Skills Exam 2 questions

A 62 year old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that: 1. A safe environment promotes patient activity 2. Assessment focuses on environmental factors only 3. Teaching home safety is difficult to do in the hospital setting 4. Most accidents in the older adult are caused by lifestyle factors

1. A safe environment promotes patient activity Older adults are frequently fearful of falling and thus often limit activity. A safe environment, which decreases the risk of a fall, promotes patient activity.

How does the nurse support a culture of safety? (Select all that apply.) 1. Completing incident reports when appropriate 2. Completing incident reports for a near miss 3. Communicating product concerns to an immediate supervisor 4. Identifying the person responsible for an incident

1. Completing incident reports when appropriate 2. Completing incident reports for a near miss 3. Communicating product concerns to an immediate supervisor Completing incident reports for actual and near-miss events helps the facility track information and identify trends and patterns that need to be addressed. Communicating product concerns to a responsible supervisor allows the facility to further investigate and determine if additional action is required.

The nursing assessment of an 80 year old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: 1. Place a bed alarm device on the bed 2. Place the patient in a belt restraint 3. Provide one on one observation of the patient 4. Apply wrist restraints

1. Place a bed alarm device on the bed Consider and implement alternatives as appropriate before the use of a restraint. A bed alarm is an alternative that the nurse implements independently.

At 3 AM the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first? 1. Prepare of an influx of patients 2. Contact the American Red Cross 3. Determine how to restore essential services 4. Evacuate patients per the usual disaster plan

1. Prepare of an influx of patients 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 evacuated but not initially. The American Red Cross is not contacted initially. Determination of how to restore essential services is part of the disaster plan and is determined before an actual event.

To ensure the safe use of oxygen in the home by a patient which of the following teaching points does the nurse include? (Select all that apply.) 1. Smoking is prohibited around oxygen 2. Demonstrate how to adjust the oxygen flow rate based on patient symptoms 3. Do not use electrical equipment around oxygen 4. Special precautions may be required when traveling with oxygen

1. Smoking is prohibited around oxygen 3. Do not use electrical equipment around oxygen 4. Special precautions may be required when traveling with oxygen When oxygen is in use, precautions need to be taken to prevent fire and protect the patient. Patients need to be taught precautions, which include posting "Oxygen in Use" signage, not using oxygen around electrical equipment or flammable products, properly handling oxygen cylinders/containers, ensuring that tubing is unobstructed, not adjusting liter flow without a physician's order, and taking precautions when traveling with oxygen.

It is important to take precautions to prevent medication errors. A nurse is administering an oral tablet to a patient. Which of the following steps is the second check for accuracy in determining the patient is receiving the right medication? 1. Logging on to automated dispensing system(ADS) or unlocking medicine drawer or cart. 2. Before going to patients room, comparing patients name and name o f medication on label of prepared drugs with MAR. 3. Selecting correct medication from ADS, unit dose drawer, or stock supply and comparing name of medication on label with MAR or computer print out 4. Comparing MAR or computer print out with acmes of medications on medication labels and patient name at patients bedside.

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The nurse found a 68 year old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.) 1. Insert a urinary catheter 2. Leave a night light on in the bathroom 3. Ask the physician to order a restraint 4. Keep the bed in low position with upper and lower side rails up 5. Assign a staff member to stay with the patient 6. Provide scheduled toileting during the night shift 7. Keep the pathway from the bed to the bathroom clear

2. Leave a night light on in the bathroom 6. Provide scheduled toileting during the night shift 7. Keep the pathway from the bed to the bathroom clear Older adults in an unfamiliar environment may become confused. A night light may be beneficial for safety and orientation. Toileting is a common reason for a patient attempting to get out of bed. Placing the patient on a routine toileting schedule should help decrease this risk factor. Hospital environments can quickly become cluttered with equipment, personal items, and other things that create a hazard for falling. Keep pathways clear. All alternatives should be tried and considered before using a restraint. Restraint should not be an initial response. The bed should be kept in a low position. Upper side rails may be used; however, the addition of lower side rails can increase the risk of injury. The use of side rails alone for a disoriented patient may cause more confusion and further injury. A confused patient who is determined to get out of bed attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt usually results in a fall or injury.

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.) 1. Contact the nursing supervisor 2. Restrict the family's visiting privileges 3. Ask the family to stay with the patient if possible 4. Inform the family of the risks associated with side rail use 5. Thank the family for being conscientious and put the four rails up 6. Discuss alternatives with the family that are appropriate for this patient.

3. Ask the family to stay with the patient if possible 4. Inform the family of the risks associated with side rail use 6. Discuss alternatives with the family that are appropriate for this patient. 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 presences 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 parent calls the pediatrician's office frantic about the bottle of cleaner that her 2 year old son drank. Which of the following is the most important instruction the nurse gives to this parent? 1. Give the child milk 2. Give the child syrup of ipecac 3. Call the poison control center 4. Take the child to the emergency department

3. Call the poison control center A poison control center is the best resource for patients and parents needing information about the treatment of an accidental poisoning.

A physician writes an order to apply a wrist restraint to a patient who has been pulling out a surgical wound drain. Place the following steps for applying the restraint in the correct order. 1. Explain what you plan to do 2. Wrap a limb restraint around wrist or ankle with soft part toward skin and secure 3. Determine that restraint alternatives fail to ensure patient's safety 4. Identify the patient using proper identifier 5. Pad the patient's wrist

3. Determine that restraint alternatives fail to ensure patient's safety 4. Identify the patient using proper identifier 1. Explain what you plan to do 5. Pad the patient's wrist 2. Wrap a limb restraint around wrist or ankle with soft part toward skin and secure

The nurse's first action after discovering an electrical fire in a patient's room is to: 1. Activate the fire alarm 2. Confine the fire by closing all doors and windows 3. Remove all patients in immediate danger 4. Extinguish the fire by using the nearest fire extinguisher

3. Remove all patients in immediate danger Follow the acronym RACE. The first step, R, is to rescue and remove all patients in immediate danger. R.emove all patients in immediate danger A.ctivate the fire alarm C.onfine the fire by closing all doors and windows E.xtinguish the fire by using the nearest fire extinguisher

You are admitting Mr. Jones, a 64 year old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an anti-hypertensive and a diuretic. Currently he exhibits left sided neglect and problems with spacial and perceptual abilities and is impulsive. He has a 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 IV line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply.) 1. Smokes a pack a day 2. Used a cane to walk at home 3. Takes anti-hypertensive and diuretics 4. History of recent fall 5. Neglect, spatial and perceptual abilities 6. Requires assistance with activity, unsteady gait 7. IV line, urinary catheter

3. Takes anti-hypertensive and diuretics 4. History of recent fall 5. Neglect, spatial and perceptual abilities 6. Requires assistance with activity, unsteady gait 7. IV line, urinary catheter Smoking is not a risk factor for falls. Because the patient used the cane at home, it is not a current risk factor for falls. Risk is determined by his current status.

