. leave a pillow under the patient's head and lower the side rails. pts face the bed with one foot slightly in front of the other. three people should assist, ideally.

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. His wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. Which factors increase his fall risk at this time? Select all that apply. a. smokes a pack a day b. uses a cane to walk at home c. takes antihypertensives and diuretics. d. has a history of recent fall e. neglect, spatial and perceptual abilities, impulsive f. requires assistance with activity, unsteady gait g. IV line and urinary catheter

C, D, E, F, G. Smoking is not a risk factor for falls. Use of the cane at home is not a current risk factor for falls. Risk is determined by his current status.

the nurse applies wrist restraints, prescribed to prevent a client from polling out an NG tube *nasogastric tube* how should the nurse determine that the restraints are not too constrictive? a. observe the skin in the wrist area for redness. b. check the temp of the skin in the hands. c. place 2 fingers under the restraints to determine snugness. d. remove the restraint and exercise q2h.

C. Rationale: limb restraints are often prescribed to prevent clients from pulling out tubes/injuring themselves. the restraint is prescribed for 24h and the nurse must verify the restraint is protecting the client from self injuring but not too constrictive to impair circulation or harm the skin. limb restraints are made with padding to protect the client's skin. the nurse determines the tightness of the wrist restraint by placing two fingers under the restraint. observing the skin and checking temp. is not as thorough or as accurate as checking the restraints. and restraints need to be removed q2h but this is not an evaluation of tightness.

restricting a pts movements on a long term basis can cause a. diarrhea b. anxiety c. atrophy d. hypertension

C. atrophy pg 335

what is the formula to convert Fahrenheit to Celsius THE BOARD EQUATIONS WERE WRONG

C= (F-32)x5/9

The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. the nurse should pan to maintain bed rest for this patient in which position? a. high fowlers b. supine with no head elevation c. left lateral d. supine with the head elevated no more than 30 degrees

D. rationale: after a cardiac cath. the extremity into which the cath was inserted is kept straight for the prescribed time to prevent arterial occlusion or bleeding and hematoma. with a femoral approach, the client's affected extremity is kept straight and the HOB is raised no more than 30 degrees until hemostasis is achieved. the client may turn side to side. bathroom privileges are not allowed. the other positions are not effective in preventing complications while allowing comfort.

one of the most common injuries for health care workers is... a. wrist strain b. knee strain c. neck strain d. lower back strain

D. one of the most common injuries for health care workers is lower back strain. it could be avoided in many situations with the use of proper body mechanics.

The nurse is preparing to reposition a dependent client who weighs more than 250#. Which intervention should the nurse use to move the client? Select all that apply. a. use friction-reducing sliding sheet b. use mechanical lift to move the client c. place the patient in trendeleburg position d. keep elbows close and work close to the body. e. administer oral pain meds 5 mins before moving the client f. obtain assistance of a second caregiver to assist with mechanical aids

a, b, d, f. manually lifting or transferring clients can result in work related injuries and back problems. shearing of the pt's skin over bony prominences may occur if a worker moves a pt independently. the nurse should get assistance from another care giver, use proper body mechanics while using mechanical aids. placing the pt in trandelenburg is not a useful technique, it could be harmful due to the pressure on the diaphragm and blood rushing to the head. admin of PO pain meds should be done >30 mins before activity.

which of the following considerations should be followed when using a safety razor? a. lubricate the skin b. hold the razor at a 90 degree angle to the skin c. let the skin hang loosely d. shave against hair growth

a. lubricate the skin chapter 19

body mechanics require the individual to use which of the following during lifting? a. proper alignment b. extension of the elbows. c. a solid narrow base of support. d. stationary position to prevent a pivot.

a. proper alignment chapter 18

routine vital sing measurements include: a. temp b. height c. weight d. fluid

a. temp temp. HR, RR, BP, Pain

the nurse is reinforcing home care instructions to a client and family regarding care after left cataract surgery with lens implant. which statements made by the client indicates understanding of the teaching? Select all that apply. a. I will bend over to tie my shoes b. I will not sleep lying on my left side c. i will sit at the table to eat breakfast. d. i will sit in my recliner with my feet elevated e. i will not lift anything more than 10# f. i will resume my exercise routine which includes pushups

b, c, d, e after cataract surgery, the client should not assume positions that will increase the intraocular pressure. this could lead to injury at the surgical site and damage the lens implant. the client should not sleep on the side of the body that was operated on. the client may resume sitting upright at the table or sitting in the recliner with feet up. they should not lift anything more than 10#. client should not perform activities that increase the pressure.

