130 Unit 1

A client is being discharged from the hospital after surgery on hydrocodone and acetaminophen (Lorcet). What discharge instruction is most important for this client? a. "Call the doctor if the Lorcet does not relieve your pain." b. "Check any over-the-counter medications for acetaminophen." c. "Eat more fiber and drink more water to prevent constipation." d. "Keep your follow-up appointment with the surgeon as scheduled."

b. "Check any over-the-counter medications for acetaminophen." (All instructions are appropriate for this client. However, advising the client to check over-the-counter medications for acetaminophen is an important safety measure. Acetaminophen is often found in common over-the-counter medications and should be limited to 3000 mg/day.)

The nurse in the surgery clinic is discussing an upcoming surgical procedure with a client. What information provided by the nurse is most appropriate for the client's long-term outcome? a. "At least you know that the pain after surgery will diminish quickly." b. "Discuss acceptable pain control after your operation with the surgeon." c. "Opioids often cause nausea but you won't have to take them for long." d. "The nursing staff will give you pain medication when you ask them for it."

b. "Discuss acceptable pain control after your operation with the surgeon." (The best outcome after a surgical procedure is timely and satisfactory pain control, which diminishes the likelihood of chronic pain afterward. The nurse suggests that the client advocate for himself and discuss acceptable pain control with the surgeon. Stating that pain after surgery is usually short lived does not provide the client with options to have personalized pain control. To prevent or reduce nausea and other side effects from opioids, a multimodal pain approach is desired. For acute pain after surgery, giving pain medications around the clock instead of waiting until the client requests it is a better approach.)

The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the client's blood glucose readings have been elevated. What question by the nurse is most appropriate? a. "Are you compliant with following the diabetic diet?" b. "Have you been taking glucosamine supplements?" c. "How much exercise do you really get each week?" d. "You're still taking your diabetic medication, right?"

b. "Have you been taking glucosamine supplements?" (All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse should ask about its use. The other questions all have an element of nontherapeutic communication in them. "Compliant" is a word associated with negative images, and the client may deny being "noncompliant." Asking how much exercise the client "really" gets is accusatory. Asking if the client takes his or her medications "right?" is patronizing.)

The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.) a. It affects single joints only. b. Antibodies lead to inflammation. c. It consists of an autoimmune process. d. Morning stiffness is rare. e. Permanent damage is inevitable.

b. Antibodies lead to inflammation. c. It consists of an autoimmune process. (RA is a chronic autoimmune systemic inflammatory disorder leading to arthritis-type symptoms in the joints and other symptoms that can be seen outside the joints. Antibodies are created that lead to inflammation. Clients often report morning stiffness. Permanent damage can be avoided with aggressive, early treatment.)

A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The client's oxygen saturation is 87%. What action should the nurse perform first? a. Apply oxygen at 4 L/min. b. Attempt to arouse the client. c. Give naloxone (Narcan). d. Notify the Rapid Response Team.

b. Attempt to arouse the client. (The Pasero Opioid-Induced Sedation Scale is used to assess for unwanted opioid-associated sedation. A Pasero Scale score of 3 is unacceptable but is managed by trying to arouse the client in order to take deep breaths and staying with the client until he or she is more alert. Administering oxygen will not help if the client's respiratory rate is 7 breaths/min. Giving naloxone and calling for a Rapid Response Team would be appropriate for a higher Pasero Scale score.)

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit

b. Client with a red, hot, swollen right wrist (All of the options are possible manifestations of RA. However, the presence of one joint that is much redder, hotter, or more swollen that the other joints may indicate infection. The nurse needs to see this client first.)

A nurse on the medical-surgical unit has received a hand-off report. Which client should the nurse see first? a. Client being discharged later on a complicated analgesia regimen b. Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale c. Postoperative client who received oral opioid analgesia 45 minutes ago d. Client who has returned from physical therapy and is resting in the recliner

b. Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale (Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset abdominal pain needs to be seen first. The postoperative client needs 45 minutes to an hour for the oral medication to become effective and should be seen shortly to assess for effectiveness. The client going home requires teaching, which should be done after the first two clients have been seen and cared for, as this teaching will take some time. The client resting comfortably can be checked on quickly before spending time teaching the client who is going home.)

A client diagnosed with rheumatoid arthritis (RA) is started on methotrexate (Rheumatrex). Which statement made by the client indicates to the nurse that further teaching is needed regarding drug therapy? "Drinking alcoholic beverages should be avoided." "The health care provider should be notified 3 months before a planned pregnancy." "Any side effects of this drug will be mild." "I will avoid any live vaccines."

"Any side effects of this drug will be mild." (Further teaching is needed if the client states that, "Any side effects of this drug will be mild." Methotrexate can have devastating side effects and toxic effects, and the client should be carefully monitored when taking this drug. Alcoholic beverages increase the risk for hepatotoxicity and should be avoided. Strict birth control is recommended for any client of childbearing age because of the possibility of birth defects. Severe reactions may occur when live vaccines are given because of the immunosuppressive effect of methotrexate.)

The physiologic changes that normally occur in older adult patients have which implication for drug response? Protein binding is more efficient. Drug metabolism is quicker. Drug elimination is faster. Drug half-life is lengthened.

Drug half-life is lengthened. (Drug half-life is extended secondary to diminished liver and renal function in older adults.)

A patient will be discharged with a 1-week supply of an opioid analgesic for pain management after abdominal surgery. The nurse will include which information in the teaching plan? How to prevent dehydration due to diarrhea The importance of taking the drug only when the pain becomes severe How to prevent constipation The importance of taking the drug on an empty stomach

How to prevent constipation (Gastrointestinal (GI) adverse effects, such as nausea, vomiting, and constipation, are the most common adverse effects associated with opioid analgesics. Physical dependence usually occurs in patients undergoing long-term treatment. Diarrhea is not an effect of opioid analgesics. Taking the dose with food may help minimize GI upset.)

A nurse working with older adult patients is concerned about the number of medications prescribed for each patient. Which older adult assessment should be of highest priority related to polypharmacy? Nonadherence to drug regimen Cost of medications Drug interactions Schedule of medications

Drug interactions (The highest priority for older adult patients with multiple medications (polypharmacy) is the assessment for drug interactions. The more medications an older adult patient takes, the higher the risk for drug interactions.)

The nurse assesses a client diagnosed with Sjögren's syndrome. The nurse anticipates that the client will also have which common condition? Dry eyes Abdominal bloating after eating Excessive production of saliva in the mouth Intermittent episodes of diarrhea

Dry eyes (Clients with Sjögren's syndrome experience dry eyes (keratoconjunctivitis sicca). Abdominal bloating, excessive saliva production, and diarrhea are not common conditions in clients with Sjögren's syndrome; however, dry mouth is commonly described.)

The nurse teaches a patient prescribed the fentanyl (Duragesic) transdermal delivery system to change the patch at what interval? When pain recurs Every 72 hours Once a week Every 24 hours

Every 72 hours (The fentanyl transdermal delivery system is designed to slowly release analgesic over a 72-hour time frame.)

The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the patient's functional ability. What question would be the most appropriate? "Are you able to shop for yourself?" "Do you use a cane, walker, or wheelchair to ambulate?" "Do you know what today's date is?" "Were you sad or depressed more than once in the last 3 days?"

"Do you use a cane, walker, or wheelchair to ambulate?" ("Do you use a cane, walker, or wheelchair to ambulate?" will assist the nurse in determining the patient's ability to perform self-care activities. A nutritional health risk assessment is not the functional assessment. Knowing the date is part of a mental status exam. Assessing sadness is a question to ask in the depression screening.)

The nurse is talking to a group of active senior citizens about making healthy lifestyle choices. Which suggestion is most important in promoting health and safety? "Continue to eat healthy foods, especially protein." "Seek counseling for depression, because it is not a normal part of aging." "Enroll in a safe driving refresher course and avoid risky driving situations." "Walk 30 minutes three to five times a week."

"Enroll in a safe driving refresher course and avoid risky driving situations." (Safe driving refresher courses are one method to help older adults identify and manage these lifestyle choices. Motor vehicle crashes are the most common cause of injury-related death for those between 65 and 74 years of age. To promote health and safety, driving should be discontinued when vision, reflexes, or confidence begin to suffer.Eating healthy foods and exercise promote health but not safety. Encouraging good mental health promotes well-being but not safety.)

The patient asks the nurse to explain exactly what fibromyalgia is. What is the appropriate response by the nurse? "Fibromyalgia is an inflammatory disease with symptoms of stiffness, tenderness, and pain located at specific sites. Increased muscle tenderness may be caused by the inability to tolerate pain, possibly related to dysfunction in the brain, especially the thalamus and hypothalamus." "Fibromyalgia is a chronic pain syndrome with symptoms of stiffness, tenderness, and pain located at specific sites. Increased muscle tenderness may be caused by the inability to tolerate pain, possibly related to dysfunction in the brain, especially the thalamus and hypothalamus." "Fibromyalgia is an inflammatory disease with symptoms of stiffness, tenderness, and pain located at specific sites. Increased muscle tenderness may be caused by the inability to tolerate pain, possibly related to dysfunction in the brain, especially the limbic system and basal ganglia." "Fibromyalgia is a chronic pain syndrome with symptoms of stiffness, tenderness, and pain located at specific sites. Increased muscle tenderness may be caused by the inability to tolerate pain, possibly related to dysfunction in the brain, especially the limbic system and basal ganglia."

"Fibromyalgia is a chronic pain syndrome with symptoms of stiffness, tenderness, and pain located at specific sites. Increased muscle tenderness may be caused by the inability to tolerate pain, possibly related to dysfunction in the brain, especially the thalamus and hypothalamus." (Fibromyalgia syndrome (FMS), also referred to as simply fibromyalgia, is a chronic pain syndrome, not an inflammatory disease. However, arthritis and other comorbidities are commonly present in patients diagnosed with FMS. Increased muscle tenderness may be caused by the inability to tolerate pain, possibly related to dysfunction in the brain, especially the thalamus and hypothalamus, not the limbic system or the basal ganglia.)

Which statement indicates to the nurse that a client with fibromyalgia syndrome is using a complementary therapy to help relieve symptoms? "My Thera-Band really helps me loosen up my arms." "The brace on my lower leg is helping me walk better." "Focusing on the slow stretching movements and my breathing in tai chi helps me relax." "Water aerobic exercises have helped me sleep better."

"Focusing on the slow stretching movements and my breathing in tai chi helps me relax." (Tai chi is an alternative or complementary therapy that focuses on slow, gentle, and relaxing stretching movements and breathing. Thera-Band exercises are used in physical therapy. Splints or braces are used in occupational therapy. Water aerobics is an example of a low-impact exercise, and is not considered an alternative therapy.)

The nurse is assessing the nutritional status of an older adult client. Which statement made by the client needs to be explored further? "Although I enjoy eating sweets and desserts, I need to balance them with healthier foods." "For protein in my diet, I like to get the fish sandwich and fries at the fast-food drive-through at least three times a week." "To keep my bowel movements regular, I try to eat some fresh fruits or vegetables each day." "With less activity and exercise in my life these days, I should reduce my total calorie intake."

"For protein in my diet, I like to get the fish sandwich and fries at the fast-food drive-through at least three times a week." (Fast food is a contributor to high carbohydrate and caloric intake in older adults. Because fast food is relatively inexpensive and convenient, this population tends to abuse it, thus gaining weight from unhealthy calories.Older adults do enjoy sweets and desserts because their taste acuity changes, but they still need to eat a variety of foods that are high in protein and vitamins, as well as with different textures and fiber content. Consuming fresh fruits and vegetables is characteristic of a healthy lifestyle in older adults; this practice will help keep bowel habits routine. As older adults begin to lead a more sedentary lifestyle, they need to decrease their caloric intake to match a diminished basal metabolic rate.)

The nurse provides education about safety precautions to a patient who has undergone right total hip arthroplasty. Which statement from the patient indicates the need for additional teaching? "I should avoid twisting my body when moving." "I should avoid crossing my legs to be more comfortable." "I should avoid putting more weight on my right leg while walking." "I should avoid adaptive devices when putting on shoes and socks."

"I should avoid adaptive devices when putting on shoes and socks." (Adaptive devices help patients dress without putting any pressure on the site of surgery. Therefore, the nurse recommends the use of assistive or adaptive devices while dressing. Twisting the body may result in hip dislocation or other injury. Crossing the legs may provide comfort but may also dislocate the joint. Therefore, crossing the legs is restricted for the patient who has undergone hip surgery. The patient should avoid putting more weight on the right leg while walking.)

The nurse is assessing an older adult client's alcohol use. Which client statement warrants a follow-up collection of more data? "I am a 'teetotaler'; I never drink anything alcoholic." "I had three glasses of champagne at my granddaughter's wedding last month." "I like to have a glass of wine every once in a while." "I usually drink two vodkas to help me get to sleep each night."

"I usually drink two vodkas to help me get to sleep each night." (The recommended alcohol intake (National Institute on Alcohol Abuse and Alcoholism) for people over 65 years of age is one drink daily or seven drinks weekly. The practice of drinking two vodkas daily exceeds those recommendations and needs to be followed up by the nurse.Although it is impossible to determine whether someone who abstains from alcohol is an alcoholic, many people choose not to drink any alcohol at all. Unless evidence is available to dispute, the client who is a "teetotaler" should be believed. An occasional drink of an alcoholic beverage is within the range of normal consumption for older adults. Unless other alcohol was reported and is used more routinely, the level of consumption for the other clients should cause no alarm on a routine assessment.)

The nurse is teaching a patient with arthritis about exercise. Which statement by the patient indicates that further teaching is needed? "I will exercise only on good days." "I will do the exercises prescribed for me." "I will do active exercises whenever possible." "I will do my exercises in addition to my normal activities."

"I will exercise only on good days." (Exercises should be consistently done on both good days and bad days to maintain or increase mobility and reduce pain. The patient should follow the exercises specifically prescribed by the health care provider. Active exercises, rather than active-assist or passive exercises, are done whenever possible as this enhances self-esteem. Patients need to be taught not to substitute normal activities or household tasks for the prescribed exercises to maintain independence as well as increase mobility and reduce pain.)

The nurse is teaching a patient with fibromyalgia. Which statement by the patient indicates that further teaching is needed? "I swim because it is a low-impact exercise." "I will experience increased alertness due to pregabalin." "I will do stretching and strengthening exercises daily." "I take a muscle relaxant to decrease my pain."

"I will experience increased alertness due to pregabalin." (The patient should understand that pregabalin can cause drowsiness and sleepiness. Physical therapy along with NSAIDs and possibly muscle relaxants may also be prescribed to help decrease fibromyalgia pain. The patient should be instructed to exercise regularly. Home exercise should include low-impact aerobic exercise such as walking, swimming, rowing, biking, and water exercise, as it helps strengthen muscles and decrease pain by consistently exercising. Stretching and strengthening exercises should also be included in a home-exercise regimen. Muscle relaxants, along with physical therapy and NSAIDs, may help decrease the pain associated with fibromyalgia.)

A postoperative client is requesting medication for pain every 4 hours. In planning effective pain management, what assessment question does the nurse ask the client before administering the medication? "Are you bleeding?" "Are you able to last more than 4 hours?" "Is your pain controlled between doses?" "What do you do for pain when you're at home?"

"Is your pain controlled between doses?" (Asking the client about the frequency of pain and how the pain is being controlled by rating the pain helps in formulating an effective pain management plan.Asking the client about the occurrence of bleeding does not address the pain issue and is a separate problem. Indicating that the client may be able to go without pain medication longer sounds judgmental and places the client on defense. Asking what the client does for pain at home is helpful in assessing chronic pain, but not for assessing postoperative pain and is not relevant in this scenario.)

A patient prescribed massage therapy for musculoskeletal pain asks the nurse, "How is rubbing my muscles going to make the pain go away?" What is the nurse's best response? "Massaging muscles helps relax the contracted fibers and decrease painful stimuli." "Massaging muscles activates small sensory nerve fibers that send signals to the spinal cord to open the gate and allow endorphins to reach the muscles and relieve the pain." "Massaging muscles activates large sensory nerve fibers that send signals to the spinal cord to close the gate, thus blocking painful stimuli from reaching the brain." "Massaging muscles decreases the inflammatory response that initiates the painful stimuli."

"Massaging muscles activates large sensory nerve fibers that send signals to the spinal cord to close the gate, thus blocking painful stimuli from reaching the brain." (The gate theory of pain control identifies large sensory nerve fibers that, when stimulated, send signals to the spinal cord to close the gate, blocking pain stimuli from reaching the brain. Therefore, the patient is not having the sensation of pain even if the stimulus is still present.)

The nurse is caring for a middle-aged client diagnosed with rheumatoid arthritis. Which client statement requires further assessment for unproductive coping strategies? "I'm letting my husband do most of the cooking, but I help plan the menus." "Since I started taking etanercept (Enbrel), I can walk up and down the stairs of my home easier." "My husband is getting used to having sex only once a month." "I worry about what's going to happen to me if my husband cannot take care of me, but he says he'll hire someone if he must."

"My husband is getting used to having sex only once a month." (The client's comment that her husband is getting used to sex only once a month could indicate negative body image or depression; additional open-ended questions by the nurse are required. Being involved in the meal process is a productive coping strategy. The client's statement about the positive effects of etanercept therapy indicates productive coping because it describes improved mobility. Expressing concerns about the future but then identifying a plan is a productive coping strategy.)

A client who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PCA button for the sleeping client. What does the nurse say to the visitor? "Please allow the client to push the button when needed." "Please don't touch any equipment in the client's room." "Thank you. I am sure the client appreciated that." "The client is asleep and is not in pain."

"Please allow the client to push the button when needed." (The nurse will request that the visitor allow the client to push the button for medication when needed. The "PC" in "PCA" means "patient-controlled," so having someone else push the button and administer analgesia defeats the purpose. More important, this action could cause oversedation and possible serious safety issues.Telling the family member not to touch any equipment in the client's room is not only nonspecific, it may also be perceived as disrespectful. Expressing appreciation is inappropriate because the nurse is condoning an unauthorized and potentially unsafe action. The fact that the client is asleep does not mean that the client is pain-free.)

A 70-year-old client whose spouse died the previous year says to the nurse, "Life is not fun anymore." How does the nurse respond? "Are you getting enough sleep? That makes me feel better!" "Tell me about your support network, such as friends or family." "How are you feeling about the death of your spouse after this length of time?" "Why don't you go on a vacation? A change of scenery will do you good."

"Tell me about your support network, such as friends or family." (Establishing and maintaining relationships with others throughout life is especially important to a person's happiness. Older adults who have close, intimate, and stable relationships with others in whom they can confide are more likely to cope with crises.Sleep can affect coping, but this is not the best answer, and is a closed-ended question not allowing for elaboration. The nurse providing information about "self" is also nontherapeutic. Asking about the spouse's death is leading, and the source of the client's statement may have nothing to do with the spouse's death. Suggesting a vacation does not address the issue at hand. "Why" questions are typically nontherapeutic and often place clients in a defensive stance.)

Which statement by the nurse is the most effective when communicating with a patient who was just been diagnosed with fibromyalgia after waiting for over 10 years for a diagnosis? "You must be so happy to finally have a diagnosis." "Now that you finally have a diagnosis, things will be easier." "Tell me what you are feeling after finally getting a diagnosis." "If I were you, I would be so thankful that you finally got a diagnosis."