A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent? 1. Home accidents 2. Physiological changes of aging 3. Poisoning and child abduction 4. Automobile accidents, suicide, and substance abuse

4. Automobile accidents, suicide, and substance abuse Risks to the safety of adolescents involve many factors outside the home because much of their time is spent away from home and with their peer group. According to the Centers for Disease Control and Prevention, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. In an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs.

A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation? 1. Begin cardiopulmonary respiration 2. Restrain the child to prevent injury 3. Place a tongue blade over the tongue to prevent aspiration 4. Clear the area around the child to protect the child from injury

4. Clear the area around the child to protect the child from injury Once a seizure begins, you need to monitor the patient and provide a safe environment. A seizure is not an indication for cardiopulmonary resuscitation. A person having a seizure should not be restrained, but the environment should be made safe. Objects should not be forced into the mouth. See the Skills in the chapter for more information.

The nursing assessment on a 78 year old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? 1. Activity intolerance 2. Impaired bed mobility 3. Acute pain 4. Risk for falls

4. Risk for falls For adults age 65 and older, impaired balance and difficulty with gait are risks for the nursing diagnosis of risk for falls.

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history? a. "Does your baby seem to startle with loud noises?" b. "Has your baby had any surgeries on her ears?" c. "Have you noticed any drainage from her ears?" d. "How many ear infections has your baby had since birth?

A. "Does your baby seem to startle with loud noises?" Children at risk for a hearing deficit include those exposed in utero to a variety of conditions, such as maternal rubella or to maternal ototoxic drugs.

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction? a. Air conduction is the normal pathway for hearing. b. Vibrations of the bones in the skull cause air conduction. c. Amplitude of sound determines the pitch that is heard. d. Loss of air conduction is called a conductive hearing loss.

A. Air conduction is the normal pathway for hearing. The normal pathway of hearing is air conduction, which starts when sound waves produce vibrations on the tympanic membrane. Conductive hearing loss results from a mechanical dysfunction of the external or middle ear. The other statements are not true concerning air conduction.

If a nurse experiences a problem reading a physician's medication order, the most appropriate action will be to A. Call the physician to verify order. B. Call the pharmacist to verify order. C. Consult with other nursing staff to verify. D. Withhold the medication until physician makes rounds.

A. Call the physician to verify order

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. The most likely cause of his hearing loss is: a. Otosclerosis. b. Presbycusis. c. Trauma to the bones. d. Frequent ear infections.

A. Otosclerosis. Otosclerosis is a common cause of conductive hearing loss in young adults between the ages of 20 and 40 years. Presbycusis is a type of hearing loss that occurs with aging. Trauma and frequent ear infections are not a likely cause of his hearing loss

The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse's next best course of action? A. Ask the prescriber to change the order B. Crush the pill with a mortar and pestle C. Hide the capsule in a piece of solid food D. Open the capsule and sprinkle it over pudding

A. Rationale: Enteric-coated or sustained-release capsules should not be crushed; the nurse needs to contact the prescriber to change the medication to a form that is liquid or can be crushed.

The nurse takes a medication to a patient, and the patient tells him or her to take it away because she is not going to take it. What is the nurse's next action? A. Ask the patient's reason for refusal B. Explain that she must take the medication C. Take the medication away and chart the patient's refusal D. Tell the patient that her physician knows what is best for her

A. Rationale: When patients refuse a medication, first ask why they are refusing it.

The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the: a. Auricle. b. Concha. c. Outer meatus. d. Mastoid process.

A. auricle The external ear is called the auricle or pinna and consists of movable cartilage and skin.

37. During an oral examination of a 4-year-old American-Indian child, the nurse notices that her uvula is partially split. Which of these statements is accurate? a. A bifid uvula may occur in some American-Indian groups. b. This condition is a cleft palate and is common in American Indians. c. A bifid uvula is torus palatinus, which frequently occurs in American Indians. d. This condition is due to an injury and should be reported to the authorities.

ANS: A Bifid uvula, a condition in which the uvula is split either completely or partially, occurs in some American-Indian groups. This finding is not a cleft palate, a torus palatinus (benign bony ridge running in the middle of the hard palate), or due to injury.

26. A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. What do these findings indicate? a. Candidiasis b. Leukoplakia c. Koplik spots d. Aphthous ulcers

ANS: A Candidiasis is a white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that easily bleeds. It also occurs after the use of antibiotics or corticosteroids and in people who are immunosuppressed. Leukoplakia appears as chalky white, thick, raised patches with well-defined borders on the buccal mucosa. Koplik spots are small blue-white spots with irregular red halo scattered over mucosa opposite the molars and is an early sign of measles. Aphthous ulcers, or canker sores, first appear as a vesicle and then a small, round, "punched out" ulcer with a white base surrounded by a red halo and are quite painful and last for 1-2 weeks. The findings for this patient indicate candidiasis.

17. During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. What do these findings indicate? a. Dehydration b. A normal oral assessment c. Irritation from gastric juices d. Side effects from nausea medication

ANS: A Dehydration can cause dry mouth and deep vertical fissures in the tongue (due to reduced tongue volume). These finding are not normal and are not associated with irritation from gastric juices or from nausea caused by medications.