the nurse is administering a cleansing enema to a client with a fecal impaction. before administering the enema, the nurse asks the client to assume the sims position. the nurse explains that this position is preferred because of which reason? a. the nurse is right handed b. the rectal sphincter will relax c. the enema will flow into the bowel easily d. the client is more likely to retain the enema solution

c. when administering an enema, the client is placed in left sims position so that the enema solution can flow by gravity in the natural direction of the colon. the anatomy of the colon consists of the ascending on the right, transverse across, with descending on the left leading to the sigmoid and rectum. if the pt lies on the left side, the enema solution will flow more easily into the bowel. the hand dominance of the nurse is not a factor. the nurse assists the client to relax the rectal sphincter by asking them to take a deep breath. the nurse assists the client to retain the enema by administering it slowly. the nurse should also use teach back to help the lcient understand the reason for the enema

a basic position for a patient resting in bed is: a. knee-chest b. lithotomy c. side lying/lateral d. sims position

c. side lying/lateral chapter 18. the other positions are variations of basic positions!

a full thickness skin loss of the subcutaneous tissue without involvement of muscle or bone is classified as which type of pressure injury? a. stage I b. stage II c. stage III d. stage IV

c. stage III chapter 19

one of two instruments used to measure bp is a. oximeter b. skin probe c. sphygmomanometer d. electric thermometer

c. this thing + stethoscope

patients entering the ER are triaged based on a. order of arrival b. age c. type of care required d. type of insurance

c. type of care pg 335

after a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side lying position. the nurse understands that the purpose of this intervention is to accomplish which of the following? a. promote bile flow b. limit client discomfort c. promote hepatic glucose storage d. limit bleeding from the biopsy site

d. after a liver biopsy, the client is assisted with assuming a right side lying position with a small pillow or folded pillow under the puncture site for at least 3 hours to apply pressure and limit bleeding from the biopsy site. the liver produces bile that flows through the common bile duct; client discomfort may be decreased; and the liver does store glucose as glycogen but these are not reasons for the right side lying positions

what is the largest organ in the body?

*Skin* it has two layers and has a large surface area and mass.

the body temp may be affected by a. time of day b. height c. time of year d. gender

a time of day chapter 21

a pt has recently had rectal surgery, which bath would you give to promote healing and relieve discomfort for this pt?

*Sitz bath* used to apply moist heat and clean the perineal or anal area as well as promote healing and relive discomfort.

a nurse finds a pressure ulcer on a patient's sacrum that resembles a blister. what stage is this pressure ulcer?

*Stage II* pressure ulcer is a partial thickness skin loss involving the epidermis and/or the dermis. A stage I pressure ulcer is an area of red, deep pink or mottled skin that does not blanch with fingertip pressure. a deep tissue injury is localized discolored intact skin that results from damage to underlying soft tissue from pressure or shear. a stage III pressure ulcer is a full thickness skin loss that may extend to the fascia.

which type of fire extinguisher is used for electrical fires? a. type A b. type B c. type C d. type D

*TYPE C*- electrical fires and contain CO2 A- water under pressure that is used for paper, wood, or cloth B- CO2 used on gasoline, oil, paint, fat, flammable liquid fires. D is not a type

the nurse is evaluating a pt who is in soft wrist restraints. which of the following activities does the nurse perform? select all that apply a. check the pts peripheral pulses in the restrained extremity. b. evaluate the pts need for toileting c. offer the pt fluids if appropriate. d. release both limbs at the same time to perform ROM e. inspect skin under each restraint.