"Tell me what you are feeling after finally getting a diagnosis." (Patients with fibromyalgia and chronic fatigue syndrome are often frustrated because they have not been diagnosed or have been misdiagnosed. When the nurse says, "Tell me what you are feeling after finally getting a diagnosis," it is a therapeutic response that gives the patient the opportunity to share freely on a subject. Non-therapeutic responses such as, "You must be so happy to finally have a diagnosis" limit reflection by the patient and imply a need for patients to have the nurse's support and approval. The nurse is giving false reassurance when saying, "Now that you finally have a diagnosis things will be easier," which discounts the patient's feelings and cuts off conversation about legitimate concerns of the patient. The nurse is giving advice when saying, "If I were you, I would be so thankful that you finally got a diagnosis," which tends to limit the patient's ability to explore alternative solutions to issues that need to be faced.)

A client being discharged after hip replacement says, "I am going to use hypnosis instead of medication to manage my pain. I believe in mind over body." How does the nurse respond? "I will discuss cancelling your medication order with your provider." "That sounds like a great plan; can you tell me more about it?" "That sounds like a wonderful idea; and I think it will definitely work!" "Your plan will not work; people with your type of pain need narcotics."

"That sounds like a great plan; can you tell me more about it?" (Complementary and alternative therapies should supplement, not replace, medication management. The nurse needs to obtain more data, and so will ask for more information about the client's plan.Contacting the provider to cancel the medication order is inappropriate. Telling the client that his idea is wonderful and will definitely work is inappropriate. Telling the client that his or her plan will not work is dismissive of the client. Also, the client may not need to be prescribed narcotics for the pain.)

The nurse is caring for an older, alert adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies? "I do not know how long my wife will be able to take care of me at home." "The bus is coming to pick me up from the senior center three times a week so I can play cards." "I am helping with the dishes and laundry, but I hurt so badly when I am doing it." "I do not know how much longer my neighbor can continue to help clean my house."

"The bus is coming to pick me up from the senior center three times a week so I can play cards." (Participation in diversional activities is a way to cope with daily stressors of osteoarthritis and shows good use of available resources for support. Caregiving responsibilities can be a source of stress; the client worrying about his wife's caregiving abilities does not indicate that the client is effectively coping. Routine tasks, such as doing dishes and laundry, need to be reassigned or effective pain management should be instituted before activities are undertaken to demonstrate effective coping. Neighbors are not reliable resources for in-home needs, and asking a neighbor to help does not indicate that the client is coping effectively.)

The nurse is teaching a client about the difference between rheumatoid arthritis (RA) and osteoarthritis (OA). Which statement by the client indicates a need for further teaching? "RA is inflammatory. OA is degenerative." "The risk factors or causes of RA are probably autoimmune, whereas OA may be caused by age, obesity, trauma, or occupation." "The typical onset of RA is seen between 35 and 45 years of age, whereas the typical onset of OA is seen in clients older than 60 years." "The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints."

"The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints." (Further teaching is needed if the client states that, "The disease pattern of RA is usually unilateral and is seen in a single joint, whereas OA is usually bilateral and symmetric, and is noted in multiple joints." OA is unilateral and usually affects a single joint, whereas RA is bilateral and affects multiple joints. RA is an inflammatory process, while OA is a degenerative process. Research is being done to find a possible genetic cause for OA, but age, trauma, obesity, and occupation are the main causes of degeneration. RA occurs most often in women, usually between 35 and 45 years of age, whereas older age is a cause of OA.)

The client asks the nurse about the use of herbal and dietary supplements to treat arthritis pain. What is the nurse's best response? "Ginkgo biloba has shown tremendous benefit as an antiinflammatory drug and is used to treat the symptoms of pain." "There is evidence that glucosamine sulfate with chondroitin does decrease joint stiffness and pain. Discuss this with your health care provider." "There really are no safe herbal treatments for pain. Your best action would be to take your prescription medications." "High doses of vitamins and minerals have been used for many years to help maintain joint health."

"There is evidence that glucosamine sulfate with chondroitin does decrease joint stiffness and pain. Discuss this with your health care provider." (There is evidence that clients would benefit from glucosamine and chondroitin supplements to decrease the pain of osteoarthritis. However, they should always be used in consultation with a health care provider.)

A staff nurse reports a medication error, failure to administer a medication at the scheduled time. An appropriate response of the charge nurse would be "We'll do a root cause analysis." "That means you'll have to do continuing education." "Why did you let that happen?" "You'll need to tell the patient and family."

"We'll do a root cause analysis." (In a just culture the nurse is accountable for their actions and practice, but people are not punished for flawed systems. Through a strategy such as root cause analysis the reasons for errors in medication administration can be identified and strategies developed to minimize future occurrences. Requiring continued education may be an appropriate recommendation but not until data is collected about the event. Telling the patient is part of transparency and the sharing and disclosure among stakeholders, but it is generally the role of risk management staff, not the staff nurse.)

When assessing a client for acute or chronic pain, what question does the nurse ask the client to obtain the most data? "Did someone do this to you?" "Does it hurt badly?" "Is the pain really that bad?" "When does it hurt?"

"When does it hurt?" (Asking when the pain occurs helps determine precipitating factors to identify the source of pain. It is an open-ended question that requires a descriptive response and so will allow the nurse to obtain the most data.Asking if someone hurt the client may be appropriate in rare circumstances, but typically it is not an appropriately focused question; the question does not relate to the severity or character of the pain. The nurse should ask the client open-ended questions, not questions requiring a "yes-or-no" answer, such as "Does it hurt badly?" Asking "Is the pain really that bad?" minimizes the client's perception of pain; it is also a closed-ended question requiring a "yes-or-no" answer.)

An older client who lives alone is being discharged on opioid analgesics. What action by the nurse is most important? a. Discuss the need for home health care. b. Give the client follow-up information. c. Provide written discharge instructions. d. Request a home safety assessment.

d. Request a home safety assessment. (All these activities are appropriate when discharging a client whose needs will continue after discharge. A home safety assessment would be most important to ensure the safety of this older client.)

A patient arrives at the urgent care center complaining of leg pain after a fall when rock climbing. The x-rays show no broken bones, but he has a large bruise on his thigh. The patient says he drives a truck and does not want to take anything strong because he needs to stay awake. Which statement by the nurse is most appropriate? "It would be best for you not to take anything if you are planning to drive your truck." "We will discuss with your doctor about taking an opioid because that would work best for your pain." "You can take acetaminophen, also known as Tylenol, for pain, but no more than 1000 mg per day." "You can take acetaminophen, also known as Tylenol, for pain, but no more than 3000 mg per day."

"You can take acetaminophen, also known as Tylenol, for pain, but no more than 3000 mg per day." (Acetaminophen is indicated for mild-to-moderate pain and does not cause drowsiness, as an opioid would. Currently, the maximum daily amount of acetaminophen is 3000 mg/day. The 1000-mg amount per day is too low. Telling the patient not to take any pain medications is incorrect.)

A patient with osteoarthritis wants to use capsaicin cream. Which information should the nurse provide to the patient? "You may have drowsiness for a short period after applying it." "You may have a burning sensation for a short period after applying it." "You may have increased blood pressure for a short period after applying it." "You may have increased blood sugar levels for a short period after applying it."

"You may have a burning sensation for a short period after applying it." (Capsaicin is an over-the-counter (OTC) medication that works by blocking pain neurotransmitters. Capsaicin may cause a burning sensation on the skin for a short time after application. Capsaicin cream does not cause drowsiness, an increase in blood pressure, or an increase in blood sugar levels.)

A client with osteoarthritis pain tells the nurse, "I take two arthritis-strength Tylenol (650 mg) every 8 hours." How does the nurse respond? "Aspirin would be a better, more effective choice for your pain relief." "More Tylenol is needed to provide effective pain relief for you." "That is the appropriate dose of Tylenol for your pain." "You will need to have routine liver and kidney function laboratory tests."

"You will need to have routine liver and kidney function laboratory tests." (The nurse responds by informing the client that taking Tylenol, especially high doses of it, would need routine liver and kidney function laboratory testing done. Hepatotoxicity and nephrotoxicity are adverse effects associated with long-term use of Tylenol.Acetaminophen (Tylenol) is a better choice for pain relief than aspirin because it has fewer side effects on the gastrointestinal system, such as bleeding. The client is actually taking more than the recommended upper limit of Tylenol; no more than 3600 mg daily would be used, and no more than 2400 mg for older adults.)

A patient receiving narcotic analgesics for chronic pain can minimize the GI side effects by: eating foods high in lactobacilli. taking Lomotil with each dose. taking the medication on an empty stomach. increasing fluid and fiber in the diet.

increasing fluid and fiber in the diet. (Narcotic analgesics decrease intestinal motility, leading to constipation. Increasing fluid and fiber in the diet can prevent constipation.)

A patient is prescribed an opioid analgesic for chronic pain. Which information should the nurse discuss with the patient to minimize the GI adverse effects? Avoid eating foods high in lactobacilli. Increase fluid intake and fiber in the diet. Take diphenoxylate-atropine (Lomotil) with each dose. Take the medication on an empty stomach.

Increase fluid intake and fiber in the diet. (Opioid analgesics decrease GI intestinal motility (peristalsis), leading to constipation. Increasing fluid and fiber in the diet or use of stool softener or mild laxative can prevent constipation.)

A 38-year-old man has come into the urgent care center with severe hip pain after falling from a ladder at work. He says he has taken several pain pills over the past few hours but cannot remember how many he has taken. He hands the nurse an empty bottle of acetaminophen (Tylenol). The nurse is aware that the most serious toxic effect of acute acetaminophen overdose is which condition? Tachycardia Central nervous system depression Hepatic necrosis Nephropathy

Hepatic necrosis (Hepatic necrosis is the most serious acute toxic effect of an acute overdose of acetaminophen. The other options are incorrect.)

A patient is recovering from abdominal surgery, which he had this morning. He is groggy but complaining of severe pain around his incision. What is the most important assessment data to consider before the nurse administers a dose of morphine sulfate to the patient? His pulse rate His respiratory rate The appearance of the incision The date of his last bowel movement

His respiratory rate (One of the most serious adverse effects of opioids is respiratory depression. The nurse must assess the patient's respiratory rate before administering an opioid. The other options are incorrect.)

A 72-year-old client admitted to the hospital for congestive heart failure has a history of a fractured hip due to a previous fall. The client is taking oxycodone-acetaminophen (Tylox) as needed for pain secondary to a recent dental procedure. Which risk factor puts this client at greatest risk for a fall? Age Diagnosis History of a fall Narcotic use

History of a fall (The client's recent history of falling is the single most important predictor for falls.Adults age 80 years and older and those with multiple diagnoses are at higher risk for falls. Tylox may cause mental changes, but this is not the greatest risk for a fall.)

The nurse is caring for a patient with opioid addiction. The nurse anticipates that the patient will be prescribed which medication? Meperidine (Demerol) Naloxone (Narcan) Methadone (Dolophine) Morphine (MS Contin)

Methadone (Dolophine) (Methadone is a synthetic opioid analgesic with gentler withdrawal symptoms and is the drug of choice for detoxification treatment.)

The nurse is reviewing herbal therapies. Which is a common use of the herb feverfew? Muscle aches Migraine headaches Leg cramps Incision pain after surgery

Migraine headaches (Feverfew is commonly used for migraine headaches, menstrual problems, arthritis, and fever. Possible adverse effects include muscle stiffness and muscle and joint pain.)

The nurse is reviewing the medication history for a client diagnosed with rheumatoid arthritis (RA) who has been ordered to start sulfasalazine (Azulfidine) therapy. The nurse plans to contact the health care provider if the client has which condition? Glaucoma Hypertension Hypothyroidism Sulfa allergy

Sulfa allergy (Sulfasalazine contains sulfa and is contraindicated in clients with sulfa allergies. Sulfasalazine (Azulfidine) is not contraindicated in clients with glaucoma, hypertension, or hypothyroidism.)

The home care nurse is trying to determine the necessary services for a 65-year-old patient who was admitted to the home care service status after left knee replacement. Which tool(s) will assist with this determination? Minimum Data Set (MDS) Functional Status Scale (FSS) 24-Hour Functional Ability Questionnaire (24hFAQ) The Edmonton Functional Assessment Tool

24-Hour Functional Ability Questionnaire (24hFAQ) (The 24hFAQ assesses the postoperative patient in the home setting. The MDS is for nursing home patients. The FSS is for children. The Edmonton is for cancer patients.)

Which action is appropriate for a patient managing osteoarthritis with prescribed exercises? Maintain the usual number of repetitions when inflammation is severe. Substitute prescribed exercises with household tasks. Use passive and active-assist rather than active exercises whenever possible. Avoid resistive exercises when joints are severely inflamed.

Avoid resistive exercises when joints are severely inflamed. (The patient should avoid resistive exercises when his or her joints are severely inflamed. The patient may reduce the number of repetitions when inflammation and pain are severe. The patient should not substitute household tasks for prescribed exercises. The patient should use active rather than passive and active-assist exercises whenever possible.)

The nurse is assessing a patient's ability to perform basic activities of daily living (BADLs). Which of the following activities are considered in the BADLs assessment? Select all that apply. Brushing teeth or dentures Dressing oneself in the mornings Washing, drying, and folding laundry Counting own pulse and taking heart pill Taking the bus to the park Calling family members

Brushing teeth or dentures Dressing oneself in the mornings (BADLs include actions related to self care and mobility and also includes eating, personal hygiene, and grooming activities. Instrumental activities of daily living (IADLs) include shopping, meal preparation, housekeeping, doing laundry, managing finances, using the telephone, taking medications, and using transportation.)

Which laboratory and diagnostic tests are used to detect osteoarthritis (OA)? Select all that apply. C-reactive protein assay X-ray studies Rheumatoid factor assay Antinuclear antibody test Magnetic resonance imaging

C-reactive protein assay X-ray studies Magnetic resonance imaging (Assessment for OA includes serological and imaging studies. The high-sensitivity C-reactive protein (hsCRP) may be slightly elevated when synovial inflammation occurs. Imaging studies of OA include routine x-ray images and magnetic resonance imaging (MRI) to determine structural joint changes. Rheumatoid factor assay and antinuclear antibody testing are used for diagnosing rheumatoid arthritis.)

While conducting a health history for an older adult patient with heart failure, the patient tells the nurse, I have chronic constipation." The nurse suspects this gastrointestinal complaint is caused by which class of drugs? Nonsteroidal antiinflammatory drugs Calcium channel blockers Potassium-sparing diuretics Anticoagulants

Calcium channel blockers (Calcium channel blocker drugs may worsen constipation in the older adult population and thus should be avoided.)

In the role of client advocate, what does the nurse do first for a client who reports pain? Administers pain medication Assesses the level of pain Believes the client's report of pain Calls the provider for a medication order

Believes the client's report of pain (The nurse's primary role in pain management is to advocate for the client by believing reports of pain, so believing the client's report of pain is the nurse's first action. This has become the clinical definition of pain worldwide and reflects an understanding that the client is the authority and the only one who can describe the pain experience. In other words, self-report is always the most reliable indication of pain.Administering pain medication, assessing the pain level, and calling the provider are not the first steps to take.)

When teaching a client about potential adverse effects of NSAID therapy, the nurse will teach the client to immediately notify the health care provider of which effect? Nonproductive cough Black tarry stools Diarrhea Mild indigestion

Black tarry stools (A major adverse effect of NSAID therapy is gastrointestinal (GI) distress with potential GI bleeding. Black or tarry stools are indicative of a GI bleed.)

The nurse is planning a dressing change on a postoperative mastectomy client. The client is receiving acetaminophen and oxycodone (Percocet) orally for pain every 4 hours and is due to receive them at 4:00 p.m. When will the nurse change the dressing? 3:30 p.m. 4:00 p.m. 4:30 p.m. 7:00 p.m.

4:30 p.m. (The nurse will change the dressing at 4:30 p.m. About 30 minutes after administration of an analgesic is an optimal time to perform a procedure on a client. At 4:30 p.m., the opioid has had time to take effect and provide relief for the client.It would be inappropriate to perform a painful procedure, such as a dressing change, just before a scheduled analgesic is received (i.e., 3:30 p.m.), because the pain medication will be at its lowest concentrations in the client's system. At 4:00 p.m., the analgesic has not had time to enter the client's system, so it is too soon to perform the dressing change. If the client received the analgesic at 4:00 PM, it is not at the highest or best concentration at 7:00 p.m. to facilitate a dressing change with minimal discomfort.)

The nurse should question a prescription to administer acetylsalicylic acid (aspirin) to which client? A 45-year-old patient with a history of heart attack A 62-year-old patient with a history of stroke A 14-year-old patient with a history of flulike symptoms A 28-year-old patient with a history of sports injury

A 14-year-old patient with a history of flulike symptoms (Aspirin should never be administered to children with flulike symptoms. The use of aspirin in children with flulike symptoms has been associated with Reye's syndrome.)

Which client does the RN arriving for duty assess first? A 27-year-old who has chronic severe back pain with movement A 51-year-old with lung cancer who reports pain "whenever I cough" A 56-year-old with acute pancreatitis who reports increasing abdominal pain A 63-year-old who reports ongoing pain associated with rheumatoid arthritis

A 56-year-old with acute pancreatitis who reports increasing abdominal pain (The nurse arriving for duty will first assess the 56-year-old client with acute pancreatitis and abdominal pain. Because acute pain is a biological warning signal, the nurse would assess the client with pancreatitis for complications such as bleeding or perforation that may be causing the client's increasing pain.The clients with back pain, lung cancer pain, and rheumatoid arthritis have chronic pain and would be assessed and treated as rapidly as possible, but the client with acute pain takes priority.)

The RN is arriving for night duty at an acute care hospital. Which client does the RN assess first? A 65-year-old scheduled for next-day surgery A 68-year-old with chronic protein-calorie malnutrition A 70-year-old with a history of gout and joint pain A 72-year-old admitted with postoperative delirium

A 72-year-old admitted with postoperative delirium (The postoperative client with delirium is at risk for injury because associated agitation and/or combativeness may lead to behaviors such as climbing out of bed or pulling at invasive catheters.Clients such as a 65-year-old scheduled for next-day surgery, a 68-year-old with chronic protein-calorie malnutrition, or a 70-year-old with a history of gout and joint pain need to be assessed as soon as possible, but scheduled surgery, malnutrition, and a diagnosis of gout with joint pain do not indicate any acute risk for complications.)

A client with chronic pain feels no relief with high-dose opioids and says, "I just can't manage living right now." What intervention does the nurse anticipate the health care provider will order for this client? Adding acetaminophen (Tylenol) Adding duloxetine (Cymbalta) as adjuvant therapy Increasing the opioid dose to control the pain Replacing the opioid with desipramine (Norpramin) for depression

Adding duloxetine (Cymbalta) as adjuvant therapy (The nurse anticipates that the health care provider will order duloxetine as adjuvant therapy. Both tricyclic and other antidepressants such as duloxetine (Cymbalta) help treat the depression that can accompany chronic pain. They also stimulate the activity of endogenous opiates (endorphins and enkephalins) by increasing levels of the neurotransmitter serotonin.Adding acetaminophen would not address the client's depression. Increasing the opioid dose can cause respiratory depression. Discontinuing the opioid can cause relapse pain.)

The nurse is assessing a patient for contraindications to drug therapy with acetaminophen (Tylenol). Which patient should not receive acetaminophen? A patient with a fever of 101° F (38.3° C) A patient who is complaining of a mild headache A patient with a history of liver disease A patient with a history of peptic ulcer disease

A patient with a history of liver disease (Liver disease is a contraindication to the use of acetaminophen. Fever and mild headache are both possible indications for the medication. Having a history of peptic ulcer disease is not a contraindication.)