13. The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? a. Avoiding touching the nasal septum with the speculum b. Inserting the speculum at least 3 cm into the vestibule c. Gently displacing the nose to the side that is being examined d. Keeping the speculum tip medial to avoid touching the floor of the nares

ANS: A The correct technique for using an otoscope to examine the nasal cavity is to insert the apparatus into the nasal vestibule, avoiding pressure on the sensitive nasal septum. The tip of the nose should be lifted up before inserting the speculum.

36. During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. Which is the best response by the nurse? a. "You should never use over-the-counter nasal sprays because of the risk for addiction." b. "You should try switching to another brand of medication to prevent this problem." c. "Continuing to use this spray is important to keep your allergies under control." d. "Frequent use of these nasal medications irritates the lining of the nose and may cause rebound swelling."

ANS: A The dorsal surface of the tongue is normally roughened from papillae. A thin white coating may be present. The ventral surface may show veins. Smooth, glossy areas are abnormal and may indicate atrophic glossitis.

1. During an assessment, a patient mentions that "I just can't smell like I used to. I can barely smell the roses in my garden. Why is that?" For which possible causes of changes in the sense of smell will the nurse assess? (Select all that apply.) a. Aging b. Chronic allergies c. Cigarette smoking d. Chronic alcohol use e. Herpes simplex virus I f. Frequent episodes of strep throat

ANS: A, B, C The sense of smell diminishes with cigarette smoking, chronic allergies, and aging. Chronic alcohol use, a history of strep throat, and herpes simplex virus I are not associated with changes in the sense of smell. Chronic alcohol use, herpes simplex virus I, and frequent episodes of strep throat do not common causes of a diminished sense of smell. The sense of smell diminishes with cigarette smoking, chronic allergies, and aging. Chronic alcohol use, a history of strep throat, and herpes simplex virus I are not associated with changes in the sense of smell.

31. When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process? a. Teeth appearing shorter b. Tongue that looks smoother in appearance c. Buccal mucosa that is beefy red in appearance d. Small, painless lump on the dorsum of the tongue

ANS: B In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly yellowed and appear longer because of the recession of gingival margins.

30. A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. Which is the best response by the nurse? a. "How many teeth did you have at this age?" b. "This is a normal number of teeth for an 18 month old." c. "Normally, by age 2 1/2 years, 16 deciduous teeth are expected." d. "All 20 deciduous teeth are expected to erupt by age 4 years."

ANS: B The guidelines for the number of teeth for children younger than 2 years old are as follows: the child's age in months minus the number 6 should be equal to the expected number of deciduous teeth. Normally all 20 teeth are in by 2 1/2 years old. In this instance, the child is 18 months old, minus 6, equals 12 deciduous teeth expected.

15. The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? a. No sensation b. Firm pressure c. Pain during palpation d. Pain sensation behind eyes

ANS: B The person should feel firm pressure but no pain. Sinus areas are tender to palpation in persons with chronic allergies or an acute infection (sinusitis). A normal finding when palpating the sinus areas is for the patient to feel firm pressure, not no sensation at all, pain during palpation, or pain behind the eyes. Sinus areas that are tender to palpation may indicate chronic allergies or an acute infection (sinusitis). Feeling firm pressure but no pain is a normal finding.

5. In assessing the tonsils of a 30-year-old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is the correct response to these findings? a. Refer the patient to a throat specialist. b. No response is needed; this appearance is normal for the tonsils. c. Continue with the assessment, looking for any other abnormal findings. d. Obtain a throat culture on the patient for possible streptococcal (strep) infection

ANS: B The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes. There is no need to refer the patient to a throat specialist, obtain a throat culture, or look for other abnormal findings because the findings in this question are normal. Although the tonsils look more granular and their surface shows deep crypts, they are the same color as the surrounding mucous membrane and tonsillar tissue enlarges during childhood until puberty and then involutes.

9. While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response? a. "While sitting up, place a cold compress over your nose." b. "Sit up with your head tilted forward and pinch your nose." c. "Allow the bleeding to stop on its own, but don't blow your nose." d. "Lie on your back with your head tilted back and pinch your nose."

ANS: B With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between the thumb and forefinger for 5 to 15 minutes.

19. A 10-year-old is at the clinic for "a sore throat that has lasted 6 days." Which of these findings would be consistent with an acute infection? a. Tonsils 3+/1-4+ with pale coloring b. Tonsils 3+/1-4+ with large white spots c. Tonsils 2+/1-4+ with small plugs of white debris d. Tonsils 1+/1-4+ and pink; the same color as the oral mucosa

ANS: B With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection.

24. While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess? a. Nutritional status b. When the patient first noticed the lesion c. Whether the patient has had a recent cold d. Whether the patient has had any recent exposure to sick animals

ANS: B With carcinoma, the initial lesion is round and indurated, but then it becomes crusted and ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred. Therefore, the nurse should try to establish how long the lesion has been there and ask the patient when the patient first noticed the lesion.

27. The nurse is assessing a patient in the hospital who has received numerous antibiotics for a lung infection and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? a. "We will need to get a biopsy to determine the cause." b. "This is an overgrowth of hair and will go away in a few days." c. "Black, hairy tongue is a fungal infection caused by all the antibiotics you have received." d. "This is probably caused by the same bacteria you had in your lungs."

ANS: C A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus. It is not caused by the same bacteria as his lung infection but occurred after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus. There is no need to get a biopsy.

22. The nurse is assessing a 3-year-old for "drainage from the nose." On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next? a. Refer to the physician for an antibiotic order. b. Have the mother bring the child back in 1 week. c. Perform an otoscopic examination of the left nares. d. Tell the mother that this drainage is normal for a child of this age.

ANS: C Children are prone to put an object up the nose, producing unilateral purulent drainage with a foul odor. Because some risk for aspiration exists, removal should be prompt.

23. During an assessment of a 26-year-old for "a spot on my lip I think is cancer," the clinic nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What is the most appropriate action by the nurse? a. Tell the patient she needs to see a skin specialist. b. Discuss the benefits of having a biopsy performed on any unusual lesion. c. Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days. d. Tell the patient that these vesicles are most likely the result of a riboflavin deficiency and discuss nutrition.

ANS: C Cold sores are groups of clear vesicles with a surrounding erythematous base. These evolve into pustules or crusts and heal in 4 to 10 days. The most likely site is the lip-skin junction. Infection often recurs in the same site. Recurrent herpes infections may be precipitated by sunlight, fever, colds, or allergy.