A, B, C, E. The nurse should evaluate patient for signs of injury every 15 minutes e.g., circulation, vital signs, ROM, physical and psychological status, and readiness for discontinuation. The nurse should evaluate patient's need for toileting, nutrition and fluids, hygiene, and elimination and release restraint at least every 2 hours but should do it one limb at a time

what are the components of the musculoskeletal system? select all that apply. a. skeletal muscles b. ligaments c. bones d. blood vessels

A, B, C. skeletal muscles, ligaments and bones are part of the musculoskeletal system, blood vessels are part of the cardiovascular system.

a pt has a very high fever that has persisted for 3 days. which symptoms should the nurse recognize as being associated with prolonged, high fever? select all that apply. a. hypertension b. dehydration c. delirium d. convulsions

B, C, D. If the fever is very high, or if it lasts for an extended period, dehydration, delirium, and convulsions may occur. Dehydration occurs as fluid is lost with perspiration and rapid breathing. Delirium may occur because the fever affects neurologic function. Convulsions may occur because the fever affects neurologic function. Hypertension is not associated with a persistent, high fever

a nursing assistant is helping with bathing, dressing, and grooming pts. the NA knows that a safety razor can be used on which patient? a. pt with low platelet count b. pt with pneumonia c. pt taking anticoagulants d. pt on chemotherapy

B. pt with pneumonia may be shaved with a safety razor if there is no risk of bleeding.

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? Select all that apply. a. contact the nursing supervisor b. restrict family visiting privileges c. ask the family to stay with the pt if possible. d. inform the family of risks associated with siderail use. e. thank the family for being conscientious and put them all up f. discuss alternatives that are appropriate for this pt with the family

C, D, F. The family is concerned about ensuring a safe environment for their loved one. The nurse should discuss their concerns, the risk of using restraints related to using four side rails, and safer alternatives such as the presence of a family member. If the family still insists on use of four side rails, you could contact the nursing supervisor to further discuss the situation with them. This is not a reason to restrict visitation; but, although you should appreciate their concern, the use of four side rails should be avoided.

a critically ill pt has faster and deeper, the slower respirations. these are followed by a period of no breathing for 21 seconds with continuation of this cycle. this respiratory pattern is called: a. cheyne-stokes respirations b. kussmaul's respirations c. hyperventilation d. biot's respirations.

Cheyne-Stokes respirations consist of a pattern of dyspnea followed by a short period of apnea. Kussmaul's respirations are seen in patients with diabetic acidosis and renal failure. Hyperventilation may occur in patients who have high levels of anxiety or fear. Biot's respirations occur in patients with increased intracranial pressure

the elderly have a greater risk of skin breakdown because they have a. decreased circulation b. increased muscle mass c. poor skin turgor d. capillary fragility.

D capillary fragility

What does PASS stand for?

PASS is how you extinguish a fire. Pull the pin on the fire extinguisher Aim the nozzle at the base Squeeze the lever Sweep at the base of the fire

an effective backrub should last: a. 3-5mins b. 10-15 mins c. 20-25 mins d. 30-40 mins

a 3-5 mins chapter 19

tachycardia refers to a pulse that is: a. >100bpm b. irregular c. <60 bpm d. weak

a >100bpm chapter 21

kinesiology is the study of a. body chemistry b. body mechanics c. joint dysfunction d. muscle building

b. body mechanics (chapter 18)

what should the approximate temperature for the water be when bathing a patient? a. 75F b. 90F c. 105F d. 120F

c. 105F (75 is too cold 90 will cool quickly, 120 is too hot) ALWAYS ASK YOUR PATIENT chapter 19

temperature measurements may be taken by a. placing the palm of your hand on the pts forehead b. checking the atmospheric temp first c. checking the pts throat for redness d. using an axillary thermometer

d. using an axillary thermometer *remember axillary is 1 degree less that oral, and rectal is one degree more than oral

the nurse is assisting with planning care for a client with an internal radiation implant. which should be included in the plan of care, select all that apply. a. wearing gloves when emptying the client's bedpan. b. keeping all linens in the room until the implant is removed. c. wearing a film badge when in the client's room d. wearing a lead apron when providing direct care to the patient. e. place the pt in a semiprivate room at the end of the hall.

A, B, C, D the nurse should follow std. precautions when caring for any client. linens are kept in the room as a safety precaution in case of contamination or part of the implant is lost. the film badge allows the nurse to visualize the estimated amount of radiation exposure during the shift. the nurse wears the lead apron to protect oneself and block the radiation. pt must have private room and bathroom.

which is a true statement regarding the organs of respiration? a. surfactant is necessary for alveoli to remain open b. there are three lobes in the left lung and two in the right lung c. gas exchange with the blood occurs int he bronchi d. the slight positive pressure in the chest on inspiration draws air into the lung

A. Surfactant reduces surface tension on the alveolar wall, allowing expansion. There are three right lobes and two left lobes. Gas exchange with the blood occurs in the alveoli. The slight negative pressure draws air into the lungs

which statement describes proper body alignment of a patient? a. when supine, the vertebral column should be in alignment b. when sitting, the knees should be flexed at 60 degrees. c. when supine, support the head with two pillows. d. when sitting, the arms should be crossed over the lap.