A patient is diagnosed with osteoarthritis (OA). Which medication is considered the primary drug of choice for treatment? Methotrexate (MTX) Adalimumab Acetaminophen Leflunomide

Acetaminophen (Drug therapy in OA is used for reducing pain caused by cartilage damage. The American Pain Society recommends acetaminophen as the primary choice of drug for osteoarthritis. Methotrexate, adalimumab, and leflunomide are drugs used in the treatment of rheumatoid arthritis (RA).)

A postoperative client reports, "I have pain from a mild headache." Which PRN medication does the nurse administer? Acetaminophen (Tylenol) Hydromorphone (Dilaudid) Midazolam (Versed) Oxycodone hydrochloride/acetaminophen (Tylox)

Acetaminophen (Tylenol) (The nurse will administer Acetaminophen (Tylenol). Nonopioid analgesics such as Tylenol are the first line of therapy for mild to moderate pain.Dilaudid is appropriate for acute pain, such as pain from surgery, but it is inappropriate to give it for headache pain, especially for a mild headache. Versed is not appropriate for routine postoperative pain or headache; it is often used as a preoperative sedative. Although Tylox contains acetaminophen, it is also a narcotic; this level of pain control is not needed for a mild headache.)

While admitting a patient for treatment of an acetaminophen (Tylenol) overdose, the nurse prepares to administer which medication to prevent toxicity? Methylprednisolone (Solu-Medrol) Acetylcysteine (Mucomyst) Naloxone (Narcan) Phytonadione (vitamin K)

Acetylcysteine (Mucomyst) (Acetylcysteine is the antidote for acetaminophen overdose. It must be administered as a loading dose followed by subsequent doses every 4 hours for 17 additional doses and started as soon as possible after the acetaminophen ingestion (ideally within 12 hours).)

Before administering prednisone IV push to a middle-aged adult with rheumatoid arthritis (RA), the nurse notes that the client's random blood glucose level is 139 mg/dl (7.7 mmol/L). Which action is most important for the nurse to take? Instruct the client to drink diet soda to prevent elevation of blood sugar. Administer the prescribed prednisone on schedule. Notify the health care provider of the random blood glucose result. Review the client's antinuclear antibody (ANA) level.

Administer the prescribed prednisone on schedule. (For this client, giving the medication per schedule is essential in treating the disease. Blood sugar is only slightly elevated and the blood glucose value will be monitored regularly because the client is receiving prednisone. Blood sugar is only slightly elevated, so encourage fluids other than soda (diet or otherwise). Blood glucose levels are performed and parameters are set as to when the health care provider should be notified, but usually this is done only if the random blood glucose level is greater than 150 mg/dl (8.325 mmol/L). Reviewing the client's ANA level is not required before prednisone is given; the client's ANA is elevated because of the RA.)

A 57-year-old woman being treated for end-stage breast cancer has been using a transdermal opioid analgesic as part of the management of pain. Lately, she has been experiencing breakthrough pain. The nurse expects this type of pain to be managed by which of these interventions? Administering NSAIDs Administering an immediate-release opioid Changing the opioid route to the rectal route Making no changes to the current therapy

Administering an immediate-release opioid (If a patient is taking long-acting opioid analgesics, breakthrough pain must be treated with an immediate-release dosage form that is given between scheduled doses of the long-acting opioid. The other options are not appropriate actions.)

A client with cancer is receiving low-dose oral morphine but is reporting both "sharp, tingly" pain and constipation. What intervention does the nurse implement first? Administers ordered docusate sodium (Colace) and gabapentin (Neurontin) Decreases the morphine (morphine sulfate) dosage for the client Gives the client a Fleet's (sodium biphosphate) enema Records the client's bowel movements

Administers ordered docusate sodium (Colace) and gabapentin (Neurontin) (As a first intervention, docusate (Colace) and gabapentin (Neurontin) take priority. Docusate is a stool softener and gabapentin is an adjuvant for neuropathic pain.Constipation is a side effect of morphine, but decreasing the morphine dose will cause this client's pain to become even worse. Giving an enema is not the first intervention that should be tried by the nurse. Recording bowel movements is helpful for assessment, but does nothing to relieve the client's constipation.)

A 78-year-old patient is in the recovery room after having a lengthy surgery on his hip. As he is gradually awakening, he requests pain medication. Within 10 minutes after receiving a dose of morphine sulfate, he is very lethargic and his respirations are shallow, with a rate of 7 per minute. The nurse prepares for which priority action at this time? Assessment of the patient's pain level Immediate intubation and artificial ventilation Administration of naloxone (Narcan) Close observation of signs of opioid tolerance

Administration of naloxone (Narcan) (Naloxone, an opioid-reversal agent, is used to reverse the effects of acute opioid overdose and is the drug of choice for reversal of opioid-induced respiratory depression. This situation is describing an opioid overdose, not opioid tolerance. Intubation and artificial ventilation are not appropriate because the patient is still breathing at 7 breaths/min. It would be inappropriate to assess the patient's level of pain.)

The nurse recognizes that it is not uncommon for an elderly patient to experience a reduction in the stomach's ability to produce hydrochloric acid. This change may result in which effect? Delayed gastric emptying Increased gastric acidity Decreased intestinal absorption of medications Altered absorption of weakly acidic drugs

Altered absorption of weakly acidic drugs (Reduction in the stomach's ability to produce hydrochloric acid is an aging-related change that results in a decrease in gastric acidity and may alter the absorption of weakly acidic drugs. The other options are not results of reduced hydrochloric acid production.)

The acetic acid derivative indomethacin (Indocin) has which properties? (Select all that apply.) Select all that apply. Antirheumatic Antiinflammatory Antipyretic Antinausea Anticonvulsant

Antirheumatic Antiinflammatory Antipyretic (NSAIDs are known for their antiinflammatory effects. Indomethacin, in addition, is also used for its antirheumatic and antipyretic properties. NSAIDs are often known to have nausea as a common adverse effect. Indomethacin is not used as an anticonvulsant.)

The nurse is caring for a postoperative patient with total joint arthroplasty. What actions does the nurse take to prevent venous thromboembolism (VTE) postoperatively? Select all that apply. Massage the legs. Keep the legs slightly abducted. Use the knee gatch on the bed. Apply elastic stockings. Administer anticoagulants.

Apply elastic stockings. Administer anticoagulants (Support stockings provide compression, which helps prevent VTE. Anticoagulants help prevent VTE because they inhibit the formation of blood clots. Massaging the legs could cause a blood clot to dislodge and should be avoided. Legs are kept slightly abducted to prevent adduction. Using the knee gatch can constrict circulation in the popliteal area and should be avoided.)

The nurse is caring for a postoperative client with total joint arthroplasty. What actions does the nurse take to prevent venous thromboembolism (VTE) postoperatively? Select all that apply. Massage the legs. Keep the legs slightly abducted. Use the knee gatch on the bed. Apply elastic stockings. Administer anticoagulants.

Apply elastic stockings. Administer anticoagulants. (Support stockings provide compression, which helps prevent VTE. Anticoagulants also help prevent VTE because they inhibit the formation of blood clots. The legs should never be massaged, because it could cause a blood clot to dislodge. Legs are kept slightly abducted to prevent adduction. Using the knee gatch can constrict circulation in the popliteal area and should be avoided.)

A patient has joint inflammation. Which interventions should the nurse add to the discharge plan of care? Select all that apply. Apply ice packs Apply heat packs Ensure adequate rest Begin a running program Perform daily stretching exercises

Apply ice packs Apply heat packs Ensure adequate rest Perform daily stretching exercises (Adequate rest, proper positioning, and ice and heat applications are important in pain management. If acute inflammation is present, ice packs may be applied to "hot" joints for pain relief until the inflammation lessens. The ice pack should not be too heavy. At home, the patient can use a small bag of frozen peas or corn as an ice pack. Daily stretching exercises and gentle low-impact exercises like walking and swimming (not running) help improve symptoms.)

The home health aide reports that a 70-year-old client is noncompliant in taking prescribed medications. What does the nurse do to solve this problem? Asks what the barriers are to taking the medications Color-codes the labels or places dots on the bottles Provides a weekly pill box with daily compartments Provides medications with bottle caps that are easy to open

Asks what the barriers are to taking the medications (Assessing why the client is noncompliant and overcoming those barriers are key to obtaining information and facilitating compliance.Using a color-coding system is a great technique, but the client's noncompliance may not be caused by failure to identify medications correctly. Use of a pill box is a good method, but the client's noncompliance may not be caused by failure to remember which medications are to be taken and when. Use of caps that are easy to open is helpful, but the client's noncompliance may not be caused by difficulty with opening medication bottles.)

The nurse is caring for a patient who has undergone total hip arthroplasty. What interventions does the nurse provide to prevent the complication of dislocation? Avoids the use of abduction devices Assesses the patient for extremity shortening Places pillows on either side of the patient to prevent movement Keeps the patient's heels off the bed

Assesses the patient for extremity shortening (When caring for the patient who has undergone a total hip arthroplasty, the nurse assesses the patient for pain, rotation, and extremity shortening. An abduction pillow or splint helps prevent dislocation; abduction devices are used if the patient is restless or has an altered state of mind. A pillow is placed between the patient's legs to prevent adduction beyond the midline of the body. The patient's heels are kept off the bed to prevent skin breakdown, not to prevent dislocation.)

The RN at a skilled nursing facility is supervising a staff of LPN/LVNs and nursing assistants. Which of these nursing actions does the RN delegate to a nursing assistant? Admitting a new client with multiple bruises over the upper thighs Assisting a client with chronic joint stiffness to ambulate Making hourly assessments on a client with delirium and dementia Monitoring a confused client who has been placed in a jacket restraint

Assisting a client with chronic joint stiffness to ambulate (Nursing assistant education and scope of practice include ambulation of stable clients.Nursing actions require broad education and scope of practice and need to be done by licensed nurses. Admission of a new client who has clinical manifestations that may have been caused by abuse is the responsibility of the RN. The RN must assess the client with acute problems such as delirium and dementia. LPN/LVN education and scope of practice include monitoring, repositioning, and toileting of clients who require restraints.)

What nursing interventions may be performed to prevent dislocation of the hip joint in a patient who has undergone total hip arthroplasty (THA)? Select all that apply. Avoid hip flexion beyond 90 degrees. Use aseptic technique for wound care. Instruct the patient to do leg exercises. Instruct the patient to wear elastic stockings. Assess acute pain, rotation, and extremity shortening.

Avoid hip flexion beyond 90 degrees. Assess acute pain, rotation, and extremity shortening. (Hip flexion beyond 90 degrees should be avoided because it and may lead to dislocation and also causes pain in the hip. Acute pain, rotation, and extremity shortening should be assessed after a THA. Using aseptic techniques for wound care would help in preventing infections. Instructing the patient to do leg exercises or to wear elastic stockings would help to prevent venous thromboembolism.)

An alert client who recently underwent total hip arthroplasty and is on anticoagulants is preparing for discharge from the hospital. Which information is most important for the nurse to provide to the client and caregiver? Use an abduction pillow between the legs. Keep heels off the bed. Avoid using a straight razor. Re-orient frequently.

Avoid using a straight razor. (Using a straight razor should be avoided. The client will be on anticoagulants for 4 to 6 weeks at home and should avoid injury to the skin that can occur when shaving. Using an abduction pillow between the legs is usually done immediately after surgery, especially if the client is confused or restless and cannot maintain proper joint positioning. Keeping the heels off the bed prevents pressure ulcers during the in-hospital postoperative period. Changes in mental status can occur immediately after surgery as a result of anesthesia.)

Match the activities listed with the appropriate functional level of ability: IADLs and BADLs A. Uses a cane B. Bathes daily C. Takes medications as prescribed D. Dresses self E. Balances the checkbook F. Cleans the house

BADL BADL IADL BADL IADL IADL (Functional impairment, disability, or handicap refers to varying degrees of an individual's inability to perform the tasks required to complete normal life activities without assistance. IADLs are more complex skills that are essential to living in the community.)

Which dietary supplements may be prescribed specifically to a patient with osteoarthritis (OA)? Select all that apply. Iron Garlic Chondroitin Glucosamine Niacin

Chondroitin Glucosamine (The intake of dietary supplements can replace traditional drug therapy for decreasing OA pain and repairing cartilage. Chondroitin strengthens cartilage, and glucosamine decreases inflammation. Iron, garlic, and niacin are not used specifically to manage OA.)

A patient was diagnosed with pancreatic cancer last month, and has complained of a dull ache in the abdomen for the past 4 months. This pain has been gradually increasing, and the pain relievers taken at home are no longer effective. What type of pain is the patient experiencing? Acute pain Chronic pain Somatic pain Neuropathic pain

Chronic pain (Chronic pain is associated with cancer and is characterized by slow onset, long duration, and dull, persistent aching. The patient's symptoms are not characteristics of acute pain, somatic pain, or neuropathic pain.)

Which type of disorder is fibromyalgia syndrome (FMS)? Autoimmune Inflammatory Chronic pain Connective tissue

Chronic pain (Fibromyalgia syndrome is a chronic pain syndrome that specifically affects the trigger points of the back of the neck, upper chest, trunk, low back, and extremities. It is not accurately described as an autoimmune, inflammatory, or connective tissue disorder.)

You are a new graduate nurse working with a nurse who has been out of school for 10 years. The seasoned nurse states, "I don't see the difference between this clinical reasoning and the nursing process." Which of the following statements would be an appropriate response? Select all that apply. Clinical reasoning is limited to assessing, evaluating, and treating the nursing diagnosis. Clinical reasoning involves reflecting on interventions and reevaluating the plan of care based on the results of reflection. Clinical reasoning involves assessing, diagnosing, and planning and using interventions based on assessments. Clinical reasoning is the thinking process by which a nurse reaches a clinical judgment. Clinical reasoning is an iterative process of noticing, interpreting, and responding—reasoning in transition with a fine attunement to the patient and how the patient responds to the nurse's actions.

Clinical reasoning involves reflecting on interventions and reevaluating the plan of care based on the results of reflection. Clinical reasoning is the thinking process by which a nurse reaches a clinical judgment. Clinical reasoning is an iterative process of noticing, interpreting, and responding—reasoning in transition with a fine attunement to the patient and how the patient responds to the nurse's actions. (Clinical reasoning is an iterative process of noticing, interpreting, and responding—reasoning in transition with a fine attunement to the patient and how the patient responds to the nurse's actions. The nursing process is limited to assessment, diagnosis, planning, and developing interventions based on assessments.)

When caring for a patient who takes methotrexate, which laboratory data is most important for the nurse to monitor? Glucose Potassium Complete blood count (CBC) White blood cells (WBCs)

Complete blood count (CBC) (Decreasing WBCs and platelets (as a result of bone marrow suppression) should be monitored in patients taking methotrexate; a CBC provides data on red blood cells, hemoglobin, hematocrit, platelets, and white blood cell count. Glucose and potassium are not affected by methotrexate.)

When assessing a patient for adverse effects related to morphine sulfate (MS Contin), which clinical findings is the nurse MOST likely to find? (Select all that apply.) Weight gain Excessive bruising Constipation Inability to void Diarrhea

Constipation Inability to void (Morphine sulfate causes a decrease in GI motility (delayed gastric emptying and slowed peristalsis). This leads to constipation, not diarrhea. Morphine can also cause urinary retention (inability to void).)

Vicodin (acetaminophen/hydrocodone) is prescribed for a patient who has had surgery. The nurse informs the patient that which common adverse effects can occur with this medication? (Select all that apply.) Diarrhea Constipation Lightheadedness Nervousness Urinary retention Itching

Constipation Lightheadedness Urinary retention Itching (Constipation (not diarrhea), lightheadedness (not nervousness), urinary retention, and itching are some of the common adverse effects that the patient may experience while taking Vicodin.)

An older adult client who lives with her daughter is admitted to the hospital. During the admission assessment, the nurse notes strong body odor, several large pressure ulcers, and limb contractures. What does the nurse do first? Asks the daughter about the ulcers and contractures Contacts the hospital social worker Gives the client a bath Notifies the health care provider

Contacts the hospital social worker (The social worker will assess the client's situation and will contact the appropriate authorities if needed.Asking the daughter sets up a potential confrontation that need not be handled by the nurse. The client needs a bath, but this is not the first action to be taken. Notifying the health care provider will be appropriate at a later time, but is not the best action to take at this point.)

The nurse is assessing a patient's functional performance. What assessment parameters will be most important in this assessment? Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer assessment Height, weight, body mass index (BMI), vital signs assessment Sleep assessment, energy assessment, memory assessment, concentration assessment Healthy individual, volunteers at church, works part time, takes care of family and house

Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer assessment (Functional impairment, disability, or handicap refers to varying degrees of an individual's inability to perform the tasks required to complete normal life activities without assistance. Height, weight, BMI, and vital signs are physical assessment. Sleep, energy, memory, and concentration are part of a depression screening. Healthy, volunteering, working, and caring for family and house are functional abilities, not performance.)

The nurse is completing a hospital admission assessment on an 86-year-old client with renal impairment. The client's daughter gives the nurse a long list of drugs that the client is taking at home, both prescription and over-the-counter. What does the nurse do next? Calls the pharmacy to verify that the drugs do not interact adversely Calls the health care provider to verify the drug list Copies the list to the assessment data form Ensures that all of the drugs have been ordered for the client's hospital stay

Copies the list to the assessment data form (Copying the list to the assessment data form is done first.After copying the list to the assessment data form, the health care provider should be notified of all drugs, which may or may not be ordered during the client's stay, depending on the client's diagnosis. Calling the pharmacy and calling the provider are not the priority for admission. The client may not require all the medications during the hospital stay.)

A patient is suffering from tendonitis of the knee. The nurse is reviewing the patient's medication administration record and recognizes that which adjuvant medication is most appropriate for this type of pain? Antidepressant Anticonvulsant Corticosteroid Local anesthesia

Corticosteroid (Corticosteroids have an anti-inflammatory effect, which may help to reduce pain. The other medications do not have anti-inflammatory properties.)

A patient with a diagnosis of pneumonia asks the nurse, "Why am I receiving codeine when I have no pain?" The nurse's response is based on knowledge that codeine also has what effect? Bronchodilation Increases sputum production Expectorant Cough suppressant

Cough suppressant (Codeine provides both analgesic and antitussive (cough suppressant) therapeutic effects.)

A new graduate nurse (GN) is working with an experienced nurse to chart assessment findings. The GN notes that the physical therapist wrote on the chart that the patient is lazy and did not want to participate in assigned therapies this AM. The experienced nurse asks the GN what may be going on here. What is the best explanation for this statement? Data on the chart can sometimes be documented in a biased manner. Data on the chart changes as the patient's condition changes. Data on the chart is usually accurate and can be verified from the patient. Reading the chart is not a wise use of time as this can be time consuming and tedious.

Data on the chart can sometimes be documented in a biased manner. (It is important that the nurse records only what is assessed, without adding judgments or interpretations to the record. Data do indeed change (and need to be charted) as the patient's condition changes, but this would not be the best answer to this question. Assessment data may at times be difficult to obtain, but that would not occur often enough to warrant a warning about the difficulty in charting it. Also, obtaining data is clearly a different activity from charting it. Charting can be time consuming and tedious, but this is not the most complete answer to this question.)