20. Immediately after birth, the nurse is unable to suction the nares of a crying newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next? a. Attempt to suction again with a bulb syringe. b. Wait a few minutes, and try again once the infant stops crying. c. Recognize that this situation requires immediate intervention. d. Contact the physician to schedule an appointment for the infant at his or her next hospital visit.

ANS: C Determining the patency of the nares in the immediate newborn period is essential because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are gently suctioned with a bulb syringe. If obstruction is suspected, then a small lumen (5 to 10 Fr) catheter is passed down each naris to confirm patency. The inability to pass a catheter through the nasal cavity indicates choanal atresia, which requires immediate intervention.

7. The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? a. Hypertrophy of the gums b. Increased production of saliva c. Decreased ability to identify odors d. Finer and less prominent nasal hair

ANS: C Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases. Rhinorrhea is a runny nose, epistaxis is a bloody nose, and xerostomia is a dry mouth. Rhinorrhea is a runny nose, epistaxis is a bloody nose, and xerostomia is a dry mouth; none of which are expected findings in a patient who had a stroke with drooping on the right side of the face. Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases.

16. During an oral assessment of a 30-year-old black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding? a. Check the patient's Hb for anemia. b. Assess for other signs of insufficient oxygen supply. c. Proceed with the assessment, this appearance is a normal finding. d. Ask if he has been exposed to an excessive amount of carbon monoxide.

ANS: C Some blacks may have bluish lips and a dark line on the gingival margin; this appearance is a normal finding so the nurse should proceed with the assessment. Some blacks may have bluish lips and a dark line on the gingival margin, so this is a normal finding and there is no need to check the Hb for anemia, assess for other signs of insufficient oxygen supply, or ask if he has been exposed to an excessive amount of carbon monoxide. Instead, the nurse should continue with the assessment.

1. What is the primary purpose of the ciliated mucous membrane in the nose? a. To warm the inhaled air b. To filter out dust and bacteria c. To filter coarse particles from inhaled air d. To facilitate the movement of air through the nares

ANS: C The nasal hairs, or cilia, filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria. The rich blood supply of the nasal mucosa warms the inhaled air. The rich blood supply of the nasal mucosa warms the inhaled air, not the ciliated mucous membrane. The mucous blanket, not the cilia, filters out dust and bacteria. The cilia in the nose do not facilitate the movement of air through the nares. Instead, the nasal hairs, or cilia, filter the coarsest matter from inhaled air.

21. The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. What should the nurse look for during an inspection of this child's mouth? a. Swollen, red tonsils b. Ulcerations on the hard palate c. Bruising on the buccal mucosa or gums d. Small yellow papules along the hard palate

ANS: C The nurse should notice any bruising or laceration on the buccal mucosa or gums of an infant or young child. Trauma may indicate child abuse from a forced feeding of a bottle or spoon.

2. What are the projections in the nasal cavity that increase the surface area are called? a. Meatus b. Septum c. Turbinates d. Kiesselbach plexus

ANS: C The projections in the nasal cavity that increases the surface area are called turbinates. The lateral walls of each nasal cavity contain three parallel bony projections: the superior, middle, and inferior turbinates. These increase the surface area, making more blood vessels and mucous membrane available to warm, humidify, and filter the inhaled air. A meatus is the passageway or canal underlying each turbinate that collects drainage. The septum is what divides the nasal cavity into two slitlike air passages. The Kiesselbach plexus is a rich vascular network in the anterior part of the septum.

14. The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? a. "Have you had any symptoms of a cold?" b. "Do you have an elevated temperature?" c. "Are you aware of having any allergies?" d. "Have you been having frequent nosebleeds?"

ANS: C With chronic allergies, the mucosa looks swollen, boggy, pale, and gray. Elevated body temperature, colds, and nosebleeds do not cause these mucosal changes. Elevated body temperature, colds, and nosebleeds do not cause the nasal mucosa to appear pale, gray, and swollen. Chronic allergies do cause the mucosa to look swollen, boggy, pale, and gray.

29. A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother? a. "This area of irritation is caused from teething and is nothing to worry about." b. "This finding is abnormal and should be evaluated by another health care provider." c. "This area of irritation is the result of chronic drooling and should resolve within the next month or two." d. "This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and is normal."

ANS: D A normal finding in infants is the sucking tubercle, a small pad in the middle of the upper lip from the friction of breastfeeding or bottle-feeding. This condition is not caused by irritation, teething, or excessive drooling, and evaluation by another health care provider is not warranted.

25. A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started to bleed. What would be an appropriate response by the nurse? a. "Your condition is probably due to a vitamin C deficiency." b. "I'm not sure what causes swollen and bleeding gums, but let me know if it's not better in a few weeks." c. "You need to make an appointment with your dentist as soon as possible to have this checked." d. "Swollen and bleeding gums can be caused by a change in hormonal balance during pregnancy."

ANS: D Although with gingivitis (which can be caused by a vitamin C deficiency) gum margins are red and swollen and easily bleed, a changing hormonal balance during puberty or pregnancy may also cause these symptoms. Since this patient is pregnant, a change in hormonal balance is likely the cause.

18. A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5-cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? a. "These spots indicate an infection such as strep throat." b. "These bumps could be indicative of a serious lesion, so I will refer you to a specialist." c. "This condition is called leukoplakia and can be caused by chronic irritation such as with smoking." d. "These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition."

ANS: D Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant. Chalky white, thick, raised patches would indicate leukoplakia. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots and leukoplakia would appear as chalky white, thick, raised patches. These findings are not indicative of a serious lesion but are fordyce granules. Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant.

6. The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." What is the best response by the nurse? a. "You're right, drooling is usually a sign of the first tooth." b. "It would be unusual for a 3-month-old to be getting her first tooth." c. "This could be the sign of a problem with the salivary glands." d. "She is just starting to salivate and hasn't learned to swallow the saliva."

ANS: D In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does. Although many parents think the start of drooling signals the eruption of the first tooth, it does not. Although teeth usually erupt between 6 and 24 months, the nurse should not just say it would be unusual for a 3-month-old to be getting her first tooth as that does not address the issue of the drooling. It is also not a sign of a problem.