A. When supine, the vertebral column should be centered and aligned with no observable curves. when sitting, the knees should be flexed 90 degrees. when supine, support the head with one pillow so the neck is not hyperflexed. when sitting, the arms should lie comfortably in the lap or supported by arm rests

the nurse providing care to a patient with a pressure ulcer should know that the initial wound care involves: a. a surgical flap. b. intravenous antibiotic therapy. c. debridement d. amputation.

C. initial care involves debridement, wound cleaning and application of dressings. subsequent wound care may involve a surgical flap. IV antibiotics are used for infected wound, and amputation is not usually the first route.

avg. rm temp for an adult pt would ideally be between a. 57-61F b. 62-67F c. 68-74F d. 75-80F

C. 68-74F pg 321

a client has a pulse deficit. which of the following defines a pulse deficit? a. the difference between the carotid and radial pusle b. the difference between the carotid and the apical pulse c. the difference between the apical and radial pulse d. the difference between the apical and dorsalis pedis pulse.

C. The radial pulse subtracted from the apical pulse equals the pulse deficit.

when should a nurse make a bed with the pt in the bed. a. pt leving for procedures b. pt c. visitors c. pt c. amputation d. pt on bedrest

D A patient on bed rest would have the bed made while in the bed. An occupied bed is made only if the patient absolutely cannot be out of bed. An unoccupied bed is made when the patient is out of bed in a chair or out of the room.

what changes in vital signs occur in the elderly? a. the olderperson often has a higher than normal temperature b. the heart rate is often slower. c. the systolic bp drops slightly d. the hearth rhythm may be slightly irregular

D. Heart rhythm may be slightly irregular, but the normal range for the heart rate does not change. A lower normal temperature is found in the elderly. The systolic blood pressure rises slightly

a pt mat protect oneself from radiation by: a. wearing a device to deflect the radiation. b. taking special medication to decrease exposure. c. limiting exposure to family/friends who have had radiation d. decreasing the amount of time near a source

D. There are three basic ways to protect the body from radiation: decrease time near a source, increase your distance from a source, and increase the barrier or shield between you and the source

what is the formula to convert Celsius to Farenheit THE BOARD EQUATIONS WERE WRONG

F=(cx9/5)+32

when making the pts bed it is important to: a. use proper body alignment & wide base of support b. continually switch to the other side to be sure linen is even c. remove all linens together to save time and energy. d. flip and fan linen to remove MOs

a use proper body alignment & wide base of support. pg 329

a ligament connects a. muscle to bone b. muscle to muscle c. bone to bone d. cartilage to bursa

c. bone to bone chapter 18

elevation of the knees above 15 degrees in the supine position is contraindicated in a. stroke pts b. cardiac pts. c. elderly pts. d. pregnant pts.

c. elderly patients. elevation of knees above 15 degrees is contraindicated in the elderly and postop pts because it is associated with decreased circulation of the lower extremities.

if no laundry hamper is available, the next best place for soiled linens is: a. the floor b. the pt closet c. the pt sink d. a pillowcase

d. a pillow case pg 324

an example of a normal age-related change in skin condition is increased: a. nail growth b. redness c. oiliness d. collagen loss

d. collagen loss chapter 19

how often should full mouth care for the unconscious patient be performed? a. q2h b. q8h c. q12h d. q24h

q8h at least once a shift chapter 19 pg 310

which factors affecting a pt's environment must be controlled? select all that apply a. temp b. ventilation c. decor d, odor

temp, ventilation, humidity, lighting, ordor and noise must be controlled. rooms should be kept between 68-74, ventilation supplies a room with fresh air. odors can be controlled by good ventilation and cleanliness, decor is not somethng that needs to be controlled.

what are the main functions of the skin? select all that apply a. protection b. sensation c. excretion d. metabolism

the four main functions of skin are Protection, sensation, temp regulation and secretion/excretion.

where are pillows placed in supine position?

under the knees and allows ankles to hang. under both elbows under the head and shoulders