The son of an older adult client states that he has noticed progressive periods of forgetfulness in his father over the past year. After noting the son's comments and assessing the client, which cognitive problem does the nurse suspect the client may have? Drug adverse effects Delirium Dementia Depression

Dementia (Dementia is a broad term used for a syndrome that involves a slowly progressive cognitive decline and recent progressive periods of forgetfulness. It is sometimes referred to as chronic confusion.Drug adverse effects will be related to a specific medication and not appear progressively over time. Further cognitive and medical/neurologic testing would be needed to establish this diagnosis, which would not be done by a nurse. Delirium is an acute state of confusion, which differs from dementia in that it is usually short term and reversible within 3 weeks. It is often seen in older adults when they are in an unfamiliar setting. Depression is broadly defined as a mood disorder that can have cognitive, affective, and physical manifestations.)

A nurse has designed an individualized nursing care plan for a patient, but the patient is not meeting goals. Further assessment reveals that the patient is not following through on many items. Which action by the nurse would be best for determining the cause of the problem? Assess whether the actions were too hard for the patient. Determine whether the patient agrees with the care plan. Question the patient's reasons for not following through. Reevaluate data to ensure the diagnoses are sound.

Determine whether the patient agrees with the care plan. (Having patient and/or family provide input to the care plan is vital in order to gain support for the plan of action. The actions may have been too difficult for the patient, but this is a very narrow item to focus on. The nurse might want to find out the rationale for the patient not following through, but instead of directly questioning the patient, which can sound accusatory, it would be best to offer some possible motives. Reevaluation should be an ongoing process, but the more likely cause of the patient's failure to follow through is that the patient did not participate in making the plan of care.)

The nurse is conducting a medication assessment on an older adult client who is being admitted to a long-term care facility for rehabilitation following a hip replacement. With Beers Criteria used as a resource, which drug poses a potential risk for this client? Acetaminophen (Tylenol) Celecoxib (Celebrex) Digoxin (Lanoxin) Mesalamine (Asacol)

Digoxin (Lanoxin) (Beers Criteria is a guideline for health care professionals to help improve the safety of prescription medications for older adults. It involves potentially inappropriate medication use in older adults. Digoxin is listed in the Beers Criteria as a drug that leads to toxicity and drug interaction problems. Clients receiving this medication are at greater risk for serious side effects and interactions.Acetaminophen, celecoxib, and mesalamine are not listed in the Beers Criteria as drugs that lead to toxicity and drug interaction problems.)

A patient is to receive acetylcysteine (Mucomyst) as part of the treatment for an acetaminophen (Tylenol) overdose. Which action by the nurse is appropriate when giving this medication? Giving the medication undiluted for full effect Avoiding the use of a straw when giving this medication Disguising the flavor with soda or flavored water Preparing to give this medication via a nebulizer

Disguising the flavor with soda or flavored water (Acetylcysteine has the flavor of rotten eggs and so is better tolerated if it is diluted and disguised by mixing with a drink such as cola or flavored water to help increase its palatability. The use of a straw helps to minimize contact with the mucous membranes of the mouth and is recommended. The nebulizer form of this medication is used for certain types of pneumonia, not for acetaminophen overdose.)

A client reports increasing pain during dressing changes. Which interventions are recommended for the client? Select all that apply. Assistance by the client with the dressing change Distraction Epidural analgesic Music therapy Premedication Transcutaneous electrical nerve stimulation (TENS)

Distraction Music therapy Premedication (Interventions recommended for the client include distraction, music therapy, and premedication. Distraction stimulates efferent nerve fibers and reduces the client's perception of painful experiences. Music therapy provides a distraction and can reduce the client's pain perception; efferent nerve fibers are stimulated. Premedication before painful treatments is a good method of controlling pain during treatment.Involving the client in an uncomfortable dressing change would tend to increase the client's perception of pain; it is a better tactic to distract the client. Although epidural analgesia is effective, it is a method of providing pain relief that requires an epidural catheter to be in place; the use of such an invasive procedure would not be indicated for pain relief during a dressing change. Use of a TENS unit is effective in controlling certain types of pain, such as incisional pain, but its use during a dressing change would not be feasible.)

The nurse is establishing a plan of care for a hospitalized client with chronic pain caused by fibromyalgia. Which nursing action does the nurse delegate to a nursing assistant? Application of a transcutaneous electrical nerve stimulation (TENS) device Education about nonpharmacologic interventions for pain control Referral to available community resources for pain management Engagement in conversation about the client's family to distract the client

Engagement in conversation about the client's family to distract the client (The nurse delegates the nursing assistant the task of engaging in conversation about the client's family to distract the client. Distraction techniques such as conversation, music, and television may be implemented by unlicensed nursing staff members.Application of a TENS unit, education about nonpharmacologic pain interventions, and community resource referrals require specialized nursing education and scope of practice and would be performed by licensed nursing staff.)

The nurse is caring for an 85-year-old woman 6 weeks following a hysterectomy secondary to ovarian cancer. The patient will need chemotherapy and irradiation on an outpatient basis. The nurse should identify and address which barriers to healing? Select all that apply. Can feed herself and prepare meals but cannot drive to the store Lives on a fixed income and can balance her checkbook Experiences stress incontinence Cannot participate in activities at the senior center Lives alone and has no nearby relatives Has no transportation to the oncology clinic

Experiences stress incontinence Lives alone and has no nearby relatives Has no transportation to the oncology clinic (The patient will not be able to get treatment if she has no transportation or no relatives that live nearby who can help her with recovery. Stress incontinence increases the risk of falls because of urgency and rushing to get to the bathroom. Income and social abilities are lower priorities during this phase of recovery.)

The primary health care provider prescribes a medication to a patient with osteoarthritis. During the follow-up visit, the patient reports dark tarry stools and indigestion. Which medication may be the cause of this finding? Cortisone Lidoderm Ibuprofen Hyaluronate

Ibuprofen (Ibuprofen is a non-steroid anti-inflammatory drug that sometimes causes dark tarry stools and indigestion related to bleeding of the gastrointestinal tract. Cortisone is a steroid; overuse can cause osteonecrosis. Lidoderm is a topical medication used to control pain; side effects are skin irritation. Hyaluronate is used to relieve knee and hip pain associated with osteoarthritis. This medication may cause tingling and skin irritation around the knee.)

A 70-year-old man who recently lost his spouse reports feeling lonely and sad much of the time. He lives alone and has no identified health problems, but reports "not feeling well" on most days. What will the nurse assess first to help prevent problems associated with this client's situation? The availability of activities for senior citizens Physical strength and ability to exercise Spending sprees on unnecessary items Food intake and recent weight changes

Food intake and recent weight changes (Older adults may respond to depression by not eating, and this can lead to undernutrition. Many who live alone, especially men, lose the incentive to prepare or eat balanced diets, especially if they do not "feel well."The nurse will assess the availability of activities and exercise ability, but the primary concern is nutrition. Older adults, especially those with depression, do not typically go on spending sprees.)

The nurse is assessing a patient's functional abilities and asks the patient, "How would you rate your ability to prepare a balanced meal?" "How would you rate your ability to balance a checkbook?" "How would you rate your ability to keep track of your appointments?" Which tool would be indicated for the best results of this patient's perception of their abilities? Functional Activities Questionnaire (FAQ)™ Mini Mental Status Exam (MMSE) 24hFAQ Performance-based functional measurement

Functional Activities Questionnaire (FAQ)™ (The FAQ is an example of a self-report tool which provides information about the patient's perception of functional ability. The MMSE assesses cognitive impairment. The 24hFAQ is used to assess functional ability in postoperative patients. Performance-based tools involve actual observation of a standardized task, completion of which is judged by objective criteria.)

Assessment findings reveal that an older adult client with severe osteoarthritis of the left hip can no longer perform activities of daily living (ADLs) and has had several falls in the home over the past month. To which community resource does the nurse refer the client? Local senior citizen center Citizens for Better Care Home health care agency Meals on Wheels

Home health care agency (Home health care agencies can obtain referrals and order a nurse to assess the home situation and notify the health care provider of any in-home needs. These needs can include a nurse, an aide, physical therapist, occupational therapist, or social worker. Senior citizen centers provide activities, meals, and sometimes transportation, but do not help with ADLs. Citizens for Better Care is concerned with clients' rights and safety in health care facilities. The home health care agency may make a referral to Meals on Wheels if it is indicated, but this will not help with all ADLs or safety measures.)

The nurse is caring for a client who had a fractured ankle repaired. Twenty minutes after receiving 1.5 mg of hydromorphone (Dilaudid) IV push, the client is slow to respond and has constricted pupils and a respiratory rate of 6 breaths/min. What action does the nurse take initially? Calls the care provider for a change in the medication order Changes the order to every 6 hours rather than every 4 hours Gives the client a dose of naloxone (Narcan) 0.4 mg IV Performs a cognitive assessment on the client

Gives the client a dose of naloxone (Narcan) 0.4 mg IV (Initially, the nurse would give the client a dose of naxalone 0.4 mg IV. For an unresponsive client, the nurse would administer naloxone (Narcan) 0.4 mg (diluted in 10 mL) over a 2-minute time period to reverse the action of the opioid analgesic.The order may need to be altered or changed, but calling for a medication order change is not the first action that the nurse would take in an unresponsive client. Nurses do not change orders in terms of dosage or frequency; the care provider changes the order. A sedated client will not be able to complete a cognitive assessment, and this action would waste time that should be spent on reversing the effects of hydromorphone.)

A client with cancer who is taking pain medication states, "I am still having pain." During the assessment, the client does not exhibit any physical manifestations of pain. What does the nurse do next? Decreases the client's standard pain medication dose Gives the client a placebo and monitors the outcome Gives the pain medication as requested Withholds the pain medication

Gives the pain medication as requested (The nurse will administer the pain medication as requested. Both types of chronic pain (chronic cancer pain and chronic noncancer pain) do not cause sympathetic reactions. Therefore, some clients do not appear to be in pain, even when they are. Clients with cancer tend to know what medication works for them. The nurse needs to follow the protocol for the client regardless of the client's responses when it is chronic cancer pain.The nurse would never decrease pain medication under the assumption that, because the client does not exhibit pain, the client must not have any pain. Unless the client is involved in a clinical research trial, giving a placebo in place of medication is never appropriate. It is never appropriate to withhold prescribed pain medication.)

After assessing a patient with osteoarthritis, the nurse suspects crepitus. Which finding supports the nurse's assessment? Inflammation near the joint Grating heard when the joint is palpated Enlarged joint with bone hypertrophy Bony nodules at the distal interphalangeal joint

Grating heard when the joint is palpated (Crepitus is a condition in which the cartilage disintegrates and pieces of bone and cartilage float in the diseased joint. A grating sound can be heard because of loosened bone and cartilage in the joint. Secondary synovitis occurs if inflammation is present near the joint. An enlarged joint with bone hypertrophy indicates an advanced stage of the disease. Bony nodules at the distal interphalangeal joint indicate Heberden's nodes.)

The nurse is assessing a patient's functional ability. Which activities most closely match the definition of functional ability? Healthy individual, works outside the home, uses a cane, well groomed Healthy individual, college educated, travels frequently, can balance a checkbook Healthy individual, works out, reads well, cooks and cleans house Healthy individual, volunteers at church, works part time, takes care of family and house

Healthy individual, volunteers at church, works part time, takes care of family and house (Functional ability refers to the individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, each option has advanced or independent activities in the context of the option.)

A hospitalized client expresses satisfaction after using a recommended complementary and alternative medicine (CAM) therapy, saying that pain was diminished and anxiety reduced. Which CAM did the client most likely use? Herbs Homeopathy Imagery Tai chi

Imagery (The CAM most likely used was imagery. Imagery is often used for reducing pain, nausea and vomiting, and anxiety.Certain CAM therapies are not typically used for pain control. Herbs are typically used as a means to promote health, prevent disease, or cure a variety of ailments. Homeopathic medicine uses small doses of specially prepared plant extracts and minerals to promote healing. Tai chi integrates body movements, mind concentration, muscle relaxation, and breathing to achieve a desired outcome.)

A hospitalized client anticipates a daily painful dressing change. Which complementary and alternative medicine therapy might the nurse offer before the procedure? Animal-assisted therapy Hydrotherapy Imagery Acupuncture

Imagery (The nurse might offer imagery before the procedure. Changing dressings or performing other procedures may produce pain for the client. Imagery can be used to calm and distract the client from pain.Animal-assisted therapy would be difficult because the nurse will be performing a dressing change, and the animal could get in the way, contaminate the wound, or cause the client to move around too much. Hydrotherapy may be contraindicated for this client. Acupuncture is not something that the nurse can easily offer during a dressing change.)

In developing a plan of care for a patient receiving morphine sulfate (MS Contin), which nursing diagnosis has the highest priority? Constipation related to decreased GI motility Acute pain related to metastatic tumor cancer Impaired gas exchange related to respiratory depression Risk for injury related to CNS adverse effects

Impaired gas exchange related to respiratory depression (Using Maslow's hierarchy of needs and the ABCs of prioritization, impaired gas exchange is a priority over pain, constipation, and a risk for injury. If a patient cannot oxygenate sufficiently, all of the other problems will not matter because the patient will not live to worry about them.)

At a follow-up home-care visit after repair of a fractured radial bone, an older adult client states, "I am not sleeping at all during the night." The client's partner reports that the client is sleeping all day. Which intervention does the nurse suggest? Increasing the client's daytime activities Placing a "Do not disturb" sign on the door at night Taking additional pain medication (analgesic) during the day Taking herbal sleep remedies to enhance the effects of prescribed medications

Increasing the client's daytime activities (Older adult clients should try to stay awake during the day to prevent insomnia at night. Increasing activities will facilitate this goal.The client did not report interruptions, but insomnia; placing a "Do not disturb" sign on the door, although it may be effective in increasing "sleep time," does not address the client's problem. Pain medication is best taken at night because it causes drowsiness. Encouraging herbal sleep remedies to try to enhance the effects of other medications is not an appropriate suggestion for the nurse to make.)

What is the mechanism of action of nonsteroidal antiinflammatory drugs (NSAIDs)? Inhibiting prostaglandin production Increasing the supply of natural endorphins Increasing blood flow to painful areas Enhancing pain perception

Inhibiting prostaglandin production (Prostaglandins are produced in response to activation of the arachidonic pathway. NSAIDs work by blocking cyclooxygenase (COX-1 and COX-2), the enzyme responsible for conversion of arachidonic acid into prostaglandins. Decreasing the synthesis of prostaglandins results in decreased pain and inflammation.)

A nurse wishes to obtain data about a new patient's self-esteem. To gain the clearest picture, the nurse uses which assessment technique? Completing an entire head-to-toe assessment first Conducting a structured interview with direct questions Interviewing the patient in an unstructured format Disregard any nonverbal clues from the patient

Interviewing the patient in an unstructured format (An unstructured interview format allows the nurse to establish rapport and get insight into the patient's perspective. Combined with observation, this would yield the best information. Observation often results in gathering a depth of data that is difficult to gain by other methods. Combined with an unstructured interview to gain the patient's trust, this technique would be very valuable. A head-to-toe assessment would not yield information about self-esteem. A structured interview is often used to gather specific information, but since this nurse has not yet had time to develop rapport, focusing questions on a sensitive issue such as self-esteem would probably not elicit accurate information. Also, structured interviews are most often used in emergency situations, and this does not qualify as an emergency.)

A postoperative client is vomiting and states, "I am having a lot of pain—about a 7 on a scale of 0 to 10." Which route of administration does the nurse choose to administer an analgesic to the client? Intravenous Oral Rectal Transdermal

Intravenous (The intravenous route is the best choice for fast relief of nausea and pain.Oral pain medication may exacerbate the client's nausea and is not the best choice. The rectal route and the transdermal route are not the routes of choice for short-term pain control because their effect is not as rapid or controlled as that of other routes.)

The nurse is teaching a class of older adults about ways to promote their cognitive health. Which collaborative interventions will be most helpful for them? Select all that apply. Allowing for increased rest and relaxation time Having solitary times to reminisce about life experiences Joining a peer group with a common learning goal Learning a new skill Meditating for 30 minutes every day Starting a new physical activity

Joining a peer group with a common learning goal Learning a new skill Starting a new physical activity (Cognitive health problems (depression, delirium, and dementia) can be offset by social engagement with a peer group, learning a new skill, and physical activity.Increased rest time, meditation, and increased solitude may be helpful for other aspects of aging but do not benefit the older adult's cognitive capabilities.)

A nursing instructor assigns their clinical group the task of writing a journal depicting the student's clinical day. What is the most likely rationale for this assignment? Journaling allows reflection, an important critical thinking skill. Journaling gives you time to review what happened in your clinical. Journaling is a way to organize your thoughts about your experiences. Journaling teaches open-mindedness, a critical thinking disposition.

Journaling allows reflection, an important critical thinking skill. (Critical thinking requires reflection on what occurred, how data were processed, and how decisions were made. Journaling is one method of developing critical thinking skills. Journaling does give nurses time to review what happened in their clinical, but this statement does not go far enough in explaining the importance of the journal-writing process. Journaling may be a way to organize thoughts about one's experiences, but this statement is too narrow an explanation and does not account for the critical aspect of reflection. Open-mindedness is a critical thinking disposition that allows one to be tolerant of divergent views. Journaling can assist with developing this disposition, but only if what is written reflects that specific topic.)

What is advantage of COX-2 inhibitors over other NSAIDs? Are less likely to cause hepatic toxicity Maintain GI mucosa Have a longer duration of action Have a more rapid onset of action

Maintain GI mucosa (By not inhibiting the COX-1 enzyme to maintain an intact gastric mucosal barrier by increasing secretion of mucus, the risks of GI adverse effects are decreased.)

A patient needs to switch analgesic drugs secondary to an adverse reaction to the current treatment regimen. The patient is concerned that the new prescription will not provide optimal pain control. The nurse's response is based on knowledge that doses of analgesics are determined using an equianalgesic table with which drug prototype? Fentanyl Meperidine Morphine Codeine

Morphine (An equianalgesic table is a conversion chart for commonly used opioids. It identifies oral and parenteral dosages that provide comparable analgesia. The equianalgesic table identifies dosages of various narcotics that are equal to 10 mg of morphine. It is important to use when changing to a new opioid or different route. Morphine is the drug prototype for all opioid drugs.)

Which medication is used to treat a patient with severe adverse effects of a narcotic analgesic? Flumazenil (Romazicon) Methylprednisolone (Solu-Medrol) Acetylcysteine (Mucomyst) Naloxone (Narcan)

Naloxone (Narcan) (Naloxone is the narcotic antagonist that will reverse the effects, both adverse and therapeutic, of opioid narcotic analgesics.)

In an agency with a culture of safety, when an error or patient safety issue is identified, the individual who reports the problem knows which information? Is disciplined according to established protocols Must communicate the problem to the patient Near misses in health care are used to improve care. Shares details to locate the individual at fault

Near misses in health care are used to improve care. (In an agency with a culture of safety, a nurse knows that near misses are used to improve care. Individual people are not punished for flawed systems, and there are no protocols for discipline. Consequences are individualized to improve the system and minimize the opportunity for future problems. Telling the patient is part of the transparency and the sharing and disclosure among stakeholders but is generally the responsibility of the risk management staff, not the staff nurse. Through a strategy such as root cause analysis, the reasons for errors in medication administration can be identified and strategies developed to minimize future occurrences, not to point a finger at a certain person.)

An 18-year-old basketball player fell and twisted his ankle during a game. The nurse will expect to administer which type of analgesic? Synthetic opioid, such as meperidine (Demerol) Opium alkaloid, such as morphine sulfate Opioid antagonist, such as naloxone HCL (Narcan) Nonopioid analgesic, such as indomethacin (Indocin)

Nonopioid analgesic, such as indomethacin (Indocin) (Somatic pain, which originates from skeletal muscles, ligaments, and joints, usually responds to nonopioid analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs). The other options are not the best choices for somatic pain.)