39. A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. What is the likely reason for this? a. Inappropriate use of nasal sprays b. A problem with the patient's coagulation system c. Increased susceptibility to colds and nasal irritation d. Increased vascularity in the upper respiratory tract as a result of the pregnancy

ANS: D Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract. Inappropriate use of nasal sprays often causes rebound congestion or swelling, but not usually nosebleeds. Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract so this patient's nose bleeds are more likely to be due to the increased vascularity in the upper respiratory tract than to a problem with the coagulation system or an increased susceptibility to colds and nasal irritation.

3. The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant? a. Sphenoid sinuses are full size at birth. b. Maxillary sinuses reach full size after puberty. c. Frontal sinuses are fairly well developed at birth. d. Maxillary and ethmoid sinuses are the only sinuses present at birth.

ANS: D Only the maxillary and ethmoid sinuses are present at birth. The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty. The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty. Only the maxillary and ethmoid sinuses are present at birth but the maxillary sinus does not reach full size until all permanent teeth have erupted (not after puberty).

11. While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "It makes a great pacifier." What is the best response by the nurse? a. "You're right. Bottles make very good pacifiers." b. "Using a bottle as a pacifier is better for the teeth than thumb-sucking." c. "It's okay to use a bottle as long as it contains milk and not juice." d. "Prolonged use of a bottle can increase the risk for tooth decay and ear infections."

ANS: D Prolonged bottle use during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections.

32. When examining the nares of a 45-year-old patient who is experiencing rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause? a. Nasal polyps b. Acute rhinitis c. Acute sinusitis d. Allergic rhinitis

ANS: D Rhinorrhea, itching of the nose and eyes, and sneezing are manifestations of allergic rhinitis. On physical examination, serous edema is noted, and the turbinates usually appear pale with a smooth, glistening surface. Nasal polyps appear as smooth, pale gray nodules which are overgrowths of mucosa most commonly caused by chronic allergic rhinitis and often cause absence of sense of smell and a sensation of a "valve that moves" in the nose when breathing. Acute rhinitis initially presents with clear, watery discharge (rhinorrhea) which later become purulent, with sneezing nasal itching, stimulation of cough reflex, and inflamed mucosa with dark red and swollen turbinates which cause nasal obstruction. With sinusitis, there is usually mucopurulent drainage, nasal obstruction, facial pain or pressure, and may have fever, chills, and malaise. This patient's symptoms of rhinorrhea, itching of the nose and eyes, and sneezing are manifestations of allergic rhinitis. On physical examination, serous edema is noted, and the turbinates usually appear pale with a smooth, glistening surface.

38. A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. What do these findings indicate? a. Nasal polyps b. Frontal sinusitis c. Posterior epistaxis d. Maxillary sinusitis

ANS: D Signs of maxillary sinusitis include facial pain after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. The person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in the cheeks and teeth on the same side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital ridge. Nasal polyps appear as smooth, pale gray nodules which are overgrowths of mucosa most commonly caused by chronic allergic rhinitis and often cause absence of sense of smell and a sensation of a "valve that moves" in the nose when breathing. Epistaxis is a nosebleed and the most common site of bleeding is the Kiesselbach plexus in the anterior septum. With frontal sinusitis, pain is above the supraorbital ridge. This patient's signs and symptoms are indicative of maxillary sinusitis. Signs of maxillary sinusitis include facial pain after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. The person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in the cheeks and teeth on the same side, and pain with palpation is present.

4. What is the tissue that connects the tongue to the floor of the mouth called? a. Uvula b. Palate c. Papillae d. Frenulum

ANS: D The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongue's dorsal surface. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongue's dorsal surface. The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth

28. The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of what disease or disorder? a. Measles b. Leukemia c. A carcinoma d. Acquired immunodeficiency syndrome (AIDS)

ANS: D This dark red confluent macule on the hard palate is an oral Kaposi's sarcoma. An oral Kaposi's sarcoma is a bruiselike, dark red or violet, confluent macule that usually occurs on the hard palate but may also appear on the soft palate or gingival margin. Oral lesions such as a Kaposi's sarcoma are among the earliest lesions to develop with AIDS.

34. The nurse is performing an assessment. Which of these findings would cause the greatest concern? a. A painful vesicle inside the cheek for 2 days b. The presence of moist, nontender Stensen's ducts c. Stippled gingival margins that snugly adhere to the teeth d. An ulceration on the side of the tongue with rolled edges

ANS: D Ulceration on the side or base of the tongue or under the tongue raises the suspicion of cancer and must be investigated. The risk for early metastasis is present because of rich lymphatic drainage. The vesicle may be an aphthous ulcer, which is painful but not dangerous. The other responses are normal findings. The presence of moist, nontender Stensen's ducts and stippled gingival margins that snugly adhere to the teeth are normal findings. Although a painful vesicle inside the cheek for 2 days is not that uncommon or concerning, but an ulceration on the side, base, or under the tongue raises the suspicion of cancer and must be investigated. The risk for early metastasis is present because of rich lymphatic drainage. The vesicle may be an aphthous ulcer, which is painful but not dangerous.

12. A 72-year-old patient has a history of hypertension and chronic lung disease. Which is an important question for the nurse to include in this patient's health history? a. "Do you use a fluoride supplement?" b. "Have you had tonsillitis in the last year?" c. "At what age did you get your first tooth?" d. "Have you noticed any dryness in your mouth?"

ANS: D With a history of hypertension and chronic lung disease, this patient is likely on medications and a side effect of antihypertensive and bronchodilator medication (and many other drugs such as antidepressants, anticholinergics, antispasmodics, and antipsychotics) is dry mouth, or xerostomia. The nurse should ask the patient if they've noticed dryness in their mouth.

The nurse must take a verbal order during an emergency on the unit. Which of the following guidelines can be used for taking verbal or telephone orders? (Select all that apply). 1. Only authorized staff may receive and record verbal or tele- phone orders. The health care agency identifies in writing the staff who are authorized. 2. Clearly identify patient's name, room number, and diagnosis. 3. Read back all orders to health care provider. 4. Use clarification questions to avoid misunderstandings. 5. Write "VO" (verbal order) or "TO" (telephone order), includ- ing date and time, name of patient, and complete order; sign the name of the health care provider and nurse.

Answer: 1, 2, 3, 4, 5. Rationale: These are all acceptable guidelines for taking verbal and telephone orders in a health care setting. All of the stated guidelines should be used by the nurse.

An older adult states that she cannot see her medication bottles clearly to determine when to take her prescription. What should the nurse do? (Select all that apply.) 1. Provide a dispensing system for each day of the week. 2. Provide larger, easier-to-read labels. 3. Tell the patient what is in each container .4. Have a family caregiver administer the medication. 5. Use teach-back to ensure that the patient knows what medication to take and when

Answer: 1, 2, 5. Rationale: Larger print and a dispensing system can ensure safe medication administration in older adults. Medication pamphlets in larger print are also available. The use of teach-back ensures that the patient understands his or her medications and increases safety.

After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection." What should the nurse do next? (Select all that apply.) 1. Assess the injection site. 2. Administer an oral medication for pain. 3. Notify the patient's health care provider of assessment findings. 4. Document assessment findings and related interventions in the patient's medical record. 5. This is a normal finding, so nothing needs to be done. 6. Apply ice to the site for relief of burning pain.

Answer: 1, 3, 4. Rationale: Assessing the injection site may reveal a site reaction or induration from the injection. The health care provider needs to be notified in case there is an adverse effect from the injection. The nurse must always document adverse effects so that the site and patient can be monitored.

A nurse is administering ophthalmic ointment to a patient. Place the following steps in correct order for the administration of the ointment .1. Clean eye, washing from inner to outer canthus. 2. Assess patient's level of consciousness and ability to follow instructions. 3. Apply thin ribbon of ointment evenly along inner edge of lower eyelid on conjunctiva. 4. Have patient close eye and rub lightly in a circular motion with a cotton ball.

Answer: 2, 1, 5, 3, 4. Rationale: This is the correct order for safe administration of ophthalmic ointment.

A nurse is administering a metered-dose inhaler (MDI) with a spacer to a patient with chronic obstructive pulmonary disease. Place the steps of the procedure in the correct order .1. Insert MDI into end of spacer. 2. Perform a respiratory assessment. 3. Remove mouthpiece from MDI and spacer device. 4. Place the spacer mouthpiece into patient's mouth, and instruct patient to close lips around the mouthpiece. 5. Depress medication canister, spraying 1 puff into spacer device. 6. Shake inhaler for 2-5 seconds. 7. Instruct patient to hold breath for 10 seconds.8. Instruct patient to breathe in slowly through mouth for 3 to 5 seconds.

Answer: 2, 3, 6, 1, 4, 5, 8, 7. Rationale: Obtains baseline respiratory assessment before medication. Ensures optimal delivery of medication using a metered-dose inhaler.

The nurse is administering an IV push medication to a patient who has a compatible IV fluid running through intravenous tub- ing. Place the following steps in the appropriate order. 1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration. 2. Select injection port of IV tubing closest to patient. Whenever possible, injection port should accept a needleless syringe. Use IV filter if required by medication reference or agency policy. 3. After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate. 4. Connect syringe to port of IV line. Insert needleless tip or small-gauge needle of syringe containing prepared drug through center of injection port 5. Clean injection port with antiseptic swab. Allow to dry.6. Occlude IV line by pinching tubing just above injection port. Pull back gently on syringe plunger to aspirate blood return.

Answer: 2, 5, 4, 6, 1, 3. Rationale: These are the correct steps to administer an IV push medication in an existing line with compatible fluid running.

A patient is to receive medications through a small-bore nasogastric feeding. Which nursing actions are appropriate? (Select all that apply.) 1. Verifying tube placement after medications are given 2. Mixing all medications together to give all at once 3. Using an enteral tube syringe to administer medications 4. Flushing tube with 30 to 60 mL of water after the last dose of medication 5. Checking for gastric residual before giving the medications6. Keeping the head of the bed elevated 30 to 60 minutes after the medications are given

Answer: 3, 4, 5, 6. Rationale: An enteral tube syringe is necessary to avoid dangerous misconnections and accidentally administering the medications through another tube. Flushing the tubing after medication administration clears the tubing of any residual medication and ensures that the tube remains patent. If gastric residuals are high, then the absorption of the enteral tube medication is reduced. Elevating the head of the bed helps to reduce the risk for aspiration. Verifi- cation of tube placement is essential before administering anything via a nasogastric tube. Medications are given sep- arately to avoid any drug-to-drug interactions, which could clog the feeding tube.

Place the steps of administering an intradermal injection in the correct order .1. Inject medication slowly. 2. Note the presence of a bleb. 3. Advance needle through epidermis to 3 mm. 4. Using nondominant hand, stretch skin over site with forefinger. 5. Insert needle at a 5- to 15-degree angle into the skin until resistance is felt. 6. Cleanse site with antiseptic swab.

Answer: 6, 4, 5, 3, 1, 2. Rationale: This is the correct sequence of steps to administer an intradermal injection.

The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal? a. If the drum has ruptured, then purulent drainage will result. b. Bloody or clear watery drainage can indicate a basal skull fracture. c. The auditory canal many be occluded from increased cerumen. d. Foreign bodies from the accident may cause occlusion of the canal.

B. Bloody or clear watery drainage can indicate a basal skull fracture. Frank blood or clear watery drainage (cerebrospinal leak) after a trauma suggests a basal skull fracture and warrants immediate referral. Purulent drainage indicates otitis externa or otitis media.

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding: a. Is normal for people of his age. b. Is a characteristic of recruitment. c. May indicate a middle ear infection. d. Indicates that the patient has a cerumen impaction.

B. Is a characteristic of recruitment. Recruitment is significant hearing loss occurring when speech is at low intensity, but sound actually becomes painful when the speaker repeats at a louder volume. The other responses are not correct.