Before administering low-molecular-weight heparin (LMWH) to an older adult client after total knee arthroplasty, the nurse notes that the client's platelet count is 50,000/mm3 (50 x 109/L). What action is most important for the nurse to take? Notify the health care provider of the platelet count. Administer the prescribed LMWH on schedule. Assess the activated partial thromboplastin time (aPTT). Assess the international normalized ratio (INR).

Notify the health care provider of the platelet count. (Normal platelet count is between 150,000 mm³ (150 x 109/L) and 400,000 mm³ (400 x 109/L), so 50,000 mm³ (50 x 109/L) is quite low. If the platelet count falls below 20,000/mm3 (20 x 109/L) spontaneous bleeding could occur. Notifying the health care provider before the LMWH is given is essential. LMWH can cause thrombocytopenia, so it should not be administered when the client's platelet count is low. The aPTT is not affected by LMWH, so its assessment is not necessary. Usually, LMWH is given in a low prophylactic dose and does not affect the INR.)

Which element is a risk factor for osteoarthritis (OA)? Thin build Obesity Nonsmoker Male

Obesity (Being obese places an individual at higher risk for slow joint degeneration and the development of OA. Having a thin build does not place an individual at higher risk for slow joint degeneration and the development of OA. Smoking leads to knee cartilage loss, especially in clients with a family history of knee OA. Women tend to develop OA more than men, and it is believed that obesity may be a contributing factor; as women age and have children, they tend to gain more weight than men.)

Which statements may be used to describe osteoarthritis (OA)? Select all that apply. Obesity is a risk factor. It is an autoimmune disorder. Its disease process is degenerative. It usually affects the upper extremities first. Its disease pattern is bilateral and symmetric.

Obesity is a risk factor. Its disease process is degenerative. (Osteoarthritis is the progressive deterioration and loss of cartilage in a joint. Obesity is a risk factor for osteoarthritis, and it is a degenerative disease process. Osteoarthritis occurs due to aging and may or may not be genetic, but it is not an autoimmune disorder. Osteoarthritis affects weight-bearing joints and hands, and it may be unilateral.)

What is the fastest-growing subgroup of older adults? Young old Middle old Old old Elite old

Old old (The old, people aged 85 to 99 years, is the fastest-growing subgroup of older adults.The young old are people ages 65 to 74 years, and the middle old are people ages 75 to 84 years. The elite old are people age 100 years or older.)

Which statement is true about assessing pain in an older adult client? The nurse should assess for present and past pain. Older adults typically believe that expressing pain is acceptable. Older adults are at great risk for undertreated pain. Older adults usually believe that pain signifies a minor illness.

Older adults are at great risk for undertreated pain. (Older adults are at great risk for undertreated pain because of outdated beliefs by some health care providers about older adults' pain sensitivity, tolerance, and ability to take opioids.The nurse should assess only for present pain. Older adults often believe that expressing pain is unacceptable. Older adults often believe that pain signifies a major illness.)

A patient has been admitted for a skin graft following third degree burns to the bilateral calves. The plan of care involves 3 days inpatient and 6 months outpatient treatment, to include home care and dressing changes. When should the nurse initiate the educational plan? After the operation and the patient is awake On admission, along with the initial assessment The day before the patient is to be discharged When narcotics are no longer needed routinely

On admission, along with the initial assessment (Initial discharge planning begins upon admission. After the operation has been completed is too late to begin the discharge planning process. The day before discharge is too late for the nurse to gather all pertinent information and begin teaching and coordinating resources. After a complicated operation, the patient may well be discharged on narcotic analgesics. Waiting for the patient to not need them anymore might mean the patient gets discharged without teaching being done.)

A patient has been treated for lung cancer for 3 years. Over the past few months, the patient has noticed that the opioid analgesic is not helping as much as it had previously and more medication is needed for the same pain relief. The nurse is aware that this patient is experiencing which of these? Opioid addiction Opioid tolerance Opioid toxicity Opioid abstinence syndrome

Opioid tolerance (Opioid tolerance is a common physiologic result of long-term opioid use. Patients with opioid tolerance require larger doses of the opioid agent to maintain the same level of analgesia. This situation does not describe toxicity (overdose), addiction, or abstinence syndrome (withdrawal).)

A patient is receiving gabapentin (Neurontin), an anticonvulsant, but has no history of seizures. The nurse expects that the patient is receiving this drug for which condition? Inflammation pain Pain associated with peripheral neuropathy Depression associated with chronic pain Prevention of seizures

Pain associated with peripheral neuropathy (Anticonvulsants are often used as adjuvants for treatment of neuropathic pain to enhance analgesic efficacy. The other indications listed are not correct.)

The nurse plans pharmacologic management for a patient with pain. The nurse should administer the pain medication based on what dosage schedule? Pain relief is best obtained by administering analgesics around the clock. Administer the analgesic when the pain level reaches a "6" on a scale of 1 to 10. Opioid analgesics should not be used for more than 24 hours to prevent drug addiction. Analgesics should be administered as needed (prn) to minimize adverse effects.

Pain relief is best obtained by administering analgesics around the clock. (When pain is present for more than 12 hours a day, analgesic dosages are best administered around the clock rather than on an as-needed basis, but dosages should always be within the dosage guidelines for each drug used. The around-the-clock (or "scheduled") dosing maintains steady-state levels of the medication and prevents drug troughs and escalation of pain.)

A client with extensive burn injuries is to be weaned from long-term opioid use. What type of opioid dependence does the nurse expect this client to have? Addiction Tolerance Physical dependence Pseudoaddiction

Physical dependence (The nurse expects the client to have a physical dependence on the opioid. Physical dependence occurs in people who take opioids over a period of time. When it is necessary to discontinue opioid analgesia for the client who is opioid dependent, slow tapering (weaning) of the drug dosage lessens or alleviates physical withdrawal symptoms.Addiction is a condition influenced by genetic, psychosocial, and environmental factors and characterized by impaired control over drug use, compulsive use, craving, or continued use despite harm; this description does not accurately reflect the client's situation. Tolerance is similar to physical dependence, but occurs earlier and consists of a decrease in one or more of the effects of the opioid. Pseudoaddiction is a condition created by the undertreatment of pain, and is characterized by behaviors such as anger and escalating demands for more or different medications; this description does not accurately reflect the client's situation.)

A client has symptoms of rheumatoid arthritis (RA). Which laboratory finding indicates to the nurse that the client may have RA? Total serum complement, 75 units/mL Positive total antinuclear antibody (ANA) Erythrocyte sedimentation rate (ESR), 20 mm/hr Beta-globulin level, 1.0 g/dL (10 g/L)

Positive total antinuclear antibody (ANA) (Elevation of total ANA is common in systemic lupus erythematosus, systemic sclerosis, and RA. A serum complement of 75 units/mL is the normal range for total serum complement. An ESR rate of 22 mm/hr is normal for a female. A beta-globulin level of 1.0 g/dL (10 g/L) is normal.)

After reviewing the prescription list of a patient with rheumatoid arthritis, the nurse advises calcium supplements. Which drug on the patient's prescription list requires calcium supplements to prevent side effects? Infliximab Abatacept Prednisone Methotrexate

Prednisone (Prednisone is associated with the risk of osteoporosis, so calcium supplementation is recommended for patients on prednisone therapy. Infliximab, abatacept, and methotrexate do not cause osteoporosis; therefore, calcium supplementation is not needed.)

Which medication would be beneficial to the patient with fibromyalgia syndrome who develops nerve pain? Tramadol Pregabalin Amitriptyline Nortriptyline

Pregabalin (Pregabalin is an antidepressant drug approved for treating nerve pain in patients with fibromyalgia syndrome. It acts by increasing the release of serotonin and norepinephrine in the brain. Tramadol is an opioid analgesic used for treating pain, but not specifically nerve pain, associated with fibromyalgia syndrome. Amitriptyline and nortriptyline are tricyclic antidepressants that help in reducing pain and muscle spasms.)

The nurse would question a prescription to administer misoprostol (Cytotec) to a client with which condition? Gastroesophageal reflux disease Peptic ulcer Chronic obstructive pulmonary disease Pregnancy

Pregnancy (Misoprostol is an abortifacient and thus is contraindicated in pregnancy.)

The nurse is assessing a patient's ability to perform instrumental activities of daily living (IADLs). Which of the following activities are considered in the IADLs assessment? Select all that apply. Feeding oneself Preparing a meal Balancing a checkbook Walking Toileting Grocery shopping

Preparing a meal Balancing a checkbook Grocery shopping (IADLs include shopping, meal preparation, housekeeping, doing laundry, managing finances, taking medications, and using transportation. The other activities listed are activities of daily living (ADLs) related to self-care. IADLs are more complex skills that are essential to living in a community.)

The nurse manager for an oncology unit is evaluating a newly hired staff nurse. Which action by the nurse is of greatest concern to the nurse manager? Asking a client with chest pain if the pain is sharp and stabbing Instructing a confused postoperative client about how to use patient-controlled analgesia Preparing to administer a placebo to a client with chronic back pain Requesting that a client with chronic pain describe the specific location of the pain

Preparing to administer a placebo to a client with chronic back pain (The action by the newly hired staff nurse of greatest concern to the nurse manager is preparing to administer a placebo to a client with chronic back pain. Current national guidelines from regulatory agencies and nursing organizations indicate that placebos would never be used for clients who are experiencing pain.Asking the client a closed-ended question about his or her pain, attempting to instruct a confused client, and asking the client with chronic pain to specify its location all indicate a need for further education in assessment and management of pain, but would not be as great a concern as the possible use of placebos.)

What assessment finding helps the nurse to identify rheumatoid arthritis in a patient with joint pain? Presence of bilateral joint swelling Pain in weight-bearing joints Crepitus may be felt or heard Joint stiffness after inactivity

Presence of bilateral joint swelling (Rheumatoid arthritis can be identified by the presence of bilateral joint swelling. It follows a bilateral, symmetric pattern affecting multiple joints. The patient with osteoarthritis manifests pain in weight-bearing joints. Crepitus may be felt or heard when the joints are put through range-of-motion exercises. Joint stiffness usually lasts less than 30 minutes after a period of inactivity.)

A postoperative client is receiving epidural analgesia and reports itching. What does the nurse do next? Reduces the analgesic dose Gives diphenhydramine (Benadryl) Gives an antiemetic Calls the surgeon

Reduces the analgesic dose (The next action taken by the nurse is to reduce the analgesic dose. Pruritus (itching) is a common side effect of epidural opioids and is first treated by reducing the analgesic dose.Because epidural-induced pruritus does not appear to be caused by histamine release, diphenhydramine (Benadryl) may not be effective in relieving itching and may work only via its sedating effects. Antiemetics are given to relieve nausea and vomiting. If a health care provider needs to be called, it would be the anesthesiologist, not the surgeon.)

A client with end-stage lung cancer and metastasis to the brain has been admitted to the medical-surgical unit. After trying all options to provide a safe environment, the nursing staff is required to apply restraints. Which nursing intervention is required for this client? Checking the restraints every 1 to 2 hours Releasing the restraints at least every 2 hours Using chemical sedation instead of restraints Using the most restrictive devices to prevent falls

Releasing the restraints at least every 2 hours (The Joint Commission recommends releasing restraints every 2 hours for client care such as turning, repositioning, and toileting.The restraints must be checked every 30 to 60 minutes and not every one to two hours. Chemical sedation is also considered a restraint. The least restrictive devices should be used.)

An 80-year-old client is being relocated from a home setting to a long-term care facility. Which nursing intervention best minimizes the effects of relocation stress syndrome? Explaining all procedures and routines to the client's family at the time of relocation Keeping the room clear of personal belongings to reduce the risk of falling Providing the client with limited decision making to avoid stressful situations Reorienting the client frequently to his or her new location

Reorienting the client frequently to his or her new location (Relocation stress syndrome usually occurs in older adults shortly after moving from a private residence to a nursing home or assisted-living facility. Characteristic symptoms can include anxiety, confusion, hopelessness, and loneliness. Reorienting the client to the new location helps minimize relocation stress syndrome effects.All procedures and routines should be explained to the client as well as to the family just before they occur. Familiar and special personal belongings are helpful to keep at the client's bedside to minimize the effects of relocation stress syndrome. The client needs opportunities to assist in decision making, which helps the client feel more in control.)

The nurse is assessing a patient who has been admitted to the emergency department for a possible opioid overdose. Which assessment finding is characteristic of an opioid drug overdose? Dilated pupils Restlessness Respiration rate of 6 breaths/min Heart rate of 55 beats/min

Respiration rate of 6 breaths/min (The most serious adverse effect of opioid use is CNS depression, which may lead to respiratory depression. Pinpoint pupils, not dilated pupils, are seen. Restlessness and a heart rate of 55 beats/min are not indications of an opioid overdose.)

The nurse is aware that confusion, forgetfulness, and increased risk for falls are common responses in an elderly patient who is taking which type of drug? Laxatives Anticoagulants Sedatives Antidepressants

Sedatives (Sedatives and hypnotics often cause confusion, daytime sedation, ataxia, lethargy, forgetfulness, and increased risk for falls in the elderly. Laxatives, anticoagulants, and antidepressants may cause adverse effects in the elderly, but not the ones specified in the question.)

A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is assessing the patient's risk for falls so that falls prevention can be implemented if necessary. Select all the risk factors that apply from this patient's history and physical. (Select all that apply.) Being a woman Taking more than six medications Having hypertension Having cataracts Muscle strength 3/5 bilaterally Incontinence

Taking more than six medications Having cataracts Muscle strength 3/5 bilaterally Incontinence (Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does not contribute to falls. Dizziness does contribute to falls.)

In monitoring a patient for adverse effects related to morphine sulfate (MS Contin), the nurse assesses for stimulation of which area in the central nervous system (CNS)? Autonomic control over circulation Sympathetic baroreceptors The cough reflex center The chemoreceptor trigger zone

The chemoreceptor trigger zone (Morphine sulfate can irritate the gastrointestinal (GI) tract, causing stimulation of the chemoreceptor trigger zone in the brain, which in turn causes nausea and vomiting.)

An elderly patient with a new diagnosis of hypertension will be receiving a new prescription for an antihypertensive drug. The nurse expects which type of dosing to occur with this drug therapy? Drug therapy will be based on the patient's weight. Drug therapy will be based on the patient's age. The patient will receive the maximum dose that is expected to reduce the blood pressure. The patient will receive the lowest possible dose at first, and then the dose will be increased as needed.

The patient will receive the lowest possible dose at first, and then the dose will be increased as needed. (As a general rule, dosing for elderly patients should follow the admonition, "Start low, and go slow," which means to start with the lowest possible dose (often less than an average adult dose) and increase the dose slowly, if needed, based on patient response. The other responses are incorrect.)

Which statements are true regarding the elderly and pharmacokinetics? (Select all that apply.) The levels of microsomal enzymes are decreased. Fat content is increased because of decreased lean body mass. Fat content is decreased because of increased lean body mass. The number of intact nephrons is increased. The number of intact nephrons is decreased. Gastric pH is less acidic. Gastric pH is more acidic.

The levels of microsomal enzymes are decreased. Fat content is increased because of decreased lean body mass. The number of intact nephrons is decreased. Gastric pH is less acidic. (In the elderly, levels of microsomal enzymes are decreased because the aging liver is less able to produce them; fat content is increased because of decreased lean body mass; the number of intact nephrons is decreased as the result of aging; and gastric pH is less acidic because of a gradual reduction of the production of hydrochloric acid. The other options are incorrect statements.)

A student nurse learns that there are physical consequences to unrelieved pain. Which factors are included in this problem? (Select all that apply.) a. Decreased immune response b. Development of chronic pain c. Increased gastrointestinal (GI) motility d. Possible immobility e. Slower healing

a. Decreased immune response b. Development of chronic pain d. Possible immobility e. Slower healing (There are many physiologic impacts of unrelieved pain, including decreased immune response; development of chronic pain; decreased GI motility; immobility; slower healing; prolonged stress response; and increased heart rate, blood pressure, and oxygen demand.)

The nurse is implementing a plan of care for a patient newly diagnosed with type 2 diabetes mellitus. The plan includes educating the patient about diet choices. The patient states that they enjoy exercising and understand the need to diet; however, they can't see living without chocolate on a daily basis. Using the principles of responding in the Model of Clinical Judgment, how would the nurse proceed with the teaching? The nurse explains to the patient that chocolate has a high glycemic index. The nurse then focuses on foods that have low glycemic indexes and provides a list for the patient to choose from. The nurse explains that the patient may eat whatever they would like as long as the patient's glucose reading and A1c remain stable. The nurse derives a new nursing diagnosis of Knowledge Deficit and readjusts the plan of care to include additional sessions with the registered dietician. The nurse examines the patient's daily glucose log and incorporates the snack into the time of day that has the lowest readings. The nurse then follows up and evaluates the response in 1 week.

The nurse examines the patient's daily glucose log and incorporates the snack into the time of day that has the lowest readings. The nurse then follows up and evaluates the response in 1 week. (Responding entails adjusting the plan of care to the particular patient issue through one or more nursing interventions. In this case, the nurse is working with the patient's wishes, knowing that the patient will most likely cheat. The patient will be allowed to "cheat." The plan will be evaluated to be sure the snack does not elevate the glucose excessively and be readjusted if warranted. While it is true that most chocolate has a high glycemic index, providing a list of foods that do not include the one thing the patient enjoys will most likely lead to nonadherence to the diet. Advising the patient that they can have whatever they want to eat may lead to further dietary indiscretions and cause side effects such as obesity or high glucose readings. Knowledge Deficit is an inaccurate diagnosis for this patient as evidenced by the patient stating they understand the need to exercise and the need to diet.)

The nurse is assessing a newly admitted 83-year-old patient and determines that the patient is experiencing polypharmacy. Which statement most accurately illustrates polypharmacy? The patient is experiencing multiple illnesses. The patient uses one medication for an illness several times per day. The patient uses over-the-counter drugs for an illness. The patient uses multiple medications simultaneously.

The patient uses multiple medications simultaneously. (Polypharmacy usually occurs when a patient has several illnesses and takes medications for each of them, possibly prescribed by different specialists who may be unaware of other treatments the patient is undergoing. The other options are incorrect. Polypharmacy addresses the medications taken, not just the illnesses. Polypharmacy means the patient is taking several different medications, not just one. Polypharmacy can include prescription drugs, over-the-counter medications, and herbal products.)

What group is primarily protected under the laws that regulate nursing practice? The public Practicing nurses The employing agency People with health problems

The public (Each state protects the health of the public by regulating nursing practice. Standards of nursing practice provide the framework for nurses. An employing agency (e.g., hospital, clinic, or home care agency) is responsible for ensuring that employees are qualified. More people than just those with health problems are protected by the laws.)

The drug nalbuphine (Nubain) is an agonist-antagonist (partial agonist). The nurse understands that which is a characteristic of partial agonists? They have anti-inflammatory effects. They are given to reverse the effects of opiates. They have a higher potency than agonists. They have a lower dependency potential than agonists.

They have a lower dependency potential than agonists. (Partial agonists such as nalbuphine are similar to the opioid agonists in terms of their therapeutic indications; however, they have a lower risk of misuse and addiction. They do not have anti-inflammatory effects, nor are they given to reverse the effects of opiates. They do not have a higher potency than agonists.)

A student nurse receives an order for diazepam to be given intravenously. Diazepam tablets are available. The student nurse crushes a tablet and mixes it with sterile water for injection. The instructor notes that the solution is cloudy and asks to see the medication vial. When the student produces the vial of sterile water for injection and the instructor stops the medication from being given, what type of error is prevented? Communication error Diagnostic error Preventive error Treatment error

Treatment error (The nurse avoided a treatment error; she was prevented from giving the wrong type of medication. Diazepam (Valium) for intravenous administration is clear and comes prepared in a vial labeled for intravenous administration. According to Leape, treatment errors occur in the performance of an operation, procedure, or test; in administering a treatment; in the dose or method of administering a drug; or in an avoidable delay in treatment or in responding to an abnormal test. A communication error results from a failure to communicate. Diagnostic errors are the result of a delay in diagnosis, a failure to employ indicated tests, the use of outmoded tests, or a failure to act on results of monitoring or testing. Preventive errors occur when there is a failure to provide prophylactic treatment when monitoring is inadequate, or when follow-up of treatment is inadequate.)

The nurse is attending to a patient with osteoarthritis. What nonpharmacologic interventions does the nurse suggest to this patient? Select all that apply. Use a small pillow under the head or neck. Use a large pillow under the knee. Avoid elevating the legs when sleeping. Use moist heating pads that are not heavy. Wear supportive shoes with foot insoles.

Use a small pillow under the head or neck. Use moist heating pads that are not heavy. Wear supportive shoes with foot insoles. (A small pillow may be used under the head or neck when the patient is in a supine position. Hot packs, compresses, and moist heating pads that are not heavy help to decrease muscle tension around tender joints. The patient must wear supportive shoes with foot insoles to relieve pressure on painful metatarsal joints. The use of large pillows under the head or knees may result in flexion contractures. Elevating the legs about 8-10 inches helps to reduce back discomfort.)

A patient who had a total hip arthroplasty will be discharged from the hospital shortly. What teaching does the nurse provide for this patient? Select all that apply. Use a walker as an ambulatory aid. Cleanse the hip incision with antiseptic solution. Sit up in a firm, supporting chair during the daytime. Perform postoperative exercises such as crossing over of the legs. Avoid bending the hips more than 90 degrees.

Use a walker as an ambulatory aid. Sit up in a firm, supporting chair during the daytime. Avoid bending the hips more than 90 degrees. (The patient should be taught to use a walker as an ambulatory aid and asked to avoid putting more weight on the affected leg than allowed. The patient should avoid prolonged sitting in a 90-degree position to prevent dislocation of the prosthesis. The patient should be taught to avoid bending the hips more than 90 degrees. The hip incision should be cleaned with mild soap and water and the area dried thoroughly. Postoperative exercises include straight leg raises, gluteal sets, ankle pumps, and "ham" sets. The patient should not cross the legs to prevent blood clots.)

Which instructions for joint protection does the nurse recommend for a client with a connective tissue disease? Select all that apply. Use long-handled devices such as a reacher. When getting out of bed, use fingers to push off. Sit in a low back chair. Bend at the waist while keeping the back straight. Use adaptive devices such as Velcro closures. Turn a doorknob clockwise.

Use long-handled devices such as a reacher. Use adaptive devices such as Velcro closures. (For clients with a connective tissue disease, the use of long-handled devices such as a reacher and other adaptive devices, such as Velcro closures, helps to protect the joints. When getting out of bed, the client should not push off with fingers, but use the entire palm of both hands. Clients with connective tissue disease should sit in a chair that has a high, straight back, and not a low chair, and should bend at the knees, not the waist, while keeping the back straight. Doorknobs should be turned counterclockwise, not clockwise, to avoid twisting the arm and promoting ulnar deviation.)

An older adult client who is admitted to the medical-surgical unit with a diagnosis of heart failure states to the nurse, "I am of no use to anyone. I just want to die." What therapy does the nurse expect the provider to order to ensure this client's safety? Treatment with a tricyclic antidepressant medication Encouraging the client to rest. He or she may feel better in the morning. Obtaining a social work consultation to evaluate the client's family situation Using a selective serotonin reuptake inhibitor to manage depression

Using a selective serotonin reuptake inhibitor to manage depression (Older adults have a high suicide rate, especially Euro-Caucasian men between 75 and 85 years of age. Any suicidal tendencies should be reported to the health care provider to assess the need for selective serotonin reuptake inhibitors and risk to the client.Tricyclic antidepressants are not safe for older clients. Encouraging the client to rest and asking for a social work consultation to evaluate the client's family situation do not address the safety issue at hand.)

Which is the best nursing action to prevent complications in an older adult patient who has undergone total hip arthroplasty and is under postoperative care? Prohibiting the patient from coughing Using an abduction pillow to prevent adduction Measuring the temperature to assess infection Giving medication for pain only when the patient asks verbally

Using an abduction pillow to prevent adduction (Using an abduction pillow helps to prevent adduction in an older adult patient because he or she may be restless after the surgery. Coughing should not be prohibited after the surgery since it helps in preventing respiratory complications. Measuring the patient's temperature might not be a valid sign of infection in older adult patients. Older adult patients may be too confused to report pain; therefore, care should be taken to provide analgesics to alleviate pain.)

A client had a hip replacement 2 days ago and reports having a moderate amount of pain, stating that it is "a 7 on a 0-to-10 scale" of intensity. What intervention has the highest priority in the client's nursing care plan? Encouraging diversional activities Incorporating activities of daily living as soon as possible Teaching key points of the relaxation response Using preemptive analgesia

Using preemptive analgesia (The intervention that has the highest priority in the client's nursing care plan is the use of preemptive analgesia. This technique is designed to decrease pain in the postoperative period, decrease the requirements for a postoperative analgesic, prevent morbidity, and decrease the duration of hospital stay.Use of diversion in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day. Getting the client to perform activities of daily living is an important step in recovery; however, it is not related to pain relief, but rather to other postoperative complications, such as circulation and elimination problems. Use of the relaxation response in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day.)

The nurse encourages a patient who has undergone total hip joint arthroplasty to drink fluids and instructs the patient's caregivers not to massage the leg. The nurse also observes for signs of redness, swelling, and pain in the patient's leg. Which complication is the nurse seeking to avoid with these interventions? Dislocation Infection Hypotension Venous thromboembolism

Venous thromboembolism (A patient with venous thromboembolism may show redness, swelling, and pain in the region that underwent surgery. The patient should drink a high amount of fluids and avoid massaging the region of surgery in order to decrease the risk of venous thromboembolism. To avoid dislocation of the joint, the nurse checks the patient's position and instructs the patient to keep the leg slightly abducted. To avoid infections, the nurse uses aseptic techniques and washes hands thoroughly while caring for the patient. The nurse observes the patient's vital signs every 4 hours to avoid the risk of hypotension.)

The nurse is developing a teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan? Begin a running program. Take up knitting to slow down joint degeneration. Eat at least 2 cups (17 ounces) of yogurt per day. Wear supportive shoes.

Wear supportive shoes. (Wearing supportive shoes will help prevent falls and damage to foot joints, especially metatarsal joints. Running promotes stress on joints and should be avoided. Repetitive stress activities such as knitting or typing should be avoided for prolonged periods. No single food can cure OA; a well-balanced diet should be recommended.)

A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.) a. "Avoid acetaminophen in over-the-counter medications." b. "It may take several weeks to become effective on pain." c. "Pregnancy and breast-feeding are not affected by MTX." d. "Stay away from large crowds and people who are ill." e. "You may find that folic acid, a B vitamin, reduces side effects."

a. "Avoid acetaminophen in over-the-counter medications." b. "It may take several weeks to become effective on pain." d. "Stay away from large crowds and people who are ill." e. "You may find that folic acid, a B vitamin, reduces side effects." (MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take 4 to 6 weeks for effectiveness. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug.)

Which older adult client's living situation typically presents highest risk for abuse? At home alone At home with a spouse In a long-term care facility With adult daughter and grandchildren

With adult daughter and grandchildren (Older adults are often abused by a family member who becomes frustrated or distraught over the burden of caring for the older adult. Prolonged caregiving by a family member is a new and unexpected role for adult children, most often women (as in this case), and is highly stressful.The client living at home alone may suffer from self-neglect, but not from neglect and abuse by another person. Although it is possible that the client living at home with a spouse or in a long-term care facility may suffer from abuse, this is not as common as with clients who live with children and grandchildren.)

The nurse is preparing to administer an intravenous injection of morphine to a patient. The nurse assesses a respiratory rate of 10 breaths/min. Which action should the nurse perform? Withhold the medication and notify the health care provider. Administer a smaller dose and document in the patient's record. Administer the next prescribed dose intramuscularly. Check the pulse oximeter reading and reevaluate respiratory rate in 1 hour.

Withhold the medication and notify the health care provider. (Respiratory depression is an adverse effect of opioid analgesia. Therefore, because the patient's respiratory rate is below normal, the nurse should withhold the morphine and notify the health care provider.)

A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. What response by the experienced nurse is best? a. "Being able to sleep doesn't mean pain doesn't exist." b. "Have you ever experienced any type of pain?" c. "The client should be assessed for drug addiction." d. "You're right; I would put the medication back."

a. "Being able to sleep doesn't mean pain doesn't exist." (A client's description is the most accurate assessment of pain. The nurse should believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them should not supersede the client's descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippant, and does not provide useful information. This amount of information does not warrant an assessment for drug addiction. Putting the medication back and ignoring the client's report of pain serves no useful purpose.)

The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny changes in physical condition and is "on the light constantly" asking for more pain medication. When assessing this client's pain, what statement or question by the nurse is most appropriate? a. "Help me understand how pain is affecting you right now." b. "I wish I could do more; is there anything I can get for you?" c. "You cannot have more pain medication for 3 hours." d. "Why do you think the medication is not helping your pain?"

a. "Help me understand how pain is affecting you right now." (This is an example of therapeutic communication. A client who is preoccupied with physical symptoms and is "demanding" may have some psychosocial impact from the pain that is not being addressed. The nurse is providing the client the chance to explain the emotional effects of pain in addition to the physical ones. Saying the nurse wishes he or she could do more is very empathetic, but this response does not attempt to learn more about the pain. Simply telling the client when the next medication is due also does not help the nurse understand the client's situation. "Why" questions are probing and often make clients defensive, plus the client may not have an answer for this question.)

A nurse is assessing coping in older women in a support group for recent widows. Which statement by a participant best indicates potential for successful coping? a. "I have had the same best friend for decades." b. "I think I am coping very well on my own." c. "My kids come to see me every weekend." d. "Oh, I have lots of friends at the senior center."

a. "I have had the same best friend for decades." (Friendship and support enhance coping. The quality of the relationship is what is most important, however. People who have close, intimate, stable relationships with others in whom they confide are more likely to cope with crisis.)

A home health care nurse assesses an older client for the intake of nutrients needed in larger amounts than in younger adults. Which foods found in an older adult's kitchen might indicate an adequate intake of these nutrients? (Select all that apply.) a. 1% milk b. Carrots c. Lean ground beef d. Oranges e. Vitamin D supplements

a. 1% milk b. Carrots d. Oranges e. Vitamin D supplements (Older adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk has calcium; carrots have vitamin A; the vitamin D supplement has vitamin D; and oranges have vitamin C. Lean ground beef is healthier than more fatty cuts, but does not contain these needed nutrients.)

A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching? a. Acetaminophen (Tylenol) b. Cyclobenzaprine hydrochloride (Flexeril) c. Hyaluronate (Hyalgan) d. Ibuprofen (Motrin)

a. Acetaminophen (Tylenol) (All of the drugs are appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug.)

A client has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed medications. What nonpharmacologic measures can the nurse suggest to help manage this condition? (Select all that apply.) a. Acupuncture b. Stretching c. Supplements d. Tai chi e. Vigorous aerobics

a. Acupuncture b. Stretching d. Tai chi (There are many nonpharmacologic means for controlling the symptoms of fibromyalgia, including acupuncture, stretching, tai chi, low-impact aerobics, swimming, biking, strengthening, massage, stress management, and hypnosis. Dietary supplements and vigorous aerobics are not recommended.)

A faculty member explains the concepts of addiction, tolerance, and dependence to students. Which information is accurate? (Select all that apply.) a. Addiction is a chronic physiologic disease process. b. Physical dependence and addiction are the same thing. c. Pseudoaddiction can result in withdrawal symptoms. d. Tolerance is a normal response to regular opioid use. e. Tolerance is said to occur when opioid effects decrease.

a. Addiction is a chronic physiologic disease process. d. Tolerance is a normal response to regular opioid use. e. Tolerance is said to occur when opioid effects decrease. (Addiction, tolerance, and dependence are important concepts. Addiction is a chronic, treatable disease with a neurologic and biologic basis. Tolerance occurs with regular administration of opioid analgesics and is seen when the effect of the analgesic decreases (either therapeutic effect or side effects). Dependence and addiction are not the same; dependence occurs with regular administration of analgesics and can result in withdrawal symptoms when they are discontinued abruptly. Pseudoaddiction is the mistaken diagnosis of addictive disease.)

What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement? a. Administer preoperative antibiotic as ordered. b. Assess the client's white blood cell count. c. Instruct the client to shower the night before. d. Monitor the client's temperature postoperatively.

a. Administer preoperative antibiotic as ordered. (To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery. Simply taking a shower will not help prevent infection unless the client is told to use special antimicrobial soap. The other options are processes to monitor for infection, not prevent it.)

A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate? (Select all that apply.) a. Allow the client uninterrupted rest time. b. Assess the client's usual bedtime routine. c. Limit environmental noise as much as possible. d. Offer a massage or warm shower at night. e. Request an order for a strong sleeping pill.

a. Allow the client uninterrupted rest time. b. Assess the client's usual bedtime routine. c. Limit environmental noise as much as possible. d. Offer a massage or warm shower at night. (Clients with fibromyalgia often have sleep disturbances, which can be exacerbated by the stress, noise, and unfamiliar environment of the hospital. Allowing uninterrupted rest time, adhering to the client's usual bedtime routine as much as possible, limiting noise and light, and offering massages or warm showers can help. The client does not need a strong sleeping pill unless all other options fail and the client requests something for sleep. At that point a mild sleeping agent can be tried.)

The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The client's surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best? a. Assess neurovascular status in both legs. b. Elevate the affected leg and apply ice. c. Prepare to administer pain medication. d. Try to place the affected leg in abduction.

a. Assess neurovascular status in both legs. (This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess the client.)

A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia. The client scores a zero. What action by the nurse is best? a. Assess physiologic indicators and vital signs. b. Do not give pain medication as no pain is indicated. c. Document the findings and continue to monitor. d. Try a small dose of analgesic medication for pain.

a. Assess physiologic indicators and vital signs. (Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this population. The nurse should next look at physiologic indicators of pain and vital signs for clues to the presence of pain. Even a low score on this index does not mean the client does not have pain; he or she may be holding very still to prevent more pain. Documenting pain is important but not the most important action in this case. The nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess for effectiveness. However, if the client has a condition that could reasonably cause pain (i.e., recent surgery), the nurse does need to treat the client for pain.)

A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started "acting up," especially both hips and knees. What action by the nurse is best? a. Assess the client for the presence of subcutaneous nodules or Baker's cysts. b. Inspect the client's feet and hands for podagra and tophi on fingers and toes. c. Prepare to teach the client about an acetaminophen (Tylenol) regimen. d. Reassure the client that the problems will fade as the weather changes again.

a. Assess the client for the presence of subcutaneous nodules or Baker's cysts. (Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and Baker's cysts. Podagra and tophi are seen in gout. Acetaminophen is not used for rheumatoid arthritis. Telling the client that the symptoms will fade with weather changes is not accurate.)

A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last month's visit. What actions should the nurse perform first? (Select all that apply.) a. Assess the client's ability to drive or transportation alternatives. b. Determine if the client has dentures that fit appropriately. c. Encourage the client to continue the current exercise plan. d. Have the client complete a 3-day diet recall diary. e. Teach the client about proper nutrition in the older population.

a. Assess the client's ability to drive or transportation alternatives. b. Determine if the client has dentures that fit appropriately. d. Have the client complete a 3-day diet recall diary. (Assessment is the first step of the nursing process and should be completed prior to intervening. Asking about transportation, dentures, and normal food patterns would be part of an appropriate assessment for the client. There is no information in the question about the older adult needing to lose weight, so encouraging him or her to continue the current exercise regimen is premature and may not be appropriate. Teaching about proper nutrition is a good idea, but teaching needs to be tailored to the client's needs, which the nurse does not yet know.)

A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best? a. Assess the client's culture more thoroughly. b. Discuss options for performing duties. c. See if the client will call a community meeting. d. Suggest the client give up the role of elder.

a. Assess the client's culture more thoroughly. (The nurse needs a more thorough understanding of the client's culture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions. If the nurse does not understand the consequences of what is suggested, the client may simply be unwilling to listen or participate in problem solving. The other options may be reasonable depending on the outcome of a better cultural understanding.)

The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met? a. Attends meetings of a book club b. Has a positive outlook on life c. Takes medication as directed d. Uses assistive devices to protect joints

a. Attends meetings of a book club (All of the activities are appropriate for a client with RA. Clients who have a poor body image are often reluctant to appear in public, so attending public book club meetings indicates that goals for this client problem are being met.)

A nurse on the postoperative unit administers many opioid analgesics. What actions by the nurse are best to prevent unwanted sedation as a complication of these medications? (Select all that apply.) a. Avoid using other medications that cause sedation. b. Delay giving medication if the client is sleeping. c. Give the lowest dose that produces good control. d. Identify clients at high risk for unwanted sedation. e. Use an oximeter to monitor clients receiving analgesia.

a. Avoid using other medications that cause sedation. c. Give the lowest dose that produces good control. d. Identify clients at high risk for unwanted sedation. e. Use an oximeter to monitor clients receiving analgesia. (Sedation is a side effect of opioid analgesics. Some sedation can be expected, but protecting the client against unwanted and dangerous sedation is a critical nursing responsibility. The nurse should identify clients at high risk for unwanted sedation and give the lowest possible dose that produces satisfactory pain control. Avoid using other sedating medications such as antihistamines to treat itching. An oximeter can alert the nurse to a decrease in the client's oxygen saturation, which often follows sedation. A postoperative client frequently needs to be awakened for pain medication in order to avoid waking to out-of-control pain later.)

A home health care nurse is planning an exercise program with an older client who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult? a. Building strength and flexibility b. Improving exercise endurance c. Increasing aerobic capacity d. Providing personal training

a. Building strength and flexibility (This older adult is mostly homebound. Exercise regimens for homebound clients include things to increase functional ability for activities of daily living. Strength and flexibility will help the client to be able to maintain independence longer. The other plans are good but will not specifically maintain the client's functional abilities.)

A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.) a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower.

a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower. (Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side. Stepping into a bathtub may also require the client to bend the hip more than the allowed 90 degrees.)

A nurse manager institutes the Fulmer Spices Framework as part of the routine assessment of older adults in the hospital. The nursing staff assesses for which factors? (Select all that apply.) a. Confusion b. Evidence of abuse c. Incontinence d. Problems with behavior e. Sleep disorders

a. Confusion c. Incontinence e. Sleep disorders (SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion, evidence of falls, and skin breakdown)

A nurse working with older adults assesses them for common potential adverse medication effects. For what does the nurse assess? (Select all that apply.) a. Constipation b. Dehydration c. Mania d. Urinary incontinence e. Weakness

a. Constipation b. Dehydration e. Weakness (Common adverse medication effects include constipation/impaction, dehydration, and weakness. Mania and incontinence are not among the common adverse effects, although urinary retention is.)