Nurses are legally required to document medications that are administered to patients. The nurse is mandated to document which of the following? A. Medication before administering it B. Medication after administering it C. Rationale for administering it D. Prescriber rationale for prescribing it

B. Medication after administering it

When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear: a. Light pink with a slight bulge. b. Pearly gray and slightly concave. c. Pulled in at the base of the cone of light. d. Whitish with a small fleck of light in the superior portion.

B. Pearly gray and slightly concave. The tympanic membrane is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles.

After seeing a patient, the physician gives a nursing student a verbal order for a new medication. The nursing student first needs to: A. Follow ISMP guidelines for safe medication abbreviations. B. Explain to the physician that the order needs to be given to a registered nurse. C. Write down the order on the patient's order sheet and read it back to the physician. D. Ensure that the six rights of medication administration are followed when giving the medication.

B. Rationale: Nursing students cannot take orders.

A nursing student takes a patient's antibiotic to his room. The patient asks the nursing student what it is and why he should take it. Which information does the nursing student include when replying to the patient? A. Only the patient's physician can give this information. B. The student provides the name of the medication and a description of its desired effect. C. Information about medications is confidential and cannot be shared. D. He has to speak with his assigned nurse about this.

B. Rationale: Patients need to know information about their medications so they can take them correctly and safely.

If a patient who is receiving intravenous (IV) fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects: A. Sepsis. B. Phlebitis. C. Infiltration. D. Fluid overload.

B. Rationale: Redness, warmth, and tenderness at the IV site are signs of phlebitis.

The nurse receives an order to start giving a loop diuretic to a patient to help lower his or her blood pressure. The nurse determines the appropriate route for administering the diuretic according to: A. Hospital policy. B. The prescriber's orders. C. The type of medication ordered. D. The patient's size and muscle mass.

B. Rationale:The order from the prescriber needs to indicate the route of administration.

A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infant's hearing? a. Rubella may affect the mother's hearing but not the infant's. b. Rubella can damage the infant's organ of Corti, which will impair hearing. c. Rubella is only dangerous to the infant in the second trimester of pregnancy. d. Rubella can impair the development of CN VIII and thus affect hearing.

B. Rubella can damage the infant's organ of Corti, which will impair hearing. If maternal rubella infection occurs during the first trimester, then it can damage the organ of

In performing a voice test to assess hearing, which of these actions would the nurse perform? a. Shield the lips so that the sound is muffled. b. Whisper a set of random numbers and letters, and then ask the patient to repeat them. c. Ask the patient to place his finger in his ear to occlude outside noise. d. Stand approximately 4 feet away to ensure that the patient can really hear at this distance.

B. Whisper a set of random numbers and letters, and then ask the patient to repeat them. With the head 30 to 60 cm (1 to 2 feet) from the patient's ear, the examiner exhales and slowly whispers a set of random numbers and letters, such as "5, B, 6." Normally, the patient is asked to repeat each number and letter correctly after hearing the examiner say them.

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to: a. Speak loudly so the patient can hear the questions. b. Assess for middle ear infection as a possible cause. c. Ask the patient what medications he is currently taking. d. Look for the source of the obstruction in the external ear.

C. Ask the patient what medications he is currently taking. A simple increase in amplitude may not enable the person to understand spoken words. Sensorineural hearing loss may be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging and by ototoxic drugs, which affect the hair cells in the

A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to: a. Maintain balance. b. Interpret sounds as they enter the ear. c. Conduct vibrations of sounds to the inner ear. d. Increase amplitude of sound for the inner ear to function.

C. Conduct vibrations of sounds to the inner ear. Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. The other responses are not functions of the middle

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding: a. Is probably the result of lesions from eczema in his ear. b. Represents poor hygiene. c. Is a normal finding, and no further follow-up is necessary. d. Could be indicative of change in cilia; the nurse should assess for hearing loss

C. Is a normal finding, and no further follow-up is necessary. Asians and Native Americans are more likely to have dry cerumen, whereas Blacks and Whites usually have wet cerumen.

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says that he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change? a. Atrophy of the apocrine glands b. Cilia becoming coarse and stiff c. Nerve degeneration in the inner ear d. Scarring of the tympanic membrane

C. Nerve degeneration in the inner ear Presbycusis is a type of hearing loss that occurs in 60% of those older than 65 years of age, even in those living in a quiet environment. This sensorineural loss is gradual and caused by nerve degeneration in the inner ear. Words sound garbled, and the ability to localize sound is also impaired. This communication dysfunction is accentuated when background noise is present.

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct? a. Tilting the person's head forward during the examination b. Once the speculum is in the ear, releasing the traction c. Pulling the pinna up and back before inserting the speculum d. Using the smallest speculum to decrease the amount of discomfort

C. Pulling the pinna up and back before inserting the speculum The pinna is pulled up and back on an adult or older child, which helps straighten the S-shape of the canal. Traction should not be released on the ear until the examination is completed and the otoscope is removed.

A patient is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe medication administration for the discharge nurse? A. Set up the follow-up appointments with the physician for the patient. B. Ensure that someone will provide housekeeping for the patient at home. C. Ensure that the home care agency is aware of medication and health teaching needs. D. Make sure that the patient's family knows how to safely bathe him or her and provide mouth care.

C. Rationale: A nursing responsibility is to collaborate with community resources when patients have home care needs or difficulty understanding their medications.

A nurse is administering medications to a 4-year-old patient. After he or she explains which medications are being given, the mother states, "I don't remember my child having that medication before." What is the nurse's next action? A. Give the medications B. Identify the patient using two patient identifiers C. Withhold the medications and verify the medication orders D. Provide medication education to the mother to help her better understand her child's medications

C. Rationale: Do not ignore patient or caregiver concerns; always verify orders whenever a medication is questioned before administering it.

A patient is receiving an intravenous (IV) push medication. If the drug infiltrates into the outer tissues, the nurse: A. Continues to let the IV run. B. Applies a warm compress to the infiltrated site. C. Stops the administration of the medication and follows agency policy. D. Should not worry about this because vesicant filtration is not a problem.

C. Rationale: When an IV medication infiltrates, stop giving the medication and follow agency policy.

The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination? a. Immobility of the drum is a normal finding. b. An injected membrane would indicate an infection. c. The normal membrane may appear thick and opaque. d. The appearance of the membrane is identical to that of an adult.