A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best? a. Consult with the health care provider about administering both drugs to the client. b. Inform the client that the celecoxib will be started when he or she goes home. c. Teach the client that, since morphine is stronger, celecoxib is not needed. d. Tell the client he or she should not take both drugs at the same time.

a. Consult with the health care provider about administering both drugs to the client. (Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help with the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this medication postoperatively.)

A client reports a great deal of pain following a fairly minor operation. The surgeon leaves a prescription for the nurse to administer a placebo instead of pain medication. What actions by the nurse are most appropriate? (Select all that apply.) a. Consult with the prescriber and voice objections. b. Delegate administration of the placebo to another nurse. c. Give the placebo and reassess the client's pain. d. Notify the nurse manager of the physician's request. e. Tell the client what the prescriber ordered.

a. Consult with the prescriber and voice objections. d. Notify the nurse manager of the physician's request. (Nurses should never give placebos to treat a client's pain (unless the client is in a research study). This practice is unethical and, in many states, illegal. The nurse should voice concerns with the prescriber and, if needed, contact the nurse manager. The nurse should not delegate giving the placebo to someone else, nor should the nurse give it. The nurse should not tell the client unless absolutely necessary (the client asks) as this will undermine the prescriber-client relationship.)

The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further? a. Creatinine: 3.9 mg/dL b. Platelet count: 210,000/mm³ c. Red blood cell count: 5.2/mm³ d. White blood cell count: 4400/mm³

a. Creatinine: 3.9 mg/dL (Lupus nephritis is the leading cause of death in clients with SLE. The creatinine level is very high and the nurse needs to perform further assessments related to this finding. The other laboratory values are normal.)

A nurse working with older adults in the community plans programming to improve morale and emotional health in this population. What activity would best meet this goal? a. Exercise program to improve physical function b. Financial planning seminar series for older adults c. Social events such as dances and group dinners d. Workshop on prevention from becoming an abuse victim

a. Exercise program to improve physical function (All activities would be beneficial for the older population in the community. However, failure in performing one's own activities of daily living and participating in society has direct effects on morale and life satisfaction. Those who lose the ability to function independently often feel worthless and empty. An exercise program designed to maintain and/or improve physical functioning would best address this need.)

A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.) a. Grab bars to reach high items b. Long-handled bath scrub brush c. Soft rocker-recliner chair d. Toothbrush with built-up handle e. Wheelchair cushion for comfort

a. Grab bars to reach high items b. Long-handled bath scrub brush d. Toothbrush with built-up handle (Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner and wheelchair cushion are comfort measures but do not help increase independence.)

A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important? a. Have adequate help to transfer the client. b. Provide socks so the client can slide easier. c. Tell the client full weight bearing is allowed. d. Use a footstool to elevate the client's leg.

a. Have adequate help to transfer the client. (The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the leg greater than 90 degrees is not allowed.)

A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberden's nodules. What assessment technique is correct? a. Inspect the client's distal finger joints. b. Palpate the client's abdomen for tenderness. c. Palpate the client's upper body lymph nodes. d. Perform range of motion on the client's wrists.

a. Inspect the client's distal finger joints. Herberden's nodules are seen in osteoarthritis and are bony nodules at the distal interphalangeal joints. To assess for this finding, the nurse inspects the client's distal fingertips. These nodules are not found in the abdomen, lymph nodes, or wrists.

An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this client? a. Keep the light on in the bathroom at night. b. Order a bedside commode for the client. c. Put the client on a toileting schedule. d. Use siderails to keep the client in bed.

a. Keep the light on in the bathroom at night. (Although this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom will help reduce the likelihood of falling. The client does not need a commode or a toileting schedule. Siderails used to keep the client in bed are considered restraints and should not be used in that fashion.)

An emergency department (ED) manager wishes to start offering clients nonpharmacologic pain control methodologies as an adjunct to medication. Which strategy would be most successful with this client population? a. Listening to music on a headset b. Participating in biofeedback c. Playing video games d. Using guided imagery

a. Listening to music on a headset (Listening to music on a headset would be the most successful cognitive-behavioral pain control method for several reasons. First, in the ED, the nurse does not have time to teach clients complex modalities such as guided imagery or biofeedback. Second, clients who are anxious and in pain may not have good concentration, limiting the usefulness of video games. Playing music on a headset only requires the client to wear the headset and can be beneficial without strong concentration. A wide selection of music will make this appealing to more people.)

A nursing student is studying pain sources. Which statements accurately describe different types of pain? (Select all that apply.) a. Neuropathic pain sometimes accompanies amputation. b. Nociceptive pain originates from abnormal pain processing. c. Deep somatic pain is pain arising from bone and connective tissues. d. Somatic pain originates from skin and subcutaneous tissues. e. Visceral pain is often diffuse and poorly localized.

a. Neuropathic pain sometimes accompanies amputation. c. Deep somatic pain is pain arising from bone and connective tissues. d. Somatic pain originates from skin and subcutaneous tissues. e. Visceral pain is often diffuse and poorly localized. (Neuropathic pain results from abnormal pain processing and is seen in amputations and neuropathies. Somatic pain can arise from superficial sources such as skin, or deep sources such as bone and connective tissues. Visceral pain originates from organs or their linings and is often diffuse and poorly localized. Nociceptive pain is normal pain processing and consists of somatic and visceral pain.)

During assessment of a patient with osteoarthritis pain, the nurse knows that which condition is a contraindication to the use of nonsteroidal anti-inflammatory drugs (NSAIDs)? a. Renal disease b. Diabetes mellitus c. Headaches d. Rheumatoid arthritis

a. Renal disease (Contraindications to NSAIDs include known drug allergy and conditions that place a patient at risk for bleeding, such as vitamin K deficiency, and peptic ulcer disease. Patients with documented aspirin allergy must not receive NSAIDs. Other common contraindications are those that apply to most drugs, including severe renal or hepatic disease. The other options are not contraindications.)

The nurse is reviewing the history of a patient who has a new order for a nonsteroidal anti-inflammatory drug (NSAID) to treat tendonitis. Which conditions are contraindications to the use of NSAIDs? (Select all that apply.) a. Vitamin K deficiency b. Arthralgia c. Peptic ulcer disease d. Neuropathy e. Pericarditis

a. Vitamin K deficiency c. Peptic ulcer disease (Contraindications to NSAIDs include known drug allergy as well as conditions that place the patient at risk for bleeding, such as Vitamin K deficiency and peptic ulcer disease. NSAIDs may be used to treat arthralgia and pericarditis. Neuropathy is not a contraindication.)

An older adult is brought to the emergency department because of sudden onset of confusion. After the client is stabilized and comfortable, what assessment by the nurse is most important? a. Assess for orthostatic hypotension. b. Determine if there are new medications. c. Evaluate the client for gait abnormalities. d. Perform a delirium screening test.

b. Determine if there are new medications. (Medication side effects and adverse effects are common in the older population. Something as simple as a new antibiotic can cause confusion and memory loss. The nurse should determine if the client is taking any new medications. Assessments for orthostatic hypotension, gait abnormalities, and delirium may be important once more is known about the client's condition.)

A nurse caring for an older client in the hospital is concerned the client is not competent to give consent for upcoming surgery. What action by the nurse is best? a. Call Adult Protective Services. b. Discuss concerns with the health care team. c. Do not allow the client to sign the consent. d. Have the client's family sign the consent.

b. Discuss concerns with the health care team. (In this situation, each facility will have a policy designed for assessing competence. The nurse should bring these concerns to an interdisciplinary care team meeting. There may be physiologic reasons for the client to be temporarily too confused or incompetent to give consent. If an acute condition is ruled out, the staff should follow the legal procedure and policies in their facility and state for determining competence. The key is to bring the concerns forward. Calling Adult Protective Services is not appropriate at this time. Signing the consent should wait until competence is determined unless it is an emergency, in which case the next of kin can sign if there are grave doubts as to the client's ability to provide consent.)

A client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. What finding in the client's health history would lead the nurse to consult with the provider over the choice of medication? a. 25-pack-year smoking history b. Drinking 3 to 5 beers a day c. Previous peptic ulcer d. Taking warfarin (Coumadin)

b. Drinking 3 to 5 beers a day (The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which should be investigated prior to taking chronic acetaminophen. The nurse should relay this information to the provider. Smoking is not related to acetaminophen side effects. Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.)

An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication would the nurse plan to educate the client? a. Desipramine (Norpramin) b. Duloxetine (Cymbalta) c. Morphine sulfate d. Nortriptyline (Pamelor)

b. Duloxetine (Cymbalta) (Antidepressants and anticonvulsants often are used for neuropathic pain relief. Morphine would not be used for this client. However, older adults do not tolerate tricyclic antidepressants very well, which eliminates desipramine and nortriptyline. Duloxetine would be the best choice for this older client.)

A client with a broken arm has had ice placed on it for 20 minutes. A short time after the ice was removed, the client reports that the effect has worn off and requests pain medication, which cannot be given yet. What actions by the nurse are most appropriate? (Select all that apply.) a. Ask for a physical therapy consult. b. Educate the client on cold therapy. c. Offer to provide a heating pad. d. Repeat the ice application. e. Teach the client relaxation techniques.

b. Educate the client on cold therapy. d. Repeat the ice application. e. Teach the client relaxation techniques. (Nonpharmacologic pain management can be very effective. These modalities include ice, heat, pressure, massage, vibration, and transcutaneous electrical stimulation. Since the client is unable to have more pain medication at this time, the nurse should focus on nonpharmacologic modalities. First the client must be educated; the effects of ice wear off quickly once it is removed, and the client may have had unrealistic expectations. The nurse can repeat the ice application and teach relaxation techniques if the client is open to them. A physical therapy consult will not help relieve acute pain. Heat would not be a good choice for this type of injury.)

A nursing student working in an Adult Care for Elders unit learns that frailty in the older population includes which components? (Select all that apply.) a. Dementia b. Exhaustion c. Slowed physical activity d. Weakness e. Weight gain

b. Exhaustion c. Slowed physical activity d. Weakness (Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, and weakness. Weight gain and dementia are not part of this cluster of manifestations.)

The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.) a. Anorexia b. Felty's syndrome c. Joint deformity d. Low-grade fever e. Weight loss

b. Felty's syndrome c. Joint deformity e. Weight loss (Late manifestations of RA include Felty's syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease.)

A nurse is caring for a client on an epidural patient-controlled analgesia (PCA) pump. What action by the nurse is most important to ensure client safety? a. Assess and record vital signs every 2 hours. b. Have another nurse double-check the pump settings. c. Instruct the client to report any unrelieved pain. d. Monitor for numbness and tingling in the legs.

b. Have another nurse double-check the pump settings. (PCA-delivered analgesia creates a potential risk for the client. Pump settings should always be double-checked. Assessing vital signs should be done per agency policy and nurse discretion, and may or may not need to be this frequent. Unrelieved pain should be reported but is not vital to client safety. Monitoring for numbness and tingling in the legs is an important function but will manifest after something has occurred to the client; monitoring does not prevent the event from occurring.)

A hospitalized client has a history of depression for which sertraline (Zoloft) is prescribed. The client also has a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse choose? a. Hydrocodone and acetaminophen (Lorcet) b. Hydromorphone (Dilaudid) c. Meperidine (Demerol) d. Tramadol (Ultram)

b. Hydromorphone (Dilaudid) (Hydromorphone is a good alternative to morphine for moderate to severe pain. The nurse should not choose Lorcet because it contains acetaminophen (Tylenol) and the client has a history of alcoholism. Tramadol should not be used due to the potential for interactions with the client's sertraline. Meperidine is rarely used and is often restricted.)

An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for pain. The client is allergic to morphine and reports pain and muscle spasms. When the nurse calls the surgeon, which medication should he or she suggest in place of the morphine? a. Cyclobenzaprine (Flexeril) b. Hydromorphone hydrochloride (Dilaudid) c. Ketorolac (Toradol) d. Meperidine (Demerol)

b. Hydromorphone hydrochloride (Dilaudid) (Cyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are all on the Beers list of potentially inappropriate medications for use in older adults and should not be suggested. The nurse should suggest hydromorphone hydrochloride.)

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply? a. Heating pad b. Ice packs c. Splints d. Wax dip

b. Ice packs (Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A wax dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness.)

A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps? a. Have the client use a walker or cane on the steps. b. Install contrasting color strips at the edge of each step. c. Instruct the client to use the garage door instead. d. Tell the client to use a two-footed gait on the steps.

b. Install contrasting color strips at the edge of each step. (As a person ages, he or she may experience a decreased sense of touch. The older adult may not be aware of where his or her foot is on the step. Installing contrasting color strips at the end of each step will help increase awareness. If the client does not need an assistive device, he or she should not use one just on stairs. Using an alternative door may be necessary but does not address making the front steps safer. A two-footed gait may not help if the client is unaware of where the foot is on the step.)

An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm³, red blood cell count: 3.2/mm³, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate? a. Instruct the client to avoid large crowds. b. Prepare to administer epoetin alfa (Epogen). c. Teach the client about foods high in iron. d. Tell the client that all laboratory results are normal.

b. Prepare to administer epoetin alfa (Epogen). (This client is anemic, which needs correction prior to surgery. While eating iron-rich foods is helpful, to increase the client's red blood cells, hemoglobin, and hematocrit within 2 months, epoetin alfa is needed. This colony-stimulating factor will encourage the production of red cells. The client's white blood cell count is normal, so avoiding infection is not the priority.)

A 6-year-old child who has chickenpox also has a fever of 102.9° F (39.4° C). The child's mother asks the nurse if she should use aspirin to reduce the fever. What is the best response by the nurse? a. "It's best to wait to see if the fever gets worse." b. "You can use the aspirin, but watch for worsening symptoms." c. "Acetaminophen (Tylenol) should be used to reduce his fever, not aspirin." d. "You can use aspirin, but be sure to follow the instructions on the bottle."

c. "Acetaminophen (Tylenol) should be used to reduce his fever, not aspirin." (Aspirin is contraindicated in children with flu-like symptoms because the use of this drug has been strongly associated with Reye's syndrome. This is an acute and potentially life-threatening condition involving progressive neurologic deficits that can lead to coma and may also involve liver damage. Acetaminophen is appropriate for this patient. The other responses are incorrect.)

A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue? a. "Cut some sodium out of your diet." b. "Dehydration can cause incontinence." c. "Have something to drink every 1 to 2 hours." d. "Take your diuretic in the morning."

c. "Have something to drink every 1 to 2 hours." (Older adults often lose their sense of thirst. Since they should drink 1 to 2 liters of water a day, the best remedy is to have the older adult drink something each hour or two, whether or not he or she is thirsty. Cutting "some" sodium from the diet will not address this issue. Although dehydration can cause incontinence from the irritation of concentrated urine, this information will not help prevent the problem of dehydration. Instructing the client to take a diuretic in the morning rather than in the evening also will not directly address this issue.)

A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management? a. "I can bend down to pick something up." b. "I no longer need to do my exercises." c. "I will not sit with my legs crossed." d. "I won't wash my incision to keep it dry."

c. "I will not sit with my legs crossed." (There are many precautions clients need to take after hip replacement surgery, including not bending more than 90 degrees at the hips, continuing prescribed exercises, not crossing the legs, and washing the incision daily and patting it dry.)

A student nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. What response by the registered nurse is best? a. "A multimodal approach is the preferred method of control." b. "Doctors are much more liberal with pain medications now." c. "Pain is so complex it takes different approaches to control it." d. "Clients are consumers and they demand lots of pain medicine."

c. "Pain is so complex it takes different approaches to control it." (Pain is a complex phenomenon and often responds best to a regimen that uses different types of analgesia. This is called a multimodal approach. Using this terminology, however, may not be clear to the student if the terminology is not understood. Doctors may be more liberal with pain medications, but that is not the best reason for this approach. Saying that clients are consumers who demand medications sounds as if the nurse is discounting their pain experiences.)

A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client calls the clinic and asks the nurse why an antidepressant drug has been prescribed. What response by the nurse is best? a. "A little sedation will help you get some rest." b. "Depression often accompanies fibromyalgia." c. "This drug works in the brain to decrease pain." d. "You will have more energy after taking this drug."

c. "This drug works in the brain to decrease pain." (Duloxetine works to increase the release of the neurotransmitters serotonin and norepinephrine, which reduces the pain from fibromyalgia. The other answers are inaccurate.)

A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best? a. "Let's ask the provider about increasing your pain pills." b. "Hold ice bags against your hands before quilting." c. "Try a paraffin wax dip 20 minutes before you quilt." d. "You need to stop quilting before it destroys your fingers."

c. "Try a paraffin wax dip 20 minutes before you quilt." (Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. The nurse can suggest this comfort measure. Increasing pain pills will not help with movement. Ice has limited use unless the client has a "hot" or exacerbated joint. The client wants to finish her project, so the nurse should not negate its importance by telling the client it is destroying her joints.)

A 75-year-old woman has been given a nonsteroidal anti-inflammatory drug (an NSAID for the treatment of rheumatoid arthritis. The nurse is reviewing the patient's medication history and notes that which types of medications could have an interaction with the NSAID? (Select all that apply.) a. Antibiotics b. Decongestants c. Anticoagulants d. Beta blockers e. Diuretics f. Corticosteroids

c. Anticoagulants e. Diuretics f. Corticosteroids (Anticoagulants taken with NSAIDs may cause increased bleeding tendencies because of platelet inhibition and hypoprothrombinemia. NSAIDs taken with diuretics may cause reduced hypotensive and diuretic effects. NSAIDs taken with corticosteroids may cause increased ulcerogenic effects. See Table 44-5. The other options are incorrect.)

The nurse is reviewing the therapeutic effects of nonsteroidal anti-inflammatory drugs (NSAIDs), which include which effect? a. Anxiolytic b. Sedative c. Antipyretic d. Antimicrobial

c. Antipyretic (NSAIDs have antipyretic effects but not the other effects listed.)

A nurse is caring for four clients receiving pain medication. After the hand-off report, which client should the nurse see first? a. Client who is crying and agitated b. Client with a heart rate of 104 beats/min c. Client with a Pasero Scale score of 4 d. Client with a verbal pain report of 9

c. Client with a Pasero Scale score of 4 (The Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4 indicates unacceptable somnolence and is an emergency. The nurse should see this client first. The nurse can delegate visiting with the crying client to a nursing assistant; the client may be upset and might benefit from talking or a comforting presence. The client whose pain score is 9 needs to be seen next, or the nurse can delegate this assessment to another nurse while working with the priority client. A heart rate of 104 beats/min is slightly above normal, and that client can be seen after the other two clients are cared for.)

A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What pain assessment tool would the nurse choose for this assessment? a. Numeric rating scale b. Verbal Descriptor Scale c. FACES Pain Scale-Revised d. Wong-Baker FACES Pain Scale

c. FACES Pain Scale-Revised (All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults.)

A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the registered nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess skin redness when turning. b. Document Braden Scale results. c. Keep the client's skin dry. d. Obtain a pressure-relieving mattress. e. Turn the client every 2 hours.

c. Keep the client's skin dry. d. Obtain a pressure-relieving mattress. e. Turn the client every 2 hours. (The nurses' aide or UAP can assist in keeping the client's skin dry, order a special mattress on direction of the RN, and turn the client on a schedule. Assessing the skin is a nursing responsibility, although the aide should be directed to report any redness noticed. Documenting the Braden Scale results is the RN's responsibility as the RN is the one who performs that assessment.)

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. d. Engage in weight-bearing exercise.

c. Lose weight if needed. (Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and weight-bearing exercise are both important for osteoporosis.)

A patient is taking the nonsteroidal anti-inflammatory drug indomethacin (Indocin) as treatment for pericarditis. The nurse will teach the patient to watch for which adverse effect? a. Tachycardia b. Nervousness c. Nausea and vomiting d. Dizziness

c. Nausea and vomiting (Gastrointestinal effects include dyspepsia, heartburn, epigastric distress, nausea, vomiting, anorexia, abdominal pain, and others. See Table 44-2 for the other adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs). The other options are not adverse effects of NSAIDs.)

A postoperative client has an epidural infusion of morphine and bupivacaine (Marcaine). What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Ask the client to point out any areas of numbness or tingling. b. Determine how many people are needed to ambulate the client. c. Perform a bladder scan if the client is unable to void after 4 hours. d. Remind the client to use the incentive spirometer every hour. e. Take and record the client's vital signs per agency protocol.

c. Perform a bladder scan if the client is unable to void after 4 hours. d. Remind the client to use the incentive spirometer every hour. e. Take and record the client's vital signs per agency protocol. (The UAP can assess and record vital signs, perform a bladder scan and report the results to the nurse, and remind the client to use the spirometer. The nurse is legally responsible for assessments and should ask the client about areas of numbness or tingling, and assess if the client is able to bear weight and walk.)

A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse perform first? a. Auscultate bowel sounds. b. Check skin turgor. c. Perform an oral assessment. d. Weigh the client.

c. Perform an oral assessment. (Poorly fitting dentures and other dental problems are often manifested by a preference for soft foods and constipation from the lack of fiber. The nurse should perform an oral assessment to determine if these problems exist. The other assessments are important, but will not yield information specific to the client's food preferences as they relate to constipation.)

A nurse admits an older client to the hospital who lives at home with family. The nurse assesses that the client is malnourished. What actions by the nurse are best? (Select all that apply.) a. Contact Adult Protective Services or hospital social work. b. Notify the provider that the client needs a tube feeding. c. Perform and document results of a Braden Scale assessment. d. Request a dietary consultation from the health care provider. e. Suggest a high-protein oral supplement between meals.

c. Perform and document results of a Braden Scale assessment. d. Request a dietary consultation from the health care provider. e. Suggest a high-protein oral supplement between meals. (Malnutrition in the older population is multifactorial and has several potential adverse outcomes. Appropriate actions by the nurse include assessing the client's risk for skin breakdown with the Braden Scale, requesting a consultation with a dietitian, and suggesting a high-protein meal supplement. There is no evidence that the client is being abused or needs a feeding tube at this time.)

A registered nurse (RN) and nursing student are caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). What action by the student requires the RN to intervene? a. Assesses the client's pain level per agency policy b. Monitors the client's respiratory rate and sedation c. Presses the button when the client cannot reach it d. Reinforces client teaching about using the PCA pump

c. Presses the button when the client cannot reach it (The client is the only person who should press the PCA button. If the client cannot reach it, the student should either reposition the client or the button, and should not press the button for the client. The RN should intervene at this point. The other actions are appropriate.)

An older adult client takes medication three times a day and becomes confused about which medication should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying "Those are for old people." What action by the nurse would be most helpful? a. Arrange medications by time in a drawer. b. Encourage the client to use easy-open tops. c. Put color-coded stickers on the bottle caps. d. Write a list of when to take each medication.

c. Put color-coded stickers on the bottle caps. (Color-coded stickers are a fast, easy-to-remember system. One color is for morning meds, one for evening meds, and the third color is for nighttime meds. Arranging medications by time in a drawer might be helpful if the person doesn't accidentally put them back in the wrong spot. Easy-open tops are not related. Writing a list might be helpful, but not if it gets misplaced. With stickers on the medication bottles themselves, the reminder is always with the medication.)

A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed? a. Assess the distal circulation in 30 minutes. b. Change the settings based on range of motion. c. Raise the lower siderail on the affected side. d. Remind the client to do quad-setting exercises.

c. Raise the lower siderail on the affected side. Because the client's leg is strapped into the CPM, if it falls off the bed due to movement, the client's leg (and new joint) can be injured. The nurse should instruct the UAP to raise the siderail to prevent this from occurring. Assessment is a nursing responsibility. Only the surgeon, physical therapist, or specially trained technician adjusts the CPM settings. Quad-setting exercises are not related to the CPM machine.

The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement? a. Needs multiple dental fillings b. Over age 85 c. Severe osteoporosis d. Urinary tract infection

c. Severe osteoporosis (Osteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the new prosthesis is implanted. The client who needs fillings should have them done prior to the surgery. Age greater than 85 is not an absolute contraindication. A urinary tract infection can be treated prior to surgery.)

A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the client demonstrates a need for further review? a. Barley soup b. Black beans c. White rice d. Whole wheat bread

c. White rice (Older adults need 25 to 50 grams of fiber a day. White rice is low in fiber. Foods high in fiber include barley, beans, and whole wheat products.)

A home care nurse receives a physician order for a medication that the patient does not want to take because the patient has a history of side effects from this medication. The nurse carefully listens to the patient, considers it in light of the patient's condition, questions its appropriateness, and examines alternative treatments. This nurse would most likely call the physician, explain rationale, and suggest a different medication. consult an experienced nurse on whether there are other similar treatments. hold the drug until the physician returns to the unit and can be questioned. question other staff as to the physician's acceptance of nursing input.

call the physician, explain rationale, and suggest a different medication. (Determining how best to proceed on behalf of a patient's best health care outcomes may require clinical judgment. At the committed level of critical thinking, the nurse chooses an action after all possibilities have been examined. A home care nurse who is using good clinical judgment techniques should have confidence in their decision and may not have another nurse available as this is an autonomous setting. Holding the drug might jeopardize the patient's health, so this is not the best solution. The nurse working at this level of critical thinking makes choices based on careful examination of situations and alternatives; whether or not the physician is open to nursing input is not relevant.)

A patient has used enteric aspirin for several years as treatment for osteoarthritis. However, the symptoms are now worse and she is given a prescription for a nonsteroidal anti-inflammatory drug and misoprostol (Cytotec). The patient asks the nurse, "Why am I now taking two pills for arthritis?" What is the nurse's best response? a. "Cytotec will also reduce the symptoms of your arthritis." b. "Cytotec helps the action of the NSAID so that it will work better." c. "Cytotec reduces the mucous secretions in the stomach, which reduces gastric irritation." d. "Cytotec may help to prevent gastric ulcers that may occur in patients taking NSAIDs."

d. "Cytotec may help to prevent gastric ulcers that may occur in patients taking NSAIDs." (Cytotec inhibits gastric acid secretions and stimulates mucous secretions; it has proved successful in preventing the gastric ulcers that may occur in patients taking NSAIDs.)

A patient who has a history of coronary artery disease has been instructed to take one 81-mg aspirin tablet a day. The patient asks about the purpose of this aspirin. Which response by the nurse is correct? a. "Aspirin is given reduce anxiety." b. "It helps to reduce inflammation." c. "Aspirin is given to relieve pain." d. "It will help to prevent clot formation."

d. "It will help to prevent clot formation." (Aspirin can reduce platelet aggregation; low doses of aspirin (81 to 325 mg once daily) are used for thromboprevention. Higher doses are required for pain relief, reduction of inflammation, and reduction of fever. The other options are incorrect.)

The nurse is assessing a client's pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. What question by the nurse would be best to ask the client for completing a comprehensive pain assessment? a. "Are you worried about addiction to pain pills?" b. "Do you attach any spiritual meaning to pain?" c. "How high would you say your pain tolerance is?" d. "What pain rating would be acceptable to you?"

d. "What pain rating would be acceptable to you?" (A comprehensive pain assessment includes the items listed in the question plus the client's opinion on a functional goal, such as what pain rating would be acceptable to him or her. Asking about addiction is not warranted in an initial pain assessment. Asking about spiritual meanings for pain may give the nurse important information, but getting the basics first is more important. Asking about pain tolerance may give the client the idea that pain tolerance is being judged.)

The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client taking celecoxib (Celebrex) and ranitidine (Zantac) b. Client taking etanercept (Enbrel) with a red injection site c. Client with a blood glucose of 190 mg/dL who is taking steroids d. Client with a fever and cough who is taking tofacitinib (Xeljanz)

d. Client with a fever and cough who is taking tofacitinib (Xeljanz) (Tofacitinib carries a Food and Drug Administration black box warning about opportunistic infections, tuberculosis, and cancer. Fever and cough may indicate tuberculosis. Ranitidine is often taken with celecoxib, which can cause gastrointestinal distress. Redness and itchy rashes are frequently seen with etanercept injections. Steroids are known to raise blood glucose levels.)

A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client should the nurse see first? a. Client who appears to be sleeping soundly b. Client with no bolus request in 6 hours c. Client who is pressing the button every 10 minutes d. Client with a respiratory rate of 8 breaths/min

d. Client with a respiratory rate of 8 breaths/min (Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse should first check this client. The client sleeping soundly could either be overly sedated or just comfortable and should be checked next. Pressing the button every 10 minutes indicates the client has a high level of pain, but the device has a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose. The nurse should next assess that client's pain. The client who has not needed a bolus of pain medicine in several hours has well-controlled pain.)

A student asks the nurse what is the best way to assess a client's pain. Which response by the nurse is best? a. Numeric pain scale b. Behavioral assessment c. Objective observation d. Client's self-report

d. Client's self-report (Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client.)

A mother brings her toddler into the emergency department and tells the nurse that she thinks the toddler has eaten an entire bottle of chewable aspirin tablets. The nurse will assess for which most common signs of salicylate intoxication in children? a. Photosensitivity and nervousness b. Tinnitus and hearing loss c. Acute gastrointestinal bleeding d. Hyperventilation and drowsiness

d. Hyperventilation and drowsiness (The most common manifestations of chronic salicylate intoxication in adults are tinnitus and hearing loss. Those in children are hyperventilation and CNS effects, such as dizziness, drowsiness, and behavioral changes.)

A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like "pins and needles" and that the neck is very painful since returning from surgery. What action by the nurse is best? a. Assist the client to change positions. b. Document the findings in the client's chart. c. Encourage range of motion of the neck. d. Notify the provider immediately.

d. Notify the provider immediately. (Clients with RA can have cervical joint involvement. This can lead to an emergent situation in which the phrenic nerve is compressed, causing respiratory insufficiency. The client can also suffer a permanent spinal cord injury. The nurse needs to notify the provider immediately. Changing positions and doing range of motion may actually worsen the situation. The nurse should document findings after notifying the provider.)

A hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain. What action by the nurse is most important for client safety? a. Assess and record the client's pain every 4 hours. b. Ensure the client is eating a high-fiber diet. c. Monitor the client's bowel function every shift. d. Remove the old patch when applying the new one.

d. Remove the old patch when applying the new one. (The old fentanyl patch should be removed when applying a new patch so that accidental overdose does not occur. The other actions are appropriate, but not as important for safety.)

A nurse admits an older client from a home environment where she lives with her adult son and daughter-in-law. The client has urine burns on her skin, no dentures, and several pressure ulcers. What action by the nurse is most appropriate? a. Ask the family how these problems occurred. b. Call the police department and file a report. c. Notify Adult Protective Services. d. Report the findings as per agency policy.

d. Report the findings as per agency policy. (These findings are suspicious for abuse. Health care providers are mandatory reporters for suspected abuse. The nurse should notify social work, case management, or whomever is designated in policies. That person can then assess the situation further. If the police need to be notified, that is the person who will notify them. Adult Protective Services is notified in the community setting.)

A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. What intervention for pain management does the nurse include in the client's care plan? a. As-needed pain medication after therapy b. Client-controlled analgesia with a basal rate c. Pain medications prior to therapy only d. Round-the-clock analgesia with PRN analgesics

d. Round-the-clock analgesia with PRN analgesics (Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain associated with specific procedures is managed with additional medication. An as-needed regimen will not control postoperative pain. A client-controlled analgesia pump might be a good idea but needs basal (continuous) and bolus (intermittent) settings to accomplish adequate pain control. Pain control needs to be continuous, not just administered prior to therapy.)

A nurse is assessing pain in an older adult. What action by the nurse is best? a. Ask only "yes-or-no" questions so the client doesn't get too tired. b. Give the client a picture of the pain scale and come back later. c. Question the client about new pain only, not normal pain from aging. d. Sit down, ask one question at a time, and allow the client to answer.

d. Sit down, ask one question at a time, and allow the client to answer. (Some older clients do not report pain because they think it is a normal part of aging or because they do not want to be a bother. Sitting down conveys time, interest, and availability. Ask only one question at a time and allow the client enough time to answer it. Yes-or-no questions are an example of poor communication technique. Giving the client a pain scale, then leaving, might give the impression that the nurse does not have time for the client. Plus the client may not know how to use it. There is no normal pain from aging.)

A nurse is preparing to give a client ketorolac (Toradol) intravenously for pain. Which assessment findings would lead the nurse to consult with the provider? a. Bilateral lung crackles b. Hypoactive bowel sounds c. Self-reported pain of 3/10 d. Urine output of 20 mL/2 hr

d. Urine output of 20 mL/2 hr (Drugs in this category can affect renal function. Clients should be adequately hydrated and demonstrate good renal function prior to administering ketorolac. A urine output of 20 mL/2 hr is well below normal, and the nurse should consult with the provider about the choice of drug. Crackles and hypoactive bowel sounds are not related. A pain report of 3 does not warrant a call to the physician. The medication may be part of a round-the-clock regimen to prevent and control pain and would still need to be given. If the medication is PRN, the nurse can ask the client if he or she still wants it.)

An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury? a. Administer mild sedation. b. Keep all four siderails up. c. Restrain the client's hands. d. Use an abduction pillow.

d. Use an abduction pillow. (Older clients often have trouble metabolizing anesthetics and pain medication, leading to confusion or restlessness postoperatively. To prevent the hip from dislocating, the nurse should use an abduction pillow since the client cannot follow directions at this time. Sedation may worsen the client's mental status and should be avoided. Using all four siderails may be considered a restraint. Hand restraints are not necessary in this situation.)

A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection? a. Assess the client's white blood cell count. b. Culture any drainage from the wound. c. Monitor the client's temperature every 4 hours. d. Use aseptic technique for dressing changes.

d. Use aseptic technique for dressing changes. (Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains. The other actions do not prevent infection but can lead to early detection of an infection that is already present.)

The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA). What assessment would be most important for the client whose chart contains the diagnosis of Sjögren's syndrome? a. Abdominal assessment b. Oxygen saturation c. Renal function studies d. Visual acuity

d. Visual acuity (Sjögren's syndrome is seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Visual disturbances can occur. The other assessments are not related to RA and Sjögren's syndrome.)

A GN appears to be second-guessing herself and is constantly calling on the other nurses to double-check their plan of care or rehearse what they will say to the doctor before she call on the patient's behalf. This seems to be annoying some of the nurse's coworkers. The nurse manager's best response to this situation is to explain to coworkers that this is a characteristic of critical thinking and is important for the GN to improve reasoning skills. agree with the staff and have someone follow and work more closely with a preceptor. have a talk with the nurse and suggest asking fewer questions. tell the staff that all new nurses go through this phase, and ignore their behavior.

explain to coworkers that this is a characteristic of critical thinking and is important for the GN to improve reasoning skills. (Reflection-on-action is critical for development of knowledge and improvement in reasoning. It is where learning from practice is incorporated into experience. Inquisitiveness is a characteristic of critical thinking and reflects a desire to learn even when the knowledge may not appear readily useful. The manager should promote this. Suggesting the nurse work more closely with a preceptor implies that the manager thinks the nurse needs to learn more and increase confidence. In reality, this nurse is demonstrating a characteristic of critical thinking. Suggesting that the nurse ask fewer questions would hamper the development of the nurse as a critical thinker. All new nurses do go through a phase of asking more questions at one time, but dismissing the nurse's behavior with this explanation is simplistic and will discourage critical thinking.)

Essential elements of a standard order set to verify a medication order include volume only. number of tablets. metric dose/strength. hour of administration.

metric dose/strength. (The ISMP recommendations for standardized medication order sets include such elements as the drug name (generic followed by brand when appropriate), metric dose/strength, frequency and duration, route, and indication. Although a prescription may include volume or number of tablets, the essential component is dose or strength, because the volume or number of tablets may vary by manufacturer. The exact hour of administration can be based on factors such as the frequency, agency protocols, and patient preferences.)

When assessing for the MOST serious adverse effect to an opioid analgesic, what does the nurse monitor for in this patient? Blood pressure Respiratory rate Mental status Heart rate

respiratory rate (The most serious adverse effect of opioid analgesics is respiratory depression.)

Prior to drug administration the nurse reviews the seven rights, which include right patient, right medication, right time, right dose, right education, right documentation, and right room. route. physician. manufacturer.

route. (The right route (e.g., oral or intramuscular) is an essential component to verify prior to the administration of any drug. The patient does not need to be in a specific location. There may be a number of physicians caring for a patient who prescribe medications for any given patient. A similar drug may be made by a number of different companies, and checking the manufacturer is not considered one of the seven rights. However, the nurse will want to be aware of a difference, because different companies prepare the same medication in different ways with different inactive ingredients, which can affect patient response.)

Nursing demonstrates dedication to improving public health through changing health care standards. legal regulations. scope of practice. technology.

scope of practice. (Through the scope of practice, specialized knowledge, and code of ethics, the discipline of nursing has demonstrated its dedication to improving public health. The changing health care environment is one of the challenges to nursing, not an indicator of dedication. Legal regulations are generally promulgated by legislators rather than nurses to protect the public. A highly technological environment is considered a challenge to nursing rather than an indicator of dedication.)

A sentinel event refers to an event that could have harmed a patient, but serious harm didn't occur because of chance. harms a patient as a result of underlying disease or condition. harms a patient by omission or commission, not an underlying disease or condition. signals the need for immediate investigation and response.

signals the need for immediate investigation and response. (A sentinel event is an unexpected occurrence involving death or serious physical or psychologic injury or the risk thereof called sentinel, because they signal the need for immediate investigation and response. A near-miss refers to an error or commission or omission that could have harmed the patient, but serious harm did not occur as a result of chance. Harm that relates to an underlying disease or condition provides the rationale for the close monitoring and supervision provided in a health care setting. An adverse event is one that results in unintended harm because of the commission or omission of an act.)

Instruments such as the Functional Activities Questionnaire (FAQ) for postoperative patients who are at home, the Minimum Data Set for Nursing Facility Resident Assessment and Care Screening (MDS) for nursing home patients, the Functional Status Scale (FSS) for children, and the Edmonton Functional Assessment Tool for cancer patients are used to assess activities of daily living (ADLs). The nurse needs to remember that a disadvantage of these instruments includes: the measurement of efficacy and reliability of the instruments used to assess activities of daily living (ADLs). the variations in assessments and responses may be subjective because of self-reporting of functional activities. the instruments do not show a true measure of ability because of a lack of interactivity during the assessments. the information contained in the instruments is insufficient to make a determination about functional status in these populations.

the variations in assessments and responses may be subjective because of self-reporting of functional activities. (A disadvantage of many of the ADLs and instrumental activities of daily living (IADLs) instruments is the self-reporting of functional activities. Efficacy and reliability are not measured when assessing ADLs and IADLs. Interaction with the patient is necessary to complete the ADL and IADL assessments. The FAQ and FSS are comprehensive tools that can help the nurse determine functional status.)