C. The normal membrane may appear thick and opaque. During the first few days after the birth, the tympanic membrane of a newborn often appears thickened and opaque. It may look injected and have a mild redness from increased vascularity. The other statements are not correct.

The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti? a. I b. III c. VIII d. XI

C. VIII The nerve impulses are conducted by the auditory portion of CN VIII to the brain.

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? a. Sticky honey-colored cerumen is a sign of infection. b. The presence of cerumen is indicative of poor hygiene. c. The purpose of cerumen is to protect and lubricate the ear. d. Cerumen is necessary for transmitting sound through the auditory canal.

C. the purpose of cerumen is to protect and lubricate the ear The ear is lined with glands that secrete cerumen, which is a yellow waxy material that lubricates and protects the ear.

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse? a. "It is unusual for a small child to have frequent ear infections unless something else is wrong." b. "We need to check the immune system of your son to determine why he is having so many ear infections." c. "Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear." d. "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily."

D. "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily." The infant's eustachian tube is relatively shorter and wider than the adult's eustachian tube, and its position is more horizontal; consequently, pathogens from the nasopharynx can more easily migrate through to the middle ear. The other responses are not appropriate.

Who should you verify medications calculations with and why? A. The Nurse Assistant, to ensure accuracy. B. The pharmacy, because only the pharmacist knows accurate calculations. C. The patient, because they are a math teacher. D. Another Nurse, to ensure accuracy.

D. Another nurse, to ensure accuracy.

You are caring for a patient who has diabetes complicated by kidney disease. You need to make a detailed assessment when administering medications because this patient may experience problems with: A. Absorption. B. Biotransformation. C. Distribution. D. Excretion.

D. Excretion

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? a. "Do you ever notice ringing or crackling in your ears?" b. "When was the last time you had your hearing checked?" c. "Have you ever been told that you have any type of hearing loss?" d. Is a normal finding, and no further follow-up is necessary.

D. Is a normal finding, and no further follow-up is necessary. Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs.

The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true? a. The eustachian tube is responsible for the production of cerumen. b. It remains open except when swallowing or yawning. c. The eustachian tube allows passage of air between the middle and outer ear. d. It helps equalize air pressure on both sides of the tympanic membrane.

D. It helps equalize air pressure on both sides of the tympanic membrane. The eustachian tube allows an equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture during, for example, altitude changes in an airplane. The tube is normally closed, but it opens with swallowing or yawning.

During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is the: a. Cochlea. b. CN VIII. c. Organ of Corti. d. Labyrinth.

D. Labyrinth. If the labyrinth ever becomes inflamed, then it feeds the wrong information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo.

In performing an examination of a 3-year-old child with a suspected ear infection, the nurse would: a. Omit the otoscopic examination if the child has a fever. b. Pull the ear up and back before inserting the speculum. c. Ask the mother to leave the room while examining the child. d. Perform the otoscopic examination at the end of the assessment

D. Perform the otoscopic examination at the end of the assessment In addition to its place in the complete examination, eardrum assessment is mandatory for any infant or child requiring care for an illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination.

The patient has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her? A. 2 mL B. 5 mL C. 16 mL D. 30 mL

D. Rationale: 1 tablespoon = 15 mL; 2 tablespoons = 30 mL.

A nurse is administering eardrops to an 8-year-old patient with an ear infection. How does the nurse pull the patient's ear when administering the medication? A. Outward B. Back C. Upward and back D. Upward and outward

D. Rationale: Eardrops are administered with the ear positioned upward and outward for patients greater than 3 years of age.

A nurse accidently gives a patient a medication at the wrong time. The nurse's first priority is to: A. Complete an occurrence report. B. Notify the health care provider. C. Inform the charge nurse of the error. D. Assess the patient for adverse effects.

D. Rationale: Patient safety and assessing the patient are priorities when a medication error occurs.

A patient is to receive cephalexin (Kefl ex) 500 mg PO. The pharmacy has sent 250-mg tablets. How many tablets does the nurse administer? A. ½ tablet B. 1 tablet C. 1 ½ tablets D. 2 tablets

D. Rationale: Using dimensional analysis: Tablets = 1 tablet/250 mg x 500 mg = 500/250 = 2 tablets.

The health care provider has written the following orders. Which orders does the nurse need to clarify before administering the medication? Provide rationale for your answers, and rewrite the order so that it follows the ISMP current medication order safety guidelines. Timoptic .25% solution 1 drop OD BID Metoprolol 12.50 mg QDInsulin Glargine 6 u SC twice a dayEnalapril 2.5 mg. PO three times a day, hold for systolic blood pressure <100

The nurse needs to clarify all the orders. Timoptic .25% solution 1 drop OD BID has a "naked" decimal point, and OD (right eye) could be mistaken for AD (right ear). Metoprolol 12.50 mg QD has a trailing zero, and the dos- age could be mistaken for 1250 mg if the decimal point is not seen; it also has no route identified. Insulin Glargine 6 u SC twice a day includes the letter u, which means units but could be mistaken as the number 0 or 4, and SC could be mistaken as SL. Enalapril 2.5 mg. PO three times a day, hold for systolic blood pressure <100 has a period after mg, which could be mistaken as the number 1, and the < sign could be mistaken as greater than. The correctly written orders are "Timoptic 0.25% solution 1 drop right eye BID." Metoprolol 12.5 mg QD POInsulin glargine 6 units subcutaneous twice a dayEnalapril 2.5 mg PO three times a day, hold for systolic blood pressure less than 10

A fragile, 87 year old nursing home resident is admitted to the hospital with dehydration and increased confusion. The patient has upper limb restraints to prevent her from pulling out her nasogastric tube. What instructions does the nurse give to NAPs?

The use of restraints is associated with serious complications resulting from immobilization such as pressure ulcers, pneumonia, constipation, and incontinence. In some cases death has resulted because of restricted breathing and circulation. The restraint itself could injure the underlying skin. Routine checks are required to prevent or decrease these complications. The NAP needs to notify the nurse if there is a change in skin integrity, circulation, or patient's breathing and provide range of motion, nutrition and hydration, skin care, toileting, and opportunities for socialization at least every 2 hours.